Miscommunication in doctor-patient communication: Is getting it wrong, getting it right?
Rose McCabe, Exeter University
So called ‘nonspecific’ effects of treatment account for up to 60% of the benefit patients derive from treatment. One locus of ‘nonspecific’ effects is doctor-patient communication. Indeed, the quality of healthcare professional-patient communication is associated with patient outcome. This offers an interesting possibility for identifying successful communication. But what is successful communication? And according to whom? And how is this tied to the activities at hand? I will discuss these questions vis-à-vis studies of psychiatrist-patient communication in psychiatry, with a focus on shared understanding.
Each time a person speaks, they display to the previous speaker if they have understood the first speaker’s utterance. This is the primary site of intersubjectivity in conversation (Schegloff 1992). It offers the opportunity to analyse exactly how understanding is negotiated in communication. If an utterance is understood, the conversation moves on. If not, the current speaker may try to clarify the meaning using a specific conversational mechanism called repair.
I will focus on repair practices, which speakers use to formulate understanding in their own talk, clarify understanding of another’s talk and address misunderstanding of their own and other’s talk. I will discuss various methods we have used to analyse repair, from micro-analysis (using conversation analysis) of repair practices in context to automated computational linguistic methods (with Matt Purver) and the tension between analyzing communicative practices in their specific context and stripping them of their context to apply higher level codes.
In a cross-sectional observational study, we found that more psychiatrist self-repair or revision of one’s own talk (an index of effort invested in formulating understanding) was associated with higher patient satisfaction with treatment and with observer rated shared decision making. This was reinforced in a further (intervention) study to improve psychiatrist-patient communication, whereby psychiatrist self-repair was higher in the psychiatrists who received communication skills training and patients were more satisfied with treatment.
With respect to patient repair, we have found that patient clarification questions (next turn repair initiators) seeking to clarify the psychiatrist’s talk are associated with the patient’s adherence to treatment, as assessed by the psychiatrist. Patients who requested clarification of the psychiatrist’s talk were almost 6 times more likely to be more adherent six months later (OR 5.82, 95% CI 1.31–25.82, p = 0.02).
Looking more closely at these patient clarification questions using conversation analysis, they were mostly formulated as ‘pardon?’ or ‘sorry?’ (i.e., open-class repair initiators, Drew 1997) to flag some trouble with a psychiatrist question. As such, they occurred in environments where the psychiatrist’s and patient’s talk was misaligned (e.g., in cases of abrupt topical or sequential shifts). Patient clarification comprises two activities, namely correcting something previously said by the psychiatrist (getting the record straight) and understanding what the psychiatrist is saying. Both demonstrate an interest in improved communication.
Different types of repair appear to be related to particular outcomes, which are tied to the specific communicative context and task domain. In particular, psychiatrist effort in formulating and revising their contributions is associated with patient satisfaction while patient clarification in the medical visit is associated with their subsequent behaviour.
In summary, repair practices, which can appear to be ‘negative’ by indicating trouble in a (prior) speaker’s talk and can be present in environments characterized by misalignment, ultimately appear to be positive, which is reflected in their association with treatment outcomes.