Communicating risk to patients

Principal Supervisor: Name: Dr Gareth Walker
Department: School of English
Tel: 0114 222 0238
Email: g.walker@sheffield.ac.uk

Co-supervisor: Name: Dr Steven Ariss
Department: School of Health and Related Research (SChARR)
Tel: 0114 222 5426
Email: s.ariss@sheffield.ac.uk

Description of proposed project

Any decision over medical treatment has associated risks. A key task for a clinician is to communicate these risks to the patient to allow a well-informed decision about treatment options to be made, and to ensure that there is alignment with the patient over those decisions. Clinicians can communicate risk in a number of ways and may make use of written materials (e.g. patient decision aids [10], statistics, graphical representations) and verbal descriptions. Risks associated with treatment options for type 2 diabetes [T2DM] include continuation of diabetic symptoms, increased risk of heart attacks and strokes, weight gain and hypoglycaemia. This project will look at the organisation of clinician-patient interactions to answer three main questions:

1. How do clinicians communicate the risks of treatment options to patients with T2DM in clinics? e.g. to what extent are the risks of different treatment options described? are the risks quantified, or described in general terms? does the clinician or the patient initiate the discussion of risk? do clinicians check patients’ understanding of risk, and if so how?
2. Is decisional quality of patients with T2DM related to how clinicians communicate the risks of treatment options in clinics?
3. How is the discussion of risk and other evidence managed in the consultation to reach agreement on treatment decisions?

Making links between the communication of risk and decisional quality – including the extent to which the patient feels supported in making choices, feels that the choices are well-informed and likely to be implemented, and feels certainty over those decisions [8] – gives this project the potential to inform clinical training in straightforward practical ways by identifying patients’ favoured methods for communicating risk, and identifying features in patients’ responsive behaviour which indicate risk has been communicated successfully.

Methods

The principle research method will be Conversation Analysis (CA). CA is the dominant method for qualitative research into interpersonal communication [9]. Furthermore, CA has provided an important foundation for the study of medical interaction [4, 11]. CA is distinct from other approaches to spoken interaction due to its emphasis on interaction as a collaborative achievement: the patient is not considered a passive recipient of information [1, 2, 6, 7]. CA has a track record of yielding insights which can be straightforwardly adopted by clinicians to improve their communication with patients and increase patient satisfaction [5]. The data will be video recordings of primary care consultations between clinicians (doctors and nurses) and patients with T2DM who are considering treatment. Patients will be asked questions post-consultation to establish how well they feel the risks of the treatment options have been communicated to them and to assess the overall quality of the decision made. A short oral questionnaire administered to clinicians will be recorded to camera immediately after each consultation to ascertain their responses to, and risk-based assessment of, the lifestyle information reported by patients during the consultation. Patients and clinicians will be asked about the extent to which they feel aligned over the decision made. All data will be collected and used in accordance with University of Sheffield ethics policies, and governance approval procedures of host organisations.

Rationale

The project will provide a better understanding of (i) structural aspects of medical interactions, and patient involvement in those interactions; (ii) how risk is communicated by clinicians to patients with T2DM in diabetes clinics; and (iii) how risk is more effectively communicated, in terms of patient decisional quality. The findings of the study could provide important input into the refinement of clinicians’ communicative skills. This is the first collaboration of its type between the School of English and ScHARR, and is important for student development. There is no current straightforward access for Arts and Humanities students to primary health care environments, and postgraduates in health research do not currently have the opportunity to investigate in detail how the use of language impacts on the clinical effectiveness of complex interventions [3].

Requirements of the student

The successful student would need a proven track record in at least two of the following, with a desire to engage fully and develop in all three areas: (i) primary healthcare (either academic or applied), possibly encompassing long term illness, healthcare policy, clinician-patient relationships; (ii) qualitative study of language use in social interaction (e.g. CA or other approaches to discourse); (iii) data-collection i.e. making and subsequent processing of audio and/or video recordings.

References

[1] Sarah Collins et al. “‘Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment.” In: Social Science & Medicine 61 (2005), pp. 2611-2627.
[2] Brian A. Costello and Felicia Roberts. “Medical recommendations as joint social practice.” In: Health Communication 13.3 (2001), pp. 241-260.
[3] Peter Craig et al. “Developing and evaluating complex interventions: The new Medical Research Council guidance.” In: British Medical Journal 337 (2008), pp. 979-983.
[4] John Heritage and Douglas Maynard, eds. Communication in Medical Care: Interactions between Primary Care Physicians and Patients. Cambridge: Cambridge University Press, 2006.
[5] John Heritage and Jeffrey D. Robinson. “‘Some’ vs ‘any’ medical worries: Encouraging patients to reveal their unmet concerns.” In: Applied conversation analysis: Changing institutional practices. Ed. by Charles Antaki. Basingstoke: Palgrave Macmillan, 2011, pp. 15-31.
[6] Pamela L. Hudak, Shannon J. Clark, and Geoffrey Raymond. “How surgeons design treatment recommendations in orthopaedic surgery.” In: Social Science & Medicine 73.7 (2011), pp. 1028-1036.
[7] Christopher J. Koenig. “Patient resistance as agency in treatment decisions.” In: Social Science & Medicine 72.7 (2011), pp. 1105-1114.
[8] Nigel Mathers et al. “Clinical effectiveness of a patient decision aid to improve decision quality and glycaemic control in people with diabetes making treatment choices: A cluster randomised controlled trial (PANDAs) in general practice.” In: BMJ Open 2.6 (2012). Url: http://bmjopen.bmj.com/content/2/6/e001469.
[9] Jack Sidnell and Tanya Stivers, eds. The handbook of conversation analysis. Oxford: Wiley-Blackwell, 2013.
[10] Dawn Stacey et al. “Decision aids for people facing health treatment or screening decisions.” In: Cochrane Database of Systematic Reviews 10 (2011).
[11] Tanya Stivers. Prescribing under pressure: Parent-physician conversations and antibiotics. Oxford: Oxford University Press, 2007.

Summary

Clinicians communicate the risk of treatment options to their patients in a number of ways. They may make use of written materials (e.g. patient decision aids), statistics, graphical representations, verbal descriptions, or some combination of these. This project will look in detail at the organisation of interactions between clinicians and patients with type 2 (maturity onset) diabetes [T2DM] to answer three main questions:

1. How do clinicians communicate the risks of treatment options to patients with T2DM in clinics?
2. Is decisional quality of patients with T2DM related to how clinicians communicate the risks of treatment options in clinics, and if so, how?
3. How is the discussion of risk and other evidence managed in the consultation to reach agreement on treatment decisions?

The principal research method will be Conversation Analysis: a well-established method for rigorous investigation into the structural organisation of social interaction, including clinician-patient interaction. A key part of the project will involve exploring the relationship between what can be observed in the interaction in terms of the behaviour of the clinicians and the patients, and patients’ own reports of decisional quality including the extent to which the patient feels supported in making choices, feels that the choices are well-informed and likely to be implemented, and feels certainty over those decisions. By making links between the communication of risk and decisional quality, this project has the potential to inform future clinical training in straightforward practical ways.

Additional Information

Dr Gareth Walker; Senior Lecturer in Linguistics. First supervisor for 1 PhD (successful completion; lecturer, University of Azad Jammu & Kashmir Muzaffarabad); second supervisor for 3 PhDs (1 successful completion, 2 ongoing); external examiner for 1 PhD (University of Azad Jammu & Kashmir Muzaffarabad); internal examiner for 5 PhDs across 4 departments (English, Human Communication Science, Computer Science, Germanic Studies); MPhil/PhD upgrade panel member for 2 PhDs (English); published research relevant to this project in peer reviewed journals including Journal of Pragmatics, Language & Speech, Phonetica, and Text & Talk; currently editing a special issue of Clinical Linguistics & Phonetics.

Dr Steven Ariss; Research Fellow in Health Services Research. Second supervisor for 2 ongoing PhDs and 1 DMedSci; PhD upgrade examiner for 3 PhDs (ScHaRR); published research on video recordings of primary care consultations in Social Science & Medicine and diabetes specific consultations in Qualitative Health Research; experience of research design including collecting and analyzing audio/visual data in health-care settings; experience in research ethics and governance; active member of ScHaRR Research Ethics Committee; ethics and governance advisor for CLAHRC SY Stroke Research theme; 2 years’ experience working in an NHS R&D unit; strong local and regional connections with health-care services as lead evaluator of CLAHRC SY (and the proposed YH CLAHRC) and evaluator for the YH Academic Health Science Network.