In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of “the” EPR needs to be replaced by an “unpacking” of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed (...) individually. Following from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three “models of patienthood” implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship. (shrink)

Objective To study how doctors care for their patients, both medically and as fellow humans, through observing their conduct in patient–doctor encounters. Design Qualitative study in which 101 videotaped consultations were observed and analysed using a Grounded Theory approach, generating explanatory categories through a hermeneutical analysis of the taped consultations. Setting A 500-bed general teaching hospital in Norway. Participants 71 doctors working in clinical non-psychiatric departments and their patients. Results The doctors were concerned about their patients' health and (...) how their medical knowledge could be of service. This medical focus often over-rode other important aspects of the consultations, especially existential elements. The doctors actively directed the focus away from their patients' existential concerns onto medical facts and rarely addressed the personal aspects of a patient's condition, treating them in a biomechanical manner. At the same time, however, the doctors attended to their patients with courteousness, displaying a polite and friendly attitude and emphasising the relationship between them. Conclusions The study suggests that the main failing of patient–doctor encounters is not a lack of courteous manners, but the moral offence patients experience when existential concerns are ignored. Improving doctors' social and communication skills cannot resolve this moral problem, which appears to be intrinsically bound to modern medical practice. Acknowledging this moral offence would, however, be the first step towards minimising the effects thereof. (shrink)

In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of “the” EPR needs to be replaced by an “unpacking” of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed (...) individually. Following from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three “models of patienthood” implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship. (shrink)

The American Journal of Bioethics, Volume 12, Issue 5, Page 18-20, May 2012.

Against the usual paternalism, this article develops the proposition to structure the interaction between the doctor and the patient as an inter-subjective consultation. This means that the "information" of the patient prior to treatment, when "informed consent" is secured, as well as the actual medical treatment would have to be turned into an interaction between two responsible individuals. The "irresponsibility" of this patient, which is supposed to result from his "uninformedness", as is often argued in (...) favour of keeping to paternalism, does not have to lead to an interaction model of prescription and compliance. Even for the interaction with patients who are unable to understand or consent, the concept of dialogical interaction must be maintained counterfactually; it has only to be supplemented by the variant of "tutorial action". The prescriptive model of behaviour is extended by the obligation—even when the doctor is the sole decision maker—of acting in the well-understood self-interest of the patient and, if necessary, of providing evidence for this orientation of the treatment. Thus, the model of dialogical interaction is shown to be the comprehensive model, because it covers the interests of the doctor and of the patient. (shrink)

Introduction: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor–patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. Method: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor–patient consultation occurring simultaneously. Results: Each question of (...) all 100 questionnaires was completed. 58% of patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. Discussion: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics. (shrink)

Doctor-patient interaction has gained increasing attention among sociologists and linguists during the last few decades. The problem with the studies performed so far, however, has been a lack of a theoretical framework which could bring together the various phenomena observed within medical consultations. Mikhail Bakhtin's philosophy of language offers us tools for studying medical practice as socio-cultural semiotic phenomenon. Applying Bakhtin's ideas of polyphonic, context-dependent and open-ended nature of human communication opens the possibilities to develop prevailing theoretical and (...) empirical approaches to the study of medical consultations. (shrink)

Pragmatic presupposition is analyzed in this paper as grounded on an implicit reasoning process based on a set of presumptions, which can define cultural differences. The basic condition for making a presupposition can be represented as a reasoning criterion, namely reasonableness. Presuppositions, on this view, need to be reasonable, namely as the conclusion of an underlying presumptive reasoning that does not or may not contain contradictions with other presumptions, including the ordering of the hierarchy of presumptions. Presumptions are in turn (...) analyzed considering their nature and their hierarchy, namely their object and their possible contextual backing, which eliminates some of their possible defaults. This analysis of presupposition brings to light the relationship between communicative infelicities or misunderstandings deriving from presuppositional failures and the underlying system of presumptions and presumptive reasoning. This approach can be applied to the investigation of communicative problems within the medical context, and more precisely the communication in diabetes cases. (shrink)

The article focuses on talk and cognition in terms of action. It outlines methodological alternatives for approaches addressing meaning construction and the accounts people give of their actions. There are studies, rooted especially in phenomenology and ethnomethodology, that manifest the idea of intersubjective reality seen as achievements of situated actions. In this framework, conversation and communication are seen per se as significant forms of social action. Instead of intersubjective reality, often brought about with an inductive research method, the article argues (...) for instrumental reality as the context for understanding talk and cognition in terms of action. The aim is a method that studies multivoicedness of activity in terms of situated actions. The method integrates situational features in dialogue with the cultural-historical processes of meaning construction. It is based on the theoretical notion of activity as a system that emerges and changes in time and place through internal contradictions. In the context of instrumentality, dialogical processes are also considered historically emerging and internally conflicting processes of rationality. I discuss this method with data on conversations between a patient and a doctor at a primary health care consultation. The study considers medical knowledge less as a substance than as a historically produced perspective through which the rationality of problem solving is accomplished by doctor and patient. The study aims to break away from the epistemological dualism of conflicting domains of meaning: the one of medicine that is objective and the one of experience that is subjective. The context of instrumentality includes a working hypothesis of a zone of proximal development of the doctor-patient relationship. (shrink)

General practice consultation has often been characterized by pragma-dialecticians as an argumentative activity type. These characterizations are typically derived from theoretical insights and qualitative analyses. Yet, descriptions that are based on quantitative data are thus far lacking. This paper provides a detailed account of the development of an instrument to guide the quantitative analysis of argumentation in doctor–patient consultation. It describes the implementation and preliminary results of a content analysis of seventy videotaped medical consultations of which (...) the extent and type of doctors’ argumentative support for medical opinions and advice are analyzed. Based on the study results, this paper addresses the merits of observational studies using content analysis as a method for the analysis of argumentative discourse in context as well as some of its key challenges and limitations, laying bare the opportunities for future research. (shrink)

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little (...) attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician. -/- Critical to a proper appreciation of the significance of this conflict is a distinction that the literature on biomedical ethics has largely failed to draw: that between medical paternalism and physician integrity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lisa’s StoryLisa P. (wife of patient) and Jeanne KerwinMy husband suffered from sudden onset of heart failure with a very low ejection fraction and was on IV Milrinone at the age of 47. One of the most powerful things he told me was that he was not afraid to die and therefore did not want to move forward with Milrinone. He eventually “did it for the kids.” After (...) the Milrinone drip was no longer working, he was offered an LVAD (left ventricular assist device) to keep him alive. He refused, but the doctor again convinced him to “do it for your kids” and said, “we put these devices in 80-year-olds.” He did not have time to explore any other options and reluctantly accepted the LVAD. It was implanted in May of 2014 in a very long and complicated surgery with a long and difficult recovery. He was in the hospital for a long time, and then he refused to go to rehab upon discharge, making it difficult for our family to manage, as he was extremely weak and needed care of his wound dressing. He worried about the financial [End Page 7] impact of a heart transplant and the medications required, as we were already struggling with the medical bills. He refused to have more surgery with the potential complications and never agreed to get on the transplant waiting list.After the implanted LVAD, my husband was not able to do most of what he loved in life. He couldn’t work (he was a truck driver), he couldn’t go fishing or swimming in the ocean, he couldn’t go hunting and fishing, and his overall physical condition was so poor that he couldn’t cook, garden and, most aggravating to him, he could not take a regular hot shower. The LVAD had to be covered with plastic in order to avoid getting the drive-line area wet, so bathing was a complicated process. He had trouble with stairs, had neuropathic pain in his legs from diabetes, and because of the pain medications, he felt cloudy and dizzy and slept most of the day in his recliner. I took care of him, even after I had to go back to work, and at the same time, I managed our two children (ages 9 and 12 at the time of LVAD).After almost two years of living with the LVAD, multiple hospitalizations for GI bleeds then seizures, more medications, and weekly blood draws for INR1, my husband requested that the LVAD be de-activated and that he be allowed to die of his heart failure. He described his life as “miserable.” He watched as his misery impacted his children and me. He suffered daily and had none of the joys that made life worth living for him. When we approached the cardiac team that implanted and monitored his LVAD with his request, they said “no.” They would not de-activate the LVAD because it was working. It was keeping him alive and he had no other terminal illness. His palliative doctor, who was treating his pain, also heard his request and told us to call for an “ethics consult” to determine if he would be “allowed” to have the LVAD de-activated. We got the number and called on March 31, 2016.At the time of the call to Ethics, we had no idea what “Ethics” was, other than a general definition of the word ethics as in professional behaviors and such. We did not know what to expect but we called. We would never have known to call “Ethics” if the palliative doctor had not advised us to do so, and my husband might have suffered a longer, more painful life both mentally and physically prolonged by the LVAD.We explained the request to the ethics consultant. She listened to my husband describe his daily living and his dissatisfaction with the quality of his life, his physical and emotional suffering, and his wish to rid himself of the LVAD and allow nature to take its course. There was actually no decision to be made on his part. He had already made up... (shrink)

The Clinical ethics centre in Paris offers its services equally to doctors and patients/proxies. Its primary goal is to re-equilibrate doctor–patient roles through giving greater voice to patients individually in medical decisions. Patients are present at virtually all levels, initiating consults, providing their point of view and receiving feedback. The implications of patients' involvement are threefold. At an operational level, decision-making is facilitated by repositioning the debate on ethical grounds and introducing a dynamic of decisional partnership, although contact (...) with patients can make it difficult to deny their demands and set the limits of our role. Ethically, it reinforces patients' autonomy and grants them a place of veritable ethics ‘actors’, with the danger that this may become excessively autonomy oriented. Finally, at a collective level, the programme fulfils its political purpose in promoting patients' rights and the ideal of démocratie sanitaire, but complicates balancing individual demands with collective values. (shrink)

Throughout the 20th century, many doctors did not view pain management as an important aspect of their practice. Because pain cannot be objectively measured by the doctor, many doctors found it dif...

Background: Ethics consultation is used regularly by some doctors, whereas others are reluctant to use these services.Aim: To determine factors that may influence doctors to request or not request ethics consultation.Methods: A survey questionnaire was distributed to doctors on staff at the University Community Hospital in Tampa, Florida, USA. The responses to the questions on the survey were arranged in a Likert Scale, from strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree to strongly agree. Data were (...) analysed with the Wilcoxon test for group comparisons, the χ2 test to compare proportions and a logistic regression analysis.Results: Of the 186 surveys distributed, 121 were returned, giving a 65% response rate. Demographic data were similar between the groups saying yes and no . No statistically significant differences were observed between the user and non-user groups in terms of opinions about ethics consultants having extensive training in ethics or participating in ethics educational opportunities. On the issue “Ethics committee members or consultants cannot grasp the full picture from the outside”, the non-users were neutral, whereas the users somewhat disagreed . Even more significant was the difference between surgeons and non-surgeons, where, by logistic regression analysis, surgeons who believed that ethics consultants could not grasp the full picture from the outside were highly likely to not use . Non-users of ethics consultations thought that it was their responsibility to resolve issues with the patient or family . Users of ethics consultation believed in shared decision making or the importance of alternate points of view .Implications: Ethics consultations are used by doctors who believe in shared decision making. Doctors who did not use ethics consultation tended to think that it was their responsibility to resolve issues with patients and families and that they were already proficient in ethics. (shrink)

In most U.S. jurisdictions, clinicians providing informal “curbside” consults are protected from medical malpractice liability due to the absence of a doctor-patient relationship. A recent Minnesota Supreme Court case, Warren v. Dinter, offers the opportunity to reassess whether the majority rule is truly serving the best interests of patients.

BackgroundPatient-centred care and patient autonomy is one of the key factors to better quality of service provision, hence patient outcomes. It enables the development of patients’ trusts which is an important element to a better doctor-patient relationship. Given the increasing number of patient disputes and conflicts between patients and doctors in Chinese public hospital, it is timely to ensure patient-centred care is fully and successfully implemented. However, limited studies have examined the views and practice (...) in different aspects of patient-centred care among doctors in the Chinese public hospitals.MethodsA quantitative approach was adopted by distributing paper-based questionnaires to doctors and patients in two hospitals (Level III and Level II) in Jinan, Shandong province, China.ResultsIn total, 614 doctors from the surgical and internal medicine units of the two hospitals participated in the survey yielding 90% response rates. The study confirmed the inconsistent views among doctors in terms of their perception and practice in various aspects patient-centred care and patient autonomy regardless of the hospital where they work (category II or category III), their unit speciality (surgical or non-surgical), their gender or seniority. The high proportion of doctors (more than 20%) who did not perceive the importance of patient consultation prior to determining diagnostic and treatment procedure is alarming. This in in part due to the belief held by more than half of the doctors that patients were unable to make rational decisions and their involvement in treatment planning process did not necessarily lead to better treatment outcomes.ConclusionThe study calls for the development of system level policy and organisation wide strategies in encouraging and enabling the practice of patient-centred care and patient autonomy with the purposes of improving the quality of the service provided to patients by Chinese hospitals. (shrink)

Background This study was designed to investigate how patient-reported shared decision-making relates to other aspects of patient centredness and satisfaction. Methods Questionnaire study with patients. Consecutive patients in primary care responding post visit. Associations are presented as proportions, positive predictive values, with 95% confidence intervals. Results 223 patient questionnaires were included. 62% (95% Confidence interval (CI): 55–69) of the patients indicated the highest possible rating of being involved in the decisions about their ongoing care (self-reported SDM). Self-reported (...) SDM had a positive predictive value (PPV) of between 85% (CI: 77–90) and 95% (CI: 90–98) for five other patient-centred aspects and satisfaction. Conclusion The results suggest that shared decision making is the patient-centred aspect hardest to achieve and that a patient-centred process leading up to the decision-making increases the chance of the patient being involved in the decision-making. (shrink)

Background: Current practice relies on patient-designated and next-of-kin surrogates, in consultation with clinicians, to make treatment decisions for patients who lose the ability to make their own decisions. Yet there is a paucity of data on whether this approach is consistent with patients' preferences regarding who they want to make treatment decisions for them in the event of decisional incapacity. Methods: Self-administered survey of patients at a tertiary care center. Results: Overall, 1169 respondents completed the survey (response rate (...) = 59.8%). Of the 229 respondents who had previously designated a surrogate, 78.2% wanted their surrogate to make treatment decisions in the event of decisional incapacity, whereas 21.8% wanted their doctors to make treatment decisions. Of the 822 respondents who had not designated a surrogate, 66.1% wanted their family to make treatment decisions, whereas 33.9% wanted their doctors to make treatment decisions. The most common explanation provided for why respondents wanted their surrogate or family to make treatment decisions for them in the event of decisional incapacity was the belief that loved ones knew the patient's treatment preferences. Conclusions: Contrary to current practice, 33.9% of respondents who had not designated a surrogate and 21.8% of those who had designated a surrogate indicated that they wanted their doctors to make treatment decisions for them in the event of decisional incapacity. Moreover, many of those who wanted their surrogates or family members to make treatment decisions explained this preference by citing a belief that loved ones knew the patient's treatment preferences. This belief is undermined by prior research that suggests that surrogates and family members frequently are unable to predict which treatments their charges would want. Future research should assess these two concerns with current practice and, where necessary, identify approaches to address them. (shrink)

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system–paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide ‘high-value, cost-conscious care’ (HVCCC), which proponents believe is the future of sustainable (...) medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors’ professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients–redefining the currency of value from monetary costs to a patient’s quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation. (shrink)

Title III of the Americans with Disabilities Act (ADA) grants people with disabilities access to public accommodations, including the offices of medical providers, equal to that enjoyed by persons without disabilities. The Department of Justice (DOJ) has unequivocally declared that the law requires effective communication between the medical provider and the Deaf patient. Because most medical providers are not fluent in sign language, the DOJ has recognized that effective communication calls for the use of appropriate auxiliary aids, including sign (...) language interpreters. The final decision on what to offer the Deaf patient is the doctor's, and under current DOJ regulations, the doctor does not have to consult with the patient or give "primary consideration" to the patient's choice of auxiliary aid as long as what the doctor offers results in effective communication. However, given the great variation in people's communication styles and skills, a standard, one-size-fits-all auxiliary aid would fail to achieve effective communication in many cases, harming not only that Deaf patient, but also the medical provider, who would be potentially liable for violating the ADA as well as hamstrung in getting accurate information for purposes of diagnosis and treatment. Moreover, most doctors are not savvy about Deafness and Deaf culture. Thus, the best way to ensure effective communication would be to require the medical provider to ask the Deaf patient for his or her choice of auxiliary aid and to give "primary consideration" to the patient's expressed choice of auxiliary aid. Such an approach is required under Title II of the ADA, which makes it mandatory for state and local governments to consult with people with disabilities and give "primary consideration" to the patient's choice of auxiliary aid. Given that there is no difference between a public doctor and a private doctor that would justify the two different approaches and that cost is not a factor, since under either title, a medical provider cannot pass on the costs to the person with a disability, the DOJ should revise its interpretation of Title III in order to bring in into line with its interpretation of Title II. To fail to do so would operate to frustrate both the letter and the spirit of the ADA. Until the DOJ brings the titles into line, the courts should decline to give controlling weight to the DOJ's interpretation of Title III. (shrink)

There is an increasing recognition internationally of the critical impact of communication within healthcare. The link between ineffective communication, patient dissatisfaction and critical incidents is well established. Family Planning New South Wales has sought to address patient-centred care and communication in its policy platform. This article reports on research conducted within FPNSW, which analysed the discourse features that constituted effective doctor–patient1 communication in sexual and reproductive health consultations. The principal aim of the research was to understand how (...) effectively messages were conveyed and received and to what degree patients were active participants in their own sexual healthcare. Analysed consultations were characterised by extremely high levels of communicative competence on the part of the doctors who integrated medical expertise with the development of interpersonal relationships with patients, thus positioning patients as active contributors to the consultations and to decisions about their ongoing treatment. The detailed linguistic analysis identified characteristic features of patient-centred communication that are essential to patient-centred care. These interactions demonstrate that communicating care is just as important as delivering care and involves a drawing together of the medical and the interpersonal in consultations. The article details strategies for interweaving medical knowledge and establishing rapport that can inform practitioner communication practices across different healthcare contexts. (shrink)

Argumentation can play an important role in medical consultation. A doctor could, for instance, argue in support of a treatment advice to overcome a patient’s hesitance about it. In this argumentation, the doctor might explicitly present him- or herself as an authority, thereby presenting an argument by authority. Depending on the specific conditions under which the doctor advances such an argument, the doctor’s argument by authority can constitute a sound or a fallacious contribution to (...) the discussion. In this paper, I shall determine what the specific soundness conditions are that apply to a doctor’s argumentation by authority in medical consultation. Keywords: medical consultation, pragma-dialectical analysis, soundness condition, argument by authority, doctor-patient communication. (shrink)

While online medical consultations have become increasingly popular, not least in times when epidemics make access to medical facilities difficult, research exploring the interactive value of OMC is still in its infancy. This study examines patients’ disalignment with speculative diagnosis and its management by doctors in OMC interactions, which to my best knowledge are not examined. From a discourse analytic perspective, this study adopts Du Bois’s notion of stance-taking to approach text-based interactions collected from a widely used OMC website in (...) China. This study finds that patients’ disalignment is often based on hard evidence, which is different from the major findings of previous studies. When addressing such disalignment, doctors adopt varied discursive strategies, which are hardly mentioned in prior studies, in particular, strategies that address the affective aspect of patients’ disalignment. This study thus provides a different perspective on disalignment and its management in the clinical context. (shrink)

When natural time sequences were replaced by clocks, time became a measurable commodity and the ‘speedy use of time’ a virtue. In medical practice shorter consultations allow more patients to be seen, whereas longer consultations result in a better understanding of the patient and her problems. Crossing the line of time-efficiency and time-effectiveness compromises the balance between short-term turnover and long-term outcomes. The consultation has all the hallmarks of a complex adaptive system whose characteristics are not determined by (...) the characteristics of the components, but by the patterns of interaction among the components. Systems are dynamic and change over time; the dynamic nature is not incidental, but necessary as complex systems operate at conditions far from equilibrium. The central notion when we talk of time and complexity is that of ‘memory’. Memory is carrying something from the past over into the future. Memory is filtered/interpreted, separating noise from information. Memory therefore is not an instantaneous thing, it takes time to develop; it is slow. The dynamics between the participating agents in the consultation will create shared memories that live on to shape future interactions. Shared memories are stronger and contain more relevant knowledge if they are based on frequent interactions and ongoing doctor–patient relationships, leading to a better understanding of the whole person – a process that takes time. Sufficient time, that is, ‘a certain slowness’, is an essential element of the healing relationship in the consultation. It creates a sufficiently stable, but adaptive, environment that can withstand changing demands. Hence a more complete understanding of the consultation and its time demands will not only lead to more effective treatment, it will also humanize a situation which has become to a large extent purely instrumental. This process of humanization is important not only for the patient, but also for the doctor. (shrink)

_Just Doctoring_ draws the doctor-patient relationship out of the consulting room and into the middle of the legal and political arenas where it more and more frequently appears. Traditionally, medical ethics has focused on the isolated relationship of physician to patient in a setting that has left the physician virtually untouched by market constraints or government regulation. Arguing that changes in health care institutions and legal attention to patient rights have made conventional approaches obsolete, Troyen Brennan (...) points the way to a new, more aware and engaged medical ethics. The medical profession is no longer isolated, even theoretically, from the liberal, market-dominated state. Old ideas of physician beneficence and altruism must make way for a justice-based medical ethics, assuming a relationship between equals more compatible with liberal political philosophy. Brennan offers clinical examples of many of today's most challenging medical problems—from informed consent to care rationing and the repercussions of the HIV epidemic—and gives his recommendation for a new ethical perspective. This lively and controversial plea for a rethinking of medical ethics goes right to the heart of medical care at the end of the twentieth century. (shrink)

The latest book is a timely application of the Pragma-Dialectical argumentative approach to medical consultation. The book consists of six chapters, which are concerned with topics pertaining to resolving differences of the opinion in doctor-patient interaction. With the publication of the book, the authors have made new contributions to the field of doctor-patient argumentative discourse.

High-quality doctor-patient communication in end-of-life care results in better quality of life for patients. In linguistically and culturally diverse societies, language discordant consultations become daily practice, leading to difficulties in eliciting patient preferences toward end-of-life care. Although family members invariably act as informal interpreters, this may cause some ethical dilemmas. We present a case of a palliative patient whose son acted as an interpreter. This case generated a triple- layered ethical dilemma: how to safeguard patient (...) autonomy against paternalistic interventions by family members, how to respect the relational context in which patient autonomy can be realized, and how to respect the ethno-cultural values of the patient and his family. These issues are being discussed and reflected upon within the framework shared decision making involving informal- and professional interpreters. The complementary use of professional interpreters next to family members acting as informal interpreters is recommended. (shrink)

In recent years, the model of shared decision-making has become increasingly promoted as the preferred standard in doctor-patient communication. As the model considers doctor and patient as coe-qual partners that negotiate their preferred treatment options in order to reach a shared decision, shared de-cision-making notably leaves room for the usage of argumentation in the context of medical consultation. A paradigm example of argumentative conflict in consultation is the discussion that emerges between doctors and their (...) patients concerning antibiotics as a method of treatment for what is presumed to be a viral infec-tion. In this paper, a case of such argumentative conflict is studied, using the extended pragma-dialectical theory to argumentation. It is examined how a patient and her physician manoeuvre strategically in order to maintain a balance between dialectical reasonableness and rhetorical effectiveness, as well as an equilibri-um between patient participation and evidence-based medication, while arguing their case for and against antibiotics respectively. (shrink)

Over the past decade, the ideal model of shared decision-making has been increasingly promoted as the preferred standard of doctor-patient communication in medical consultation. The model advocates a treatment decision-making process in which the doctor and his patient are considered coequal partners that carefully negotiate the treatment options available in order to ultimately reach a treatment decision that is mutually shared. Thereby, the model notably leaves room for—and stimulates—argumentative discussions to arise in the context of (...) medical consultation. A paradigm example of a discussion that often emerges between doctors and their patients concerns antibiotics as a method of treatment for what is presumed to be a viral infection. Whereas the doctor will generally not encourage treatment with antibiotics, patients oftentimes prefer the medicine to other methods of treatment. In this paper, two cases of such antibiotic-related discussions in consultation are studied using insights gained in the extended pragma-dialectical theory to argumentation. It is examined how patient and physician maneuver strategically in order to maintain a balance between dialectical reasonableness and rhetorical effectiveness, as well as an equilibrium between patient participation and evidence-based medication, while arguing a case for and against antibiotics respectively. (shrink)

The global crisis of the COVID-19 pandemic has considerably accelerated the adoption of teleconsultation—a form of consultation between patient and health care professional that occurs via videoconferencing platforms. For this reason, it is important to investigate the way in which this form of interaction modifies the nature of the clinical encounter and the extent to which this modification impacts the healing process. For this purpose, I will refer to insights into the clinical encounter as a face-to-face encounter drawn (...) from the phenomenology of medicine (R. Zaner, K. Toombs, E. Pellegrino). I will also take into account a criticism that has been expressed by various contemporary phenomenologists (H. Dreyfus, T. Fuchs, L. Dolezal, H. Carel), namely, that due to the lack of physical proximity to the other in all types of online encounters, such encounters lack significant features that are present in face-to-face encounters, with the most important of these being the possibility of attaining an empathetic perception of the other and a sense of embodied risk. As these elements are essential features of the clinical encounter, the aim of this paper is to determine whether teleconsultation exhibits these features. To do that, I will integrate phenomenological philosophy with qualitative research drawing materials from both the philosophical tradition, particularly with respect to the concepts of the face-to-face encounter and embodied risk (A. Schutz and H. Dreyfus), and qualitative research study regarding patient experiences of teleconsultation. I will argue that teleconsultation does involve both the possibility of perceiving the other empathetically and the possibility of experiencing a sense of embodied risk. (shrink)

A cross-sectional study to ascertain what the Singapore population would regard as material risk in the anaesthesia consent-taking process and identify demographic factors that predict patient preferences in medical decision-making to tailor a more patient-centered informed consent. A survey was performed involving patients 21 years old and above who attended the pre-operative evaluation clinic over a 1-month period in Singapore General Hospital. Questionnaires were administered to assess patients’ perception of material risks, by trained interviewers. Patients’ demographics were obtained. (...) Mann–Whitney U test and Kruskal-Wallis one-way analysis of variance was used. Statistical significance was taken at p < 0.05. Four hundred fourteen patients were eligible of which 26 refused to participate and 24 were excluded due to language barrier. 364 patients were recruited. A higher level of education, being employed and younger age group are factors identified in patients who wanted greater participation in medical decisions. Gender, marital status, type of surgery, and previous surgical history did not affect their level of participation. The complications most patients knew about were Nausea, Drowsiness and Surgical Wound Pain. Patients ranked Heart Attack, Death and Stroke as the most significant risks that they wanted to be informed about in greater detail. Most patients wanted to make a joint decision with the anaesthetist, instead of letting the doctor decide or deciding for themselves. Discussion with the anaesthetist is the preferred medium of communication compared to reading a pamphlet or watching a video. Age and educational level can influence medical decision-making. Despite the digital age, most patients still prefer a clinic consult instead of audio-visual multimedia for pre-operative anaesthetic counselling. The local population appears to place greater importance on rare but serious complications compared to common complications. This illustrates the need to contextualize information provided during informed consent to strengthen the doctor-patient relationship. (shrink)

Without any warning, in September 1999, David Newman was told he had a rare and life-threatening tumor in the base of his skull. In the compressed space of five weeks, he consulted with leading physicians and surgeons at four major medical centers. The doctors offered drastically differing opinions; several pronounced the tumor inoperable and voiced skepticism about the effectiveness of any nonsurgical treatment. _Talking with Doctors_ is the story of Newman's efforts, at a time of great stress and even impending (...) death, to wend his way through the dense thicket of medical consultations in search of a physician and a treatment that offered the possibility of survival. It is the story, especially, of the harrowing process of assessing conflicting "expert" opinions and, in so doing, of making sense of the priorities, personalities, and vulnerabilities of different doctors. All too often, he found, the leading specialists to whom he was sent were strangers in the consulting room-and strangers who became stranger still, both cognitively and emotionally, when ambiguous findings pushed them to the outer limits of their training and experience. Newman writes poignantly of his sense of powerlessness and desperation, of the painstaking means by which he ascertained what could be known about his tumor, and of the fortuitous events that finally led him to life-saving help. _Talking with Doctors_ is a compelling, absorbing, unsettling story that touches a collective raw nerve about the experience of doctors and medical care when life-threatening illness leads us to subspecialists at major medical centers. Probing the nature of medical authority and the grounds of a trusting doctor-patient relationship, Newman illuminates with grace and power what it now means for a patient to participate in life-and-death medical decisions. (shrink)

Empathy is an important way for doctors to demonstrate their understanding of patients’ subjective experiences. This research considers the role of empathy in 37 doctor–patient palliative or end-of-life care consultations recorded in a hospice. Specifically, it focuses on four contexts in which there is a disparity between patients’ displayed experience of their illness and the doctor’s biomedical, expertise-driven perspective on their illness. These include cases in which the patient is sceptical of the medical perspective, cases in (...) which the patient’s expectations exceed what can realistically be provided and cases in which patients have an overly pessimistic view of their condition. The analysis shows how doctors can use empathic statements to display that they are attentive to the patient’s subjective experience even when the task at hand is, ostensibly, an expertise-driven, biomedical one. It thus demonstrates that empathy is of importance throughout palliative care consultations, even in those phases which might seem biomedical or task-driven. (shrink)

Ethics consultation at the bedside has been hailed as a better way than courts and ethics committees to empower patients and make explicit the value components of treatment decisions. But close examination of the practice of ethics consultation reveals that it in fact risks subverting those ends by interpolating a third (expert) party into the doctor-patient encounter. In addition, the practice of bioethics through consultation does the broader cultural work of fashioning a shared moral order (...) in the face of manifestly plural individual commitments. In doing so, however, bioethics furthers medicine's position as a privileged domain of public moral discourse in contemporary American society. (shrink)

Context The attitudes of medical professionals towards physician assisted dying have been widely discussed. Less explored is the level of agreement among physicians on the possibility of ‘rational suicide’—a considered suicide act made by a sound mind and a precondition of assisted dying legislation. Objective To assess attitudes towards rational suicide in a representative sample of senior doctors in England and Wales. Methods A postal survey was conducted of 1000 consultants and general practitioners randomly selected from a commercially available database. (...) The main outcome of interest was level of agreement with a statement about rational suicide. Results The corrected participation rate was 50%; 363 questionnaires were analysed. Overall 72% of doctors agreed with the possibility of rational suicide, 17% disagreed, and 11% were neutral. Doctors who identified themselves as being more religious were more likely to disagree. Some doctors who disagreed with legalisation of physician assisted suicide nevertheless agreed with the concept of rational suicide. Conclusions Most senior doctors in England and Wales feel that rational suicide is possible. There was no association with specialty. Strong religious belief was associated with disagreement, although levels of agreement were still high in people reporting the strongest religious belief. Most doctors who were opposed to physician assisted suicide believed that rational suicide was possible, suggesting that some medical opposition is best explained by other factors such as concerns of assessment and protection of vulnerable patients. (shrink)

BackgroundSelf-prescribing and prescribing to personal contacts is explicitly discouraged by General Medical Council guidelines.AimsThis study examines how widespread the practice of self-prescribing and prescribing to personal contacts is.MethodsA 16-item questionnaire was distributed via an online forum comprising 4445 young medical doctors (representing 20% of all Irish registered doctors), which asked respondents about previous prescribing to themselves, their families, friends and colleagues, including the class of medication prescribed. Demographic details were collected including medical grade and specialty.ResultsA total of 729 responses were (...) obtained, the majority of which were from young non-consultant hospital doctors from a range of specialties. Two-thirds of respondents had self-prescribed, over 70% had prescribed to family, and nearly 60% had prescribed to a friend or colleague. Older doctors were more likely to self-prescribe (χ2=17.51, p<0.001). Interns being less likely to self-prescribe was not unexpected (χ2=69.55, p<0.001), while general practitioners (GPs) and paediatricians were more likely to self-prescribe (χ2=13.33, p<0.001;χ2=11.35, p<0.001). GPs, paediatricians and hospital medicine specialties were more likely to prescribe to family (χ2=5.19, p<0.05;χ2=8.38, p<0.05;χ2=6.17, p<0.05) and surgeons were more likely to prescribe to friends (χ2=15.87, p<0.001). Some 3% to 7% who had self-prescribed had prescribed an opiate, benzodiazepine or psychotropic medication. Male doctors, anaesthetists and surgeons were more likely to self-prescribe opioids (χ2=7.82, p<0.01;χ2=7.31, p<0.01;χ2=4.91, p<0.05), while those in hospital medicine were more likely to self-prescribe psychotropic medications (χ2=5.47, p<0.05).ConclusionPrescribing outside the traditional doctor-patient relationship is widespread despite clear professional guidance advising against it. (shrink)

_Just Doctoring_ draws the doctor-patient relationship out of the consulting room and into the middle of the legal and political arenas where it more and more frequently appears. Traditionally, medical ethics has focused on the isolated relationship of physician to patient in a setting that has left the physician virtually untouched by market constraints or government regulation. Arguing that changes in health care institutions and legal attention to patient rights have made conventional approaches obsolete, Troyen Brennan (...) points the way to a new, more aware and engaged medical ethics. The medical profession is no longer isolated, even theoretically, from the liberal, market-dominated state. Old ideas of physician beneficence and altruism must make way for a justice-based medical ethics, assuming a relationship between equals more compatible with liberal political philosophy. Brennan offers clinical examples of many of today's most challenging medical problems—from informed consent to care rationing and the repercussions of the HIV epidemic—and gives his recommendation for a new ethical perspective. This lively and controversial plea for a rethinking of medical ethics goes right to the heart of medical care at the end of the twentieth century. (shrink)

Clinical bioethics plays a significant role in hospital settings through bioethics consultations, which focus on providing ongoing assistance in complex situations within the doctor-patient dynamic. These consultations entail regular interaction between physicians and clinical bioethicists. This situation prompts an exploration into how bioethics consultations affect physicians. The current research aims to understand the influence of bioethics consultations on physicians’ bioethical knowledge by analyzing the lexical content in their patients’ medical records. Medical records are a synthesis carried out by (...) physicians, often reflecting collaborative efforts, and capturing verbal statements indicative of thought processes suggestive of learning. The study is a sequential mixed-methods design with a retrospective descriptive approach, comparing medical records from the early years of the Department of Humanism and Bioethics’ operation (2013–2015) to the more recent ones (2019). Technical bioethical terminology such as “therapeutic effort limitation,” “futility,” “beneficence,” and “respect for autonomy” is more prevalent in recent medical records. This trend may stem from the positive impact of bioethics consultations conducted by the Department, with haptic communication serving as a particularly effective form of interaction with others during experiences of moral distress. This appears to be characteristic of cultures like those in Latin America. (shrink)

In recent years, the opioid crisis in the United States has sparked significant discussion on doctor–patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic (...) resources when describing chronic pain, narrating symptoms and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions. (shrink)

BackgroundThe principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations.Material & MethodThe study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was (...) observed through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors.ResultsSome degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors.ConclusionObservance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics. (shrink)