The structure of patients’ presenting concerns: the completion relevance of current symptoms

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Abstract

This article uses conversation analysis to investigate the problem-presentation phase of 302 visits between primary-care physicians and patients with acute problems. It analyzes the social–interactional organization of problem presentation, focusing on how participants recognize and negotiate its completion. It argues that physicians and patients mutually orient to the presentation of current symptoms—that is, concrete symptoms presented as somehow being experienced in the here-and-now—as a locus of transition between the patient-controlled problem-presentation phase of the visit and the physician-controlled information-gathering phase. This is a resource for physicians to distinguish between complete and incomplete presentations, and for patients to manipulate this distinction.

Introduction

Patients visit primary-care physicians for a variety of different types of medical issues, including relatively new acute problems (e.g., injuries, infections, etc.), continuing chronic conditions (e.g., high blood pressure, depression, etc.), and general–physical examinations. At least in the United States and Britain, when patients with acute problems visit primary-care physicians, their communication tends to be organized into six phases: opening (e.g., greeting, sitting down, etc.), problem presentation, information gathering (i.e., history taking and physical examination), diagnosis, treatment, and closing (e.g., leave-taking) (for a review, see Robinson, 2003). This is the second of a series of articles dealing with acute problem presentation in US, primary-care visits (see Heritage & Robinson, in press b).

Problem presentation is typically initiated by physicians with questions, such as What can I do for you today?, and is the only phase in which patients are licensed to present their problems in their own ways and according to their own agendas. This phase is significant for a number of reasons. Apart from the sheer expressive value for patients of presenting medical concerns in their own terms (Roter & Hall, 1992), patients’ expositions of symptoms are associated with improved systolic blood pressure (Orth, Stiles, Scherwitz, Hennrikus, & Vallbona, 1987) and increased visit satisfaction (Stiles, Putnam, Wolf, & James, 1979; cf. Putnam, Stiles, Jacob, & James, 1985). Furthermore, soliciting the full spectrum of patients’ concerns in the early stages of visits can better prepare physicians for diagnosis and treatment (Arborelius, Bremberg, & Timpka, 1991; McWhinney, 1989; Mishler, 1984; Peppiatt, 1992). Despite these implications for patients’ health outcomes, research suggests that patients frequently do not complete problem presentation; that physicians frequently interdict patients’ presentations and ‘prematurely’ or ‘interruptively’ progress to the next phase of information gathering (Beckman & Frankel, 1984; Marvel, Epstein, Flowers, & Beckman, 1999). However, this research by medical scholars and educators has not been based on how physicians and patients show themselves to understand and organize the activity of presenting problems. This article addresses this gap by answering the questions: do physicians and patients mutually orient to a set of norms dealing with the ‘completion’ of problem presentation and, if so, what are they? Stated differently, does problem presentation have an internal social–interactional organization? This organization would be a resource for physicians—and thus for scholars and educators—to distinguish between complete and incomplete presentations, and for patients to manipulate this distinction toward a variety of socio-medical ends.

Previous research suggests that problem presentation is, in fact, socially organized at both the cultural and interactional level. Culturally, patients’ understandings of their illness—which have been variously labeled patients’ illness attributions (Stoeckle & Barsky, 1981), explanatory models (Kleinman, 1980), and differential diagnoses (Bergh, 1998)—partially overlap those of physicians (Bergh, 1998; Helman, 1978). This suggests that physicians and patients have similar ideas about what constitute ‘doctorable’ medical problems (Heritage & Robinson, in press a) and what it means to present them for investigation.

Interactionally, the activity of presenting acute problems is part of a medically institutionalized project of phased activities (i.e., opening, problem presentation, information gathering, diagnosis, treatment, closing), the ordering and functions of which are jointly and independently understood by physicians and patients (Robinson, 2003). Previous research has described: (1) the interactional organization of the phase that precedes problem presentation (i.e., opening; for review and analysis, see Robinson, 1998); (2) how physicians’ questions can ‘frame’ and shape problem presentation (Robinson, in press; Heritage & Robinson, in press b); (3) how contingencies (e.g., legitimacy) associated with classes of acute problems (e.g., new, recurrent, unknown) can shape problem presentation (Heritage & Robinson, in press a); and (4) how the presentation of self diagnoses (vs. just symptoms) can shape physicians’ expectations of patients’ treatment objectives (Stivers, 2002). All of this research suggests that medical activities within acute visits have internal, social–interactional organizations. Missing from this research, however, is an account of the normative organization of problem presentation as a socio-medical activity that shapes participants’ understandings of what is to be presented, how it is to be presented, and what constitutes a complete presentation. Such an account would provide an explanatory framework for the constitution and recognition of social action during problem presentation. Along these lines, Marvel et al. (1999) found a statistically insignificant, 3.9-s differential between presentations in which patients explicitly oriented to being complete (e.g., by saying And that's why I’m here today) and those in which physicians’ merely assumed completion; in both cases, problem presentations ended when physicians began information gathering (e.g., history taking). This indicates that physicians are at least roughly accurate in predicting when patients are complete, which suggests that problem presentation may have a stable social organization.

Patients’ problem presentations emerge with great variation in terms of content, cogency, affective expression, and organization. Physicians can be conceived as monitoring presentations not only for their content, but for their moment of completion. This moment potentially arises toward the end of each of the patients’ sentences, including the very first one. As patients talk, physicians tend to show that they are attending with verbal and/or nonverbal behaviors (e.g., head nods, Okay, Mm hm), which display physicians’ understandings of patients’ talk and thus can encourage or discourage patients’ continuance. Furthermore, physicians may take steps to curtail presentations that are too expansive or invite expansion of ones that are too terse.

This article contends that, independent from other factors that shape it—such as the design of physicians’ opening questions (Heritage & Robinson, in press b)—problem presentation has its own social organization that shapes how physicians solicit problems and how patients present them. This organization facilitates physician–patient coordination in the ongoing management and completion of patients’ presentations. Specifically, this article contends that physicians and patients mutually orient to current symptoms—that is, concrete symptoms presented as somehow being experienced in the here-and-now—as a locus of transition between problem presentation and information gathering. Analogous to the ‘baton-passing’ zone in a relay race, the presentation of current symptoms constitutes a place where patients indicate their willingness to relinquish the interactional floor and physicians tend to take it. This transfer is interactionally negotiated and not always smooth. Physicians can interruptively take the baton too soon; patients can hold onto it too long; patients can offer it several times before it is accepted, and it can be fumbled. Thus, at every point in patients’ presentations, dilemmas of co-construction and coordination can inhabit the interaction. In this context, our aim in describing the social organization of problem presentation is to establish a basis to provide analytically defensible claims of interactional missteps and meaningful characterizations of physician–patient negotiation and co-construction.

Section snippets

Data and method

Data are 302 randomly selected, videotaped visits between patients with acute problems seeing primary-care physicians in community-based clinics in the United States. Data represent 77 physicians and 41 clinics. Visits did not include those in which patients described their problems by physically presenting/displaying them with minimal vocalization (e.g., Look at this); the ‘showability’ of problems affects their presentation, and this will be the subject of a separate article. In all, 191

Analysis

This article argues that problem presentation normatively requires the presentation of current symptoms. Seven forms of evidence are provided: (1) physicians’ opening questions often make reference to current symptoms; (2) physicians and patients frequently treat responses that do not contain current symptoms as incomplete; (3) physicians can treat patients’ arrivals at current symptoms as completing problem presentation; (4) patients may treat physicians’ shifts into information gathering

Discussion

This article examined the activity, or phase, of problem presentation in US, primary-care, acute visits. It qualitatively and quantitatively demonstrated that physicians and patients mutually orient to a set of norms dealing with the ‘completion’ of problem presentation. Specifically, participants understand that current symptoms—that is, concrete symptoms presented as somehow being experienced in the here-and-now— are a required feature of problem presentation and are a locus of transition

Acknowledgement

Research for this paper was supported in part by the Agency for Healthcare Research and Quality: Grant#: RO1 HS10922-03.

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