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Conversation analysis (CA) is well established as a means of exploring the interactional detail of conventional healthcare encounters. It is also becoming increasingly popular in action to CAM. This article outlines the main features of CA, how it can be used in a CAM context, and the type of information it can be expected to reveal. Examples of original CA data obtained from CAM consultations are presented to illustrate the CA method.
INTRODUCTION: This paper introduces medical educators to the field of conversation analysis (CA) and its contributions to the understanding of the doctor-patient relationship. THE CONVERSATION ANALYSIS APPROACH: Conversation analysis attempts to build bridges both to the ethnographic and the coding and quantitative studies of medical interviews, but examines the medical interview as an arena of naturally occurring interaction. This implies distinctive orientations and issues regarding the analysis of doctor-patient interaction. We discuss the CA approach by highlighting 5 basic features that are important to the enterprise, briefly illustrating each issue with a point from research on the medical interview. These features of conversation analytic theory and method imply a systematic approach to the organisation in interaction that distinguishes it from studies that rely on anecdote, ethnographic inquiry or the systematic coding of utterances. CONVERSATION ANALYSIS AND THE MEDICAL INTERVIEW: We then highlight recent CA studies of the "phases" of the internal medicine clinic and the implications of these studies for medical education. We conclude with suggestions for how to incorporate CA into the medical curriculum. It fits with biopsychosocial, patient-centred and relationship-centred approaches to teaching about medical communication.
This study focuses on the assessment and treatment of the conversations of a couple where one partner has aphasia. The assessment and treatment, informed by conversation analysis, are described, and some implications for the relation between language and psychosocial issues discussed.
CONTEXT: The accurate identification and interpretation of germline mutations in mismatch repair genes in colorectal cancer cases is critical for clinical management. Current data suggest that mismatch repair mutations are highly heterogeneous and that many mutations are not detected when conventional DNA sequencing alone is used. OBJECTIVE: To evaluate the potential of conversion analysis compared with DNA sequencing alone to detect heterogeneous germline mutations in MLH1, MSH2, and MSH6 in colorectal cancer patients. DESIGN, SETTING, AND PARTICIPANTS: Multicenter study with patients who participate in the Colon Cancer Family Registry. Mutation analyses were performed in participant samples determined to have a high probability of carrying mismatch repair germline mutations. Samples from a total of 64 hereditary nonpolyposis colorectal cancer cases, 8 hereditary nonpolyposis colorectal cancer-like cases, and 17 cases diagnosed prior to age 50 years were analyzed from June 2002 to June 2003. MAIN OUTCOME MEASURES: Classification of family members as carriers or noncarriers of germline mutations in MLH1, MSH2, or MSH6; mutation data from conversion analysis compared with genomic DNA sequencing. RESULTS: Genomic DNA sequencing identified 28 likely deleterious exon mutations, 4 in-frame deletion mutations, 16 missense changes, and 22 putative splice site mutations. Conversion analysis identified all mutations detected by genomic DNA sequencing--plus an additional exon mutation, 12 large genomic deletions, and 1 exon duplication mutation--yielding an increase of 33% (14/42) in diagnostic yield of deleterious mutations. Conversion analysis also showed that 4 of 16 missense changes resulted in exon skipping in transcripts and that 17 of 22 putative splice site mutations affected splicing or mRNA transcript stability. Conversion analysis provided an increase of 56% (35/63) in the diagnostic yield of genetic testing compared with genomic DNA sequencing alone. CONCLUSIONS: The data confirm the heterogeneity of mismatch repair mutations and reveal that many mutations in colorectal cancer cases would be missed using conventional genomic DNA sequencing alone. Conversion analysis substantially increases the diagnostic yield of genetic testing for mismatch repair mutations in patients diagnosed as having colorectal cancer.
Inaccuracy in reporting dietary intakes is a major problem in managing diet-related disease. There is no single best method of dietary assessment, but the diet history lends itself well to the clinical setting. In many diet histories data are collected orally, so analysis of interviews can provide insights into reporting behaviors. Conversation analysis is a qualitative method that describes the systematic organization of talk between people. Patterns are identified and checked for consistency within and among individual interviews. The aim of this study was to describe consistent ways of reporting diet histories and to identify conversational features of problematic reporting. Diet history interviews from 62 overweight and insulin-resistant adult volunteers (50 women, 12 men) attending an outpatient clinic and 14 healthy volunteers (7 men, 7 women) participating in an energy balance study were audiotaped and transcribed. Conversation analysis identified a remarkably consistent pattern of reporting diet histories and 3 conversational features that indicated problematic reporting: "it depends," denoting variability (least of all at breakfast); "probably," suggesting guesswork (related to portion sizes); and elaborated talk on certain foods, distinguishing sensitive topics (e.g., alcohol, chocolate, butter/margarine, take-out foods) from safe topics. These findings indicate that there are ways in which dietetics practitioners may conduct the diet history interview to foster more accurate reporting.
This paper explores the impact of linguistic impairments on conversational ability in aphasia using conversation analysis (CA). Using a combination of quantitative and qualitative techniques, an analysis of the distribution of turns at talk in three aphasic participants' conversations with a relative and with the researcher is described. Using extracts from the conversations for illustration, three major factors are proposed which influence the sharing of conversational turns: (1) shared knowledge of interlocutors, (2) the manifestations of linguistic impairments in conversation, and (3) individual discourse styles. Finally, the implications of the findings for remediation are considered.
This single case study investigated the use of Conversation Analysis (CA) in assessing pragmatic language difficulties after closed head injury (CHI). The aim was to see if CA captures the types of communication breakdown observed after CHI and whether results from CA can be directly related to scores on formal tests more typically applied after CHI. The results suggested that CA was a sensitive tool for identifying and investigating pragmatic deficits in this case. It facilitated an exploration of whether language impairments identified on formal tests manifest themselves in functional communication; it revealed how different interlocutors adapt to these language difficulties in conversation and also explained why some conversational partners were more successful than others. Considered together, formal test results and CA insights facilitated an in-depth analysis into the precise nature of the communicative impairments of the speaker in this exploratory study, suggesting that CA is a promising approach to the assessment of pragmatic impairments in the CHI population.
PURPOSE: The purpose of this study was to understand conversations and to identify typical conversational problems between nurses and patients with dementia. METHOD: A conversation analysis method was used. The data was collected in a geriatric institutional setting, using a videotape recorder, and transcribed. The transcribed data was analyzed in terms of expressions, contents, and relationships to identify communicative problems and their resolutions. RESULTS: Among a total of 532 episodes, 440(82.7%) were identified as nurse-involved episodes. In addition, 66 of the 440 episodes were selected based on the significance of the conversation. The communicative problems between nurses and patients in terms of expressions were identified as "directive and authoritative expressions", "emotional and competitive expressions", "evasive and on-looking expressions", and "excessive use of title only", such as calling them granny or grandpa without proper names. In terms of content and relationships, "lack of themes in psychosocial areas" and "nurse-led relations" were identified respectively as communicative problems. CONCLUSION: The results of this study will provide substantial guidelines for nurses in caring for elderly patients with dementia by deeply understanding linguistic structures and problems of everyday conversations between nurses and patients with dementia.
The study analysed the dynamics of a mediated medico-legal interview using conversation analysis (CA) as a key methodology. The aim of using CA was to identify both facilitators and inhibitors of a successfully mediated interview, using a detailed microscopic analysis of the dynamics involved. A 45-minute interview with the client's parents, the speech pathologist and the interpreter was tape recorded and analysed according to CA principles. Results revealed several facilitators, including equal and active roles, use of code switching, familiarity between the interviewer and interpreter, and use of repetition. Inhibitors included different agendas, complicated repair trajectories and interruptions. In addition, aspects such as cultural brokerage were identified that could be considered neither as facilitators nor as inhibitors. Each area is discussed in detail using extracts from the transcription.
As governmental priorities worldwide continue to emphasise the inclusion of patients in healthcare consultations, there is a pressing need for a research approach that accurately captures the contribution of both participants within nurse-patient interaction. With this in mind, this paper examines, via selective data extracts, the contribution that conversation analysis (CA) could make to this area of nursing research. In the United Kingdom (UK) over the last two decades, CA has been neglected as a method for exploring nurse-patient communication, and a case is made here for its entry into the mainstream of nursing research. The case is made particularly persuasive in the light of conversation analysts' use of naturally occurring research data, a form of data that is regrettably lacking in much of the published research on nurse-patient interaction.
In this article we challenge a common definition of therapeutic advice as a linear, one-way accomplishment, enacted by therapists toward clients. We also offer a novel conception of advice as a dialogical "performance," to which both therapists and clients contribute. We discuss the results of a conversation analysis of a family therapy session by Karl Tomm, showing sequential practices employed by a family therapist and a family as they jointly work out common ground to set the stage for the therapist's eventual offering of advice. We discuss the results of this study in light of the literature on advice provision in various contexts.
BACKGROUND: It is clear that much of the success of health-care provision depends on the quality of interactions between health professionals and patients. For instance, it is widely recognized that patients are more likely to take medication effectively if they have been involved in discussions about treatment options, and understand and support the decision about what is prescribed (patient concordance). Hence, patient participation is important for the success of medical outcomes. The key is to explore how communicative choices made by health professionals impact on the quality of interactions in general, and of patient participation in particular. However, to date there has not been an appropriate method for investigating this connection or impact. OBJECTIVE: To outline the perspective and method of Conversation Analysis (CA). Developed within sociology and linguistics, CA offers a rigorous method (applicable to large data sets) to the study of interaction in health settings. STRATEGY: The method of CA is illustrated through a review of CA studies of doctor-patient interactions. Two such studies, one from the US and the other from Finland, are reviewed, in order to show how CA can be applied to identifying both forms of patient participation, and the interactional conditions which provide opportunities for patient participation. These studies focus principally on the medical examination and diagnostic stages of the consultation. Further research will examine the forms and conditions of patient participation in decision-making.
BACKGROUND: PEG disruptions during conversions to skin-level gastrostomy devices have been described, but specific risk factors have not been reported. In this study, possible risk factors for tract disruption in a pediatric population were identified, and management of complications described. METHODS: The medical records of patients who underwent gastrostomy conversions during 1994 were reviewed. Statistical analysis was performed using two-tailed student's t test, and risk ratios with 95% confidence limits were calculated. RESULTS: Gastrostomy tract disruption occurred in 6 to 30 (20%) of tube conversions. Complicated and uncomplicated cases did not differ with regard to age, sex, primary or associated diagnoses, pregastrostomy or postgastrostomy nutritional status, tract maturity, or percutaneous gastrostomy tube type. The use of an 18F obturator-type skin-level gastrostomy tube increased the risk for gastric separation 4.8-fold. Tract disruptions were managed by fluoroscopic gastrostomy tube replacement, repeat PEG, or exploratory laparotomy with open gastrostomy. CONCLUSIONS: The use of obturator-type skin-level gastrostomy tubes was associated with an increased risk of tract disruption. Fluoroscopic verification of intragastric placement is warranted after initial conversions to skin-level gastrostomy tubes.
The paper reports a conversation analytical study of patients' responses to interpretations in psychoanalysis. The data come from 27 tape-recorded and transcribed psychoanalytic sessions involving three analyst-patient dyads. The study seeks to facilitate dialogue between conversation analytical (CA) findings and psychoanalytic theory by using CA to describe the practices in and through which the psychoanalytic theory concerning interpretation is realized in actual interactions. Four empirical observations are reported in the paper: (1) The analysts actively pursue a more than minimal response from the patient to their interpretations. (2) A typical extended response to an interpretation involves an elaboration, which is an utterance in which the patient takes up some aspect of the interpretation and continues discussion on that. (3) Even though elaborations convey agreement with the interpretation, they often also involve different degrees of discontinuity with what the interpretation initially aimed at. (4) This discontinuity is sometimes facilitated by the analyst's own actions. These observations invite some specifications in the picture of interpretations provided by psychoanalytic theory.
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The utility of the amide II absorption band at 1537 cm-1 as internal reference for calculation of monomer conversion in urethane dimethacrylates (UDMA)-based dental restorative materials and sealants by means of Fourier transform infrared spectroscopy (FTIR) is demonstrated in this paper.
Composite restorative material has undergone gradual change in composition since its introduction in the 1960's. Early commercial resins were mixtures of BIS-GMA and TEGDMA. Today, these mixtures are still present, but urethane dimethacrylates and large oligomeric structures of BIS-GMA-urethanes exist. Because of these changes in composition, the past methods of calculating monomer conversion by means of infrared spectroscopy may need modification. This research investigates different methods used to formulate calibration curves for determination of monomer conversion by infrared spectroscopy of contemporary commercial composites containing aromatic structures. Conversion calibration procedures using various baseline methods with BIS-GMA, Bisphenol-A/TEGDMA, and a hydrogenated bonding resin were established. Both peak and area infrared absorptions were determined. One particular baseline method proved the best fit to the Beer-Lambert law. Bisphenol-A was found unsuitable as an infrared calibration model for resin composites. The BIS-GMA/TEGDMA calibration model closely simulates conversion values obtained when a hydrogenated commercial resin model was used.
Through analysis of video data of interaction between staff and clients with learning disabilities and limited vocal skills, it was possible to demonstrate that clients used gaze and body orientation to display a readiness that was often not responded to by staff. Yet staff could recognize that readiness from the videos. Video analysis was therefore developed as a medium for education and training where staff were helped to become more aware of strategies for non-vocal communication, which could help them achieve their policies of supporting clients more successfully. The study also allowed development of methodology in the field of services for people with learning disabilities.