Doctor–patient interaction in a randomised controlled trial of decision-support tools
Introduction
In the social sciences, the world of experiments and the world of qualitative research have an uneasy relationship. The MRC (see Campbell et al., 2000) has recently argued that experimental trials of complex interventions should have a qualitative component. Currently, qualitative research is most commonly used in the piloting and development stages (e.g. Donovan et al., 2002), especially to understand and increase patient and clinician recruitment and retention (e.g. Ford, Havstad, & Tilley, 2003; Hepworth, Paine, Miles, Marley, & MacLennan, 2002; Mohanna & Tunna, 1999). In this way, evidence from qualitative research has been used to smooth the design of interventions (and the tools used to measure the outcomes of the interventions) and to better populate trials with experimental subjects. Albeit for good reasons, understandings of the effectiveness of interventions have been given in the language of statistics. However, qualitative research that describes and interprets the dynamics of the range of processes that occur within experimental trials of complex interventions can also contribute to our understanding of the effectiveness of such interventions.
Our research aimed to understand how randomised controlled trials (RCTs) and decision-support tools shape and are shaped by the interactional features of consultations. In this paper, we draw on the analytic perspectives of ethnomethodology (Garfinkel, 1967) to explore doctor–patient encounters in an experimental trial of a complex intervention—an efficacy RCT of decision-support tools. We show how the experimental context in which these encounters take place pervades the interactions within them. We focus on the interactional orders that the participants orientate to and reflexively produce in and through their actions. We argue that two interactional orders are at work in the encounters that we observed: (i) the ceremonial order of the consultation and (ii) the assemblage of the decision-support tool trial. Before going on to discuss the background and context for our work, we first need to explain what we are referring to by these terms.
The ceremonial order of the everyday consultation is richly described in a range of studies of doctor–patient interaction in many different contexts (see, e.g. Armstrong, 1985; Heath, 1986; Mishler, 1984; Silverman, 1987). It depends on asymmetries of knowledge and practice—in which the doctor embodies the epistemological authority of medicine—against which backgrounds patients are seen to either consent or conflict. The assemblage of the decision-support tool trial refers to a combination of two other interaction orders that are also at work in this context. Firstly, the decision-support tools themselves produce a specific order of practice as they require specific forms of information to be collected, that this information be entered into the appropriate fields of the tool, that the tool produces some sort of output and then discussions about a decision are related to the output from the tool. Secondly, the efficacy RCT also produces a specific order of practice, chiefly that the individual encounters between patients, doctors and tools, and the outcome data collected from them, are standardised enough for comparisons to be made across all the patient–doctor–tool encounters. Hence, we have described the arrangement of these two deeply interrelated interaction orders as the assemblage of the decision-support tool trial. This assemblage produces a specific order of practices, rights and responsibilities and, as the encounter proceeds, fabricates multiple identities.
We show how the doctors in the trial oscillate between positions as authoritative clinician and neutralistic decision-support tool-implementer, and patients move between positions as passive recipients of clinical knowledge and as active subjects required to render their experience as open and calculable in terms of the demands of the assemblage. None of these proceed smoothly and all involve practices that reconfigure the assemblage and threaten the calculability on which it depends. Importantly, we show how the normative structure of the clinical encounter is, at some moments, in tension with the demands of the assemblage of the decision-support tool trial.
Section snippets
Background: the decision-support tools
Following a shift towards ideas of patient-centredness, researchers and clinicians have increasingly recognised the importance of strategies that lead to shared decision-making with patients Bower, Gask, May, and Mead (2001), especially where decisions about treatment may have significant effects on quality of life or where there are real choices between alternative therapies with differing risks and benefits (Edwards & Elwyn, 2001; Frosch & Kaplan, 1999). Decision-making aids or tools are also
Context: the trial and observational study
An efficacy RCT of the DARTS decision tool was undertaken in the North East of England. There were three arms to the RCT:
- (1)
A computerised decision-support tool (full tool).
- (2)
A simplified computerised decision-support tool (simple tool).
- (3)
A paper-based guidelines decision tool.
Individual patients were randomly allocated to take part in one of the arms. Each arm of the trial was delivered by a single GP. The three GPs involved in the trial each received training in using the computerised decision aids
Methodology
This paper focuses on videoed interactions between the GPs and the patients in the trial consultations. It draws on the analytic perspective of ethnomethodology to explore in detail, the moment by moment, interactional organisation of these encounters. More specifically, it is part of a growing body of video-based ethnographies that focus on how people organise and coordinate orientation to each other as well as to the objects and artefacts in the local milieu (e.g. Hindmarsh & Heath, 2000;
Analysis
Initially, we show how at the start of consultations the doctors worked to integrate the patients into a new and relatively unfamiliar set of activities and associated social roles. The patients have to learn that they are not only patients but also research subjects and that there is a specific format to the consultation. We then explore how patients and doctors did, for brief moments, work to produce the consultation as a routine doctor–patient interaction. We show how patients make sense of
Discussion
In this paper, we have shown how ideas about the form of the clinical encounter that are embedded in the everyday experience of both doctors and patients can struggle to compete with the requirements of calculability and co-operation that are embedded the assemblage of the decision-support tool trial. The paper outlines the interactional processes through which the decision-support tools and the RCT shape and are shaped by the interactional features of the consultation. We have documented how
Conclusion
One of the important lessons of interactionist sociology—especially the work of Garfinkel (1967) and Goffman (1974)—is that the rules of social encounters are often so deeply embedded in everyday life that they are unacknowledged and unquestioned as interactions take place. These rules become evident only where they are transgressed. In this study, we saw the transgression of everyday norms formed not simply around the local features of the clinical encounter, but actually built into it. This
Acknowledgements
We gratefully acknowledge the co-operation and candour of participating patients and general practitioners. We acknowledge the financial support of the Wellcome Trust (Grant HSR GR068380AIA). CM's contribution to this paper was partly supported by an ESRC personal research fellowship (RES 000270084), EFK's contribution was supported by an NHS Career Scientist Award. We thank Emma Hutchinson and Margaret Childs for their secretarial support, and the practice staff of contributing practices for
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