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Anne White Dissertation 10-6-17 UNIVERSITY OF CALIFORNIA Los Angeles Additional Concern Initiations in General Surgery Visits: A Longitudinal Analysis of Doctor-Patient Communication A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Sociology by Anne Elizabeth Clark White 2017 1 Ó Copyright by Anne Elizabeth Clark White 2017 2 ABSTRACT OF THE DISSERTATION Additional Concern Initiations in General Surgery Visits: A Longitudinal Analysis of Doctor-Patient Communication by Anne Elizabeth Clark White Doctor of Philosophy in Sociology University of California, Los Angeles, 2017 Professor John Heritage, Chair This dissertation analyzes video-recordings of general surgery office visits in order to investigate when and how patients initiate additional concerns, and investigates why some patient-initiated additional concerns are more likely to receive the surgeon’s help than others. This dissertation also examines how surgeons themselves initiate additional concerns during the office visit, and the interactional dilemmas they face when telling the patient about this new area of concern. In other words, how do patients and doctors try to introduce extras into the interactions, how do they formulate them as legitimate, and how are they recognizable? Additional concerns are medical problems (e.g., pain, skin lesions, hernias) that are seemingly unrelated to the main reason for the visit. This analysis utilized a mixed-methodology approach combining Conversation Analysis, ethnography, interviews, and statistics. Data are video recordings of pre- and post-operative office visits for hernia repairs, colonoscopies, and ii cholecystectomies, with a longitudinal focus of following patients across consecutive visits. This community-based study, set in rural Texas, serves as an example of the importance of incorporating the setting and context into analysis, and shows that rural patients raise additional concerns frequently and early in their visits. Patient-initiations of additional concerns were analyzed by looking at their turn design and position in order to assess what characteristics contributed to them receiving "help" by their general surgeon. This analysis identified where in the visit’s phase-structure these concerns arose and three methods patients used to launch them: fitted to method, fitted to topic, or disjunctive. Each concern was coded and analyzed for a variety of design features (e.g., lexical choice, social action, first or subsequent mentions) and contextual factors (e.g., concern falls inside or outside the surgeon’s domain of expertise, patient mentions another doctor in relation to this concern, the degree of the relationship between the surgeon and patient). In total, 62 patients spanning 175 visits were coded with 377 patient-initiated concerns found. 188 of them ultimately received help. Next, surgeon-initiations of additional concerns were analyzed for their turn-design, position, and function, with a focus on when surgeons perceptually notice a physical abnormality on the patient’s body and how they discussed this with their patient. Only 22 surgeon-initiated additional concerns were found in the data collection, and this analysis argues that this is because surgeons orient to raising additional concerns as first-position dispreferred actions. As the analysis reveals, surgeons must cope with several interactional dilemmas when presenting them, including patient awareness, rights to assess, health optimization, and other contextual factors. By investigating how rural patients and surgeons initiate and discuss additional concerns, this dissertation shows how the surgeon’s domain of practice consists of permeable boundaries that are negotiated, constituted, and enacted during visits. iii This dissertation of Anne Elizabeth White is approved. Tanya Jean Stivers Derjung Mimi Tarn John Heritage, Committee Chair University of California, Los Angeles 2017 iv Table of Contents Chapter 1: Introduction ...................................................................................................................... 1 1.1 ACCESS TO HEALTHCARE IN RURAL AMERICA .............................................................................. 3 1.2 THE SETTING ............................................................................................................................................. 6 1.2.1 HISTORY OF THE TOWN .................................................................................................................................. 7 1.2.2 HISTORY OF THE PRACTICE ........................................................................................................................... 9 1.2.3 HISTORY OF THE HOSPITAL ........................................................................................................................ 14 1.3 TURF BATTLES ........................................................................................................................................ 18 1.4 ISSUES SURROUNDING ADDITIONAL CONCERNS ........................................................................ 20 1.5 LAUNCHING NEW TOPICS IN CONVERSATION IN GENERAL ..................................................... 23 1.6 METHODOLOGIES AND DATA ............................................................................................................ 25 1.6.1 DATA COLLECTION .......................................................................................................................................... 28 1.6.2 FINDING THEMES ............................................................................................................................................. 30 1.6.3 NARROWING THE DATA ............................................................................................................................... 32 1.6.4 COLLECTION BUILDING ................................................................................................................................ 33 1.6.5 CODING .................................................................................................................................................................. 34 1.6.6 QUANTITATIVE AND QUALITATIVE APPROACH ............................................................................... 35 1.6.7 SUMMARY ............................................................................................................................................................ 37 1.7 REFERENCES ............................................................................................................................................ 39 Chapter 2: Patient-initiated Additional Concerns .................................................................. 44 2.1 DEFINING PATIENT-INITIATED ADDITIONAL CONCERNS ........................................................ 45 2.2 DEFINING VISIT-PHASES OF GENERAL SURGERY VISITS .......................................................... 49 2.3 CODING SCHEMA .................................................................................................................................... 50 2.4 HOW PATIENTS INITIATE .................................................................................................................... 53 v 2.4.1 FITTED-TO-TOPIC METHOD ......................................................................................................................... 53 2.4.2 FITTED-TO-ACTIVITY METHOD .................................................................................................................. 62 2.4.3 DISJUNCTIVE METHOD ................................................................................................................................... 67 2.5 DISTRIBUTION BY METHOD ............................................................................................................... 72 2.6 PHASE-LEVEL IMPLICATIONS ............................................................................................................ 73 2.6.1 PRE-OPERATIVE VERSUS POST-OPERATIVE DISTRUBITION ...................................................... 75 2.7 DISCUSSION & CONCLUSION ............................................................................................................... 77 2.8 REFERENCES ............................................................................................................................................ 81 Chapter 3: Which patient-initiated additional concerns receive help? .......................... 90 3.1 DEFINING “HELPED” VERSUS “NOT HELPED” ............................................................................... 91 3.2 QUALITATIVE HYPOTHESES OF CHARACTERISTICS .................................................................. 93 3.3 INTER-OBSERVER RELIABILITY ..................................................................................................... 130 3.4 STATISTICAL ANALYSIS .................................................................................................................... 131 3.4.1 DISCUSSION OF STATISTICS ...................................................................................................................... 144 3.5 LIMITATIONS OF A SINGLE-METHOD APPROACH .................................................................... 146 3.6 PATIENT STRATEGIES & CONCLUSION ........................................................................................ 148 3.7 REFERENCES ........................................................................................................................................
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