Synthesis of qualitative linguistic research—A pilot review integrating and generalizing findings on doctor–patient interaction

Patient Education and Counseling 82 (2011) 429–441

Contents lists available at ScienceDirect

Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou

Synthesis of qualitative linguistic research—A pilot review integrating and generalizing findings on doctor–patient interaction Peter Nowak * Ludwig Boltzmann Institute Health Promotion Research, Rooseveltplatz 2, 1090 Vienna, Austria

A R T I C L E I N F O

A B S T R A C T

Article history: Received 29 October 2010 Received in revised form 21 January 2011 Accepted 21 January 2011

Objective: There is a broad range qualitative linguistic research (sequential analysis) on doctor–patient interaction that had only a marginal impact on clinical research and practice. At least in parts this is due to the lack of qualitative research synthesis in the field. Available research summaries are not systematic in their methodology. This paper proposes a synthesis methodology for qualitative, sequential analytic research on doctor–patient interaction. Methods: The presented methodology is not new but specifies standard methodology of qualitative research synthesis for sequential analytic research. Results: This pilot review synthesizes twelve studies on German-speaking doctor–patient interactions, identifies 45 verbal actions of doctors and structures them in a systematics of eight interaction components. Three interaction components (‘‘Listening’’, ‘‘Asking for information’’, and ‘‘Giving information’’) seem to be central and cover two thirds of the identified action types. Conclusions: This pilot review demonstrates that sequential analytic research can be synthesized in a consistent and meaningful way, thus providing a more comprehensive and unbiased integration of research. Future synthesis of qualitative research in the area of health communication research is very much needed. Practice implications: Qualitative research synthesis can support the development of quantitative research and of educational materials in medical training and patient training. ß 2011 Elsevier Ireland Ltd. All rights reserved.

Keywords: Synthesis of qualitative research Doctor–patient communication Sequential analysis Qualitative methods

1. Introduction Since the 1950s, scientific interest in the characteristics and outcomes of doctor–patient encounters has increased as the importance of the communication between doctors and patients for the outcomes of medical treatment has become apparent. As Michael Balint put it in his classic book [1]: ‘‘Our chief aim was a reasonably thorough examination of the ever-changing doctor– patient relationship, i.e. the study of the pharmacology of the drug ‘‘doctor.’’ Especially since the path breaking study of Byrne and Long [2], research has focused not only on the psychological aspects of the doctor–patient relationship, but also on the verbal aspects of this ‘‘pharmacology’’. Diverse linguistic and sociological disciplines have provided a large body of research on the interactive details of this encounter. One main research tradition takes a ‘‘microanalytic’’ sequential analysis approach [3,4] to

¨ sterreich GmbH, Stubenring 6, 1010 Vienna, * Present address: Gesundheit O Austria. Tel.: +43 1 515 61 0; fax: +43 1 513 84 72. E-mail addresses: [email protected], [email protected]. 0738-3991/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2011.01.022

look into the interconnectedness and meaning of single turns of the interaction as they evolve in time. The main focus of this paper is on sequential analytic research on doctor–patient interaction. It takes the term ‘‘sequential analytic research’’ as an overarching category for diverse anthropological, linguistic, and sociological approaches. The common methodological ground of these qualitative research approaches is the investigation of the evolving meaning of encounters in the interplay of interactional turns. The basis of these approaches, such as conversation analysis, discourse analysis, sequential analysis or interaction analysis are verbatim transcripts. The statistical tool termed ‘‘sequential analysis’’ and used to analyze coded data on sequential events [5] is not used in the current analysis. The contribution of this kind of qualitative research to the understanding of doctoring is to disclose the time-dependent interactive processes, in which the orientations, individual experiences, understandings, and objectives of medical visits are emerging [3]. Thus the understanding on how meaning is established in these interactions can be deepened and used as a basis for training and further research in the field of health communication. Although there is a growing acknowledgement of the importance of communication in medical practice [6], results from such

430

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

research have only found marginal integration in clinical research and practice. One barrier to access these research results are the methodological problems of integrating complex qualitative results with quantitative research [7–11]. A second cause might be the isolated character of most of the sequential analytic research (small samples, specific – sometimes idiosyncratic – methodologies, few references to previous research). Thus, it is of great importance to the research on doctor–patient interaction to integrate and generalise the findings of available sequential qualitative analysis. However, to my knowledge, until now, no systematic syntheses of sequential analytic research on doctor– patient interaction have been conducted. Examples of systematic syntheses of qualitative research in the field of doctor–patient relationship can be found in the literature [12], but these did not synthesize sequential analytic research. There are some other attempts to generalize research results on doctor–patient communication especially for the purpose of teaching medical students [13], but these are not based on a systematic synthesis of available research. A systematic methodology is favourable over more ‘‘traditional’’ summaries of research, because ‘‘traditional’’ summaries are usually more selective and thus bear a high risk of researcher’s bias. Therefore, the reliability of results is questionable. To overcome these limitations, this article asks: what kind of methodology is able to systematically integrate qualitative sequential analyses of doctor–patient interactions and make their results accessible for further research and practice? A fivestep synthesis approach is proposed and complemented by an up-to-date overview over the methodological debate on the synthesis of qualitative research. The current study was conducted between 2006 and 2007. At that time, no internationally approved standards for qualitative research synthesis were available. Hence the present article is more a report of a pilot study than of a model of excellence from today’s perspective. Nevertheless, this paper aims to inspire future qualitative research syntheses and methodological discussions in the field of doctor–patient relationship by sharing the experience and showing the potential of this particular approach for qualitative research synthesis. 2. Methods Under a broad definition, qualitative research synthesis can be seen as a method for sampling, selecting, appraising and integrating (or comparing) the findings from diverse qualitative studies. The term ‘‘synthesis’’ indicates [cf. 14] a methodological process that produces more knowledge than the sum of the reviewed studies [15]. The systematic synthesis of qualitative research is still in a developmental stage: classical approaches are currently being developed further [16,17], and there is considerable debate regarding what approach is appropriate for what research field and how generalizable or transferable the results of a synthesis of qualitative research actually are [15,18–20]. Thus, the methods for synthesizing still remain underdeveloped; however, first comparative reviews and evaluations of synthesis methods are already available [14,21,22]. One issue in this development is that of clarifying the terminology for various approaches to avoid the inconsistent and sometimes technically incorrect naming of a particular method [19]. With reference to the Cochrane Collaboration’s Qualitative Research Methods Group [15], I will use ‘‘qualitative research synthesis’’ as an overarching notion for the various methodological approaches. Despite the newness of this development, strong claims are made that the synthesis of qualitative research could have a profound potential to inform practice and policy in health care, especially in the field of user experiences [23,24].

A number of methodological approaches for the synthesis of qualitative research are under development. First methodical reviews provide some overview over available synthesis methods [9,19,25–27]. International expert groups recently established some consensus on methodological principles and main steps of the synthesis process [18,19,28]. This provides guidance and first comprehensive frameworks for good practice. However, those guidelines and frameworks as well as methodological standards for qualitative synthesis were not available at the time of this study. In the development of the current synthesis (a comprehensive description of the methods and their development is available in German [29]), twelve approaches for the synthesis of qualitative research were reviewed. Six approaches were considered to be applicable in the context of sequential analyses of verbal communications: meta-ethnography [27,30], meta-study [31], realist synthesis [32], meta-narrative review [33], meta-interpretation [25,34], and critical interpretative synthesis [7,16]. In addition, some of the discussion on integrating quantitative and qualitative research in systematic reviews was included in the methodical considerations [e.g. 9,35]. The basic approach of this synthesis can be identified as a Grounded Theory [36] approach that generates new theoretical concepts in an iterative process between analysis of data (in selected studies) and conceptual clarification. Thus the presented methodology combines well known procedures of qualitative synthesis for application in the field of sequential analytic research. The following five steps of this qualitative synthesis are largely designed in accordance with the research process of the ‘‘metanarrative review’’ [33]. 2.1. Exploring the field and defining research questions The exploration of the research field has to be more elaborate and systematic and is at the same time more uncertain and open in the context of complex research like the synthesis of qualitative studies [32,33]. In the case of this synthesis, the basic aim of the study remained the same throughout the research, but the specific research question changed in the process of exploring the research field in this early phase. With a focus on the potential use of the synthesis results within the context of quantitative clinical research, the synthesis was confined to two questions: (1) Which forms of verbal activities that doctors engage in within the context of doctor–patient interaction have been described in the selected sequential analytic studies, and (2) according to these studies, what kinds of effects do these verbal activities have on respective patients? The focus on doctors’ verbal contribution was motivated by the basic asymmetric character of this interaction [37]. This focus may appear contradictory to the ‘‘co-constructive’’ character of interaction [cf. 38] but is seen as justifiable as a first very limited step of synthesis. In an open research process such as the one presented here, these research questions function more like a compass rather than an anchor [39] and should be initially outlined in a broad, open-ended format [33]. 2.2. Search, selection and appraisal of studies Generally, systematic reviews need comprehensive, systematic and explicit search strategies [40]. There is some discussion regarding literature search strategies in the context of qualitative research, especially because indexing systems of literature databases are limited for qualitative research [41–43]. One reason for that is the fact that many qualitative papers include only poorly structured abstracts or no abstract at all [44]. Thus, a relevant proportion of the literature can only be identified via ‘‘snowballing’’ and personal knowledge [45]. There is an additional debate

[()TD$FIG]

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

Reference lists from preliminary research: 150 Titles & abstracts

Keyword-search in own literature data base: 250 Titles & abstracts

Hand search: 17 most relevant journals

431

Hints by colleagues; newly published studies

Keyword-search journals: 270 Titles & abstracts References of references

Citation tracking

appr. 700 Titles: preliminary selection of 215 potential studies References of references in selected studies

Checking publication lists of authors of selected studies

appr. 2650 Titles & Abstracts ca. 2150 excluded titles on doctor-patient communication Bibliography of sequential analytic research on German-speaking doctor-patient interaction: 493 potential publications for the review (1969 – 2007)

Analysis of 12 selected studies Fig. 1. Overview of literature search.

on whether qualitative research syntheses could also use a more purposive sampling approach, where the search and selection of studies are driven by the need to reach theoretical saturation [35]. In such approach, there is an even greater need to explicitly document the selection process [41]. The following five inclusion criteria guided the literature search of this synthesis: (1) The studies should analyze spoken, German-language interactions between doctor and patient (not interactions with other health professionals or with relatives of the patients). (2) All types of encounters from all organizational settings of the health care systems are included. (3) Only naturally occurring interactions are included (no acted interactions as may be found in talk shows or medical training).

(4) The interactions must be either video or audio taped (i.e. not only be comprised of interviews or participant observations). (5) The analysis has to be on the basis of verbatim transcripts. Sequential qualitative analyses of German-language doctor– patient interactions are mostly published in books or grey literature (before 2007), which are not systematically indexed in electronic literature databases. Therefore, in this study, a multi-strategic and multi-stage literature search had to be applied (see Fig. 1). This process included the analysis of reference lists from previous studies and research reports in the field (citation tracking and references of references), expert advice from colleagues, hand search in relevant journals. Until no better indexing systems for this kind of research is available, it is recommended to supplement database searches by handsearch and by consulting experts to track studies. Applying the inclusion criteria, 493 potential publications on sequential analytic research were identified (systematically

Table 1 Main features of the twelve included studies and their respective samples of interactions. Source paper

Publication date

No. of interactions

Types of interactions

Organizational context of interactions

Primary purpose of interactions

Bliesener [53]

1982

1

Bru¨nner and Gu¨lich [47]

2002

104

Ward round

Hospital ward

Treatment

First consultation (history taking)

Hospital ward, out-patient department Hospital ward Hospital ward and primary care office Hospital ward Primary care office Hospital ward

Treatment

Gu¨lich [48] Lalouschek [50]

2005 2004

1 20

Follow up consultation First consultation (history taking)

Lalouschek [49] Lo¨ning [54] Menz et al. [51]

2005 1993 2002

Not stated 1 101

Meyer [55] Quasthoff [56] Raspe and Siegrist [57] Spranz-Fogasy [52] Wimmer [58]

2000 1982 1979 2005 1993

1 2 500 (Not stated) 60 3 (Not stated)

First consultation (history taking) Follow up consultation Personal semi-structured interviews by attending doctors Diagnostic information Ward round Ward round First consultation (history taking) Ward round and first consultation (history taking) and discharge consultation

Treatment Treatment Research

Hospital ward Hospital ward Hospital ward Primary care office Hospital ward

Treatment Treatment Treatment Treatment Treatment

Treatment Training

432

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

Table 2 Data extraction form. 1. Key features of the publication and study Citation of the analysed publication Peer reviewed Underlying research project and further publications Research site of the study

Citation In what form? Title; leading researcher; duration; further publications Research facility

2. Research context and conceptual basis—theory 2.1. How transparent are origin, background and assumptions of the researcher? Are constraints/biases disclosed? 2.2. Which (personal) interest of research is motivating the study? 2.3. Who was the study’s commissioner/financier? 2.4. Which personal, historical, intellectual, intercultural and political context can be found for the study? 2.5. What is the prevailing theoretical approach (interactional theory, communication model)? Is the theoretical approach made explicit from the beginning? 2.6. What are the study’s central research questions? Are the interactive actions of the doctor in the focus of the research? If not, what else? 3. Methods 3.1. Basic data on sample, context and interactions analysed Organizational context of the doctor–patient interaction Patients in the sample Doctors in the sample Interactions in the sample

Hospital, departments, outpatient department, medical specialty resident doctor, and medical specialty Quantity, age, sex, education, and diseases Quantity, age, sex, medical speciality, position (chief physician/assistant/in training, etc.) Quantity: Length of interactions: min. Type of interaction: Ward round; first consultation (history taking); follow up consultation, etc. Other specific characteristics of the interactions and its context: Documentation of interaction Tape- and video recording; type of transcription; published transcripts Additionally used methods of inquiry Interviews with patients, doctors; interviews in written form; participants’ observations; etc. 3.2. Participant selection? (systematic selection, random selection, etc.) 3.3. What specific methodology of sequential analysis is used? 3.4. What steps of analysis were carried out? 3.5. How or why were the analysed texts chosen? 3.6. Transdisciplinarity: How were representatives from the field of research (doctors, patients, etc.) included into the study? 3.7. Application: Is the distribution or application of the results part of the research? Was stakeholder’s feedback included into the study? 4. Results 4.1 Which interactive procedures of doctors are described to have which effects? Verbal activity of the doctor Corresponding transcripts

Ascribed impact on the patient !

4.2. Indications of patient empowerment? 4.3. In what way are the results surprising, interesting, or suspect? 5. Quality appraisal 5.1. Are the research questions clear? 5.2. Are the main steps of the research process clearly described? Selection of interactions Description of the context of the interactions Methods of data collection and transcription Methods of sequential analysis 5.3. Are the encounters systematically analysed? 5.4. Are the steps of the research process appropriate to the research question? 5.5. Are also roadblocks, false steps, etc. in the research process described? 5.6. Reflexivity: Are possible biases of the authors described and accounted for in the research process? 5.7. Are the presented results supported by sufficient analyses of interactions? 5.8. Are the theoretical approach, sequential analyses, the interpretations and conclusion clearly integrated? 5.9. How the authors deal with contradictory results? 5.10. How well is the study presented as a narrative? 5.11. Does the paper make a useful contribution to the knowledge about verbal activities of doctors?

searched until October 2006). The comprehensiveness of this search process was confirmed by a follow-up study that aimed to build a full record of all sequential qualitative analyses of Germanlanguage doctor–patient interactions as an online-database (www.univie.ac.at/linguistics/florian/api-on/index.htm) [46]. For reasons of scope and feasibility, the sample of included studies had to be restricted to a very small number. In a first phase of preliminary analysis, six studies [47–52] were selected in a ‘‘purposive sampling’’ process [32], starting with recently published, high quality publications. The selection of recently published studies allowed for a quick up-to-date insight into the state-of-the-art of sequential analysis in the field. In a subsequent second round, six additional studies [53–58] were selected via ‘‘maximum variation sampling’’ [59] to test the methodology with studies with maximum diversity (cf. Table 1). In addition to ensuring variance regarding theory and methodology, this second round was also intended to diversify the sample of studies regarding authorship, publication date, size of the patient sample,

interaction type, and interaction context. To meet the requirement of explicitness, an ‘‘audit trail’’ [34] documented the rationales for the selection of each study. Appraisal of study quality is an aspect of synthesis of qualitative studies that has received particular attention. Up until now no consensus on standardized appraisal processes and criteria was found [18]. Even the question of whether a structured approach would provide a consistent assessment of selected studies is challenged by a methodological review [7]. In the present synthesis, eleven specific appraisal questions (cf. Table 2) that were modified from two previous articles [60,61] were included in the data extraction form. The appraisal questions fulfil four purposes: 1. to exclude studies of ‘fatally’ flawed quality, 2. to assess the plausibility of the results of the included studies, 3. to assess the comparability of the included studies, particularly in cases of contradictory results, and 4. to assess the generalizability of the results.

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

433

Table 3 Excerpt from the meta-matrix (numbers in column 1 refers to the number of action type in Fig. 2). No.

Category

I. Opening the encounter 2 Introduction of the doctor

3

Mutual orientation on the interaction

II. Opening initiative 1 Opening question 1.1 Questions concerning the reasons for the consultation or the patient’s condition.

2 2.1

Inviting a narrative Open invitation of a narrative

2.1.1

Open invitation of a narrative with a specific content

III. (Not-)listening 2 Encouraging to continue 2.1 Orientation about an expected answer

Further description

Corresponding transcripts

Ascribed impact on the patient

With name and function

‘‘Doctor: my name is XX, I am a medical student – and I am currently doing my internship here at this practice. If you don’t object I would like to ask you some questions before the doctor arrives. Patient: Yes, ok.’’ [50] ‘‘Doctor: I have/we have/about three quarters of an hour for this conversation – and I like to start by letting you tell me which conflict or problem you come with – and then I would ask additional questions if I need more information. Patient: mhm – The problem is..’’ [49]

!Establishes equal starting conditions for the interaction

‘‘Doctor: Now please tell me how you are! Patient: [1.sec. pause] Yes, all in all I’m always – good. I also tolerate the infusion well. Doctor: Hmhm. [writing] Patient: But – sometimes you.. – well [sights], but in my feelings, Doctor: Yes. [writing] Patient: So, is it alright.. - - I always have to – have to [1.5 sec. pause] fight a lot . . . that I don’t [1.5 sec. pause] let myself down, you know? – Isn’t that somehow.. Doctor: [sighs]’’ [54]

!Gives the patient the opportunity to start an extensive narrative and to freely choose the form of presentation

General example: ‘‘Alright, please start to explain!’’ [52] ‘‘Doctor: Now, Mrs Trecker, please describe the pain your are feeling NOW. Patient: Yes, I talk about it HERE, but usually I don’t like to talk about it. That’s how it is! Doctor: Yes’’ [48]

!Demanding an answer, content open !Encourages detailed description by the patient

‘‘Patient: Problem is: – where can I start? Doctor: Whatever springs to your mind Patient: Yes. my biggest problem is that I suffer from Morbus Crohn Doctor: Yes’’ [50]

!Supporting systematic and detailed narratives

Clarifying the aims of the conversation and conveying the time frame.

Elicits patient’s concerns

Which demands – or at least permits – complex answers

Accompanying support of narratives through exact orientation about the expected answer

!Both dialog partners are in the same pattern of interaction !More clarity; enhances comprehensibility, coherent narratives and specific answers !Helps the patient to plan the amount of detail and the appropriateness of his or her contribution and to concentrate on the description of his or her problems !Less ambiguities, conflicts, repetitions, misunderstandings and non-specific explanations !Gives the patient the chance to assess the doctor, which creates a foundation of trust

!Giving the patient the role of the primary speaker and the doctor the role of the listener for the duration of the narrative 3 3.1

Feedback tokens Accompanying and supporting (awaiting) feedback signal

Especially for accompanying support of longer accounts and narratives by the patient

‘‘Patient: Yes. my biggest problem is that I suffer from Morbus Crohn Doctor: Yes Patient: That’s been discovered half a year ago Doctor: Mhm Patient: Thankfully it didn’t do anything at the beginning – was very glad about that– and at christmas/yes, shortly before christmas it started again’’ [49]

!Indicates that the patient can take the time to find the right words !Supports systematic and detailed narratives !Gives the patient the role of the primary speaker and the doctor the role of the listener for the duration of the account

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

434 Table 3 (Continued ) No.

Category

5 5.1

Asking further details Asking for the literal meaning

Further description

Corresponding transcripts

Ascribed impact on the patient

Frequently by repeating the patient’s first statement

‘‘Doctor: you are not feeling yourself, er, or how should I imagine that? Patient: all the delicacy of feeling – it’s all gone. If I cook I also have to tell the others – I hope it’s good. I also don’t taste anything-’’ [47]

!Deepens the understanding !If asked too frequently, it makes the patient doubt the mutual understanding

6 6.1

Checking understanding By repeating parts of the patient’s statement

In particular metaphors used by the patient

‘‘Patient: Anyway, I don’t KNOW whether anything induced it – – I notice it before. It somehow.–. it’s like, like some kind of deep hole when I get up – I can’t even describe it – I immediately notice Doctor: Like some kind of deep hole? Patient: yes – but I own a shop so I have to and I always think I have to go downstairs, but that – I don’t really do that anymore [..]’’ [47]

!Securing the doctor’s understanding, especially enabling the patient to correct or substantiate the doctor’s understanding

8 8.1

Rejecting a patient’s initiative By failing to follow up a patient’s initiative

Represents a violation of the norms and is therefore rare

‘‘Patient: I’m still not feeling so well. Well, I hardly ate anything recently, you know, I’ve been afraid because of the gall-thing and now.. (Doctor skimming through the chart, Patient falls silent, pause ca. 5 sec.) Doctor: (to nurse) Do you know where the pictures have gone?’’ [57]

!Discouraging any further initiatives by the patient !Confusing effect: ‘‘shared center of attention’’ [57] is endangered or cannot develop

Goal: elicit patient’s account; no predetermined answer options provided

General example: ‘‘Doctor: How did this happen?’’ [52]

!Broad option of responses

‘‘Doctor: you have had asthma for two years. Patient: for two years, so since eightysix Doctor: uh-huh can you recall exactly how that started Patient: So my theory is it started when..’’ [49] ‘‘Patient: okay so WHEN the seizures happened – what kinds of seizures they were and about – how MANY, right Doctor: uh-huh Patient: and the intensity I’ve written down all this – if you can use it that’s good Doctor:– yes of course this is helpful – ahm – but still – uh – it would be nice if you could again NOW describe – what you YOURSELF are experiencing in the moment of the seizure’’ [47]

!To give the patient a frame for an individual account that includes individual indications of relevance

‘‘Meta-discursive marker’’

‘‘Doctor: Well. I’ll listen to your lungs again later and now I’ll ask you some general questions, like if you’ve had any other diseases?’’[50]

! The absence of local orientation leads to disaccording expectations for the interaction and is thereby causing the course of conversation to become chaotic and the dialog partner to be discontent

Doctor is not giving precise information about an unfavourable diagnoses

‘‘Doctor: Well, let’s remove it – alright – well, very well would be kind of an overstatement. Patient: Why, what’s the problem? Doctor: – see, we removed a part of the lung, but it’s a systemic disease – it’s not only the lung that’s ill, but also – by now also in-between, in-between both lungs there are some little focuses, or there were some little focuses – where one has to consider what to do.’’ [58]

!Patient is unable to start handling his/her situation !Patient cannot develop a clear goal or a positive attitude towards his/her therapy !Patient is afraid and insecure ! patient alternates between hope and desperation ! rate of complications rises

IV. Asking for information 1 Open questions

1.1

Open questions, giving an orientation frame in terms of quality and content of the expected answer

2

Encouraging of a narrative

V. Giving orientation 1 Local orientation during change of focus

VI. Giving information 2 Giving no ‘‘bad news’’ 2.1 Doctor is talking about future steps and results of the surgery instead of giving details about the diagnosis

Doctor makes evident that s/he attributes great value to a patient’s immediate, oral account

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

435

Table 3 (Continued ) No.

Category

3 3.1

Explanation Long, complex explanations

4

Announcing and instructing future actions

6 6.1

Instructing patient’s activities Orientation about activities the patient is supposed to carry out

Further description

in the form of a description of the activities

VII. Mutual planning and decision making 1 Rejecting a patient’s wish 1.1 Arguing the doctor’s point Declaration of non-debatable of view with ‘‘have to’’ necessities

VIII. Closing 4 Explicit closing

These appraisal questions cover most aspects of the frequently used ‘‘Critical Appraisal Skills Programme’’ (CASP) instrument [62] except the question on ethical considerations (No. 7). This aspect should be added in future quality appraisal forms. Compared to the CASP instrument, the appraisal questions used in this synthesis elaborate more on reflexivity of the research process (Table 2: questions 5.5. and 5.6.) and quality of presentation of results (Table 2: question 5.10.). None of the included studies fulfilled all eleven quality assessment items, ranging from meeting five [54] to ten [56] quality assessment items. The most critical appraisal questions were the questions on false steps (Table 2: question 5.5.), on reflexivity (Table 2: question 5.6.), and the question on dealing with contradictory results (Table 2: question 5.9.). This indicates the difficulty to reflect and report on adverse events during the research process in this body of literature. Included studies had to fulfil at least the two questions on the congruity (Table 2: questions 5.7. and 5.8.) and the question of relevance (Table 2: question 5.11.). Failing one of these three questions, a study was assessed as being of ‘‘fatally flawed’’ quality. The selection

Corresponding transcripts

Ascribed impact on the patient

‘‘Doctor: Well – – yes, what it’s about Mrs Z. er – – mh about the diagnosis or the cause of disease or the disease itself, right? Whether it’s just an attrition or whether there are inflammatory Patient: Yes Doctor: Changes involved, right? Patient: Yes Doctor: Quite a few facts indicate that it’s inflammatory, for example [..]’’ [56] ‘‘Patient: Yes, I already had that twice. Doctor: Exactly. That’s why we want to repeat the examination, so we can see if everything is alright. And you also had a mucosal inflammation – – in the lower oesophagus. And we also want to look at that again. Patient: [1 sec. pause] Yes.’’ [55]

! the principle of the ‘‘primary speaker’’ keeps the patient from taking the initiative

‘‘Doctor: You get/you have to swallow a tube, – right? Patient: Hm Doctor: [1 sec. pause] It is inserted, – and then – you swallow and it goes down the oesophagus into the stomach. – Right? – And then we can look at the stomach and parts of the duodenum, right? Then we can see whether there are any – sources of bleeding or – ulcers, – that have to be examined. Patient: Gastric ulcers.’’ [55] [accentuation PN]

!Enabling the patient’s cooperation

‘‘Patient: I also hope that it won’t return. Doctor: Yes [7 sec. pause] so do we [4 sec. pause] But you do understand that we have to give you the medicine, Patient: Mhm Doctor: in order to prevent it from coming back and that, because of that, we have to put up with side-effects.’’ [53]

!Supposed to make the doctor’s argument seem mandatory

‘‘Doctor: I’ll look if I have forgotten anything important < paper rustling> <11 sec.> no, we can continue the examination, then.’’ [50]

process served the aim of maximum variation of studies (see above) and no systematic selection of all adequate studies was intended. Because of this, the number of excluded studies in the pre-selection of studies had not been documented. As a general suggestion the selection and appraisal of the selected studies, as well as all subsequent steps of a qualitative synthesis should be done by at least two researchers independently to reduce reviewer ‘‘bias’’ [16]. For the quality appraisal of sequential analytic research the use of questions on reflexivity of the research process seems to be pivotal and should be emphasized. 2.3. Data extraction The actual analysis of qualitative research publications involves complex processes of perception, selection, abstraction and description by the analyzing researcher. These have to become transparent to meet the principle of intersubjectivity of synthesis. Some researchers [27,32] suggest that synthesis of qualitative research is not easy for beginners, and that analysis and synthesis should ideally be carried out within closely cooperating teams of

436

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

experienced researchers. Such comments indicate the concomitant problems of standardization and quality assurance of the analysis phase. Data were abstracted onto a structured data extraction form (Table 2) based on Greenhalgh et al. [33]. Such a form supports the consistent identification and extraction of the sought after data. The data extraction form has to be adapted to the specific field of research and the research questions of the synthesis. In contrast to Greenhalgh et al. the data extraction form was specified for sequential analysis of doctor–patient communication, mainly in the methods and the results section. Another change was the introduction of the basic three-fold structure of theory, methods and results [31] that proved itself valuable in handling. Including sections on key features and quality appraisal of the study the data extraction form has five sections with a total of 31 principal data entries (Table 2): (1) Basic, formal, quantitative aspects of the study (title, author, year of publication, etc.). (2) Six items regarding the theoretical framework, interests and potential bias of the study. (3) Seven items regarding its methodological approach (sample of patients, encounters, doctors, documentation of the interaction, analytic steps, etc.). (4) Three items regarding the results (doctor’s turns – including corresponding transcripts, impact on the patient, patient empowerment). (5) Eleven items assessing the quality of the study (clarity of research questions and of the research process, reflexivity, appropriateness of methods, etc.). This last section of the data extraction form is based on previously defined assessment questions for qualitative research [60,61]. The quality and effort of the data extraction process relies largely on the precision and convenience of the extraction form. It is suggested especially to clarify the kind of information one needs to answer the research questions of the synthesis. Ideally, data extraction forms should be always pilot tested with a few studies. Afterwards, the data extraction form should be adapted accordingly. Otherwise, if the data extraction form does not capture all relevant data, a very time consuming process of recollecting data from the selected studies may have to be done in the later steps of the synthesis. A specific clarification in the synthesis of sequential analysis is how much of the original transcripts are extracted to illustrate and confirm the results of the synthesis. In the case of this synthesis all transcripts of the original studies were extracted, if they were interpreted by the respective authors as an example of the doctor’s verbal action. To date there are no guidelines on this, but the example of this synthesis could be taken as a starting point (see also Table 3). 2.4. Aggregation Basically, two main approaches of integrating the findings of selected studies are distinguished: an aggregative or an interpretive approach [16,34]. The first sets a focus on accumulating comparable ‘‘data’’ (especially results) with the aim to summarize the findings of several studies, and is more suitable for quantifiable data. The interpretative approach focuses mainly on the integration of concepts and theories, thus aiming on the development of new theoretical perspectives and conceptual understanding. In the present synthesis both approaches were combined, as a succession of two steps: firstly, aggregating all identified verbal actions and their ascribed effects in a meta-matrix and secondly, interpreting these findings by further developing the meta-matrix in a cognitive landscape of doctors’ verbal actions. The use of a

Table 4 Eight interaction components of doctor–patient interaction. I. II. III. IV. V. VI. VII. VIII.

Opening Initial initiative (Not-) listening Asking for information Giving orientation Giving information Mutual planning and decision making Closing

meta-matrix for integrating complex results was borrowed from ‘‘cross-case technique’’ [63] and the step-by-step development of complex categorizations [9] and is also known as ‘‘data integration table’’ [64]. Each data entry is taken from the data extraction form and includes a categorization of the verbal action, a short description, the corresponding transcript, and (if provided in the study) a description of any (interactive) impact on the patient (Table 3 shows an excerpt of the meta-matrix). As an overall basic structure for this meta-matrix, a set of eight chronologically and functionally defined interaction components (cf. Table 4) was established. This basic structure is based on an action theory approach (cf. [52]) and the integration of five previous attempts to classify the inner structure of doctor–patient interaction [2,13,52,65,66]. It should be acknowledged at this point that a linear phasing of the doctor–patient encounter cannot fully capture the complexity of the unique patterns of each interaction analysed [67]. It is the sometimes long-term back and forth processes within these interactions that can reveal potentially important meaning within the analysis [68]. This is the background on which these overarching interactive strands within the doctor– patient encounter were defined as ‘‘components’’ (not ‘‘phases’’). The entries from the selected studies were structured in an evolving differentiation of sub-categories of the eight interaction components, in a process of ‘‘constant comparison’’ [36]. In the course of this process for each entry a fitting categorization was established, on the basis of iterative comparisons and match-ups of data-entries on different levels and fields of the matrix. This also involved a ‘‘Reciprocal translation’’ [30] of data-entries from different studies as well as restructuring of the matrix itself in cases of contradictory or incompatible results (cf. ‘‘Refutational synthesis’’ [27,30,33]). For the integration of complex, multidimensional qualitative results the use of a meta-matrix is recommended. This allows keeping an overview over the aggregated results without losing the details and specific context of each piece of information from the studies. 2.5. Synthesis In the present review, the synthesis process, i.e. generating new concepts, started already during the phase of aggregation. Especially the formulation of new overarching categories (‘‘synthetic constructs’’ [16]) is a first, vital step of a synthesis. The main challenge in the final synthesis is to develop a meaningful overview over the multitude of concepts and categories extracted from the studies to answer the research questions by systematic interpretation. The 140 verbal actions of doctors identified here are indicative of the complexity of the phenomenon. To reconstruct the basic structure and the differentiation of categories as a cognitive map, graphical mind-mapping software was used (cf. Fig. 2). This process led to the identification of duplications, contradictions and gaps within the evolving systematics. The use of electronic mindmapping techniques is explicitly recommended as this supports the generative aspects of perception to identify possibilities of a coherent new whole deriving from diverse findings [27]. In a final step this systematics was summarized, interpreted and discussed

[()TD$FIG]

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

437

Fig. 2. Systematics of doctor‘s verbal actions.

on the background of recent research in the field. Conclusions were drawn for further methodological and empirical research as well as training and practice of doctor–patient interaction. As the main purpose of this paper is outlining the synthesis methodology, the summary of findings and the conclusion from this synthesis are only presented very shortly.

the provision of orientation to facilitate a sharing of expectations of the participants. Four studies report on a total of six action types of opening the encounter (14 transcripts): greeting [50]; self-introduction of the doctor [49,50]; placement [49,52]; mutual orientation towards the interaction [49,50,57]; general invitation to ask questions [50]; closing of the preliminaries [52].

3. Results 3.2. Opening initiative This synthesis identified a total of appr. 140 distinct verbal actions of doctors documented with 166 transcripts from the twelve selected studies. These were integrated in a systematics of 45 ‘‘action types’’, which were summarized in eight components of doctor–patient interaction (cf. Fig. 2; Table 3 shows examples of action types from all interaction components). The units of this systematics are verbal sequences of interactions (‘‘action types’’), which are primarily differentiated by their interactive function, and their interpretations in the selected studies. The following overview of the eight interaction components of doctor–patient encounter offers a very short summary of the main findings. The complexity and comprehensiveness of these findings are indicated by the number and references of studies contributing to each component and the number of integrated transcript excerpts from the selected studies (the complete findings are published in German [29] and in an English summary [69]). 3.1. Opening The opening of the encounter is described as essential for the development of the relationship between doctor and patient and for the subsequent phases of the interaction [13]. The main challenges are the provision of a welcoming and respectful setting, the reliable identification of the individual patient, and

Physicians open the discussion about patients’ concerns in various forms. The interactive openness of this initiative seems to be essential to whether and when the patient will present his/her concerns. It also structures the expectations about the topics of the interaction and the interactive roles of the participants. Six studies report on a total of three action types of the opening initiative (19 transcripts): opening question [49,50,52–54]; inviting a narrative [48–50,52]; ‘‘making oneself available’’ [52]. 3.3. (Not-)Listening Since the beginning of research on doctor–patient interaction, ‘listening patterns’ of physicians have been criticized. The main functions of ‘‘listening’’ are to ‘‘leave the floor’’ to the patient, to encourage self-determined narratives, to acknowledge patients’ cues and presentations, to secure understanding, to take patients’ views seriously. Eleven studies report on a total of ten action types of (not-)listening (69 transcripts): providing space/time for expansion [48,54,56]; encouraging to continue [49,52]; feedback tokens [54,56] [48,49,52,53]; accompanying commentaries [48,52,53]; asking for further details [47,49–52,54]; checking understanding [47,49,51,52,54]; interrupting; rejecting the patient’s initiative[49,57,58]; transforming the patient’s initiative

438

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

into the doctor’s initiative [53]; and inhibiting the patient’s initiative [56]. 3.4. Asking for information Asking questions are also part of the components ‘‘Opening initiative’’ and ‘‘Listening’’, but the need to ask questions arises all throughout the encounter. Previous analyses have shown that the main challenge in formulating questions is to elicit not only preferred answers [70]. Four studies report on a total of eight action types of asking for information (18 transcripts): open questions [49,52]; encouraging a narrative [47]; closed questions [49,50,52,54]; indirect questions [52]; suggestive questions [52]; (abbreviated) routine questions [50]; vague/confusing questions [50]; and clear, standard questions [50].

3.8. Closing The closing of the meeting usually bears the functions (and challenges) of summarizing the results, providing a last opportunity to initiate new questions or topics, and giving a prospect regarding future steps. There is some evidence that a noticeable proportion of patients use this opportunity to present a new concern to the doctor. This is seen as a result of having missed opportunities earlier in the meeting and of an invitation by the doctor to do so in the closing [74]. The closing seems to be decisive for the continuity of the treatment relationship. Three studies report on a total of four action types of giving orientation (mainly conceptually; one transcript): summarizing the meeting [49]; final invitation to ask questions [49]; orientation regarding future steps [49]; and explicit closing [50,57]. 4. Discussion and conclusions

3.5. Giving orientation 4.1. Discussion Giving orientation on the procedure, the time available, the topics, the expected roles, etc., gives the patient the possibility to synchronize his/her expectations with the doctor’s and to take an active role in the meeting. This seems particularly important during the opening and the closing of the encounter (see above and below), but seems to be necessary during the whole encounter (cf. [13]). Four studies report on a total of two action types of giving orientation (5 transcripts): local orientation during change of focus [50,53,55]; excluding patients from the interaction [57]. 3.6. Giving information Patients typically want more information than physicians expect, especially regarding ‘‘bad news’’. There is a longstanding research tradition documenting positive consequences (e.g. compliance, satisfaction, and self-management) of appropriate information given by physicians (e.g. [71]). The main challenges in informing patients seem to be: to find out what information each individual patient needs and expects; to take time for informing patients; to give neither too much nor too little information; to break up the information into understandable pieces and check back on understanding (‘‘chunking and checking’’); to structure the information and set priorities; to avoid jargon; and to give specific (and not general) advice. Seven studies report on a total of eleven action types of giving information (36 transcripts): giving information early and in detail [58]; giving no ‘‘bad news’’ [57,58]; explanation [55,56]; announcing and instructing future actions [55]; instructing patients’ activities [55]; implicit assessment of information [55,58]; illustrating [47,55]; indirectly initiating self-awareness of a problem [53]; using jargon [47]; giving information to third parties [54]; and monitoring/checking [55]. 3.7. Mutual planning and decision making Early research on compliance already invoked discussions on patients’ participation in treatment planning and decision-making [72]. With the publication of the ‘‘shared decision-making model’’ [73] and other related concepts, patient participation gained high scientific, practical and political momentum. The basic aims of this component are to invite patients to participate appropriately and to find a well-accepted consensus between doctor and patient. However, in the synthesis of the included studies almost no discussion of decision-making processes could be found. Only one study discussed decision-making from a conceptual point of view [55], and a second study analysed ‘‘rejection of a patient’s wish’’ (four transcripts) [53].

This synthesis identifies 45 ‘‘verbal actions’’ of physicians in doctor-patient encounters with a total of appr. 140 subcategories, and synthesizes these interactive processes into eight interaction components of a comprehensive systematics. The eight components are: opening, opening initiative, (not-)listening, asking for information, giving information, giving orientation, mutual decision making and closing. Three components (listening, asking for information, and giving information) emerged to be especially differentiated in the selected studies and cover two-thirds of the identified action types (N = 29) and three quarters of all included transcripts (N = 123). This might be a hint that these components can be seen as the prominent part of the interactive work of physicians (cf. Fig. 2). In this synthesis, nearly no decision-making processes could be identified. This may be a consequence of the limited sample. It also could affirm a recently proposed differentiation of the process of arriving at a decision (deliberation) and the determination of a decision [75]. The deliberation process is mostly established within the three in this review findings extensively differentiated interaction components (listening, asking for information, and giving information) or even outside the observed encounter (‘‘distributed nature of decision-making’’ [76]). This would imply that the greater part of decision making is hardly observable as ‘‘decision making’’ in the doctor–patient encounter. To clarify this issue, specific qualitative research syntheses of sequential analytic research on decision making are recommended. In two further areas the systematics does not confirm previous research: there are no interruptions by physicians documented in the included studies. Note, however, that recent micro-analytic studies analyze interruptions as a complex co-constructive activity and argue for a respective re-conceptualization of interruptions [77,78]. Further, the (problematic) use of jargon did not appear as a prominent result within the included studies and might hence be overestimated in training concepts. This systematics of doctors’ ‘‘verbal actions’’ is obviously fragmentary, but it demonstrates that sequential analytic research can indeed be successfully synthesized and can produce a more differentiated framework of interactive processes than each of the single studies by itself. As methodological pilot research, this study has some major limitations. The first limitation is that it integrates the results of only twelve studies on German-speaking doctor–patient interaction (from a quite small number of research groups). This implies that some action types might not have been identified, because the studies reported only on specific aspects of the consultations. For example, it can be assumed that a further interaction component of physical examination has to be added, as there is some sequential

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

analytic research in English-speaking doctor–patient encounters in this area [e.g. 79,80], but none in the selected studies. Therefore, the developed systematics is no representative account of doctor– patient interactions. For further differentiation and broader generalization of results, the synthesis of more sequential analytic research is required (including research in other languages). Secondly, the established systematics is focused on the verbal contributions of doctors only, and do not integrate the interactive participation of the patient. Thirdly, this synthesis was conducted by a single researcher without the support of a closely cooperating team. Nevertheless, some necessary critical feedback or ‘‘checks and balances’’ (cf. [16]) were gained through several discussions of preliminary results at diverse international conferences. 4.2. Conclusion Sequential analytic research on doctor–patient interaction has had only a marginal impact on clinical research and practice so far. At least in parts this is probably due to the lack of systematic qualitative reviews. Despite its limitation, this study demonstrates that the synthesis of qualitative health communication research can provide a more complex reconstruction and comprehensive integration of this research. Up until now generalizations of sequential analytic research were usually drawn unsystematically from the specific knowledge base of the respective researcher (often his or her own empirical research). Being not systematic in its methodology ‘‘traditional’’ summaries are usually more selective and thus bear a high risk of researcher’s bias, as indicated before. The contribution of this paper is to introduce the rigour and consistent methods of systematic qualitative reviews to the field of sequential analytic research. With this methodology a much more comprehensive and unbiased integration of available research becomes possible. There are thousands of sequential analytic studies on doctor–patient interaction available, but no reliable integration of their findings. The purpose of such syntheses is to extend the level of interpretation of diverse findings [12]. Thus more generalized evidence can be provided. A specific observation in the findings of this pilot review is that many of the identified sequential analytic studies did not meet relevant quality criteria. One might conclude the need of more rigorous publication rules, which incorporate international standards for good qualitative research [18,19,28], such as giving clear statements of research questions, a comprehensive description of used methods (including researcher bias), etc. Synthesis methodology may be particularly useful in the field of sequential analytic research, as this research usually provides some of the primary data as verbatim transcripts. These offer a very differentiated and rich picture of health communication in its specific interactive context while at the same time the synthesis itself provides integrated understanding and abstraction from the singularity of the observed encounters [34,68,81]. This combination of abstraction and contextualized specification can be of particular interest for the further development of the operationalization of quantitative measures in health communication research. Thus, for example, coding systems for medical encounters (e.g. RIAS [82], Verona Medical Interview Classification System [83]) use sets of categories which could be further developed from the perspective of synthesized sequential analytic research [84]. The development of such coding systems usually relies on expert panels [e.g. 85] which could be complemented by a systematic qualitative review of the available sequential analytic research in the specific field. Thus more external validity can be gained in its operationalization. The developed systematics of this synthesis could contribute to this development with its specifications of action types and their subcategories with their described specific impacts on the patients.

439

Further, in the context of recently broadly discussed models of shared decision-making [86], one finds a mixture of vague terminologies focusing on concepts like ‘‘observable behaviors’’, ‘‘qualities’’, ‘‘elements’’, ‘‘competencies’’ of communication. A better differentiation and understanding of the underlying interactive processes provided by sequential analytic research could help clarifying these concepts. But as already mentioned, very little sequential analytic research is found on decision making at least in German-speaking doctor–patient interaction. So in the field of decision making a systematic search and synthesis could provide a clearer picture on what we know and where new empirical studies should be initiated. Another area of future research supported by qualitative research synthesis would be the reconstruction of the impact of the doctor–patient interaction on the patient in a broader conceptual model. It seems worthwhile to develop such a model on the basis of concepts of patient empowerment and participation (cf. [87–89]). The proposed systematics is a starting point for a more complex conceptual framework; but it is also in need of continued development from different theoretical perspectives (e.g. conversational analysis, systems theory). The further elaboration of a comprehensive theoretical framework for health communication research, and one that would support interdisciplinary research could use specific synthesis methods of ‘‘meta-theorizing’’. Thus, for example, Paterson et al. [31], within their ‘‘meta-study’’ approach, propose some methodological guidance for integrating diverse theoretical perspectives of included studies. In conclusion, there are still some methodological questions in qualitative research synthesis to be discussed and solved (e.g. systematic search strategies for qualitative linguistic research, quality appraisal of qualitative research, the range and limitations of generalizations of findings [12,20,60,61,90]). These challenges still need to be explored. But there is new guidance for synthesizing qualitative research available [18,19,28], which – along with the suggestions of this paper – can guide future syntheses of qualitative linguistic research. This pilot synthesis of qualitative research may stimulate this new methodological approach to raise the treasures of already existing sequential analytic research in the area of health communication research. In particular, such synthesis can ultimately also facilitate an interfacing of qualitative health communication research with quantitative empirical research from diverse disciplines. 4.3. Practice implication The synthesis of qualitative linguistic research can foster the systematic development of quantitative instruments in health communication research like patient surveys, content analysis software, and as already mentioned the further specification of rating systems. In addition this kind of findings can enhance the quality of educational materials in medical training by including comprehensive and systematized collections of transcripts of ‘‘real’’ interactions from diverse studies. The same holds true for the development of trainings for (chronic) patients, which might be a promising tool to effectively develop the practice of doctor– patient interaction [91]. Conflict of interest This study was done in the context of my dissertation at the University of Vienna. No other interests were involved. Role of funding force No funding was given to this study.

440

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

Acknowledgements [29]

I am grateful to Florian Menz for supporting this study with his valuable advice and for commenting the manuscript. Thanks to Rosemarie Felder-Puig for comments to the manuscript. Thanks to Barbara Soukup and Ursula Mager for the native English check. Thanks to unknown reviewers for valuable comments and suggestions.

[30] [31]

[32]

References [1] Balint M. The doctor, his patient and the illness. London: Pitman; 1957 . [2] Byrne PS, Long BEL. Doctors talking to patients: a study of the verbal behaviour of general practitioners consulting in their surgeries. London: HSMO, Royal College of General Practitioners; 1976. [3] Heritage JC, Maynard DW, Problems. Prospects in the study of physician– patient interaction: 30 years of research. Annu Rev Sociol 2006;32:351–74. [4] Bensing JM, Zandbelt L, Zimmermann C, Introduction. Sequence analysis of patient–provider interaction. Epidemiol Psychiatr Soc 2003;12:78–80. [5] Observing interaction: an introduction to sequential analysis, 2nd ed., Cambridge University Press; 1997. [6] Hart JT. Expectations of health care: promoted, managed or shared? Health Expect 1998;1:3–13. [7] Dixon-Woods M, Sutton A, Shaw R, Miller T, Smith J, Young B, et al. Appraising qualitative research for inclusion in systematic reviews: a quantitative and qualitative comparison of three methods. J Health Serv Res Policy 2007;12:42–7. [8] Bryman A. Integrating quantitative and qualitative research: prospects and limits. University of Leicester; 2006, Methods Briefing. [9] Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy 2005;10:45–56. [10] Dixon-Woods M, Agarwal S, Young B, Jones D, Sutton A. Integrative approaches to qualitative and quantitative evidence. London: Health Development Agency; 2004. [11] Mays N, Popay J, Pope C. Review and synthesis of qualitative and quantitative research and other evidence. London: Canadian Health Service Research Foundation; NHS SDO Programme; 2004. [12] Larun L, Malterud K. Identity and coping experiences in chronic fatigue syndrome: a synthesis of qualitative studies. Patient Educ Couns 2007;69: 20–8. [13] Silverman J, Kurtz SM, Draper J. Skills for communicating with patients, 2nd ed., Oxford: Radcliff Medical Press; 2005. [14] Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med 2003;56:671–84. [15] Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Inform Libr J 2009;26:91–108. [16] Dixon-Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Harvey J, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol 2006;6. [17] Bondas T, Hall EOC. Challenges in approaching metasynthesis research. Qual Health Res 2007;17:113–21. [18] Noyes J, Popay J, Pearson A, Hannes K, Booth A. Chapter 20: qualitative research and Cochrane reviews. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions. Chichester: John Wiley & Sons Ltd., The Cochrane Collaboration; 2008. p. 571–92. [19] Centre for Reviews and Dissemination. Systematic Reviews. CRD’s guidance for undertaking reviews in health care. York: University of York; 2009. [20] Finfgeld-Connett D. Generalizability and transferability of meta-synthesis research findings. J Adv Nurs 2010;66:246–54. [21] Garside R. A comparison of methods for the systematic review of qualitative research: two examples using meta-ethnography and meta-study. Exeter, Peninsula Postgraduate Health Institute, Universities of Exeter and Plymouth; 2008. [22] Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol 2009;9:59. [23] Moving beyond effectiveness in evidence synthesis. London: National Institute for Health and Clinical Excellence; 2006. [24] Thorne S. The role of qualitative research within an evidence-based context: can metasynthesis be the answer? Int J Nurs Stud 2009;46:569–75. [25] Weed M. Interpretive qualitative synthesis in the sport & exercise sciences: the meta-interpretation approach. Eur J Sport Sci 2006;6:127–39. [26] Dixon-Woods M, Booth A, Sutton AJ. Synthesizing qualitative research: a review of published reports. Qual Res 2007;7:375–422. [27] Thorne SE, Jensen LA, Kearney MH, Noblit GW, Sandelowski M. Qualitative metasynthesis: reflections on methodological orientation and ideological agenda. Qual Health Res 2004;14:1342–65. [28] Cochrane Qualitative Research Methods Group. Tools to assist qualitative reviewers. Adelaide, Australia: The Joanna Briggs Institute; 2010[last update:

[33]

[34]

[35]

[36] [37] [38]

[39]

[40]

[41] [42]

[43]

[44]

[45]

[46]

[47]

[48]

[49]

[50]

[51]

[52]

23.02.2010; last access: 13.12.2010]http://www.joannabriggs.edu.au/cqrmg/ tools.html. Nowak P. Eine Systematik der Arzt-Patient-Interaktion: Systemtheoretische Grundlagen, qualitative Synthesemethodik und diskursanalytische Ergebnisse ¨ rzten[[ul]]A systematic of zum sprachlichen Handeln von A¨rztinnen und A doctor–patient interaction: systems theoretical foundations, qualitative synthesis methodology and discourse analytical results on the verbal actions of doctors]. Frankfurt a.M. u.a.: Peter Lang Verlag; 2010. Noblit GW, Hare RD. Meta-ethnography: synthesising qualitative studies. London: Sage; 1988. Paterson BL, Thorne SE, Canam C, Jillings CR. Meta-study of qualitative health research: a practical guide to meta-analysis and meta-synthesis. Thousand Oaks (CA): Sage Publications; 2001. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist synthesis: an introduction. University of Manchester; 2004 [editor 55, Manchester. ESRC Research Methods Programme. RMP Methods Paper 2/2004]. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O, Peacock R. Storylines of research in diffusion of innovation: a meta-narrative approach to systematic review. Soc Sci Med 2005;61:417–30. Weed M. Meta interpretation: ‘‘a method for the interpretive synthesis of qualitative research [53 paragraphs]’’. Forum Qualitative Sozialforschung/ Forum Qualitative Social Research [On-line Journal] 2005;6. Dixon-Woods M, Bonas S, Booth A, Jones DR, Miller T, Sutton AJ, et al. How can systematic reviews incorporate qualitative research? A critical perspective. Qual Res 2006;6:27–44. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. New York: Aldine de Gruyter; 1967. Maynard DW. Interaction and asymmetry in clinical discourse. Am J Sociol 1991;97:448–95. Heritage JC, Maynard DW. Introduction: Analyzing interaction between doctors and patients in primary care encounters. In: Heritage JC, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 1–21. Eakin JM, Mykhalovskiy E. Reframing the evaluation of qualitative health research: reflections on a review of appraisal guidelines in the health sciences. J Eval Clin Pract 2003;9:187–94. Booth A. Chapter 5 – Searching for studies. Draft chapter – in peer review with Cochrane handbook editors. In: Cochrane Qualitative Research Methods Group, editor. Cochrane Qualitative Methods Group Handbook. 2009. Booth A. ‘‘Brimful of STARLITE’’: toward standards for reporting literature searches. J Med Libr Assoc 2006;94:421–9. Grant MJ. How does your searching grow? A survey of search preferences and the use of optimal search strategies in the identification of qualitative research. Health Inform Libr J 2004;21:21–32. Barroso J, Gollop C, Sandelowski M, Meyiiell J, Pearce P, Collins L. The challenge of searching for and retrieving qualitative studies. Western J Nurs Res 2003;25:153–78. Atkins S, Lewin S, Smith H, Engel M, Fretheim A, Volmink J. Conducting a metaethnography of qualitative literature: Lessons learnt. BMC Med Res Methodol 2008;8. Greenhalgh T, Peacock R. Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. Br Med J 2005;331:1064–5. Menz F, Nowak P, Rappl A, Nezhiba S. Arzt-Patient-Interaktion im deutschsprachigen Raum: Eine Online-Forschungsdatenbank (API-onß) als Basis fu¨r Metaanalysen [Doctor–patient interaction in German-speaking countries: an online-research database (API-onß) as basis for meta analysis]. Gespra¨chsforschung - Online-Zeitschrift zur verbalen Interaktion 2008;129–63. Bru¨nner G, Gu¨lich E. Verfahren der Veranschaulichung in der Experten-LaienKommunikation [Processes of representation within expert-lay communication]. In: Bru¨nner G, Gu¨lich E, editors. Krankheit verstehen. Interdisziplina¨re Beitra¨ge zur Sprache in Krankheitsdarstellungen. Bielefeld: Aisthesis Verlag; 2002. p. 17–94. Gu¨lich E. Krankheitserza¨hlungen [Illness narratives]. In: Neises M, Ditz S, Spranz-Fogasy T, editors. Psychosomatische Gespra¨chsfu¨hrung in der Frauenheilkunde. Ein interdisziplina¨rer Ansatz zur verbalen Intervention. Stuttgart: Wissenschaftliche Verlagsgesellschaft; 2005. p. 73–89. Lalouschek J. Medizinische Konzepte und a¨rztliche Gespra¨chsfu¨hrung – am Beispiel der psychosomatischen Anamnese Medical concepts and medical discourse – exemplified with a psychosomatic anamnesis In: Neises M, Ditz S, Spranz-Fogasy T, editors. Psychosomatische Gespra¨chsfu¨hrung in der Frauenheilkunde. Ein interdisziplina¨rer Ansatz zur verbalen Intervention. Stuttgart: Wissenschaftliche Verlagsgesellschaft; 2005. p. 48–72. Lalouschek J. Kommunikatives Selbst-Coaching im beruflichen Alltag. Ein sprachwissenschaftliches Trainingskonzept am Beispiel der klinischen Gespra¨chsfu¨hrung Communicative self-coaching in everyday work. A linguistic training concept exemplified in medical discourse In: Becker-Mrotzek M, Bru¨nner G, editors. Analyse und Vermittlung von Gespra¨chskompetenz. Verlag fu¨r Gespra¨chsforschung; 2004. p. 137–58. Menz F, Lalouschek J, Sto¨llberger C, Vodopiutz J. Geschlechtsspezifische Unterschiede bei der Beschreibung von Brustschmerz: Ergebnisse einer medizinisch-linguistischen transdisziplina¨ren Studie Gender specific differences in the description of chest pain: results of a medical-linguistic, transdisciplinary study Linguistische Berichte 2002;343–66. Spranz-Fogasy T. Kommunikatives Handeln in a¨rztlichen Gespra¨chen – Gespra¨chsero¨ffnung und Beschwerdenexploration Communicative action in

P. Nowak / Patient Education and Counseling 82 (2011) 429–441

[53]

[54]

[55]

[56]

[57]

[58]

[59] [60] [61]

[62] [63] [64]

[65]

[66] [67] [68]

[69]

medical encounters – opening and illness narratives In: Neises M, Ditz S, Spranz-Fogasy T, editors. Psychosomatische Gespra¨chsfu¨hrung in der Frauenheilkunde. Ein interdisziplina¨rer Ansatz zur verbalen Intervention. Stuttgart: Wissenschaftliche Verlagsgesellschaft; 2005. p. 17–47. Bliesener T. Konfliktaustragung in einer schwierigen ‘‘therapeutischen’’ Visite Conflict in a difficult ‘‘therapeutic’’ ward round In: Ko¨hle K, Raspe H-H, editors. Das Gespra¨ch wa¨hrend der a¨rztlichen Visite. Empirische Untersuchungen. Wien/Mu¨nchen/Baltimore: Urban & Schwarzenberg; 1982. p. 249–68. Lo¨ning P. Psychische Betreuung als kommunikatives Problem. Elizitierte Schilderung des Befindens und ‘a¨rztliches Zuho¨ren´ in der onkologischen Facharztpraxis Mental care as a communicative problem. Elicitated narratives of complaints and ‘medical listening’ in a oncological practice In: Lo¨ning P, Rehbein J, editors. Arzt-Patienten-Kommunikation. Analysen zu interdisziplina¨ren Problemen des medizinischen Diskurses. Berlin [u.a.]: de Gruyter; 1993. p. 191–227. Meyer B. Medizinische Aufkla¨rungsgespra¨che Struktur und Zwecksetzung aus diskursanalytischer Sicht, Medical information encounters Structure and purpose from a discourse analytic perspectivevol. 45. Hamburg: Universita¨t Hamburg, Sonderforschungsbereich 538; 2000[Arbeiten zur Mehrsprachigkeit - Folge B, Nr. 8/2000]. Quasthoff UM. Frageaktivita¨ten von Patienten in Visitengespra¨ch Konversationstechnische und diskursstrukturelle Bedingungen Questions of patients in ward round encounters: conversation-technical discourse structural conditions In: Ko¨hle K, Raspe H-H, editors. Das Gespra¨ch wa¨hrend der a¨rztlichen Visite. Urban & Schwarzenberg; 1982. p. 70–101. Raspe H-H, Siegrist J. Zur Gestaltung der Arzt-Patient-Beziehung im stationa¨ren Bereich On the design of the doctor–patient relationship in the hospital In: Siegrist J, Hendl-Kramer A, editors. Wege zum Arzt. Ergebnisse medizinsoziologischer Untersuchungen zur Arzt-Patient-Beziehung. Mu¨nchen, Wien: Urban & Schwarzenberg; 1979. p. 113–38. Wimmer H. Information und Beratung von Krebspatienten im Krankenhaus. Voraussetzungen und Mo¨glichkeiten von Patienten im Gespra¨ch mit dem Arzt Information and counseling of cancer patients in the hospital. Preconditions and possibilities of patients in encounters with doctors In: Lo¨ning P, Rehbein J, editors. Arzt-Patienten-Kommunikation. Analysen zu interdisziplina¨ren Problemen des medizinischen Diskurses. Berlin, New York: de Gruyter; 1993 . p. 403–18. Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks (CA): Sage; 1985. Dixon-Woods M, Shaw RL, Agarwal S, Smith JA. The problem of appraising qualitative research. Qual Saf Health Care 2004;13:223–5. Jones K. Mission drift in qualitative research, or moving toward a systematic review of qualitative studies, moving back to a more systematic narrative review. The Qualitative Report 2004;9:95–112. Critical Appraisal Skills Programme (CASP). 10 questions to help you make sense of qualitative research. NHS England: Public Health Resource Unit; 2006. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. Thousand Oaks (CA): Sage; 1994. Ryan R, Kaufman C, Hill S. Building blocks for meta-synthesis: data integration tables for summarising, mapping, and synthesising evidence on interventions for communicating with health consumers. BMC Med Res Methodol 2009;9:16. Ko¨hle K, Koerfer A, Kretschmer B, Obliers R, Reimer T, Thomas W, et al. Manual A¨rztliche Gespra¨chsfu¨hrung + Mitteilung schwerwiegender Diagnosen,Manual for the medical encounter and the information on serious diagnosis 4 u¨berarbeitet Auflage ed., Ko¨ln: Institut und Poliklinik fu¨r Psychosomatik und Psychotherapie der Universita¨t zu Ko¨ln; 2007. Roter DL. The enduring and evolving nature of the patient–physician relationship. Patient Educ Couns 2000;39:5–15. Meeuwesen L. Sequential analysis of the phasing of the medical interview. Epidemiol Psichiatr Soc 2003;12:124–9. Connor M, Fletcher I, Salmon P. The analysis of verbal interaction sequences in dyadic clinical communication: a review of methods. Patient Educ Couns 2009;75:169–77. Nowak P. A first qualitative meta-study on (linguistic) discourse research— Developing a ‘‘simplest systematics’’ of doctors’ ‘‘verbal actions’’ in doctor–

[70]

[71]

[72] [73]

[74]

[75] [76] [77]

[78] [79]

[80]

[81] [82]

[83]

[84]

[85]

[86] [87] [88] [89]

[90] [91]

441

patient interaction. In: De Cillia R, Gruber H, Krzyzanowska M, Menz F, editors. Diskurs Politik Identita¨tDiscourse Politics Identity. Festschrift fu¨r Ruth WodakTu¨bingen: Stauffenburg Verlag; 2010. p. 185–95. Boyd E, Heritage JC. Taking the history: questioning during comprehensive history-taking. In: Heritage JC, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 151–84. Ong LML, Visser MRM, Lammes FB, De Haes JCJM. Doctor–patient communication and cancer patients’ quality of life and satisfaction. Patient Educ Couns 2000;41:145–56. Slack WV. The patient’s right to decide. Lancet 1977;310:240. Charles C, Gafni A, Whelan TJ. Shared decision-making in the medical encounter: what does it mean? (Or it takes at least two to tango) Soc Sci Med 1997;44:681–92. West C. Coordinating closings in primary care visits: producing continuity of care. In: Heritage JC, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 379–415. Elwyn G, Miron-Shatz T. Deliberation before determination: the definition and evaluation of good decision making. Health Expect 2010;13:139–47. Rapley T. Distributed decision making: the anatomy of decisions-in-action. Sociol Health Ill 2008;30:429–44. Li HZ, Krysko M, Desroches NG, Deagle G. Reconceptualizing interruptions in physician-patient interviews: cooperative and intrusive. Comm Med 2004;1:145–57. Menz F, Al-Roubaie A. Interruptions, status, and gender in medical interviews: The harder you brake, the longer it takes. Discourse Soc 2008;19:645–66. Heath C. Body work: the collaborative production of the clinical object. In: Heritage JC, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 185–213. Heritage JC, Elliott MN, Stivers T, Richardson A, Mangione-Smith R. Reducing inappropriate antibiotics prescribing: the role of online commentary on physical examination findings. Patient Educ Couns 2010;81:119–25. Mishler EG. Meaning in context: is there any other kind? Harvard Educ Rev 1979;49:1–19. Roter DL, Larson S. The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 2002;46:243–51. Del Piccolo L, Mead N, Gask L, Mazzi MA, Goss C, Rimondini M, et al. The English version of the Verona medical interview classification system (VRMICS): an assessment of its reliability and a comparative cross-cultural test of its validity. Patient Educ Couns 2005;58:252–64. Sandvik M, Eide H, Lind M, Graugaard PK, Torper J, Finset A. Analyzing medical dialogues: strength and weakness of Roter’s interaction analysis system (RIAS). Patient Educ Couns 2002;46:235–41. Nelson E-L, Miller EA, Larson KA. Reliability associated with the Roter Interaction Analysis System (RIAS) adapted for the telemedicine context. Patient Educ Couns 2010;78:72–8. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns 2006;60:301–12. Salmon P, Hall GM. Patient empowerment and control: a psychological discourse in the service of medicine. Soc Sci Med 2003;57:1969–80. Aujoulat I, D’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Educ Couns 2007;66:13–20. Nowak P. 20 Thesen zu Gesundheit, Partizipation und Empowerment im Gespra¨ch zwischen Arzt und Patient [20 thesis on health, participation and empowerment within the doctor-patient encounter]. Balint J. 2011;12: in press. Barbour RS, Barbour M. Evaluating and synthesizing qualitative research: the need to develop a distinctive approach. J Eval Clin Pract 2003;9:179–86. van Dam HA, Van der Horst F, Van den Borne B, Ryckman R, Crebolder H. Provider–patient interaction in diabetes care: effects on patient self-care and outcomes. A systematic review. Patient Educ Couns 2003;51:17–28.