Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment

ARTICLE IN PRESS

0277-9536/$ - se

doi:10.1016/j.so

�CorrespondHull York Me

Research Sectio

YO10 5DD, UK

E-mail addr

Social Science & Medicine 61 (2005) 2611–2627

www.elsevier.com/locate/socscimed

‘Unilateral’ and ‘bilateral’ practitioner approaches indecision-making about treatment

Sarah Collinsa,b,�, Paul Drewa, Ian Wattb, Vikki Entwistlec

aDepartment of Sociology, University of York, Heslington, York YO10 5DD, UKbDepartment of Health Sciences and Hull York Medical School, University of York, First Floor Research Section (Area 2),

Seebohm Rowntree Building, York YO10 5DD, UKcHealth Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill AB25 2ZD, UK

Available online 11 July 2005

Abstract

Practitioners can present and discuss decisions about the management of health problems in a variety of ways during

consultations. This paper examines in detail how doctors talk with patients in relation to decision-making about

treatment. Conversation analyses of decision-making sequences in consultations about diabetes in primary care and

about treatment of ear nose and throat (ENT) cancer in a specialist oncology setting, both in the UK, revealed a

spectrum of practitioner approaches ranging from more ‘bilateral’ to more ‘unilateral’. This paper identifies the key

communicative and organisational features of these approaches and provides some preliminary observations about the

implications of these for patient participation in decision-making.

r 2005 Elsevier Ltd. All rights reserved.

Keywords: Doctor–patient consultations; Decision-making; Conversation analysis; Patient participation; United Kingdom

Introduction

In recent years, there has been a growing recognition

of the importance of communication in consultations

and increased interest in ensuring that patients can play

active roles in decision-making about their treatment

(Department of Health, 2000, 2001; General Medical

Council, 2001; Kaplan, 2004; Richards, 1998).

A number of observational studies of consultations

have attempted to assess the extent of patient participa-

tion in decision-making by coding the presence or

absence of pre-identified features of such participation

e front matter r 2005 Elsevier Ltd. All rights reserve

cscimed.2005.04.047

ing author. Department of Health Sciences and

dical School, University of York, First Floor

n (Area 2), Seebohm Rowntree Building, York

. Tel.: +01904 321330; fax: +01904 321383.

ess: [email protected] (S. Collins).

(e.g. Braddock, Edwards, Hasenberg, Laidley, & Levin-

son, 1999; Britten, Stevenson, Barry, Barber, & Bradley,

2000; Byrne & Long, 1976; Gwyn & Elwyn, 1999;

Kaplan, Greenfield, Gandek, Rogers, & Ware, 1996;

Roter & Frankel, 1992). Studies of routine practice have

generally reported low levels of participation.

A growing body of conversation analytic research is

also contributing to our understanding of patient

participation in decision-making. Conversation analysis

is a method that directly considers how participants

manage their communication. It is based on empirical

observation of patterns of communication, in which a

contribution from one participant provides the context for

interpretation of the prior contribution, and the form for

construction of the next. The analysis proceeds from the

viewpoint of participants’ understandings of one another’s

actions, rather than from analysts’ views or interpretations

of what is happening (Drew, Chatwin, & Collins, 2001).

d.

www.elsevier.com/locate/socscimed

ARTICLE IN PRESSS. Collins et al. / Social Science & Medicine 61 (2005) 2611–26272612

Conversation analytic studies of consultations illumi-

nate details of the organisation of patient-professional

communication. These studies are not based on pre-

conceptions of what patients’ participation in consulta-

tions ought to look like. Thus they can shed light on the

forms which patients’ contributions to discussions take,

and on the ways in which patients’ contributions are

influenced by health professionals’ contributions. For

example, Robinson (2003) reviewed the conversation

analysis literature to develop a conceptualisation of how

organisational features of consultation activities might

account for the low levels of participation that patients

generally adopt in consultations. In the context of

patients presenting with new medical problems, he shows

that, by attending to interactional relevancies and

particular consultation phases, it is possible to predict

locations where patients are ‘free’ to initiate sequences of

action (e.g., patients tend to ask questions during the final

stages of treatment presentations). Stivers (2002) identi-

fied four ways in which parents advocate antibiotic

treatment, and illustrated how parents are oriented to the

delicacy of their proposals as intrusions into medical

authority. She also notes that when parents push for

antibiotics, this can compel doctors to prescribe them

even when this might be inappropriate, and discusses the

consequences for shared decision-making. Boyd and

Heritage (in press) demonstrate that patients, not

infrequently, exert initiative and agency in proposing

alternative agendas, challenging presuppositions, and

maintaining their contrary preferences. Gill and Maynard

(in press) show how patients construct explanations that

do not disrupt doctors’ information-gathering activities—

e.g., during the collection of medical data, patients’

explanations are constructed so as to provide doctors

with sequential options other than immediately produ-

cing confirming or disconfirming assessments.

Overall, relatively little research has analysed re-

corded instances of decision-making in detail (Clarke,

Hall, & Rosencrance, 2004). Those which have have

tended to focus on single types of consultation and/or

treatment decisions. Constituent features of practitioner

style have been underspecified, and the question of how

practitioners’ actions might promote (or inhibit) pa-

tients’ participation remains largely unaddressed.

This paper reports conversation analyses of record-

ings of consultations across different clinical settings. It

examines health professionals’ talk across decision-

making trajectories and considers the implications of

practitioners’ approaches for patients’ participation in

treatment decision-making.

Method and analysis

The analyses reported here were conducted as part of

a broader study of patient participation in decision-

making (see also Entwistle et al., 2004). Five areas of

clinical practice (family planning, general practice

management of diabetes, homeopathy, clinical cancer

genetics, ENT oncology) were selected to represent

variety in terms of traditional practice cultures and

professional–patient relationships; professionals’ train-

ing backgrounds; extent to which people are likely to be

informed and confident about contributing to decisions;

types of health problems and treatment/management

decisions. Within each area, purposive sampling techni-

ques were employed to identify a wide range of

experiences and views relating to the participation of

individuals in decisions about their care. We recorded

consultations (on video where permitted) and inter-

viewed (separately) the health professionals and patients

involved. A total of 168 consultations involving 114

patients and 47 health professionals were recorded,

providing the data source for the analysis presented in

this paper. Decision-making sequences in 80 of these

consultations were transcribed and analysed for the

present paper, with a particularly detailed focus on 45

(22 consultations for diabetes in primary care; 23 in

ENT oncology).

We used conversation analytic techniques to study

how decision-making is enacted through patient–practi-

tioner communication in consultations. We watched

consultation videotapes and listened repeatedly to

recordings, and prepared detailed transcripts using a

notation system designed to portray features of verbal

and nonverbal actions and their timing (see the

appendix).

The recordings revealed considerable variation

in how individual practitioners approached and

managed decisions in consultations with patients.

We made extensive notes on sequences of decision-

making and associated activities in consultations.

We identified typical trajectories of decision-making

and considered how their interactional configuration

shaped opportunities for patients’ involvement. At the

level of turn and sequence, we noted features of their

design and delivery, and collated instances of the

communication characteristics they contained. To take

one example, we recorded variations in the design of

practitioners’ turns in which decisions were initially

referenced. For each instance, we noted: the context in

which the initial reference was made; how it was

phrased and delivered; and what happened next (e.g.

whether or not a patient responded, and if so how). We

also took content into account, e.g. which treatment

options were presented, and what types of information

were supplied.

By documenting contrasts and variations at this

level of detail, we constructed a picture of how

practitioners manage decision-making in consultations

and how they provide opportunities for patients to

contribute.

ARTICLE IN PRESSS. Collins et al. / Social Science & Medicine 61 (2005) 2611–2627 2613

Findings

We identified a spectrum of practitioners’ manage-

ment of communication in decision-making that ranged

from more ‘bilateral’ to more ‘unilateral’. In a more

‘bilateral’ approach, decision-making was enacted as an

integral part of communication in consultations, nego-

tiated between the practitioner and the patient, and

dependent in part on the patient’s contributions. In

more ‘unilateral’ approaches, the practitioner more or

less autonomously conducted the decision-making pro-

cess, structuring it somewhat independently of his or her

conversation with the patient.

In this paper, we show that more bilateral and more

unilateral approaches can be seen across different

clinical settings, but also that they may tend to vary

across settings. In order to elucidate key features of each

type of approach, we describe the decision-making

sequences in four consultations, two concerning the

management of raised blood glucose levels (diabetes in

primary care) and two concerning a newly diagnosed

cancer (specialist ENT oncology). We selected these

cases from our data because they display the greatest

diversity in, and allow clearest portrayal of the contrast

between, ‘bilateral’ and ‘unilateral’ practitioner ap-

proaches. Also, the treatment decision-making se-

quences within these consultations are relatively self-

contained and distinguishable from other parts of the

consultation, and show the most consistent variations in

practitioner approach, allowing for detailed identifica-

tion of differences across instances.

The decision-making trajectory

From repeated viewing of the data, we observed a

trajectory of decision-making, extending from the

transition into a decision-making phase initiated by the

practitioner, through to the arrival at a decision (or

some conclusion about the decision to be made). The

findings presented below are organised according to

moments along this trajectory, which can be charac-

terised as follows:

�
The ‘opening of the decision-making sequence’ sets the
scene for presenting and characterising a problem

�
The ‘presentation and evaluation of the test result or
diagnosis’ provides various opportunities and ave-

nues for talking about and reflecting on the problem.

�
The ‘introduction of the decision point’, i.e. how a
decision is initially referenced.

�
‘Consideration and discussion of options’ in which one
or more options are identified and debated.

�
The ‘conclusion of the decision-making phase’ presents
the chosen course of action (a treatment selection, or

agreement to continue discussion on another occasion)

and transition to another consultation phase begins.

Discussions of treatment of diabetes in primary care

The first two examples we present are from consulta-

tions between two different GPs and patients with Type

2 diabetes. They are both ‘review’ consultations, and in

each example, the latest glycosylated haemoglobin

(HbA1c) test results for the patient, who has had

diabetes for some time, indicate that the patient’s blood

glucose levels are high enough to cause concern. There

are a number of options that might be considered in

such cases: ‘do nothing’ or ‘leave it and see what

happens’; make lifestyle changes; and add in, or increase

the dose of, oral medication or insulin. In each of our

examples, both oral medication and insulin are con-

sidered. In the ‘bilateral’ example, ‘doing nothing’ and

lifestyle (dietary) changes are also entertained.

Opening the decision-making sequence

The difference between more ‘bilateral’ and more

‘unilateral’ approaches first becomes apparent in the

opening of the decision-making sequence.

The more ‘bilateral’ case

As this sequence begins, a lengthy phase of discussion

about the patient’s diet is drawing to a close. This

discussion about diet serves as the preface to the

introduction of the problem of the high blood glucose

levels, and enables the doctor to sound out the patient’s

opinion.

1a: B1-112-353

1 D:
Er:m (1.2) how do you think you are 2 with your diet now 3 P: hhhh –e::hh (3.0) huh h-h-he 4 hh (0.7) I rea: :ly h-don’t know 5 (0.4) eh-but again I’ve al::ways 6 been high [at tea time 7 D: [Hm – hm 8 D: Pk-.hh (0.3) do you think looking at 9 your diet there’s anything (1.8) 10 that really (.) you think’s not 11 quite as good from the diabetic 12 point of view (3.5) 1you know we 13 talked about cakes and biscuits 14 last time1 15 (2.5) 16 P: Not – not that I’m aware of 17 (0.3) 18 D: 1Right1 11okay11 19 D: One of the questions I think we have 20 today (0.2) i:s
The discussion is drawn into focus from the practi-

tioner’s initial question ‘how do you think you are with

your diet now’ (line 1) to a reformulation that builds a


connection between diet and diabetes: ‘do you think

looking at your diet there’s anything that really you

think’s not quite as good from the diabetic point of view’

(lines 8–12). Correspondingly, there is a sharpening of

focus through the answers the patient produces, from

the more vague ‘I really don’t know but again I’ve

always been high at teatime’ (lines 4–6), in which he

attributes the peak in blood glucose levels at teatime to

‘normal’ fluctuations for him, to the more specific ‘not

that I’m aware of’. That the first answer was not the one

the doctor was looking for is evidenced in that: firstly,

she begins to rephrase her question (line 8) as soon as it

becomes apparent that the patient is focusing on the

‘normality’ (‘always’) of his high blood glucose levels at

teatime; secondly, she re-specifies the question (‘from the

diabetic point of view’); thirdly, she adds ‘we talked

about cakes and biscuits last time’; fourthly, she waits

for the patient to answer (lines 15,17). The doctor’s re-

specification of her question provides guidance for the

patient in how to reply, and points out the connection

between diabetes and diet.

The doctor pursues a comment from the patient on his

management of his diabetes through diet. She repeatedly

solicits his view: ‘how do you think’ (line 1), ‘do you

think’ (line 8), ‘you think’ (line 10). Thus, the patient is

encouraged to display his opinion, as evidenced in the

answers he produces. The doctor builds her next turn,

and the next phase of the decision-making (lines 19–20),

on the patient’s answers.

The more ‘unilateral’ case

This case exhibits a number of features which show it

to be more ‘unilateral’. The sequence opens with the

main focus of the doctor’s attention directed towards the

template displayed on the computer screen (line 3).

2a: B1-119-338

1 D:
11So we’re gonna do the diabetic 2 follow up11 1clinic1 3 ((looking at computer monitor)) 4 (5.0) 5 D: Okay I’m gunna set you target level 6 two (0.6) er:: now that (0.5) that 7 is: um:: (0.5) result of some tests 8 (.) 9 P: Yeh 10 (.) 11 D: That we’ve 4done from the nurse.o 12 an we we 4want ah- youo (.) 13 controlled to a certain level .hh 14 (.)mthuh most important test
When the doctor begins to talk to the patient (line 5),

he sets a ‘target level’, the phrasing of which stands

independently of the patient’s viewpoint. This is

evidenced in the transitive verb forms ‘I’m gunna set

you target level two’ (lines 5–6), and ‘we want you

controlled to a certain level’ (lines 12–13); the profes-

sional ‘we’ combined with the verb ‘want’ suggesting

‘our determination of your treatment’ (line 12); ‘con-

trolled’ (line 13) implying a passive role for the patient.

In the course of the doctor’s pronouncement, the patient

produces an agreement token, ‘yeh’ (line 9).

As the doctor comes to the end of this first phase, he

immediately proceeds with the next. He introduces the

test result within the same turn in which he presents the

target level, leaving no room in which the patient can

respond to the proposed targets (line 14).

Comparison of features

In the ‘bilateral’ instance, the sequence opens with an

invitation from the doctor to the patient to consider and

express his views in relation to his own management.

The doctor pursues the topic of diet with a question,

seeking a specific response, and building on the one the

patient eventually supplies.

In the ‘unilateral’ instance, the interaction proceeds

with considerations outside the patient’s perspective. By

the end of this opening phase (in comparison to the

‘bilateral’ instance), the patient’s perception of the

current state of his diabetes remains unelicited, and

there has been no discussion of the patient’s self-

management by diet.

In the ‘bilateral’ case, the patient is given time to

respond; in the ‘unilateral’ one, there is not time for the

patient to respond.

Presenting the test result

The test result is presented differently in ‘unilateral’

and ‘bilateral’ cases.

The ‘bilateral’ case

Having established that the patient perceives little

scope for improvement in diet, the doctor introduces the

HbA1c result, and proceeds to detail the patient’s

situation in light of it.

1b: B1-112-353

20 D:
One of the questions I think we have 21 today (0.2) i:s (2.0) your blood 22 sugar is high 23 (0.2) 24 P: Ye[a 25 D: [it is better than it was last time 26 P: Yes ¼
27 D:
¼ it’s not as good as it has been 28 (1.5) er:m if we look back – to – 29 (2.8) august (0.4) the year before 30 P: Yea 31 D: It was a bit better down at


32
(eigh[t) but it’s higher than it ¼
33 P:
[Hm – hm 34 D: ¼ has been �h and ideally we’d like it 35 down at seven 36 D: �hh we know that down into seven 37 (0.9) helps to protect you quite 38 dramatically �hh against heart 39 attacks (.) against strokes and 40 against all the complications in 41 your feet and your eyes of diabetes 42 (4.0)
¼

By beginning with ‘one of the questions I think we

have today’ (line 20), the decision point is signposted for

the patient prior to its specification. It is framed as a

‘question’ shared by the doctor and the patient (‘we

have’) to be answered in the consultation (‘today’).

By gradually staging the problem presentation

through details of fluctuations in levels over time, the

doctor enlists the patient’s voiced agreement on the

nature of this problem at a number of points (lines

24,26,30,33) and highlights the significance of this latest

result for this individual patient.

The doctor cites the benefits of bringing the patient’s

blood sugar down by drawing on medical evidence ‘we

know that y’ (lines 36–41), and linking it with this

patient (‘helps to protect you..’, ‘your feet and your

eyesy’). A focus on this individual patient’s blood

glucose levels is established and maintained by the non-

technical introduction of the HbA1c result, its con-

textualisation within the ‘question we have’, and the

tracing of results over time.

The doctor specifies a desirable level based on

professional opinion ‘ideally we’d like it down at seven’.

The target is set conditionally, allowing room for

negotiation (the conditional form ‘we’d’; the emphasis

on ‘ideally’). This target is fitted to the individual patient:

built on the description of the patient’s results over time,

and presented separately from the discussion of options.

The ‘unilateral’ case

By comparison with the ‘bilateral’ presentation of the

test result in Example 1a, the case below displays

features of a more ‘unilateral’ approach.

2b: B1-119-338

14 D:
y (.)mthuh most important test 15 kthat we do is the HbA1c 16 P: ((nods)) (0.9) 17 D: Have yuh heard of this one 18 [before] 19 P: [ y e s] this is the: er 20 (1.3) 21 P: Erm 22 (2.0) 23 P: The actual control of the: er
24 D:
Tck yeh it give[s an indication of] ¼
25 P:
[ uv (the) sugar ] 26 ¼ how we[ll y]our diabetes is ¼
27 P:
[(uh yeh)] 28 D: ¼ con[troll]ed 29 P: [y e s] 30 (.) 31 D: It’s actually ah- measuring how 32 much glucose is combined with 33 the red blood cell pigment 34 P: 1(Yes)1 35 D: And because the red blood cell 36 pigment is locked up in the red 37 cells which .hh have a half life 38 of a-(.)pproximately six to eight 39 weeks .hh (.) it gives us an 40 averaging out figure over that 41 period ¼
42 P:
¼ That’s right (.) yeh 43 D: hhh now:? yours is nine point six 44 (0.4) 45 an[d that is] hi:[g h ::]. 46 P: [ Y e s : ] [that i]s high ¼
47 D:
Y[eh] 48 P: [Ye]h 49 D: I would like tuh see that somewhere 50 near:: (.) sih- between six and 51 seven percent
Having explained that he will go through the test

results, the doctor proceeds with a detailed technical

description of the HbA1c test and what it measures. This

is done independently of, and is given prominence over,

individual patient considerations. It is placed immedi-

ately following (within the same turn as) the doctor’s

assertion ‘we want you controlled to a certain level’ and

highlighted in general terms that emphasise its signifi-

cance, ‘the most important test that we do’ (lines 14–15).

The question ‘have you heard of this before’ (lines

17–18) invites the patient to express his general under-

standing; his partial response (line 23) is sufficient to

allow the doctor’s continuation. The patient does not

relate the test to his own situation, nor does his response

influence the course of the explanation that the doctor

subsequently supplies.

The doctor’s report of the test result (line 43), and his

evaluation of it (line 45), are direct and emphatic,

carrying a note of urgency. The result is reported as

news: ‘no:w’ announces its arrival; the emphasis on

‘yours’ and ‘high’ gives it greater impact. This news

format (told from the doctor to the patient) leaves little

part for the patient in constructing its significance.

The presentation of the test result is not accompanied

by supporting evidence or rationales for how to interpret

this result for this patient, either in the light of previous

results or in relation to disease implications. The


phrasing ‘that is high’ (line 45) does not invite talk about

how the result has come about, or how the patient feels

about it.

The patient expresses a form of agreement (repeating

and stressing the assessment ‘that is high’, line 46),

displaying that he knows this to be a high figure

generally speaking, but leaving unexpressed (and un-

explored in subsequent turns) his interpretation of it in

relation to his own situation. While the patient

demonstrates understanding of this result’s general

significance, his response does not indicate how he feels

about it in relation to himself. His agreement is

overlapped with the doctor’s continuation (lines 47,

49–50) and assertion of an ideal level.

The doctor’s presentation of the target (‘I would like

to see thaty between six and seven per cent’, lines

49–51) is built on his view (I would likey) and produced

immediately following his own evaluation of the result.


In the ‘bilateral’ instance, the test result is introduced

as a question, which the doctor presents as one to be

answered together. The delivery of the test result is

phased to invite the patient’s agreement. The presenta-

tion is phrased with reference to this individual patient,

and the target is specified so as to allow room for

negotiation.

In the ‘unilateral’ instance, the medical and scientific

rationale of the HbA1c test takes precedence. The

doctor dictates the target for the patient’s HbA1c. The

agreement the patient produces is limited to under-

standing the general severity of this result, rather than

participation in constructing or reflecting on its source

or its significance for his situation.

Introducing the decision point

The way the ‘decision’ is initially referred to shapes

how it is subsequently discussed.


1c: B1-112-353

43 D:
so we’ve got- (2.0) we’ve got a 44 couple of choices about that 45 really (1.8) either we say
The phrasing ‘we’ve got a couple of choices about that

really’ alerts the patient to the shared status of these

choices in advance of the doctor naming them.


2c: B1-119-338

52 D:
Tck (.) so we need tuh get that down
53
(0.7) an it means changing your 54 treatment
The doctor’s presentation of the decision point

continues directly from his statement of a target. The

decision is stated unequivocally (‘need to get that down

y it means changing your treatment’).


In the ‘bilateral’ case, the doctor signposts that a

decision is imminent, and refers to it as ‘choices’ we

have. In the ‘unilateral’ case, the transition is not

signposted, the decision is cast as necessary, and dictates

treatment change.

Presenting and discussing options

Presentation and discussion of options follows the

introduction of the decision point.


The doctor begins by talking about non-medical

options, setting the scene for decision-making widely

and inclusively.

1d B1-112-353

43 s
o we’ve got- (2.0) we’ve got a 44 c ouple of choices about that 45 r eally (1.8) either we say (1.2) 46 w ell (.) we leave it (0.2) and don’t 47 t ry and do anything I’m not 48 i nterested in doing anything �hh and 49 t ake the risk with the complications 50 ( 0.2) it wouldn’t be a (0.9) it 51 w ouldn’t be a route I’d (0.2) suggest 52 b ut it’s- it’s an option1 (0.7) then 53 t he other option we’ve got is 54 l ooking at your diet (0.5) even more 55 c losely (0.5) but it sounds like 56 y ou’ve- (1.8) you feel that that’s 57 f airly much honed down now 58 P: p k- �hh I hope so 59 (1.4) 60 D: W e have two more options (1.0) one is 61 t o (0.4) increase your insulin (1.5) 62 t he other option might be to add in a 63 t ablet (0.7) but keep your insulin 64 ( 0.3) the same 65 P: H -[hm 66 D: [and that’s been quite successful 67 f or some people 68 P: H m 69 ( 0.8) 70 D: E rm �hh I don’t know whether you’ve 71 h ad this tablet in the past it’s 72 c alled metformin


73 P: H
m (.) I’ve had that that’s one I had ((10 lines omitted—patient relates his previous
experience of Metformin))

84 D: 1
Yea1 (0.4) p- �h[h what we used to ¼
85 P:
[ �hh 86 D: ¼ (1.0) what we used to do was it was 87 e ither insulin or tab[lets 88 P: [Hmm – h[m 89 D: [ �hh 90 w hat they’re finding nowadays is for 91 s ome people �hh the combination of the 92 t ablet and the insulin work—quite 93 w ell ¼
94 P
: ¼ Hm 95 (1.0) 96 D: S o (there are f) (0.5) or the other 97 o ption is putting your insulin up 98 P: H m
In presenting the first option (‘we leave it’, lines

46–52) the doctor offers the possibility ‘we don’t try and

do anything’, and qualifies this ‘it wouldn’t be a route

I’d suggest, but it’s an option’. Her opinion invites

consideration of the medical implications in doing

nothing (‘we take the risk of complications’). At the

same time, ‘what [she]’d suggest’ is separated from ‘it’s

still an option’. Thus, her expressed opinion does not

detract from its optional status for the patient. The

second choice (‘looking at your diet even more closely’,

line 54), and her report of the patient’s assessment of its

relative infeasibility (‘sounds like you feely’), displays

the doctor’s understanding of the discussion that has

just been concluded, and precipitates the patient’s ‘I

hope so’ (line 58).

The doctor continues by signposting further options

‘we have two more options’ and detailing these

(lines 60–67). Each option is presented neutrally

(‘increase your insulin’; ‘add in a tablet but keep your

insulin the same’). The doctor gradually introduces

the second option. She begins by referring to it as

a ‘tablet’; she then relates it to the patient’s experience

‘I don’t know whether you’ve had this tablet in the

past’; thirdly, she names it ‘it’s called Metformin’;

finally, she refers to its effectiveness ‘and that’s been

quite successful for some people’. This gradated delivery

invites the patient to begin to entertain it from his

perspective.

Following the patient’s recollections of having tried

this tablet before, the doctor reintroduces the tablet

option in such a way as both to accommodate the

patient’s experience and set it in the past (‘what we used

to do’, line 86), and to reinstate it as an option for the

present (‘what they’re finding nowadays’, lines 90–93),

thereby demonstrating the current viability of combin-

ing tablets and insulin. The reiteration of insulin (lines

96–97) redresses any bias introduced by the immediately

preceding in-depth discussion of the tablet.


In this case, non-medical options (e.g. ‘doing nothing’;

the patient’s own lifestyle and management) are

precluded from consideration in the doctor’s opening

turn (lines 43–44).

2d: B1-119-338

52 D:
Tck (.) so we need tuh get that down 53 (0.7) an it means changing your 54 treatment 55 P: 11Yeh11 56 D: mHave you been using (metformin) 57 kin the past 58 (0.4) 59 P: I tried it and it made me violently 60 ill 61 D: Okay (0.4) right ((16 lines omitted—effectiveness of the patient’s current
tablet is called into question))

77 D:
yeah (0.5) I- I- think thut- the 78 thing is thut (0.6) we- we need to 79 change things y- ¼
80 P:
¼ yeh ¼
81 D:
¼ Yer on a maximum dose of er: 82 gliclazide 83 (0.6) 84 P: Yeh ¼
85 D:
¼ Ahrn: an ah don’t think (.) I can 86 increase the Acarbose without 87 causing you bowel problems 88 P: Yeh 89 D: .hhh so I think the choice is of 90 using a very new drug which I’ve 91 never used? before. (0.4) an I 92 would need to talk to one of the 93 consultants about that 94 P: Yeh 95 D: .hh or:: we switch yuh to insulin 96 (0.7) 97 P: Yeh 98 D: Now most people when we talk about 99 switching to insulin are horrified 100P: Ah: know 101D: But in fact? the actual process 102 (0.6) is easy to learn. 4an you 103 actually feel be[tter when 104P: [1?yeh?1 105 you’re on on insulino 106P: Yeh 107D: There are very few patients that 108 have said to me (0.4) er:m (0.9) 109 1I- I- I’ve- hated this switch 110 they’v-1by and large they’ve all


111
said (0.5) I feel so much better 112 on insulin 113 (0.4) 114P: Yes 115D: So I think the reality is (0.7) the 116 reality is we’ll probably switch 117 you to insulin (.) .hh but I I’d 118 like to just suss this out 119 because there’s a new drug on 120 thuh on thuh market ((21 lines omitted—new drug is discussed, and patient
recalls having heard of it))

141D:
Now this second one’s come come has 142 come along an it’s much s:afer. .hh 143 but I still think I’d like tuh suss 144 this out with thuh consult[ant] ¼
145P:
[yeh] 146 ¼ before we do 147P: (yes ) 148D: Tck okay .hhh ah so we need to make 149 some changes
Following directly from his opening line (lines 52–54),

the doctor presents the first option within a question,

‘have you been using Metformin in the past’ (lines

56–57), which assumes a place for medication (and this

particular form of it) as an option.

Throughout the ensuing discussion, the scope for

decision-making is restricted to medication options.

These are presented as matters for the doctor to

decide, and are partially concealed from and handled

somewhat independently of the interaction.

The doctor discounts the first two options he presents.

The first (‘Glyclazide’, lines 81–82) is a definitive

statement. The second (‘Acarbose’) attributes responsi-

bility and opinion to the doctor (‘I don’t think I can

increasey without causing you bowel problems’, lines

85–87).

The second set of options (‘a drug I’ve never used

before’ and ‘switch to insulin’) are presented as a choice

from the doctor’s point of view (‘I think y’, line 89).

This signposts that more options are to be mentioned,

without accommodating the patient’s opinion. The

response the doctor actively pursues is information

about Metformin. The phrasing in the presentation of

each option limits the patient’s part: ‘we switch you to

insulin’ (with its transitive verb form we ‘do something’

to you), and, ‘I would need to talk with one of the

consultants about that’ (making recourse solely to

professional opinion).

Expansion of insulin as the most likely option (lines

98–112) is unilaterally initiated by the doctor, and

proceeds from the viewpoint of ‘most people’. The

doctor anticipates that this patient will resist, on the

basis of what he knows about people in general. In

response, the patient demonstrates familiarity with the

general reaction (‘I know’, line 100), without conveying

his own feelings.


The ‘bilateral’ case shows a greater degree of

negotiation with the patient, facilitated by beginning

with non-medical options: ‘doing nothing’; ‘looking at

your diet’. The doctor’s presentation indicates how to

assess the import and benefits of each option, but the

medical options are signposted, counterbalanced and

related to the patient’s perspective.

In the ‘unilateral’ case, the doctor frames the

discussion in terms of medical options, and their

phrasing and delivery leave less room for negotiation

and the patient’s perspective.

Concluding the decision-making sequence

The way in which the decision-making is brought to a

close differs across ‘bilateral’ and ‘unilateral’ instances.


1e: B1-112-353

96 D:
So (there are f) (0.5) or the other 97 option is putting your insulin up 98 P: Hm 99 (1.0) 100D: and I don’t know how you feel about 101 (0.6) where we should go (1.0) as 102 far as the sugar’s concerned 103P: I’d prefer to try the tablet 104D: 1Would you1 105P: Hm
The doctor’s conclusion (‘I don’t know how you

feely, lines 100–102) explicitly invites the patient’s

opinion while conveying, at the same time, that the

selection of a course of action is negotiable and to be

shared (‘ywhere we should go’).

The forthright expression of preference from the

patient, which follows, ‘I’d prefer to try the tablet’ (line

103) leaves little doubt about his view. It comes in

conclusion to (and is informed by) the doctor’s position,

spelt out through the decision-making sequence. The

doctor’s follow-up ‘would you’ (line 104) reinforces the

patient’s stated preference.


In this case, the decision-making sequence concludes

on the note of necessity on which it began.

2e: B1-119-338

148 D:
Tck okay .hhh ah so we need to make 149 some changes


150
(.) 151 D: ah:nd (I’[ll )] 152 ((D turns to computer screen)) 153 P [yuh see] diet? I- I 154 can’t do anything with diet. 155 (0.6) 156 P: I:m:: eating as li[ttle] 157 D: [I: :] I agree 158 with you because your body mass 159 index is fine
The doctor’s ‘okay’ signals closure and transition to a

new topic (Beach, 1995) and is followed by his own next

turn ‘so we need to make some changes’ (lines 148–149).

Immediately, the doctor continues ‘an:dy’, turning

back to the computer screen, signalling a transition to a

new activity.

Just as the doctor moves out of the decision-making

phase (line 126), the patient mentions his diet (lines

153–154). By being raised at the point of sequence

closure (rather than in a space provided within the

sequence), scope for talking about the patient’s experi-

ence of his lifestyle management in the context of the

decision is restricted.


In the ‘bilateral’ instance, the doctor gradually

concludes the decision-making, inviting the patient to

choose between options. In the ‘unilateral’ instance, the

doctor abruptly concludes the decision-making, with

reference to necessary actions he will take. Following the

sequence closure, the patient raises a lifestyle option, but

the doctor has moved on.

Summary of contrastive features of ‘unilateral’ and

‘bilateral’ approaches

The two cases presented above illustrate characteristics

of more ‘unilateral’ and more ‘bilateral’ approaches that

pertain across our data set. In Table 1 we summarise the

variations between different approaches and their corre-

sponding communication features.

Comparison across settings: ENT oncology consultations

for newly diagnosed cancer

In order to exemplify how these ‘unilateral’ versus

‘bilateral’ approaches hold across different clinical

settings, we now illustrate their features in the context

of treatment decisions in response to diagnosis of an

ENT cancer.

In each of these cases, the patient has throat cancer,

and is receiving an official diagnosis for the first time

(the patient in the ‘bilateral’ case had previously been

told that the surgeon suspected a malignancy, and had

been given an indication of the type of treatment that

the surgeon would propose if this was confirmed). In

both cases the surgeons advocate treatment by surgery,

followed by a course of radiotherapy. In the ‘unilateral’

instance, only one option (surgery) is presented. In the

‘bilateral’ instance, radiotherapy alone is presented as an

alternative, as are the possibilities of doing nothing, and

watchful waiting.

We note that in general, a more ‘unilateral’ format was

observed in our recordings of ENT oncology consulta-

tions than was observed in primary care diabetes

consultations. Where a cancer diagnosis prefigures talk

about treatment, the decision-making trajectory and its

constituent features appear to be managed and organised

in ways which reflect the critical nature of this diagnosis

and the associated treatment considerations.

Opening the decision-making phase

In the decision-making in ENT oncology, both

approaches begin with discussions about treatment.


In this ‘bilateral’ case, the surgeon introduces the

prospect of treatment (‘I think that there are two ways of

doing it’, lines 6-10) in advance of identifying options.

3a: B1-102-348

1 D:
I’m gonna wait for the- well I’m uh- 2 I’m gonna carry on talking because 3 uh although: I’m waiting for the 4 biopsy just to confirm I think 5 there’s �hhh there’s no doubt about 6 uh in my mind that you’ve got a 7 tumour in your tonsil. 8 (0.3) 9 D: Okay? �hhh And (0.3) as I said to you 10 last week I think that there are two 11 ways of 12 (1.5) 13 P: doin’ it ¼
14 D:
¼ odoing that [for ] 15 P: [wih-] we (really-) 16 P: We agreed on thi[s (one.)] 17 D: [We mdid ] really 18 an’ I was jus’ gonna go over them 19 for for: (.) your benefit as much as 20 for mine so that you understand what 21 what the issues a:re. �hh It’s (0.2) 22 quite a large tumour (.) but it 23 certainly is very treatable: �hhh
By casting the alternatives as ‘ways of doing’ an action

is made prominent.

ARTICLE IN PRESS

Table 1

Contrastive features of ‘unilateral’ and ‘bilateral’ approaches

Components of decision making More ‘unilateral’ practitioner approaches More ‘bilateral’ practitioner approaches

Introducing the decision-making

phase

Begins from considerations not shared with

the patient

Begins from an accommodation of the patient’s

perspective, and practitioner shares his/her

considerations with the patient

No preface inviting the patient’s view (and/

or discussing patient’s management)

Preface invites the patient to consider their

views/understanding of possible treatment

(and/or their own management)

Presents decision as ‘made’ Presents decision as ‘to be made’

Presenting test results or diagnosis Emphatic presentation of test results or

diagnosis, pointing to the necessity of

doing something, and perhaps of acting

quickly

Deliberated presentation of test results or

diagnosis, accompanied by explanations or

guides as to how results/problems are to be

interpreted

Presentation of the situation premised on

the practitioner’s opinion

Presentation of the situation premised on

consideration of the patient’s understanding

Introducing the decision point Presentation of the decision as ‘news’,

‘necessity’, ‘information’, or ‘explanation’

Presentation of the decision as a ‘decision’ or

‘choice’

Presenting and discussing options Identifying choices or options within the

same turn in which the decision point is

introduced

Signposts that choices, options, or decision

points are about to be presented, in advance of

naming or specifying them

Discussion centres on medically controlled

options

Discussion includes relevant lifestyle and

patient controlled options alongside medically

controlled options

Lists or runs through options without

providing an opportunity for patient to

participate

Paces the delivery of options, and separates

options from decision point (by producing

them in different turns)

Relatively fewer options (single options

generally presented without their

counterparts)

Relatively more options (with inclusion of

counterparts)

Omits consideration of the option of ‘doing

nothing’

Includes ‘doing nothing’ alongside other

options

S. Collins et al. / Social Science & Medicine 61 (2005) 2611–26272620

The assessment of the tumour as ‘quite large’ (line 22)

provides the foundation for subsequent justification of

surgery (‘because of the extent of it’) as preferable. The

note of optimism carried in ‘certainly very treatable’

(line 23), coupled with the earlier emphasis on action,

stresses that treatment is worthwhile and, by implica-

tion, counters the possibility of doing nothing.


The surgeon introduces the diagnosis and treatment

discussion in terms of news: ‘results day’ (line 1) ‘good

news and bad news’ (line 5).

4a: B1-133-358

1 D:
Results day 2 (0.4) 3 P: Yes. (1.3) (I’ve turned up so you can 4 tell me to my face) 5 (0.4) 6 D: Yeah well (.) there’s good news and
7
bad news. 8 (0.7) 9 P: Mm hm, 10 (0.5) 11 D: Shall we start off with the bad news 12 first 13 (.) 14 P: Mmm 15 (0.5) 16 D: You’ve got cancer. 17 P: I (thought) yeah, (.)I had assumed 18 that I would 1have1 19 (0.3) 20 D: Indeed (.) you’ve got cancer there, 21 (0.2) and you’ve got cancer there, ((59 lines omitted- surgeon explains anatomy and
describes the cancer’s location and spread))

80 D:
And it’s become trapped (0.7) in 81 these glands here 82 (0.5) ((D draws on paper))


83 P:
This is here 84 ((indicating on his own throat)) 85 (.) 86 D: Yes. (.) indeed. 87 (1.1) 88 ((D turns away to draw on paper)) 89 D: .t an:d (0.8) what we need to do (.) 90 is
By equating ‘treatment’ with ‘news’, treatment is

presented as inevitable. The contrast of ‘good’ and ‘bad’

prefigures talk about a treatment decision, and has

particular consequences for how discussion proceeds. By

pitting ‘good news’ (surgery need not be as extensive as

it might have been; the patient does not have to have his

voice box removed) against ‘bad’, the ‘bad news’ of

having cancer becomes subsumed overall within the ‘bad

news’ of the need for surgery. Consequently, discussions

of the patient’s response to the diagnosis and of

alternative treatment options are deflected.

The detailed information the surgeon provides blocks

opportunities for exploration of the patient’s response

and sets the stage for talking about treatment. The

patient’s response to the surgeon’s descriptions (‘this is

here’, line 83) and the surgeon’s following ‘yes indeed’

(line 86) produce a level of understanding and agreement

that establish the patient’s awareness of the location of

his tumour in relation to the surgery being proposed, but

do not convey how he feels about the treatment decision.

The surgeon moves from one activity (describing the

cancer) to a next (talking about treatment) through his

own turns, drawing on the paper in between (lines

86–89). The unmarked transition restricts the space for

the patient to speak and limits the practitioner’s

responsiveness to the patient’s opinions or feelings

about the proposed surgery.

Comparison with diabetes

Across diabetes and oncology, in the ‘bilateral’

approach, doctors share considerations about possible

courses of action with the patients, and invite the

patients’ opinion. In the ‘unilateral’ approach, doctors

present results as ‘news’, decisions as ‘made’ and

treatments as ‘necessary’. They supply descriptions of

technical and medical aspects (the location of the cancer

and its spread; how the HbA1c test works), within which

patients’ contributions are limited to displays of under-

standing and agreement of given descriptions. They

move abruptly from definition of the problem to

presentation of treatment.

There are two overall points of contrast with diabetes

in the ENT oncology consultations. One concerns the

emphasis on treatment. Another relates to the structure

of the opening sequence in the decision-making trajec-

tory, which accommodates within it the decision point

itself.

Presenting and discussing options


The surgeon presents two options—radiotherapy and

surgery—alongside one another.

3b: B1-102-348

21 D:
ywhat the issues a:re. �hh It’s 22 (0.2) quite a large tumour (.) but 23 it certainly is very treatable: �hhh 24 And because of thee, extent of it, I 25 think that radio therapy would stand 26 a very small chance:: (.) of: (1.4) 27 completely uhm (0.3) getting rid of 28 it it. I think the other option:- 29 (0.2) which: (1.0) is: (.) much more 30 of a (0.3) of a (0.7) 1m-1 (0.7) 31 viable (1.0) treatment, is surgery. 32 (0.3) which would invo:lve removing 33 that- (.) ar:ea of the palette ‘n 34 tonsil (0.2) �hhh uh (0.3) what I 35 didn’t go in: to detail of la:st week, 36 was the details of the surgery one of 37 the things we would do: havin:g (0.2) 38 removed the tumour would be to use a 39 (0.4) patch of skin from down he:re, 40 (0.5) uz a (.) what’s called a skin 41 fla:p to put in there to fill the 42 a:rea. Cos you can’t just �h sew it 43 directly together �h like you could 44 a little thing on the ski:n 45 (.) 46 D: Uh:m (0.3) �t �h (0.5) A:nd what we 47 would then do is obviously send off 48 the: (.) the specimen from: the 49 biopsy from the the excision (0.6) 50 an::d have a look at that under the 51 microscope an’ I would think that 52 (1.0) I would probably (1.4) 53 recommen:d that you had (0.4) 54 pla:nned (.) post operative 55 radiotherapy (0.5) about four to 56 six weeks (0.3) after the surgery. 57 The reason for that is that the the 58 results of �hh treatment (.) show 59 that (0.8) although surgery (0.9) 60 I think- (0.2) on its ow:n stands a 61 much better chance of getting rid’v 62 this: (.) than: does radio therapy. 63 (1.6) There’s still a cha:nce: of 64 (1.0) the:re being (0.4) tiny 65 little satellites (0.3) of disea:se 66 left around afterwards (0.5) an’ if


67
they do come back, (0.5) the 68 likelihood of them bein:g (.) got 69 rid of: (.) are (.) less if you 70 wait, until they presen:t than if you 71 (.) nip it in the bud, �h and assume 72 that they’re the:re, �an’ get on with 73 radio therapy straight a:fter.
Radiotherapy alone is presented first, and closed

down by its juxtaposition with surgery, which is then

immediately elaborated within the same turn. The

options are presented contrastively: radiotherapy ‘would

stand a very small chance’; surgery is ‘much more of a

viable treatment’. Radiotherapy is named prior to its

explanation; surgery is named following its justification.

Thus radiotherapy is physically distanced; and by the

time surgery is mentioned, radiotherapy alone has

receded and is not reintroduced.

The surgeon expands on surgery by detailing what it

‘would involve’ and ‘what we would do’ (lines 32–44),

pacing and structuring his explanation with reference to

the stages to be followed. While the status of the

treatment is viable and actual, the details of the

procedures it entails are presented conditionally (‘what

it would involve’). This allows the patient to consider this

option hypothetically, and from a distance. This

presentation recognises that the decision to carry out

surgery is not yet final, and provides scope for the

patient to influence its course. The surgeon also

recommends, but does not assume, ‘planned post-

operative radiotherapy’ and displays the reasoning

behind his recommendation (lines 51–73).

The ‘unilateral’ instance

In this ‘unilateral’ instance, the presentation of

options begins on a note of necessity.

4b: B1-133-358

89 D: .
t and (0.8) what we need to do (.) is 90 w e will need to sort- (.) we will need 91 t o get rid of this (0.4) these glands 92 c ontaining cancer, (2.0) and we need 93 t o get rid of where it started out 94 f rom. (2.7) so that’s the bad news. 95 ( 0.4) You need to have something 96 d one. ¼
97 P: M
m hm 98 ( 0.4) 99 D: A nd (0.6) the: (0.2) something that 100 y ou need to have done for these (0.5) 101 t hey are of a reasonable size. (1.0) 102 a nd we need to do an operation to get 103 r id of the cancer here. 104 ( 0.2)
105P: Y
eah I can see the ( ) 106 ( 0.6) 107D: ( indeed)
((81 lines omitted- in which surgeon gives expansive

descriptions of the cancer’s location and spread))

188D: S
o- (.) so I’ve [given you- (.) what ¼
189P:
[heh heh heh 190 ¼ I’ve done is I’ve given you the bad 191 n ews (.) you need to have an 192 o peration.
The ‘bad news’ (the diagnosis) is bound up with

necessary treatment ‘that’s the bad news you need to

have something done’ (lines 94–96, 190–192). The

practitioner attributes responsibility for treatment to

professionals by specifying ‘we need to do an operation’

(line 102).

The presentation is paced by the reiteration of ‘need

to’ (‘need to sort’, ‘need to get rid of’, ‘need to do’, lines

89–96). The emphasis on the necessity of surgery

restricts the scope for entertaining alternatives and for

patient choice, limiting the patient’s participation to

minimal forms of agreement (lines 97, 105).

Comparison with diabetes

Across diabetes and ENT oncology, in the ‘bilateral’

approaches the doctors contrast two alternative options

to display their preference, and present options as ‘not

yet decided on’. In the ‘unilateral’ approaches, the

decision point, treatment option, and diagnosis are

intertwined in the news presentation, and treatment is

cast as necessary.

Concluding the main option presentation and the decision-

making sequence

In managing decision-making in the ENT oncology

consultations recorded in this study, certain structural

adaptations are made, reflected in the ordering of

aspects of the decision-making. Firstly, some options

fall outside the main decision-making sequence. Sec-

ondly, the decision-making concludes at different places.

Options that ‘fall outside’ the main decision-making

sequence

In the ENT oncology cases, certain options are

presented outside the main decision-making sequence.


Two ‘non-treatment options’ are mentioned outside

the main treatment presentation. After discussing

surgical procedures and post-operative recovery, the

surgeon raises the possibilities of ‘doing nothing’, or

‘putting it off to see what happens’.

3c: B1-102-348

1 D:
I think the other op- you know: the 2 other option? (1.1) is to do


3
nothin:g. 4 (0.6) 5 D: An’ I can promise you unfortunately 6 I can promise you that this will get 7 (0.5) steadily wo:rse: and, (0.2) 8 s:teadily more unpleasant to deal 9 with or f- or for you to deal with. 10 �hhh And I think also (.) it’s not 11 a matter of let’s put it off an’ 12 see what happens until after 13 Christmas because I think �hhhh (0.3) 14 as far as I’m concerned technically 15 it will reach a point where it’s: 16 (0.2) beyond the realms of sensible 17 surgery
As options, ‘doing nothing’ and ‘putting it off’ do not

receive consideration on the same terms as, and are set

well apart from, presentations of surgery and radio-

therapy. The surgeon presents these ‘non-treatment’

options as untenable, and as having unpleasant con-

sequences.


In the ‘unilateral’ case, only surgery is initially

discussed; later in the consultation, post-operative

radiotherapy is mentioned as an aside.

4c: B1-133-358

1 D:
yby doing the operation on the neck 2 (1.0) and doing- giving the 3 radiotherapy(0.3) I think we: (0.2) 4 stand a- (.) an extremely good 5 chance (.) of getting a very (0.9) 6 significant result. 7 (.) 8 P: Do we 9 (0.3) 10 D: But I think we need to get on with it 11 (.) we- (0.4) we shouldn’t muck 12 around. (0.2) we should get you 13 sorted. 14 (.) 15 P: Mm hm, 16 (0.4) 17 D: Alr[ight, 18 P: [( ) 19 (.) 20 D: Absolu[tely 21 P: [And don’t delay. 22 (0.6) 23 D: No. 24 (.) 25 P: So after that (0.3) I’ll be having 26 uh- (1.7) radiotherapy (shortly) ¼
27 D:
¼ Absolutely (.) to go to the
28
primary (0.8) Um he might 29 [want to 30 P: [( ) 31 (0.2) 32 D: He might want to give you some 33 radiotherapy to the neck as well.
The practitioner makes passing reference to post-

operative radiotherapy (lines 2–3) in the context of

talking about the operation. Thus radiotherapy is

introduced as a foregone conclusion. This leads the

patient to infer ‘so after that I’ll be having radiotherapy’

(lines 25–26), implying that this is not open to

discussion. It prompts the surgeon to provide further

information and explanation of what the radiotherapist

‘might want to do’ (lines 28–29, 32–33). The emphasis

on ‘what he might want to do’ gives prominence to

professional choice, setting a professional domain for

the entertainment of treatment possibilities. The pa-

tient’s ‘and don’t delay’ (line 16) concurs with the line

being taken by the surgeon, echoing and amplifying it,

without adding anything of his own opinion.

Concluding the main option presentation in the ‘bilateral’

case

In the ‘bilateral’ case, the main option presentation

(see 3b) is followed by a conclusion of its own—a check

from the surgeon of the patient’s understanding thus far.

3d: B1-102-348

74D:D
oes that make any sense, 75 (0.7) 76P: Y a:h, Oh yah,1 ¼ 77D:I t does 78P: m m 79D:G ood. �hh Uh:m so that’s: that’s 80 b asically my approach to this.
The surgeon seeks to confirm the patient’s under-

standing ‘does that make any sense’ (line 74) and follows

this up with ‘it does’ (line 77). The surgeon’s summary

(‘that’s basically my approachy’, line 80) distinguishes

his view from the patient’s opinion and choice, which

are given room for expression later in the consultation.

Concluding the decision-making sequence as a whole

In the ‘bilateral’ case, the conclusion to the decision-

making is deferred until the end of the consultation as a

whole.

The ‘bilateral’ instance

3e: B1-102-348

1 D:
So I think that we (.) we- you know we


2
need to sort of 3 (1.0) 4 D: make our minds up within the next few 5 days. I don’t know whether you’ve 6 you’ve chatted to [nurse] about it,
The surgeon makes the first reference to a decision

towards the close of the consultation, at some distance

from the initial option presentation in which his preferred

option was stated. The surgeon casts responsibility for the

final choice as shared between the patient, himself and the

nurse ‘we need to make our minds up.’ (lines 1–4). By

positioning the decision-making outside the consultation’s

time span (‘in the next few days’), the patient is given an

opportunity to think about and state his preferences.

The ‘unilateral’ instance

In the ‘unilateral’ case, the conclusion to the decision-

making is placed early in the consultation (following

4b).

4d:B1-133-358

188D: S
o- (.) so I’ve [given you- (.) what ¼
189P:
[heh heh heh 190 I ’ve done is I’ve given you the bad 191 n ews (.) [you need to have an. 192P: [((coughs)) 193 o peration. 194 (0.8) 195D: t o get rid of the glands here 196P: ( (pointing on his throat)) 197 (1.0) 198D: I ndeed (.) an we’ve got to get rid of 199 t he glands there (0.7) at [the- with ¼
200P:
[Oh 201 ¼ the operati[on 202P: [oh 203 ( .) 204P: ( You set the X-ray to some glands here) 205 ( 0.9) 206D: W e need to get rid of that lot there 207 ( 0.3) 208P: A nd th[at 209D: [and then that lot there 210P: Y eah 211 ( 0.4) 212D: A nd what we’ll- (.) the way to do that 213 ( 0.5) i[s to make a cut ¼
214P:
[Mmm 215D: ¼ like that, (1.3) and to take the 216 g lands out ((287 lines omitted- patient asks surgeon to be careful
and surgeon reassures the patient, relates his previous

successes, reiterates the need to operate and details how

the operation will be done))

503P: (
(coughs)) (0.3) Now what’s the good 504 n ews. (0.2) ((coughs))
505 (
.) 506D:T he good news is we don’t have to 507 t ake your voice-box out. ¼
508P: ¼
Oh that’s very good 509D:I t’s- it’s extremely good.
The surgeon’s conclusion (‘yI’ve given you the

bad news (.) you need to have an operation’,

lines 188–193) reiterates and underlines the impact of

the whole treatment presentation. The decision-

making in this consultation thus begins and concludes

with the surgeon’s references to news and to necessity—

what has to be done (lines 191, 198, 206) and what

does not have to be done (lines 506–507). Framing

the treatment in this way limits the patient’s

participation.

Summary of features of ‘unilateral’ and ‘bilateral’

practitioner approaches in ENT oncology

The ENT oncology cases presented above are

illuminating in two respects. Firstly, they show how

features of ‘unilateral’ and ‘bilateral’ practitioner

approaches hold across different clinical areas and types

of decision. There are parallels with the diabetes cases:

the option of ‘doing nothing’ is absent in the ‘unilateral’

case, but present in the ‘bilateral’ one; the doctor’s

preferred course of action is presented as a matter of

necessity in the ‘unilateral’ case, and is thereby closed to

negotiation and discussion; there is some discrimination

between professional opinion and patient choice in the

‘bilateral’ case. Secondly, they show that ENT oncology

treatment decisions tend to be more ‘unilateral’. The

decision-making is underpinned by a sense of urgency,

and a limited time span within which to make the

treatment decision. These constraints on patient parti-

cipation are manifested in the ‘bilateral’ case as follows:

the surgeon pushes the remit for the decision-making

out beyond the boundaries of the consultation to

maximise the scope for patient involvement; the option

of ‘doing nothing’ comes towards the end of the

consultation and is given less prominence than the

corresponding option in the ‘bilateral’ diabetes case; the

degree of discrimination between professional opinion

and patient choice is not as clearly demarcated as in the

‘bilateral’ diabetes case, allowing professional opinion

and responsibility for making the choice to play a

greater part.

Overview of characteristics of approaches

The analyses presented in this paper have highlighted

a variety of communication features associated with


‘bilateral’ and ‘unilateral’ practitioner approaches.

These analyses have characterised approaches at either

end of a ‘unilateral’–’bilateral’ continuum. In this paper,

we have demonstrated that bilateral and unilateral

approaches can be seen in two clinical areas. Our

broader data set suggests that they can be seen across

the full range of settings we studied.

The key characteristics of more ‘bilateral’ and more

‘unilateral’ approaches are as follows. In ‘bilateral’

approaches, the practitioner talks in a way which

actively pursues patient’s contributions, providing

places for the patient to join in, and building on any

contributions the patient makes: e.g. signposting options

in advance of naming them; eliciting displays of under-

standing and statements of preference from the patient.

In ‘unilateral’ approaches the practitioner talks in

formats less conducive to patient’s participation: e.g.

the scene for the decision is already set; the decision is

presented as ‘made’; the practitioner concludes the

decision-making independently of the patient’s contri-

butions.

Our data set suggests that one approach tends to

predominate through a single consultation or decision-

making episode (although elements characteristic of the

other approach may also be observed at points). We

have documented some variations in approach accord-

ing to individual patients and their preferences, but

overall we have observed that particular practitioners

tend to use either a unilateral or a bilateral approach

fairly consistently.

Possible implications of ‘bilateral’ and ‘unilateral’

approaches for patients’ participation

Our analyses have focused predominantly on

practitioners’ talk, but the ‘bilateral’ and ‘unilateral’

approaches that we have identified have implications

for the potential for different forms of participation

by patients. Although we cannot examine in detail

here how patients’ turns are constructed in response

to practitioners’ talk, we offer some preliminary

observations about apparent differences in

patients’ participation in decision-making when

practitioners adopt ‘bilateral’ and ‘unilateral’

approaches.

In ‘unilateral’ instances, when practitioners give

general explanations, patients seem to respond

with expressions of general understanding, not

linked to individual preference or experience (see

for example extracts 2d line 100 ‘I know’, 4a line 83

‘this is here’). Practitioners’ definitive presentations of

treatment rationales and proposals seem to be re-

sponded to by patients with forms of general agree-

ment/acceptance, which the practitioner then

subsequently reiterates (e.g. 4b lines 95–107 D-’you need

to have something done’, P – ‘mhm’, D – ‘to get rid of the

cancer here’, P- ‘yeh I can see they’). Patients’ responses

appear to display acceptance of a ‘given’ state of affairs

(e.g. 4c lines 25–26 ‘so after that I’ll be having

radiotherapy’).

In the ‘bilateral’ cases, there are more indications that

the practitioners’ talk accommodates patients’ experi-

ence, opinion and understanding, and patients express

their view in response. Patients seem able to answer

questions of whether or not they see scope for

improvement in their own management (e.g. 1a line

16, 1d line 58); can remind doctors of previous

discussions (e.g. 3a line 16 recalling a previously agreed

a course of action); and express their own treatment

preference (e.g. 1e line 103).

Overall, though, our data suggest that patient

participation in decision-making is limited. Patients

tended to say very little in the decision-

making trajectory, and what they did say did not

always appear to influence the selection of a particular

course of action. Examples of practitioner talk char-

acteristic of ‘bilateral’ approaches did not always

lead to patients’ contributing significantly to discussion

about or the selection between treatment options, as this

extract from a third consultation about diabetes

illustrates.

5: B1-117-329

1 D: S
o the next step if we did need to 2 m ake a change would be: to 3 c onsider(0.4) switching you from 4 t ablets. to insulin injections 5 P: M m hm 6 (0.9) 7 D: H ave you ever, considered that. 8 (1.8) 9 P: m Well (I’ll) do whatever you (say:,) 10 D: 1 1(no) 11
11 P: k
I’m not gonna. (.) you know me by 12 n ow.
This extract raises the question of whether and

when it is appropriate for health professionals to

encourage apparently reluctant patients to express

preferences between treatment options. Although

policies promoting greater patient participation in

decision-making would apparently tend to favour

‘bilateral’ approaches on the part of health profes-

sionals, we should not assume that such approaches are

universally ‘better’.

Overall, our data generally support the notion that the

organisation of interaction in a consultation influences

opportunities for patient participation (Robinson, 2003),

and that practitioners manage the decision-making

trajectory in different ways with different consequences

for patient participation (Charles, Whelan, Gafni, Willan,


& Farrell, 2003). We have elucidated a number of ways

in which practitioners might create or enhance opportu-

nities for patients to influence the process of decision-

making over the course of a decision-making trajectory.

Features of ‘bilateral’ approaches such as creating

distinctions between moments along the trajectory (e.g.

by signalling the transition to the decision-making

sequence or by naming an option prior to embarking

on discussion about it) seem to offer more scope for

patient input. More detailed analyses of each of these

features (and their implications for patient participation,

as compared with their ‘unilateral’ counterparts) are now

warranted.

Conclusion

Drawing primarily on data relating to two types of

decision made in consultations conducted in two

different clinical settings, this paper has identified and

elucidated some key features of ‘unilateral’ and ‘bilat-

eral’ practitioner approaches to treatment decision-

making, and provided some preliminary observations

on their likely implications for patient participation. It

also suggests that the characteristics and qualities of a

‘bilateral’ approach may tend to vary across clinical

situations.

In contexts in which patient participation in decision-

making is advocated, it might be recommended that

practitioners adopt more ‘bilateral’ approaches to

facilitate this. Further research is needed to refine the

characterisation of these approaches and to investigate

the extent to which they facilitate greater patient

participation. If it does transpire that ‘bilateral’

approaches effectively encourage more appropriate

forms of patient participation in decision-making,

then efforts should be made to develop and evaluate

training interventions to encourage health professionals

to implement them in practice in different clinical

situations.

Acknowledgements

The PaPaYA (Patient Participation in York and

Aberdeen) project was funded by the Department of

Health: Health in Partnership Programme (reference

3700514). The opinions expressed in this paper are those

of the authors and may not be shared by the funding

body. We are most grateful to the patients and

practitioners who took part. We thank Sue Lawal,

Stewart Mercer, Anne Walker and the anonymous

reviewers for their comments on earlier versions of

this paper.

Appendix. Transcript notation for conversation analysis

Relative timing of utterances:

(0.7). Intervals within or between turns

(.) Discernible pause too short to be timed mechanically.

Square brackets indicate overlaps between utterances.

Point of overlap onset is marked with a single left hand

bracket.

Contiguous utterances are linked by an equals sign. Also

used to indicate very rapid move from one unit in a turn

to the next.

Characteristics of speech delivery

Various aspects of speech delivery are captured by

punctuation symbols (which, therefore, are not used to

mark conventional grammatical units) and other forms

of notation, as follows:

Full stop indicated a falling intonation.

Comma indicates a continuing intonation.

Question mark indicates a rising inflection (not

necessarily a question).

Stretching of a sound is indicated by colons, the number

of which correspond to the length of the stretching.

.h indicates inhalation, the length of which is indicated

by the number of h’s.

h. indicates outbreath, the length of which is indicated

by the number of h’s.

(hh) Audible aspirations are indicated in the speech in

which they occur (including in laughter).

11 Degree signs indicate word(s) spoken very softly or

quietly.

Underlining is used to denote words or parts of a word

which are emphasised.

Particularly emphatic speech, usually with raised pitch,

is shown by capital letters.

Unclear words are placed in parentheses.

References

Beach, W. A. (1995). Preserving and constraining options:

‘okays’ and ‘official’ priorities in medical interviews. In G.

H. Morris, & R. J. Chenail (Eds.), The talk of the clinic:

Explorations in the analysis of medical and therapeutic

discourse. New Jersey: Lawrence Erlbaum Associates.

Boyd, E., & Heritage, J. (in press). Taking the history:

questioning during comprehensive history taking. In J.


Heritage, D.W. Maynard (Eds.), Communication in medical

care. Cambridge: Cambridge University Press.

Braddock, C. H., Edwards, K. A., Hasenberg, N. M.,

Laidley, T. L., & Levinson, W. (1999). Informed decision-

making in outpatient practice: Time to get back to basics.

Journal of the American Medical Association, 282(24),

2313–2320.

Britten, N., Stevenson, F. A., Barry, C. A., Barber, N., &

Bradley, C. P. (2000). Misunderstandings in prescribing

decisions in general practice: Qualitative study. British

Medical Journal, 320, 484–488.

Byrne, P. S., & Long, B. E. L. (1976). Doctors talking to

patients. London: HMSO.

Charles, C., Whelan, T., Gafni, A., Willan, A., & Farrell, S.

(2003). Shared treatment decision making: What does it

mean to physicians? Journal of Clinical Oncology, 21(5),

932–936.

Clarke, G., Hall, R. T., & Rosencrance, G. (2004). Physician–-

patient relations: No more models. The American Journal of

Bioethics, 4(2), 16–19.

Department of Health. (2000). NHS Plan. A plan for invest-

ment. A plan for reform. Norwich: HMSO.

Department of Health. (2001). The expert patient: A new

approach to chronic disease management for the 21st century.

London: Department of Health.

Drew, P., Chatwin, J., & Collins, S. (2001). Conversation

analysis: A method for research in health care professio-

nal–patient interaction. Health Expectations, 4(1), 58–71.

Entwistle, V. A., Watt, I. S., Gilhooly, K., Bugge, C., Haites,

N., & Walker, A. (2004). Assessing patients’ participation

and quality of decision making: Insights from a study of

routine practice in diverse settings. Patient Education and

Counselling, 55, 105–113.

General Medical Council. (2001). Good Medical Practice (3rd

ed.). http://www.gmc-uk.org/standards/htm

Gill, V. T., & Maynard, D. W. (in press). Explaining illness:

Patients’ proposals and physicians’ responses. In J. Heri-

tage, D. W. Maynard (Eds.), Communication in medical

care. Cambridge: Cambridge University Press.

Gwyn, R., & Elwyn, G. (1999). When is a shared decision not

(quite) a shared decision? Negotiating preferences in a

general practice encounter. Social Science & Medicine, 49,

437–447.

Kaplan, R. M. (2004). Shared medical decision making: a new

tool for preventive medicine. American Journal of Preventive

Medicine, 26(1), 81–83.

Kaplan, S. H., Greenfield, S., Gandek, B., Rogers, W. H., &

Ware, J. E. (1996). Characteristics of physicians with

participatory decision-making styles. Annals of Internal

Medicine, 124, 497–504.

Richards, T. (1998). Partnership with patients: Patients want

more than simply information; they need involvement too.

British Medical Journal, 316, 85–86.

Robinson, J. (2003). An interactional structure of medical

activities during acute visits and its implications for patients’

participation. Health Communication, 15(1), 27–59.

Roter, D., & Frankel, R. (1992). Quantitative and qualitative

approaches to the evaluation of the medical dialogue. Social

Science & Medicine, 34(10), 1097–1103.

Stivers, T. (2002). Participating in decisions about treatment:

Overt parent pressure for antibiotic medication in paediatric

encounters. Social Science & Medicine, 54(7), 1111–1130.

http://www.gmc-uk.org/standards/htm

Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment

Documents

Transcript of Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment