Talk And Institutions

Front 1

Phase Structure of Acute Medical Visits

Back 1

1.Opening
2. Presenting Complaint
3. Examination (history taking/physical)
4. Diagnosis
5. Treatment/Conseling
6. Closing

Front 2

Importance of Problem Presentation

Back 2

-good source of information
- patien't illness model emerges
-environment where patient can express fear and concerns
-therapeutic value for patient

Front 3

Beckman and Frankel:
Problem Presentation

Back 3

-it is short; approx 18 sec
-anything DR says can derail the presentation
-exceptions: "mmhmm", 'uh huh" etc..

Front 4

Why is problem presentation SHORT?

Back 4

1. DR;s have little time
2. DR's assume the first symptom is the main problem
3. DR's are trained to "cut to the chase"
***dr's interrupt patient!

Front 5

DR's problem?

Back 5

Figuring out when the patient is done, and the initiave baton is passed from patien to dor to begin history taking.

*involves collaboration between patient/dr

Front 6

Patien's Problem?

Back 6

Justifying the medical visit

- when history taking begins the dr recognizes the problem as potentially doctorable

Front 7

When will the patient be done?

Back 7

After every second the dr should ask himself " is the patient done yet?

Front 8

First Solution: Beginning the Problem Presentation

Back 8

1. One Liners
2. Preface + Detailing
3. Narrative

Front 9

One Liners

Back 9

-Summative
- Period Intonation
-Specific (High grunalarity)

Front 10

Prefaces

Back 10

-longer than 1 sentence
-headlines
-loose granularity: too general to be heard as the complaint itself

Front 11

Narratives

Back 11

-more than 1 sentence
-start at a point in the past
-use past tense
-the narrative winds up in the present

Front 12

Doctors solution to problem presentation?

Back 12

- use acknowledgement tokens
-mmhmm & uh huh=continuers
-okay & right = preparedness to move into Hx

Front 13

2nd solution: Ending the problem presentation?

Back 13

-dr's intervene after patient describes 1 or more "current symptoms"

- shift to history taking; treats patient as complete

Front 14

When do DRs initiate history taking?

Back 14

-usually after 2+ symptoms (53%)
- after 1 symptom (25%)

Front 15

Summary Problem presentation

Back 15

1. co- construction
2. length of patient presentation is negotiated with DR.
3. sometimes dr/pt drop the baton
4. patients give "cues" that project what type of presentation it will be and how long it will last
5. doctors can hedge their bets on when patients will be done: "right" & "okay" are ideal
6. current symptoms--> create the normal baton passing area
7. exit devices are resources for definitelye ending the problem presentation

Front 16

Sick Role: RIGHTS
(Parsons)

Back 16

- there is an entitlement to some exemption from normal activities
- the patient cannot help recovering through and act of will thus needs to be taken care of.

Front 17

Sick Role: OBLIGATIONS
(Parsons)

Back 17

- being sick must be seen as undesirable
-patient should not take advantage of secondary gains (center of attention)
-must seek help and cooperate with treatment process

Front 18

Justifying the Medical Visit:
DOCTORABILITY

Back 18

A doctorable problem is one that is worthy of evaluation as a potentially significant medical condition, an worthy of advice and where necessary, medical treatment.

Front 19

Example of Doctorability

Back 19

1. Headline downgrades doctorability
2. problem presentation= narrative format
3. invokes a 3rd party
4. fights in overlap to downgrade the problem
5. injects breathy laugh particles at places where talking about deciding to visit

Front 20

After DR evaluates problem

Back 20

1. patient agrees with no problem evaluation
2. re invokes a 3rd party
3. uses breathy laugh particles
4. dr Valdiates decision to make the visit

Front 21

Doctorability IS a problem
(3 acute types)

Back 21

1. Routine problems
2. Recurrent Problems
3. New/Unknown problems

Front 22

Routine Problems

Back 22

-special symptom
-waited a long time (trouble resistant)
-past experience

Front 23

Recurrent Problems
(Patients self-diagnose)

Back 23

~self-diagnose is dispreferred
~self-diagnose is often indirect
~more direct if previous condition was serious

Front 24

New Problems
(Uncertainty about problem)

Back 24

-describing uncertain symptoms (pain/discomfort)
-description diffuses responsiility for the visit by invoking 3rd parties
-narrative format with trouble resistant elements (self-medicated/waited)
-trouble resistant narratives contain Turning Point!

Front 25

Summary: Acute Problem Presentation

Back 25

-problem presentation varies with the type of illness whether routine, recurrent or new
-strategies of legitimation vary with type of illness

Front 26

Four Features of Question Design

Back 26

1. Agenda Setting
2. Presupposition
3. Epistemic Gradient
4. Preference

Front 27

Agenda Setting

Back 27

Questions set agendas: Topic and action agenda
- patients responses conform (or not) to these agendas

Front 28

Presupposition

Back 28

1. Questions embody presuppositions
2. patients reponse confirm them or not

Front 29

Epistemic Gradient

Back 29

1. Questions are designed to convey degrees of K-position (applies to yes/no qsts)
2. Patients responses are congruent (or not) with the epistemic gradient of a question.

Front 30

Preference

Back 30

1. Questions are designed for, aniticipate, expect or "prefer" particular answers
(applies to yes/no qsts)
2. patients responses align (or not) with those preferences.

Front 31

Interrogatives

Back 31

1. interrogative describes the grammatical form of a sentence or other turn constructional unit (tcu)
2. They do not always question and some interrogatives do.

Front 32

Questions

Back 32

1. question: an action term and describe a particular type of action - requesting info- thats a sentence can do\
2. questions can be done as declarative sentences as well as interrogative ones

Front 33

Methods for Bulding- Yes Preferring

Back 33

1. Straight Interrogative Qsts
2. Statement + Neg tag
- you are married, arent u?
3. Declarative qsts
4. Negative Interrogatives

Front 34

Gramatically-NO preferring

Back 34

1. Neg statement + positive tag
2. negative declaratives
3. straight interrogatives with negative polarity items

Front 35

Negative Polarity

Back 35

any, ever, at all etc..

Front 36

Grammatical vs Social Preferences

Back 36

a question can be designed to reinforce a personal or social preference, or to cut against it
*grammatical structure can reinforce or cross-cut the objectives or social preferences indexed by a qst.

Front 37

Reinforcing

Back 37

a doenst want to have to pay for prescription medicines
ex: ask for samples
*grammatical preference is yes

Front 38

Cross cutting

Back 38

a doesnt want to have to pay for prescription medicines
ex: you dont have any samples do you?
*grammatical preference is no
-involve positively framed qsts in search of negative answers

Front 39

Two Principles of Medical Questioning

Back 39

1. Optimization
2.Recipient Design