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39 Cards in this Set

  • Front
  • Back
Phase Structure of Acute Medical Visits
1.Opening
2. Presenting Complaint
3. Examination (history taking/physical)
4. Diagnosis
5. Treatment/Conseling
6. Closing
Importance of Problem Presentation
-good source of information
- patien't illness model emerges
-environment where patient can express fear and concerns
-therapeutic value for patient
Beckman and Frankel:
Problem Presentation
-it is short; approx 18 sec
-anything DR says can derail the presentation
-exceptions: "mmhmm", 'uh huh" etc..
Why is problem presentation SHORT?
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!
DR's problem?
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
Patien's Problem?
Justifying the medical visit

- when history taking begins the dr recognizes the problem as potentially doctorable
When will the patient be done?
After every second the dr should ask himself " is the patient done yet?
First Solution: Beginning the Problem Presentation
1. One Liners
2. Preface + Detailing
3. Narrative
One Liners
-Summative
- Period Intonation
-Specific (High grunalarity)
Prefaces
-longer than 1 sentence
-headlines
-loose granularity: too general to be heard as the complaint itself
Narratives
-more than 1 sentence
-start at a point in the past
-use past tense
-the narrative winds up in the present
Doctors solution to problem presentation?
- use acknowledgement tokens
-mmhmm & uh huh=continuers
-okay & right = preparedness to move into Hx
2nd solution: Ending the problem presentation?
-dr's intervene after patient describes 1 or more "current symptoms"

- shift to history taking; treats patient as complete
When do DRs initiate history taking?
-usually after 2+ symptoms (53%)
- after 1 symptom (25%)
Summary Problem presentation
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
Sick Role: RIGHTS
(Parsons)
- 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.
Sick Role: OBLIGATIONS
(Parsons)
- 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
Justifying the Medical Visit:
DOCTORABILITY
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.
Example of Doctorability
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
After DR evaluates problem
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
Doctorability IS a problem
(3 acute types)
1. Routine problems
2. Recurrent Problems
3. New/Unknown problems
Routine Problems
-special symptom
-waited a long time (trouble resistant)
-past experience
Recurrent Problems
(Patients self-diagnose)
~self-diagnose is dispreferred
~self-diagnose is often indirect
~more direct if previous condition was serious
New Problems
(Uncertainty about problem)
-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!
Summary: Acute Problem Presentation
-problem presentation varies with the type of illness whether routine, recurrent or new
-strategies of legitimation vary with type of illness
Four Features of Question Design
1. Agenda Setting
2. Presupposition
3. Epistemic Gradient
4. Preference
Agenda Setting
Questions set agendas: Topic and action agenda
- patients responses conform (or not) to these agendas
Presupposition
1. Questions embody presuppositions
2. patients reponse confirm them or not
Epistemic Gradient
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.
Preference
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.
Interrogatives
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.
Questions
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
Methods for Bulding- Yes Preferring
1. Straight Interrogative Qsts
2. Statement + Neg tag
- you are married, arent u?
3. Declarative qsts
4. Negative Interrogatives
Gramatically-NO preferring
1. Neg statement + positive tag
2. negative declaratives
3. straight interrogatives with negative polarity items
Negative Polarity
any, ever, at all etc..
Grammatical vs Social Preferences
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.
Reinforcing
a doenst want to have to pay for prescription medicines
ex: ask for samples
*grammatical preference is yes
Cross cutting
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
Two Principles of Medical Questioning
1. Optimization
2.Recipient Design