Background
Methods
Data source
This Corpus houses a digitally stored collection of patient / practitioner consultation data that includes video-recorded consultations and verbatim transcripts. |
Included data has been collected since 2003 as part of funded studies. |
These studies include the: |
- Interaction Study (IS) exploring clinical decision-making when rationing is explicit; |
- Tracking Study (TS) exploring communication processes throughout a single complete episode of care of patients referred from primary to secondary care; |
- Diabetes Study (DS) tracking the contact of newly diagnosed patients with Type 2 diabetes with healthcare professionals over a six-month period. |
The combined dataset for the IS and TS comprised an unselected sample of 183 routine consultations involving 15 general practitioners recorded in 21 participating general practices in the Wellington region of New Zealand between 2004 and 2007. The data for the DS was purposively collected in Wellington and Auckland; for this study, 36 patients newly diagnosed with type 2 diabetes were recruited prospectively via 21 general practices (6 of which had participated in the previous studies) and tracked for a period of 6 months between 2008 and 2011. Their consultations with general practitioners and nurses at the general practice and related consultations with allied health professional staff were video-recorded. |
All consultations were made in the course of ‘practice as usual’ and are therefore typical of routine interactions occurring in New Zealand healthcare. |
Written consent was sought from participants in these original studies to use their data for secondary analysis. |
At the time of sampling the ARCH Corpus included 418 video-recorded consultations recorded between 2003 and 2011, 337 of which were eligible for inclusion. These comprised 247 individual patients, 30 general practitioners, 31 nurses and 15 other practitioners. |
Identification of gout consultations
Patient characteristics
| |
• 18 individual patients | |
- Male n = 13; female n = 5 | |
- Age: mean 54 years; median 52 years | |
- Age range: 36 to 67 years | |
Health practitioner characteristics
| |
• 17 individual practitioners | |
- General practitioners n = 10 | |
- Nurses n = 4 | |
- Podiatrists n = 2, | |
- Dietitian n = 1 |
Data analysis
1. CM identified and coded conversation sequences related to gout in the transcripts. CM then reviewed the video-recordings to confirm and enrich the analysis. A note was made of any important contextual non-verbal communication from either party e.g. nodding of the head, smiling, sighing, listening attentively, examining the patient, turning away from the patient. |
2. Initial coding included: |
- how gout was introduced into a consultation and by whom |
- the location within the consultation |
- the importance of the condition from the patient perspective |
- diagnosis and treatment of the condition |
- emphasis placed on biochemical test results and dietary and lifestyle advice |
3. Themes and sub-themes were identified from the data. Initial interpretations of the clinical relevance and importance of the themes derived were debated and discussed between CM, a pharmacist and experienced qualitative researcher, and AD, the general practitioner member of the project team. |
4. LM and MS, researchers with experience in linguistics, contributed to a second round of discussion and interpretation. Examples of refinements at this point include: |
- “Gout as an incidental part of the consultation” and “Impact of gout for patients” being combined as sub-themes of the over-arching theme “The importance of gout” |
- A linguistic interpretative viewpoint to the differences observed around lifestyle and medicines |
- Acknowledgement of the importance and possible ambiguity of ‘semi-verbal’ communication (e.g. the use of “mm” by participants) |
5. Disagreements were resolved by consensus. |
6. All authors reviewed and agreed the final themes and interpretation |
Results
Themes that are the focus of this paper | |
• The importance of gout | |
- Gout as an ‘incidental’ part of the consultation | |
- The impact of gout on patients | |
• ‘Telling’ versus ‘listening’ in consultations | |
Medicine-related themesa
| |
• Level of patient knowledge | |
• Patient attitudes to medicines | |
• Attributes of practitioner communication | |
- Delivery and content of information provided | |
- Taking the opportunities presented | |
Other themes | |
• Patient interpretation of symptoms | |
• Patient understanding of gout management | |
• Patient understanding of uric acid levels |
The importance of gout
Consultation Identifier* | Patient age (years) | Practitioner | Incidental or presenting complaint (PC) | Initiator of gout conversation | Point of consultation gout first mentioned | Discussion length; context | Gout medicines mentioned | Lifestyle advice/diet mentioned | Uric acid levels mentioned |
---|---|---|---|---|---|---|---|---|---|
DS-GP01–04 | 41–50 | GP | Incidental | Patient | Early | Short; no current symptoms | Yes | Yes | Yes |
DS-NS10–01 | 41–50 | Nurse | Incidental | Practitioner | Late | In passing#
| No | Yes | Yes |
DS-NS14-02a | 51–60 | Nurse | Incidental | Practitioner | Late | In passing#
| No | Yes | No |
DS-GP19-02b | 51–60 | GP | Incidental | Patient | Start | Substantive; no current symptoms | Yes | Yes | Yes |
DS-NS14-02b | 51–60 | Nurse | Incidental | Patient | Start | Short; No current symptoms | Yes | Yes | No |
DS-GP29–01 | 41–50 | GP | Incidental | Patient | Start | Substantive; acute flare, new diagnosis | Yes | Yes | Yes |
DS-NS13-01a | 31–40 | Nurse | Incidental | Patient | Middle | Short; patient thought they had gout | No | Yes | Yes |
DS-NS13-01b | 31–40 | Nurse | Incidental | Practitioner | Early | Short; following up discussion of previous visit where patient thought they had gout | Yes | No | No |
DS-GP18–01 | 31–40 | GP | Incidental | Practitioner | Middle | Substantive; discussion of preventive therapy | Yes | No | No |
DS-HP06-01a | 31–40 | Dietitian | Incidental | Patient | Start | Short; struggling with gout | Yes | Yes | No |
DS-HP07-01a | 31–40 | Podiatrist | Incidental | Patient | Start | Substantive; no current symptoms | Yes | Yes | No |
DS-NS13-01c_GP18 | 31–40 | Nurse & GP | Incidental | Patient | Start | Substantive; acute flare | Yes | No | No |
DS-HP06-01b | 31–40 | Dietitian | Incidental | Practitioner | Start | Substantive; acute flare | Yes | Yes | No |
DS-HP07-01b | 31–40 | Podiatrist | Incidental | Practitioner | Start | Substantive; no current symptoms | Yes | No | No |
DS-NS13-01d_GP18 | 31–40 | Nurse & GP | Incidental | Patient | Early | Substantive; acute flare subsiding | Yes | No | Yes |
DS-NS13-04d_GP21 | 61–70 | Nurse & GP | Incidental | Patient | Start | Short; mention of recent flare | No | No | Yes |
DS-NS25–01 | 51–60 | Nurse | Incidental | Practitioner | Early | In passing#
| Yes | No | No |
DS-NS27–02 | 41–50 | Nurse | Incidental | Practitioner | Close | In passing#
| Yes | No | Yes |
DS-HP10-02a | 41–50 | Podiatrist | Incidental | Patient | Middle | Short; making conversation | Yes | No | No |
DS-HP10-02b | 41–50 | Podiatrist | Incidental | Patient | Middle | Short; making conversation | Yes | Yes | Yes |
IS-GP02–03 | 41–50 | GP | Incidental | Practitioner | Start | Substantive; no current symptoms | Yes | No | No |
IS-GP02–14 | 41–50 | GP | PC | Patient | Start | Substantive; acute flare, pre-existing diagnosis | Yes | No | Yes |
IS-GP03–06 | 61–70 | GP | Incidental | Practitioner | Late | In passing#
| Yes | No | Yes |
IS-GP07–05 | 61–70 | GP | Incidental | Practitioner | Start | In passing#
| Yes | No | No |
IS-GP07–06 | 41–50 | GP | Incidental | Practitioner | Middle | In passing#
| Yes | No | No |
TS-GP03–08 | 51–60 | GP | Incidental | Practitioner | Middle | In passing#
| Yes | No | No |
TS-GP03–12 | 61–70 | GP | Incidental | Practitioner | Start | In passing#
| Yes | No | No |
TS-GP03–17 | 61–70 | GP | Incidental | Practitioner | Middle | Short; gout considered before being eliminated | Yes | No | No |
TS-GP08–10 | 51–60 | GP | Incidental | Practitioner | Early | In passing#
| Yes | No | Yes |
TS-GP09–05 | 41–50 | GP | PC | Patient | Start | Substantive; acute flare, pre-existing diagnosis | Yes | Yes | No |
TS-GP14–04 | 61–70 | GP | Incidental | Practitioner | Middle | Substantive; no current symptoms | Yes | No | No |
Gout as an ‘incidental’ part of the consultation
Three patients intentionally and explicitly re-focus their diabetes review visits to gout by raising the issue at the beginning of the consultation. Following a very short discussion about their weight this patient abruptly changes the subject to gout symptoms:NS: “If we can check everything [blood tests] … it’s part of the annual review that’s very important … we also check your uric acid, that’s for, you know, your gout” (DS-NS27–02)
Re-focusing a consultation to gout is not always patient-driven. This GP makes gout a focus right at the start of the consultation despite the patient’s primary reason for visiting being influenza-like symptoms:PT: “Right now … look, [patient shows GP their foot], I can’t touch it, I can’t bend it and it hurts like mad … [I’ve had it] for a week and a half … it hurts” (DS-GP29–01)
A lengthy dialogue then ensues around gout and its treatment before the patient sighs heavily and clearly and deliberately re-focuses the consultation to the presenting complaint.GP: “You saw [Doctor’s name] since I last saw … and he thought you had resistant gout” (IS-GP02–03)
“ … and I also gave you some [medicine name] for your gout back then as well” (TS-GP03–12)
The impact of gout on patients
Patients also comment on the impact of the lifestyle changes they make to help manage their condition. Most patients with diagnosed disease are aware of some of their potential dietary triggers:GP consultation:PT: “at night it is really swollen and I’ve had to put my foot out of the bed … night-time it is worse … and I’ve been wearing [sandals] because I can’t have anything touch it …” (DS-GP29–01)Podiatrist consultation:PT: “I had a big wave of gout for a little while [that] lasted for about a good three weeks, it took a while to wear off”POD: oh you poor thing, … whereabouts did it affect you the most?PT: … “it started from my toes, round to my ankle and then it just stayed there for a while and it just slowly headed up this way [points up the leg].” (DS-HP07-01b)
PT: “I used to eat mussels but it gives me a lot of trouble with my gout … I keep away from foods that make me sick … ” (DS-NS14-02a)
The ways in which patients in our data typically conceptualised gout and their experience of its symptoms and management are clearly displayed in the language used in these excerpts to describe symptoms and the degree to which discomfort is beyond what is considered normal. As shown in the podiatrist consultation this usually elicits a sympathetic response which serves to validate the severity of the patient’s reported symptoms and potentially demonstrates the justification for medical attention.PT: “… I ate all these wrong kind of foods and I gave myself gout which is a real drag cos I haven’t had an attack for ages, but it’s totally self-inflicted … I ate all kinds of shell fish and [expletive] chocolate and all the things that triggered it” (TSGP09–05)
‘Telling’ versus ‘listening’ in consultations
Although the patient immediately responds by articulating their difficulty in managing the pain, particularly at night, the GP moves straight into providing information on treatment options and lifestyle changes. The didactic approach means there is little attempt to identify the patient’s understanding of gout or the psychological or social impact of the condition.GP: “We call it gout … there is one acid called uric acid … if the level in the blood is high it forms crystals and they deposit in the joint and make the joint painful - it is painful and swells up at times ” (DS-GP29–01)
As uric acid levels are a defined biochemical marker for the diagnosis of gout, GPs often discuss this condition with patients from a biochemical perspective:POD: “The gout tablet allopurinol is to prevent you having a gout attack”PT: The colchicinePOD: “That’s for when you get the attack … Gout’s very painful as well, it’s a type of arthritis, it causes intense pain and inflammation in a joint usually in these ones [points to the toes] but I have seen it round the ankles and down the sides of the feet … if they leave it untreated you can get damage to the joints which is permanent damage …” (DS-HP10-02b)
The GP gave information about uric acid levels without any discussion about how the patient currently felt about their gout or its impact on them.GP: “OK, it looks to me like you’re doing well with the diabetes and the gout. The uric acid level in that last blood test was normal and we probably should get you to have another blood test at some stage so I might just print you [off a blood test form].” (DS-NS13-01d_GP18)
This immediately precipitates a short conversation that focuses on information provision:PT: “… [I’m] cutting down [on certain foods], because of my cholesterol and my uric acid …”
NS: “Do you suffer from gout? Yeah, and you’ve had good information about things that trigger your gout? Do you go on the internet at all?”PT: now and thenNS: “OK, so I’m just going to write up your care plan and we’re really nearly there” (DS-NS10-01)
At this point the patient volunteers information about their diet which the GP assesses and then reframes biomedically in the context of uric acid levels:GP: “… you’ve got information about the foods to avoid with regard to your gout”PT: I don’t have any information about that, but I just think in my mind that I don’t really eat too much red meat, maybe fish, but I haven’t had any information about thatGP: “OK well I’ll give you something to read about that, about the sorts of food to avoid [and] what tends to precipitate it; but the things you said are all the things that tend to bring it on and so just try to eat those in moderation or avoid them if they do cause flare-ups. Some of the other main things are shell fish, also alcohol, beer and carbonated drinks as well like fizzy drinks” (DS-GP19-02b)
The patient maintains eye contact throughout the conversation and nods his head indicating an unspoken acknowledgment of what has been said.PT: “I avoid them all except sea food, I ate mussels, is that OK”?GP: Did it cause any symptoms after you had the mussels?PT: NoGP: “if you’re having small amounts and you don’t get symptoms that should be OK although your uric acid level in your blood … it is still high” (DS-GP19-02b)
Medicines play a key role in the optimal management of gout. In this topic area the style of consultation was observed to move away from a didactic one towards a greater degree of listening to the patient. In the following example the GP negotiates options and checks that the patient is happy with a decision before it is finalised:POD: “I think it’s about the only type of arthritis that it’s been proven that certain food will have an effect on it and you’re supposed to avoid foods that are high in uric acid I think like shell fish … and alcohol.” (DS-HP10-02b)
Many patients were willing to consider long-term preventive treatment and others were very positive about it. Although there were no examples of patients refusing allopurinol specifically, some patients are less than comfortable with medicines per se:GP: “we should be probably giving you something to prevent the gout”PT: oh OK, cos I do get it quite regularly especially in my ankle and my toe and it just throbs and I know that runs in my familyGP: we’d start you with a low [dose] - you can choose to start the tablet now or we can put it off for a while, it’s up to you really …PT: just do it, just get it over and done withGP: “[so], we start with a low dose and sometimes it can flare it up a little bit so it’s probably good to do it now if you haven’t got any gout … it’s probably better to just get this a little bit sorted out for you if we can” (DS-GP18-01)
In this case the GP acknowledges the patient’s view and carefully introduces the possibility that allopurinol may be the best option if the clinical situation alters. The patient non-verbally indicates their acceptance by a nod of their head:PT: “… I don’t like tablets … I don’t want to take any more tablets …” (DS-GP19-02b)
GP: “… so I think if you do start having regular flare-ups then we should look again at putting you back on allopurinol.” (DS-GP19-02b)