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Managing Patient-centeredCommunication across the Type 2Diabetes Illness Trajectory: A GroundedPractical Theory of InteractionalSensitivityChristopher J. Koenig, Leah M. Wingard, Christina Sabee, DavidOlsher & Ilona VandergriffPublished online: 07 May 2014.

To cite this article: Christopher J. Koenig, Leah M. Wingard, Christina Sabee, David Olsher &Ilona Vandergriff (2014) Managing Patient-centered Communication across the Type 2 DiabetesIllness Trajectory: A Grounded Practical Theory of Interactional Sensitivity, Journal of AppliedCommunication Research, 42:3, 244-267, DOI: 10.1080/00909882.2014.911943

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Managing Patient-centeredCommunication across the Type 2Diabetes Illness Trajectory: A GroundedPractical Theory of InteractionalSensitivityChristopher J. Koenig, Leah M. Wingard, Christina Sabee,David Olsher & Ilona Vandergriff

This article uses the theoretical and methodological framework of Grounded PracticalTheory (GPT) to provide a lens for analyzing and interpreting discourse as a situatedform of social action in routine Type 2 diabetes visits. Drawing on a total data-set of 400audio-recorded routine visits, we randomly selected 55 visits for qualitative analysis. Inthis article, we use Conversation Analysis to document communication techniques,which we in turn use as evidence to ground our claims within the GPT framework. Weuse two single cases of interaction to analyze communication techniques physicians usewhen recommending a change from oral medication to insulin. We argue treatmentintensification is a key moment in health communication to reflect about patientcenteredness because physicians can find themselves in an interactional dilemma: whileinsulin may effectively help control unstable disease, an insulin recommendation maysimultaneously counter patient values and treatment preferences. Our analysis suggeststhat physicians use what we call interactional sensitivity to balance medical need andpatient preferences when making medical decisions by tailoring their communicationaccording to the local situation and the patient’s larger illness trajectory. We propose

Christopher J. Koenig is an Assistant Professor at the Department of Medicine at San Francisco VeteransAdministration Medical Center and the Philip R. Lee Institute for Health Policy Studies at University ofCalifornia. Leah M. Wingard is an Associate Professor in the Department of Communication Studies at SanFrancisco State University. Christina Sabee is an Associate Professor in the Department of CommunicationStudies at San Francisco State University. David Olsher is an Associate Professor in the Department of English atSan Francisco State University. Ilona Vandergriff is an Associate Professor in the Department of ForeignLanguages and Literatures at San Francisco State University. Correspondence to: Christopher J. Koenig,Department of Medicine, San Francisco Veterans Administration Medical Center, 4150 Clement Street, 111-A1,San Francisco, CA 94121, USA. E-mail: christopher.koenig@ucsf.edu.

Journal of Applied Communication ResearchVol. 42, No. 3, August 2014, pp. 244–267

ISSN 0090-9882 (print)/ISSN 1479-5752 (online) © 2014 National Communication Associationhttp://dx.doi.org/10.1080/00909882.2014.911943

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that interactional sensitivity is a type of communication work and a quality of patient-centered communication characterized by the theoretical relationship between tailoringcommunication to the contingencies of the local interaction and the global illnesstrajectory. Overall, this article contributes to health communication scholarship byproposing a normative model for reflecting on how physicians negotiate challenginginteractions with patients during routine chronic illness visits.

Keywords: Health Communication; Patient-centered Communication; Physician–Patient Interaction; Treatment Decision-making; Type 2 Diabetes; Grounded PracticalTheory; Conversation Analysis

Introduction

When a patient’s blood sugar is chronically high, physicians often recommendinsulin to help keep blood sugar levels low. However, recommending insulin canplace the physician in an interactional dilemma. While insulin may be medicallyneeded, a recommendation for insulin may counter treatment preferences or raisepatient concerns. In this article, we use Grounded Practical Theory (GPT) tohighlight how physicians balance medical need with patient preference in ways thatcan support patient-centered communication using interactional sensitivity. Wecharacterize interactional sensitivity as a type of communication work and a qualityof patient-centered care that health care providers can use to tailor their social andcommunicative actions according to the contingencies of the local social situationand the patient’s larger illness trajectory over time.

Patient-centered Communication

Patient-centered care is a philosophical orientation that seeks to place patients at thecenter of their own care (Berwick, 2009). Over the last decade, patient-centered carehas been held up as an ideal to guide different facets of medical practice (Smith,Dwamena, Grover, Coffey, & Frankel, 2011; Swenson, Zettler, & Lo, 2006), healthoutcomes (Charlton, Dearing, Berry, & Johnson, 2008; J. H. Robinson, Callister,Berry, & Dearing, 2008), and health care system redesign (Hibbard, 2004). Forexample, in 2011 the Department of Veterans Affairs (VA) launched the Office ofPatient Centered Care and Cultural Transformation to develop and evaluate newhealth care models to provide effective, patient-centered, and culturally appropriateservices to veterans in an attempt to improve health care quality (Planetree, 2011;Office of Public and Intergovernmental Affairs, 2011). Despite its philosophicalinfluence, little empirical evidence explains how the ideals of patient-centered care(PCC) are applied to actual clinical practice.

PCC is rooted in health-care service delivery where providers and patients interact(Barry, Stevenson, Britten, Barber, & Bradley, 2001; Beach & Inui, 2006; Epstein

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et al., 2005; Killion, 2007) and policy research (Berwick, 2009; Hibbard, 2004). Priorresearch links PCC with promoting patient adherence to provider recommendations(Hahn, 2009; J. H. Robinson et al., 2008) patient satisfaction (Visser & Wysmans,2010), and trust (Shim, 2010). Relationally, PCC has also been characterized asbroadly empathic in nature (Aita, McIlvain, Backer, McVea, & Crabtree, 2005;Suchman, Markakis, Beckman, & Frankel, 1997).

While the idea of PCC has exerted a significant philosophical influence on health-care delivery, little prior literature has investigated PCC empirically. For example, inthe context of a medical visit, sharing information with patients is generally regardedas a PCC behavior (Epstein, et al., 2005). However, prior literature suggests that“medical information” can be shared in ways that emphasize biomedical aspects of adisease or its treatment and deemphasize biographical aspects of the illnessexperience (Corbin & Strauss, 1991; Donovan-Kicken, Tollison, & Goins, 2012;Koenig, Dutta, Kandula, & Palaniappan, 2012). While sharing information withpatients may be necessary for PCC, it may not be sufficient or even adequate to do soby itself because a single communicative action can be used in multiple ways and tovarious effects according to the larger contexts of disease and illness.

Against this trend, multiple scholars (Heidenreich, 2013; McCormack et al., 2011;Taylor, 2009) have called for a conception of PCC that highlights “the degree towhich an individual physician can adapt the consultation to the changing needs ofone patient, or to different needs of different patients” (Epstein et al., 2005, p. 1524),which they call informed flexibility. This is significant because it recognizes that PCCmust be sensitive to multiple, potentially conflicting interactional goals, including thephysician’s professional orientation to the biomedical aspects of the patient’s diseaseas well as the patient’s preferences for managing her or his illness as well as thelocation of the patient along her or his illness trajectory.

The Diabetes Illness Trajectory

Academic medicine has long recognized that chronic diseases, such as Type 2diabetes, have their own phases, turning points, and periods of stability andinstability. Corbin and Strauss (1991) developed the illness trajectory model thatconceives of chronic disease as a multidimensional experience with biomedical,psychosocial, and environmental components that constitute the illness experience.Originally developed as a conceptual model for nursing and for chronic, progressive,and eventually terminal illnesses, the model has since been expanded to include thefull life course of nonterminal chronic illnesses by taking into account a person’sdisease over time. One key component of the model is the recognition that chronicillness can be managed through the application of medical, behavioral, and socialtechniques that can shape how a chronic disease unfolds and develops over time toaffect an individual’s everyday life, her or his personal relationships, and health-careprovider team (Corbin, 1998). Shaping an illness trajectory requires collaborationamong multiple participants over time, including the affected individual, her or his

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close personal relationships, and the health-care providers. Donovan-Kicken et al.(2012) characterize the coordinated social interaction among the individual and heror his health-care team and caregivers as communication work, an ongoing series ofinteractional opportunities among providers, patients, and their close personalrelationships that both shapes and is shaped by the illness trajectory and itsconstituent phases. In Figure 1, we offer a visual diagram to illustrate thecontingencies of the illness trajectory.

In this article, we apply Corbin and Strauss (1991) illness trajectory model to Type2 diabetes in routine outpatient visits. The Type 2 diabetes illness trajectory typicallybegins with a diagnosis recognizing an individual’s inability to regulate blood sugarlevels. Once diagnosed, a person with Type 2 diabetes must incorporate newbehavioral modifications, such as changes in diet, exercise, and stress. Further, thenewly diagnosed person may be expected to monitor blood sugar levels and to takeoral medication to regulate blood sugar. While many people can manage blood sugarlevels with behavioral modification and oral medication, others may vacillate betweenstable and unstable phases of blood sugar control that can negatively impact everydaylife activities. Even with the individual’s active participation, environmental stress, orgenetic predisposition can cause blood sugar levels to remain chronically high.Extreme crises can include hospitalization or even coma. After a period of stability, ifblood sugar levels start to become chronically unstable, physicians orient to therelevance of an upcoming change in the patient’s illness management scheme,including oral medication, insulin, and complementary or alternative treatments.When blood sugars are chronically high, doctors may recommend treatmentintensification, that is, increasing dosage of a current medication or adding additionalmedication to manage blood sugar levels, such as insulin. Treatment intensificationsinvolving insulin can be delicate for the physician–patient relationship because manypatients fear taking insulin due to the stigma of using a needle or the implications ofa moral evaluation of the patient’s lack of success managing behaviors that affectillness management (Brod, Kongsø, Lessard, & Christensen, 2009, Kabadi, 2008;Ryan, 2010).

Figure 1 Linear representation of the chronic illness trajectory.

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Interactional Sensitivity

The term interactional sensitivity is used in several independent research traditions.In developmental psychology, interactional sensitivity is associated with attachmenttheory (Bowlby, 1969). The theory proposes that interactional competence deter-mines the strength of psychosocial attachment between mother and infant, andstronger the attachment results in positive psychosocial outcomes (Laakso, Poikkeus,Katajamaki, & Lyytinen, 1999; Oyen & Landy, 2010; Paavola, 2005). Althoughattachment theory was initially used to characterize primary socialization as a formof psychological development, subsequent work has broadened the notion to includeadult relationships as well (Collins & Read, 1990; Guerrero & Burgoon, 1996; Hazan& Shaver, 1987).

Adapting the psychological research to studies of interpersonal communication,Trees (2005) defines interactional sensitivity as the “active involvement in aconversation with a relational partner in which a person responds appropriately tohis or her partner’s needs in a smooth, synchronized manner” (2005, p. 251). Trees(2000) discerns three facets of interactional sensitivity: (1) conversational involve-ment in which participants actively engage with one another; (2) responseappropriateness in which participants’ responses are tailored to the interaction; and(3) interactional synchrony in which participants coordinate embodied behavior.

A concept closely related to interactional sensitivity in the conversation analytictradition is the principle of recipient design (Sacks, Schegloff, & Jefferson, 1974). CAassumes that speakers tailor facets of their talk, including lexical choice, turn design,and sequence initiation, in contextually appropriate ways that take into account theshifting contingencies of the local interaction. Pomerantz and Rintel (2004) applyrecipient design to routine medical visits to show how physicians report numericalreadings, such as a patient’s current temperature, and may presume that the patientmay be likely (or unlikely) to understand and interpret the results on her or his own.This suggests that physicians report different medical facts that may be responsive topresumed knowledge of their recipient and the contingencies of the turn-by-turndefinition of the situation.

Other discourse analytic works have shown that speakers are sensitive tointeractional contexts in other ways as well. Tracy (2002) demonstrated that thepractice of asking a question in 911 calls is not a neutral, information-gatheringtechnique. Depending on its sequential and pragmatic features, a call taker’s questionfor information can be construed as questioning the legitimacy of the emergency call,threatening the caller’s face. The resulting analysis suggests that call takers must beinteractionally sensitive to the possible understanding associated with askingquestions to avoid misunderstandings that can have dire outcomes in this context(Whalen, Zimmerman, & Whalen, 1988).

Drawing on these research traditions and the literature on PCC, we defineinteractional sensitivity as a type of communication work in which health-careproviders tailor their local social actions according to where the patient is along heror his illness trajectory. Using two single case analyses to illustrate different points

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along the Type 2 diabetes illness trajectory we focus on a key moment in eachinteraction—a treatment recommendation in which a physician advocates a shiftfrom oral medication to insulin. We argue that treatment intensification is a keymoment in health communication because physicians can find themselves in aninteractional dilemma: while insulin may effectively help control the unstable disease,an insulin recommendation may simultaneously counter patient values andtreatment preferences. We describe interactional sensitivity as a quality of PCCcharacterized by the theoretical relationship between how physicians tailor theircommunication to balance medical need with patient preferences according to thecontingencies of the local interaction and the global illness trajectory.

Methods and Data

This article is based on the work from a larger study of patient-centeredcommunication using a mixed-methods design across two sequenced phases(Creswell & Klassen, 2011). In the first year, we started with an inductive qualitativephase and moved in year two to a deductive quantitative phase. Both phases exploredthe construct of interactional sensitivity as a type of communication work and aquality of PCC. We started with qualitative analyses by focusing on interactionalfeatures of the medical visits, including recipient design, turn-taking, and sequentialorganization of Type 2 diabetes visits.

Theoretical Orientation

This article uses the theoretical and methodological framework of GPT to provide alens for analyzing and interpreting discourse as a situated form of social action (Craig& Tracy, 1995). GPT conceives of communication as a practical activity (Craig, 1999)by concentrating on the problems, interactional dilemmas, and communicationrequirements faced by participants engaged in social interaction. As a meta-theoretical framework, GPT seeks to develop pragmatic theories that are empiricallygrounded and useful for practice and reflection.

GPT builds on the idea that communication is a practical discipline (Craig, 1999).Drawing on Aristotle’s notion of phronesis (Aristotle, trans. 1999) and Americanpragmatism (Dewey, 1989), GPT employs theoretical reconstruction as its keyanalytic move across three interrelated levels of analysis. A theoretical reconstructionis a typified or idealized social practice where particular features of that practice are(re-)described in general terms. The goal of theoretical reconstruction is to makeimplicit values and principles of a social practice explicit and available for criticalevaluation and, ultimately, the construction of a normative model applicable tosimilar situations.

Within GPT, a practice can be reconstructed across three interconnected levels ofanalysis. The technical level is the most concrete and focuses on the routine practicesof social actions, communication techniques, and discursive strategies empiricallyemployed by participants in interaction. The technical level provides evidence for the

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analysis at the two next levels. The problem level focuses on the communicationproblems or interaction dilemmas participants experience in and through their socialactions. The problem level generalizes routine practices from the technical level byarticulating the multiple and competing goals potentially available to participants inindividual interactional episodes. Finally, the philosophical level is the most abstractand focuses on explicating the situated ideals to “provide a rationale for theresolution of problems” (Craig & Tracy, 1995, p. 253) as they are played out acrossrelated episodes of talk. In this analysis, we use GPT to suggest that whenintensifying treatment in Type 2 diabetes, physicians ideally employ interactionalsensitivity at the philosophical level to balance medical need with patient preferencesat the problem level by tailoring their treatment recommendations for insulinaccording to the contingencies of where the patient is in her or his illness trajectoryat the technical level. In this article, we use empirical description of how physiciansapproach this delicate communication to generate a normative model for reflectingon and advancing investigation on an important problem in health communication.

Data

In the larger project, we started with 400 audio-recorded Type 2 diabetes visitsbetween general internal medicine and specialist endocrinologist physicians andpeople with Type 2 diabetes. The data were collected by Verilogue as part of anational sample of diverse physicians, practice types, illness conditions, and patientsfrom different socioeconomic strata, insurance types, ethnicities and regions withinthe USA for commercial and research purposes. Of the total 400 visits, we randomlyselected 55 recordings and their associated professional transcripts for analysis.

Method

We use the qualitative methodology of Conversation Analysis (CA) as applied to thestudy of medical encounters (Drew, Chatwin, & Collins, 2001; Heritage & Maynard,2006; Robinson, 2011) to empirically document communication techniques enactedbetween physicians and patients, which we use as evidence to ground our claimswithin the GPT framework. Our interdisciplinary team of scholars conducted thisproject over three years and across two phases. In Phase 1, we met biweekly to builda qualitative interpretation of the data (ten Have, 1999) before moving onto thequantitative phase (Sabee et al., under review) in year two. The final year was spentdisseminating results (Sabee et al., in press; Wingard, Olsher, Sabee, Vandergriff, &Koenig, 2014).

We used the philosophical orientation of patient-centered communication as asensitizing concept (Blumer, 1954) to explore the frequency and range of interac-tional techniques that occur during Type 2 diabetes visits. We noticed that physiciansroutinely begin the diabetes component of the visit by soliciting blood sugar levels(Wingard et al., 2014). Building on this practice-based analysis, we noticed thatchronically elevated blood sugar levels seemed to foreshadow treatment intensifying

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recommendations. Across the data-set, we noticed that patients unproblematicallyaccepted changes in medication they were already taking, including oral medicationand insulin. However, patients often resisted changes in medication when it requiredtreatment intensification, especially when the recommended change was from oralmedication to insulin. We searched the corpus for mentions of insulin that resultedin a corpus of 17 interactions. Out of that subcollection, we identified six visits inwhich physicians and patients negotiated a possible change from oral medication toinsulin.1 We decided to focus on these cases because the resulting interactionsembodied a particularly challenging facet of patient-centered communication wheremedical need and patient preference appeared to be in tension.

To develop our analysis, the first author retranscribed these interactions accordingto standard CA conventions (Hepburn & Bolden, 2012; Jefferson, 2004). Next, theresearch team systematically examined participant lexical choices, turns at talk,sequence organization, activity structure, and overall structural organization toconstruct a provisional analytic scheme using the limited cases our sample provided,while simultaneously drawing on the larger data-set for comparative and contrastivepurposes. In this article, we analyze two focal cases that crystalized the candidatepractices we saw more widely in the data. From this analysis, we propose a normativemodel of communication for reflecting on how physicians negotiate insulinrecommendations in Type 2 diabetes visits.

Analysis

In the following analysis, we compare the two interactions with different patients atdifferent points along the Type 2 diabetes illness trajectory to illustrate howphysicians may interactively negotiate treatment intensification according to thepatient’s locus along the illness trajectory. First, when blood sugar levels start tobecome chronically unstable, physicians can orient to the relevance of an upcoming,but nonurgent change in the patient’s illness management scheme, which we callapproaching a clinical key moment. Second, if the unstable phase continues and bloodsugar levels remain high, physicians can orient to the relevance of an imminent, andpotentially urgent, change in the patient’s illness management scheme, which we callarriving at a clinical key moment. These two ideals are played out implicitly at theproblem level through an interactional dilemma in which physicians strive to balancemedical need with patient preferences or concerns. Finally, these situated ideals andthe underlying values are explicitly enacted at the technical level through varioustechniques we discuss below. We argue that physicians simultaneously orientto medical need and patient preferences, but how aggressively they pursue oneover the other depends on the contingencies of the clinical situation, the patient’severyday life activities, and where the patient is along her or his illness trajectory(Figure 2).

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Approaching a Clinical Key Moment: Projecting a Possible Future Change in IllnessManagement

The first case is a person with Type 2 diabetes whose blood sugar levels may begin toshow evidence of being uncontrolled. This is a delicate moment in the provider–patient relationship because patients often resist insulin recommendations (Silverman,1997). The physician uses two communication techniques to balance the interactionaldilemma between a medically needed recommendation and the patient’s resistance tothat recommendation (Stivers, 2005a, 2005b).

The physician began the visit with exchanging information about the patient’sblood sugar levels (not shown), a common method to begin routine diabetes medicalvisits (Wingard et al. 2014). The patient’s response indicated a range of high bloodsugar measurements. The transcript below shows the physician assessing the patient’ssugar levels as “running a little too high” (Lines 88–90).

Extract 1.1 VLT 142988 DR: What that’s telling me also [PATIENT89 NAME] is that your sugars are running90 a little too high.91 PT: Yeah.92 DR: And you know that’s from the diabetes,93 okay? Now, the Avandamet that I gave you94 to take-95 PT: Right.96 DR: And I think I told you to take that once97 a day in the morning.98 PT: Right.99 DR: I want you to now take that before dinner also.100 PT: Okay.

Figure 2 Normative model of interactional sensitivity for routine Type 2 diabetes visits.

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101 DR: Start taking that twice a day. I’ll write102 you a new prescription on that.103 PT: Okay.104 DR: >> Okay, but I wanna see your blood sugars

105 >> running in the morning no higher than

106 >> 120.

107 PT: 120.108 DR: >> Okay? That’s my goal.

109 PT: Okay.

The physician’s assessment (Lines 88–90) is incrementally extended to make explicitthat the cause of the high blood sugar is the patient’s diabetes (Line 92). Next, thephysician reviews the patient’s current oral medication, Avandamet (Lines 93–103),in relation to the time of day (Lines 96–98) and other everyday life activities, such aseating (Line 99), all of which the patient affirmatively receipts (Lines 95, 98, 100, and103). The physician initially recommends increasing the frequency of the medication,“Start taking that twice a day. I’ll write you a new prescription on that” (Lines101–102), an intensification of the oral medication. The patient immediatelyaccepts the recommendation with okay (Line 103), before moving to a next activity(Koenig, 2011).

The next activity begins with the physician naming a target number for hismorning blood sugar levels, “Okay, but I wanna see your blood sugars running in themorning no higher than 120.” (Lines 104–106). We call this a benchmark becausethe physician articulates the biomedical standard tailored to the unique aspects of thepatient’s clinical condition to which the patient can be subsequently evaluated.2 Thebenchmark has two analytically significant components. First, the patient’s bloodsugar should be measured at a particular time of day—in the morning (line 105).Morning is an important time to measure blood sugar levels because the body hasbeen fasting overnight, so the measurements at this time indicate a daily baselinelevel. Second, the physician offers a candidate ideal number for the patient’s bloodsugar levels, “120” (Line 106). For a person with Type 2 diabetes, fasting blood sugarlevels of 120 suggest that this patient’s blood sugar levels may have been chronicallyhigh for some time and constitute evidence that the patient may be entering anunstable phase where the current treatment may not be effectively controlling bloodsugar. The physician designates 120 as “my goal” (line 108) for the patient’s sugarlevels emphasizes the physician’s role in advising the patient to keep his blood sugarlevels within the biomedical ideal. Overall, the physician uses the benchmark toprovide the patient tailored clinical information about the biomedical ideal for bloodsugar levels according to the patient’s current condition and unique location alongthe illness trajectory.

After establishing a benchmark as an evaluative heuristic, the physician explainsthat if the current treatment does not maintain low blood sugar levels (Lines 110–111), the patient may be approaching a clinical key moment for switching medicationto manage the disease (Lines 111–112).

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Extract 1.2 VLT 1429110 DR: >> And if we’re not able to do that with the

111 >> Avandamet, then, yknow, we may have to

112 >> switch you to something else.

113 PT: I can’t take the, uh -114 DR: Insulin?115 PT: I can’t do that.=They- it will jack up116 my job.117 DR: Uh, you’re not a smoker.118 PT: No I’m not a smoker [and >I never-<).119 DR: [Uh, they have an120 inhaler now, where you inhale this one.121 You don’t shoot it up.122 PT: Yeah, but will it, uh- what- uh- it’s been123 a while that the uh, federal. Uh I don’t124 know exactly. But I do know that you can’t125 take insulin and drive a truck. That’s my126 livelihood.127 DR: I hear ya. Yeah, my brother-in-law’s128 same way he drives a truck, yknow, lumber129 truck and he can’t take insulin either.130 But we just scratched the surface as far131 as your diabetes.132 PT: Um-hum.133 DR: All right? The first thing I would do is134 the Avandamet, take it twice a day.135 PT: Okay.136 DR: But keep taking the Cardizem at night the137 Benicar in the morning, cause you need138 that for your blood pressure. Your139 pressure’s running a little high today.

Rather than baldly announcing the possible future medication, the physician uses acautious recommendation formulation for “something else” (Line 112). In theconversation analytic literature, a formulation is a generic order of conversationalorganization that refers to the careful selection of lexical items where severalalternatives are potentially available (Schegloff, 2006). Previous research on treatmentrecommendation formulations argues that nonspecific medication references, such assomething else, may help manage delicate treatment recommendations (Koenig,2008). Additionally, the nonspecific formulation may also be a first mention(Wingard, 2006), a possibly first occasion in which the physician mentions a nextpossible treatment option to manage the patient’s disease. In this case, the physicianuses the nonspecific formulation to index progression along the patient’s illnesstrajectory and may be approaching a clinical key moment where a switch inmedication may be medically necessary.

In response, the patient explicitly orients to the nonspecific formulation as an itemfor active discussion because it portends a possible recommendation for insulin,

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which he actively resists (Lines 113–116), “I can’t take the, uh-” (Line 113). When thepatient’s turn breaks off, the physician helps coconstruct the turn by independentlysupplying the anticipated item, “insulin” (Line 114) as a next possible treatmentoption.

At this point in the interaction, the situated ideals of medical need and patientpreference are in overt tension. From the physician’s perspective, because the patientmay be approaching a clinical key moment, a switch from oral medication to insulinmay be needed to help keep his blood sugar levels low. From the patient’sperspective, the physician may not be aware of a specific treatment preferenceunderlying his objection, which he explicitly articulates, “it will jack up my job”(Lines 115–116). Rather than eliciting more information about the patient’s perceivedbarriers, the physician continues an orientation to medical need by suggesting analternate treatment option, another method of administration, “they have an inhalernow, where you inhale this one. You don’t shoot it up” (Lines 119–121). Bysuggesting an alternative treatment option, the physician treats the patient’sresistance as potentially related to an objection to administering insulin using asyringe. However, the patient’s objection turns out not to be due to how insulin isdelivered, but due to his work as a professional truck driver (Lines 122–126). In otherwords, the basis of the patient’s resistance to a projected future treatment option isnot due to a generalized stigma to taking insulin or using a syringe, but aparticularized treatment preference based in a legal restriction that prohibits thepatient from taking insulin while working as a commercial truck driver.

Once the patient provides this specific reason, the physician demonstratesindependent understanding of the patient’s situation. The physician’s brother-in-law, who also has diabetes and works as a truck driver, cannot take insulin for thesame reason (Lines 127–129). Revealing this connection, the physician treats thepatient’s resistance as reasonable by discontinuing further discussion of a projectedfuture possible change to insulin by asserting, “we have just scratched the surface asfar as your diabetes” (Lines 130–131). This response suggests that while the physicianmay back away from an insulin recommendation for now, depending on how thepatient continues to manage his disease, there may be more discussions along theselines. Thus, the physician may orient to the idea that the patient is only approachinga clinical key moment for a change in medication from oral medications to insulinuntil a later date. Finally, this portion of the interaction ends with a reissue of thephysician’s original treatment recommendation (Lines 93–97) to increase thefrequency of the current oral medication, Avandamet, from once to twice daily(Lines 133–135). The patient again unproblematically accepts this recommendation(Line 135), and the physician moves to a next problem, the patient’s blood pressuremedication (Lines 136–139) that brings the diabetes component of the visit to a close.

This interaction provides evidence for how a physician may orient to the situatedideal of approaching a clinical key moment within one patient’s Type 2 diabetesillness trajectory. The physician uses two techniques, benchmarking and a mitigatedrecommendation formulation, to balance the tension between medical need andpatient preference when projecting an upcoming change in medication.

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In summary, the benchmark provides the patient-tailored clinical information byestablishing the biomedical norm and helps to guide the patient when interpretinghis daily blood sugar levels. Second, the physician uses a recommendationformulation to project future treatment options, implying a change from the currenttreatment using a nonspecific medication reference. In contrast to the physician’srecommendation for intensifying the patient’s current oral medication, which thepatient unproblematically accepts, when the physician obliquely refers to a possiblenext medication as something else, the patient actively resists despite the delicateformulation. Used together, the benchmark and delicate recommendation formula-tion suggest the patient’s blood sugar control may be unstable with the current illnessmanagement scheme and that the patient may be approaching a clinical key momentin illness management.

We propose that the physician backs away from a treatment intensifyingrecommendation because the patient may be only approaching a clinical key momentwhere insulin may be needed to control blood sugar levels at a future, undeterminedtime. Only after hinting at the need to change the patient’s medication does theconversation shift to discussing patient preferences to arrive at a negotiated treatmentrecommendation. The fact that the physician backs away from an insulinrecommendation shows that physicians can tailor their recommendations to thecontingencies of the local situation according to where the patient is in his illnesstrajectory. By projecting future possible changes in medication, this case providesevidence that while medical need and patient preference may be in tension,physicians negotiate treatment by taking patient’s concerns as legitimate and can offersolutions that overcome those concerns, even if it means postponing treatment—anddiscussion of treatment—until a future time.

Arriving at a Clinical Key Moment: Recommending an Imminent Change in DiseaseTreatment

In this second case is a person with Type 2 diabetes whose blood sugar levels arealready known to be chronically uncontrolled, and the physician’s verbal behaviororients to this patient as being further along the Type 2 diabetes illness trajectory.Because the patient’s disease may have been unstable for some time, we argue thatthe physician orients to the situated ideal of arriving at a clinical key momentthrough an immediate change from oral medication to insulin. This is a delicatemoment because informing patients they have advanced along an illness trajectorycan be received as bad news. For patients, disease progression typically meanschanges in illness management that can impact everyday life activities in unpredict-able ways. Additionally, the suggestion of insulin may also imply a moral evaluationof the patient’s inadequate blood sugar control, which can be face threatening andimpact a patients’ sense of identity and mental health. In the following interaction,the physician uses both benchmarking and recommendation formulations toreinforce the medical need for an insulin recommendation, which the patientstrongly resists. To balance tension between medical need and patient preferences,

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the physician overtly explores the basis for the patient’s active resistance througheliciting his perceived barriers to the proposed change in treatment.

The physician begins the visit with a brief social opening (Lines 01–03), andsolicits the patient’s blood sugar levels, “How are the sugars” (Line 04).

Extract 2.1 VLT 1834301 DR: Okay, so what’s been going on:? (1.5) How02 have you been?03 PT: Good?04 DR: Okay=good. How are the sugars.05 (0.5)06 DR: mkay=hh07 (0.5)08 DR: so they’re hi:gh.09 (0.8)

A gap ensues (Lines 05, 07) after the blood sugar solicitation in which the patientavoids verbally reporting blood sugar levels, however, it is possible the patient mayrespond with an embodied response, such as with a gesture or other action, such ashanding the physician a written log of his blood sugar levels.3 The physician’s firstreceipts (Line 06), then negatively assesses the patient’s blood sugar levels, “so they’rehi:gh.” (Line 08), which provides the patient with information about his medicalcondition. Rather than moving to a next activity, the physician expands the bloodsugar sequence (Wingard et al., 2014) by eliciting more specific blood sugarmeasurements according to the time of day and eating.

Extract 2.2 VLT 1834310 DR: hh (1.0) What’s been going on with your11 di:et.12 (2.0)13 DR: Because in the morning, they’re running,14 (.5) you know, one- one eighty to two15 hundred?16 (3.5)17 DR: >> an:d they really should be less than like18 >> one twenty. And in the afternoon you’re19 run:nin:g sometimes, as I see, there’s a20 300 over here also. This is before dinner21 or af:ter dinner?22 PT: Uh:, after dinner.23 (4.5)24 DR: Are you urinating a lot or not?25 PT: Well, (0.5) yes.26 DR: Any blurry vision or anything like that?27 (0.5) or not.28 PT: No.29 (4.5)30 DR: >> Well, (.5) you ready for me to put you on31 >> insulin?

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The physician first inquires about the patient’s dietary habits (Lines 10–12), butwhen the patient withholds a response (Line 12), the physician summarizes thepatient’s daily blood sugar log by specifying the range of measurements at differentpoints of the day (Lines 13–23). The physician first notes high sugar levels areelevated, “in the morning, they’re running (.5) you know, one-one eighty to twohundred?” (Lines 13–15) and explicitly provides a benchmark for the ideal bloodsugar levels, “they really should be less than like one twenty” (Lines 17–18). Ratherthan using the benchmark to educate the patient as in the prior interaction, in thisinteraction, the benchmark is used as an embedded sanction, emphasizing thepatient’s inability to meet the biomedical ideal in his day-to-day blood sugarmanagement. As the physician continues, he notes that the patient’s blood sugarlevels are also high in the afternoon, “And in the afternoon you’re run:nin:gsometimes, as I see, there’s a 300 over here also” (Line 18), and after dinner (Line 21).The physician summarizes the information provided by the patient to confirm thepresence of chronically elevated blood sugar levels. The implication is that thispatient may be approaching a potentially high-risk medical situation since chronic-ally uncontrolled blood sugar can cause both short- and long-term problems, such asdizziness, neuropathy, loss of sight, and coma.

Until this point in the interaction, the patient’s verbal participation is limited toone or two word answers to the physician’s questions. Despite several opportunities(Lines 05, 09, 12, 16) where the patient could take a turn to respond or elaboratesome facet of his condition, he withholds verbal contribution. This lack ofresponsiveness enables the physician to tailor the unfolding sequence as anaccumulation of biomedical facts about the patient’s current condition and locationalong the illness trajectory.

The physician next inquires about the presence of specific diabetes-relatedsymptoms, frequent urination (Lines 24–25) and blurry vision (Lines 26–28). Thephysician’s questions may suggest that he anticipates these symptoms because thepatient’s blood sugar levels have been increasingly unstable for an extended amountof time. Additionally, by asking the patient a series of questions related to thepossible presence of symptoms the physician may also invite the patient toindependently arrive at the conclusion that his blood sugar control may be poor.As a result, the physician issues a direct recommendation formulation for insulin,“Well, you ready for me to put you on insulin?” (Lines 30–31). Both composition andposition of this treatment recommendation formulation diverge from the priorexample. Compositionally, the formulation “you ready for” (Line 30) implies that therecommendation is no longer a first mention, but rather a next instance of anongoing discussion about insulin as the next medically necessary treatment. Second,in contrast to the previous case in which the physician uses a nonspecificformulation, in this case the physician uses a name formulation, insulin (Line 31),to identify the class of treatment recommended (Koenig, 2008). Prior research hasshown that name formulations are used when physicians presume that patient mayrecognize the name of the proposed treatment. This suggests that the unmitigatedtreatment recommendation alludes to at least one previous instance of discussing

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treatment options where insulin may have been recommended and rejected by thepatient.

Positionally, the recommendation follows two previous activities aimed atestablishing the presence of high medical risk. An explicit discussion of chronicallyhigh blood sugar implies a causal relationship between elevated blood sugar and thesespecific symptoms due to the diabetes. From the physician’s perspective, the patient’sbehavior and medication are not enough to maintain low blood sugar levels.Specifically, the physician relies on the patient’s high blood sugar measurements atdifferent times of day and over time and the patient’s current symptoms as evidencefor building a case that the patient has arrived at a clinical key moment for an insulinrecommendation. However, the insulin recommendation is overtly at odds with thepatient’s treatment preferences (Lines 32, 33).

Extract 2.3 VLT 1834330 DR: >> Well, (.5) you ready for me to put you on31 >> insulin?32 PT: NO↓33 DR: Tha-that’s what you ne:ed?34 PT: No.35 DR: I have you on (.5) every medication I36 can have you on. and we’re still not37 (0.5) well controlled.38 (2.0)39 You haven’t lost weight.40 (1.0)41 It’s not good for your hea::rt.42 (3.5)43 >> Have you been to the eye doctor recently?44 >> or not.45 PT: °Yeah.

The patient responds to the recommendation with an emphatic, “NO↓” (Line 32),which baldly resists the recommendation. The physician challenges this resistance byrecompleting the recommendation, “That’s what you need” (Line 33). The patientactively resists a second time with a less emphatic, “No” (Line 34). Unlike theprevious interaction in which the patient articulates the basis of his resistance, in thiscase the patient’s rationale remains as yet unarticulated. The physician provides aseries of medical accounts to further justify his recommendation on the basis ofmedical need: the patient already takes “every medication I can have you on” (Lines35–37); the patient is overweight (Line 39); and high blood sugar is “not good foryour hea::rt.” (Line 41), a common comorbid problem for people with diabetes. Theunarticulated conclusion is that the patient needs insulin to prevent more severesymptoms.

Rather than further pressing the patient to consider insulin, the physician changestactics after a gap (Line 42) in which he temporarily disattends the prior problematictalk (Maynard & Hudak, 2008) to focus on other medical business. The physicianstarts with a question about recent contact with an eye doctor (Line 43), which the

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patient confirms (Line 45). Over the next three minutes, the physician temporarilyavoids further talk about the insulin recommendation as he addresses other aspectsof the patient’s overall health.

The physician restarts discussion of the insulin recommendation while engaged inthe physical examination, a recurrent activity type during routine Type 2 diabetesvisits (Sabee et al, in press). While listening to the patient’s lungs (Lines 87–91), thephysician directly asks the basis of his resistance.

Extract 2.4 VLT 18343 No87 Okay, deep breaths in and out88 slowly through your mouth for me,89 please.90 PT: (gasp?).91 DR: Okay, just regular now. (1.5)92 >> What’s scaring you so much about93 >> taking injections?94 PT: (moaning)95 DR: I would put you on one shot a day, one96 shot. Take it before you go to sleep.97 That’s how we would start. I think you’d98 feel better. I think your sugars would be99 better.100 PT: Bu- but I don’t know how to do it.101 DR: Well I’ll teach you. We’ll teach you. It102 comes in a pen. We’ll start you. We’ll103 see how you do. I don’t think it’s going104 to be as bad as you think … ((continues))

In contrast to the initial recommendation for insulin, the physician shifts strategiesby asking a direct question, “What’s scaring you so much about taking injections?”(Lines 92–93). Note the design of the turn—the physician relies on the patient toassociate “taking injections” with the insulin recommendation. Inviting the patient tomake the association between insulin and injections provides further evidence thatthe direct question is a next instance of an ongoing discussion of appropriatetreatment options where the physician recommends insulin to the patient acrossseveral visits. Prior research has suggested that explicitly eliciting patient barrierstopicalizes previously sensitive, unknown, or unarticulated preferences or concernsand may de-stigmatize delicate topics by treating them in a straightforward manner(Koenig, 2013). The sequential position of this turn is also significant because itrestarts a problematic activity begun earlier in the visit—the discussion of an insulinrecommendation—that is resumed after several other intervening activities. Thephysician may use sequential delay (Maynard & Hudak, 2008) with those interveningactivities to allow the patient’s high affect levels to drop before reintroducing thetopic at a later time. While it may be significant that the physician resumesproblematic treatment talk while in close physical contact with the patient, the audiorecording does not provide visual access to the spatial and haptic organization of theparticipants during this delicate moment.

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The patent responds with a moan (Line 94), a response cry that may vocallydisplay his objection to restarting the sensitive topic. Rather than responding to thepatient’s vocal response, the physician continues by concretely describing what theinsulin recommendation would mean for the patient’s everyday life—one insulininjection per day (Lines 95–96), administered at night (Line 96) that would likelyhelp the patient feel better (Lines 97–98) by improving blood sugar levels (Lines98–99).

After previously objecting, the patient finally reveals a previously unarticulatedreason for his resistance as he complains: “I don’t know how to do it” (Line 100).When the patient explicitly articulates a reason for his resistance, the physicianaddresses the patient’s concern with an offer, “I’ll teach you. We’ll teach you” (Lines101–102). From this point forward, the physician and patient discuss the insulinrecommendation, to which the patient ultimately agrees.

This interaction provides comparative evidence for how physicians may usecommunication techniques to achieve interactional sensitivity. We use this case totheorize that the physician may implicitly orient to the situated ideal of arriving at aclinical key moment according to the patient’s current medical circumstance as areflection where he may be along the Type 2 diabetes illness trajectory. This is acritical moment because physicians can be caught in an interactional dilemma inwhich they must present convincing clinical evidence that current treatments appearto be no longer effective and insulin is immediately needed to keep blood sugar levelslow, which patients can strongly resist.

The physician uses three communication techniques to balance the tensionbetween medical need and patient preference, benchmarking, a bald recommenda-tion formulation, and directly eliciting patient barriers to the recommendation. Thesetechniques provide evidence for how physicians’ actions can be sensitive to the localinteraction and to the unique features of where each patient is along her illnesstrajectory. The first two techniques offer comparative evidence as the physicians ineach interaction employed benchmarks and treatment recommendation formulationsin different ways. Whereas in the first case, the physician uses the benchmark toexchange information as a motivational tool to help the patient evaluate his dailyblood sugar measurements, in the second case, the physician uses the benchmark todemonstrate the patient’s inability to live up to the biomedical ideal in his everydayblood sugar measurements. Similarly, whereas in the first case, the physician uses anindirect formulation to imply the patient’s upcoming need for insulin as a treatmentoption, in the second case, the physician uses a direct recommendation formulationto baldly recommend insulin is medically necessary immediately to control bloodsugar levels effectively.

While directly eliciting patient barriers only occurs in the second case, it may alsodemonstrate how physicians’ actions can be interactionally sensitive. By explicitlyeliciting patient barriers, the physician creates an opportunity for the patient toactively participate in the recommendation by inviting him to voice previouslyunarticulated treatment concerns (Koenig, 2011). The physician demonstrates notonly recognition of the patient’s preference against insulin, but also treats the

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patient’s preferences as secondary to the patient’s clinical condition as a matter forimmediate attention. While we would not argue that a physician should simplyprioritize medical need over patient preference, this case suggests that for thephysician, when a patient is arriving at a clinical key moment medical need mayoccasionally trump patient preference. However, this must be accomplished ininteractionally sensitive ways.

Discussion

We use the GPT framework to develop the concept of interactional sensitivity as atype of communication work and a quality of PCC in routine Type 2 diabetes visits.We empirically analyze communication techniques to ground our claims thatphysicians balance the interactional dilemmas when negotiating treatment decisions.We analyze these dilemmas through the situated ideals of balancing medical needand patient preference through the contexts of approaching and arriving at a clinicalkey moment. We argue that physicians may orient to these moments through theirobservable social actions as well as through the conceptual values and ideals that maybe embedded within routine medical visits. This article provides several implicationsfor practice and reflection.

First, our findings cast doubt on the premise that any single communicationtechnique or social action may be universally “patient centered” without regard to itscontext of use. Physicians may demonstrate interactional sensitivity by how theytailor their communication according to the contingencies of the local interactionand the location of the patient along the chronic illness trajectory. For example,benchmarks can be used as a tool to exchange information about biomedical normsthat help motivate a patient to achieve a specific self-management goal or sanction apatient for not meeting an agreed-upon self-management goal. We demonstrate thatthe same communication technique can be adjusted to pragmatically and contextu-ally adapt communication to the patient’s biological and psychosocial circumstancesthat change over time. This suggests that there may be many versions of interactionalsensitivity associated with various communication techniques and practices and thatthey must be tailored to specific disease conditions or to particular points along anillness trajectory. This has implications for how different activities are done,including exchanging information, discussing options, and negotiating decisionsaccording to clinical and social circumstances.

Second, our analysis suggests a general principle for how physicians may tailortheir communication according to the local interaction of the medical visit, thepatient’s clinical and social circumstances. Because the tension between medical needand patient preference is at the generative heart of interactional sensitivity, thesituated ideals could be use as a general conceptual tool for thinking about how tocommunicate with a patient. For example, when patients may only be entering into aperiod of unstable disease, which we characterize as approaching a clinical keymoment, physicians may focus on illness management strategies that maximize as acontext for illness management strategies that maximize the needs and preferences of

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the patient by exchanging information, providing counseling and education anddiscussing options to negotiate decisions about treatment to shape the illnesstrajectory in support of long-term patient health. Similarly, when patients have beenin a period of unstable disease that may require an imminent change of themanagement strategy, which we characterize as arriving at a clinical key moment,physicians may focus on strategies that maximize management of the medical aspectsof disease management, such as providing explicit explanations, discussing anarrowed range of clinically acceptable treatment options, and inviting the patientinto the decision-making negotiation with the goal of minimizing negative outcomesthroughout the patient’s illness trajectory. These situated ideals may help physiciansreflect upon how to adapt communication behavior according to the contingencies ofthe local interaction and the location of the patient along the illness trajectory todemonstrate interactional sensitivity even when patients actively resist physicians’treatment recommendations.

Third, our analysis provides practical resources for physicians who find themselvesin an interactional dilemma when patients actively resist physician’s treatmentrecommendations due to differences between medical need and patient preference.One recommendation is that physicians can raise and discuss difficult topics while apatient is still approaching, but before she has arrived at a clinical key moment.Routinizing discussion about difficult topics, such as insulin recommendations overan extended period of time when affect is low, may help establish trust betweenphysician and patient so that when difficult issues emerge, emotional risk may belower due to previous and frequent discussions. This suggests a testable hypothesisthat the frequency of raising delicate health communication may help normalizedifficult health decisions by helping patients imagine a future in which alternativetreatment may be needed due to their location along the illness trajectory.

Finally, our study contributes to the GPT framework. Drawing on normativeconcepts from PCC and the chronic illness trajectory model, we blend empiricalanalysis with conceptual framing to create a normative model for reflecting on animportant interactional problem in health communication. Drawing on the two casestudies as well as the larger process of prolonged engagement with the full data-set,our reconstruction of the communication techniques enables us to critically reflect onhow these techniques are empirically used in specific instances of interaction in orderto recommend how these techniques could be used to improve health-care decision-making communication for physicians and patients managing chronic illness moregenerally.

Conclusion

In this article, we aim to empirically specify some interactional features of interactionalsensitivity as a facet of PCC. Overall, we show that PCC is diverse and complex and isbest understood through a lens that considers empirical and conceptual context acrossmultiple levels. Good medical care must involve patient education and must includechallenging the patient’s lay understanding if it runs counter to evidence-based

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recommendations. For this reason, effective PCC must go beyond simply honoring apatient’s values and preferences in order to challenge them when necessary at theappropriate time.

Acknowledgments

This project received funding from both the Office for Sponsored Research and theCollege of Liberal and Creative Arts at San Francisco State University. The authorswish to thank Verilogue, Inc., for access to their corpus of doctor–patient dialogs. Weacknowledge Nicole Azuma, Nick Chivers, and Jamie Foster and their researchassistance throughout this project. Finally, we thank the two anonymous peer-reviewers, Robert Craig, and Karen Tracy, whose thoughtful critiques helped us honeour argument.

Notes[1] Out of the total 17 cases identified, besides the six visits in which physicians and patients

negotiated treatment intensification, the remaining cases included seven visits in which thepeople with Type 2 diabetes had been taking insulin for a long period of time and discussedinsulin in matter-of-fact ways, and four miscellaneous cases in which insulin was variablymentioned in relation to insurance claims, family members with Type 1 diabetes, and similarlogistical issues related to everyday life contexts.

[2] Benchmarks were a recurrent communication action we observed throughout the data-set.During our qualitative phase, we noticed that benchmarks occurred in almost all visits, andmost visits had multiple instances of benchmarks. We are currently in the process ofpreparing a manuscript to present this communication practice and its interactional effects.

[3] Written blood sugar logs are typically small booklets in which patients record the date, time,and blood sugar measurements. While blood sugar logs are frequently used for patients totrack their blood sugar levels, they may also play a role in helping physicians monitor patientadherence to medication and measurement procedures.

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