Using a patient decision aid for insulin initiation in …...clinics and c) one primary care clinic in a public university hospital), in the Klang Valley, Malaysia. Participants :

For peer review only

Using a Patient Decision Aid on Insulin Therapy-A Conversation Analytic Study of Doctor-Patient Talk in

Primary Care Consultations

Journal: BMJ Open

Manuscript ID bmjopen-2016-014260

Article Type: Research

Date Submitted by the Author: 12-Oct-2016

Complete List of Authors: Syed, Ayeshah; University of Malaya Faculty of Languages and Linguistics, English Language Mohd Don, Zuraidah; University of Malaya Faculty of Languages and

Linguistics, English Language Ng, Chirk Jenn; University of Malaya, Department of Primary Care Medicine Lee, Yew Kong; Universiti of Malaya, Department of Primary Care Medicine Khoo, Ee Ming; University of Malaya, Department of Primary Care Medicine Lee, Ping Yein; University Putra Malaysia, Fakulti Perubatan dan Sain Lim Abdullah, Khatijah; University of Malaya, Department of Nursing Science Zainal, Azlin; University of Malaya Faculty of Languages and Linguistics, English Language

Primary Subject Heading:

Communication

Secondary Subject Heading: General practice / Family practice, Qualitative research, Patient-centred

medicine, Diabetes and endocrinology

Keywords: patient decision aid, insulin, consultation, type 2 diabetes, conversation analysis

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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pril 29, 2020 by guest. Protected by copyright.

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Title: Using a Patient Decision Aid on Insulin Therapy- A Conversation Analytic Study of Doctor-

Patient Talk in Primary Care Consultations

Article Word Count: 3827 (Main Article excluding Tables, Figure and Extracts (in Table format))

Corresponding author at

Ayeshah Syed

Department of English Language

Faculty of Languages and Linguistics

University of Malaya

50706 Kuala Lumpur, Malaysia

Tel +603-7967-3177, Fax+603-7957-9707

e-mail: [email protected]

Authors

No. Name Last

Name

Affiliation e-mail address

1 Ayeshah Syed

(corresponding

author)

Syed Department of English Language



Kuala Lumpur, Malaysia

[email protected]

.my

2 Zuraidah Mohd

Don

Mohd

Don



University of Malaya,


[email protected]

3 Ng Chirk Jenn Ng Department of Primary Care Medicine

Faculty of Medicine,



[email protected]

4 Lee Yew Kong Lee Department of Primary Care Medicine

Faculty of Medicine


Kuala Lumpur Malaysia

[email protected]

5 Khoo Ee Ming Khoo Faculty of Medicine



[email protected]

6 Lee Ping Yein Lee Department of Family Medicine

Faculty of Medicine and Health Sciences

Universiti Putra Malaysia

Serdang, Malaysia

[email protected]

7 Khatijah Lim

Abdullah

Lim

Abdullah

Department of Nursing Science

Faculty of Medicine



[email protected]

8 Azlin Zainal Zainal Department of English Language




[email protected]

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Title: Using a Patient Decision Aid on Insulin Therapy-A Conversation Analytic Study of Doctor-


Abstract

Objective: To explore how doctors and patients with type 2 diabetes use a patient decision aid (PDA)

on starting insulin therapy by analysing their interaction in primary care consultations.

Design: Conversation Analysis of 7 single cases of audio/ video recorded consultations between

doctors and patients with type 2 diabetes, in which a patient decision aid on starting insulin is used

Setting: Primary Care in three healthcare settings: a) one private clinic; b) two public community

clinics and c) one primary care clinic in a public university hospital), in the Klang Valley, Malaysia.

Participants: 5 clinicians and 7 patients with type 2 diabetes, for whom insulin had been

recommended. Purposive sampling was used to select a sample high in variance across health care

setting, participant demographics and perspectives on insulin.

Primary outcome measures: Interaction between doctors and patients in a clinical consultation when

a patient decision aid on starting insulin is used

Results: Doctors brought the PDA into the conversation mainly by asking information-focused

Yes/No questions, and used the PDA for information exchange only if patients said they had not read

it. While their contributions were limited by doctors’ questions, some patients disclosed issues or

concerns. Although doctor’s PDA-related questions acted as a pre-sequence to deliberations on

starting insulin, doctors’ interactional practices raised questions on whether patients were informed

and their preferences prioritised.

Conclusions: Though habits from ordinary talk may play a role, the doctors’ limited competence in

implementing shared decision making is likely to be the primary factor behind their physician-centred

practices in using the PDA. Further research involving larger collections of consultations will enable

the identification of patterns of interaction in consultations in which a PDA is used.

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Article Summary

Strengths and Limitations:

• By providing a talk-based view of how doctors and patients use a patient decision aid, this

study adds information in an area which is underrepresented in research on PDAs

• The data involves diverse patient perspectives which are salient to the context of starting

insulin for type 2 diabetes in Malaysia’s multi-cultural setting (use of traditional medicine,

language issues, fear of injections, resistance to insulin), showing how doctors and patients

manage these perspectives in talk.

• As the sample size is small, generalizable conclusions on patterns of PDA use may not be

drawn.

• However, the analysis can provide insights into how doctors’ interactional practices when

implementing PDAs could be adapted to better fulfil their aims of supporting informed and

shared decision making,

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Title: Using a Patient Decision Aid on Insulin Therapy- A Conversation Analytic Study of Doctor-


Article Manuscript

INTRODUCTION

One means of implementing shared decision making (SDM), considered the ideal treatment decision

making model1-3

, is using patient decision aids (PDAs)4. Developed for various clinical conditions in

print, DVD or digital form4, PDAs are designed to support treatment decision making by providing

patients with evidence-based information on their illness and treatment options4. PDAs can also help

“create a conversation” 5, in which patients can seek clarification of information and discuss concerns,

values and preferences.

Research on PDA use has largely involved data collected outside the consultation, through

questionnaires or interviews (e.g. 6-7), or quantitative analysis of consultations using coding schemes

including the RIAS and OPTION scales (e.g.8-11). The literature describes some doctors’ practices,

including giving fewer details about treatment to older or less-educated patients7, and dominating

discussions prior to decision making8. Also, doctors may not use PDAs as prescribed, by neglecting to

use them, providing inaccurate information or using PDAs to support personal biases10-11. However,

Tiedge et al.12 conclude that the flexible use of PDAs encourages discussion, making them suitable

across decision making models.

Examining the discursive use of PDAs has been identified as an important concern for SDM

research13. Yet, only a few studies describe how doctors and patients utilise PDAs in consultations11-12

and these largely overlook the collaborative nature of interaction, for example, by using quantitative

methods8, or focusing only on doctors11.

Through micro-analysis of interaction, we explore how doctors and patients with type 2 diabetes use a

printed PDA on starting insulin. By examining PDA use in different patient contexts, we hope to

extend the discussion beyond doctors’ practices to include the crucial but often overlooked role of the

patient.

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METHOD

Setting

The data was collected during a project to develop and test a PDA on starting insulin for patients with

type 2 diabetes. Guided by the Ottawa Decision Support Framework14, the 13-page PDA covers

patients’ concerns; comparison of treatment options; assessment of patient knowledge and values

clarification, and finally, prompts a decision if patients are ready. Patients can engage with the

content, checking options or making notes on topics for discussion with their doctors. (See

http://dmit.um.edu.my/?modul=DMIT_PDA)

To test how the PDA could be implemented, health care providers (HCPs), comprising twelve

doctors, two nurses and one pharmacist, used it in consultations. HCPs received a guidebook and two

hours’ training on using the PDA, which can be used pre-consultation, by the patients alone or with

their families, or in-consultation with the HCP. HCPs conducted consultations in Negeri Sembilan and

the Klang Valley in Malaysia between November 2012 and April 2013 in three health care settings:

private clinics, public community clinics and the primary care clinic of a public university teaching

hospital. In public healthcare, patients may see different doctors on each visit and patient volume is

high, while private clinics have lower patient volumes and the same doctor may see the patient on

each visit. Clinical setting may therefore impact doctor-patient interaction through the time available

for consultations and the doctor-patient relationship.

Data Collection

Purposive sampling was used, aiming for variance in healthcare settings, patient perspectives on

insulin and socio-demographics. For linguistic reasons, participants were selected from the major

ethnic groups in Malaysia: Malay, Chinese and Indian. Patients may lack fluency in the consultation

language, which could be Malay or English, or as is common in Malaysia, some mixture of Malay,

English, Tamil or Chinese. Although the PDA is available in all four languages, education level may

also impact the patient’s approach to self-education. Fifteen consultations were audio recorded, with

supplementary video recordings for four hospital-based consultations. To avoid language

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complications, this paper focuses on consultations conducted mainly in English. The final dataset

comprises seven consultations by five clinicians: one general practitioner (private clinic) and four

medical officers (public clinics and hospital). (See Appendix A-Participants’ Demographic Profiles).

Analysis

We draw on Conversation Analysis (“CA”) to describe the interaction as it unfolds, describing

participants’ collaborative performance of social actions through talk. CA research has been

conducted widely in various health care contexts [e.g. 15-19] and CA findings have helped

operationalise patient participation and shared decision making20-23

and been applied in medical

practice and training 24-25

.

The recorded consultations were anonymised, and transcribed using Jefferson’s transcription

conventions26

(Appendix B) by author AS, and reviewed by authors ZMD and AZ. Sequences of talk

in which the PDA was mentioned or used were identified through repeated listening and viewing. To

facilitate analysis, CA research often focuses on one phase of the consultation, such as openings or

examination18

, but since PDA talk occurred at different points in the consultations, we focused on

initial PDA talk to enable analysis across consultations. Given the limited research on interaction

surrounding PDAs, we approached our data as preliminary analysis of several single-episodes (see

Ten Have27

and Maynard & Heritage28

). Throughout the analytic process, several rounds of review

were conducted by the research team, which comprised clinicians (NCJ, KEM, LPY, KLA) a

sociologist (LYK) and applied linguists (AS, ZMD, AZ).

This study received ethics approval from the Medical Research and Ethics Committee, Ministry of

Health, Malaysia (Ref No: NMRR-10-1233-7299) and the Medical Ethics Committee, University of

Malaya Medical Centre, Kuala Lumpur (MECRef No: 841.6). All participants gave informed consent.

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RESULTS

Doctors’ initial enquiries centred on whether patients had read and understood the PDA, and the

patients’ responses to these questions determined how doctors used the PDA. This is unsurprising

given doctors’ legal and ethical duty to ensure patients make informed decisions. We first present data

from a consultation in which the patient has not read the PDA.

Exchanging Information with the PDA

In two consultations (B8 and B15) in community clinics, the patient discloses that she has not read the

PDA. The doctor does not bring up the PDA immediately, but begins by addressing test results (B8)

or asking about the patient’s lifestyle (B15). Both patients initially affirm they have read the PDA,

and only disclose otherwise on further questioning. The doctors then begin going through the PDA

with the patients, using it to provide information or to elicit patient perspectives on starting insulin.

Here we present an extract from consultation B8 to exemplify the interactional practices observed in

this context.

Patient Discloses She Has Not Read the PDA

The doctor (DR1) has given the patient (P1) her recent test results, showing a high sugar level. P1 has

disclosed that she had stopped taking her oral medication, and is only taking Ayurvedic (traditional

Indian) medicine. After explaining the complications of sustained high sugar, DR1 brings up the PDA

six minutes into the consultation, with a polar question (requiring a yes/no response) on whether P1

has read it (Extract 1, 283).

Extract 1- Consultation B8 (Public Clinic) 283 DR1 So u::m, have you read about ↑↑this? Your,

284 a:[: ]

285 P1 [Y:]a:p=

286 DR1 =Okay. You feel that you want (.) to still

287 try the ayurve↑dic?=

288 P1 =Y:as, still

289 DR1 O::hm-[kay]

290 P1 [Goi]ng ]on with it=

291 DR1 =So it means you feel that you::,(0.7) you

292 feel that ayurvedic can help you?

293 P1 Yah can <help me>.

294 DR1 >Okay< from this sugar level nineteen point nine,

295 do you feel that it’s helping ↑you?=

296 P1 =You can see me in the £next appoint↑ment,

297 whe[ther it’s help]inghh me or not [hh hh]

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298 DR1 [oka:y alri:ght] [fine]

299 P1 =[hh hh] ((laughs))

P1’s affirmation of this (“Yap”) is hurried, overlapping DR1’s turn. Acknowledging P1’s response

(286), DR1 shifts topic from the PDA to ask two polar questions, to confirm P1’s preference for

Ayurvedic medicine (286-287) and to explore the reasons behind her preference (291-292 “..you feel

that Ayurvedic can help you?”). P1 responds with affirmations but does not elaborate (288, 293).

DR1’s next question (294-295) appears to seek P1’s view on the effectiveness of Ayurvedic.

However, by foregrounding P1’s high sugar against Ayurvedic medicine, DR1’s question presents a

rhetorical contradiction which limits P1’s ability to respond affirmatively. P1 then challenges DR1 to

defer her evaluation until the next appointment (296-297), which receives DR1’s overlapped

acceptance (298,). P1’s laughter (297, 299) indicates her orientation towards a delicate situation29-30.

Extract 1a-continued

300 DR1 =[Fi:ne] But you have read about this book

301 ri:ght?

302 P1 Y- y:a:h. N- not yet, not [yet just a::]

303 DR1 [not ye::t ]

304 Okay-okay. So, oka:y. There a:re, okay, w-, this 305 is s- trying to show what are the concerns ↑lah=

306 P1 =Y:a:h

307 DR1 Okay what is the concerns of, um, taking the

308 insulin?=

309 P1 =[M:h?]

310 =[Ai-,] so it >was telling< “Are you afraid of

311 injection and ↑pain?”

312 P1 No, I’m [not] afraid. Yup=

313 DR1 [No:]

314 =Afraid of sugar getting too lo:w?

315 P1 .h No::.

316 DR1 No=no. Afraid of getting, a:, gaining

317 wei:ght? (0.5) A- d’ you know about insulin?

318 After I have explained=

319 P1 [Ya: I guess]

320 DR1 =[to you and ]so ↑on?=

321 P1 =Yah, I guess I [will gain ] weight. Mm=

322 DR1 [Ye:s, ye:s]

323 =So, oka:y. (0.7)↑How=ho:w a- y- the rea:so:n

324 is because you want to try something else ↓lah

325 a::?=

326 P1 =Y:a:h,

The “but” that prefaces DR1’s response after her initial acceptance (Extract 1a, 300) suggests she

intends to continue the topic. She asks again whether P1 has read the PDA. After a hesitant

affirmation, P1 discloses that she has not read the PDA. In responding, DR1 echoes P1’s “not yet”

followed by “Okay” uttered four times, indicating she now understands the situation (304). DR1

begins explaining the content of the PDA, going through the first section, ‘What are your Concerns?’

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with P1. It is here that the doctor shifts from merely topicalising the PDA to going through it in the

consultation with P1. Reading from a list of common patient concerns, DR1 rephrases the affirmative

sentences in the PDA as questions (310, 314 and 316), attempting to elicit P1’s concerns. For

example, DR1 reformulates the sentence ‘I am afraid of injections and pain’ as “Are you afraid of

injections and pain?” (310). After P1 gives several negative responses, DR1 seeks confirmation that

P1’s decision against insulin is due to her preference for Ayurvedic medicine, rather than unstated

concerns. This sequence is repeated several times throughout the consultation (not shown), with DR1

going through the sections of the PDA and P1 reiterating her preference for Ayurvedic medicine.

Opening Up Deliberation with the PDA

Having confirmed that a patient has read the PDA, the doctor can ascertain further the patient’s

preparedness for decision making. Initial considerations are largely information-focused, namely,

whether the patient understands the content or has any questions. Also relevant are patient concerns,

values and opinions. We present extracts from four consultations, showing different responses from

patients who, on their own assertion, have read the PDA.

Patient Does Not Raise Issues or Concerns

Two patients (consultations A4 and C14) do not raise issues or express concerns in response to the

doctor’s PDA-related questions. After asking about the patient’s comprehension and opinion of the

PDA, the doctors proceed to elicit a decision from the patients. Extract 2 is from Consultation A4, a

triadic consultation involving the patient’s husband (H), who helps interpret between English and

Tamil. The doctor (DR2) initiates the PDA talk early in the consultation, by asking whether the

patient has read it.

Extract 2-Consultation A4(Private Clinic)

001 DR2 Mrs B and Mr B, ye:?=

002 H =[Yes]

003 P2 [A::]

004 DR2 [You] have read the book ri:ght?=

005 H =Y[es]

006 P2 [Ya]::=

007 DR2 =A::, so what you think of the boo:k?

008 (0.5)

009 P2 >I’m no:t sure< mh h h=((laughs))

010 DR2 =Herh [↑herh herh] ((laughs))

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011 H [Er, the ] book=

012 P2 =Is er=

013 H =Is in very simple langua:[:ge]

014 P2 [ Ve]ry=

015 DR2 =Ye:[:s?]

016 P2 [sim][ple]

017 H [And] very easy to understand.

DR2’s initial reference to the PDA is formulated as a question (004), and comes immediately after a

brief identity-confirmation sequence, which functions as a greeting. Ending with a tag question, the

enquiry (“You have read the book, right?”) favours an affirmative response, which both P2 and H

provide (005, 006). DR2 then asks for P2’s views on the PDA using a Wh-question (open-ended

question). After a silence, P2’s response displays uncertainty (“I think, I’m not sure”). Her laughter,

which is reciprocated by DR2, indicates a delicate situation 29-30

. H resumes discussing the PDA

(011), delivering a favourable assessment of it (“…very simple language”). P2 then partially echoes

her husband, briefly interrupted by DR2’s encouragement to complete her utterance (“Yes?” 015).

Overlapped by H’s elaboration, P2 completes her brief assessment of the PDA.

Extract 2a-continued

((lines 018-36 omitted as P2 and H explain how long it took

them to read the PDA))

037 DR2 Right. So what [do you] think of the book.

038 P2 [and so]

039 (.) I think very easy lah [(can,) better]

040 DR2 [Aha:, do you]

041 understand what it’s trying to tell you?=

042 P2 =Tell you a::, what a:: (0.2) must (.) tell

043 her? ((Speaking Tamil))[hh hh ] ((laughs))

044 DR2 [herh herh ]herh=((laughs))

045 H [Ya lah, sh]

046 =she understands.=

047 P2 =[Hm:: ]

048 DR2 [You ]understand ya?

049 P2 Hm::=

050 DR2 =a::.Do you (.) agree or not?

051 (.)

052 P2 Ag- agree lah=

053 DR2 =You agree?=

054 P2 =M[:h

055 DR2 [E:r, you know why you have to take the insulin?

056 P2 Y:a:h, Because I:’m- cannot take a med’cine

057 already.

058 DR2 Aha::?

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059 P2 A- no choice,(.) ↑lah=

060 DR2 =erhh((laughs)), £(you) no

061 choice?£ [A-ha]

062 P2 [A::,] must take the:(.)[insulin]

063 DR2 [So you ]

064 right, so you agree to start the insulin

065 injection?

066 P2 Y:a::

Following further elaboration by P2 and H (omitted), DR2 resumes questioning (Extract 2-continued),

with a Wh-question (037). Although designed to allow P2 to express her opinion, the question

remains focused on the PDA (“the book”), rather than the decision on starting insulin. Producing a

preferred response, P2 describes the PDA as “easy” (038). DR2 then asks whether P2 understands the

PDA. P2’s pauses, hesitation and incomprehensible utterance indicate her difficulty comprehending

the doctor’s question, leading to her delayed response (042-43). She speaks in Tamil to H, who then

confirms that P2 has, in fact, understood (045-046). DR2 seeks this confirmation from P2 (“You

understand, ya?” 048), receiving a weak affirmation (049). Taking the unmarked token as

confirmation of understanding, the doctor commences talk on the treatment decision with a series of

questions, soliciting P2’s agreement to start insulin (050), and her explanation for (055) and

confirmation of (063-065) this decision. DR2’s question presents the decision as a proposal, with P2

providing the relevant and preferred acceptance through minimal responses (Mh-054, Ya-066). This

shows DR2 orienting, however minimally, to P2’s right to accept or reject the recommended

treatment. Yet, in exploring P2’s decision, DR2’s use of ‘have to’ depicts starting insulin as an

obligation (you know why you have to take the insulin? 055-056), which is mirrored in P2’s response

that she has ‘no choice’ and ‘must take the insulin’.

Patient Raises Issues or Concerns

Doctors’ initial questions on the PDA can give patients the opportunity to disclose questions,

concerns, fears, or resistance to starting insulin. Here we examine three consultations, in which the

patient responds by a) raising issues concerning the PDA, b) disclosing fears, and c) disclosing a

preference against insulin.

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Patient raises issues about the PDA

Consultation A3 was also conducted by D2, who begins as she did in Consultation A4, by enquiring

whether the patient has read “the book” (Extract 3). The rising intonation of DR2’s confirmation-

seeking statement indicates a response is required, and the wording shows affirmation is expected

(Lines 001-002). P3 responds with a minimal affirmation, which the doctor echoes (“Yes” 004). She

then asks a Wh-question to elicit P3’s opinion, repeating it (006) after P3’s overlapping turn (005).

After a silence (007), P3 produces an assessment of the PDA (008-012), describing its contents as

“just basic.” DR2 then asks about the information P3 requires.

Extract 3-Consultation A4 (Private Clinic)

001 DR2 -ning. E:rm, e:rm, e:rm, e:rm I believe

002 you have read the: ↑book?

003 P3 Yea:h

004 DR2 Yes, [er what d’ you think? ]=

005 P3 [yes I’ve read, I’ve read]

006 DR2 =A:h, what do you think of the ↑book ?

007 (0.5)

008 P3 That’s just basi:c information nah

009 DR2 [Right]

010 P3 [There’s] not, there’s not, much

011 information that (0.7)that I’d like to::

012 find out lah [actually I nee::d]

013 DR2 [E:r, what kind of] information

014 do you like to find out?

015 P3 You ↑see this ↓e:r without insulin, [what ]=

016 DR2 [yerh?]

017 P3 =are the effect, if you sta:y if your

018 glucose level sta:y (0.7) at the high level.

019 It doesn’t state ↑here lah.

020 DR2 Right

021 P3 E:r what if you: over-control yourse:lf.

022 DR2 Right

P3 begins listing questions he would like the PDA to address, beginning with the effects of sustained

high glucose level (017-018). DR2’s response, a minimal acknowledgment token (“Right”) (020),

leads P3 to continue, with a question about ‘over-control’ (021), referring to hypoglycaemia, a side-

effect of insulin.

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Patient discloses fears of injections

Consultation C12 is conducted in a public hospital by DR3, who had given the patient (P4) the PDA

on her previous visit. The doctor brings the PDA up early, after a brief greeting (not shown in Extract

4). As video recording was possible, participants’ physical actions were also transcribed.

Extract 4-Consultation C12 (Primary Care Clinic)

017 DR3 =Fi:ne. Oka:y. So a:::h, if you can reme:mbe:r

018 the last visit er I have given you: (.)a::, a

019 booklet,=

020 P4 =M:[m:: ]

021 DR3 [E::r] that booklet is basically: is something on

022 e:r,e:r starting in in er insu[lin ]=

023 P4 [((nods))]

024 DR3 = Okayh? And then that= booklet have e:r contents

025 about er insulin and the way of injectio:n and

026 then de:: e::rm:(.) tsk, e:r and the the side

027 effects and ev’↑rything. Okay? Did you go through the

028 booklet?

029 P4 Yes I did ((nodding))

030 DR3 Ah, you went through the booklet.=

031 P4 =[ Hm]

032 DR3 =[↑Ok]ay quite good that you went through hh

033 e:r was it easy to read? E:rhh hh=((small

034 laugh))

035 [(0.5) ]

036 P4 =[((nods, smiling))] Easy:::,

037 DR3 Is [i:t? ]

038 P4 [but I]’m very scared of needle ↑hh-

039 [hh-hh ]((laughs))

040 DR3 [Aha-↑ha]((laughs)) you’re scared of needle?

041 Oh-kay, ↑so a::h, do you want to discuss e:rh,

042 did you understand the booklet

043 P4 Ye:s [ (((nodding repeatedly)) ]

044 DR3 [You understand quite we:ll ]

045 Okay. .h you know about the side [effects]=

046 P4 [((nod))]

047 DR3 =and everything



Unlike the other doctors, DR3 initiates the topic of the PDA with statements (line 17-26), referring to

the previous consultation when the PDA was given. DR3 describes the PDA as ‘something on starting

insulin,’ rather than something to help the patient decide whether or not to start insulin, and asks if P4

has read it (028). P4’s affirmative response is acknowledged by DR3, who asks another Yes/No

question on P4’s experience of reading the PDA (033). P4’s contributions throughout these sequences

are minimal, namely continuers “mm” (020) and “hm” (031), nodding (023), or brief confirmation

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(029). Her pause after DR3’s question in line 033, followed by nodding, smiling and the drawn-out

final syllable of her one-word echo response (036-Easy), indicate some hesitation. Using ‘but’ to

signal a topic shift, P4 then voices her fear of needles. Laughter from both sides indicates that they

recognise the situation as being delicate. However, while acknowledging P4’s fears with a

confirmation-type question (040), DR3 does not immediately address them. Instead, he asks whether

P4 understands the content in the PDA (042-049), with P4 giving minimal affirmations. DR3 starts

addressing P4’s fears only after several question-answer sequences (not shown).

Patient discloses decision not to start insulin

Throughout Consultation C11, the doctor (DR4) refers several times to the PDA. Extract 5 is from the

beginning of the consultation. The transcript in Extract 5 includes participants’ physical actions.

Extract 5-Consultation C11 (Primary Care Clinic)

001 DR4 …problem about the:: y-you understand (.)

002 about the book or you want to-

003 P5 =[Yes, no, no, I understand ]=

[((looking for PDA in bag))]

004 DR4 =Yes, [perfect]

005 P5 [But I ] have to wait, now I don’t want.

006 DR4 Oh, okay, but, anyway, you understand most of the

007 things is talking in book la?

008 P5 Yes. ((nods, finds PDA & hands it to DR4))

009 DR4 Okay. ((takes PDA & starts looking through it))

010 So aright, okay so because this is all about

011 whether, what is the things=

012 P5 [((nods))]

013 DR4 =[ What ] is your concerns and everythings right=

014 P5 =((nods))

015 DR4 So, you, you saying you don’t want insulin right?

016 P5 Mmh((nods))

DR4 initiates PDA talk (001) by enquiring whether P5 has any problems with “the book”, or whether

she understands it, beginning what appears to be an invitation to talk or ask questions (“or you want

to..”). P5 interrupts this (003), denying she has any difficulty understanding it (“yes, no, no”), and

then affirms with the statement “I understand”. She intercepts DR4’s next turn, and instead of

discussing the PDA, pursues her own agenda. Using ‘but’ to introducing a contrasting topic (005), she

proposes her decision to wait with a strong modal (“have to”) and refuses insulin without explicitly

mentioning it. DR4 acknowledges this with “Okay”, but continues asking P5 if she understands the

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PDA (006). P5 briefly affirms this, handing DR4 her PDA (008). She responds only with a nod (012,

014) to DR4’s further talk on the PDA. P4’s lack of uptake forces the doctor to focus on P4’s

preference, for which DR4 solicits confirmation (015). P5 nods again, adding a minimally verbalised

confirmation that she does not want insulin (016).

DISCUSSION

Opening sequences influence the way a consultation unfolds17, 18, 31

. While the sequences analysed

here are not ‘openings’ in the traditional sense, they mark the beginning of decision making, in that

patient responses to doctors’ PDA-related questions lead to different trajectories: information

exchange, or deliberation, culminating in a decision on whether or not to start insulin.

Figure 1: Initial PDA Talk and Decision Making Trajectory

As Figure 1 shows, the doctors’ initial questions are information-focused, mostly Yes/No questions.

Yet some patients respond by disclosing issues or even refusing insulin. If patients do not resist,

doctors move the consultation towards closure, seeking patient acceptance of the treatment

recommendation. Deliberation occurs only when patients resist insulin and the PDA is used as a tool

for information exchange only if patients say they have not read it. While this is time-efficient, it

raises questions about whether patients are actually informed and their contributions prioritised.

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Our findings add further evidence showing how doctors’ questioning practices constrain patient

contributions21, 24, 32, 33. By asking mainly Yes/No questions about whether patients have read or

understood the PDA, the doctors rely on single-word responses to decide if further information

exchange is needed. As Extract 1 shows, a patient's first response to ‘Have you read the PDA?” may

be unreliable. Other comprehension-focused questions also tend to generate ‘no issue’ responses; e.g.,

patients say ‘yes’ to enquiries such as “Do you understand?’/‘You know why you have to take the

insulin, right’; and ‘no’, to ‘Do you have any questions?’. Because the doctors move quickly from

PDA-related questions to deliberation on insulin, superficial assessment of patient knowledge means

they risk entering into decision making with uninformed patients.

Heritage’s32 proposition that norms from ordinary conversation cause dysfunction in doctor-patient

interaction may provide an explanation, where the doctors’ tendency not to thoroughly explore patient

knowledge may be influenced by norms of news delivery. Given the deeply ingrained practice to

avoid telling others information they already know32, doctors may habitually avoid probing if a patient

claims to have understood the PDA, especially when several doctors manage one patient, as they may

not know what was discussed in previous consultations.

Preference organisation, or the bias that phrasing conveys towards specific responses32-35, may both

explain and offer solutions for patients' hesitation to disclose that they have not read the PDA. Yes/No

questions generally prefer 'yes-type' responses, unless negative polarity, e.g. 'any', is introduced;

moreover, doctors’ questions tend to favour 'no problem' responses32-33. For example, patients tend to

disclose unmet concerns when doctors use 'some/other', rather than ‘any', in closing questions (e.g.

‘Do you have other problems you want to discuss?’)33, 35. Additionally, the preference for an affiliative

response36 may prevent patients from admitting that they have not read the PDA as recommended.

Patient disclosures may be encouraged through repeated questioning (e.g. Section 3.1), but doctors

could also err on the side of caution by using questions that prefer negative responses, (e.g., 'Did you

have any time to read the PDA?') or that provide patients with a built-in reason for not reading the

PDA, (e.g., 'I know you’ve been busy, but did you manage to read the PDA?'). Since reading the PDA

does not necessarily mean understanding it, similar care must be taken in eliciting patients’ questions.

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Doctors should resist the habit of using ‘any,’ and instead formulate ‘yes’-preferring questions, for

example, 'Do you have some questions?' or 'Is there something you don't understand?’. However, this

is only the beginning of the conversation. The reliable assessment of patient knowledge requires going

beyond yes/no questions to apply the “teach-back” method, by asking patients to reformulate the PDA

content2.

The doctors' initial PDA-related questions act as pre-sequences, allowing them to approach treatment

deliberation without explicitly mentioning "insulin" or "decision." This could be useful, given the

patient fears37

; misperceptions38

and resistance39

linked to insulin. Yet patients may still orient to

questions on the PDA as pressure to discuss or accept the treatment recommendation. In Extracts 4

and 5, the patients respond by initiating new topics (needle fear & refusal of insulin) rather abruptly,

although topic shift is usually collaborative and prolonged40

. This 'minimal response-topic shift41

,

along with paralinguistic features such as laughter, repetition and interjections, may indicate that

patients find the conversation difficult.

The interactions are largely physician-centred and doctors’ questions are mostly closed-ended

questions, which limit patients’ opportunities to participate. The doctors also seemed to prioritise their

own agendas over patient cues and contributions, continuing to refer to the PDA after patients

disclosed fears (Extract 4) or stated their preference against insulin (Extracts 1,5). This could be

related to the Observer’s Paradox, i.e. the doctors’ awareness of the research focus, or because they

wanted to ensure patients were informed before engaging in further discussion. However, being more

patient-centred would involve following the patient's lead, for example, addressing fears immediately

or acknowledging patient preferences, and then asking if they want to continue discussing treatment

options. Awareness of interactional cues, for example, that minimal responses and silence (Extract 5)

could indicate resistance16, 42

, and that laughter (Extracts 1, 2 and 4) can accompany talk on ‘delicate’

matters29.30 or disaffiliation43, can also help doctors be more responsive. Also, even though insulin is

the medically recommended option, doctors can choose more neutral vocabulary to describe the PDA

and to elicit patient’s views on starting insulin. This can reduce the interactional and social burden

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imposed on patients by having to refuse or disagree with the doctor if their preference is against

starting insulin.

While the small sample size prevents the identification of patterns in PDA use, we have described

some practices of doctors and patients in using a PDA in consultations where salient patient factors,

including preference for complementary medicine, language barriers, and varying perspectives on

insulin, are enacted in the talk. Through micro-analysis, we exemplify the intricacies of implementing

a PDA on insulin for treating type 2 diabetes in Malaysia, providing insights which may be useful in

other contexts. Although our focus is on interaction, we are mindful of other possible influencing

factors, including doctors’ paternalism and communication skills, PDA design and delivery, and

systemic or individual barriers to SDM. Clinical context is also relevant; because decisions in chronic

care can be prolonged, doctors may have explored patients’ knowledge and concerns in previous

consultations.

CONCLUSION

Referring to a randomised PDA trial which found little effect on patient empowerment44

, Hargraves

and Montori 45

advocate examining the doctor-patient consultation because PDAs “function or fail to

function in this environment”. However, studies describing the discursive use of PDAs in doctor-

patient consultations are underrepresented in PDA research. Our analysis shows how doctor-centred

practices impede the PDA’s objectives, where the doctors’ PDA-focused enquiries can overshadow

patient contributions while also failing to ascertain patients’ knowledge. Though habits from ordinary

conversation may play a role, it is likely that the doctors lacked competence in implementing SDM

and could not adapt their practices appropriately when incorporating the PDA. Appropriate training is

crucial so that doctors can implement decision tools without losing sight of their aims within the

framework of patient-centred care. Further studies on PDA use in different clinical contexts, patient

groups and delivery modes can inform this training, by identifying patterns of use and context-specific

recommendations on using PDAs, from when they are given to patients up to the decision point.

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Appendix A

Table A.1: Final Dataset: Participant Demographic Profiles (by Consultation)

NO* PATIENT DOCTOR

Sex Age Ethnicity Education Sex Ethnicity

A3 M 69 Malay Degree F Malay

A4 F 73 Indian Primary school F Malay

B8 F 70 Indian Secondary school F Malay

C11 F 54 Indian Primary school F Chinese

C12 F 69 Chinese Secondary school M Indian

C14 M 57 Chinese Diploma F Chinese

B15 F 50 Indian Secondary school F Indian

*Consultation Code: A-private clinic, B-public community clinic, C-primary care clinic at a public hospital

Appendix B

Table B. 1: Key to Transcription Symbols (Jefferson, 2004)26

[ ] Overlapping talk

= No discernible interval/silence between turns

(.), Discernible silence but less than 0.2 of second

(0.2) Silence within turns or in talk

. Closing intonation

, Slightly rising intonation

? Rising intonation :, wo:rd Elongation of preceding sound

Word Emphasis

WORD Spoken more loudly

◦word◦ Spoken more softly

↑, ↓ Marked increase/decrease in pitch Hhh Outbreath or laughter

.hh In breath or laughter

Hah, heh etc. Laughter

£word£ ‘Smiley’ voice

<word> Talk is drawn out

>word< Talk is speeded up

((word )) Transcriber’s notes

(), (word) Transcriber unable to hear or uncertain

Acknowledgments

We would like to acknowledge the University of Malaya for funding the project under which this data

was collected (University Malaya Research Grant No.UMRG236/10HTM) and the Director-General

of Health for allowing the study to be conducted in public health clinics under approval of the

Medical Research and Ethics Committee, Ministry of Health (Reference:NMRR-10-1233-7299).

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Contributors

Contributors NCJ and LYK conceptualised, designed, planned and coordinated the larger study from

which the data was obtained. Contributors AS, ZMD and AZ conceptualised and designed the

manuscript. Contributors AS, ZMD,AZ, NCJ, LYK, KEM, LPY, KAL contributed to the data

analysis. The initial draft of the manuscript was prepared by AS and ZMD and then circulated among

all authors for critical revision. All authors read and approved the final manuscript.

Funding

This work was supported by the University of Malaya (University Malaya Research Grant

No.UMRG236/10HTM)

Competing Interests

None

Ethics Approval




Data Sharing

Ethics approval does not permit sharing of the audio and video recorded consultations.

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292x120mm (96 x 96 DPI)

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Article Title: Using a Patient Decision Aid on Insulin Therapy- A Conversation Analytic Study of

Doctor-Patient Talk in Primary Care Consultations

Standards for Reporting Qualitative Research (SRQR) Checklist

(from O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting

qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251: pg

3, Table 1)

NO TOPIC ITEM PAGE NO

TITLE & ABSTRACT

S1 Title Concise description of the nature and topic of the

study Identifying the study as qualitative or indicating the approach (e.g., ethnography,

grounded theory) or data collection methods (e.g., interview, focus group) is recommended

Title, 1, 2, 4

S2 Abstract Summary of key elements of the study using the

abstract format of the intended publication; typically includes background, purpose,

methods, results, and conclusions

Abstract, 2

INTRODUCTION

S3 Problem formulation Description and significance of the problem/phenomenon studied; review of relevant

theory and empirical work; problem statement

4

S4 Purpose or research question Purpose of the study and specific objectives or

questions 4

METHODS

S5 Qualitative approach and research paradigm,

Qualitative approach (e.g., ethnography, grounded theory, case study, phenomenology,

narrative research) and guiding theory if appropriate; identifying the research paradigm

(e.g., postpositivist, constructivist/interpretivist)

is also recommended; rationaleb

6

S6 Researcher characteristics and reflexivity

Researchers’ characteristics that may influence

the research, including personal attributes, qualifications/experience, relationship with

participants, assumptions, and/or

presuppositions; potential or actual interaction between researchers’ characteristics and the

research questions, approach, methods, results, and/or transferability

6

S7 Context Setting/site and salient contextual factors;

rationale 5

S8 Sampling strategy How and why research participants, documents, or events were selected; criteria for deciding when no further sampling was necessary (e.g., sampling saturation); rationaleb

5

S9 Ethical issues pertaining to human subjects

Documentation of approval by an appropriate

ethics review board and participant consent, or explanation for lack thereof; other confidentiality

and data security issues

6

S10 Data collection methods Types of data collected; details of data collection procedures including (as appropriate) start and

stop dates of data collection and analysis, iterative process, triangulation of

sources/methods, and modification of procedures in response to evolving study findings; rationaleb

5

S11 Data collection instruments Description of instruments (e.g., interview 5-6

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Article Title: Using a Patient Decision Aid on Insulin Therapy- A Conversation Analytic Study of

Doctor-Patient Talk in Primary Care Consultations

and technologies guides, questionnaires) and devices (e.g., audio recorders) used for data collection; if/how the

instrument(s) changed over the course of the

study

S12 Units of study Number and relevant characteristics of

participants, documents, or events included in

the study; level of participation (could be reported in results)

5-6 Appx A

S13 Data processing Methods for processing data prior to and during analysis, including transcription, data entry, data

management and security, verification of data

integrity, data coding, and anonymization/deidentification of excerpts

6

S14 Data analysis Process by which inferences, themes, etc., were

identified and developed, including the researchers involved in data analysis; usually

references a specific paradigm or approach; rationale b

6

S15 Techniques to enhance

trustworthiness

Techniques to enhance trustworthiness and

credibility of data analysis (e.g., member checking, audit trail, triangulation); rationaleb

6

RESULTS & FINDINGS

S16 Synthesis and interpretation Main findings (e.g., interpretations, inferences, and themes); might include development of a theory or model, or integration with prior

research or theory

7-15

S17 Links to empirical data Evidence (e.g., quotes, field notes, text excerpts,

photographs) to substantiate analytic findings

Extract 1 (p7) Extract 1a (p8) Extract 2 (p9) Extract 2a (p10) Extract 3 (p12) Extract 4 (p13) Extract 5 (p14)

DISCUSSION

S18 Integration with prior work, implications, transferability, and

contribution(s) to the field

Short summary of main findings; explanation of how findings and conclusions connect to,

support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of

application/ generalizability; identification of

unique contribution(s) to scholarship in a discipline or field

15-18

S19 Limitations Trustworthiness and limitations of findings 18

OTHER

S20 Conflicts of interest Potential sources of influence or perceived

influence on study conduct and conclusions; how

these were managed

20

S21 Funding Sources of funding and other support; role of

funders in data collection, interpretation, and

reporting

20

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Using a Patient Decision Aid for Insulin Initiation in Patients with Type 2 Diabetes: A Qualitative Analysis of Doctor-

Patient Conversations in Primary Care Consultations in Malaysia

Journal: BMJ Open

Manuscript ID bmjopen-2016-014260.R1

Article Type: Research

Date Submitted by the Author: 11-Mar-2017

Complete List of Authors: Syed, Ayeshah; University of Malaya Faculty of Languages and Linguistics, English Language Mohd Don, Zuraidah; University of Malaya Faculty of Languages and Linguistics, English Language Ng, Chirk Jenn; University of Malaya, Department of Primary Care Medicine Lee, Yew Kong; Universiti of Malaya, Department of Primary Care Medicine Khoo, Ee Ming; University of Malaya, Department of Primary Care Medicine Lee, Ping Yein; University Putra Malaysia, Fakulti Perubatan dan Sain Lim Abdullah, Khatijah; University of Malaya, Department of Nursing Science

Zainal, Azlin; University of Malaya Faculty of Languages and Linguistics, English Language

Primary Subject Heading:

Communication

Secondary Subject Heading: General practice / Family practice, Qualitative research, Patient-centred medicine, Diabetes and endocrinology

Keywords: patient decision aid, insulin, consultation, type 2 diabetes, conversation analysis


BMJ Open on A

pril 29, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2016-014260 on 9 May 2017. D

ownloaded from



1

Revised Title: Using a Patient Decision Aid for Insulin Initiation in Patients with Type 2 Diabetes: A

Qualitative Analysis of Doctor-Patient Conversations in Primary Care Consultations in Malaysia

Article Word Count: 4548 (Main Article excluding Tables, Figure and Extracts (in Table format))

Corresponding author at

Ayeshah Syed




50706 Kuala Lumpur, Malaysia

Tel +603-7967-3177, Fax+603-7957-9707

e-mail: [email protected]

Authors

No. Name Last

Name

Affiliation e-mail address

1 Ayeshah Syed

(corresponding author)

Syed Department of English Language

Faculty of Languages and Linguistics University of Malaya


[email protected].

my

2 Zuraidah Mohd

Don

Mohd

Don



University of Malaya, Kuala Lumpur, Malaysia

[email protected]

3 Ng Chirk Jenn Ng Department of Primary Care Medicine Faculty of Medicine,



[email protected]

4 Lee Yew Kong Lee Department of Primary Care Medicine

Faculty of Medicine

University of Malaya, Kuala Lumpur Malaysia

[email protected]

5 Khoo Ee Ming Khoo Faculty of Medicine University of Malaya


[email protected]

6 Lee Ping Yein Lee Faculty of Medicine and Health Sciences

Universiti Putra Malaysia

Serdang, Malaysia

[email protected]

7 Khatijah Lim

Abdullah

Lim

Abdullah

Department of Nursing Science

Faculty of Medicine



[email protected]

8 Azlin Zainal Zainal Department of English Language




[email protected]

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Title: Using a Patient Decision Aid for Insulin Initiation in Patients with Type 2 Diabetes: A


Abstract

Objective: To investigate whether the use of the PDA for insulin initiation fulfils its purpose of

facilitating patient-centred decision making through identifying how doctor and patient interact when

using the PDA during primary care consultations.

Design: Conversation Analysis of 7 single cases of audio/video recorded consultations between

doctors and patients with type 2 diabetes, using a patient decision aid on starting insulin.

Setting: Primary Care in three healthcare settings: a) one private clinic; b) two public community

clinics and c) one primary care clinic in a public university hospital), in Negeri Sembilan and the

Klang Valley in Malaysia.

Participants: 5 clinicians and 7 patients with type 2 diabetes to whom insulin had been

recommended. Purposive sampling was used to select a sample high in variance across healthcare

settings, participant demographics and perspectives on insulin.

Primary outcome measures: Interaction between doctors and patients in a clinical consultation

involving the use of a patient decision aid about starting insulin.

Results: Doctors brought the PDA into the conversation mainly by asking information-focused

Yes/No questions, and used the PDA for information exchange only if patients said they had not read

it. While their contributions were limited by doctors’ questions, some patients disclosed issues or

concerns. Although doctor’s PDA-related questions acted as a pre-sequence to deliberations on

starting insulin, their interactional practices raised questions on whether patients were informed and

their preferences prioritised.

Conclusions: Interactional practices can hinder effective PDA implementation, with habits from

ordinary conversation potentially influencing doctors’ practices and complicating their

implementation of patient centred decision making. Effective interaction should therefore be

emphasised in the design and delivery of PDAs and in training clinicians to use them.

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Article Summary

Strengths and Limitations:

• By providing a talk-based view of how doctors and patients use a patient decision aid, this

study adds information in an area which is underrepresented in research on PDAs.

• The data involves a range of patient perspectives which emerge in the context of starting

insulin for type 2 diabetes in Malaysia’s multi-cultural setting (the use of traditional medicine,

language issues, fear of injections, resistance to insulin), showing how doctors and patients

manage these perspectives in talk.

• As the sample size is small, it may not be possible to draw general conclusions on patterns of

PDA use.

• However, the analysis can provide insights into how doctors’ interactional practices in

initiating talk on PDAs could be adapted to better fulfil their aims of supporting informed and

shared decision making.

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Title: Using a Patient Decision Aid for Insulin Initiation in Patients with Type 2 Diabetes: A


Article Manuscript

INTRODUCTION

Shared decision making (SDM), which involves doctors and patients exchanging information,

deliberating on treatment options and reaching a mutually accepted decision1, is widely considered the

ideal treatment decision making model.2-4 In contrast with paternalistic or informed decision making,

SDM emphasises partnership between doctor and patient,5 which is particularly significant in

managing chronic illnesses such as diabetes, as patient self-management plays a crucial role. One

means of implementing SDM is using patient decision aids (PDAs).6 These are designed to support

treatment decision making by providing patients with evidence-based information on their illness and

treatment options in print, DVD or digital form

6. They can also help “create a conversation”,

7, in

which patients can seek clarification on information and discuss concerns, values and preferences.

Research on PDA use has identified doctors’ practices, and these include giving fewer details about

treatment to older or less-educated patients,8 dominating discussions

9, and not using PDAs as

prescribed, by neglecting to use them, providing inaccurate information or using PDAs to support

personal biases.10-11 Although Tiedge et al. conclude that the flexible use of PDAs encourages

discussion12, only a few studies describe how doctors and patients utilise PDAs in consultations

11-12

and these tend to overlook the collaborative nature of interaction, for example, by using quantitative

methods,8-11 or focusing only on doctors.11

Qualitative methods of interaction analysis, such as Conversation Analysis (CA), have been used to

examine how doctors and patients jointly perform social actions through talk in various clinical

contexts.13-17

By analysing talk as it unfolds in consultations, CA research has identified patterns of

doctor-patient interaction,13,15

helped operationalise patient participation and shared decision

making,18-21 and produced findings applicable in medical practice and training.22-23

In this study, we draw on the tools of CA to explore the way doctors and patients with type 2 diabetes

use a printed PDA for decisions on insulin. By examining doctor-patient talk in different patient

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contexts, we hope to extend the discussion on PDA use beyond doctors’ practices to include the

crucial but often overlooked role of the patient. Our objective is to investigate whether the use of the

PDA for insulin initiation fulfils its purpose of facilitating patient-centred decision making through

identifying how doctor and patient interact when using the PDA during primary care consultations.

METHOD

Setting

The data was collected during a project to develop and test a PDA about starting insulin for patients

with type 2 diabetes. Guided by the Ottawa Decision Support Framework,24 the 13-page PDA covers

patients’ concerns; comparison of treatment options; assessment of patient knowledge and values

clarification, and finally, prompts a decision if patients are ready. Patients can engage with the

content, checking options or making notes about topics for discussion with their doctors. (See

http://dmit.um.edu.my/?modul=DMIT_PDA)

To test how the PDA could be implemented, a group of healthcare providers (HCPs), including twelve

doctors, two nurses and one pharmacist, used it in consultations. HCPs received a guidebook

(Healthcare Professionals’ Guide to the Patient Decision Aid,

http://dmit.um.edu.my/images/dmit/doc/PDA_HCP%20Guide.pdf) and two hours of training on

implementing the PDA, which can be used pre-consultation, by the patients alone or with their

families, or in-consultation with the HCP. The training was conducted by SDM experts with clinical

experience (authors NCJ, LPY & KLA), and included lectures, interactive activities and role play.

HCPs were trained in different manners of delivery of the PDA; however, the specifics of delivery

were not prescribed to allow HCPs to tailor their PDA use to their setting and patients. Subsequently,

consultations were held in three healthcare settings: private clinics, public community clinics and the

primary care clinic of a public university teaching hospital in Negeri Sembilan and the Klang Valley

in Malaysia between November 2012 and April 2013. All patients received the PDA in advance, at

times ranging from the last visit to the HCP, or several months in advance to just hours before the

consultation, when they were already in the waiting room.

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Data Collection

To capture a range of doctor and patient practices in using the PDA, purposive sampling was used,

aiming for variance in healthcare settings, patient perspectives on insulin and socio-demographics.

For doctors, the demographic variables were clinical qualifications (general practitioner, medical

officer or specialist) and gender. Patients were selected according to age, gender, ethnicity and

educational background. For linguistic reasons, participants were selected from the major ethnic

groups in Malaysia, namely Malay, Chinese and Indian. Since some patients are not sufficiently fluent

in the consultation language, which could be Malay or English, or as is common in Malaysia, some

mixture of Malay, English, Tamil or Chinese, versions of the PDA are available in all four languages.

Fifteen consultations were audio recorded, with supplementary video recordings for four hospital-

based consultations. As a preliminary exploration of PDA use in interaction, this paper reports on

single-case analyses of doctor-patient consultations in English. Consultations with other HCPs were

excluded in view of their different roles in decision making, in that nurses and pharmacists may use

the PDA to counsel the patient, but the treatment decision itself is made with the doctor. In line with

the CA practice of analysing data in a common language (e.g., 18-23), this paper focuses on

consultations conducted mainly in English to facilitate comparison of language structures across the

data. The final dataset for this paper comprises seven consultations by five clinicians: one general

practitioner (private clinic) and four medical officers (public clinics and hospital). (See Appendix A-

Participants’ Demographic Profiles).

Analysis

In accordance with CA methods, the recorded consultations were anonymised, and then transcribed

using Jefferson’s transcription conventions25 (Appendix B) by author AS, and reviewed by authors

ZMD and AZ. Sequences of talk in which the PDA was mentioned or used were identified through

repeated listening and viewing by AS, a doctoral student in applied linguistics, and reviewed by

ZMD, a professor in applied linguistics. To facilitate analysis, CA research often focuses on one

phase of the consultation, such as openings or examination.16 Since PDA talk occurs at different

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points and with varying frequency in the consultations, we focused on initial PDA talk to enable

analysis across consultations. Because opening sequences influence how consultations unfold,15-16, 26

the initial sequences of PDA talk were considered appropriate starting points at which to begin

exploring PDA use in the data.

Given the limited research on interaction surrounding PDAs, we made preliminary investigations of

several single-episodes27, 28

, describing the interactional aspects of the talk (e.g., turn taking, structural

organisation, turn design and lexical choice29) in relation to patient centred decision making As the

analysis proceeded, the work was reviewed by the research team, the initial interactional analysis

being made by the applied linguists (AS, ZMD & AZ) followed by input from the clinicians (NCJ,

KEM, LPY, KLA) and healthcare sociologist (LYK).




RESULTS

Doctors began by asking whether patients had read and understood the PDA, which is unsurprising

given their legal and ethical duty to ensure patients make informed decisions. The PDA was then used

to exchange information or to initiate deliberation on treatment depending on whether the patients had

read it or not.

Exchanging Information

In two consultations (B8 and B15) in community clinics, the patient disclosed that she had not read

the PDA. The doctor did not bring up the PDA immediately, but began by addressing test results (B8)

or asking about the patient’s lifestyle (B15). Both patients initially affirmed they had read the PDA,

and only reveal that they had not on further questioning. The doctors then began going through the

PDA with the patients, using it to provide information or to elicit patient perspectives towards starting

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insulin. Here we present an extract from consultation B8 to exemplify the interactional practices

observed in this context.

The doctor (DR1) has given the patient (P1) her recent test results, showing a high sugar level. P1 has

disclosed that she had stopped taking her oral medication, and is only taking Ayurvedic (traditional

Indian) medicine. After explaining the complications of sustained high sugar, DR1 brings up the PDA

six minutes into the consultation, with a polar question (requiring a yes/no response) on whether P1

has read it (Table 1-Extract 1, 283).

Table 1: Extract 1-Consultation B8 (Public Clinic) 283 DR1 So u::m, have you read about ↑↑this? Your,

284 a:[: ]

285 P1 [Y:]a:p=

286 DR1 =Okay. You feel that you want (.) to still

287 try the ayurve↑dic?=

288 P1 =Y:as, still

289 DR1 O::hm-[kay]

290 P1 [Goi]ng ]on with it=

291 DR1 =So it means you feel that you::,(0.7) you

292 feel that ayurvedic can help you?

293 P1 Yah can <help me>.

294 DR1 >Okay< from this sugar level nineteen point nine,

295 do you feel that it’s helping ↑you?=

296 P1 =You can see me in the £next appoint↑ment,

297 whe[ther it’s help]inghh me or not [hh hh]

298 DR1 [oka:y alri:ght] [fine]

299 P1 =[hh hh] ((laughs))

P1’s affirmation of this (“Yap”) is hurried, overlapping DR1’s turn. Acknowledging P1’s response

(286), DR1 shifts the topic away from the PDA to ask two polar questions, to confirm P1’s preference

for Ayurvedic medicine (286-287) and to explore the reasons behind her preference (291-292 “..you

feel that Ayurvedic can help you?”). P1 responds with affirmations but does not elaborate (288, 293).

DR1’s next question (294-295) appears to seek P1’s view on the effectiveness of Ayurvedic medicine.

However, by foregrounding P1’s high sugar against Ayurvedic medicine, DR1’s question presents a

rhetorical contradiction which limits P1’s ability to respond affirmatively. P1 then challenges DR1 to

defer her evaluation until the next appointment (296-297), which receives DR1’s overlapped

acceptance (298). P1’s laughter (297, 299) indicates her orientation towards a delicate situation.30-31

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Table 2: Extract 1a-continued

300 DR1 =[Fi:ne] But you have read about this book

301 ri:ght?

302 P1 Y- y:a:h. N- not yet, not [yet just a::]

303 DR1 [not ye::t ]

304 Okay-okay. So, oka:y. There a:re, okay, w-, this

305 is s- trying to show what are the concerns ↑lah=

306 P1 =Y:a:h

307 DR1 Okay what is the concerns of, um, taking the

308 insulin?=

309 P1 =[M:h?]

310 =[Ai-,] so it >was telling< “Are you afraid of

311 injection and ↑pain?”

312 P1 No, I’m [not] afraid. Yup=

313 DR1 [No:]

314 =Afraid of sugar getting too lo:w?

315 P1 .h No::.

316 DR1 No=no. Afraid of getting, a:, gaining

317 wei:ght? (0.5) A- d’ you know about insulin?

318 After I have explained=

319 P1 [Ya: I guess]

320 DR1 =[to you and ]so ↑on?=

321 P1 =Yah, I guess I [will gain ] weight. Mm=

322 DR1 [Ye:s, ye:s]

323 =So, oka:y. (0.7)↑How=ho:w a- y- the rea:so:n

324 is because you want to try something else ↓lah

325 a::?=

326 P1 =Y:a:h,

The “but” that prefaces DR1’s response after her initial acceptance (Table 2: Extract 1a, 300) suggests

she intends to continue the topic. She asks again whether P1 has read the PDA. After a hesitant

affirmation, P1 discloses that she has not read the PDA. In response, DR1 echoes P1’s “not yet”

followed by “Okay” uttered four times, indicating she now understands the situation (304). DR1

begins explaining the content of the PDA, going through the first section, ‘What are your Concerns?’

with P1. It is here that the doctor shifts from merely topicalising the PDA to going through it. Reading

from a list of common patient concerns, DR1 rephrases the affirmative sentences in the PDA as

questions (310, 314 and 316), attempting to elicit P1’s concerns. For example, DR1 reformulates the

sentence ‘I am afraid of injections and pain’ as “Are you afraid of injections and pain?” (310). After

P1 gives several negative responses, DR1 seeks confirmation that P1’s decision against insulin is due

to her preference for Ayurvedic medicine, rather than unstated concerns. This sequence is repeated

several times throughout the consultation (not shown), with DR1 going through the sections of the

PDA and P1 reiterating her preference for Ayurvedic medicine.

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Opening Up Deliberation on Treatment

Having confirmed that a patient has read the PDA, the doctor can ascertain further the patient’s

preparedness for decision making. Initial considerations are largely information-focused: whether the

patient understands the content or has any questions. Also relevant are patient concerns, values and

opinions. We present extracts from four consultations involving patients who claim to have read the

PDA. The extracts show four patient responses to doctors’ initiation of deliberation on treatment:1)

not raising issues/concerns; 2) raising issues about the PDA; 3) disclosing fears and 4) disclosing a

preference against insulin.

Patient Does Not Raise Issues or Concerns

Two patients (consultations A4 and C14) do not raise issues or express concerns in response to the

doctors’ PDA-related questions. After asking about the patient’s comprehension and opinion of the

PDA, the doctors elicit a decision from the patients. Extract 2 (Tables 3-4) is from Consultation A4, a

triadic consultation involving the patient’s husband (H), who helps interpret between English and

Tamil. The doctor (DR2) initiates the PDA talk early in the consultation, by asking whether the

patient has read it.

Table 3: Extract 2-Consultation A4(Private Clinic)

001 DR2 Mrs B and Mr B, ye:?=

002 H =[Yes]

003 P2 [A::]

004 DR2 [You] have read the book ri:ght?=

005 H =Y[es]

006 P2 [Ya]::=

007 DR2 =A::, so what you think of the boo:k?

008 (0.5)

009 P2 >I’m no:t sure< mh h h=((laughs))

010 DR2 =Herh [↑herh herh] ((laughs))

011 H [Er, the ] book=

012 P2 =Is er=

013 H =Is in very simple langua:[:ge]

014 P2 [ Ve]ry=

015 DR2 =Ye:[:s?]

016 P2 [sim][ple]

017 H [And] very easy to understand.

DR2’s initial reference to the PDA is formulated as a question (004), and comes immediately after a

brief identity-confirmation sequence, which functions as a greeting. Ending with a tag question, the

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enquiry (“You have read the book, right?”) favours an affirmative response, which both P2 and H

provide (005, 006). DR2 then asks for P2’s views on the PDA using a Wh-question (open-ended

question). After a silence, P2’s response displays uncertainty (“I think, I’m not sure”). Her laughter,

which is reciprocated by DR2, indicates a delicate situation.30-31 H resumes discussing the PDA (011),

delivering a favourable assessment of it (“…very simple language”). P2 then partially echoes her

husband, briefly interrupted by DR2’s encouragement to complete her utterance (“Yes?” 015).

Overlapped by H’s elaboration, P2 completes her brief assessment of the PDA.

Table 4: Extract 2a-continued

((lines 018-36 omitted as P2 and H explain how long it took

them to read the PDA))

037 DR2 Right. So what [do you] think of the book.

038 P2 [and so]

039 (.) I think very easy lah [(can,) better]

040 DR2 [Aha:, do you]

041 understand what it’s trying to tell you?=

042 P2 =Tell you a::, what a:: (0.2) must (.) tell

043 her? ((Speaking Tamil))[hh hh ] ((laughs))

044 DR2 [herh herh ]herh=((laughs))

045 H [Ya lah, sh]

046 =she understands.=

047 P2 =[Hm:: ]

048 DR2 [You ]understand ya?

049 P2 Hm::=

050 DR2 =a::.Do you (.) agree or not?

051 (.)

052 P2 Ag- agree lah=

053 DR2 =You agree?=

054 P2 =M[:h

055 DR2 [E:r, you know why you have to take the insulin?

056 P2 Y:a:h, Because I:’m- cannot take a med’cine

057 already.

058 DR2 Aha::?

059 P2 A- no choice,(.) ↑lah=

060 DR2 =erhh((laughs)), £(you) no

061 choice?£ [A-ha]

062 P2 [A::,] must take the:(.)[insulin]

063 DR2 [So you ]

064 right, so you agree to start the insulin

065 injection?

066 P2 Y:a::

Following further elaboration by P2 and H (omitted), DR2 resumes questioning (Table 4: Extract 2-

continued), with a Wh-question (037). Although designed to allow P2 to express her opinion, the

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question remains focused on the PDA (“the book”), rather than the decision on starting insulin.

Producing a preferred response, P2 describes the PDA as “easy” (038). DR2 then asks whether P2

understands the PDA. P2’s pauses, hesitation and incomprehensible utterance indicate her difficulty

comprehending the doctor’s question, leading to her delayed response (042-43). She speaks in Tamil

to H, who then confirms that P2 has, in fact, understood (045-046). DR2 seeks this confirmation from

P2 (“You understand, ya?” 048), receiving a weak affirmation (049). Taking the unmarked token as

confirmation of understanding, the doctor commences talk on the treatment decision with a series of

questions, soliciting P2’s agreement to start insulin (050), and her explanation for (055) and

confirmation of (063-065) this decision. DR2’s question presents the decision as a proposal, with P2

providing the relevant and preferred acceptance through minimal responses (Mh-054, Ya-066). This

shows DR2 orienting, however minimally, to P2’s right to accept or reject the recommended

treatment. Yet, in exploring P2’s decision, DR2’s use of ‘have to’ depicts starting insulin as an

obligation (“you know why you have to take the insulin?” 055-056), which is mirrored in P2’s

response that she has “no choice” and “must take the insulin”.

Patient raises issues about the PDA

Consultation A3 was also conducted by D2, who begins as she did in Consultation A4, by enquiring

whether the patient has read “the book” (Table 5: Extract 3). The rising intonation of DR2’s

confirmation-seeking statement indicates a response is required, and the wording shows affirmation is

expected (Lines 001-002). P3 responds with a minimal affirmation, which the doctor echoes (“Yes”

004). She then asks a Wh-question to elicit P3’s opinion, repeating it (006) after P3’s overlapping turn

(005). After a silence (007), P3 produces an assessment of the PDA (008-012), describing its contents

as “just basic”. DR2 then asks about the information P3 requires.

Table 5: Extract 3-Consultation A3 (Private Clinic)

001 DR2 -ning. E:rm, e:rm, e:rm, e:rm I believe

002 you have read the: ↑book?

003 P3 Yea:h

004 DR2 Yes, [er what d’ you think? ]=

005 P3 [yes I’ve read, I’ve read]

006 DR2 =A:h, what do you think of the ↑book ?

007 (0.5)

008 P3 That’s just basi:c information nah

009 DR2 [Right]

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010 P3 [There’s] not, there’s not, much

011 information that (0.7)that I’d like to::

012 find out lah [actually I nee::d]

013 DR2 [E:r, what kind of] information

014 do you like to find out?

015 P3 You ↑see this ↓e:r without insulin, [what ]=

016 DR2 [yerh?]

017 P3 =are the effect, if you sta:y if your

018 glucose level sta:y (0.7) at the high level.

019 It doesn’t state ↑here lah.

020 DR2 Right

021 P3 E:r what if you: over-control yourse:lf.

022 DR2 Right

P3 begins listing questions he would like the PDA to address, beginning with the effects of sustained

high glucose level (017-018). DR2’s response, a minimal acknowledgment token (“Right”, 020), leads

P3 to continue, with a question about ‘over-control’ (021), which refers to hypoglycaemia, a side-

effect of insulin.

Patient discloses fear of injections

Consultation C12 is conducted in a public hospital by DR3, who had given the patient (P4) the PDA

on her previous visit. The doctor brings the PDA up early, after a brief greeting (not shown in Table 6:

Extract 4). As video recording was possible, participants’ physical actions were also transcribed.

Table 6: Extract 4-Consultation C12 (Primary Care Clinic)

017 DR3 =Fi:ne. Oka:y. So a:::h, if you can reme:mbe:r

018 the last visit er I have given you: (.)a::, a

019 booklet,=

020 P4 =M:[m:: ]

021 DR3 [E::r] that booklet is basically: is something on

022 e:r,e:r starting in in er insu[lin ]=

023 P4 [((nods))]

024 DR3 = Okayh? And then that= booklet have e:r contents

025 about er insulin and the way of injectio:n and

026 then de:: e::rm:(.) tsk, e:r and the the side

027 effects and ev’↑rything. Okay? Did you go through the

028 booklet?

029 P4 Yes I did ((nodding))

030 DR3 Ah, you went through the booklet.=

031 P4 =[ Hm]

032 DR3 =[↑Ok]ay quite good that you went through hh

033 e:r was it easy to read? E:rhh hh=((small

034 laugh))

035 [(0.5) ]

036 P4 =[((nods, smiling))] Easy:::,

037 DR3 Is [i:t? ]

038 P4 [but I]’m very scared of needle ↑hh-

039 [hh-hh ]((laughs))

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040 DR3 [Aha-↑ha]((laughs)) you’re scared of needle?

041 Oh-kay, ↑so a::h, do you want to discuss e:rh,

042 did you understand the booklet



045 Okay. .h you know about the side [effects]=

046 P4 [((nod))]

047 DR3 =and everything



Unlike the other doctors, DR3 initiates the topic of the PDA with statements (17-26), referring to the

previous consultation when the PDA was given. DR3 describes the PDA as “something on starting

insulin” rather than something to help the patient decide whether or not to start insulin, and asks if P4

has read it (028). P4’s affirmative response is acknowledged by DR3, who asks another Yes/No

question on P4’s experience of reading the PDA (033). P4’s contributions throughout these sequences

are minimal, namely continuers “mm” (020) and “hm” (031), nodding (023), or brief confirmation

(029). Her pause after DR3’s question in line 033, followed by nodding, smiling and the drawn-out

final syllable of her one-word echo response (036-Easy), indicate some hesitation. Using ‘but’ to

signal a topic shift, P4 then voices her fear of needles. Laughter from both sides indicates that they

recognise the situation as being delicate. However, while acknowledging P4’s fears with a

confirmation-type question (040), DR3 does not immediately address them. Instead, he asks whether

P4 understands the content in the PDA (042-049), with P4 giving minimal affirmations. DR3 starts

addressing P4’s fears only after several question-answer sequences (not shown).

Patient discloses the decision not to start insulin

Throughout Consultation C11, the doctor (DR4) refers several times to the PDA. Extract 5 (Table 7)

is from the beginning of the consultation. The transcript records the participants’ physical actions.

Table 7: Extract 5-Consultation C11 (Primary Care Clinic)

001 DR4 …problem about the:: y-you understand (.)

002 about the book or you want to-

003 P5 =[Yes, no, no, I understand ]=

[((looking for PDA in bag))]

004 DR4 =Yes, [perfect]

005 P5 [But I ] have to wait, now I don’t want.

006 DR4 Oh, okay, but, anyway, you understand most of the

007 things is talking in book la?

008 P5 Yes. ((nods, finds PDA & hands it to DR4))

009 DR4 Okay. ((takes PDA & starts looking through it))

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010 So aright, okay so because this is all about

011 whether, what is the things=

012 P5 [((nods))]

013 DR4 =[ What ] is your concerns and everythings right=

014 P5 =((nods))

015 DR4 So, you, you saying you don’t want insulin right?

016 P5 Mmh((nods))

DR4 initiates PDA talk (001) by enquiring whether P5 has any problems with “the book”, or whether

she understands it, beginning what appears to be an invitation to talk or ask questions (“or you want

to..”). P5 interrupts this (003), denying she has any difficulty understanding it (“yes, no, no”), and

then affirms this with the statement “I understand”. She intercepts DR4’s next turn, and instead of

discussing the PDA, pursues her own agenda. Using ‘but’ to introduce a contrasting topic (005), she

proposes her decision to wait with a strong modal (“have to”) and refuses insulin without explicitly

mentioning it. DR4 acknowledges this with “Okay”, but continues asking P5 if she understands the

PDA (006). P5 briefly affirms this, handing DR4 her PDA (008). She responds only with a nod (012,

014) to DR4’s further talk on the PDA. P5’s lack of uptake forces the doctor to focus on her

preference, for which DR4 solicits confirmation (015). P5 nods again, adding a minimally verbalised

confirmation that she does not want insulin (016).

DISCUSSION

Our analysis of the initial sequences of doctor-patient talk shows that use of the PDA did not

effectively support patient-centred decision making. The main barriers to fulfilling the PDA’s

informational purpose are that patients’ disclosures about having read it may not be reliable, and that

it is unclear whether patients understood the PDA content since its use was limited in most

consultations. Also, while PDA talk led towards deliberation on treatment, the doctors’ interaction

was not patient-centred, even when patients mentioned their concerns or showed that they found these

conversations difficult. Moreover if the patients did not bring up issues, treatment was not deliberated

at length, and doctors presented the decision as acceptance or refusal of insulin, rather than a choice

among several options.

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While the initial sequences of PDA talk are not consultation ‘openings’ in the traditional sense, they

mark the beginning of decision making, in that patient responses to doctors’ PDA-related questions

lead to different trajectories of PDA use: information exchange, or deliberation, culminating in a

decision on whether or not to start insulin. Although the trajectories correspond with the analytical

stages of SDM1 the interaction in the initial sequences of talk show that patients’ knowledge, concerns

and preference are not sufficiently explored, which has implications for the decision making process

that follows.

As Figure 1 shows, the doctors’ initial questions are information-focused, mostly Yes/No questions.

Yet some patients respond by disclosing issues or even refusing insulin. If patients do not resist,

doctors move the consultation towards closure, seeking patient acceptance of the treatment

recommended treatment. Treatment is only deliberated upon if patients resist insulin and the PDA is

used as a tool for information exchange only if patients say they have not read it. While this uses time

efficiently, it does raise questions about whether patients are actually informed and their contributions

are given due priority.

Our findings show further how doctors’ questioning practices constrain patient contributions.19, 22, 32, 33

By asking mainly Yes/No questions about whether patients have read or understood the PDA, the

doctors rely on single-word responses to decide if further information exchange is needed. As Extract

1 (Tables 1-2) shows, a patient's first response to “Have you read the PDA?” may be unreliable. Other

comprehension-focused questions also tend to generate ‘no issue’ responses; e.g., patients say ‘yes’ to

enquiries such as “Do you understand?”/“You know why you have to take the insulin, right”; and

‘no’, to “Do you have any questions?”. Because the doctors move quickly from PDA-related

questions to deliberation on insulin, superficial assessment of patient knowledge means they risk

making a decision with uninformed patients.

Heritage’s32 proposition that norms from ordinary conversation cause dysfunction in doctor-patient

interaction may provide an explanation, since the doctors’ tendency not to thoroughly explore patient

knowledge may be influenced by norms of news delivery. Given the deeply ingrained tendency to

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avoid telling others information they already know,32 doctors may habitually avoid probing if a patient

claims to have understood the PDA, especially when several doctors manage one patient, as they may

not know what was discussed in previous consultations.

Preference organisation, or the bias that phrasing conveys towards specific responses,32-35 may both

explain and offer solutions for patients' hesitation to disclose that they have not read the PDA. Yes/No

questions generally prefer 'yes-type' responses, unless negative polarity, e.g. 'any', is introduced;

moreover, doctors’ questions tend to favour 'no problem' responses.32-33 For example, patients tend to

disclose unmet concerns when doctors use 'some/other', rather than ‘any', in closing questions (e.g.

‘Do you have other problems you want to discuss?’).33, 35

Additionally, the preference for an affiliative

response36 may prevent patients from admitting that they have not read the PDA as recommended.

Patient disclosures may be encouraged through repeated questioning (e.g. Extract 1), but doctors

could also err on the side of caution by using questions that prefer negative responses, (e.g., “Did you

have any time to read the PDA?”) or that provide patients with a built-in reason for not reading the

PDA, (e.g., “I know you’ve been busy, but did you manage to read the PDA?”). Since reading the

PDA does not necessarily mean understanding it, similar care must be taken in eliciting patients’

questions. Doctors should resist the habit of using ‘any,’ and instead formulate ‘yes’-preferring

questions, for example, “Do you have some questions?” or “Is there something you don't

understand?”. However, this is only the beginning of the conversation. The reliable assessment of

patient knowledge requires going beyond yes/no questions to apply the “teach-back” method, by

asking patients to reformulate the PDA content.3

The doctors' initial PDA-related questions act as pre-sequences, allowing them to approach treatment

deliberation without explicitly mentioning "insulin" or "decision." This may be useful, given the

patient fears,37 misperceptions

38 and resistance

39 linked to insulin. Yet patients may still regard

questions about the PDA as pressure to discuss or accept the recommended treatment. In Extracts 4

and 5, the patients respond by initiating new topics (needle fear & refusal of insulin) rather abruptly,

although topic shift is usually collaborative and prolonged.40 This 'minimal response-topic shift’,

41

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along with paralinguistic features such as laughter, repetition and interjections, may indicate that

patients find the conversation difficult.

The interactions are largely physician-centred and doctors’ questions are mostly closed-ended

questions, which limit patients’ opportunities to participate. The doctors also seem to prioritise their

own agendas over patient cues and contributions, continuing to refer to the PDA after patients

disclose fears (Extract 4) or state their preference against insulin (Extracts 1,5). This may be related to

the Observer’s Paradox, i.e. the doctors’ awareness of the research focus, or because they want to

ensure patients are informed before engaging in further discussion. However, being more patient-

centred would involve following the patient's lead, for example, addressing fears immediately or

acknowledging patient preferences, and then asking if they want to continue discussing treatment

options. Awareness of interactional cues, for example, that minimal responses and silence (Extract 5)

can indicate resistance,14, 42

and that laughter (Extracts 1, 2 and 4) can accompany talk on ‘delicate’

matters.30-31 or disaffiliation,43 can also help doctors be more responsive. Moreover, even though

insulin is the medically recommended option, doctors can choose more neutral vocabulary to describe

the PDA and to elicit patient’s views on treatment. Presenting treatment options, instead of limiting

patients to acceptance or refusal of insulin20 can reduce the interactional and social burden imposed on

patients by having to disagree with the doctor if they prefer not to start insulin.

The complex and chronic nature of type 2 diabetes, along with relatively low success in achieving

glycaemic control44,45 makes it necessary to improve treatment decision making practices. Several

PDAs have been developed and tested among patients with type 2 diabetes, including to empower

patients in goal-setting46 and to support treatment decisions on statins47 and anti-hyperglycemics.48

While enhanced decision making47 and patient involvement48 are reported for the treatment PDAs, the

goal-setting PDA had little effect on patient empowerment and was not fully used by many

participants.46 Referring to the latter study, Hargraves and Montori 49 recommend examining the

doctor-patient consultation because PDAs “function or fail to function in this environment”. However,

the randomised trials mentioned rely largely on patient self-report measures, with only one coding

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doctors’ interaction using the OPTION scale,48 there is little information about what occurred in the

consultations, and how this may relate to the reported outcomes.

Through the micro-analysis of interaction in several single cases, we have exemplified the intricacies

of implementing a PDA on insulin for treating type 2 diabetes in Malaysia, providing insights which

may be useful in other contexts. This approach, however, especially in view of the sample size, does

not make it possible to identify general patterns of PDA use. Nevertheless, our dataset has enabled us

to describe some practices of doctors and patients in using a PDA in consultations in which the talk

throws light on salient patient factors, including preference for complementary medicine, language

barriers, and varying perspectives on insulin. Future studies involving a larger collection of

consultations, including by other HCPs and in other languages and looking at PDA use through the

entire consultation, could build on our findings for a broader perspective on PDA use in the Malaysian

context.

Although our focus is on interaction, we are mindful that our findings may be limited by other

possible influencing factors, including doctors’ paternalism and communication skills, PDA design

and delivery, and systemic or individual barriers to SDM. First, the interactions may have been

affected by differences between healthcare settings, particularly the time available for consultations

and continuity of care, both of which are barriers/facilitators of SDM.50,51

Four of the patients (A3, A4

in the private clinic and C11, C12 in the public hospital) had seen the same doctor for their previous

consultations, when they were given the PDA. This could explain the doctors’ cursory enquiries, as

patient knowledge and concerns could have been discussed previously.

Moreover, as most consultations were in public settings, limited consultation time may have

constrained interaction of both doctors and patients. The varying time that patients had to read the

PDA must also be noted, although the data showed that more time does not ensure that patients will

read the PDA. Finally, the generally low level of education among the patients (See Appendix A) may

be a factor in their lack of participation, as suggested by research on SDM barriers.50,51

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CONCLUSION

Our analysis shows how doctor-centred practices impede the effective implementation of the PDA in

initial sequences of talk, in that the doctors’ PDA-focused enquiries can overshadow patient

contributions while also failing to ascertain patients’ knowledge. While the PDA aimed to support

patient-centred decision making, patients’ knowledge, concerns and preference are not sufficiently

explored by the doctors, which may be attributed to many factors including the influence of habits

from ordinary conversation. Effective interaction should therefore be emphasised both in training

clinicians to use PDAs and in designing the content and delivery of PDAs. Further studies on PDA

use in different clinical contexts can inform these efforts by identifying patterns of interaction and

effective practices in implementing PDAs, from when they are given to patients up to the conclusion

of decision making.

Acknowledgments

We would like to acknowledge the University of Malaya for funding the project under which this data

was collected (University Malaya Research Grant No.UMRG236/10HTM) and the Director-General

of Health for allowing the study to be conducted in public health clinics under approval of the

Medical Research and Ethics Committee, Ministry of Health (Reference:NMRR-10-1233-7299).

Contributors

Contributors NCJ and LYK conceptualised, designed, planned and coordinated the larger study from

which the data was obtained. Contributors AS, ZMD and AZ conceptualised and designed the

manuscript. Contributors AS, ZMD,AZ, NCJ, LYK, KEM, LPY, KAL contributed to the data

analysis. The initial draft of the manuscript was prepared by AS and ZMD and then circulated among

all authors for critical revision. All authors read and approved the final manuscript.

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Funding

This work was supported by the University of Malaya (University Malaya Research Grant

No.UMRG236/10HTM)

Competing Interests

None

Ethics Approval




Data Sharing

Ethics approval does not permit sharing of the audio and video recorded consultations.

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Figure 1

299x119mm (300 x 300 DPI)

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Appendix A

Table A.1: Final Dataset: Participants’ Demographic Profiles (by Consultation)

NO* PATIENT DOCTOR

Sex Age Ethnicity Education Sex Ethnicity

A3 M 69 Malay Degree F Malay

A4 F 73 Indian Primary school F Malay

B8 F 70 Indian Secondary school F Malay

C11 F 54 Indian Primary school F Chinese

C12 F 69 Chinese Secondary school M Indian

C14 M 57 Chinese Diploma F Chinese

B15 F 50 Indian Secondary school F Indian

*Consultation Code: A-private clinic, B-public community clinic, C-primary care clinic at a public hospital

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Appendix B

Table B.1: Key to Transcription Symbols (Jefferson, 2004)25

[ ] Overlapping talk

= No discernible interval/silence

between turns

(.), Discernible silence but less than 0.2 of second

(0.2) Silence within turns or in talk

. Closing intonation

, Slightly rising intonation

? Rising intonation

:, wo:rd Elongation of preceding sound

Word Emphasis

WORD Spoken more loudly

◦word◦ Spoken more softly

↑, ↓ Marked increase/decrease in pitch

Hhh Outbreath or laughter

.hh In breath or laughter

Hah, heh etc. Laughter

£word£ ‘Smiley’ voice

<word> Talk is drawn out

>word< Talk is speeded up

((word )) Transcriber’s notes

(), (word) Transcriber unable to hear or uncertain

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Revised Title: : Using a Patient Decision Aid for Insulin Initiation in Patients with Type 2 Diabetes:

A Qualitative Analysis of Doctor-Patient Conversations in Primary Care Consultations in Malaysia

Standards for Reporting Qualitative Research (SRQR) Checklist

(from O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting

qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251: pg

3, Table 1)

Note: Page Numbers refer to page in clean copy of revised manuscript

NO TOPIC ITEM PAGE NO

TITLE & ABSTRACT

S1 Title Concise description of the nature and topic of the study Identifying the study as qualitative or

indicating the approach (e.g., ethnography, grounded theory) or data collection methods

(e.g., interview, focus group) is recommended

Title, 1, 2, 4

S2 Abstract Summary of key elements of the study using the abstract format of the intended publication;

typically includes background, purpose,

methods, results, and conclusions

Abstract, 2

INTRODUCTION

S3 Problem formulation Description and significance of the

problem/phenomenon studied; review of relevant theory and empirical work; problem statement

4

S4 Purpose or research question Purpose of the study and specific objectives or

questions 4-5

METHODS

S5 Qualitative approach and research paradigm,

Qualitative approach (e.g., ethnography,

grounded theory, case study, phenomenology, narrative research) and guiding theory if

appropriate; identifying the research paradigm

(e.g., postpositivist, constructivist/interpretivist) is also recommended; rationaleb

4-5 6-7

S6 Researcher characteristics

and reflexivity

Researchers’ characteristics that may influence the research, including personal attributes,

qualifications/experience, relationship with

participants, assumptions, and/or presuppositions; potential or actual interaction

between researchers’ characteristics and the research questions, approach, methods, results,

and/or transferability

6-7

S7 Context Setting/site and salient contextual factors; rationale

5

S8 Sampling strategy How and why research participants, documents,

or events were selected; criteria for deciding when no further sampling was necessary (e.g.,

sampling saturation); rationaleb

5

S9 Ethical issues pertaining to human subjects

Documentation of approval by an appropriate ethics review board and participant consent, or

explanation for lack thereof; other confidentiality and data security issues

7

S10 Data collection methods Types of data collected; details of data collection

procedures including (as appropriate) start and stop dates of data collection and analysis,

iterative process, triangulation of sources/methods, and modification of procedures

5-6

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Revised Title: : Using a Patient Decision Aid for Insulin Initiation in Patients with Type 2 Diabetes:

A Qualitative Analysis of Doctor-Patient Conversations in Primary Care Consultations in Malaysia

in response to evolving study findings; rationaleb

S11 Data collection instruments

and technologies

Description of instruments (e.g., interview

guides, questionnaires) and devices (e.g., audio recorders) used for data collection; if/how the

instrument(s) changed over the course of the study

5-6

S12 Units of study Number and relevant characteristics of

participants, documents, or events included in the study; level of participation (could be

reported in results)

5-6 Appx A

S13 Data processing Methods for processing data prior to and during analysis, including transcription, data entry, data

management and security, verification of data

integrity, data coding, and anonymization/deidentification of excerpts

6-7

S14 Data analysis Process by which inferences, themes, etc., were

identified and developed, including the researchers involved in data analysis; usually

references a specific paradigm or approach; rationale b

6-7

S15 Techniques to enhance

trustworthiness

Techniques to enhance trustworthiness and

credibility of data analysis (e.g., member checking, audit trail, triangulation); rationaleb

6-7

RESULTS & FINDINGS

S16 Synthesis and interpretation Main findings (e.g., interpretations, inferences, and themes); might include development of a

theory or model, or integration with prior

research or theory

7-15

S17 Links to empirical data Evidence (e.g., quotes, field notes, text excerpts,

photographs) to substantiate analytic findings

Extract 1 (p8)

Extract 1a (p9) Extract 2 (p10) Extract 2a (p11) Extract 3 (p12) Extract 4 (p13) Extract 5 (p14)

DISCUSSION

S18 Integration with prior work, implications,

transferability, and contribution(s) to the field

Short summary of main findings; explanation of how findings and conclusions connect to,

support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of

application/ generalizability; identification of unique contribution(s) to scholarship in a

discipline or field

15-19

S19 Limitations Trustworthiness and limitations of findings 19-20

OTHER

S20 Conflicts of interest Potential sources of influence or perceived

influence on study conduct and conclusions; how

these were managed

22

S21 Funding Sources of funding and other support; role of

funders in data collection, interpretation, and

reporting

22

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Documents

Using a patient decision aid for insulin initiation in …...clinics and c) one primary care clinic in a public university hospital), in the Klang Valley, Malaysia. Participants :