Phased organization of oncology clinic visits
1
Workshops / Symposia / Patient Education and Counseling 34 (1998) S43 –S55 S53 and patients. Nurse practitioners sometimes interact announcing upcoming topics / activities and by resisting similarly, however, they also distance themselves from patient attempts to move outside or ahead of the current their professional authority, respond to their patients activity. Dispreference for patient questions appears to be woman to woman and undermine hegemonic understand- related to the sequential placement of the patient’s ings. Moreover, when patients struggle with their pro- question, i.e., the phase of the agenda in which they are viders‘ definition of the situation, their struggles in- placed; patient questions about causality are treated as variably fail in medical interactions but succeed in they are raised. Finally, doctors’ resistance to troubles- nursing encounters. These interactional / communicational telling underscores these visits as medical service en- differences and the production of meaning associated counters as opposed to some other type of encounter. with them have real consequences for the nature of the Conclusion. In this investigation, we see how the on- provider / patient consultation and for the diagnosis and cologist has a set of tasks to accomplish, and how he or treatment of the patient’s presenting complaint. she mentions the activities, pursues them, and at times This exploration relies on ethnomethodological and resists the patient’s attempts to move off of the task / Foucauldian methods to read naturally occurring empiri- topic underway. This is evidence not only of orientation cal data and on feminist theory to interpret it. The to an agenda, but perhaps more importantly, the deploy- analysis locates the institutions of medicine and nursing ment of the agenda as a resource for managing the historically, displays how these professions are gendered conversation such that particular treatment issues and and how the battles between them are struggles over topics are delayed. Management of the agenda in the professional prestige, institutional dominance and gender ways outlined provides a new perspective on how it is hierarchy. Historicizing the healing professions provides that asymmetrical control of medical encounters is a way to understand how and why medicine and nursing achieved and how oncologists manage and display their provide very different sites for the production of mean- institutional roles as experts and gatekeepers to infor- ing. It is in these gendered sites and in and through an mation. often contested process that meanings about gendered and professional identities are produced and / or under- Social Dimensions of ’Noncompliance’ with Medical mined. A close reading of the data also displays some of Treatment Regimens: The Case of Diabetes the social, institutional and medical consequences of these differences. Karen Lutfey, Department of Sociology, Indiana Uni- Phased organization of oncology clinic visits versity, Ballantine Hall 747, Bloomington, IN 47403, USA Felicia Roberts, University of Wisconsin Comprehensive Cancer Center, 4775 Medical Science Center, Madison, Health services research assumes that utilization of WI 53706, USA medical services improves patients health and that adher- ence to treatment regimens is essential in reaching Introduction. Medical visits are characteristically orga- desired outcomes. Understanding the extent to which, nized into a series of activity phases corresponding to and conditions under which, patients do not follow their specific medical and social tasks to be accomplished. treatment regimens is central to the study of medical However, there has been little discussion of the phased care. ‘‘Noncompliance,’’ or treatment adherence, has organization of patient visits with medical specialists. In traditionally, and widely, been studied in terms of this paper, I will describe the component activities and patients’ deviant behavior and the ways in which prac- turn organization of medical visits to discuss adjuvant titioners can compel them to conform with professional therapy for breast cancer. expectations. Investigations into the prevalence of ‘‘non- Methods. Analysis is based on a conversation analytic to compliance,’’ however, have yielded inconclusive results. 22 audiotaped oncology clinic visits in which women I re-examine the very notion of ‘‘noncompliance’’ and who have been surgically treated for breast cancer explore the ways in which patients and practitioners in consult with oncologists about adjuvant therapy. two American diabetes clinic discursively construct and Results. The shape of the turns and the content (what is use the notion of compliance in and through their treated as an appropriate contribution) construct these interaction. Ethnographic observations, interviews with interactions as particular institutional service encounters. patients and practitioners, and tape-recordings of patient- The patients are allowed uninterrupted turns in the initial practitioner interaction suggest that there are interactional phase of the encounter, in sharp contrast to findings from dimensions to ‘‘noncompliance’’ that are underappreci- investigations of general medical visits. The oncologists ated in traditional work that can contribute to our display an orientation to a six-phase order of events, by understandings of treatment adherence and outcomes.
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Transcript of Phased organization of oncology clinic visits
Workshops /Symposia / Patient Education and Counseling 34 (1998) S43 –S55 S53
and patients. Nurse practitioners sometimes interact announcing upcoming topics /activities and by resistingsimilarly, however, they also distance themselves from patient attempts to move outside or ahead of the currenttheir professional authority, respond to their patients activity. Dispreference for patient questions appears to bewoman to woman and undermine hegemonic understand- related to the sequential placement of the patient’sings. Moreover, when patients struggle with their pro- question, i.e., the phase of the agenda in which they areviders‘ definition of the situation, their struggles in- placed; patient questions about causality are treated asvariably fail in medical interactions but succeed in they are raised. Finally, doctors’ resistance to troubles-nursing encounters. These interactional /communicational telling underscores these visits as medical service en-differences and the production of meaning associated counters as opposed to some other type of encounter.with them have real consequences for the nature of the Conclusion. In this investigation, we see how the on-provider /patient consultation and for the diagnosis and cologist has a set of tasks to accomplish, and how he ortreatment of the patient’s presenting complaint. she mentions the activities, pursues them, and at timesThis exploration relies on ethnomethodological and resists the patient’s attempts to move off of the task /Foucauldian methods to read naturally occurring empiri- topic underway. This is evidence not only of orientationcal data and on feminist theory to interpret it. The to an agenda, but perhaps more importantly, the deploy-analysis locates the institutions of medicine and nursing ment of the agenda as a resource for managing thehistorically, displays how these professions are gendered conversation such that particular treatment issues andand how the battles between them are struggles over topics are delayed. Management of the agenda in theprofessional prestige, institutional dominance and gender ways outlined provides a new perspective on how it ishierarchy. Historicizing the healing professions provides that asymmetrical control of medical encounters isa way to understand how and why medicine and nursing achieved and how oncologists manage and display theirprovide very different sites for the production of mean- institutional roles as experts and gatekeepers to infor-ing. It is in these gendered sites and in and through an mation.often contested process that meanings about genderedand professional identities are produced and/or under-
Social Dimensions of ’Noncompliance’ with Medicalmined. A close reading of the data also displays some ofTreatment Regimens: The Case of Diabetesthe social, institutional and medical consequences of
these differences.
Karen Lutfey, Department of Sociology, Indiana Uni-Phased organization of oncology clinic visits versity, Ballantine Hall 747, Bloomington, IN 47403,
USA
Felicia Roberts, University of Wisconsin ComprehensiveCancer Center, 4775 Medical Science Center, Madison,
Health services research assumes that utilization ofWI 53706, USAmedical services improves patients health and that adher-ence to treatment regimens is essential in reaching
Introduction. Medical visits are characteristically orga- desired outcomes. Understanding the extent to which,nized into a series of activity phases corresponding to and conditions under which, patients do not follow theirspecific medical and social tasks to be accomplished. treatment regimens is central to the study of medicalHowever, there has been little discussion of the phased care. ‘‘Noncompliance,’’ or treatment adherence, hasorganization of patient visits with medical specialists. In traditionally, and widely, been studied in terms ofthis paper, I will describe the component activities and patients’ deviant behavior and the ways in which prac-turn organization of medical visits to discuss adjuvant titioners can compel them to conform with professionaltherapy for breast cancer. expectations. Investigations into the prevalence of ‘‘non-Methods. Analysis is based on a conversation analytic to compliance,’’ however, have yielded inconclusive results.22 audiotaped oncology clinic visits in which women I re-examine the very notion of ‘‘noncompliance’’ andwho have been surgically treated for breast cancer explore the ways in which patients and practitioners inconsult with oncologists about adjuvant therapy. two American diabetes clinic discursively construct andResults. The shape of the turns and the content (what is use the notion of compliance in and through theirtreated as an appropriate contribution) construct these interaction. Ethnographic observations, interviews withinteractions as particular institutional service encounters. patients and practitioners, and tape-recordings of patient-The patients are allowed uninterrupted turns in the initial practitioner interaction suggest that there are interactionalphase of the encounter, in sharp contrast to findings from dimensions to ‘‘noncompliance’’ that are underappreci-investigations of general medical visits. The oncologists ated in traditional work that can contribute to ourdisplay an orientation to a six-phase order of events, by understandings of treatment adherence and outcomes.
