Training Consultations

Using Discursis, we analysed each of the three training consultations separately; each consultation involved a conversation between the doctor and David (patient). First, we looked at the extent of intra-speaker and inter-speaker concept similarity (in CAT terms, accommodative approximation via same-saying on concepts) on a turn-by-turn basis. This allowed an assessment of short-term conceptual engagement between the doctor and patient, as well as the extent of conceptual consistency for each speaker. Next, we examined the conversations in 10-turn blocks, which allowed us to assess engagement and similarity across blocks of speech. Finally, we examined each conversation as a whole. We expected the consultation with good task and good rapport (Training #1) to contain stronger engagement at each level than the consultation with poor task and poor rapport (Training #2). We also expected Training #1 to contain more engagement than the consultation with poor task and good rapport (Training #3) in terms of medical content and attention to David’s medical problems, although we expected good engagement around non-medical topics in Training #3.

For Training consultation #1, turn-by-turn analysis showed the patient engaging with statements by the doctor and the doctor engaging with statements by the patient; that is, there was significant approximation or repetition of concepts across speakers. Such patterns of engagement can be seen as two-colour squares connected to the diagonal, which only occur when the doctor and patient repeat concepts mentioned in the turn immediately prior to their current turn (see Figure 2). At the 10-turn level, this impression of strong engagement around the patient’s medical problems was reinforced. For example, at the half way point of the consultation the doctor engaged strongly with the patient around the concept of drinking. This engagement was found by looking for sections of connected recurrence, which manifest as many red, red/blue, and blue blocks next to each other that are close to the diagonal. At the level of the whole conversation, the level of engagement was also high, particularly between the opening turns by the patient and the remainder of the consultation, and the final turns by the doctor and the turns that had appeared earlier. This means that both doctor and patient accommodated to the patient’s initial presentation of the problem, and this stance of approximation continued throughout the conversation. Thus, several stripes of vertical recurrence can be seen stemming from the patient’s initial turns (highlighted in Figure 2). These vertical stripes indicate that the conceptual content of these early turns was repeated throughout the remainder of the consultation. The conceptual content of these early turns recurred with both the patient’s own statements (red squares) and the doctor’s statements (red and blue squares) throughout the remainder of the consultation. This feature also indicates that these early turns framed much of the later discussion. The opening exchange of Training #1 is reproduced below, with the text of the large red square at the head of one of the vertical stripes in Figure 2 indicated in bold below:

Doctor: Good morning David, I am Dr Vivien Ling. How are you today.

David: Alright, I guess.

Doctor: This is your first visit to our clinic.

David: Yes, my family moved here from Hobart when er Karin got a job with Powerlink last year.

Doctor: Now David you’ve been having some problems ah with vertical dizziness. Errmm you’ve written me a letter and so’s your doctor in Hobart about your problem. Would you like to tell me about er the particular trouble you’ve been having.

David: Yes, well I’ve had dizzy spells as such for oh many years erm in fact looking back I’d say probably from when my children were very young which would be more than four years ago. Dizziness in that er in motion particularly. I’ve always been motion sickness, sea sickness, air sickness erm. It’s been getting progressively worse in the last few years. I’ve been treated for vague ear infections and so on which may have caused the dizziness but in the last twelve months and particularly in the last six months it’s been getting so bad that I’m almost living with dizziness all the time.

The stripes of blue and blue/red coloured horizontal recurrence stemming from the doctor’s closing statements suggest that these statements summarise many of the key concepts raised throughout the entire consultation. Such a feature may not be present if a doctor does not offer a conclusive or substantive diagnosis. One of these statements is reproduced below:

Doctor: David correct me if I am wrong. Er you’ve been suffering asthma since you started working as a panel beater. Over the last few years you have done more spray painting work without protective equipment. Since you have moved to Brisbane you have been doing a lot more spray painting in your garage. Your dizziness has increased since you started doing more of this work at home. Er David you have no family history of dizziness and you have suffered no head injuries.

For training consultation #2, turn-by-turn analysis showed a limited amount of engagement, particularly in the latter half of the consultation where not a single red/blue block is observed next to the diagonal (see Figure 3). At the 10-turn level, this impression of limited engagement around the patient’s problems is reinforced, one example being near the end of the consultation where the doctor and patient are seen to repeat their own concepts but not engage with each other’s concepts (that is, they do not approximate but maintain their own concepts). Such behaviour presents as a checkerboard style pattern due to participants repeating their own concepts but not the other participant’s concepts. In this example the doctor is curious about the patient’s home life, but the patient is concerned that his dizziness may be caused by a tumour. The doctor in this instance failed to engage the patient about his concerns over a tumour and thus was unable to get a straight answer to repeated questioning:

Doctor: How is your home life.

David: Erm good I suppose. Erm Karin and me fight sometimes but in general it’s good. I don’t get much sleep but. Cause of the kids and the dizzy spell. You don’t think is a tumour do you.

Doctor: Was your home life the same when you lived in Hobart. Did you get more sleep.

David: Yea, I suppose I did Clair didn’t like the move. Er we had to pull her out of her school and er she misses her friends. Doc my Dizziness is getting worse I am not going to die am I.

Doctor: Can you please focus on answering my questions. Is there anything at home or at work that you think might be causing the dizziness.

David: Erm nothing I can think of er na nothing. That’s why Karin thinks it’s a tumour. They can fix them these days can’t they doc.

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larger image TIFF original image Download: Figure 3. Features of a poor doctor/patient consultation. Good engagement between the doctor (blue) and patient (red) is witnessed early in the consultation; however there after the consultation degrades over time as the patient (red) begins to repeat themself. https://doi.org/10.1371/journal.pone.0038014.g003

In the block presented here, accommodative communication is not evident. First, there is little or no approximation at the conceptual level. In addition, the repetition by the speakers of their own topics indicates a lack of accommodation in discourse management. One can also see a lack of accommodation in interpersonal control and interpretability, although this is not as obvious in the visualisation. Nevertheless, the visualisation makes obvious the lower overall level of accommodation and engagement in this passage. At the level of the whole conversation, the level of engagement was also limited; instead, a large degree of repetition by the patient was observed, indicated by the presence of many red blocks. Furthermore, the doctor’s discourse framed the consultation rather than the patient’s, as it was the doctor’s initial turns that recurred (vertical stripes) throughout the remainder of the consultation.

For training consultation #3, where there was poor task focus but good rapport, two separate recurrence plots were generated (see Figure 4). As the conversation was observed to contain a large number of concepts related to sailing (a non-medical topic), one plot was generated using all concepts, and a second plot was generated using only medically relevant concepts. The effect of limiting the available concepts was a reduction in the amount of off-diagonal recurrence, particularly that of the patient. The plot that contained all concepts including those around sailing showed a high degree of engagement, but the recurrences did not stem from medically relevant conversation. The plot that was limited to only medically relevant concepts, including discussion of symptoms (dizziness, nausea), changes in personal situation (work, moving, Hobart) and personal circumstances (wife, family) showed a similar level and distribution of engagement and repetition to Training #2. For example, the vertical stripe stemming from one of the patient’s opening turns was not present after removal of non-medical concepts, indicating that there was no setting of an agenda around the medical issues.

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larger image TIFF original image Download: Figure 4. Features of a poor task focussed but good rapport building doctor/patient consultation. Good engagement between the doctor (blue) and patient (red) is observed if non-medical concepts are included (left-hand plot); however removing non-medical concepts highlights how the consultation does not contain good engagement on medical concepts (right-hand plot). https://doi.org/10.1371/journal.pone.0038014.g004

As noted in the literature review, in a doctor/patient consultation the distribution of turn taking needs to match the needs of both interactants and reflects the level of engagement by the patient. Of course, there is not only a single pattern of turn taking. Rather, consultations vary in complexity, type of problem (e.g., chronic versus acute conditions), familiarity by the patient with the problem, and so forth, all of which change the turn-taking pattern. Even so, there are clear types of turn-taking that are more appropriate than others across a range of medical consultations.

In the Discursis visualisations, the size of the on-diagonal squares in the recurrence plots represents the length of the turns (usually the number of words). A general observation about Training consultation #1 was that the patient had many large turns early, and the doctor many large turns later in the consultation. In addition, the distribution of time was shared evenly between both participants (accommodation in discourse management). In the other training examples (Training #2 and Training #3) the doctor contributed the majority of content earlier and later in the consultation. The patient contributed mostly in the middle, or else very little for the entire consultation, indicating a lack of sharing in the management of the discourse.