Managing Patient-centered Communication across the Type 2 Diabetes Illness Trajectory: A Grounded Practical Theory of Interactional Sensitivity

Abstract

This article uses the theoretical and methodological framework of Grounded Practical Theory (GPT) to provide a lens for analyzing and interpreting discourse as a situated form of social action in routine Type 2 diabetes visits. Drawing on a total data-set of 400 audio-recorded routine visits, we randomly selected 55 visits for qualitative analysis. In this article, we use Conversation Analysis to document communication techniques, which we in turn use as evidence to ground our claims within the GPT framework. We use two single cases of interaction to analyze communication techniques physicians use when recommending a change from oral medication to insulin. We argue treatment intensification is a key moment in health communication to reflect about patient centeredness because physicians can find themselves in an interactional dilemma: while insulin may effectively help control unstable disease, an insulin recommendation may simultaneously counter patient values and treatment preferences. Our analysis suggests that physicians use what we call interactional sensitivity to balance medical need and patient preferences when making medical decisions by tailoring their communication according to the local situation and the patient's larger illness trajectory. We propose that interactional sensitivity is a type of communication work and a quality of patient-centered communication characterized by the theoretical relationship between tailoring communication to the contingencies of the local interaction and the global illness trajectory. Overall, this article contributes to health communication scholarship by proposing a normative model for reflecting on how physicians negotiate challenging interactions with patients during routine chronic illness visits.

Keywords:

• Health Communication
• Patient-centered Communication
• Physician–Patient Interaction
• Treatment Decision-making
• Type 2 Diabetes
• Grounded Practical Theory
• Conversation Analysis

Acknowledgments

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

Notes

[1] Out of the total 17 cases identified, besides the six visits in which physicians and patients negotiated treatment intensification, the remaining cases included seven visits in which the people with Type 2 diabetes had been taking insulin for a long period of time and discussed insulin in matter-of-fact ways, and four miscellaneous cases in which insulin was variably mentioned in relation to insurance claims, family members with Type 1 diabetes, and similar logistical issues related to everyday life contexts.

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

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