Abstract
Over the past decade, the ideal model of shared decision-making has been increasingly promoted as the preferred standard of doctor-patient communication in medical consultation. The model advocates a treatment decision-making process in which the doctor and his patient are considered coequal partners that carefully negotiate the treatment options available in order to ultimately reach a treatment decision that is mutually shared. Thereby, the model notably leaves room for—and stimulates—argumentative discussions to arise in the context of medical consultation. A paradigm example of a discussion that often emerges between doctors and their patients concerns antibiotics as a method of treatment for what is presumed to be a viral infection. Whereas the doctor will generally not encourage treatment with antibiotics, patients oftentimes prefer the medicine to other methods of treatment. In this paper, two cases of such antibiotic-related discussions in consultation are studied using insights gained in the extended pragma-dialectical theory to argumentation. It is examined how patient and physician maneuver strategically in order to maintain a balance between dialectical reasonableness and rhetorical effectiveness, as well as an equilibrium between patient participation and evidence-based medication, while arguing a case for and against antibiotics respectively.
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Notes
The idea that the doctor and his patient must engage in a genuine dialogue in order to achieve successful medical therapy, is prominent in Plato’s Laws, Book IV and IX, where a distinction is made between “empirical physicians, who practice medicine without science” and “gentlemen physicians”: The gentleman physician “[…] carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able”.
The concept of shared decision-making and its focus on enhancement of patient choice (Charles et al. 1999, p. 658) requires that both physician and patient perceive that there are indeed treatment options to choose from. Aside from a choice between two alternative kinds of treatment (e.g., radiotherapy or chemotherapy), which according to Gwyn and Elwyn qualifies as a situation of true equipoise, there is always also a choice between doing nothing and doing something (Charles et al. 1999). According to Gwyn and Elwyn (1999), a situation of equipoise should exist in order for shared decision-making to take place. Yet, in practice, this is not always the case. When antibiotics are requested, for example, it could be argued that often a situation of pseudo-equipoise exists as the patient assumes that antibiotics form a suitable treatment option, while medical evidence counters this conviction.
The increased focus on shared decision-making in modern medical practice derives from a number of sources (Charles et al. 1997, p. 681). For example, the ethical and legal concept of informed consent (American Medical Association 2010a). Informed consent can be defined as the “willing and uncoerced acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits” (Faden et al. 1986; Jonson et al. 2010). Informed consent seems to imply at least a minimum of shared decision-making in the form of the patient’s consent to treatment prior to the intervention (Charles et al. 1997). Also increased interests in patient autonomy (excessively emphasized in the consumerism model), can be seen to have influenced the rise of shared decision-making as an ideal model of consultation.
For an overview of the pragma-dialectical discussion rules, their potential corresponding impediments (i.e., fallacious moves of argumentation), and the argumentative discussion stages see van Eemeren and Grootendorst (1992).
Coordinated strategic maneuvers can be said to be both vertically convergent and horizontally convergent. Vertical convergence means that all aspects of a strategic maneuver made reinforce each other. Horizontal convergence means that the separate maneuvers made in a certain stage, or in the discussion as a whole, reinforce each other when taken together (van Eemeren 2010, p. 47).
These cases were first presented in Elwyn et al. (1999), who studied these medical consultations taking a discourse analytic approach. Elwyn et al. purposefully selected these particular cases to highlight consultations in which ‘conflict’ occurs regarding the treatment of an upper respiratory tract infection.
The representation of the multiple, mixed difference of opinion in Table 2 follows the format used by van Eemeren et al. (1993, p. 68).
Note that, in contrast to what D suggests M has not used the term tonsillitis within the discussion.
Following Elwyn et al. (1999, p. 110), the interview coincided with a wave of publicity concerning the overuse of antibiotics.
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Acknowledgments
The author would like to thank Dr. Francisca Snoeck Henkemans for her comments on an earlier version of this paper. In addition, the author thanks Dr. Glyn Elwyn for the permission to make use of the two case studies (“Tracey” and “Ali”) presented in this paper.
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Appendices
Appendix 1: Transcript of consultation—Tracey (cf., Elwyn et al. 1999)
(.) | brackets containing a stop indicate a pause of less than two seconds |
(2) | numerals in round brackets indicate the length in seconds of other pauses |
[] | square brackets contain relevant contextual information or unclear phrases |
[.] | italicized square brackets describe a non-verbal utterance |
[ | this symbol in between lines of dialogue indicates overlapping speech |
: | a colon indicates elongation of the preceding sound |
= | an equal sign means that the phrase is contiguous with the preceding one without pause |
001 | D | Tracey you’re eight now is that right? |
002 | [inaudible: sore throat evidently the matter] | |
003 | M | she:’s suffering a lot from it um (.) |
004 | she always seems to be on antibiotics um (2.0) | |
005 | doctor A he’s seen her last he gave her | |
006 | one load lot of (.) antibiotics and then he gave me | |
007 | a pre prescript repeat prescription then (2.0) | |
008 | to have the other to get it right out of the system | |
009 | [talks to child] | |
010 | D | [to Tracey] you’re eight now how many times have you had |
011 | what we say is tonsillitis? | |
012 | (3.0) | |
013 | M | I’d say (.) about every two and a half months |
014 | D | every two and a half months |
[muttering] | ||
015 | is it stopping you going to school? | |
it is is it? | ||
016 | can I take a look in your throat (.) | |
please (.) | ||
017 | have you had this done before? | |
018 | (6.0) | |
019 | M | they said this when she went over for an examination |
020 | because she’s seeing a speech therapist about her tonsils | |
021 | being really enlarged | |
022 | D | they are rather enlarged but nothing out of the ordinary |
023 | lots of children have tonsils of this sort of size | |
[further examination takes place] | ||
024 | D | yeah okay (.) okay well the first thing to emphasize I guess |
025 | is that this is a sore throat (.) you’re right to call it a tonsillitis | |
026 | cos that’s just a Latin name for a sore throat | |
027 | M | right |
028 | D | okay (.) it’s probably caused by repeated viruses (.) right = |
[ | ||
029 | M | right |
030 | D | = like (.) repeated colds |
031 | M | yes |
032 | D | y’know when you get a cold or a flu it’s a virus |
033 | chicken pox measles they’re viruses | |
(.) | ||
034 | it’s probably caused by repeated viruses coming and going | |
035 | contact with other children contact with school | |
036 | sometimes you leave a virus hanging around in your body | |
037 | and reactivating (.) the difficulty with viruses is | |
038 | which I’m sure you know is that | |
039 | antibiotics (.) don’t do a dickie bird for them | |
040 | they don’t wipe them out | |
041 | M | right (.) the trouble is (.) |
042 | I could go away from here tomorrow | |
043 | I mean you are the doctor I’m not telling you your job | |
044 | but I’d be guaranteed back tomorrow | |
045 | because she seems to (.) this now is nothing | |
046 | to how she usually goes right down with it | |
047 | as well you know second third | |
048 | [ | |
049 | D | with a high temperature |
050 | becomes very ill = | |
051 | M | = that’s right |
052 | D | sure (.) yeah (.) and some people find that (.) |
053 | antibiotics help them through that illness | |
054 | if they extend their | |
055 | [ | |
056 | M | yes |
057 | (.) | |
058 | D | what I am saying I guess is that (.) |
059 | the best guess we can do is that this is a viral illness | |
060 | that it won’t respond to antibiotics | |
061 | it’ll just (.) take its time and get better (.) | |
062 | some people like to have a course of antibiotics | |
063 | because they feel it makes a difference (.) and (.) | |
064 | the (.) science on this is a bit 50/50 (.) | |
065 | sometimes it does (.) sometimes it doesn’t (.) | |
066 | and as you’ve probably heard from the papers | |
067 | people are a bit wary of giving antibiotics | |
068 | [ | |
069 | M | that’s right yes = |
070 | D | = yeah (.) so (.) we’ve got two choices (.) all right now? |
071 | these are the two choices (.) | |
072 | we’ll give you plenty of paracetamol (.) fluids | |
073 | and let this illness carry on | |
074 | and build up a natural immunity (.) yeah? = | |
075 | M | = all right |
076 | D | or we’ll give you some antibiotics (.) and (.) |
077 | treat it as we treated it in the past | |
078 | although as you say (.) it (.) keeps coming back | |
079 | and I don’t think we can stop that | |
080 | M | no (.) she certainly reacts better (.) I would say so |
081 | out of experience | |
082 | D | to? |
083 | M | the antibiotics really do seem to work on her |
084 | I (.) have given her paracetamol I was sent away | |
085 | going back a while ago (.) to give her [parroting] | |
086 | paracetamol plenty of fluids (.) she was burning up (.) ah no (.) | |
087 | she (.) it seemed to drag along a long way you know | |
088 | D | is that our preference? (.) to: have a go with some antibiotics |
089 | rather than try the paracetamol and = [telephone rings through following turn] | |
090 | M | = I’d rather the antibiotics |
091 | D | yeah? |
092 | M | really (.) I would |
093 | I mean if there was a way I thought she was going to be all right | |
094 | in a couple of days (.) I know it sounds awful | |
095 | if I’ve got the antibiotics into her | |
096 | I’m (.)a busy person myself I’m (.) | |
097 | back and forward to jobs you know and I can’t | |
098 | [laughing] I know that sounds awful | |
099 | but (.) the antibiotics definitely do work better on her (.) | |
100 | I would say so | |
101 | D | excuse me a second [answers phone] |
yes okay um (.) | ||
102 | have you found any particular one to be more helpful | |
103 | than any other? | |
104 | M | umm: (.) the clear one |
Appendix 2: Transcript of consultation—Ali (cf., Elwyn et al. 1999)
001 | D | okay how can I help? |
002 | F | yeah (.) he has a high fever (.) |
003 | since eight o’clock yesterday night | |
004 | and he has vomited yesterday night | |
005 | and in the morning again (.) | |
006 | he:: doesn’t eat anything (.) | |
007 | refuses everything (.) | |
008 | and (.) he’s weak (.) | |
009 | since (.) two days | |
010 | D | weak yes |
011 | F | yeah |
012 | D | (.) has he um had a temperature |
013 | F | [M assenting] yes uh thirty eight |
014 | D | thirty eight |
015 | F | yeah |
016 | D | for how long? |
017 | (2.0) | |
018 | F | yesterday night since yesterday night |
019 | M | [almost inaudible: all day] |
020 | F | [quietly] okay |
021 | D | has he carried on eating or not eating |
022 | F | not eating anything |
[ | ||
023 | M | [quietly] not eating |
024 | D | vomiting? |
025 | F | vomiting that’s right yeah = |
026 | D | =yeah? (.) any diarrhea? |
027 | F | no diarrhea at all |
[ | ||
028 | M | no |
029 | D | any coughing? [simulates sound of coughing] |
030 | F | no at all |
031 | D | not all all |
032 | F | not at all |
033 | M | [quietly] not at all |
034 | D | okay |
035 | (.) | |
036 | F | not at all not at all |
037 | D | okay (.) I’d like to just have a look at him |
038 | F | okay |
039 | D | right you keep him on your lap there and I’ll (.) |
040 | [to Ali] hullo (.) what’s your name? (.) Ali yeah? | |
041 | (.) maybe if we take the jersey off first of all | |
[ | ||
042 | F | yeah |
043 | D | (3.0) how old is Ali now? |
044 | F | (.) two years and (.) eight months |
045 | D | two years and eight months okay |
046 | I’ll listen to the chest first if I may (2.0) | |
047 | F | okay [three syllables to A] |
048 | (18.0) [D examines Ali’s chest] | |
049 | D | yes he’s quite hot |
050 | F | yeah uh do you know I’ve realized that uh |
051 | he has uh very big tonsils? | |
052 | (5.0) | |
053 | D | the other side (.) |
054 | let’s have a look in this ear as well | |
055 | (7.0) [D unwraps tongue depressor] | |
056 | F | open your mouth ah:: ah:: ah:: |
057 | D | very good |
058 | F | good |
059 | D | thank you |
060 | (2.0) | |
061 | right (3.0) it’s very clear what he’s got | |
062 | he’s got some white spots on his tonsils = | |
063 | F | = I see |
064 | D | yeah? so he’s got um a sore throat = |
065 | F | = I see |
066 | D | in medical terms we call it tonsillitis |
067 | F | yeah tonsillitis |
068 | D | = okay (.) his ears are fine |
069 | F | yeah |
070 | D | chest is fine |
071 | F | okay thanks very much = |
072 | D | = so that’s why he’s got a high temperature |
okay? = | ||
073 | F | = okay thank you |
074 | (.) | |
075 | D | now (2.0) |
076 | did you have any ideas as to how we should | |
077 | deal with this (.) problem? | |
078 | F | actually I have a (.) other son [D: mmm] (.) |
079 | six and a half years old [D: mmm] (.) he had | |
080 | lots of problem (.) about his tonsils (.) | |
081 | the same problem (.) actually he [all come?] now | |
082 | he finished this problem (1.0) he’s coming to age seven | |
083 | (.) so (.) I think it is better to keep the child from cold | |
084 | (.) no cold drinks? something like that (.) | |
085 | I don’t know any more | |
086 | D | okay (.) the the ways we deal with tonsillitis (.) um (.) |
087 | it’s quite normal for children to have this kind of problem | |
088 | (.) yeah? d’ya? | |
[ | ||
089 | F | yes = |
090 | D | = it comes and goes it’s usually a viral infection |
091 | a virus okay? (.) | |
092 | which means that (1.0) I would like to u::se (.) | |
093 | either Disprol or Calpol to keep the temperature down | |
[…] | ||
100 | D | right? (.) now (.) some people then (.) like to use (.) |
101 | antibiotics as well (.) | |
102 | but (.) I’m not so keen because | |
103 | antibiotics don’t deal with viruses (.) | |
104 | they just (.) are no use (1.0) | |
105 | and they also cause some problems (.) | |
106 | they sometimes cause diarrhea and vomiting (.) um (.) | |
107 | and it means that you have (.) problems for the future (1.0) | |
108 | so (.) those are the kind of possibilities (1.0) | |
109 | which (.) which way would you like to deal with the problem? | |
110 | (1.0) | |
111 | F | actually if I use antibiotics for my children (.) |
112 | the problem (.) is ending in a short time (.) | |
113 | which I ha ob observe (.) but the the another way (.) | |
114 | some paracetamol or things yeah (1.0) | |
115 | it will end but a little bit more than the uh (.) | |
116 | D | yes take a bit longer = |
117 | F | = yeah take longer |
118 | D | sure I understand ((yeah)) |
119 | (1.0) | |
120 | F | so it’s it’s uh (.) family I mean the parents we don’t (1.0) |
121 | want to see our children (.) going down I mean getting weak | |
122 | D | [quietly] sure = |
123 | F | = so we want to take some (.) antibiotics |
124 | (1.0) | |
125 | D | you would like to do that would you? |
[ | ||
126 | F | yeah |
127 | D | yeah? |
128 | F | yeah (.) it is too difficult to to explain but (2.0) |
129 | if we can uh (2.0) can be encouraged by doctors yeah | |
130 | we can do some uh paracetamol | |
131 | D | sure = |
132 | F | = we cannot lie |
133 | (.) | |
134 | D | my own feeling is that |
135 | you’re probably better to use paracetamol and fluids | |
136 | rather than use antibiotics | |
137 | because you can cause sickness | |
138 | and also resistance for the future | |
[ | ||
139 | F | I see |
140 | yeah I understand | |
141 | D | um (.) but if you feel strongly |
142 | that you would like to definitely have an antibiotic | |
143 | we can do that as well (.) | |
144 | um the other possibility ’s for me to give you | |
145 | a prescription for an antibiotic | |
146 | and for you to wait | |
147 | F | I see (.) yeah |
[ | ||
148 | D | and and only use it |
149 | if things get worse | |
150 | you can give me a telephone call or something | |
151 | F | yeah (.) |
152 | D | so which one of these possibilities would you like to do> |
153 | (1.0) | |
154 | F | okay [slight laughter in voice] let me ask my wife |
155 | [to M] which one paracetamol or (.) antibiotics? | |
156 | (.) antibiotics? | |
[After a subdued and brief laugh, M responds to F at some length in their own language, quietly and insistently] | ||
157 | F | yeah paracetamol this time please [M still talking quietly to F] |
158 | D | okay (2.0) Disprol or Calpol? |
159 | F | yeah |
160 | D | which one? doesn’t matter |
161 | F | I see uh Calpol is uh eh better than paracetamol or euh which one? |
[M whispers to F throughout] | ||
162 | D | children like it a bit better than most stuff [laughing] |
163 | M | yeah = |
164 | F | = okay |
[…] | ||
175 | M | thank you very much |
176 | D | no problem and he’s you know he’ll be healthy fine |
177 | F | okay |
178 | D | okay no problem |
179 | M | thanks very much |
180 | D | bye bye now |
181 | F | bye bye |
[ | ||
182 | M | bye |
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Labrie, N. Strategic Maneuvering in Treatment Decision-Making Discussions: Two Cases in Point. Argumentation 26, 171–199 (2012). https://doi.org/10.1007/s10503-011-9228-5
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DOI: https://doi.org/10.1007/s10503-011-9228-5