Beyond the 'dyad': a qualitative re-evaluation of the changing clinical consultation

Abstract

Objective: To identify characteristics of consultations that do not conform to the traditionally understood communication 'dyad', in order to highlight implications for medical education and develop a reflective 'toolkit' for use by medical practitioners and educators in the analysis of consultations.

Design: A series of interdisciplinary research workshops spanning 12 months explored the social impact of globalisation and computerisation on the clinical consultation, focusing specifically on contemporary challenges to the clinician-patient dyad. Researchers presented detailed case studies of consultations, taken from their recent research projects. Drawing on concepts from applied sociolinguistics, further analysis of selected case studies prompted the identification of key emergent themes.

Setting: University departments in the UK and Switzerland.

Participants: Six researchers with backgrounds in medicine, applied linguistics, sociolinguistics and medical education. One workshop was also attended by PhD students conducting research on healthcare interactions.

Results: The contemporary consultation is characterised by a multiplicity of voices. Incorporation of additional voices in the consultation creates new forms of order (and disorder) in the interaction. The roles 'clinician' and 'patient' are blurred as they become increasingly distributed between different participants. These new consultation arrangements make new demands on clinicians, which lie beyond the scope of most educational programmes for clinical communication.

Conclusions: The consultation is changing. Traditional consultation models that assume a 'dyadic' consultation do not adequately incorporate the realities of many contemporary consultations. A paradox emerges between the need to manage consultations in a 'super-diverse' multilingual society, while also attending to increasing requirements for standardised protocol-driven approaches to care prompted by computer use. The tension between standardisation and flexibility requires addressing in educational contexts. Drawing on concepts from applied sociolinguistics and the findings of these research observations, the authors offer a reflective 'toolkit' of questions to ask of the consultation in the context of enquiry-based learning.

Keywords: MEDICAL EDUCATION & TRAINING; QUALITATIVE RESEARCH.

Figure 1

New forms of order and the distribution of authorship in the asthma clinic (EPR, electronic patient record; N, nurse; and P, patient).

Figure 2

Disorder arising from different conventions in intonation (GP, general practitioner; PT, patient).

Figure 3

Negotiating consent for a spinal injection (Dr, doctor; Pt, patient).

Figure 4

Lost voices in distributed turn-taking sequence organisation (English translation in italics; Dr, doctor; Int, interpreter; Pt, patient).