Dilemmas of patient choice: findings from a conversation analytic study of neurology outpatient consultations

Recent, widely-publicized Royal College of Surgeons’ (RCS, 2016) guidelines on consent specify that “the aim of the discussion about consent is to give the patient the information they need to make a decision about what treatment or procedure (if any) they want” (p. 4).  The RCS argues that this will require “a change in attitude from surgeons” (p. 3), which they characterise as a shift away from a “paternalistic approach” (p. 3).  The RCS guidance is also directed at “other healthcare professionals” (p. 4), implying that similar changes may well be needed in other specialties.  At the time this guidance came out, I happened to be working as part of a team of social scientists and neurologists focused on patient choice in neurology.  This is a speciality where one could expect a version of the RCS guidance to be already embedded in practice, given that The National Service Framework (NSF) for long-term conditions (Department of Health, 2005) – which has been in place for over a decade – specifies that patients should “receive appropriate information before starting medication to enable informed choice” (p. 27, emphasis added).  However, not only do our findings suggest that neurologists are still overwhelmingly more likely to make recommendations than to use the kinds of consent practices recommended by the RCS, but there is substantial evidence within our dataset of a range of dilemmas posed – for both doctor and patient – by the enactment of patient choice in practice.  In this talk, I engage critically with the RCS guidelines on the basis of our analysis of over 200 recorded neurology outpatient consultations together with self-report data collected pre- and post-recording.  My aim is not to suggest a return to a paternalistic conceptualisation of the doctor-patient relationship, but rather to highlight the problems inherent in proposing ‘informed choice’ as necessarily the best alternative to paternalism.

Merran Toerien is Senior Lecturer in the Department of Sociology at the University of York. Her primary area of expertise is conversation analysis, an approach to examining the social world that depends on fine-grained study of real-world, recorded interactions.  Beginning with her PhD research on beauty salon interactions, she has focused mainly on talk in the workplace.This includes nurse-patient interaction during recruitment to medical trials, personal adviser-client interactions in Jobcentres, and neurologist-patient interaction in outpatient clinics.  She is fascinated by the subtle ways in which people disagree with each other, and the magnificently deft ways we have of maintaining social solidarity in the face of disagreement.