We bring an ethnomethodological perspective on language and discourse to a data source crucial for explaining behaviour in social psychologist Stanley Milgram's classic 'obedience' experiments - yet one largely overlooked by the Milgram literature. In hundreds of interviews conducted immediately after each experiment, participants sought to justify their actions, often doing so by normalizing the situation as benign, albeit uncomfortable. Examining 91 archived recordings of these interviews from several experimental conditions, we find four recurrent accounts for continuation, each used more frequently by 'obedient' than 'defiant' participants. We also discuss three accounts for discontinuation used by 'defiant' participants. Contrary to what a leading contemporary theory of Milgramesque behaviour - engaged followership - would predict, 'obedient' participants, in the minutes immediately following the experiment, did not tend to explain themselves by identifying with science. Rather, they justified compliance in several distinct and not entirely consistent ways, suggesting that multiple social psychological processes were at work in producing Milgram's 'obedient' outcome category.

This paper is the first extensive conversation-analytic study of resistance to directives in one of the most controversial series of experiments in social psychology, Stanley Milgram's 1961-1962 study of 'obedience to authority'. As such, it builds bridges between interactionist and experimental areas of social psychology that do not often communicate with one another. Using as data detailed transcripts of 117 of the original sessions representing five experimental conditions, I show how research participants' resistance to experimental progressivity takes shape against a background of directive/response and complaint/remedy conversational sequences--sequence types that project opposing and competing courses of action. In local contexts of competing sequential relevancies, participants mobilize six forms of resistance to the confederate experimenter's directives to continue. These range along a continuum of explicitness, from relatively subtle resistance that momentarily postpones continuation to techniques for explicitly trying to stop the experiment. Although both 'obedient'- and 'defiant'-outcome participants use all six of the forms, evidence is provided suggesting precisely how members of the two groups differ in manner and frequency of resistance.

Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213-2220, 2018.

BACKGROUND/OBJECTIVES People with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community‐dwelling PwD and alternative ways of addressing these needs. DESIGN Qualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers. SETTING Wisconsin, United States. PARTICIPANTS Informal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3). MEASUREMENTS Demographic characteristics of participants and data from semistructured interviews. FINDINGS Four major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision‐making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD. CONCLUSION Participants identified numerous system and individual‐level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia‐care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711–718, 2019.

BackgroundApproximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role.MethodsThis single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults’ ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit.DiscussionThis is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits.Trial registrationClinicalTrials.gov Registration: NCT02520661. Trial registration date: August 13, 2015.