Negotiating patients’ therapy proposals in paternalistic and humanistic clinics

Abstract

The negotiation of patients’ therapy proposals often makes a strong statement about doctors’ consultative styles in Nigerian clinical encounters. This invites a search into the relationship between patients’ preferred treatment options and doctors’ and patients’ approaches to negotiating them. Analysis reveals the sequential and face orientation mechanisms deployed in negotiating patients’ proposals in predominantly doctor-centred clinics, the interactional moves made by them in negotiating the proposals in predominantly patient-centred clinics, and the pragmatic Implications of therapy proposals negotiated in both clinics. The negotiations in the clinics are anchored to strategic rapport building, the colonisation of patients’ lifeworld and constrained joint decision. Rapport is poorly built in the doctor-centred clinic with power-imbued strategies which stifle patients’ voice and lead to completely-constrained joint decisions on therapy proposals by patients. Participatory consultation enhances negotiation in the patient-centred clinic, but the physician’s misleading strategic sequences and exaggerated emotions somewhat weaken the ultimate consultative outcome.

Discursive management of patients’ disagreement with doctors’ recommendations in Nigerian hospital visits

“…Our position here tallies approximately with Stivers and Tate’s (2023: 233) that ‘while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes’. A similar position, finding the middle point between clinical paternalism and humanism, has been documented in Young (1997), Hyden and Bulow (2006) and Odebunmi (2021a).…”

“…Basically, the paper selects analytical insights from aspects of Levinson’s activity type model, common ground models, and conversation analysis (CA). First off, Levinson’s model which foregrounds ‘act-activity co-constitution’ (Levinson, 1979, 1992), captures the doctor-patient interaction activity type and how the parties co-constitute and co-construct the topics of the meetings (See also Odebunmi, 2021a). These resources are complemented with aspects of common ground models (Allan, 2013; Clark, 1996; Enfield, 2008; Kecskes, 2014; Lewis, 1979; Prince, 1981; Stalnaker, 2002) which emphasise the shared discursive contents in interactants’ control in a conversation, and how these can be expanded or enriched as the conversation progresses contingent upon the addition of new information to the existing pile available to the interactants (Adeoti, 2016).…”

“…It is always an outcome either directly of doctors’ clinical reasoning following the problem presentation stage of the encounter or of a combined consideration of problem presentation, examination, investigation, clinical reasoning and diagnosis. It is, therefore, more often than not a clear evocation of the medical scientific voice (Odebunmi, 2021b) unexpected to be challenged or negotiated by the patient, being an intervention suggested by medical efficacy epistemics. Its resistance, and the consequential disagreement, is thus marked, and often taken either as a confrontation from the life world and, therefore, mostly dismissed as inconsequential or as an issue to be negotiated carefully with patients.…”

“…i. The 0.5 second elapsing between the turns is probably indicative of Pat’s cognitive struggle with Doc’s decision and his consideration of the way to formulate his resistance to it in the light of the particularly marked clinical asymmetry in Nigerian clinical encounters (See Odebunmi, 2021a).…”

“…For example, in Nigeria, and possibly some other countries in the South, more non-participatory than participatory scenarios are seen in hospital visits, and, consequently, disagreements occur from both angles. Therefore, in addition to the need to plug in the wide vacuum of non-existence of studies on the discursive management of disagreement in general in Nigerian clinics, extremely few existing studies being on paternalistic and humanistic doctoring approaches (Odebunmi, 2016, 2021a), it is imperative to provide a balanced account reflecting both participatory and non-participatory scenarios for the most representative picture of doctor-patient disagreements in clinical encounters. These constitute the attention of the current study which highlights how disagreement over doctors’ treatment recommendations in Southwestern Nigerian hospital clinics is discursively managed, and, interalia, the determinants and clinical implications of the parties’ orientations to the disagreements.…”