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Background to this study

The present study comes from a research project on patient participation in decision-making funded by the Department of Health, involving five clinical settings (Entwistle et al., 2002). We identified, among other findings, how different health professional approaches in the consultation offered more or less opportunity for patient involvement in decision-making (Collins et al., 2005); and, in a follow-up study funded by the Economic and Social Research Council, explored the combined effectiveness of different health professionals' consultations with patients in multidisciplinary care (Collins, 2005).

One of the settings was the head and neck cancer outpatients' clinic. I regularly visited one clinic, over a period of five months, observing and recording consultations and interviews with patients and the multidisciplinary team: surgeons, oncologists, radiologists, specialist nurses, clinic nurses, a dietician and a speech and language therapist. I spent one day in another clinic in a different region, observing consultations and talking with individuals from the multidisciplinary team. I collected 61 consultation recordings and conducted 39 semi-structured qualitative interviews, involving 31 patients and eight health professionals. Analyses focused on patient participation in decisions about treatment and care. I conducted interviews prior to and following the consultation, with each participant, to discuss the communication in the consultation and their views and experiences of patient involvement. Consultations were transcribed in detail for conversation analysis, which began with detailed notes on sequences from the recordings to identify interactional features, such as: the ways patients voiced and phrased concerns, and the design of professionals' turns in which they presented diagnoses or treatment. Each data set was treated separately in the first instance. For all data, I employed an inductive analytic technique, constantly revisiting the data to identify categories, noting emerging themes and where these recurred, and recording variations (such as different forms of expression of patients' concerns).

From a very early stage, my observations (recorded in fieldnotes) during initial visits to the clinics and conversations with prospective participants, highlighted the importance of geography and the use of different spaces in the clinic. For example, I began with an assumption that the surgeon's consultations in the main consulting room would be the ones to record; but it soon became apparent that many other forms of patient-professional encounter also played a part in enacting, and shaping, opportunities for patients' involvement in decisions about their care. These included spontaneous, conversation-like encounters between patients and professionals (particularly the nurses, the speech and language therapist and the dietician) in the corridor, and reflective, open-ended consultations with the specialist nurse following the delivery of a cancer diagnosis by the surgeon in the main consulting room. Following discussion with the multidisciplinary team, I was given consent to include these other forms of patient-professional interaction. I continued to make detailed ethnographic observations of the spatial layout of the clinic and its effects on communication. I kept notes on relationships between observed features of interactions between patients and health professionals in the clinic, and the space in which the interaction took place: for example, I noted the informal, spontaneous way that topics and concerns were raised in the corridor, with patients taking opportunities provided by conversation to mention something worrying them; whereas in the consulting room, those same concerns were presented in response to an invitation from the doctor.

Using an ethnographic linguistic approach to understand the health care consultation

For the purposes of this chapter, I am revisiting my observations of the geography of communication in the clinic to explore the potential of the relationship between ethnography and linguistics, and to seek to answer the following questions. How can 'the consultation' be defined and understood, given its shifting forms and locations in the clinic? How does space and the physical configuration of the clinic shape the language used in consultations? How is the clinic geography, with its various forms of patient-professional encounter, managed by patients and professionals to promote patients' participation? In seeking to provide answers to these questions, I will focus on patients' concerns regarding their understanding of their cancer diagnosis and prognosis and its treatment and management.

 
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