When and how do surgeons initiate noticings of additional concerns?

Abstract

Objective: Physicians are trained on how to best solicit additional concerns from patients. What has not yet been studied is when and how physicians initiate additional concerns. This analysis focuses on when and how general surgeons share their noticings of medical problems unrelated to the upcoming (or recent) procedures that patients are being seen for.

Methods: 281 video-recorded medical encounters with 95 patients from a rural Texas (USA) general surgery private practice were reviewed for surgeon noticings of additional concerns. In addition to analyzing the videos using Conversation Analysis, the author conducted 9 months of ethnographic research to gain understanding of the local setting.

Results: 22 cases of surgeon noticings were found in 17 visits and were typically detected during the physical examination. Surgeons shared noticings adjacent to their discovery and predominantly framed noticings as bad news tellings. This framing helped mitigate 4 dilemmas surgeons encountered: unknown patient awareness of concern, surgeons' rights to assess areas unrelated to upcoming (or recent) procedures, not meeting the desired health optimization outcome & putting additional burden on patients, and other contextual factors specific to the visit that make sharing a noticing difficult. In addition to alerting patients and potentially activating earlier treatment, sharing noticings can also function to help build physician-patient relationships across time and curtail future patient worry.

Implications: Each surgeon noticing is potentially a concern that may have otherwise remained undetected and untreated, and speaks to the importance of physicians taking time to conduct thorough physical examinations.

Keywords: Additional concerns; Conversation Analysis; Ethnography; General surgery; Noticings; Physician-patient communication; Rural medicine.