"Fire away": the opening sequence in general practice consultations.
BACKGROUND
Proponents of recent models of the doctor-patient relationship, such as concordance and shared decision making, have emphasized mutuality rather than paternalism or consumerism. However, little attention has been paid so far to the ways in which this might actually be achieved.


OBJECTIVE
The aims of this study were to establish whether there are any rules governing the opening sequence in general practice consultations, and to analyse the ways in which the observing or breaking of such rules contributes to the development of mutuality between patients and GPs.


METHODS
The paper is based on a qualitative study of 62 patients consulting 20 GPs in 20 practices in the Midlands and Southeast of England. Consultations were audio recorded and transcribed; patients were interviewed before and after each consultation, and doctors were interviewed afterwards. Data were analysed using the sociological method of Conversation Analysis. The outcomes were participants' own understandings as demonstrated in their speech.


RESULTS
A selection rule was identified whereby doctors choose between the questions "How are you?" and "What can I do for you?" to elicit patients' concerns. Deviations from this selection rule may be either repairable or strategic. Repairable deviance is based on misunderstanding between participants, and is resolved interactionally, usually by patients. Strategic deviance is the attempt by doctors to emphasize or de-emphasize certain aspects of their relationships with particular patients. Deviations from the rule which are not repaired lead to misalignment between participants.


CONCLUSIONS
In relation to concordance, or shared decision making more generally, this analysis demonstrates that alignment or misalignment between participants will occur before any discussion about treatment options occurs. In cases of misalignment, concordance will be much harder to achieve. Mutuality is an achievement of both patients and doctors, and requires the active participation of patients.
Gafaranga
Joseph
J
Department of General Practice and Primary Care, Guy's King's and St Thomas' School of Medicine, King's College London, UK.
Britten
Nicky
N
D003142:Communication; D003299:Cooperative Behavior; D004739:England; D005194:Family Practice / Q000379:methods*; D006801:Humans; D007802:Language; D008487:Medical History Taking / Q000379:methods*; D009819:Office Visits; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000145:classification*; D036301:Qualitative Research; D014705:Verbal Behavior; D014925:Wit and Humor as Topic