Communication in Surgical Practice; Sarah J. White; John A. Cartmill

Edited by

Sarah J. White [+–]

Macquarie University

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Sarah J White is a linguist and qualitative health researcher. She is a Senior Lecturer at the Faculty of Medicine and Health Sciences at Macquarie University.

John A. Cartmill [+–]

Macquarie University

John A.Cartmill is a colorectal surgeon, Associate Dean, Clinical, and Professor of Surgery at the Faculty of Medicine and Health Sciences at Macquarie University.

The selection of authors from a variety of interactive sociolinguistic disciplines in collaboration with clinicians explores a broad range of topics and the methodologies currently used to understand communication in surgical practice.

The intended audience for this book includes surgeons, medical educators, communication researchers, linguists, sociologists, and others with an interest in surgical and medical communication.

Chapter 1

Examining communication in surgical practice [+–] 1-5

Sarah J. White,John A. Cartmill FREE

Macquarie University

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Sarah J White is a linguist and qualitative health researcher. She is a Senior Lecturer at the Faculty of Medicine and Health Sciences at Macquarie University.

Macquarie University

John A.Cartmill is a colorectal surgeon, Associate Dean, Clinical, and Professor of Surgery at the Faculty of Medicine and Health Sciences at Macquarie University.

The archetype of a surgeon is one who feels communication is “touchy feely” or merely grunts and throws things, when, in fact, surgery is reliant on the highest standards of communication. Communication forms a central part of clinical work for surgeons. However, it has only been in the past several years that the uniqueness and complexity of this aspect of surgeon competence has gained currency in research and education. This volume brings together new research from key international academics, who contribute a range of linguistic, sociological, and professional views on communication in surgical practice. The primary aim is to provide an insight into the complexity of surgeon communication, covering a variety of communicative activities required in the everyday work of surgeons. Through the selection of authors from a variety of interactive sociolinguistic disciplines as well as the contribution of clinicians, this book is able to encapsulate a broad range of topics in, and methodologies currently used to understand, communication in surgical practice. The intended audience for this book includes surgeons, surgical colleges, medical educators, communication researchers and educators, linguists, sociologists, and others with an interest in surgical and medical communication.

Section I: The Consultation

Chapter 2 The Referred Consultation [+–] 9-34

Sarah J. White,Maria Stubbe,Lindsay MacDonald,Tony Dowell,Kevin Dew,Rod Gardner £17.50

Macquarie University

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Sarah J White is a linguist and qualitative health researcher. She is a Senior Lecturer at the Faculty of Medicine and Health Sciences at Macquarie University.

University of Otago

Victoria University of Wellington

Griffith University

Associate Professor
Griffith Institute for Educational Research

Numerous descriptions of the overall structure of doctor-patient consultations have shown that the structure consists of an interactional project based on a series of interdependent activities. This chapter offers an empirical description of referred surgeon-patient consultations. Using Conversation analysis (CA), which has been successful in the research of communication in health care, we analyse video-recorded consultations, describing the series of interrelated activities that are put into play when a patient is referred to a surgical clinic. Through this analysis, we that while surgeon-patient consultations follow a similar overall structural organization to other areas of medical practice, participants orient to the relevance of the referral letter in a specific sequence at the beginning of initial (referred) surgeon-patient consultations.

Chapter 3 Doing Patient-Centred Consultations: Some Challenges for International Medical Graduates [+–] 35-67

Lynda Yates,Maria R Dahm £17.50

Department of Linguistics
Macquarie University

Associate Professor
Head of Department
Linguistics

Macqaurie University

Early Career Research Fellow
Department of Linguistics

In this chapter we draw on naturally-occurring and simulated data to identify the particular challenges faced by transnational surgeons from language backgrounds other than English who are preparing to practise in Australia. While the nature of patient-centred consultations has attracted considerable attention in the literature and approaches to communications training which confine themselves to the formulaic much critiqued, there has been little focus on the specific features of interaction that promote the sense of comfort the patient needs. Yet these features are likely to vary across languages and cultures and thus pose a particular challenge for surgeons whose training and experience have been in a different culture and through a different language. Using data collected from doctors practising in a large public hospital and IMGs seeking accreditation to practice in Australia, we consider the communicative features used by native speakers to put their patients at ease and orient the consultation towards a person-centred rather than a medical focus. The implications for a targeted approach to communications training for IMG surgeons will be proposed.

Chapter 4 Psychological Effects in Surgical Decision-making: Evidence, Ethics and Outcomes [+–] 68-93

Y. Gavriel Ansara £17.50

Numerous psychological effects can influence decision-making in diverse areas of surgical practice, such as general, gynaecological, cardiothoracic, and urological surgery. Evidence suggests that conscientious surgeons may underestimate the extent to which they, potential surgical candidates and their loved ones, and colleagues in multi-disciplinary teams are influenced by cognitive, environmental, and societal influences. For example, the framing effect is one form of cognitive effect in which varying the description and presentation of information can influence surgical decision-making. Research shows that subtle changes to the way that information is presented can even lead people to change their surgical preferences and to give or withdraw consent. This finding raises a number of clinical, ethical, and legal concerns about how surgeons present information. This chapter will introduce a range of concepts used by researchers to categorise and study psychological effects in medical decision-making, with particular focus on surgical decisions. This chapter will discuss the relevance of these psychological effects to surgical practice; explore cases that illustrate how surgeons’ awareness of these effects can improve professional practice and clinical outcomes; and suggest specific steps that surgeons and other health professionals can take to integrate an awareness of these psychological effects into their professional interactions.

Chapter 5 Breaking Informed Consent: Strategies for Risk Communication in Surgical Practice [+–] 94-123

Maria R Dahm,Israel Berger £17.50

Macqaurie University

Early Career Research Fellow
Department of Linguistics

Roehampton University

PhD Candidate, Psychology
Roehampton University

This chapter examines risk communication strategies used to obtain informed consent in surgical consultations. Drawing on recordings of 37 interactions collected in the consulting rooms of a colorectal surgeon, two particular types of strategies are presented and discussed: 1) Set pieces used to relate risk information about more ‘routine’ procedures such as colonoscopies; 2) Breaking informed consent – a more unique strategy employed by the observed surgeon in more demanding situation such as the discussion of ‘big’, potentially life-changing surgeries. Particular attention will be given to breaking informed consent as a communication strategy that incorporates communicative features of breaking bad news into the information and consent process. This chapter argues that the communicative act of obtaining consent can in fact be modeled as a type of breaking bad news. By taking advantage of this overlap, the surgeon is able to draw from a wider range of communication resources to establish rapport and trust and to build a strong relationship with patients and their families ‘before the wheels fall off’. Implications for surgical training will be sketched.

Chapter 6 . Do Surgeons Want to Operate? Negotiating the Treatment Plan in Surgical Consultations [+–] 124-152

Maria Stubbe,Sarah J. White,Lindsay MacDonald,Tony Dowell,Rod Gardner,Kevin Dew £17.50

University of Otago

Macquarie University

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Sarah J White is a linguist and qualitative health researcher. She is a Senior Lecturer at the Faculty of Medicine and Health Sciences at Macquarie University.

University of Otago

Griffith University

Associate Professor
Griffith Institute for Educational Research

Victoria University of Wellington

Recent studies of decision making in surgical consultations suggest that surgeons may orient to surgery as a ‘default option’, as evidenced by recommendations not to operate tending to be interactionally more complex and requiring more extended negotiation than decisions in favour of surgery. This research also highlights the influence of patients on decision making, with treatment recommendations shown to be a joint achievement by surgeon and patient. However, it remains unclear to what extent contemporary patient-centred models of the consultation emphasising mutuality and shared decision making are reflected in surgical interactions. This chapter explores the naturally occurring interactional processes by which surgeons and patients reach decisions about treatment plans and how surgeons’ recommendations align (or not) with expressed patient wishes and concerns. The analysis draws on data from 47 video-recorded New Zealand surgical consultations in the ARCH Corpus of Health Interactions.

Chapter 7 Negotiating Treatment Recommendations in Orthopaedic Surgery Consultations [+–] 153-178

Shannon Clark,Pamela Hudak £17.50

University of Canberra

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Medical professionals’ areas of specialisation shape the types of problems that patients will consult them for, as well as the range of treatments patients will likely expect. However, patients do not always want the treatment that is recommended. This chapter considers how treatment decisions are negotiated in orthopaedic surgery consultations when patients resist surgeons’ recommendations. We examine factors that are interactionally brought to bear on the negotiation of treatment decisions between Canadian orthopaedic surgeons and patients, including the institutional bias towards surgery, matters of safety and risk, and patients’ medical history including length and severity of problems, and previous treatments. By examining how participants introduce, manage and resolve disagreements about treatment, this chapter sheds light on the complex interplay between orthopaedic surgeons’ medical specialisation, the institutional bias towards surgery, and patients’ expectations and treatment goals.

Section II: The Operating Theatre

Chapter 8 Transactions Between Matter and Meaning: Surgical Contexts and Symbolic Action [+–] 181-205

David G. Butt,Alison Moore,John A. Cartmill £17.50

Macquarie University

University of Wollongong

Alison Moore is an Associate Professor in English Language and Linguistics at the University of Wollongong, Australia. She has degrees in linguistics and public health and has previously held research and teaching positions at Macquarie University and the University of Sydney. Ongoing research interests include systemic functional linguistics, modelling register and context, health discourse, and the representation and treatment of animals. Across these concerns a unifying theme is the construal of agency and identity. Alison is currently the Vice-President of the Australian Systemic Functional Linguistics Association and an editorial board member for the Journal of Animal Studies.

Macquarie University

John A.Cartmill is a colorectal surgeon, Associate Dean, Clinical, and Professor of Surgery at the Faculty of Medicine and Health Sciences at Macquarie University.

In this chapter we argue for a reframing of the essential character of surgery as a site of transaction between the realm of matter and the realm of meaning. A very prevalent view of surgery to-date has been to see it as a confrontation between sick tissue in a patient and technical skill in their surgeon – a confrontation played out almost entirely in the world of ‘matter’. Under this view, issues of meaning are given a secondary and supporting role, arising in the discussion of how surgical skills are best taught, or of how to avoid ‘communication breakdown’ that might lead to surgical error. But generally issues of meaning are absent from discussions of what constitutes surgery proper, running smoothly. Recently, some scholarly attention has included a closer focus on meaning – for instance, emphasising how communication in surgery is always situated (Lingard 2011), showing how ‘material’ surgical activities themselves are always jointly accomplished through interaction (Bezemer et al. 2011), and demonstrating how such interaction integrates talk, touch, gesture and other semiotic modes (Moore, Butt and Cartmill 2010, Moore this volume, Bezemer et al. 2011). In our opinion, however, there is value in a more substantial reframing of surgery and its professional, institutional and historical context. What our alternative view offers is a model of surgical practice as an evolved, and therefore robust and adaptive, system where meaning is not outside the system but always in play; an inherent part of the system. Importantly, the robustness and symbolic complexity of such evolved systems contrasts with the relative simplicity and inflexibility of designed systems. This is partly because the former involve not only causal relations but relations of realization (which are explained below). The model has practical payoffs of some significance, such as helping to understand why highly standardized interventions that pertain only to one specific surgical context are often not well received or may not be sustained in the context of the system as a whole. An example could be a management intervention, however well intended, that underestimated the multilayered interlinkage of understandings and meanings that allows the system to function at all. The chapter begins by pointing out shared origins between the fields of semiotics and medicine, then moves from ‘sign systems’ to ‘health systems’, introducing the idea of ‘levels’ of organisation and abstraction in each type of system – in other words showing how each is a ‘realizational’ system. Against this background the chapter then reports on findings from our video-based observational study of surgical interaction, including problems and positive outcomes that the models helps explain and predict.

Chapter 9 Operating Together: The Collective Achievement of Surgical Action [+–] 206-233

Lorenza Mondada £17.50

University of Basel

The study of social interactions in medical work has primarily dealt with doctor-patient consultations in which the body is often talked about rather than actually manipulated. In surgery, the body itself is manipulated and radically transformed. By contrast, social interaction and detailed teamwork organization during operative surgery have been understudied. In this chapter, I first show how anatomy, or the surgical field as it is referred to by surgeons, is situated and collectively achieved during an operation, both through the way in which it is locally seen and interpreted, and also through the way the patient’s body is actually cut, dissected, cauterized, and repaired. Second, I show that surgical practice is an exemplary case of collaboration in which a team’s actions are timely, precise and coordinated. This paper deals with surgical practice as it is locally shaped within the course of an operation; it focuses on the way in which surgical action is temporally situated and interactively organized. In order to do that, the analyses are based on a substantial corpus of video recorded surgical operations, using open techniques as well as laparoscopic approaches. On this basis, the paper analyzes the systematic way in which surgeons coordinate their actions – in directives and requests concerning the management of instruments and of micro-actions responsible for the progression of the operation.

Chapter 10 “Coming Up!”: Why Verbal Acknowledgement Matters in the Operating Theatre [+–] 234-256

Terhi Kirsi Korkiakangas,Sharon-Marie Weldon,Jeff Bezemer,Roger Kneebone £17.50

Department of Surgery and Cancer, Imperial College London

Department of Surgery and Cancer

In the operating theatre, communication problems are the leading cause of patient harm. Yet, relatively little is known about the actual interactions that take place in surgical operations between surgeons and nurses. The aim of the present study was to examine, in detail, nurses’ responses to surgeon’s requests, and to identify what kinds issues occur in these exchanges. A video-based study examining team communication was conducted in a major UK teaching hospital. A total of 20 general surgical operations were observed and video-recorded. In total, approximately 68 hours of video data were reviewed. A subsample of 9 operations (13 h 40 mins in total) has been analysed using interactional analysis developed within the social sciences. Distributional analysis of the response practices was also conducted. Theatre nurses responded to surgeons’ requests/questions either through (1) “action” (i.e. physical activity) or (2) “talk+action” (i.e. verbal acknowledgement + physical activity). Scrub nurses responded to requests significantly more through action only, and circulators used significantly more talk+action responses. Occasionally, nurses did not respond verbally and it became interactionally problematic. The conditions affecting the effectiveness of these responses were the immediacy and visual noticeability of responding. A verbal acknowledgement has an important role when a request cannot be fulfilled immediately, and when a surgeon has no visual access to the addressee of their request, such as a circulating nurse. The study has practical implications for training of simple communication practices that can impact on situational awareness and patient safety.

Chapter 11 Lovers, Wrestlers, Surgeons: a Contextually Motivated View of Interpersonal Engagement and Body Alignment in Surgical Interaction [+–] 257-287

Alison Moore £17.50

University of Wollongong

This chapter draws on foundational and more recent work in proxemics (Hall 1959, Martinec 2001) to explore the role of body alignment as an important mode of meaning in surgical practice and its interaction in that context with linguistic semiosis, particularly in the exchange of what Michael Halliday has termed interpersonal meaning (Halliday 1973). At the same time the chapter uses the novel analytic demands of surgical interaction to test the possibility of an account of body alignment that is sensitive to variation in context and register. There must be room in such a model for a given distance between participants in interaction, or a specific alignment of bodies or gazes, to mean different things in different social and professional situations, and to be crucially involved in distinguishing such contexts. After all, although lovers, wrestlers and surgical teams all work in potentially highly charged interpersonal proximity, such proximity does not have the same meaning in each context. The chapter draws on data from a collaborative project between linguistics and surgery. The analysis focusses on an episode of surgery in which an established specialist surgeon is assisting a senior registrar in a colorectal surgery procedure, and features the common practice in teaching hospitals of swapping sides. Findings indicate the importance of mutual understanding of body alignment.

Chapter 12 Who’s Who?: Constructing Roles During Minor Awake Surgeries [+–] 286-311

Israel Berger,Sarah J. White £17.50

Roehampton University

PhD Candidate, Psychology
Roehampton University

Macquarie University

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Sarah J White is a linguist and qualitative health researcher. She is a Senior Lecturer at the Faculty of Medicine and Health Sciences at Macquarie University.

Role performance and inter-personal dynamics of medical consultations have been examined through conversation analysis (CA) in a variety of settings but with particular focus on paediatrics. Although the dynamics of the operating theatre have been examined in some detail, CA research has not yet looked at the dynamics of awake surgeries. Key differences exist between awake surgeries and general anaesthesia that are relevant to interaction, primarily that the patient is conscious and able to speak. In minor awake surgeries, such as cyst removal, the sterile field may be smaller, the surgical team may be smaller and lack an anaesthesiologist, and the patient’s family or friends may be present as well. In this project, we explore the ways in which diverse parties that may be present and speaking during minor awake surgeries constitute their roles. We use a corpus of publicly available minor awake surgeries to examine the timing of talk in relation to the procedure, the content of the talk, and speakers’ rights and obligations in relation to the procedure, and the ways in which participants claim expertise and authority.

Chapter 13 Toward a Language of Operative Surgery [+–] 312-330

John A. Cartmill,David G. Butt £17.50

Macquarie University

John A.Cartmill is a colorectal surgeon, Associate Dean, Clinical, and Professor of Surgery at the Faculty of Medicine and Health Sciences at Macquarie University.

Macquarie University

This speculative chapter about the physical action of operative surgery is presented as a dialogue between surgeon and linguist. The value of the collaboration lies in the difference between the two perspectives, which the reader will appreciate are not in complete alignment. We hoped that both linguists and surgeons could read this chapter with the back and forth exchange clarifying the points being made from outside their respective fields. This chapter can be read as a monologue by concentrating on the one font.

Section III: The Aftermath

Chapter 14 Inter-Professional Clinical Handovers in Surgical Practice [+–] 333-354

Peter Roger,Maria R Dahm,John A. Cartmill,Lynda Yates £17.50

Macquarie University

Peter Roger is Senior Lecturer in Linguistics at Macquarie University. His teaching spans several Master’s degree programs, including Applied Linguistics, Communication in Professions and Organisations, and Speech Pathology. He studied Medicine at the University of Sydney, and after graduating worked as a medical practitioner for several years before going on to complete a Doctor of Philosophy degree in communication sciences and disorders. He has published in a variety of journals, including Journal of Neurology, Brain Injury, Aphasiology, Neuroradiology, Asia Pacific Journal of Speech, Language and Hearing, and International Journal of Speech-Language Pathology.

Macqaurie University

Early Career Research Fellow
Department of Linguistics

Macquarie University

John A.Cartmill is a colorectal surgeon, Associate Dean, Clinical, and Professor of Surgery at the Faculty of Medicine and Health Sciences at Macquarie University.

Department of Linguistics
Macquarie University

Associate Professor
Head of Department
Linguistics

Much of the professional communication that takes place in hospitals involves members of different professional groups sharing clinical information. This is a crucial element of surgical practice, where surgeons and resident medical/surgical staff need to be able to communicate effectively with other health professionals to achieve optimal patient care outcomes, particularly in the post-operative phase. This chapter focuses on a clinical handover scenario involving a paediatric surgical case. In a series of role-played interactions, six medical practitioners with different levels and types of experience assumed the role of a resident hospital doctor receiving handover information from a registered nurse. Drawing on the concept of interactive framing in discourse (cf. Goffman 1974; Tannen 1993), analysis focuses on the ways in which doctors’ expectations and perceptions of team-based versus individual practice affect the way in which they approach the handover. Findings highlight the potential for effective clinical communication in cases where doctor and nurse share similar perceptions of their respective roles and responsibilities, as well as the potential for conflict and misunderstanding where mismatches exist in the ways in which the two professionals ‘frame’ the handover interaction. It is argued that an understanding of the ways in which such encounters are framed has important practical applications in the design of communication training and professional development programs in surgical practice. The ways in which the findings can be practically applied are outlined in detail.

Chapter 15 Open Disclosure in Surgical Practice [+–] 355-365

Stewart Dunn £17.50

University of Sydney

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This exploration of open disclosure is different. It aims to be very practical and logical, providing a clear summary of the evidence, and a strategic pathway through the minefield of what we do when things go wrong in healthcare. It also aims to be emotive, because ultimately we all suffer emotionally when things go wrong: to avoid the emotion is to court disaster. This chapter arises from the author’s direct involvement in the development and delivery of the 2003 Australian Open Disclosure Standard and the rollout of open disclosure training across NSW Health. It is rooted in the actual experiences of more than a thousand senior clinicians and health administrators.

Chapter 16 Clinical Communication Education for Surgeons [+–] 366-395

Suzanne Kurtz £17.50

Washington State University

Each chapter of this book presents compelling arguments for enhancing communication in surgical contexts and, to that end, for also raising the bar on communication education for surgeons. This final chapter therefore focuses on teaching and learning clinical communication in surgical contexts. Because the way we think about communication has such a significant impact on what we do, the chapter begins by highlighting four underlying assumptions that replace commonly held misperceptions about communication and answer the question: Is it really necessary to teach communication to surgeons – can’t they just get it from experience? Next we discuss six elements that help us decide what is worth teaching and learning, including: types of communication skills that help define ‘communication’, domains that clinical communication incorporates, paradigms that influence how we interact in surgical and other healthcare contexts, first principles of effective communication (and teaching), goals of communication in healthcare, and the more specific clinical communication skills that research has shown to make a difference. Finally, the chapter considers specific evidence-based strategies that comprise ‘best practices’ for teaching and learning clinical communication, i.e. practices that enhance not only surgeons’ understanding of communication but also the clinical communication skills and capacities surgeons actually apply in practice settings. Both the concepts about clinical communication and the strategies for teaching and learning it are essential if we want to develop programs at any level – from undergraduate to postgraduate and beyond – that significantly impact how surgeons (choose to) communicate with patients, colleagues, surgical teams, students, and others.

End Matter

Index [+–] 396-401

Sarah J. White FREE

Macquarie University

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Sarah J White is a linguist and qualitative health researcher. She is a Senior Lecturer at the Faculty of Medicine and Health Sciences at Macquarie University.

This volume brings together a range of linguistic, sociological, and professional views on communication in surgical practice. It aims to provide an insight into the complexity of communication in surgery, covering the variety of communicative activities required in everyday surgical work. The selection of authors from a variety of interactive sociolinguistic disciplines in collaboration with clinicians explores a broad range of topics and the methodologies currently used to understand communication in surgical practice. The intended audience for this book includes surgeons, medical educators, communication researchers, linguists, sociologists, and others with an interest in surgical and medical communication.

Reviews

This volume has significant academic merit and fills a gap that currently exists in the academic literature – pulling together a variety of perspectives on communication in surgery.
Marcy E. Rosenbaum, Professor of Family Medicine, University of Iowa Carver College of Medicine and Chair of tEACH, the teaching committee for European Association for Communication in Healthcare

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Communication in Surgical Practice

Sarah J. White [+–]

Macquarie University

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John A. Cartmill [+–]

Macquarie University

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