Abstract
Patients’ disagreement with doctors’ treatment recommendations, which receives participatory or non-participatory attention from the consultative parties, constitutes a major discursive issue in clinical encounters. However, the literature on medical discourse has demonstrated more concentration on the participatory than the non-participatory dimension of the encounters. This discursive representation does not adequately capture the consultative encounters in Nigeria where both situations obtain but where none has been significantly studied, leaving a lacuna in the understanding of conflict management in the hospitals. An analysis of 25 purposively sampled doctor-patient interactions in Southwestern Nigerian hospitals was undertaken with theoretical insights from the notion of activity type, common ground models and conversation analysis. Findings indicate that two types of actions are identified in treatment-related indirect disagreement in Nigerian clinical encounters: participatory and non-participatory action. Participatory orientations to indirect disagreement are contextualised in joint therapeutic efficacy or institutional convenience; non-participatory orientations in the same disagreement type are situated in salient emergency. The resulting negotiation, or lack of it, reveals clinical power dynamics, and interpenetrating evocations of the voice of medicine and the voice of the life world in paternalistic and humanistic contexts; and consequently partial or inexistent patient satisfaction. The paper concludes that participatory communication and strategic deployment of humanistic and paternalistic clinical communicative approaches are capable of producing satisfactory consultative encounters in Nigerian hospital visits.
Keywords
Introduction
Clinical consultative encounters are marked by agreement and/or disagreement between doctors and patients. There is agreement largely when doctors’ (proposals of) diagnoses or treatment recommendations mesh (perfectly) with patients’ perspectives or expectations; disagreement occurs when these partially or completely come at variance between the parties in the clinics. Thus, agreements appear to be given while disagreements are marked occurrences with implications for doctors’ epistemic and deontic power and, sometimes, the relationship between the parties in clinical meetings.
In most doctor-patient encounters in Nigeria, and by a fair extension, in many African countries, both consultative parties often agree overtly or covertly, or at least, the patient puts up the appearance of agreement, on diagnoses and treatment recommendations. Mostly, this has been attributed to cultural and received institutional-power reasons (See Odebunmi, 2011, 2016). Thus, in several instances, patients are or appear to be, satisfied with doctors’ communicative and professional approaches and clinical conflicts seem to be significantly reduced. This may not be the same situation in several Western clinics. In the view of Weingarten et al. (2010), medical consultations get conflictual when the expected outcomes of the meetings are not consistent with patients’ beliefs. Similar perspectives have been expressed by Stivers (2002, 2005) and Légaré and Thompson-Leduc (2014). In Nigerian clinics, disagreements in contexts such as these are generally not expressed by the patient; rather, in most cases, the impositions or errors indicative of the dis-sync between clinical outcomes and patient expectations or beliefs are either accommodated as part of the doctor’s power (or institutional role) or prompters for the patient to visit another hospital or an alternative medicine facility for comparison or alternative help (See Adegbite and Odebunmi, 2010).
However, on a few, yet eminently significant occasions, patients disagree with doctors largely on treatment recommendations, an area of care which typically attracts patients’ subjective judgement given its dependence on several non-medical influences such as differential patients’ biological or bodily allowance or disallowance of certain medications or treatment options, possible or suspected doctor errors, patients’ treatment-sharing experiences, and sundry other medical or non-medical considerations. When these disagreements occur in the clinics, the consultative parties either participatorily or non-participatorily orient to them. In the former orientation, which is not a common approach in Nigerian clinics, there is a joint discursive engagement in clinical encounters where doctors and patients play ‘mutable roles’ (Aronsson 1996: 2). The doctor makes treatment options partially or completely open and permits a level of joint decisions on deontic directions. In the latter, which is dominant in the clinics, the opposite occurs. In this scenario, all or most options and decisions are respectively managed and taken by the doctor (See Odebunmi, 2016). These two types of discursive engagement are somewhat respectively coterminous with patient-centred (humanistic) and doctor-centred (disease-centred or paternalistic) doctoring approaches. However, as will be shown presently, the two approaches are sometimes not absolutely mutually exclusive; for example, a dose of paternalism may be required in humanism and vice-versa for effective consultations.
The literature on medical discourse, particularly largely focused on treatment and treatment resistance, has hugely examined disagreement resulting from participatory action in Western clinics but has not given the same level of attention to the one emanating from non-participatory management of clinical encounters (see Légaré and Thompson-Leduc, 2014; Rohrbaugh and Rogers, 1994; Sherlock et al., 2019; Stivers, 2002, 2005; Stivers and Tate, 2023; Thompson and Pledger, 1993; Todd, 1984; Van Keer et al., 2015. Some (or aspects) of the few studies that have dealt with non-participation in different forms and degrees are Eldh et al. (2008), Levinson et al. (2005) and Stivers (2019). To the extent that Eldh et al. (2008) deal with non-participation in clinical encounters, it relates to the current study but differs from it in that it used the survey methods and not natural interactions. Our study also differs slightly from Levinson et al., 2005; Stivers, 2019) by its concentration on doctors’ not licencing patients’ collaborative participation in treatment decisions in emergency situations contrary to these studies’ submissions on patient’s refusal to participate. In addition, Eldh et al.’s (2008) recommendation that non-participation should be avoided differs slightly from the findings of our study, which support participation but permit a measure of humanistically well-managed non-participation in the dire need to treat patients. 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).
The dominant attention paid to the management of disagreement emerging from participatory action in hospital meetings has created a misleading impression about the discursive realities in clinical encounters in certain climes. 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. Ultimately, the study provides insights into the nature of doctors’ and patients’ discursive actions relating to clinical disagreement and demonstrates the pragmatic and professional implications of these for treatment encounters and public health in Southwestern Nigeria. It is equally capable of clarifying the notion of disagreement and the description of the practices by which disagreement is expressed in Nigerian clinical meetings. Below, in Section 2, we highlight the theoretical anchorage of the research; in Section 3, we provide the methodology; in Section 4, we undertake the analysis and report on the findings; and in Section 5, we conclude the paper.
Theoretical considerations
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). The interventions by Kecskes (2014) have, in particular, introduced more clearly the distinction between declarative or apriori and procedural or emergent common grounds, intricately connected to salience, attention, intention and egocentrism, which tie in well with doctors’ and patients’ interchanges on treatment recommendations, the expression of the parties’ preference or dispreference, their activity or inactivity and their negotiated or received regimens built on the affordances of personal, institutional, social and cultural indices demonstrated at the clinics.
Finally, aspects of CA’s turn construction and turn allocation components, which demonstrate the approach’s core interventions relating to how talk is organised and understood, have enriched the theoretical scope of the paper. These include turn distributional techniques, namely, current-speaker- selects- next- speaker, next-speaker-self-selects as –next and current-speaker- continues; adjacency pairs; footing and contribution-integral resources such as latches, loudness, voice-lowness, rising or falling tune and elapsed time between turns. These resources provide the relational mechanisms to account for doctors’ and patients’ contributions to and/or negotiations of announcements of and disagreements with treatment recommendations.
Methodology
Twenty-five (25) conversations between doctors and patients in Open Patient Department (OPD) clinics were selected from government-owned and privately-owned hospitals in Southwestern Nigeria. These conversations were selected purposively in consideration of the presence of expressions/utterances indicative of clinical disagreement in them. The selected interactions demonstrated dyadic encounters which may not always be the case in all clinics, for example, paediatric and gynaecological clinics. The recorded interactions were complemented with data interpretation sessions held with two Nigerian medical doctors and two Nigerian hospital visitors on aspects of the sampled encounters, together with the current authors’ personal experiences in hospital visits. Informed consent of all doctors and patients in the recorded interactions was obtained. Four medical cases were presented in the sampled 25 conversations: renal, antenatal, malarial and ulcerous conditions. While all the25 consultative sessions were taken into consideration in the thematic coding of the data, excerpts for analysis were taken from only four of them. Transcripts were prepared using Jefferson’s CA transcription model.
Analysis and findings
The analysis below is presented in tandem with the key objectives of this study: how treatment-related disagreement is discursively managed and, inter-alia, the clinical and pragmatic implications of the discursive management orientations These are developed in two sections on participatory and non-participatory actions below each of which gets further beefed up with its characterising contextual and constraint factors.
Participatory and non-participatory action in clinical disagreement
Participatory and non-participatory actions in the encounters are operationally described respectively as the mutually-engaging clinical orientations in which both parties contribute to the consultative session and the unilateral, non-engaging participation in which either only the doctor contributes to the session or he/she dominates the encounter, and consequently suppresses the patient’s life-world voice. Both discursive actions are constrained by the macro and micro consultative contexts of the hospital. The macro context, which often interpenetrates with or is clutched to the latter, refers to the overarching professional or institutional conditions, benchmarks or impingements that underlie doctors’ professional decisions or clinical actions. The impingements capture the interactionally grounded constraints that emerge from doctors’ and patients’ exchanges on the objects of the latter’s visit to the hospital. These constraints are characterised by three types of judgement (decision-informing consideration) in clinical disagreements: the judgement of therapeutic efficacy, the judgement of salient emergency and the judgement of institutional convenience. We take them in turns below together with the type and/or sub-types of disagreement that inform each of them.
Only one type of disagreement, the indirect disagreement, was found in the sampled interactions. This disagreement type bifurcates strong and weak indirect disagreements. While the former is situated in the participatory context, the latter is contextualised in non-participatory action, and each is variously connected to the three clinical judgements of therapeutic efficacy, salient emergency and institutional convenience. In addition, as will be illustrated shortly, while clinical disagreement occurs in both participatory and non-participatory meetings, mutually satisfactory decisions are not always assured, but participatory meetings have demonstrated more cases of joint decisions, which are partially or largely mutually satisfactory to the parties. The interpenetrating occurrences of all these features are captured and discussed in the sub-sections below.
Participatory orientations to indirect disagreement in the context of the judgment of therapeutic efficacy
The judgement of Therapeutic efficacy (JTE) which picks out the doctor’s decision of the most efficacious deontic direction for the patient sometimes results in clinical disagreement with the patient. This disagreement gets vented indirectly through hints and insinuations which are indexical of strong disagreement – the clear suggestive, though not direct, communicative cues indicative of resistance to doctors’ recommendations.
In several cases of clinical disagreements in Southwestern Nigerian hospitals, the doctor’s consideration of what is therapeutically efficacious and, therefore, best for the patient is sometimes opposed to the latter’s preference. Mostly, injection, histamine-based antimalarial, non-antibiotic, surgical and non-medication treatment recommendations are resisted actively or weakly by many patients who consider them inconvenient. Doctors’ judgement of therapeutic efficacy on treatment courses such as these, when evoked in the encounter, is sometimes offered participatorily, but this may not always guarantee a completely patient-satisfactory resolution of the disagreement that ensues.
There are two sides to the participatory action in JTE. The first occurs if the doctor announces treatment recommendations to the patient during the consultative meeting; the second takes place after the patient has received prescribed medications or prescription sheets from hospital pharmacists. Our focus in this research is on the former which occurs less frequently than the latter. In most cases, doctors in Southwestern Nigerian hospitals document their recommendations in patient’s case notes for pharmacists’ attention rather than announce them. Except as hospital visitors who have experienced this and who know persons who have done the same, we (the current authors) do not have collected data (which would also include ethnographic information) to support the analysis of this side to participatory disagreement.
JTE is often designed to elicit the patient’s approving response to the doctor’s treatment proposal. While this expectation gets fulfilled in a multitude of instances, it sometimes receives weak or active resistance in the form of direct or evasive questions, exclamations or body language suggestive of disalignment with the doctor’s proposal in some other instances.
In terms of propositional content, JTE is done in conformity to the science and ethics of medicine to provide evidence-based healing for the patient. 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.
In the negotiation of JTE, usually in the quasi-humanistic/patient-centred clinic, 1 the conflictual nature of the encounter notwithstanding, there is a preponderant use of the current-speaker-selects-next-speaker and the current-speaker-continues conversational strategies which recognise clinical asymmetry. There are also some instances of the current-speaker-self selects-as-next strategy used by both parties at cued transition relevance places. The negotiation site is also often an interesting show of doctors’ deontic and epistemic stances laced with the voice of medicine and the patient’s voice of the lifeworld. On some occasions, a compromise is achieved between the parties; in some cases, the strict voice of medicine prevails.
In connection to the strong, indirect disagreement’s patients’ hints and insinuations from which doctors infer patients’ dissatisfaction with their recommendations, JTE rides on two inferential premises which trigger the parties’ negotiation of treatment options offered by the doctor. In certain cases, patients offer the options, and doctors do or do not permit negotiation. In the latter instances, doctors either insist on their recommendations as the sole medically appropriate elixirs or reluctantly modify the recommendations as a result of patients’ pressure or priming. See Stivers (2002, 2005) and Stivers and Tate (2023) for related findings in Western clinics.
For reasons of space, we commit attention to the parties’ negotiation of options provided by doctors as a response to a patient’s strong indirect disagreement as shown in the interaction below.
In this interaction, a patient had, in a previous visit, complained of stomach pain. After the doctor has clerked and examined him, he announces a prescription of injection for 5 days. The patient’s dispreference for this treatment plan is demonstrated in his indirect resistance which gets negotiated by the parties.
In this interaction, both the doctor and the patient orient participatorily to the management of the patient’s suggestive resistance of the doctor’s recommendation of injection treatment. The participatory action indicative of the parties’ sequential negotiation of treatment offers, preferred options and mutual compromise is shown below. Henceforth, the short forms ‘Doc’ and ‘Pat’ are used respectively, in most cases, to refer to the doctor and the patient in the analysis of excerpts.
Doctor’s treatment recommendation announcement receives patient’s indirect resistance
Doc’s ‘How are you today’ at Line 3, following the exchange of greetings between lines 1 and 2, initiates the problem presentation phase of the meeting (Lines 3–16). In this phase, which culminates in the indirect disagreement between Lines 17 and 22, Doc establishes a recurrent stomach condition that needs to be urgently treated with injections. He announces this treatment recommendation with 5 days of nursing care at Line 17. The treatment course, considered the most appropriate intervention based on Doc’s problem presentation-informed clinical reasoning, is announced to Pat for his information and compliance, and, consequently, his acceptance without Doc justifying his deontic position (Line 17). The lack of justification notwithstanding, the announcement instantiates the evocation of Doc’s JTE.
The announcement, framed in a cued next-speaker self-selects-as-next turn distribution strategy, receives from Pat, at Line 18, a disaffiliative response constructed in the form of Heritage’s (2012) declarative syntax, with salience placed on the duration of injection administration. This turn indicates Pat’s indirect disagreement with Doc. A possible ambiguity resulting from sequential contiguity initially beclouds Doc’s co-construction of Pat’s turn as an evasive disagreement, given that ‘Five days?’, the immediate response to Doc’s announcement at Line 17, could be perceived as an understanding check or a request for the confirmation of Doc’s treatment-duration recommendation.
Doctor orients to patient’s resistance cue as a clarification request
Doc’s turn at Line 19 appears to be at variance with Pat’s indirect resistance goal. This is informed by the implicature of Pat’s reaction as the number of days for which injection administration has been prescribed, and therefore an evasive request for a review of that bit of the recommendation rather than resistance to injection. Doc’s loud ‘YES’ at Line 19, together with a re-insertion of the care duration, and its contextual synonym, at once provides an answer to Pat’s question, re-affirms Doc’s deontic position and constrains Pat’s next turn. Doc, taking the turn from Pat’s current-speaker-selects-next-speaker cue, evoking the medical scientific voice with authority-imbued finality suggested by the loudness of ‘yes’ and the following short duration-re-enactive phrase repetitive of his earlier deontic stance, asserts the sacrosanctity of his recommendation (Line 19). At this point, Doc re-inserts his earlier JTE in its entirety in demonstration of a non-compromising position.
Patient reverts to and intensifies indirect resistance
At Line 20, Pat’s earlier evasive resistance is both sustained and further reinforced. This is inferred from a combination of time elapsing between Doc’s and Pat’s turns, the negative formulation of Pat’s request and the falling tune on Pat’s TCUs. The turn at Line 20 is a self-select cue which deploys a marked falling tune. It, at once, overtly seeks information and covertly initiates negotiation of Doc’s recommendation. It reinforces the participatory window permitted by Doc but its evasive resistance is demonstrative of Pat’s avoidance of direct confrontation with Doc over his deontic stance. These are highlighted more specifically below:
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).
ii. The choice of phrasal ‘no’ formulations rather than the more explicit clausal formulations probably better explains Pat’s relatively long response delay. Both ‘no drug’ and ‘no other thing’ requesting alternative recommendations of Doc’s review of the prescribed injection administration are indicative of polite but evasive resistances to Doc’s deontic stance.
iii. The falling tune is particularly instructive in marking a new request rather than challenging Doc’s decision, a possible interpretation if the rising tune were selected (see Cauldwell and Hewings, 1996; Odebunmi, 2006 for pragmatic perspectives on intonation).
Doctor justifies patient-resisted recommendation as appropriate deontic intervention
Doc, at Line 21, recognising Pat’s evasive resistance, works to justify, and, consequently insists on, his recommendations. Doc’s insertion of a justification of his recommendation at Line 21 is a reinforcement of his JTE and a device to demonstrate not only his competence but also his Aesculapian empathy with Pat. His key consideration is to fetch Pat expedited healing in response to his complaint of pain. The empathy bit shows his evocation of the medical institutional voice (see Odebunmi, 2021b), an orientation that foregrounds care and associates with patients’ emotions. Ultimately, his participatory action, imbued with professional constraints, targeted at managing his disagreement with Pat, is built more on his empathy than the medical scientific benchmark for Pat’s condition. His considerations, which include the quicker and greater effectiveness of the injection, are strictly professional but implicate the possibility of alternative recommendations. One is that a non-injection treatment would be slow and the other is that it would not have the effectiveness the current recommendation has. That Doc makes no overt claim of possible alternative treatment plans implicates his consideration more for the wellness of Pat than his immediate treatment preference, and points to the disagreement as sourced more from Doc’s empathy with Pat and his concern for his expedited healing than from a rigid insistence on medical scientific perspectives (See Odebunmi (2021b) for the difference between a medical institutional and medical scientific voice or perspective).
Patient maintains indirect resistance as a preferred deontic choice
At Line 22, Pat further evasively resists the treatment option despite Doc’s justification of it. The elongated ‘Ah’, combined with the louder realisation of the identity marker ‘doctor’, respectively implicates Pat’s projected painful experience and discomfort, and Doc’s invitation to that realisation. Data interpretation chats with two 2 Nigerian trypanophobic patients confirm this interpretation. Pat’s further subtle insistence on a review of Doc’s recommendation is indicated by the elongation and loudness devices of CA in a next-speaker self-selects turn (Line 22). This establishes the point that Pat’s perspective is at variance with Doc’s, and is thus an indication of a disalignment between the voice of medicine and the voice of the lifeworld (Mishler, 1984).
Doctor offers a compromise recommendation as a truce intervention
At Lines 23 and 24, Doc overtly acknowledges the indirect disagreement between the parties and offers a compromising stance. The elongated ‘okay’ suggests doctoral authority-backed end to the duo’s arguments on the current recommendation and signals Doc’s readiness to provide an intervention. A preparatory index of this intervention is the participatorily-grounded imperative, ‘Let’s come to a level ground’ which offers a meeting point between Doc’s voice of medicine and Pat’s voice of the lifeworld. Doc compromises his earlier seemingly rigid stand by proposing a reduction of injection treatment to 2 days and a complementation of that with drugs for an unspecified number of days. The latter offer perhaps supports Doc’s earlier thesis of quickness and why he had preferred the injection course as taking drugs for a long time would be co-terminus with a slower treatment and a reduced level of therapeutic effectiveness. Thus, Doc’s turn at Lines 23–24 orients to the disalignment of the voices and offers a new proposal that tinkers with strict JTE to accommodate Pat’s lifeworld. A data interpretation session with a Nigerian medical doctor affirms the consistency of Doc’s reviewed deontic position with standard medical practice to ensure compliance on the part of Pat.
Patient reluctantly accepts doctor’s offered compromise as the appropriate therapeutic intervention
Pat’s reluctant acceptance of Doc’s reviewed deontic position at Line 25 confirms the compliance question that Doc has factored into his revised JTE at Lines 23–24. All the elongated and non-elongated prefabricated fillers (‘en::’, ‘you see’ and We:::ll) are indicators of hesitation combined with the reluctance-markers framed as pseudo agreement (‘okay Doctor’) and conditional acceptance (‘. . .if no:: other options’) tokens. The overall design of the turn with these tokens comes with the intention of Pat to seek more participatory concessions from Doc.
The entire turn at Line 25 licences the following interpretations:
a. First, Pat hesitantly accepts Doc’s proposal of mixed recommendations of injections and drugs, which means that his earlier preference uttered evasively was a completely oral therapy (drug ingestion). His evasive resistance to Doc’s medication had beclouded this. This means as well that Doc has not adequately deployed the principles of humanistic medicine 3 which would have teased out Pat’s choice right from the outset.
b. Second, Pat ab initio had preferred a different treatment and still desires to seek that at the initial point of his contribution at Line 25 with the elongated ‘En’ (yes), indicative of a reservation, and ‘you see’, implicative of a yet to be expressed desired opinion. Realising, perhaps, Doc’s recently compromised initially rigid insistence on injection and the need to preserve the ‘favour’ just received of a reviewed treatment plan, he stalls his further pressure for his actual treatment preference. Discursive indications of this interpretation include:
i. Pat’s sudden footing shift from the bid to express an opinion to an acceptance of Doc’s proposal (‘Okay, Doctor’)
ii. His post-acceptance hesitation, indicative of helplessness in the face of Doc’s power-imbued decision (‘Well’)
iii. His complete conditional surrender to Doc’s deontic position (‘If no other option’), implicative of a subtle request for further review of Doc’s recommendation.
At Line 26, Doc, discountenancing Pat’s subtle request, closes the meeting by directing Pat to the nurses for the administration of the injection recommendation and announcing a follow-up appointment date to him. His decision perhaps points to the possible exhaustion of all available medical options for Pat’s condition within the context of his revised JTE.
Participatory orientations to indirect disagreement in the context of the judgment of institutional convenience
On certain occasions, indirect disagreement, executed participatorily or non-participatorily in the Nigerian hospital setting emanates from doctors’ judgement of institutional convenience (JIC). This is the consideration of the limits of hospitals’ affordability of patients’ needs in terms of services, facilities and medicine stocks, which is reckoned with in doctors’ composition of treatment recommendations. Disagreement occurs over this mostly when doctors announce recommendations based on JIC without informing patients about the constraints. This rarely, but certainly, occurs as shown in Interaction 2 below. Most Nigerian doctors inform patients of their hospitals’ lacks and adopt referrals when required facilities or specialisations are unavailable. They also advise patients to purchase medicines that are not stocked in their hospitals in public pharmacies.
When JIC results in clinical disagreement, it is often the case that recommendations are resisted indirectly or actively by patients who do not suspect the evocation of JIC but who only find them disagreeable on the grounds of personal inconvenience (see also Odebunmi, 2016) or biological contra-indicativeness; and who directly or evasively request a review. Evidence from our data, together with our experience as Nigerian hospital visitors, shows that the resultant resistance is attended by two key reactions from doctors: immediate non-participatory review either by the re-constitution of the recommendation or purchase of this outside the hospital, and participatory delayed review. Our focus in this paper falls on the latter for space restriction reasons.
JIC in participatory delayed review format
In the JIC executed in the participatory delayed review form, doctors insert JIC contents in their recommendations either in the consideration of their being (good) alternatives for unavailable items or being the sole affordances of the hospitals. The doctors simply announce their recommendations to the patients in the expectation that the latter would accept them as inviolable institutional offers. More often than not, patients who hold divergent positions on the recommendations would request alternatives. This takes two forms: an appeal or a straight rejection. While the latter is extremely rare except in full confrontational encounters seated in previous clinical or social disalignments, the former is more frequent as a strategy considered by patients to be the best to navigate the hierarchical power relationship with doctors.
Mostly, the appeal is formulated in straight syntax (Heritage, 2012) and it routinely receives either a retort framed initially declaratively or interrogatively in socially distant power assessments/ratings, or a polite or non-committal response framed in a declarative or straight interrogative syntax. In subsequent turns dominantly executed in the current-speaker-selects-next-speaker and next-speaker-self-selects-as-next strategies, doctors and patients are often enwrapped in the negotiation of patients’ request in varying degrees of appeal, confrontation, accusation and counter-accusation. This sequence of interactive actions typically terminates in two ways: one, the patient is convinced or compromised to accept the recommendation without being overtly availed of JIC; two, the patient insists directly or evasively on a recommendation review, he/she is overtly or covertly availed of JIC and a (mutually) agreeable review is constituted.
In Interaction 2 below, used for an argument on paternalism in Odebunmi (2021a), JIC is overtly evoked.
Interaction 2
The patient presents at the clinic for leg weakness, insomnia, throat dryness, and general body weakness. Following clerking, the doctor prescribes drugs. The Patient requests a review of this recommendation by appealing to the doctor for injections instead, and this develops into a clinical disagreement which culminates in the doctor’s disclosure of JIC. Ultimately, both parties reach a compromise on the recommendation. [. . .]
Below, we show how the consultative parties participatorily manage the doctor’s JIC:
Doctor announces his recommendation as a routine professional act
Doc announces his recommendation of drugs, rather than an injection at Line 75. The repeated ‘okay’ token both acknowledges Doc’s response to his question at Line 73 and preludes the announcement of the recommendation. These are consistent with the standard and therefore constitute no special attention cue for Pat. In the announcement proper, Doc presents a treatment proposal which bifurcates into: (a). a regimen exclusively comprising drugs; (b). a compliance instruction. These do not show any institutional constraint and, therefore, come off to Pat as Doc’s best professionally-considered deontic offer but which she does not find convenient.
Patient indirectly resists doctor’s recommendation as a dispreferred deontic choice
Pat, considering Doc’s recommendation inconvenient, requests an injection instead of the proposed drugs at Line 76. Framed as an appeal, given its combination of a honorific (‘sir’) and an information-requesting straight syntax with the falling tune (See Cauldwell and Hewings, 1996) – ‘can I take injection’ -, the turn strongly indirectly resists Doc’s recommendation and, by some extension, challenges his deontic power. Consequently, it presents a potential point of clinical disagreement between the parties despite its non-confrontational nature.
Doctor demands justification for patient’s resistance
The expected ‘yes’ or ‘no’ response, which assigns clinical, claimer power to Pat, and the responder, ratifier power (Ainsworth-Vaughn, 1995: 279) to Doc by the former’s question at Line 76, is avoided by Doc, who rather reacts to the interrogative appeal with a reformulation of Pat’s request and a marked demand of Pat’s justification for her request. With his turn at Line 77, deploying, in addition, the power-imbued current-speaker-selects-next-speaker strategy, which turns Pat into a subservient responder at Line 77, Doc, has successfully re-claimed his power. The low-voiced ‘yes’ is indicative of Pat being initially subdued; however, probably pulled by her determination to have Doc’s recommendation reviewed, Pat, between Lines 78 and 79, demonstrates salient boldness with the loudness of her contribution in which she claims only personal dispreference for drugs as the reason for her resistance. This is a marked turn in the context of the high epistemic power wielded by Doc.
Patient Appeals again for preferred recommendation
Pat at Line 79 strongly indirectly appeals again for her preferred treatment course dramatically first by wrapping her dispreference in familiarity-indicative Pidgin freely inserted into her communication earlier executed in Standard English with Doc; second, by introducing her ulcer condition not in the parties’ shared knowledge in the current encounter; and finally by repeating her dispreference of drugs (Line 80), all in a next-speaker-self-selects-as-next turn. With the introduction of ulcer at Line 79, Pat has shifted the footing of the encounter from drug recommendation and injection preference to a new problem presentation. At Line 81, Doc acknowledges Pat’s response to his question with a marked rising tune which Pat perhaps interprets as a current-speaker-selects-next-speaker cue and takes up the next turn to provide a piece of vague, almost rudderless information at Line 82, all in a bid to prime Doc for a review (See Stivers and Tate, 2023 on how patients prime doctors for preferred recommendations). This is because it is difficult to determine if Pat’s argument is that she reacts to all drugs or the particular drugs which Doc hints at whose names are not known and which, therefore, are unknown to Pat. Either possibility presents a weak position from Pat and is more like the earlier justification hung on personal dispreference.
Doctor deviates from patient’s appeal to patient blame as an avoidance strategy
Rather than orienting to sequential contiguity, Doc shifts to taking up the new problem presentation account broached by Pat. The interchanges until line 123 are a mix of clerking and heavy face threats from Doc to Pat as the responsible party for her condition. Odebunmi (2016) has the details on these which are not part of the current focus. What is important to us here is Doc’s sheer time wastage on these without proffering concrete interventions. A closer, critical reading of Doc’s interactive actions is perhaps indicative of the avoidance of a clear statement on Pat’s request for injection rather than drugs for her condition which, if done, would constrain him to disclose his JIC to Pat. Confirming this agenda to some extent, our data interpretation session with a Nigerian medical doctor reveals that the swift shift to the new problem presentation by the doctor, which ultimately offers no treatment regimen for the condition focused, is inconsistent with standard clerking practices.
Doctor owns up to institutional lack and evokes JIC
Eventually, Doc, between Lines 123 and 130, reverts to Pat’s earlier appeal and announces his decision, which expressly confirms JIC. First, he has reviewed his earlier recommendation and would administer a mix of drugs and injections to Pat. Second, his hospital does not have the financial capacity to give an exclusive injection administration because of the high cost associated with it. This is understandable in the context that the hospital is a Nigerian university facility which is poorly funded. Perhaps the disagreement would have been avoided if the JIC had been disclosed earlier, and logically, the clinical time wasted would have been prevented.
The JIC from Doc’s account includes not only the inability of the hospital to afford the injections but also the administration process, such as the hospital being short-staffed in comparison to the huge number of the entire university community to care for (See the hint at Line 131). In an effort to place Doc’s clinical action correctly, we cross-checked his earlier exclusive drug recommendation with a Nigerian medical doctor, who faults his JIC-laden approach as time-wasting, and inadequately professional, but who justifies his eventual compromise as a correct professional decision consistent with Pat’s condition: The route of drug administration viz a viz oral, intramuscular or intravenous could be determined by the physician based on: i. the patient’s clinical condition i.e consciousness, ability to swallow without vomiting medication and the tendency for uptake of substantial concentration of the drug from the gut; ii. The drug formulation and the best route to be administered for effective outcome. The stereotypical view is injections are better and often preferred to the other routes. This belief is not always right and may not be the best for the patient. The choice of an injection should be evidence-based and not sentimental. In the conversation, the doctor failed to scientifically establish the reason for his/her choice of drug administration route. . . . The doctor further stated another reason of convenience for the choice which is incoherent as the oral route should be more convenient. Overall, the better reason by the doctor for the initial injection to be followed with the oral medication would have been due to the painful and dry throat (odynophagia) which could have resolved by the time the oral medication was commenced. (Dr. A. Adeoti, 24 May, 2023).
Non-participatory orientations to indirect disagreement in the context of the judgment of salient emergency
Non-participatory action, embodying weak, indirect disagreement, is associated with the doctor’s judgement of salient emergency. In some instances of clinical disagreement in Southwestern Nigerian hospitals, the doctor’s perception and consequent decision on what constitutes the best treatment plan, and the timeliness of such a plan, are taken with no regard for communication niceties but rather on the side of professional caution and demand. This defines the concept of the judgement of salient emergency (JSE).
The weak indirect disagreement is often a feeble expression of dispreference related to the patient’s inability to put up salient resistance to the doctor’s recommendations. In most cases, it is sometimes launched through the patient’s combination of verbalisations with paralinguistic and non-linguistic resources such as pressure-absent utterances, interjections, voice modulations and various forms of body language. These cues are often ignored by doctors who rather pursue their preferred deontic directions considered in the best interest of the patient or as the most appropriate therapy course for the moment. The interaction below, which reflects some of the communicative resources, illustrates indirect disagreement in the context of JSE:
Interaction 3: The interaction (3) occurs between a doctor and a pregnant woman who is in her third trimester. After examining her, the doctor directs her to the labour room. She however attempts to resist this recommendation because she does not have her hospital bag with her.
Below, the non-participatory management of JSE in the gynaecological context represented in Interaction 3 is shown:
Doctor opens the meeting paternalistically
The encounter seems to open with an irregular sequence, where Doc skips the social frame and moves to the business frame (Line 1). Doc’s mode of requesting the document held by Pat at the same line is equally done with no decorum as the imperative recontextualises the TCU as a boss-subordinate relationship. Pat obeying the command to hand Doc the document is concordant with the relational asymmetry in several but not all Southwestern Nigerian hospital clinics (see Odebunmi, 2011, 2021b).
Doctor announces his recommendation paternalistically
After Doc has studied the document (probably a laboratory or radiological result) and obviously established a clinical decision based on its contents, he, at Line 4, issues another imperative (which is his recommendation) to Pat to proceed to the labour room. The attention (see Kecskes, 2014) evoked here comes with the inference that the document studied by Doc contains scientific details which indicate immediate parturition, but Doc’s recommendation at Line 4, ‘take this to the labour room’ is presented in absolute disconnect with Pat’s expectation and thus demonstrative of paternalism.
Patient works to challenge doctor’s instruction
Doc’s instruction, however, gets a dispreferred response from Pat who at Line 5 weakly disagrees with his recommendation on the grounds that she is unprepared for labour at that moment, inferentially indicating that she was previously unaware of it, and consequently not at the clinic with all that she required for the procedure. Further inferences point to Pat’s effort at evasively appealing to Doc for a review of his recommendation.
Doctor overrules and stalls patient’s contribution, evoking judgment of salient emergency
Pat’s weak disagreement receives a disaffiliative response from Doc at Line 6 with a clinical imperative in which he requests Pat to relate further with the labour unit of the hospital to which she has been referred. Doc’s response receives another weak disagreement cue from Pat at Line 7 ( ‘Ah’::), implicating fear, helplessness and frustration. At Line 8, Doc’s silence is indicative of a completed task on his part, and Pat’s further reluctance as an action against medical advice.
Overall, Doc in Interaction 3 evokes JSE in the handling of the disagreement with Pat in the following ways:
a. He opts for Pat’s safety at the expense of satisfactory communication, which, as executed, is partly a risky professional practice as Pat might not have the appropriate emotional comportment to self-deliver her baby. In point of fact, JSE in the encounter is not activated in accordance with the stipulations of the ethics of the best medical communication, rather it reveals Doc’s clear evocation of the medical scientific voice (Odebunmi, 2021b) unexpected to be challenged by the patient, given that the medical decision is taken based not just on the epistemically tried practice but also on the deontic responsibility of the doctor.
b. He evokes institutional power by his choice of an imperative directing Pat to safe medical attention in spite of her weak verbal resistance rather than embracing the option-giving and face-considering orientation of patient-centred or humanistic medicine.
c. JSE is often designed to get the needful done, and not to solicit or elicit the approval of the patient for the proposed treatment plan. This is achieved both with Doc’s stern directive at Line 6 and his silence at Line 8 which ignores Pat’s interjective weak resistance at Line 7.
d. Despite the manifest deployment of the current-speaker-selects-next-speaker and next-speaker-self-selects as-next strategies, Doc adopts a non-participatory approach in which he provides no cue for negotiative contribution from Pat. For example, his response at Line 6 to Pat’s concern about the unavailability of her hospital bag is clinical and dismissive. The same applies to his silence as a reaction to Pat’s interjective resistance at Line 7
e. While the consideration of emergency might not be a sufficient ground to excuse poor communication as seen in Interaction 3, doctors’ ratings and response swiftness to emergencies vary from doctor to doctor, and their possible compromise of good communication for JSE in related situations is somehow consistent with the Hippocratic oath which demands of them the prioritisation of patients’ life (Encyclopaedia Britannica, 2023). Yet, as Odebunmi (2022) observes, in respect of Interaction 3, used for a different research agenda:
. . .while the instruction is successfully passed on, its delivery in the paternalistic4 rather than the humanistic mode causes fear rather than encouragement, and therefore does not prepare the patient for the labour process as is expected. (p.4)
Conclusions
In this paper, we have shown that patients’ disagreements with doctors’ recommendations are participatorily and non-participatorily managed in clinical encounters, with such disagreements being strongly or weakly indirect. With the theoretical resources from the notion of activity type, common ground models and conversation analysis, we have shown how the disagreements have been discursively managed to reflect the agendas of doctors and patients in the differential contexts of empathy, discomfort, personal preference, institutional lack and professional standards.
Beyond extant studies such as Rohrbaugh and Rogers (1994), Stivers (2002, 2005), Levinson (2005), Légaré and Thompson-Leduc (2014), Van Keer et al. (2015), Odebunmi (2016), Boefta et al. (2017), Sherlock et al. (2019) and Stivers and Tate (2023), we have focused on Nigeria where the study pioneers research on the discursively-grounded management of patients’ disagreement with doctors’ recommendations, simultaneously dealt with participatory and non-participatory treatment recommendation disagreements, distinguished different manifestations of indirect disagreements and accounted for the occurrence of these disagreements as arising from doctors’ judgement of therapeutic efficacy, judgement of institutional convenience and judgement of salient emergency. We have also shown how treatment-related disagreements are constituted and constructed, and the practices that define them.
We have centrally argued that most disagreements in Nigerian clinical encounters are essentially situated in inadequate or inexistent deployment of the principles of humanistic medicine, which could be partially excused in clinical emergencies as illustrated with Interaction 3, but which also requires more strategic interventions to count effectively towards the patient’s best interest and medical effectiveness. Thus, keeping the patient participatorily or non-participatorily in the loop of doctors’ judgements informing recommendations will work to considerably reduce disagreements in the clinics and ensure greater patient and doctor satisfaction. Future research can compare the three judgements reported in this research across global practices and regions, explore more setting or region-specific judgements there and show how these are negotiated in the clinics.
Footnotes
Acknowledgements
We are grateful to Professor Peter Auer for his incise comments which we found very useful in revising the paper. Also appreciated are the suggestions of one anonymous reviewer, the encouragement received from Professor Van Dijk and the interviews granted by two Nigerian medical doctors and two Nigerian hospital visitors.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.