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Quantifying Doctors’ Argumentation in General Practice Consultation Through Content Analysis: Measurement Development and Preliminary Results

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Abstract

General practice consultation has often been characterized by pragma-dialecticians as an argumentative activity type. These characterizations are typically derived from theoretical insights and qualitative analyses. Yet, descriptions that are based on quantitative data are thus far lacking. This paper provides a detailed account of the development of an instrument to guide the quantitative analysis of argumentation in doctor–patient consultation. It describes the implementation and preliminary results of a content analysis of seventy videotaped medical consultations of which the extent and type of doctors’ argumentative support for medical opinions and advice are analyzed. Based on the study results, this paper addresses the merits of observational studies using content analysis as a method for the analysis of argumentative discourse in context as well as some of its key challenges and limitations, laying bare the opportunities for future research.

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Notes

  1. For an overview of the various applications of the pragma-dialectical theory to the study of argumentation in context, see van Eemeren (2012).

  2. This does not imply that the pragma-dialectical framework has not been instrumental in quantitative empirical research at all. Rather than providing a practical tool to the analyst of argumentation, however, these quantitative studies focus primarily on the ways in which ordinary arguers identify and assess specific argumentative moves in practice.

  3. A sample of 93 general practitioners was drawn from the Netherlands Information Network of General Practice, a representative network of 84 general practices and more than 330.000 patients. Forty GPs (44 %) from 20 practices agreed to participate in the video observation study (de Bekker-Grob et al. 2011; Noordman et al. 2010, 2012).

  4. The codebook and coding sheet (in English) are available upon request.

  5. In this phase, both coders practiced with the OPTION-instrument—one of the measurements included in the codebook—using the official training pack and audio-tapes provided by Elwyn et al. (2005).

  6. At the start of the study, three unique sets of videos were randomly drawn from the main database. Each set consisted of fifty videos for coding, taking into account the possibility of damaged or otherwise unusable video files. The two coders were each randomly assigned one set of videos. The third set was used for the pilot study. Coders were allowed to freely determine the order in which they coded the videos. From each of the coders’ sets a random sub-sample of ten videos was drawn for reliability testing.

  7. Neuendorf (2002) recommends a random sub-sample of at least 10 % to be drawn to determine the inter-rater reliability of the overall study. In this case, the sub-set of 8 videos together constitutes 11.4 % of the overall sample.

  8. In order to calculate Krippendorff’s alpha, use was made of a SPSS macro developed and freely distributed by Hayes and Krippendorff (2007).

  9. While the original instrument intends to measure patients’ self-reported preferences in treatment decision-making, the adapted version was aimed at capturing doctors’ preferences from an observer perspective. The adapted tool was used before by Labrie et al. (under revision).

  10. As the consultations were in Dutch, equivalent Dutch signal phrases were used by the coders. For more examples of signal expressions, see van Eemeren et al. (2007).

  11. Following pragma-dialectical conventions, a dialogical situation in which the patient ‘disagrees with the doctor’s standpoint’ is characterized as a mixed difference of opinion. When the patient ‘has doubts about the doctor’s standpoint’ the difference of opinion is defined as non-mixed (cf. van Eemeren and Grootendorst 1984, 1992, 2004). Due to the institutional conventions of general practice consultation, a doctor should always assume that the patient may silently disagree with, or have doubts about, the doctor’s medical opinion or advice. As a result, such medical opinion or advice should be reconstructed as a standpoint. However, the patient may also immediately ‘agree with the doctor’s standpoint’, rendering further discussion unnecessary.

  12. While a back channel response such as yes can also be interpreted as a mere listening token, argumentatively affirmative responses like these can be seen to commit the patient to agreement to the doctor’s standpoint. In contrast, an interrogative yes? can also serve as an indicator of doubt. Coders were therefore asked to make use of contextual cues to guide their coding decisions.

  13. In the current approach, inter-rater agreement concerning standpoint identification was a prerequisite to determine the reliability figures for those variables that analytically followed the advancement of a standpoint. To avoid this, inter-rater reliability could be determined following two coding phases. First coders could seek agreement concerning standpoint identification. Then, and upon coding of all other variables, coders could establish their agreement for the remaining variables.

  14. To calculate this, the binary items to measure the patient’s position and the doctor’s advancement of argumentation were used.

  15. This could potentially have consequences for the higher order conditions that apply in the context of general practice consultation. Further in-depth discussion of this issue is required. Yet, this goes beyond the scope of the present study.

  16. For a comprehensive overview of adherence research, see Vermeire et al. (2001).

  17. For example, the RIAS coding categories shows criticism, asks for opinion, and shows agreement.

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Correspondence to Nanon Labrie.

Appendix: Advice Statement Level—Coding

Appendix: Advice Statement Level—Coding

  1. * Diagnostic codes are based on the International Classification of Primary Care (ICPC-2) method for primary care encounters (available via http://qicpd.racgp.org.au/media/57417/icpc-codes.pdf)

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Labrie, N., Schulz, P.J. Quantifying Doctors’ Argumentation in General Practice Consultation Through Content Analysis: Measurement Development and Preliminary Results. Argumentation 29, 33–55 (2015). https://doi.org/10.1007/s10503-014-9331-5

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