Chapter 3 52 In Heritage and Clayman’s model the ‘problem presentation’ (phase 2) is patient-directed, whereas in our data, phase 2 is physician-directed: the physician states the reason for the consultation (‘You are here for your threemonth check-up on your diabetes) and sets the agenda from that point on until the pre-closing/closing phase (phase 6). Another difference is that ‘data gathering’ (phase 3) in our data involves little in the way of history taking/ physical examination; instead, it consists mainly of computer-guided data collection, for instance lab results or blood pressure. As most patients have already been diagnosed, phase 4 involves evaluating the current state of the patient’s condition: is it stable, improving or deteriorating? This is followed by an ‘evaluation of the treatment’ (continue, start, stop or change). On top of that, in this fifth phase the physician often outlines the ‘course of the disease’: how he or she expects the disease to unfold (improvement, deterioration or stability, and what consequences will this have for the future?). Phases 3 to 5 are usually iterative: the physician evaluates different aspects of the diagnosis one after another, including their consequences for treatment and the future. After discussing all the various aspects of the diagnosis, the physician generally initiates a pre-closing by asking whether the patient has any questions (‘That was all I wanted to discuss, do you have any questions?’). At this stage of the consultation, the patient can take the lead. If the patient does not, this phase is followed by the closing. As can be seen, there is no phase destined for care decision conversations and hence there is no natural slot available for the introduction of this topic within the event. In the instances in our data, the topic of care decisions is introduced most often at the end of the phase ‘treatment and course of the disease’. This was the case in 11 out of the 17 cases in which the physician initiated the topic. In two consultations, the physician introduced the topic even later, in the preclosing stage or even after the closing and the physician had said, ‘hey that’s it for now, thanks for coming’. Patients, in their turn, also introduced the topic near the end of the consultation in two out of four patient-initiated cases. In only five out of 21 consultations care decisions were discussed early on in the consultation; four of these were physician-initiated.
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