Chapter 3 54 Example 1: A typical physician-initiated care decision discussion (external accountability) The patient (P) is a 64-year-old female with a history of glomerulonephritis and thyroid dysfunction. She is attending her (annual) follow-up appointment with her regular (experienced, male) nephrologist (D). The excerpt starts at the end of the treatment and course of disease phase. Previously in the consultation, the physician and patient discussed kidney function (stable), thyroid function (good), an episode of inflamed molar and urinary tract infection in the past year, and when the patient should contact the physician in between scheduled appointments. Just before this excerpt starts, the physician measured the patient’s blood pressure (good to a bit low) and they discussed possible side effects, such as dizziness. 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 D: P: D: P: D: P: D: P: D: P: D: P: D: I I have now something (.) this already is a fantastic blood pressure, if if >I measure him a few times again< then it is perhaps a bit lo↑wer. but if this works [for you? [yes. then, yes. then I do not need to know that necessarily,= =no. U:hm (.) the interesting thing about that ca↑mera project is also that the idea is that youthat we also talk about care decisions?= =not that it is an obligatory subject.= =no. but if the opportunity arises. and I was↑ (.) when we were- when I was preparing this consultation realizing that we indeed really have >nothing at all< [written up about it, [no. no. and I find that (.) in itself a bit unfortunate =cause what if you enter the emergency department and something serious has happened, then <we do not know at a:ll> [if you have= [no. =an opinion about that. and of course it could be the case that you (.) have already thought about that very carefully. and I would find that <really unfortunate>, Hereafter, the patient responds that she had not thought about care decisions regarding herself, because she feels very healthy, but did so regarding her sick mother. The physician confirms this “makes sense”, but it would still be good to know and document her opinion. The patient states she does not want any treatment limitation at this moment, again confirmed by the physician as “making sense”, but she states that this might change over time, especially when her physical condition would detoriate. This is documented in the EHR, after which the consultation is closed. In example 1, the physician initiates a topic change after closing the topic of ‘blood pressure’ in line 414. After the patient’s negatively formulated agreement ‘no’ (no need for further information) in line 415, the physician changes the topic with the hesitation marker ‘uhm’ in line 416. This turninitial ‘uhm’ seems to be marking the physician’s editing of the utterancein-progress [25,26].
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