Patient autonomy in the consultation: How signalling structure can facilitate patient-centred care.

Abstract

To identify types and functions of doctors' verbal signalling behaviours used to share consultation structure with patients. Doctors' verbal utterances signalling what would happen in the consultation were identified by two independent raters from transcripts of 78 simulated consultations from a postgraduate examination for physicians. In total, 974 behaviours were categorised as informing, inviting or instructing. Principles adopted from Speech Act Theory and Conversation Analysis were used to examine their function from their literal meaning and use in context. Signalling behaviours to inform were most frequent, particularly 'signposts', with less informative signalling behaviours also found ('posts without signs' and 'signs without posts'). Behaviours to invite involvement offered limited choice. Doctors also instructed the patient in what to do (behaviour) or not to do (emotion). Behaviours signalled more 'micro-level' changes than broader consultation aims. Signalling behaviours carried roles beyond their literal meaning ('hyperfunctions') and were combined ('stacked'), often seen deflecting the conversation away from patient concerns. Doctors use a variety of verbal signalling behaviours with multiple functions. As well as sharing information, these behaviours regulate patient agency in the consultation. Doctors' signalling behaviours may play an important role in facilitating or inhibiting patient autonomy.