The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Jamie Murdoch,John Ford,Alice Shiner,Elizabeth Lenaghan,Charlotte Salter,Nicholas Steel

doi:10.1016/j.socscimed.2020.113040

Abstract

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient's priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman's concept of ‘frames’ to present an examination of how doctors' and patients' sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients' understanding of the goal-setting consultation, GPs actively aligning with patients' framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided “telling cases” of goal-setting interactions, where doctors and patients need to negotiate each other's perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations.

Highlights

Goal-setting, the sharing of realistic health and wellbeing goals by physicians and patients, is core to the theory and effective practice of personalised care planning and seen as important for patients with multiple chronic and long-term health conditions
The study took place between November 2016 and July 2018 in Norfolk and Suffolk, UK. It was set in six general practices and recruited patients considered by their surgery to be in the top 2% most at risk of hospital admission, eligible for a new care plan, living with more than one long-term condition and able to communicate verbally
Framing the GP-patient consultation as a goal-setting discussion When patients arrived for their goal-setting consultation, they were asked to bring their prepared goals and associated paperwork with them to discuss with the GP

Summary

Introduction

Goal-setting, the sharing of realistic health and wellbeing goals by physicians and patients, is core to the theory and effective practice of personalised care planning and seen as important for patients with multiple chronic and long-term health conditions It involves “eliciting and clarifying patients’ understanding of their condition, their values, outcome preferences and priorities... Rather than a focus on specific disease management strategies, a key principle of goal-setting is that the patient decides which goals they would like to achieve Such a principle allows the possibility for patients to share concerns and priorities that, while related to their health problems, are grounded in the contextual realities of everyday life, otherwise understood as the patient’s lifeworld (Barry et al, 2001). The doctor may just need to ‘bear witness’ (Heath, 2012) to the patient’s concerns without intervention

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Conclusion