Triadic Encounters Research Articles

“You Have to Find a Way for This Child to Be at the Center”: Pediatric Cardiologists’ Views on Triadic Communication in Consultations on Congenital Heart Defects

ABSTRACT Congenital heart defects (CHDs) are present at birth and require ongoing management of personal, family, and medical aspects of care, including communication between family and medical staff. Effective communication is considered one of the main objectives of patient-centered care. Communication in pediatric medicine is especially challenging because it includes children and their parent(s), and children’s cognitive and communication skills are still developing. Based on the model of behavior in pediatric communication , this study focused on pediatric cardiologists’ views of the roles of children, parents, and physicians in the triadic encounter and their experiences in communicating information on pediatric CHDs in medical encounters. Semi-structured interviews were conducted with 17 experienced pediatric cardiologists and cardiac surgeons (five women and 12 men) at three medical centers in Israel. The grounded theory approach was used to identify three main categories: (1) the positioning (centrality) of the child in the setting (ideal vs. actual situation), (2) addressing parents’ emotional needs, and (3) the physician’s role as mediator between parent(s) and child. In each category, three elements are discussed: The physician’s agenda, obstacles and challenges, and the physician’s practical methods. Physicians strongly support children’s involvement in triadic encounters yet face challenges in effectively integrating them into the information exchange process during cardiology consultations. Struggling to balance the principles of patient- and family-centered care, and without clear guidelines, they rely on their personal beliefs and experiences to formulate communication strategies that address parents’ and children’s needs.

Adolescents, parents, and providers' experiences of triadic encounters in paediatric diabetes clinics: A qualitative study.

Adolescents with Type 1 diabetes are a cohort whose self-management of their diabetes care often declines during adolescence which can lead to adverse health outcomes. Research indicates that providers find it challenging to engage adolescents in communication exchanges during triadic encounters in diabetes clinics. Our study aimed to explore adolescents, parents, and providers' experiences of clinic encounters. A qualitative study was conducted with a convenience sample of 13 adolescents with Type 1 diabetes (aged 11-17), 14 parents, and seven providers. Participants were recruited from two outpatient diabetes clinics in two urban children's hospitals, Ireland. Data were obtained using a combination of interviews and focus groups. Data were analysed thematically. Adolescents and their parents appeared to hold both positive and negative experiences of diabetes clinic encounters. Providers reported challenges associated with engaging adolescents in communication exchanges. The structure, focus and style of clinic encounters created barriers that potentially led to suboptimal adolescent participation and impaired provider-adolescent communication during clinic visits. The findings provide insights into the challenges associated with adolescents' engagement in communication encounters in diabetes clinics. Healthcare providers could encourage adolescents to be more actively involved in their diabetes management, by taking an adolescent-centred approach and creating a nonjudgemental milieu. Focusing on adolescent's agenda could lead to more meaningful and relevant discussions between providers and adolescents and ensure more tailored education in the time available. Adolescence is a risky period for nonadherence and adverse health complications; therefore, it is critical that providers make every contact count in diabetes clinic encounters. The study's design and delivery were guided by two advisory groups, comprising (1) five adolescents living with Type 1 diabetes (T1D)and (2) five parents of an adolescent with T1D.

Archetypes of incomplete stories in chronic illness medical encounters

ObjectiveDuring encounters, patients and practitioners engage in conversations to address health concerns. Because these interactions are time-pressured events, it may be inevitable that any story exchanged during these encounters will be incomplete in some way, potentially jeopardizing how quality and safety of care is delivered. In this study, we explored how and why incomplete stories might arise in health interactions. MethodsConstructivist grounded theory methodology was used to explore how patients and practitioners approach their interactions during encounters. In this two-phase study, we interviewed patients (n = 21) then practitioners (n = 12). ResultsWe identified three distinct archetypes of incomplete storytelling - the hidden story, the interpreted story, and the tailored story. Measured information sharing, triadic encounters and pre-planned agendas influenced these storylines, respectively. ConclusionBoth patient and practitioner participants focused on what each considered important, appropriate, and useful for productive encounters. While incomplete stories may be a reality, educating practitioners about how incomplete stories come about from both sides of the conversation creates new opportunities to optimize interactions at medical encounters for in-depth patient practitioner storytelling.

Information-sharing between healthcare professionals, parents and children with cancer: more than a matter of information exchange.

This study examined participants' views on children's participation in information-sharing and communication interactions. A descriptive qualitative approach was taken with individual interviews held with children (The term 'children' is used to denote both children and adolescents and to avoid cumbersome repetition.) aged 7-16 years (n = 20), their parents (n = 22) and healthcare professionals (n = 40) at a children's hospital in Ireland. Data were analysed using the constant comparative method and managed with NVivo (version 8). The findings indicate that professionals strongly supported an open and honest approach to information-sharing; however, this viewpoint was not shared by all parents. The need to maintain hope and spirit and promote an optimistic identity influenced the amount and type of information shared by parents. Children trusted their parents to share information, and valued their parents' role as interpreters of information, advocates, and communication buffers. Most professionals endorsed parents' primacy as managers of information but experienced difficulty navigating a restricted stance. This study adds important insights into the complexities of information-sharing in triadic encounters. Professionals need to maintain an open mind about information-sharing strategies families may choose, remain sensitive to parents and children's information requirements and adopt a flexible approach to information provision.

Are you talking to me?! An exploration of the triadic physician–patient–companion communication within memory clinics encounters

ObjectiveTo explore and gain further insight into the nature of the triadic interaction among patients, companions and physicians in first-time diagnostic disclosure encounters of Alzheimer's disease in memory-clinic visits. MethodsTwenty-five real-time observations of actual triadic encounters by six different physicians were analyzed. The analysis was accomplished through an innovative combination of grounded theory text analysis and graphics to illustrate the communicational exchanges. ResultsThe “triadic” communication was actually a series of alternating dyadic exchanges where the third person tries, with inconsistent degrees of success, to become actively involved. During the initial introduction (phase 1) and summation/disclosure (phase 3), the core dyad shifts from physician–patient to physician–companion. ConclusionThe focus of communication shifts within these encounters: from talking with the patient to talking about him or ignoring him. These shifts may signify an emotionally loaded role transformation from companion to caregiver. Practice implicationsEffective and empathic management of a triadic communication that avoids unnecessary interruptions and frustrations requires specific communication skills (e.g., explaining the rules and order of the conversation). Professionals need to facilitate the emotionally difficult shift from companion to caregiver and the adjustment of companion and demented patient to this shift.

A triangle that may work well: Looking through the angles of a three-way exchange in cancer medical encounters

Following a discourse analysis approach this study examines triadic encounters of nine medical consultations carried out in an outpatient cancer clinic in Santiago, Chile involving an oncologist, a patient and a patient’s companion. Consultations are fully transcribed and analysed to understand the participatory roles patients’ companions play in the medical exchanges. In addition, the type of linguistic functions associated with each role and the advantages or downsides of companions’ involvement in the encounters are also investigated. The analysis reveals seven prominent roles that companions may engage in during the visits. These are studied in detail. The results show that although companions may not always provide information that is consistent with the patients’ views, they can be of great help. Relieving the patients of many daunting tasks, monitoring their well-being, establishing a partnership and bringing vital information to the clinic are instances where the controlling power that some may exercise in the medical encounter can be outweighed.

Patient-Centered Communication During the Disclosure of a Dementia Diagnosis

This study examined physician use of patient-centered communication during disclosure of a dementia diagnosis. Fifty-four patients (mean age = 74.13) and companions (mean age = 65.67; n = 34 spouses/partners, 12 adult children, 8 other) were diagnosed with very mild (n = 36) or mild (n = 18) dementia at an Alzheimer's Disease Research Center. Audio recordings of these triadic encounters were evaluated with the Roter Interaction Analysis System. Physicians utilized moderate but variable amounts of patient-centered behaviors including positive rapport building, facilitation, and patient activation (P < .001). Physicians far less frequently used emotional rapport building (P < 0.001). Physicians who demonstrated more patient-centered communication also exhibited greater positive affect (P < 0.05). The use of patient-centered behaviors and positive affect was more variable between physicians than within physicians and may be more dependent on individual physician characteristics than dementia severity or age and gender of patients and companions.

Behavioral dominance between female color morphs of a Lake Victoria cichlid fish

Species that exhibit genetic color polymorphism are suitable for studying the evolutionary forces that maintain heritable phenotypic variation in nature. Male color morphs often differ in behavioral dominance, affecting the evolution of color polymorphisms. However, behavioral dominance among female color morphs has received far less attention. We studied a polymorphic population of the cichlid fish Neochromis omnicaeruleus from Lake Victoria, in which 3 distinct female color morphs coexist, black-and-white blotched (WB), orange blotched (OB), and plain (P) color morphs. First, we investigated dominance relationships among female morphs using triadic and dyadic encounters in the laboratory. In triadic encounters, both WB and OB females dominated plain, whereas WB females dominated OB females. Dominance of WB over OB was confirmed using dyadic encounters. In a second experiment, blotched (WB or OB) and plain full-sib sisters were bred by crossing a blotched and a plain parent. In dyadic encounters, WB female morphs dominated their plain sisters, suggesting that dominance of WB females is a pleiotropic effect of color or that genes coding for color and those influencing behavioral dominance are genetically linked, explaining the association between color and behavioral dominance despite gene flow. We conclude that behavioral dominance asymmetries exist among female color morphs of the fish N. omnicaeruleus, and discuss possible mechanisms that may account for the tight association between color and behavioral dominance.

Prostate cancer in London: is the triadic clinical encounter the standard?

AbstractIt has been reported that men with prostate cancer in London were less satisfied with the service they received than patients with other cancers. Studies from the USA have looked at the experience of the prostate cancer couple. It has been established that the cancer couple have information needs and that when a clinical encounter is triadic in nature, these needs are more likely to be met and information is more likely to be retained. The aim of this study was to examine the clinic attendance patterns of men in London with prostate cancer (n = 200). A comparison group of women in London with breast cancer was identified (n = 200). Direct observation of the groups was performed, accompanied/unaccompanied (triadic/dyadic) attendance was recorded and demographic data were extracted from the clinical notes. Forty‐one percent (81) of the women experienced their clinical encounter as a triad compared with 24% (48) of the prostate group who experienced their clinical encounter as a dyad between themselves and their health care provider (p &lt; 0.05). In the first year of diagnosis, men with prostate cancer were more likely to experience a triadic encounter, but this was more evenly distributed throughout the cancer journey for women with breast cancer. There did not appear to be a correlation with marriage and triadic encounters for either group. Men with prostate cancer in this tertiary referral centre in London are less likely to experience a triadic clinical encounter than women with breast cancer. Further work is needed to establish a relationship between unmet informational needs of the prostate cancer couple and the high level of dissatisfaction in the prostate cancer population in London, but the nature of the dyadic encounter may play a part in this.

Opening stages in triadic medical encounters in Taiwan

Opening stages in medical interviews are important because good doctor-patient rapport facilitates the doctor's tasks in later stages, especially in triadic first-visit interviews where doctors are not acquaintances of patients and companions. Given its importance, the research examines opening stages in the Taiwanese context from two perspectives: discourse components of opening stages and discourse mechanisms of presenting non-acquaintances' identities, especially the companions' identities. By examining 30 geriatric triadic encounters collected in a teaching hospital in southern Taiwan, this research concludes that opening-stage interaction patterns in Taiwanese medical interviews differ from Western patterns in the following ways. Under time pressure, Taiwanese doctors tend to open the interview in a fast pattern that hardly allows verbal participation from the patients. The common practice of presenting non-acquaintances' identities in Western conversation openings is rarely observed in the Taiwanese context. As a result, contrary to the professional norms, most companions' identities are not clarified until they talk in the later stages, such as the pedigree stage, which is the most natural context for revealing their identities. This seeming violation of professional norms, however, can be explained by traditional Chinese interaction norms, and can be remedied by following another traditional norm-using a situational greeting. Further recommendations for Taiwanese medical professionals are also proposed to balance these potentially conflicting needs.

Physician–elderly patient–companion communication and roles of companions in Japanese geriatric encounters

Although the triadic encounter of physician, patient, and an accompanying family member is a common phenomenon in geriatrics, previous research on the communication in medical encounters has primarily focused on dyadic interactions between physician and patient. This study aimed to explore the triadic communication and communication roles of patient companions in Japanese geriatric encounters. Among elderly patients aged 65 or over who were under continuous care of nine attending physicians at a university affiliated geriatric clinic in Tokyo, 63 accompanied patients and 82 unaccompanied patients were included for this study. The consultation was audiotape recorded and analyzed using the Roter Interaction Analysis System (RIAS) with additional categories developed to code aspects of companion communication. In dyadic encounters, the average proportions of physician's talk and patient's talk were 54% and 46%, respectively, while in triadic encounters the average talk proportions of physician, patient, and companion were 49%, 29%, and 22%. Companions made a significant contribution to the communication during the visit by providing information and asking the physician questions, as well as facilitating patient's talk. The companion's communication may influence not only the patient's but also the physician's communication. The patient's expectation of the companion's role during the visit and the companion's intention regarding their role were generally related to one another, and had positive associations with the companion's actual behavior during the visit. Nevertheless, companions often anticipated playing a more direct communication role during the visit, including the provision of information and asking of questions, than patients expected of them. Further investigation is needed to explore the communication dynamics in triads and dyads, and its relation to patient outcomes.

Effect of Rival Males on the Courtship of Paedomorphic and Metamorphic Triturus alpestris (Amphibia: Salamandridae)

Current theories on the alternative mating tactics suppose that individuals may opt for particular behavioral patterns depending of their morphological status. Facultative paedomorphosis in newts and salamanders is a suitable process to explore this question because it implies the coexistence of two different morphological morphs differing by the presence of gills and epigamic traits. The aim of this study was to find out whether paedomorphs and metamorphs use similar tactics to attract mates in the presence of a rival and whether there are differences in sexual activity and success between alternative morphs. Sexual interactions in triadic encounters were staged and analyzed in a standardized experimental design. The two kinds of males did not differ in terms of sexual activity, spermatophore deposition or female responsiveness. Both rival paedomorphic and metamorphic males exhibited sexual interference, but in most encounters, intruders just disturbed the courting pair. Sperm transfer success was lower in triadic encounters than in dyadic encounters. These results illustrate that intermorph breeding also occurs in the presence of competitors but that the success rate of the newts is considerably decreased in such competitive situations. Moreover, newts do not use alternative reproductive tactics depending on their status (i.e., paedomorph or metamorph).

The organization of the ward treating psychotic patients

A chaotic treatment environment seems to be associated with a low level of intrapsychic development and social maturation of its psychotic patients. And vice versa: a well-organized external milieu may internalize and help intrapsychic structure formation. In an institutional setting, an adequate organizational environment is a necessary but not by itself sufficient precondition for successful therapy. The prime goal of organization development is to make the curative, ego-building process possible. This presupposes adequate organizational structures (e.g., a weekly timetable, treatment planning and execution, conflict solution, dyadic and triadic encounters), which encourage and motivate democratic leadership style, functional team work, and adequate environmental relations. Residents with severe psychopathology have both a destructive and a constructive influence on their treatment organization. A good therapeutic milieu, its staff, and its residents oppose and contain the former and nurture the latter....

Male dominance status, female choice and mating success in the brown lemming, Lemmus trimucronatus

The objective of this study was to determine whether female brown lemmings would selectively mate with dominant conspecific males. In dyadic encounters, oestrous females paired with dominant males engaged in more frequent lordosis and contact social behaviours than those paired with subordinate males. However, the mount and thrust scores of dominant and subordinate males did not differ significantly. When females had simultaneous access to tethered dominant and subordinate males, they spent more time in close proximity to dominant males and avoided contact with subordinate males. Copulation scores were higher with dominant males. In triadic encounters with free-moving dominant and subordinate males, oestrous females spent more time near, and engaged in more sexual behaviour with, dominant males. Intermale agonistic interactions resulted in ‘privileged access’ to females by dominant males. Sexual behaviour scores were lower and there was a 10-fold increase in intermale aggression in triadic encounters between females and unfamiliar dominant and subordinate males. Both intermale agonistic interactions and female ‘choice’ behaviour accounted for the differential copulatory success of dominant males.