Patient Education and Counseling 98 (2015) 578–587
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Communication Study
Presentation of patients’ problems during triage in emergency medicine Seung-Hee Lee a,*, Chan Woong Kim b a b
Department of English Language and Literature, Yonsei University, Seoul, South Korea Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 July 2014 Received in revised form 9 January 2015 Accepted 15 January 2015
Objective: To investigate different interactional patterns in presentation of patients’ problems depending on whether the presentation is made by patients themselves, or by their accompanying persons. Methods: Routine provider–patient interactions during triage were video-recorded at an academic emergency department in Seoul, Korea. Using the method of conversation analysis, 242 recordings were transcribed and analyzed in terms of the extent of problem presentation and interactional practices used by the presenting party. Results: Problem presentation made by accompanying persons was significantly more extensive than that by patients, in terms of its length and the number of symptoms described. Patients tended to describe physical conditions they directly experience, such as pain, whereas accompanying persons tended to provide patients’ conditions they observed as a third party, often with more objective information such as medical history. Conclusion: Compared to patients who simply present their condition(s), accompanying persons may also communicate their reasonableness in seeking emergency care. Practice implications: Providers may utilize more facilitative questioning practices to get a fuller array of concerns when interacting with patients. When accompanying persons present the complaint, providers may acknowledge legitimacy of the visit and ask patients directly to better assess the severity of conditions patients themselves experience. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Provider–patient communication Conversation analysis Problem presentation Emergency medicine Triage
1. Introduction Triage in emergency medicine is the initial process of categorizing incoming patients according to their clinical condition. It aims to optimize efficiency of the service by expediting immediate treatment for patients with life-threatening conditions and ensuring that patients are assessed and treated according to their clinical need [1–4]. The process of triage initially determines the order and priority of patients in getting medical evaluation and treatment [1]. Although brief, triage process can thus shape the route patients will take through their visit to the emergency department [1]. During and through triage interaction with patients and/or their accompanying persons, nurses make initial assessments and determinations about the severity of patients’ conditions. They are required to rapidly and accurately determine patients’ clinical
* Corresponding author at: Department of English Language and Literature, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-749, South Korea. Tel.: +82 22123 5302; fax: +82 2392 0275. E-mail address: [email protected] (S.-H. Lee). http://dx.doi.org/10.1016/j.pec.2015.01.011 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
urgency based on a variety of data they collect during the interaction, such as patients’ vital signs, chief complaints, history, symptoms, etc. [1,2,5]. While triage nurses are required to use some objective, physiological measures, such as blood pressure, respiratory rate, oxygen saturation, etc., for consistency and accountability in making acuity decisions [2], studies report that nurses also rely on subjective types of data such as patients’ accounts of their illness, behavior, speech characteristics, etc. [3,6]. Patients’ chief complaints are one of the primary, subjective data nurses collect and use for the triage decision-making, and are identified through interaction with patients and/or their accompanying persons. Presentation of patients’ problems in the interaction, referred to as ‘problem presentation’ [7], is significant in following aspects. First, a number of studies have discussed problem presentation as an important element of medical consultations. Full description of patients’ problems is associated with improved diagnosis and treatment [8–10], beneficial health outcomes [11–13], and higher degree of patient satisfaction [14]. Second, the strongest predictor of patient satisfaction in emergency departments has been identified as the quality of interpersonal interaction with providers [15–20; for a review, see
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21]; and problem presentation is essentially an interactional activity [22–24]. Triage is the first point of patient–provider encounter in the emergency department, and problem presentation often provides the first and only opportunity during triage (as well as the entire visit) in which biomedical and psychosocial concerns of patients can be described in their own words [cf. 7–9,25,26]. Problem presentation can thus affect the subsequent trajectory of provider–patient interaction in the emergency department as well as its quality and the degree of patient satisfaction. Despite this significance, little research has investigated presentation of patients’ problems and patient–provider interaction in emergency departments. Problem presentation during triage can also involve complex issues in that patients are frequently accompanied by other persons, typically their caregivers, who can contribute to and participate in the interaction to varying degrees [2,24,27,28]. This paper aims to examine different interactional patterns in presentation of patients’ problems depending on whether the presentation is made by patients themselves, or by accompanying persons on behalf of patients. Using video-recordings of actual, routine triage interactions in an academic emergency department, this paper investigates the extent of problem presentation and the interactional practices used by the presenting party in describing patients’ problems. 2. Methods 2.1. Data Data were collected in 2011 from the emergency department at a tertiary, teaching hospital in Seoul, South Korea. The triage area was located inside the waiting room, separately from the emergency room. Routine triage interactions between nurses and patients and/or their accompanying persons were videorecorded. Patients with life-threatening conditions that required time-critical assistance were excluded from the study. They typically bypassed triage and were brought to the emergency room immediately. The majority of incoming patients were first seen by triage nurses and then directed to the emergency room that is segmented according to the level of clinical urgency. This paper is based on 242 video-recordings of the triage interactions. They involved 21 nurses and 242 patients presenting to the emergency department. Two nurses were male. Patients averaged 26.5 years old (SD = 22.29, range = 2–91), with 51.7% of them female. All data collection was approved by the university’s institutional review board.
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attempts to shift out of problem presentation into a different activity’’ [7:98], such as that of asking history-taking questions (e.g. How long has that been?), making physical-exam requests (e.g. We’ll get your blood pressure), etc. We measured the extent of problem presentation in two ways, according to Heritage and Robinson [7]. First, we coded the length of presentation in seconds. Second, we coded the number of current medical symptoms formulated in present-tense (e.g. I have a sore throat). Current symptoms included descriptions of patients’ problems, their duration (e.g. My head hurts since yesterday), and location (e.g. The pain is in the right side). All statistical analyses were performed using IBM SPSS version 21. The length of problem presentation was indicated with mean and standard deviation. The length of presentation by patients was compared with that by accompanying persons using the t test. The number of current medical symptoms was operationalized into 0, 1, and 2 or more symptoms. The number of symptoms described by patients was compared with that by accompanying persons using the chi-squared test. Finally, we conducted a detailed, turn-by-turn analysis of interactional practices used in presentation of patients’ problems. Going on a case-by-case basis, we analyzed each instance of problem presentation by identifying particular elements of communication conduct that are recurrent and distinctive from other related behaviors. We developed our descriptions based on substantial collections of individual instances of the recurrent practice. The extracts in Section 3.2 were chosen because they represent especially clear instances of the practices that were recurrently found. 3. Results Table 1 shows the party presenting patients’ problems. Out of 242 incoming patients, 204 patients were accompanied by other persons (84.3%). In the 204 cases, accompanying persons frequently presented patients’ problems on behalf of patients (66.7%). Patients infrequently presented their problems on their own when accompanied by others (28.9%). Together with 38 cases in which patients alone visited the emergency department and presented their problems, patients’ own presentation of problems occurred in 40.1% of the total 242 visits. In 9 visits, patients and their accompanying persons jointly presented patients’ problems, sometimes talking at the same time. These nine visits were excluded from the analysis of the extent of problem presentation because patients and their accompanying persons made a collaborative contribution.
2.2. Methodology 3.1. The extent of problem presentation This paper used conversation analysis (CA) as a methodology [for a review, see 29 and 30], in particular as it is applied to the study of institutional interaction [31,32]. CA research has comprised a prominent portion of studies on provider–patient communication [33]. All video-recorded data were transcribed according to the CA conventions (see Appendix). Transcripts in Section 3 used a three-line system for the Korean language. The first, italicized line provides romanized Korean according to the Yale system, representing actual sounds produced by the speaker. The second line provides a literal English translation of each word with a morpheme-by-morpheme gloss. The third, boldfaced line presents an idiomatic English translation. Using CA as a method, we measured the extent of problem presentation and conducted a qualitative analysis of interactional practices that were recurrently found in problem presentation. Problem presentation was identified in line with prior research [7,34], as patients’ communication beginning after nurses’ question soliciting the problem and ending at nurses’ ‘‘initial
The mean length of problem presentations was 7.4 seconds (SD = 7.96, range = 1–52). This is much shorter compared to the 21.4 s in US primary care contexts [7] and the 23.1 s in US and Canadian primary care contexts [35]. Problem presentation made Table 1 The party presenting patients’ problems. Patient accompanied %
n
Patient not accompanied
Total
n
%
n
100.0
97 136
40.1 56.2
9
3.7
242
100.0
Patient Accompanying person Joint construction
59 136
28.9 66.7
38 0
9
4.4
0
Total
204
100.0
38
100.0
%
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Table 2 The length of problem presentation in seconds.
Patient Accompanying person
than that by patients in terms of its length as well as the current medical symptoms described.
N
Mean (range)
SD
p-Value
97 136
5.98 (1–52) 8.39 (1–49)
8.25 7.62
p = 0.022
Table 3 The number of current medical symptoms described in problem presentation. 0 symptom
1 symptom
2 or more symptoms
n
%
n
%
n
%
Patient Accompanying person
37 30
38.1 22.1
36 46
37.1 33.8
24 60
24.7 44.1
Total
67
28.8
82
35.2
84
36.1
p-Value
p = 0.004
by patients was significantly shorter than that by accompanying persons (Table 2). The number of current medical symptoms described in problem presentation averaged 1.3 (SD = 1.3, range = 0–10). No symptom was described in 28.8%, one symptom in 35.2%, and two or more symptoms in 36.1% of the 233 cases (Table 3). The number of current symptoms presented by patients was significantly less than that by accompanying persons (p = 0.004). Thus, problem presentation made by accompanying persons was more extensive
3.2. Interactional practices for problem presentation Problem presentation occurred in response to the nurse’s question soliciting a reason for visit, mostly in the form of ‘Where does it hurt so that you came?’, as in Korean primary care visits [36]. This form of question is designed to solicit a single reason for visit [36,37], literally asking for the location (‘where’) of pain or problem. In presenting their problem, patients tended to be succinct and provide simple descriptions. They normally constructed their presentation with a general term of pain (‘hurt’) and its location (45%). Such problem presentation can be as succinct as in extract (1), in which the patient simply produces a general term of pain in a particular location of his body (line 2). This is minimal, lacking information about the illness, its severity, or conditions the patient is experiencing other than pain (Table 4). Patients can incorporate descriptions that claim seriousness of pain. In extract (2) the patient provides more than minimal information in producing a general term of pain (‘hurt’) in two different parts of her body (line 3). First, in describing headache the patient indicates the duration of pain (‘since yesterday’), as well as its persistence (‘persistently’) and intensity (‘a lot’) (Table 5). Then the patient describes toothache, showing the progression of pain to a different part of her body. With the use of a particle -to ‘also’ in producing ippal ‘tooth’, the patient indicates the development of
Table 4 Extract (1) 10.15-1.
1
NUR:
eti apha-se o-sye-ss-eyo?= where hurt-so come-HON-PAST-DEF Where does it hurt so that you came?=
2
PAT:
=pay-ka apha-se. stomach-NOM hurt-so =Stomach hurts.
3
NUR:
yeki hyelap han pen-man cay.po-kkey-yo, here blood.pressure one time-only measure.try-INT-DEF Here let me take your blood pressure just once,
Table 5 Extract (2) 10.14-8.
1
NUR:
2 3
eti apha-se o-sye-ss-eyo?= where hurt-so come-HON-PAST-DEF Where does it hurt so that you came?= (0.2)
PAT:
meli-ka ecey-pwuthe kyeysok manhi aphu-kwu: head-NOM yesterday-from persistently a.lot hurt-CONN cikum-un ippal-to aphu-kwu:. now-TOP tooth-also hurt-CONN Since yesterday head hurts a lot persistently and: now tooth also hurts:.
4 5
(0.8) NUR:
anca.po-si-lkkey-yo:? sit.try-HON-INT-DEF Have a seat:?
S.-H. Lee, C.W. Kim / Patient Education and Counseling 98 (2015) 578–587 Table 6 Extract (3) 10.21-1.
1
NUR:
2
eti pwulphyenhay-se o-sye-ss-eyo where uncomfortable-so come-HON-PAST-DEF Where is it uncomfortable so that you came (.)
3
PAT:
a: onul icey konghang ka-ss-taka ecekkey-pwuthe: DM today now airport go-PAST-TRANS yesterday-from Uh: today now I went to the airport and since yesterday:
4
NUR:
ney yes Yes
5
PAT:
yakkan (.) ecilew-un key cwukicekulo ccom iss-ess-eyo, a.bit dizzy-ATTR thing periodically a.bit exist-PAST-DEF There was some (.) dizziness periodically,
6
NUR:
yey. yes Yes.
7
PAT:
kuntey son pal-i yakkan celi-n ke kath-ayo DM hand foot-NOM a.bit numb-ATTR thing seem-DEF And hands and feet seem a bit numb
8
NUR:
anca.po-sey-yo sit.try-HON-DEF Have a seat
Table 7 Extract (4) 11.03-11.
1
NUR:
eti pwulphyenhay-se o-sye-ss-eyo?= where uncomfortable-so come-HON-PAST-DEF Where is it uncomfortable so that you came?=
2
PAT:
=pay-ka apha-se-yo stomach-NOM hurt-so-DEF =Stomach hurts.
3 4
(1.0) NUR:
5
anc-usi-lkkey-yo. sit-HON-INT-DEF Have a seat. (0.4)
6
PAT:
ttalun pyungwen-ey ka-ss-nuntey different hospital-LOC go-PAST-CIRCUM I went to a different hospital and
7
NUR:
yey. yes Yes.
8
PAT:
mayngcang kath-ta-kwu appendicitis seem-DECL-COMP They said it seems like appendicitis
9
NUR:
pal an ket-usye-to.tway-yo arm not pull.up-be.okay-DEF You don’t have to pull up your sleeves
---------((PAT seats herself))----
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toothache in addition to the current existence of headache. While providing a simple description of her complaint, the patient claims the problematic nature of her pain by reporting its intensity and development. In these presentations, patients treat their complaint as transparent. They simply provide a general term of pain. While they may incorporate details that claim its seriousness, patients regard their problem as evidently relevant to emergency medical care and not requiring further elaboration, e.g. how their pain is not a ‘normal’ pain that needs medical attention [cf. 22]. Triage nurses also treat these presentations as adequate by moving to a different activity without requiring elaboration (at line 3 in (1) and line 5 in (2)). Both parties orient to simple descriptions of pain as establishing the reason for visit. This is similar in cases in which patients presented physical conditions other than pain, as in extract (3). The patient has high blood pressure and cholesterol and had been warned of a possibility of stroke in a prior medical visit, which gets disclosed later in the history-taking phase of the current visit (data not shown). Rather than providing this medical history that can indicate urgency, the patient constructs problem presentation by focusing on physical conditions he is experiencing (Table 6). At line 3, the patient starts by invoking a life event (‘I went to the airport’) – which may suggest a flight – that serves as a context for his upcoming complaint. Then the patient describes conditions he is experiencing, dizziness (lines 3–5) and numbness (line 7). While these conditions may serve as signs of a stroke, which the patient had been informed of in the prior medical visit and discloses later in the current visit, the patient does not present such medical history or indicate a potential urgency. The patient rather presents these conditions within the context of his life event, focusing on describing what he feels. Only in few cases patients provided information that can indicate a potential urgency of their problem or its relevance to
emergency care. In extract (4), the patient provides a simple description of her complaint with a general term of pain in her stomach (line 2); and the nurse treats this as adequate by shifting into a different activity (line 4) (Table 7). After 0.4 second (line 5), the patient then invokes a prior medical visit (lines 6,8). This may indicate a referral to the emergency department, as well as establishing the problem’s urgency and emergency-relevance [26]. What is to be noted is that the patient does not incorporate this bit of information in her first turn establishing the reason for visit (line 2). She offers it only after the problem presentation is possibly complete (lines 2–3) and the nurse moves to initiating another activity (line 4). In constructing problem presentation, the patient prioritizes a description of her pain over medical history that can indicate its urgency. Thus, in presenting their problem, patients tend to focus on describing physical conditions they feel. Rather than providing accounts, contexts, or other medical information that can establish seriousness or emergency-relevance of their problem, patients report their own, subjective experience and treat it as adequate. This suggests that patients may treat their body and physical conditions they feel as a proof of illness that requires emergency care. By contrast, accompanying persons tended to take a more ‘objective’ approach and engage in more extensive descriptions about the complaint. First, accompanying persons infrequently described pain patients themselves feel (18%). When their presentation concerned pain, accompanying persons tended to frame it as a saying from the patient and provide further information such as other current symptoms (as in (5)) and medical history (as in (6)). In extract (5), the daughter of an elderly patient constructs problem presentation with a list of symptoms including headache (lines 3,5). In contrast with patients as in extracts (1–2), the daughter incorporates the description of pain among other conditions the patient has, treating pain alone as not adequately establishing the reason for visit (Table 8).
Table 8 Extract (5) 10.05-2.
1
NUR:
2
eti pwulphyenhay-se o-sye-ss-eyo:? where uncomfortable-so come-HON-PAST-DEF Where is it uncomfortable so that you came:? (0.5)
3
DAU:
sok-i wullengkeli-kwu-yo: stomach-NOM nauseous-CONN-DEF She says she is nauseous and:
4
NUR:
ney. yes Yes.
5
DAU:
meli-ka aphu-si-kwu-yo head-NOM hurt-HON-CONN-DEF [cakku thoha-si-llye kule-sin-tay-yo. repeatedly vomit-HON-PURP do.so-HON-HEARSAY-DEF Her head hurts and [she keeps feeling she’s going to vomit.
6
NUR:
[ney. yes [Yes.
7
NUR:
e: yeki anca.po-sey-yo: uh here sit.try-HON-DEF Uh: have a seat here:
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What is to be noted is that the daughter frames the description of the patient’s conditions with a particle -tay (line 5) which indicates the talk as a saying from another party (‘She says’ in English translation at line 3). The conditions presented, including pain, concern the patient’s subjective feelings, which the accompanying person cannot know directly. They are experiences ‘owned’ by the patient, and, relative to the patient, the accompanying person does not have primary epistemic access to them [38–41]. Thus, rather than claiming that the patient has these symptoms, the daughter marks them as a report from the patient. In this way, the daughter displays herself as a reasonable or ‘objective’ third party who withholds a claim on physical conditions she doesn’t have direct access to. Similarly in extract (6), the mom presents pain as a report of what the patient said (-tay ‘he says’ at line 2). She withholds making a claim on her own part toward the patient’s pain she cannot know directly [38,39] (Table 9). In addition, the mom immediately follows the report of pain by invoking a prior medical visit (lines 2–5). In contrast with patients who, even with a prior medical visit, focus on presenting their physical conditions (extracts (3–4)), the accompanying person
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here describes the previous medical visit as early as in her first turn. Rather than orienting to the report of pain as adequate, the mom evidences the patient’s pain by providing more objective information that she has direct access to and that can indicate seriousness of the complaint. In so doing, the accompanying person displays relevance of, and reasonableness in, seeking emergency care [26]. Most accompanying persons constructed problem presentations by describing conditions they can observe, rather than conditions only patients can feel and have privileged access to [38– 40]. In extract (7), the mom and the patient described abdominal pain during the history-taking phase of the visit (data not shown). In constructing problem presentation, the mom starts by describing vomiting (line 3), which is a condition she can observe and know without having a first-hand experience. The mom projects a further unit of talk with -kwu ‘and’ in the description (line 3), although the nurse cuts in by requesting to have the patient seated (line 4) (Table 10). At line 5 the mom produces the projected (but interrupted) unit of talk by describing another condition she observed, which can indicate seriousness of the problem, and marks it as establishing
Table 9 Extract (6) 10.15-3.
1
NUR:
eti apha-se wa-ss-eyo?= where hurt-so come-PAST-DEF Where does it hurt so that you came?=
2
MOM:
=bay-ka aphu-tay-yo: = stomach-NOM hurt-HEARSAY-DEF
kun- (.) ceki- naka-ss-taka: there go.out-PAST-TRANS
[kunche soakwa-ey ka-ss-nuntey: nearby pediatrics-NOM go-PAST-CIRCUM =He says his stomach hurts:=and- (.) we went out- and: [went to the pediatrics nearby and: 3
NUR:
[yey. yes [Yes.
4
NUR:
yey. yes Yes.
5
MOM:
mwe
cang-i
ccoye-se
kule-nuni kul
sol-lul
what intestine-NOM obstruct-so do.so-DET do.so-ATTR talk-ACC ha-nuntey cwusa-lul han tay nwacw-ess-[ketun-yo? do-CIRUM injection-ACC one shot give-PAST-CORREL-DEF They said it’s because the intestine is obstructed and gave him an inject[ion? 6
NUR:
[eksureyi (.) X.ray ccik-ess-eyo? take-PAST-DEF [Did he get (.) an X ray?
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the reason for visit (‘so now we came’). The accompanying person thus completes the problem presentation by limiting the description to what she observed. The mom relies on her observations, rather than pain or other conditions only the patient can feel, restricting her claims to what she can accountably and responsibly know as a caregiver [38,39,42]. Finally, extract (8) illustrates a similar pattern in which the accompanying person elaborates on the patient’s conditions that are observed, in which process she shows seriousness of the problem. At line 2, the mom starts by describing high fever. She does not just claim, but evidences high fever by providing an objective measure (39 degrees Celsius) as well as its duration which is about 3 days (note that the visit occurred on Thursday). The mom thus displays seriousness of the fever on more objective grounds (Table 11). At line 4, by mentioning that the patient takes medications from the pediatrics, the mom suggests not only that the fever reducer the patient had taken (line 2) was prescribed but also that the patient’s conditions have not resolved with the prescribed medications. This can indicate seriousness of the problem as well as its relevance to (emergency) medical care. Then the mom describes further symptoms, coughing and vomiting, which she can observe and know as a third party (line 4). Throughout the presentation, the mom describes what she observed as a caretaker and indicates seriousness of the problem based on her observations. In this process, the mom displays herself as a sensible, responsible caretaker who has been attentive enough to take measures of fever and watch the conditions constantly, and reasonable enough to not rush to the emergency
care immediately but to make the visit based on her constant, watchful observations over the last few days [42]. Thus, when accompanying persons construct problem presentation, they engage in more elaborate descriptions that can communicate the relevance of seeking emergency care. Lacking direct access to patients’ own, subjective experience [38–40], accompanying persons tend to rely on their observations and/or more objective information–such as medical history, prescriptions, and physiological measures–as a basis for establishing the reason for visit. This is in contrast to patients who orient to descriptions of conditions they experience as comprising an adequate problem presentation. 4. Discussion and conclusion 4.1. Discussion We have shown that problem presentation constructed by accompanying persons is more extensive than that by patients. Patients tended to be succinct and simply describe physical conditions they directly feel, such as pain. This suggests that patients treat their problem as transparent so that it does not require further elaboration. Heritage and Robinson [26] showed that this pattern is prominent among patients with accidental injuries in US primary care visits. Injuries are often self-evident and transparent, and the physical presentation of injured parts of the body may establish patients’ chief problem. The patient’s similar use of interactional practices during triage seems to suggest that patients may treat their physical presence – the sick body – as an ‘evidence’ of their medical problem unquestionably requiring
Table 10 Extract (7) 10.19-23.
1
NUR:
2
eti apha-se wa-ss-eyo? where hurt-so come-PAST-DEF Where does it hurt so that you came? (0.5)
3
MOM:
4
NUR:
a tho-lul kyesok ha-kwu-yo: (.) [tho-eyuh vomit-ACC persistently do-CONN-DEF vomit-LOC Uh she vomits persistently and: (.) [in the vomit[yeki here ac-hi-sey-yo sit-CAUS-HON-DEF [Have her seated here.
5
MOM:
tho-lul hay-ss-nuntey: phi-ka: (0.8) nawa-kaciko icey vomit-ACC do-PAST-CIRCUM blood-NOM come.out-so now wa-ss-eyo come-PAST-DEF She vomited and: blood: (0.8) came out so now we came
6 7
(1.0) NUR:
um: myech.pen cengto hay-ss-eyo? how.many.times about do-PAST-DEF Um: about how many times did she vomit?
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Table 11 Extract (8) 10.20-11.
1
NUR:
eti-ka aphu-nka-yo? where-NOM hurt-DUB-DEF Where does it hurt?
2
MOM:
a yel-i manh-ko cikum hayyelcey mek-ko uh fever-NOM a.lot-CONN now fever.reducer eat-CONN wa-ss-nuntey samsip.kwu to-ye-ss-ess-kwu, ikey come-PAST-CIRCUM thirty.nine degree-be-PAST-PAST-CONN this hwayoil-pwuthe- welyoil pam-pwuthe kyeysok yel-i (.) Tuesday-from Monday night-from persistently fever-NOM ollaka-kwu-yo:, go.up-CONN-DEF Uh she has high fever and she took a fever reducer and came and it had been thirty-nine degrees and, since Tuesday- since Monday night the fever persistently goes up and:,
3
NUR:
yey. yes Yes.
4
MOM:
wenlay soakwa-eyse mek-kwu-yo yak-un? originally pediatrics-LOC eat-CONN-DEF medication-TOP kichim-i- kichim-i ilehkey kyeysok memchwu-ci- anh-ko. cough-NOM cough-NOM like.this persistently stop-COMM-not- CONN kuliko tto thoha-ko. and also vomit-CONN She takes medications from the pediatrics and? coughingcoughing does not stop persistently like this. And she also vomits.
5
NUR:
6 7
ah DM I see (0.5)
NUR:
kunikka icey thoha-nun ke-nun kichim-i simhay-se so now vomit-ATTR thing-TOP cough-NOM severe-so thoha-nun ke-ci mwe nappa-se thoha- thoha-nun ke-n vomit-ATTR thing-COMM what bad-so vomit vomit-ATTR thing- TOP ani-cyo? not-COMM:DEF So about vomiting she vomits because the coughing is severe, not because something is bad, right?
emergency assistance. Triage nurses also treat patients’ simple description of pain or other conditions as adequately establishing the reason for visit. This may partly relate to the Korean system of emergency care. Although patients are categorized according to their urgency during triage, every incoming patient gets medical evaluation in Korean emergency departments. The role of triage nurses is mainly
to determine the order and priority of patients according to their urgency, not to screen out non-urgent or illegitimate patients. Patients may thus orient to the presence of pain or other physical symptoms as an adequate ground for seeking emergency care. Nurses likewise may not invite patients to provide further elaboration and justify their emergency visit.
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By contrast, accompanying persons – although under the same system – tended to be more concerned with establishing the relevance of seeking emergency care. They tended to describe physical conditions they can observe as a caregiver, rather than subjective feelings such as pain, and provide information other than current symptoms such as medical history, medications, or physiological measures, which can explain the more extensive nature of their problem presentation compared to patients’. Accompanying persons are not patients and thus do not own patients’ experiences [28]. Patients’ own experiences are ‘theirs’ to know and describe; and relative to patients, accompanying persons have limited access or rights to know and describe those experiences [38–41]. Accompanying persons may observe, but lack direct access to, physical conditions patients themselves are experiencing, and thus be restrained in understanding their severity. Nonetheless, they may have to make a decision to visit the emergency department and describe patients’ problems. Thus, when presenting patients’ problems, accompanying persons may carry the burden of establishing the relevance of seeking emergency care, such as how or on what basis they know about the problem and its severity, unlike patients who can claim their own physical conditions and make decisions based on direct experience [38]. Accompanying persons may thus work to evidence and account of seriousness of patients’ problems on more objective grounds and establish reasonableness in seeking emergency care. This aspect of problem presentation has been discussed in prior research in terms of ‘doctor-ability’: a doctor-able problem is one that is worthy of medical attention and evaluation [22,26]. In US primary care visits, patients are primarily occupied with establishing doctorability in constructing problem presentation [22,26]. The issue of doctorability may be prominent in emergency care visits, because patients may also have to establish their problem as one that is worthy of emergency care in particular. In the present study, however, it is accompanying persons rather than patients that are concerned with establishing (emergency) doctorability. This is distinctive in that in US primary care parents accompanying pediatric patients tend to have somewhat ‘relaxed’ concerns with legitimizing their visit, compared to adult patients [42; cf. 26]. Further research is needed to investigate whether the pattern examined in this paper is particular to Korean contexts. 4.2. Conclusion When accompanying persons present patients’ problems, problem presentation shows different interactional patterns from
those in patients’ own presentation. In the process of problem presentation, accompanying persons may also communicate their reasonableness in seeking emergency care. Thus, problem presentation during triage does not just concern description of patients’ problems. At least for accompanying persons, it may also serve as a site for portraying reasonableness and caretaker responsibility. 4.3. Practice implications Triage nurses may utilize more facilitative questioning practices when interacting with patients who themselves present their problem. Because patients do not frequently offer various aspects of symptoms or other contextual information, this may present difficulties in assessing the clinical urgency. Nurses may need to make efforts to get a fuller array of patients’ conditions through questioning. When interacting with accompanying persons presenting patients’ problems, triage nurses may acknowledge legitimacy of the visit as a way of addressing the concern of doctorability. In addition, because accompanying persons tend to rely on their observations in presenting the complaint, physical conditions and their severity patients actually experience may be different from, or may not be included in, accompanying persons’ descriptions. Providers may need to ask patients directly to better assess the severity of conditions patients themselves experience. Finally, in providing treatment medical providers may explain to accompanying persons some conditions of the patient that will show resolution of the problem. Because accompanying persons tend to rely on their observations, their understanding of the relief of patients’ conditions may be likely shaped by what they observe. This may be different from patients’ own perception of relief, as in prior research that documented greater resolution of pain reported by pediatric patients than appreciated by their parents [43]. Providers’ explanation of signs or conditions of relief may help accompanying persons better understand patients’ recovery process, which may lead to satisfaction with the outcome of medical care. Acknowledgements Research for this study was supported in part by the National Research Foundation of Korea Grant funded by the Korean Government (KRF2009-361-A00027). The funding agency supported equipment for video-recording and digitizing, and had no involvement in the design of study, analysis and interpretation of data, writing of the report, and decision to submit the paper for publication.
Appendix. Transcription conventions The typed extracts represent efforts to indicate how the words were actually produced, according to transcription conventions used in conversation analysis. Listed below are the symbols used in the extracts in Section 3.2. [
Left-side square brackets indicate an onset of overlapping talk.
=
Equal signs indicate no gap of silence between utterances either by the same speaker or by different speakers.
(0.5)
Numbers in parentheses indicate silence, measured in seconds and tenths of a second
(.)
A period in parentheses indicates a micropause of less than 0.2 second.
.
A period indicates a falling, or final, intonation, not necessarily the end of a sentence.
?
A question mark indicates rising intonation, not necessarily a question.
,
A comma indicates continuing intonation, not necessarily a clause boundary.
::
Colons indicate the prolongation or stretching of the sound just preceding them.
word-
A hyphen indicates that the preceding sound is cut off or self-interrupted.
word
Underlining indicates some form of stress or emphasis, either by increased loudness or higher pitch.
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[22] Halkowski T. Realizing the illness: patients’ narratives of symptom discovery. In: Heritage J, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 86–114. [23] Ruusuvuori J. Control in the medical consultation: practices of giving and receiving the reason for the visit in primary health care (Unpublished doctoral dissertation). Los Angeles: University of California; 2000. [24] Stivers T. Presenting the problem in pediatric encounters: symptoms only versus candidate diagnosis presentations. Health Commun 2002;14:299–338. [25] Frankel R. From sentence to sequence: understanding the medical encounter through microinteractional analysis. Discourse Process 1984;7:135–70. [26] Heritage J, Robinson JD. Accounting for the visit: giving reasons for seeking medical care. In: Heritage J, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 48–85. [27] Nystrom M, Dahlberg K, Carlsson G. Non-caring encounters at an emergency care unit – a life-world hermeneutic analysis of an efficiency-driven organization. Int J Nurs Stud 2003;40:761–9. [28] Stivers T. Negotiating who presents the problem: next speaker selection in pediatric encounters. J Commun 2001;51:252–82. [29] Atkinson JM, Heritage J. Structures of social action: studies in conversation analysis. Cambridge: Cambridge University Press; 1984. [30] Heritage J. Garfinkel and ethnomethodology. Cambridge Polity; 1984. [31] Drew P, Heritage J. Talk at work: interaction in institutional settings. Cambridge: Cambridge University Press; 1992. [32] Heritage J, Clayman S. Talk in action: interactions, identities, and institutions. Malden: Wiley-Blackwell; 2010. [33] Heritage J, Maynard DW. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. [34] Robinson JD. An interactional structure of medical activities during acute visits and its implications for patients’ participation. Health Commun 2003;15:27–57. [35] Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved. J Amer Med Assoc 1999;281:283–7. [36] Park Y. Negotiating last-minute concerns in closing Korean medical encounters: the use of gaze, body and talk. Soc Sci Med 2013;97:176–91. [37] Park Y. Interaction between doctors and patients in Korean primary care settings: analyzing medical discourse. Seoul: Pagijong Press; 2009. [38] Heritage J. Territories of knowledge, territories of experience: empathic moments in interaction. In: Stivers T, Mondana L, Steensig J, editors. The morality of knowledge in conversation. Cambridge: Cambridge University Press; 2011. p. 159–83. [39] Heritage J. Epistemics in conversation. In: Sidnell J, Stivers T, editors. The handbook of conversation analysis. Boston: Wiley-Blackwell; 2013. p. 659–73. [40] Pomerantz A. Telling my side: limited access as a fishing device. Sociol Inq 1980;50:186–98. [41] Sacks H. On doing being ordinary. In: Atkinson JM, Heritage J, editors. Structures of social action. Cambridge: Cambridge University Press; 1984 . p. 413–29. [42] Stivers T. Prescribing under pressure: parent–physician conversations and antibiotics. Oxford: Oxford University Press; 2007. [43] Magaret ND, Clark TA, Warden CR, Magnusson AR, Hedges JR. Patient satisfaction in the emergency department – a survey of pediatric patients and their parents. Acad Emerg Med 2002;9:1379–88.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Communication Study
Presentation of patients’ problems during triage in emergency medicine Seung-Hee Lee a,*, Chan Woong Kim b a b
Department of English Language and Literature, Yonsei University, Seoul, South Korea Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 July 2014 Received in revised form 9 January 2015 Accepted 15 January 2015
Objective: To investigate different interactional patterns in presentation of patients’ problems depending on whether the presentation is made by patients themselves, or by their accompanying persons. Methods: Routine provider–patient interactions during triage were video-recorded at an academic emergency department in Seoul, Korea. Using the method of conversation analysis, 242 recordings were transcribed and analyzed in terms of the extent of problem presentation and interactional practices used by the presenting party. Results: Problem presentation made by accompanying persons was significantly more extensive than that by patients, in terms of its length and the number of symptoms described. Patients tended to describe physical conditions they directly experience, such as pain, whereas accompanying persons tended to provide patients’ conditions they observed as a third party, often with more objective information such as medical history. Conclusion: Compared to patients who simply present their condition(s), accompanying persons may also communicate their reasonableness in seeking emergency care. Practice implications: Providers may utilize more facilitative questioning practices to get a fuller array of concerns when interacting with patients. When accompanying persons present the complaint, providers may acknowledge legitimacy of the visit and ask patients directly to better assess the severity of conditions patients themselves experience. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Provider–patient communication Conversation analysis Problem presentation Emergency medicine Triage
1. Introduction Triage in emergency medicine is the initial process of categorizing incoming patients according to their clinical condition. It aims to optimize efficiency of the service by expediting immediate treatment for patients with life-threatening conditions and ensuring that patients are assessed and treated according to their clinical need [1–4]. The process of triage initially determines the order and priority of patients in getting medical evaluation and treatment [1]. Although brief, triage process can thus shape the route patients will take through their visit to the emergency department [1]. During and through triage interaction with patients and/or their accompanying persons, nurses make initial assessments and determinations about the severity of patients’ conditions. They are required to rapidly and accurately determine patients’ clinical
* Corresponding author at: Department of English Language and Literature, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-749, South Korea. Tel.: +82 22123 5302; fax: +82 2392 0275. E-mail address: [email protected] (S.-H. Lee). http://dx.doi.org/10.1016/j.pec.2015.01.011 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
urgency based on a variety of data they collect during the interaction, such as patients’ vital signs, chief complaints, history, symptoms, etc. [1,2,5]. While triage nurses are required to use some objective, physiological measures, such as blood pressure, respiratory rate, oxygen saturation, etc., for consistency and accountability in making acuity decisions [2], studies report that nurses also rely on subjective types of data such as patients’ accounts of their illness, behavior, speech characteristics, etc. [3,6]. Patients’ chief complaints are one of the primary, subjective data nurses collect and use for the triage decision-making, and are identified through interaction with patients and/or their accompanying persons. Presentation of patients’ problems in the interaction, referred to as ‘problem presentation’ [7], is significant in following aspects. First, a number of studies have discussed problem presentation as an important element of medical consultations. Full description of patients’ problems is associated with improved diagnosis and treatment [8–10], beneficial health outcomes [11–13], and higher degree of patient satisfaction [14]. Second, the strongest predictor of patient satisfaction in emergency departments has been identified as the quality of interpersonal interaction with providers [15–20; for a review, see
S.-H. Lee, C.W. Kim / Patient Education and Counseling 98 (2015) 578–587
21]; and problem presentation is essentially an interactional activity [22–24]. Triage is the first point of patient–provider encounter in the emergency department, and problem presentation often provides the first and only opportunity during triage (as well as the entire visit) in which biomedical and psychosocial concerns of patients can be described in their own words [cf. 7–9,25,26]. Problem presentation can thus affect the subsequent trajectory of provider–patient interaction in the emergency department as well as its quality and the degree of patient satisfaction. Despite this significance, little research has investigated presentation of patients’ problems and patient–provider interaction in emergency departments. Problem presentation during triage can also involve complex issues in that patients are frequently accompanied by other persons, typically their caregivers, who can contribute to and participate in the interaction to varying degrees [2,24,27,28]. This paper aims to examine different interactional patterns in presentation of patients’ problems depending on whether the presentation is made by patients themselves, or by accompanying persons on behalf of patients. Using video-recordings of actual, routine triage interactions in an academic emergency department, this paper investigates the extent of problem presentation and the interactional practices used by the presenting party in describing patients’ problems. 2. Methods 2.1. Data Data were collected in 2011 from the emergency department at a tertiary, teaching hospital in Seoul, South Korea. The triage area was located inside the waiting room, separately from the emergency room. Routine triage interactions between nurses and patients and/or their accompanying persons were videorecorded. Patients with life-threatening conditions that required time-critical assistance were excluded from the study. They typically bypassed triage and were brought to the emergency room immediately. The majority of incoming patients were first seen by triage nurses and then directed to the emergency room that is segmented according to the level of clinical urgency. This paper is based on 242 video-recordings of the triage interactions. They involved 21 nurses and 242 patients presenting to the emergency department. Two nurses were male. Patients averaged 26.5 years old (SD = 22.29, range = 2–91), with 51.7% of them female. All data collection was approved by the university’s institutional review board.
579
attempts to shift out of problem presentation into a different activity’’ [7:98], such as that of asking history-taking questions (e.g. How long has that been?), making physical-exam requests (e.g. We’ll get your blood pressure), etc. We measured the extent of problem presentation in two ways, according to Heritage and Robinson [7]. First, we coded the length of presentation in seconds. Second, we coded the number of current medical symptoms formulated in present-tense (e.g. I have a sore throat). Current symptoms included descriptions of patients’ problems, their duration (e.g. My head hurts since yesterday), and location (e.g. The pain is in the right side). All statistical analyses were performed using IBM SPSS version 21. The length of problem presentation was indicated with mean and standard deviation. The length of presentation by patients was compared with that by accompanying persons using the t test. The number of current medical symptoms was operationalized into 0, 1, and 2 or more symptoms. The number of symptoms described by patients was compared with that by accompanying persons using the chi-squared test. Finally, we conducted a detailed, turn-by-turn analysis of interactional practices used in presentation of patients’ problems. Going on a case-by-case basis, we analyzed each instance of problem presentation by identifying particular elements of communication conduct that are recurrent and distinctive from other related behaviors. We developed our descriptions based on substantial collections of individual instances of the recurrent practice. The extracts in Section 3.2 were chosen because they represent especially clear instances of the practices that were recurrently found. 3. Results Table 1 shows the party presenting patients’ problems. Out of 242 incoming patients, 204 patients were accompanied by other persons (84.3%). In the 204 cases, accompanying persons frequently presented patients’ problems on behalf of patients (66.7%). Patients infrequently presented their problems on their own when accompanied by others (28.9%). Together with 38 cases in which patients alone visited the emergency department and presented their problems, patients’ own presentation of problems occurred in 40.1% of the total 242 visits. In 9 visits, patients and their accompanying persons jointly presented patients’ problems, sometimes talking at the same time. These nine visits were excluded from the analysis of the extent of problem presentation because patients and their accompanying persons made a collaborative contribution.
2.2. Methodology 3.1. The extent of problem presentation This paper used conversation analysis (CA) as a methodology [for a review, see 29 and 30], in particular as it is applied to the study of institutional interaction [31,32]. CA research has comprised a prominent portion of studies on provider–patient communication [33]. All video-recorded data were transcribed according to the CA conventions (see Appendix). Transcripts in Section 3 used a three-line system for the Korean language. The first, italicized line provides romanized Korean according to the Yale system, representing actual sounds produced by the speaker. The second line provides a literal English translation of each word with a morpheme-by-morpheme gloss. The third, boldfaced line presents an idiomatic English translation. Using CA as a method, we measured the extent of problem presentation and conducted a qualitative analysis of interactional practices that were recurrently found in problem presentation. Problem presentation was identified in line with prior research [7,34], as patients’ communication beginning after nurses’ question soliciting the problem and ending at nurses’ ‘‘initial
The mean length of problem presentations was 7.4 seconds (SD = 7.96, range = 1–52). This is much shorter compared to the 21.4 s in US primary care contexts [7] and the 23.1 s in US and Canadian primary care contexts [35]. Problem presentation made Table 1 The party presenting patients’ problems. Patient accompanied %
n
Patient not accompanied
Total
n
%
n
100.0
97 136
40.1 56.2
9
3.7
242
100.0
Patient Accompanying person Joint construction
59 136
28.9 66.7
38 0
9
4.4
0
Total
204
100.0
38
100.0
%
580
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Table 2 The length of problem presentation in seconds.
Patient Accompanying person
than that by patients in terms of its length as well as the current medical symptoms described.
N
Mean (range)
SD
p-Value
97 136
5.98 (1–52) 8.39 (1–49)
8.25 7.62
p = 0.022
Table 3 The number of current medical symptoms described in problem presentation. 0 symptom
1 symptom
2 or more symptoms
n
%
n
%
n
%
Patient Accompanying person
37 30
38.1 22.1
36 46
37.1 33.8
24 60
24.7 44.1
Total
67
28.8
82
35.2
84
36.1
p-Value
p = 0.004
by patients was significantly shorter than that by accompanying persons (Table 2). The number of current medical symptoms described in problem presentation averaged 1.3 (SD = 1.3, range = 0–10). No symptom was described in 28.8%, one symptom in 35.2%, and two or more symptoms in 36.1% of the 233 cases (Table 3). The number of current symptoms presented by patients was significantly less than that by accompanying persons (p = 0.004). Thus, problem presentation made by accompanying persons was more extensive
3.2. Interactional practices for problem presentation Problem presentation occurred in response to the nurse’s question soliciting a reason for visit, mostly in the form of ‘Where does it hurt so that you came?’, as in Korean primary care visits [36]. This form of question is designed to solicit a single reason for visit [36,37], literally asking for the location (‘where’) of pain or problem. In presenting their problem, patients tended to be succinct and provide simple descriptions. They normally constructed their presentation with a general term of pain (‘hurt’) and its location (45%). Such problem presentation can be as succinct as in extract (1), in which the patient simply produces a general term of pain in a particular location of his body (line 2). This is minimal, lacking information about the illness, its severity, or conditions the patient is experiencing other than pain (Table 4). Patients can incorporate descriptions that claim seriousness of pain. In extract (2) the patient provides more than minimal information in producing a general term of pain (‘hurt’) in two different parts of her body (line 3). First, in describing headache the patient indicates the duration of pain (‘since yesterday’), as well as its persistence (‘persistently’) and intensity (‘a lot’) (Table 5). Then the patient describes toothache, showing the progression of pain to a different part of her body. With the use of a particle -to ‘also’ in producing ippal ‘tooth’, the patient indicates the development of
Table 4 Extract (1) 10.15-1.
1
NUR:
eti apha-se o-sye-ss-eyo?= where hurt-so come-HON-PAST-DEF Where does it hurt so that you came?=
2
PAT:
=pay-ka apha-se. stomach-NOM hurt-so =Stomach hurts.
3
NUR:
yeki hyelap han pen-man cay.po-kkey-yo, here blood.pressure one time-only measure.try-INT-DEF Here let me take your blood pressure just once,
Table 5 Extract (2) 10.14-8.
1
NUR:
2 3
eti apha-se o-sye-ss-eyo?= where hurt-so come-HON-PAST-DEF Where does it hurt so that you came?= (0.2)
PAT:
meli-ka ecey-pwuthe kyeysok manhi aphu-kwu: head-NOM yesterday-from persistently a.lot hurt-CONN cikum-un ippal-to aphu-kwu:. now-TOP tooth-also hurt-CONN Since yesterday head hurts a lot persistently and: now tooth also hurts:.
4 5
(0.8) NUR:
anca.po-si-lkkey-yo:? sit.try-HON-INT-DEF Have a seat:?
S.-H. Lee, C.W. Kim / Patient Education and Counseling 98 (2015) 578–587 Table 6 Extract (3) 10.21-1.
1
NUR:
2
eti pwulphyenhay-se o-sye-ss-eyo where uncomfortable-so come-HON-PAST-DEF Where is it uncomfortable so that you came (.)
3
PAT:
a: onul icey konghang ka-ss-taka ecekkey-pwuthe: DM today now airport go-PAST-TRANS yesterday-from Uh: today now I went to the airport and since yesterday:
4
NUR:
ney yes Yes
5
PAT:
yakkan (.) ecilew-un key cwukicekulo ccom iss-ess-eyo, a.bit dizzy-ATTR thing periodically a.bit exist-PAST-DEF There was some (.) dizziness periodically,
6
NUR:
yey. yes Yes.
7
PAT:
kuntey son pal-i yakkan celi-n ke kath-ayo DM hand foot-NOM a.bit numb-ATTR thing seem-DEF And hands and feet seem a bit numb
8
NUR:
anca.po-sey-yo sit.try-HON-DEF Have a seat
Table 7 Extract (4) 11.03-11.
1
NUR:
eti pwulphyenhay-se o-sye-ss-eyo?= where uncomfortable-so come-HON-PAST-DEF Where is it uncomfortable so that you came?=
2
PAT:
=pay-ka apha-se-yo stomach-NOM hurt-so-DEF =Stomach hurts.
3 4
(1.0) NUR:
5
anc-usi-lkkey-yo. sit-HON-INT-DEF Have a seat. (0.4)
6
PAT:
ttalun pyungwen-ey ka-ss-nuntey different hospital-LOC go-PAST-CIRCUM I went to a different hospital and
7
NUR:
yey. yes Yes.
8
PAT:
mayngcang kath-ta-kwu appendicitis seem-DECL-COMP They said it seems like appendicitis
9
NUR:
pal an ket-usye-to.tway-yo arm not pull.up-be.okay-DEF You don’t have to pull up your sleeves
---------((PAT seats herself))----
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582
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toothache in addition to the current existence of headache. While providing a simple description of her complaint, the patient claims the problematic nature of her pain by reporting its intensity and development. In these presentations, patients treat their complaint as transparent. They simply provide a general term of pain. While they may incorporate details that claim its seriousness, patients regard their problem as evidently relevant to emergency medical care and not requiring further elaboration, e.g. how their pain is not a ‘normal’ pain that needs medical attention [cf. 22]. Triage nurses also treat these presentations as adequate by moving to a different activity without requiring elaboration (at line 3 in (1) and line 5 in (2)). Both parties orient to simple descriptions of pain as establishing the reason for visit. This is similar in cases in which patients presented physical conditions other than pain, as in extract (3). The patient has high blood pressure and cholesterol and had been warned of a possibility of stroke in a prior medical visit, which gets disclosed later in the history-taking phase of the current visit (data not shown). Rather than providing this medical history that can indicate urgency, the patient constructs problem presentation by focusing on physical conditions he is experiencing (Table 6). At line 3, the patient starts by invoking a life event (‘I went to the airport’) – which may suggest a flight – that serves as a context for his upcoming complaint. Then the patient describes conditions he is experiencing, dizziness (lines 3–5) and numbness (line 7). While these conditions may serve as signs of a stroke, which the patient had been informed of in the prior medical visit and discloses later in the current visit, the patient does not present such medical history or indicate a potential urgency. The patient rather presents these conditions within the context of his life event, focusing on describing what he feels. Only in few cases patients provided information that can indicate a potential urgency of their problem or its relevance to
emergency care. In extract (4), the patient provides a simple description of her complaint with a general term of pain in her stomach (line 2); and the nurse treats this as adequate by shifting into a different activity (line 4) (Table 7). After 0.4 second (line 5), the patient then invokes a prior medical visit (lines 6,8). This may indicate a referral to the emergency department, as well as establishing the problem’s urgency and emergency-relevance [26]. What is to be noted is that the patient does not incorporate this bit of information in her first turn establishing the reason for visit (line 2). She offers it only after the problem presentation is possibly complete (lines 2–3) and the nurse moves to initiating another activity (line 4). In constructing problem presentation, the patient prioritizes a description of her pain over medical history that can indicate its urgency. Thus, in presenting their problem, patients tend to focus on describing physical conditions they feel. Rather than providing accounts, contexts, or other medical information that can establish seriousness or emergency-relevance of their problem, patients report their own, subjective experience and treat it as adequate. This suggests that patients may treat their body and physical conditions they feel as a proof of illness that requires emergency care. By contrast, accompanying persons tended to take a more ‘objective’ approach and engage in more extensive descriptions about the complaint. First, accompanying persons infrequently described pain patients themselves feel (18%). When their presentation concerned pain, accompanying persons tended to frame it as a saying from the patient and provide further information such as other current symptoms (as in (5)) and medical history (as in (6)). In extract (5), the daughter of an elderly patient constructs problem presentation with a list of symptoms including headache (lines 3,5). In contrast with patients as in extracts (1–2), the daughter incorporates the description of pain among other conditions the patient has, treating pain alone as not adequately establishing the reason for visit (Table 8).
Table 8 Extract (5) 10.05-2.
1
NUR:
2
eti pwulphyenhay-se o-sye-ss-eyo:? where uncomfortable-so come-HON-PAST-DEF Where is it uncomfortable so that you came:? (0.5)
3
DAU:
sok-i wullengkeli-kwu-yo: stomach-NOM nauseous-CONN-DEF She says she is nauseous and:
4
NUR:
ney. yes Yes.
5
DAU:
meli-ka aphu-si-kwu-yo head-NOM hurt-HON-CONN-DEF [cakku thoha-si-llye kule-sin-tay-yo. repeatedly vomit-HON-PURP do.so-HON-HEARSAY-DEF Her head hurts and [she keeps feeling she’s going to vomit.
6
NUR:
[ney. yes [Yes.
7
NUR:
e: yeki anca.po-sey-yo: uh here sit.try-HON-DEF Uh: have a seat here:
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What is to be noted is that the daughter frames the description of the patient’s conditions with a particle -tay (line 5) which indicates the talk as a saying from another party (‘She says’ in English translation at line 3). The conditions presented, including pain, concern the patient’s subjective feelings, which the accompanying person cannot know directly. They are experiences ‘owned’ by the patient, and, relative to the patient, the accompanying person does not have primary epistemic access to them [38–41]. Thus, rather than claiming that the patient has these symptoms, the daughter marks them as a report from the patient. In this way, the daughter displays herself as a reasonable or ‘objective’ third party who withholds a claim on physical conditions she doesn’t have direct access to. Similarly in extract (6), the mom presents pain as a report of what the patient said (-tay ‘he says’ at line 2). She withholds making a claim on her own part toward the patient’s pain she cannot know directly [38,39] (Table 9). In addition, the mom immediately follows the report of pain by invoking a prior medical visit (lines 2–5). In contrast with patients who, even with a prior medical visit, focus on presenting their physical conditions (extracts (3–4)), the accompanying person
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here describes the previous medical visit as early as in her first turn. Rather than orienting to the report of pain as adequate, the mom evidences the patient’s pain by providing more objective information that she has direct access to and that can indicate seriousness of the complaint. In so doing, the accompanying person displays relevance of, and reasonableness in, seeking emergency care [26]. Most accompanying persons constructed problem presentations by describing conditions they can observe, rather than conditions only patients can feel and have privileged access to [38– 40]. In extract (7), the mom and the patient described abdominal pain during the history-taking phase of the visit (data not shown). In constructing problem presentation, the mom starts by describing vomiting (line 3), which is a condition she can observe and know without having a first-hand experience. The mom projects a further unit of talk with -kwu ‘and’ in the description (line 3), although the nurse cuts in by requesting to have the patient seated (line 4) (Table 10). At line 5 the mom produces the projected (but interrupted) unit of talk by describing another condition she observed, which can indicate seriousness of the problem, and marks it as establishing
Table 9 Extract (6) 10.15-3.
1
NUR:
eti apha-se wa-ss-eyo?= where hurt-so come-PAST-DEF Where does it hurt so that you came?=
2
MOM:
=bay-ka aphu-tay-yo: = stomach-NOM hurt-HEARSAY-DEF
kun- (.) ceki- naka-ss-taka: there go.out-PAST-TRANS
[kunche soakwa-ey ka-ss-nuntey: nearby pediatrics-NOM go-PAST-CIRCUM =He says his stomach hurts:=and- (.) we went out- and: [went to the pediatrics nearby and: 3
NUR:
[yey. yes [Yes.
4
NUR:
yey. yes Yes.
5
MOM:
mwe
cang-i
ccoye-se
kule-nuni kul
sol-lul
what intestine-NOM obstruct-so do.so-DET do.so-ATTR talk-ACC ha-nuntey cwusa-lul han tay nwacw-ess-[ketun-yo? do-CIRUM injection-ACC one shot give-PAST-CORREL-DEF They said it’s because the intestine is obstructed and gave him an inject[ion? 6
NUR:
[eksureyi (.) X.ray ccik-ess-eyo? take-PAST-DEF [Did he get (.) an X ray?
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the reason for visit (‘so now we came’). The accompanying person thus completes the problem presentation by limiting the description to what she observed. The mom relies on her observations, rather than pain or other conditions only the patient can feel, restricting her claims to what she can accountably and responsibly know as a caregiver [38,39,42]. Finally, extract (8) illustrates a similar pattern in which the accompanying person elaborates on the patient’s conditions that are observed, in which process she shows seriousness of the problem. At line 2, the mom starts by describing high fever. She does not just claim, but evidences high fever by providing an objective measure (39 degrees Celsius) as well as its duration which is about 3 days (note that the visit occurred on Thursday). The mom thus displays seriousness of the fever on more objective grounds (Table 11). At line 4, by mentioning that the patient takes medications from the pediatrics, the mom suggests not only that the fever reducer the patient had taken (line 2) was prescribed but also that the patient’s conditions have not resolved with the prescribed medications. This can indicate seriousness of the problem as well as its relevance to (emergency) medical care. Then the mom describes further symptoms, coughing and vomiting, which she can observe and know as a third party (line 4). Throughout the presentation, the mom describes what she observed as a caretaker and indicates seriousness of the problem based on her observations. In this process, the mom displays herself as a sensible, responsible caretaker who has been attentive enough to take measures of fever and watch the conditions constantly, and reasonable enough to not rush to the emergency
care immediately but to make the visit based on her constant, watchful observations over the last few days [42]. Thus, when accompanying persons construct problem presentation, they engage in more elaborate descriptions that can communicate the relevance of seeking emergency care. Lacking direct access to patients’ own, subjective experience [38–40], accompanying persons tend to rely on their observations and/or more objective information–such as medical history, prescriptions, and physiological measures–as a basis for establishing the reason for visit. This is in contrast to patients who orient to descriptions of conditions they experience as comprising an adequate problem presentation. 4. Discussion and conclusion 4.1. Discussion We have shown that problem presentation constructed by accompanying persons is more extensive than that by patients. Patients tended to be succinct and simply describe physical conditions they directly feel, such as pain. This suggests that patients treat their problem as transparent so that it does not require further elaboration. Heritage and Robinson [26] showed that this pattern is prominent among patients with accidental injuries in US primary care visits. Injuries are often self-evident and transparent, and the physical presentation of injured parts of the body may establish patients’ chief problem. The patient’s similar use of interactional practices during triage seems to suggest that patients may treat their physical presence – the sick body – as an ‘evidence’ of their medical problem unquestionably requiring
Table 10 Extract (7) 10.19-23.
1
NUR:
2
eti apha-se wa-ss-eyo? where hurt-so come-PAST-DEF Where does it hurt so that you came? (0.5)
3
MOM:
4
NUR:
a tho-lul kyesok ha-kwu-yo: (.) [tho-eyuh vomit-ACC persistently do-CONN-DEF vomit-LOC Uh she vomits persistently and: (.) [in the vomit[yeki here ac-hi-sey-yo sit-CAUS-HON-DEF [Have her seated here.
5
MOM:
tho-lul hay-ss-nuntey: phi-ka: (0.8) nawa-kaciko icey vomit-ACC do-PAST-CIRCUM blood-NOM come.out-so now wa-ss-eyo come-PAST-DEF She vomited and: blood: (0.8) came out so now we came
6 7
(1.0) NUR:
um: myech.pen cengto hay-ss-eyo? how.many.times about do-PAST-DEF Um: about how many times did she vomit?
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Table 11 Extract (8) 10.20-11.
1
NUR:
eti-ka aphu-nka-yo? where-NOM hurt-DUB-DEF Where does it hurt?
2
MOM:
a yel-i manh-ko cikum hayyelcey mek-ko uh fever-NOM a.lot-CONN now fever.reducer eat-CONN wa-ss-nuntey samsip.kwu to-ye-ss-ess-kwu, ikey come-PAST-CIRCUM thirty.nine degree-be-PAST-PAST-CONN this hwayoil-pwuthe- welyoil pam-pwuthe kyeysok yel-i (.) Tuesday-from Monday night-from persistently fever-NOM ollaka-kwu-yo:, go.up-CONN-DEF Uh she has high fever and she took a fever reducer and came and it had been thirty-nine degrees and, since Tuesday- since Monday night the fever persistently goes up and:,
3
NUR:
yey. yes Yes.
4
MOM:
wenlay soakwa-eyse mek-kwu-yo yak-un? originally pediatrics-LOC eat-CONN-DEF medication-TOP kichim-i- kichim-i ilehkey kyeysok memchwu-ci- anh-ko. cough-NOM cough-NOM like.this persistently stop-COMM-not- CONN kuliko tto thoha-ko. and also vomit-CONN She takes medications from the pediatrics and? coughingcoughing does not stop persistently like this. And she also vomits.
5
NUR:
6 7
ah DM I see (0.5)
NUR:
kunikka icey thoha-nun ke-nun kichim-i simhay-se so now vomit-ATTR thing-TOP cough-NOM severe-so thoha-nun ke-ci mwe nappa-se thoha- thoha-nun ke-n vomit-ATTR thing-COMM what bad-so vomit vomit-ATTR thing- TOP ani-cyo? not-COMM:DEF So about vomiting she vomits because the coughing is severe, not because something is bad, right?
emergency assistance. Triage nurses also treat patients’ simple description of pain or other conditions as adequately establishing the reason for visit. This may partly relate to the Korean system of emergency care. Although patients are categorized according to their urgency during triage, every incoming patient gets medical evaluation in Korean emergency departments. The role of triage nurses is mainly
to determine the order and priority of patients according to their urgency, not to screen out non-urgent or illegitimate patients. Patients may thus orient to the presence of pain or other physical symptoms as an adequate ground for seeking emergency care. Nurses likewise may not invite patients to provide further elaboration and justify their emergency visit.
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By contrast, accompanying persons – although under the same system – tended to be more concerned with establishing the relevance of seeking emergency care. They tended to describe physical conditions they can observe as a caregiver, rather than subjective feelings such as pain, and provide information other than current symptoms such as medical history, medications, or physiological measures, which can explain the more extensive nature of their problem presentation compared to patients’. Accompanying persons are not patients and thus do not own patients’ experiences [28]. Patients’ own experiences are ‘theirs’ to know and describe; and relative to patients, accompanying persons have limited access or rights to know and describe those experiences [38–41]. Accompanying persons may observe, but lack direct access to, physical conditions patients themselves are experiencing, and thus be restrained in understanding their severity. Nonetheless, they may have to make a decision to visit the emergency department and describe patients’ problems. Thus, when presenting patients’ problems, accompanying persons may carry the burden of establishing the relevance of seeking emergency care, such as how or on what basis they know about the problem and its severity, unlike patients who can claim their own physical conditions and make decisions based on direct experience [38]. Accompanying persons may thus work to evidence and account of seriousness of patients’ problems on more objective grounds and establish reasonableness in seeking emergency care. This aspect of problem presentation has been discussed in prior research in terms of ‘doctor-ability’: a doctor-able problem is one that is worthy of medical attention and evaluation [22,26]. In US primary care visits, patients are primarily occupied with establishing doctorability in constructing problem presentation [22,26]. The issue of doctorability may be prominent in emergency care visits, because patients may also have to establish their problem as one that is worthy of emergency care in particular. In the present study, however, it is accompanying persons rather than patients that are concerned with establishing (emergency) doctorability. This is distinctive in that in US primary care parents accompanying pediatric patients tend to have somewhat ‘relaxed’ concerns with legitimizing their visit, compared to adult patients [42; cf. 26]. Further research is needed to investigate whether the pattern examined in this paper is particular to Korean contexts. 4.2. Conclusion When accompanying persons present patients’ problems, problem presentation shows different interactional patterns from
those in patients’ own presentation. In the process of problem presentation, accompanying persons may also communicate their reasonableness in seeking emergency care. Thus, problem presentation during triage does not just concern description of patients’ problems. At least for accompanying persons, it may also serve as a site for portraying reasonableness and caretaker responsibility. 4.3. Practice implications Triage nurses may utilize more facilitative questioning practices when interacting with patients who themselves present their problem. Because patients do not frequently offer various aspects of symptoms or other contextual information, this may present difficulties in assessing the clinical urgency. Nurses may need to make efforts to get a fuller array of patients’ conditions through questioning. When interacting with accompanying persons presenting patients’ problems, triage nurses may acknowledge legitimacy of the visit as a way of addressing the concern of doctorability. In addition, because accompanying persons tend to rely on their observations in presenting the complaint, physical conditions and their severity patients actually experience may be different from, or may not be included in, accompanying persons’ descriptions. Providers may need to ask patients directly to better assess the severity of conditions patients themselves experience. Finally, in providing treatment medical providers may explain to accompanying persons some conditions of the patient that will show resolution of the problem. Because accompanying persons tend to rely on their observations, their understanding of the relief of patients’ conditions may be likely shaped by what they observe. This may be different from patients’ own perception of relief, as in prior research that documented greater resolution of pain reported by pediatric patients than appreciated by their parents [43]. Providers’ explanation of signs or conditions of relief may help accompanying persons better understand patients’ recovery process, which may lead to satisfaction with the outcome of medical care. Acknowledgements Research for this study was supported in part by the National Research Foundation of Korea Grant funded by the Korean Government (KRF2009-361-A00027). The funding agency supported equipment for video-recording and digitizing, and had no involvement in the design of study, analysis and interpretation of data, writing of the report, and decision to submit the paper for publication.
Appendix. Transcription conventions The typed extracts represent efforts to indicate how the words were actually produced, according to transcription conventions used in conversation analysis. Listed below are the symbols used in the extracts in Section 3.2. [
Left-side square brackets indicate an onset of overlapping talk.
=
Equal signs indicate no gap of silence between utterances either by the same speaker or by different speakers.
(0.5)
Numbers in parentheses indicate silence, measured in seconds and tenths of a second
(.)
A period in parentheses indicates a micropause of less than 0.2 second.
.
A period indicates a falling, or final, intonation, not necessarily the end of a sentence.
?
A question mark indicates rising intonation, not necessarily a question.
,
A comma indicates continuing intonation, not necessarily a clause boundary.
::
Colons indicate the prolongation or stretching of the sound just preceding them.
word-
A hyphen indicates that the preceding sound is cut off or self-interrupted.
word
Underlining indicates some form of stress or emphasis, either by increased loudness or higher pitch.
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