Papers
Distributed decision making: The anatomy of decisions-in-action
Sociology of Health & Illness, 2008, Volume 30 Issue 3, Pages 429 - 444
Conceptualising the doctor-patient relationship has been a central project for both medicine and medical sociology. This paper seeks to show how an understanding of the distributed nature of medical practice can help us research the decision-making process in doctor-patient encounters. I draw on a range of empirical studies of medical interaction, knowledge, technology and work in primary and secondary care. I describe the ‘ethno-methods’ (Garfinkel 1967) of patient-orientated medical decision making in order to highlight some of the fundamental facets of distributed decision making. Initially, I outline how decision making is an ongoing event that often evolves over multiple encounters. I then show how decision making is never just a solo, cognitive, activity but rather distributed over a range of people. Finally, I outline how decision making is initiated, sustained and transformed over a range of encounters with both people and technologies. I argue that recognising the distributed nature of decision-making shifts the focus from overly prescriptive visions of decision-making to more plausible, albeit, more mundane sets of ideals. Centrally, a focus on distribution offers new opportunities to actively engage with, support and research decision-making-in-action.
Like (4)Doctor–patient interaction in a randomised controlled trial of decision-support tools
Social Science & Medicine, 2006, Volume 62, Issue 9, Pages 2267-2278; Co-authored with Carl May, Ben Heaven, Madeline Murtagh, Ruth Graham, Eileen F.S. Kaner and Richard Thomson
In this paper, we draw on the analytic perspectives of ethnomethodology to explore doctor-patient encounters in an experimental trial of a complex intervention: an efficacy randomised controlled trial (RCT) of decision-support tools in the UK. We show how the experimental context in which these encounters take place pervades the interactions within them. We argue that two interactional orders were at work in the encounters that we observed: (i) the ceremonial order of the consultation and (ii) the assemblage of the decision-support tool trial. We demonstrate how doctors in the trial oscillate between positions as authoritative clinician and neutralistic decision-support tool-implementer, and patients move between positions as passive recipients of clinical knowledge and as active subjects required to render their experience as calculable in terms of the demands of the decision-support tools and the broader trial they are embedded in. We demonstrate how the RCT coordinates the world of the clinical environment and the world of experimental evidence.
Understanding the implementation of complex interventions in health care: the normalization process model
Carl May, Tracy Finch, Frances Mair, Luciana Ballini, Christopher Dowrick, Martin Eccles, Linda Gask, Anne MacFarlane, Elizabeth Murray, Tim Rapley, Anne Rogers, Shaun Treweek, Paul Wallace, George Anderson, Jo Burns and Ben Heaven. Published in BMC Health Services Research 2007, 7:148
Background
The Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice. It offers a framework for process evaluation and also for comparative studies of complex interventions. It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice.
Methods
A formal theory structure is used to define the model, and its internal causal relations and mechanisms. The model is broken down to show that it is consistent and adequate in generating accurate description, systematic explanation, and the production of rational knowledge claims about the workability and integration of complex interventions.
Results
The model explains the normalization of complex interventions by reference to four factors demonstrated to promote or inhibit the operationalization and embedding of complex interventions (interactional workability, relational integration, skill-set workability, and contextual integration).
Conclusion
The model is consistent and adequate. Repeated calls for theoretically sound process evaluations in randomized controlled trials of complex interventions, and policy-makers who call for a proper understanding of implementation processes, emphasize the value of conceptual tools like the Normalization Process Model.
The art(fulness) of open-ended interviewing: some considerations on analysing interviews
Qualitative Research, 2001, Vol. 1, No. 3, 303-323
Considerable analytic attention has focused on interviewees' talk as 'accounts', or 'versions', rather than as direct reports of attitudes or perceptions. However, despite recognition of the 'co-construction of accounts', little analytic attention has been given to the interviewer as central in the production of the talk. With this attention, we are left with an analysis of some decontextualized-features-of-talk (or discourse/identities/narrative/repertoires/ rhetoric). By contrast, this article argues that interviews are inherently social encounters, dependent on the local interactional contingencies in which the speakers draw from, and co-construct, broader social norms. Through a close reading of one published paper and extracts from an interview, I document how interviewees and interviewers work to construct themselves as certain types-of-people in relation to the topic of the interview and reflexively the interview itself. I then show how a prescription from some interview methods texts document an ideal about interview practices. The analysis of the interview extracts shows this ideal-in-practice (cf. Hester and Francis, 1994). I argue that whatever ideals are practised, no single practice will gain 'better data' than the other practices. The 'data' obtained are highly dependent on and emerge from the specific local interactional context which is produced in and through the talk (and concomitant identity work) of the interviewee and interviewer. An awareness of this local context of data production is central to analysing interview data whatever analytic stance is taken when analysing the data.
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