Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20

Treatment Recommendation Actions,

Contingencies, and Responses: An Introduction

Tanya Stivers & Rebecca K. Barnes

To cite this article: Tanya Stivers & Rebecca K. Barnes (2017): Treatment Recommendation
Actions, Contingencies, and Responses: An Introduction, Health Communication, DOI:
10.1080/10410236.2017.1350914

To link to this article: http://dx.doi.org/10.1080/10410236.2017.1350914

Published online: 21 Aug 2017.

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 HEALTH COMMUNICATION
https://doi.org/10.1080/10410236.2017.1350914

Treatment Recommendation Actions, Contingencies, and Responses: An Introduction

a b
Tanya Stivers and Rebecca K. Barnes
a
Department of Sociology, University of California Los Angeles; bSchool of Social and Community Medicine, University of Bristol

ABSTRACT
In the era of patient participation in health care decision making, we know surprisingly little about the
ways in which treatment recommendations are made, the contexts that shape their formulation, and the
consequences of these formulations. In this article, we introduce a systematic collective investigation of
how recommendations for medications are responded to and made in primary versus secondary care, in
the US versus the UK, and in contexts where the medication was over the counter versus by prescription.
This article provides an overview of the coding system that was used in this project including describing
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what constitutes a recommendation, the primary action types clinicians use for recommendations, and
the types of responses provided by patients to recommendations.

In the era of patient participation in health care decision
making, we know surprisingly little about the ways in
which treatment recommendations are made, the contexts
that shape their formulation, and the consequences of these
formulations. There is a growing body of conversation
analytic work concerned with how treatment decisions are
reached in a range of clinical settings, including pediatrics
(Stivers, 2007); general practice (Koenig, 2011); oncology
clinics (Collins, Drew, Watt, & Entwistle, 2005; Costello &
Robert, 2001); and a range of others (Hudak, Clark, &
Raymond, 2011; Pilnick, 2008; Quirk, Chaplin, Lelliott, &
Seale, 2012; Toerien, Shaw, & Reuber, 2013). Yet this work
remains quite narrow in scope and is scattered across a
variety of medical specialties that are far from uniform.
This lack of systematic examination of treatment recom-
mendation action, design, and reception inhibits compara-
tive work whether by national context, medical specialty, or
patient demographics.
This project is part of a tradition that blends conversation
analytic work with interaction coding in order to facilitate
comparisons or investigations that are otherwise impossible.
Comparisons can be quantitative such as comparing question-
ing across different historical time periods (Clayman, Elliott,
Heritage, & McDonald, 2006) or comparing speed of turn
taking across languages and cultures (Stivers et al., 2009).
However, comparisons can also remain qualitative.
Regardless of whether the comparison is quantitative or qua-
litative, conversation analysis requires a collection of particu-
lar behaviors. This means that rules are necessary to
discriminate what “counts” as a particular communicative
behavior (Dingemanse & Enfield, 2015). This becomes all
the more critical when attempting to understand behaviors
across national contexts and across medical specialties where
we can expect big differences in recommendations.
This special issue is organized around a systematic collec-
tive investigation of how recommendations for medications
are responded to and made. This establishes a framework
within which we are beginning to examine how recommenda-
tions are shaped by whether or not the recommendation took
place in primary versus secondary care, in the US versus the
UK, and whether the medication was over the counter versus
by prescription. The five core contributions to this special
issue address these three main topics: 1) what constitutes a
recommendation for new medication, 2) how are recommen-
dation actions designed and formulated, and 3) how do
patients respond to these recommendations?
First, in terms of what constitutes a medication recom-
mendation, we were very broad. The general goal was to
identify utterances that patients typically treated as clear
recommendations. To ascertain the parameters for these
types of recommendation, preliminary work across the range
of different data sets was done to inform the final coding
scheme. In line with this, we included vague and general
recommendations “for treatment” or for “something” since
patients typically treat these as recommendations. We
included medication recommendations that were for prespe-
cified periods of time (e.g., 7 days), “as needed” medication
recommendations (e.g., cough medicine), and recommenda-
tions that were prescribed for indefinite periods (e.g., choles-
terol medication). Finally, we included in our definition of
medication both over-the-counter recommendations and pre-
scription medications.
Our pilot analyses suggested the exclusion of a variety of
medical recommendations on the grounds that they would
introduce more variation than we could hope to understand
at this point in time. Thus, for purposes of these analyses, we
excluded five types of recommendations. First, we did not
include any non-medication recommendations—referrals,

CONTACT Tanya Stivers stivers@soc.ucla.edu Department of Sociology, University of California Los Angeles, 375 Portola Plaza, 405 Hilgard Ave., Los
Angeles, CA 90095-1551, USA.
© 2017 Taylor & Francis Group, LLC
 2 T. STIVERS AND R. K. BARNES
medical tests, and treatment such as massage, icing, bandages,
and wraps. Relatedly, we excluded medication recommenda-
tions initiated by the patient through, for instance, a request.
Recommendations that were nth recommendations for the
same medication in the same visit were also excluded, as
were dosage changes to the same medication. We also
excluded recommendations that were “contingent” on the
future presence of symptoms or other factors not currently
present. Thus, recommendations for medication “if you start
having headaches” in a patient who has not reported any
headaches would not have been included. Finally, utterances
such as “Have you tried Robitussin?” were not included as
recommendations because these were rarely treated as such
and were normally understood as preliminary to actual
recommendations (Barnes, in press).
With these concepts and issues in mind, we had a goal to
identify 120 encounters that contained at least one recommen-
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dation for a new medication in each clinical context. However, in
specialty care, there were often no recommendations for new
medications, so the data sets were not necessarily large enough to
identify this many. In the end, we identified 794 recommenda-
tions for medication of which 62% were from the UK data and
38% were from US data. Of the UK data, 80% were from primary
care. The remainder were from specialty care practices. Within a
central focus on how treatment recommendations are presented
to patients, and whether and how patients received them, each
article in this issue examines a subset of the data focusing either
on a particular type of medical recommendation and its imple-
mentation within a medical specialty and/or cross-national com-
parisons within primary care.
The dimensions on which our coding scheme focused are
summarized in Table 1. Although this special issue will not
explore all of these, we provide them as background because
they nonetheless informed our thinking about treatment
recommendation delivery and reception.
Interactional coding categories
Our coding scheme is squarely focused on interactional aspects
of the treatment recommendation turn and its reception,
together with a range of non-interactional variables itemized
below under “Covariates.” Our codes were informed by both
prior work by the authors and pilot work examining a smaller
subset of our data to identify the dimensions of variation
present in the data. Seven aspects of the treatment recommen-
dation sequence were ultimately identified and coded.
(1) We identified the main social actions being relied on
by physicians to present recommendations. These
actions differ broadly in terms of who is being treated
as the instigator of the recommendation and who is
treated as the decision maker and highlight different
aspects of the recommendation in terms of whether it
is, for instance, optional or speculative.
(2) Within each social action type, we assessed the
strength of the physician’s endorsement of the med-
ication. We did this by holistically rating the recom-
mendation as strong to weak, relative to other
recommendations within the same action type.
(3) We examined whether or not patients were presented
with recommendations for multiple medications
including situations in which patients are presented
with a list of medications indicating that patients can
choose from any in a class (e.g., “I’d recommend X, Y,
or Z or whatever your favorite cough medicine is”
where each is the name of a cough medicine) and
fixed alternatives for patients to choose among.
(4) We coded how the physician’s reference to the med-
ication is done. We identified four possibilities: by
drug name, drug class, a pronominal reference, or a
“generic” reference (e.g., “some treatment” or
“something”).
(5) Some of the recommendations physicians made
invoked a reference to partnership with the patient
through the invocation of “we” or “us.” We coded for
this, excluding physicians’ use of the “institutional we”
as in “We usually prescribe X for this.”
(6) Because utterances containing recommendations nor-
mally have identifiable turn-constructional unit
boundaries inviting of response, we examined whether
those boundaries were clearly present or were, alterna-
tively, obscured by grammatical continuations or other
practices for turn extension. Where turn-construc-
tional unit boundaries were clear, we coded an
“opportunity space” for response as present. The
motivation for this code was to assess whether patient
responsivity is affected by the clear presence of an
opportunity space for response or not.
(7) We assessed the patient’s uptake of the treatment
recommendation turn as absent, acknowledging, nod-
ding, accepting, or resisting. We based our assessment
on the first form of uptake in the event that there were
multiple forms of uptake and on the strength in the
event that, for instance, nodding and verbal acceptance
were done simultaneously.
Covariates
We coded five classes of covariates: (i) national and specialty
context; (ii) physician and patient demographic information
including gender, age, and race/ethnicity; (iii) type of medical
condition (chronic, intermittent, or acute, on the one hand, and
existing or new, on the other hand); (iv) medication variables
including primary class; whether the prescription was over the
counter or by prescription in the national context; and risk of
addiction; and (v) outcome variables including diagnosis and
whether the medication being recommended was ultimately
prescribed/recommended.
Future studies on these data will provide more analysis of
the relationship between covariates and interactional vari-
ables. In the present collection, we focus primarily on the
interactional dimensions of the study.
This issue
In this volume, Stivers et al. examine the most common ways
that primary care providers in the US and the UK recommend
treatments, what conditions the use of particular treatment
 HEALTH COMMUNICATION 3

Table 1. Overview of coding dimensions.

Options (if
Coding Dimension applicable Explanation Example (if applicable)
Social action
Pronouncement Physician asserts recommendation as instigator, decision maker and presents as “I’ll start you on X”
already determined
Suggestion Physician recommends as instigator but treats patient as decision maker and “You could try X”
medication as optional
Proposal Physician recommends as instigator but decision making is treated as shared by “Let’s try X and see how that goes”
doctor and patient. Proposals highlight the recommendation as speculative
Offer Physician treats patient as having instigated recommendation and as the “Would you like me to give you X”
decision maker, thus treating medication as having been occasioned.
Assertion Physician asserts a generalization about a treatment’s benefit implying a “X is good for this”
recommendation but not proffering an overt directive.
Strength of
Endorsement
Weak-Moderate The recommendation is treated as ranging from likely to improve the patient’s Pronouncement: “I’d like to start
health to of only marginal value to the patient you . . .”
Suggestion: “You might want to
think about . . .”
Proposal: “We could try . . .”
Offer: “I’d be willing to let you try
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X”
Assertion: “Some of my patients
have felt that X helped them.”
Strong The recommendation is treated as a necessity or as very important Pronouncement: “I’m gonna start
you on. . .”
Suggestion: “You really ought to
try . . .”
Proposal: “Shall we start on . . .”
Offer: “I could give you . . .”
Assertion: “Most people find that
X relieves their symptoms.”
Multiple medications
No alternatives One medication is recommended. “Try Ibuprofen”
Patient choice Patients are offered a fixed number of choices, usually two or three. “You could use either Tylenol
or Motrin”
Medication list A series of several medications are mentioned suggesting to the patient that any “Try robitussin or triaminic or
of that sort of medication is appropriate. whatever your favorite cough
medicine is”
Medication reference
Drug name The recommendation is made through a specific reference to the name of the “I’ll start you on Amoxicillin”
drug.
Class name The recommendation is made through a reference to the class (e.g., antibiotics, “We can put you on an antibiotic”
pain killers, decongestants)
Generic The recommendation does not specify the class or drug name (e.g., “treatment” “I’ll give you something for the
or “something”) infection”
Pronoun The drug may have been mentioned already but the actual recommendation is “Let’s give it a try”
made with a reference to the medication by a pronoun.
Partnership reference
Yes/No A reference to “we” or “us” that invokes the doctor and patient (but not the “Let’s see how it goes with the
doctor and other professionals or the institution) cream first”
Opportunity space
Yes/No The physician approaches and reaches a TCU boundary at the end of the —
treatment recommendation rather than building the turn to avoid such a
transition relevance place (TRP).
Patient uptake
None The patient does nothing in response to the recommendation turn. —
Acknowledgment The patient’s response is not clearly understandable as acceptance but does Uh huh, Mm hm,
receipt the physician’s turn.
Nod In the absence of a vocal response, there is a head nod in receipt of the —
physician’s recommendation turn.
Acceptance The patient vocally accepts the physician’s recommendation. Okay, That’s fine
Resistance The patient vocally resists the physician’s recommendation by questioning it, “I don’t need Y?”; “But I’ve been
challenging it, countering, proposing, or requesting an alternative medication. on Advil”

recommendation actions, and whether the actions relied on to
recommend treatment are associated with patient uptake.
They also explore the similarities and differences between
the UK and US cases. Thompson and McCabe take us to
UK Psychiatry to examine recommendation action and the
relationship between recommendation actions and patient
uptake. Toerien examines the use of one particular type of
action, assertions, in the neurology clinic context, which
provides a deeper analysis of the affordances of this recom-
mendation action.
Barnes explores where the boundary lies between pre-recom-
mendations—inquiries that are hearable as testing the waters for
a treatment recommendation—and actual treatment recom-
mendations for new medications in general practice care in the
UK. She asks whether recommendations that are preceded by
pre-recommendations are different from those that are not, and
 4 T. STIVERS AND R. K. BARNES
what effect these pre-recommendations might have on patient
uptake. Finally, Bergen et al. examine treatment resistance with
an eye toward explanations for resistance that are similar versus
at odds in the UK and the US primary care contexts.
This collection focuses on the treatment recommendation
action and uptake, from both a qualitative and a quantitative
perspective. We believe that this area is particularly rich with
regard to cross-national and cross-specialty comparisons. With
these studies, we hope to open up new areas for research that have
previously been unexamined. In particular, although researchers
have compared patients’ responses and physicians’ orientations to
patient uptake following diagnoses and treatment recommenda-
tions and other work has identified a difference between positively
presented recommendations for medication versus negative
recommendations, our work is the first to explore the range of
ways physicians actually positively recommend medications.
Together, the papers arising from this focused comparative
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study will make a substantial contribution to literature on doctor-
patient communication, treatment decisions, and shared decision
making. That we do this through data collected in two different
healthcare systems makes our collection particularly novel.
ORCID
Tanya Stivers http://orcid.org/0000-0002-1488-5685
Rebecca K. Barnes http://orcid.org/0000-0001-8844-7496
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