Balancing task focus and relationship building: asking sleepy patients about traffic risk in treatment initiation consultations

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In chronic disorders, the establishment and maintenance of a long‐term treatment relationship between clinicians and patients is an important communicative goal. At the same time, clinicians may sometimes be expected to act as state agents by prohibiting patients from taking part in potentially risky activities. These dual goals can be conflicting and may pose a communicative challenge. Health communication research has explored clinicians’ role as gatekeepers to rights involved with being ill and patients’ claims that their problems are worthy of medical consideration 1. A less studied area is how participants, in interaction, manage potentially limiting aspects of the diagnosis on patients’ everyday lives. By examining traffic risk assessment questioning in the context of treatment initiation for obstructive sleep apnoea (OSA) patients, the current paper begins to explore how clinicians and patients manage undesirable consequences of a diagnosis.
OSA is a highly prevalent chronic disorder often associated with obesity, hypertension and cardiovascular disease 5. The soft tissues of the upper airways collapse during sleep, which leads to repeated events of obstructed breathing (i.e. apnoeas), oxygen desaturations and poor sleep quality. The following sympathetic activation, with increased levels of catecholamines, leads to atherosclerosis and increased risk for cardiovascular morbidity and mortality 7. Psychosocial issues, such as depressive symptoms and poor self‐rated health, are also associated with OSA 8 and affect both the patient 9 and partner 10. A recent Swedish study found that 59% of middle‐aged primary care patients with diagnosed and treated hypertension had undiagnosed and untreated OSA 11. An explanation for this high number of untreated patients is that persons suffering from OSA may be unaware of their problems as they occur during sleep 12.
Obstructive sleep apnoea often requires lifelong treatment with continuous positive airway pressure (CPAP). To establish adherent CPAP use, several hospital visits are needed 14. In a study of adherence promoting aspects, patients identified trust, based on a good relationship with clinicians and an adequate introduction to the treatment, as essential 15. Because nonadherence is common, daytime sleepiness is a frequent problem both before treatment and later on 16. The association between daytime sleepiness and traffic accidents has led traffic safety authorities in many parts of the world to adopt guidelines or regulations regarding driving in OSA patients 17. Patients have described the fear of losing their driving license as a negative consequence of OSA 15. Accordingly, clinicians responsible for the initial treatment consultations should educate and motivate patients to use a treatment that is sometimes perceived as burdensome 12, as well as raise and assess issues of traffic risk that patients may want to avoid. Despite this complex communicative task, there is a general lack of studies examining clinician–patient communication in OSA.
In general, clinical encounters tend to be structured around clinicians’ questions and patients’ answers 21. A body of literature has begun to show the significance of question design – that is, how questions are formulated – for patient participation and/or satisfaction 22. In an early study, Robinson 25 noted that clinicians frequently verbally and nonverbally design questions in ways that steer patients away from raising additional concerns in the closing phase of visits. Heritage et al. 22 demonstrated that this practice has impact on patient participation. Moreover, Langewitz et al. 26 saw that when clinicians use an open question design, the probability of patients giving a negative emotional cue is ten times higher than after a closed question. Question design is consequential for answers because it prescribes an appropriate action; for example, the interrogative ‘Do you feel sleepy when driving?’ renders a ‘yes’ or ‘no’ answer relevant.
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