Conversation-Analytic Research on Communication in Healthcare: Growth, Gaps, and Potential

If there was an average day for the National Health Service in England, more than 1.2 million people would attend a primary care appointment, nearly 260,000 people would attend a secondary care outpatient appointment, more than 37,000 people would call the emergency medical service, and more than 44,000 people would attend a hospital emergency department (The King’s Fund, 2023). Of course, the average day will differ across different countries and health systems, as will different peoples’ experiences of care. However, across every healthcare encounter there is a common factor central to peoples’ experiences and healthcare outcomes: communication. Understanding the practices of communication in healthcare, and creating an evidence base for improving its effectiveness, is thus a worthwhile and valuable endeavor.

As most of our readers will know, conversation-analytic (from hereon CA) studies yield robust, empirically grounded observations and insights from the systematic examination of naturally occurring (recorded) interactions. This requires investing time in the processes of data collection and in careful analysis. This time-cost is justified because the findings are so much richer and practically valuable than faster approaches that rely on indirect data. By indirect data, we mean opinion, post hoc reports, or ethnographic observations about what, when, and how people communicate. These indirect data are flawed because what people can observe and report about communication neither captures nor articulates the multifaceted, fast-moving ways in which we use, combine, and orchestrate verbal and non-verbal components of interaction. Nor can indirect data capture how we modify and adjust our conduct in response to the unique local circumstances in which we find ourselves, and in response to the particular person/s we are with. In contrast, we can, on the basis of thorough analysis, describe and explicate the social and interactional demands entailed in interactions, and the ways people manage these demands and thereby accomplish healthcare tasks. From the perspective of mainstream health services research, CA might be seen as “slow science”; however, we believe the methodological commitment to close and rigorous observation and the refusal to give in to demands for practical relevance alone have held us in good stead.

Recent years have seen the scope of CA studies of communication in healthcare widening. For CA scholars working in the field, this growth is something to celebrate, yet, at the same time, it presents an opportunity to take stock of the knowledge produced, to critically reflect on strengths and weaknesses of existing work, and to envision future research. Our aims for this special issue were threefold: first, to showcase the distinctive contributions CA studies of communication in healthcare have made, both to health services research and to the central goals of CA as a discipline—“the discovery of social actions and the full documentation of their normative-moral accountabilities” (Raymond & Robinson, 2024); second, to stimulate critical reflection about what has come under the researchers gaze - which participants, at what particular point in time, and in what particular circumstances; and, finally, to curate a collection of expert and comprehensive reviews, synthesized into coherent summaries, for CA scholars, health services researchers, clinical educators, and healthcare professionals. We have a great tradition in our discipline of building on what is already known and hope that these summaries, and their key findings and arguments, will help to generate yet more worthwhile and valuable evidence in the future.

Distinctive contributions to healthcare research

CA research has, as the reviews in this special issue document, already contributed a distinctive tranche of evidence on everyday practices of communication in healthcare. It therefore has the potential to effect behavioral changes toward the improvement of healthcare outcomes. Findings from CA studies have been used as the basis for “successful” clinical interventions in different healthcare settings, reporting statistically and clinically significant changes in health professionals’ communication behaviors and consultation outcomes (Kronman et al., 2020; McCabe et al., 2016). In contrast, interventions based on evidence from indirect data (opinion and post hoc reports about communication) have found, at best, only small and short-lasting effects on health professionals’ communication behaviors (see Parry et al., 2022).

CA research also holds the potential to influence health policy and policy-led interventions, guidance aimed at healthcare professionals, and clinical education curricula. For example, several of our reviews demonstrate the particular and distinctive contributions CA research can make to evaluating the implementation of health policy interventions (Ekberg et al., 2024) and professional guidance (Seuren et al., 2024). Others show how CA studies can furnish understandings about health policy implementation problems while also providing alternative solutions (Parry, 2024), and how the cumulative knowledge from CA research on communication in healthcare can provide an evidence base for communication skills training (Barnes & Woods, 2024).

Health policy, policy-led interventions, and professional guidance are usually inspired by statistics and population health imperatives and introduced at scale and pace, prior to real-world evaluation. By studying the interactional consequences of such interventions “in the wild,” CA evidence and insights can confirm or reject unwarranted assumptions, add new dimensions of understanding, or evidence unintended consequences (Peräkylä & Vehviläinen, 2003). Evidence-based resources for how new policies and guidance could be operationalized interactionally are rare. Yet CA studies can provide detailed specifications of practices required (Peräkylä & Vehviläinen, 2003). Furthermore, CA studies can explain why policy or guidance that might seem rational and reasonable is sometimes not implementable in ways assumed by those who create and promulgate it (Pilnick, 2022).

Contributions to the wider discipline

As pointed out by Heritage and Maynard, the “interactional practices through which persons conduct themselves elsewhere are not abandoned at the threshold of the medical clinic. That is, the organization of interaction described in CA studies of ordinary conversation … is largely carried forward from the everyday world into the doctor’s office” (2006b, p. 362).

Indeed, recorded healthcare interactions can provide rich and plentiful data on some of the interactional phenomena and challenges of fundamental interest within CA: matters such as agency, epistemics, delicacy, and participation. The reviews in this issue were confined to studies that focused on communication in healthcare. Nevertheless, because CA is a comparative and cumulative science (Drew & Heritage, 1992), the insights and evidence from these reviews articulate with and build on scholarship in the discipline more broadly. For instance, Jenkins and colleagues’ review (2024) of pediatric interaction yields insights into how co-participants can enable or constrain the involvement of other participants. These insights interconnect with broader central concerns about the nature of membership and personhood, and how identities are constructed via interactional practices. As a further example, Parry’s review (2024) of end-of-life-related and palliative care interactions examines recurrent practices and patterns entailed in cautious, step-by-step movement into topics that are highly delicate, salient, and emotionally laden. The studies in these particular settings extend both the detail previously documented in CA research on delicate interactions and the evidence that some practices and patterns are highly recurrent.

Critical reflections

A critical observation made by several contributors to this special issue is that the focus of the research reported does not always represent the exigencies of real-world practice. For example, Barnes and Woods (2024) reflect that most CA research in primary care has focused on physician–patient interactions that do not reflect modern trends toward task-shifting and task-sharing with non-medical professionals. Riou (2024) notes that, although nonurgent calls represent a sizable and growing part of the workload of emergency medical services, they have seldom been the focus of CA research on emergency care. Seuren et al. (2024) note that telephone consultations are increasingly frequent but that, to date, the bulk of research on telehealth has examined video-mediated care. This is especially unfortunate because telephone consultations are important for increasing healthcare access for underserved populations, including people in rural and remote locations and in lower- and middle-income countries (World Health Organization, 2020). Moreover, Parry’s review of research on end-of-life and palliative care conversations (2024) found that the vast majority of research in this field has been conducted in tertiary care, with specialist medical practitioners. She notes that this contrasts with everyday practice in which care for terminally ill people and end-of-life conversations are mostly delivered by nurses and assistant practitioners and in the community.

The reviews also shed light on the fact that CA research in healthcare has largely focused on professional agendas rather than the priorities of patients or the public. To do so would require involving charities, patients, and/or members of the public as partners or stakeholders when developing projects and funding applications. Most of the research studies reviewed were set in Westernized healthcare systems in higher-income countries (the vast majority in the United Kingdom, the United States, Western Europe, and Australia). Furthermore, although many of the studies reviewed failed to report sufficient detail on the settings for data collection and on participant demographics, those that did most often reported White, highly educated patient populations. To avoid reproducing inequities, we encourage studies in settings that have been largely neglected to date (e.g., deprived and rural areas, low- and middle-income countries), and the inclusion of more diverse and underserved participants. Better reporting is important, not in order to support a priori speculation about the motives and orientations of participants but, rather, to enable interactional evidence of implicit bias to be documented. If we are committed to embedding equity, diversity, and inclusion considerations in our research so as to examine interactions with the breadth of patients seeking healthcare, then our research teams, study designs, methodological practices, and the training provided for our field researchers needs to reflect this.

Seuren et al. (2024), and Dooley and Webb (2024) raise the costly and time-consuming nature of conducting research studies that are more inclusive of underserved patient groups and/or of particularly challenging healthcare circumstances. They call for funders to recognize the costs of inclusive, rigorous research. We would add that those writing research funding applications need to carefully justify the costs entailed in studies that are more inclusive. For example, studies that include people who do not speak the majority language in a location require inclusion of costs to pay for translators, plus transcribers and analysts who are specialists in the other language. Studies that involve international collaboration—particularly when healthcare interactions data are being collected in lower-income countries and perhaps for the first time—would benefit from initial “seed corn” funding to enable time for relationship building, access negotiations, carefully planned data collection, and the development of mutual understanding to support culturally competent analyses.

Another approach to increasing inclusivity is proposed by Dooley and Webb (2024). In the context of primary care research, they note that, even when an inclusive approach to recruitment is applied, people with learning difficulties will represent such a minority of service users that few if any individuals will be recruited by any one study. They propose that informed consent for reuse is sought at the point of recruitment, and researchers collaboratively amass a shared dataset—in their case, a shared dataset of healthcare interactions involving a person with learning difficulties. They point out that data sharing not only would reduce data-collection costs and participant burden but could also help build collections of interactions with underserved populations in different healthcare settings for future research. Needless to say, strict safeguards would need to be applied to any such data sharing, and we appreciate that, in certain circumstances, this would be very hard to achieve.

There are reasons for optimism: In some countries—particularly in North America and, more recently, the United Kingdom—research funders and bodies that provide ethical oversight have committed to embedding equity, diversity, and inclusion to improve the relevance and quality of all health research, and to supporting the sharing of research data in appropriate ways.

Introducing the reviews

This special issue features seven “state-of-the-art” reviews of CA studies of communication in healthcare by authors who, between them, have reviewed more than 550 studies from 27 countries and spanning 24 languages. State-of-the-art reviews entail producing a broad overview of research to date in a particular field, with the reviewers’ expert, informed take on the field having a significant role in both analysis and discussion (Barry et al., 2022). Accordingly, we invited an international group of contributors on the basis of their expertise in, and commitment to, the domain they examine. We asked them to provide context and background; to detail their methods; to chronologically tabulate the publications they reviewed; to synthesize their findings; to discuss applications; to reflect on the contribution of the research to the wider scholarly field of CA, to CA research in healthcare, and to healthcare policy, practice, and education; and, finally, to identify future research directions.

Three of the reviews focus on specific services: primary care (Barnes & Woods, 2024), secondary care (Ekberg et al., 2024), and emergency care (Riou, 2024). One focuses on the rapidly growing field of telehealth, in which care is delivered via video, telephone, or text (Seuren et al., 2024). Three reviews focus on healthcare interactions with particular patient groups: children, young people and their caregivers (see Jenkins et al., 2024), people whose interactional practices and capacities are—at least at some times or in some aspects—divergent from the majority of the population (Dooley & Webb, 2024), and people receiving palliative care and/or those whose care includes conversations about end-of-life and associated preferences and care plans (Parry, 2024).

In their review, Barnes and Woods reflect on four decades of CA studies of communication in primary care. They illustrate the progression of the research in three broad themes: managing agendas, managing participation, and managing authority. They contextualize their findings, with topics in the wider primary care literature and professional guidance. Within each research theme they bring together systematic and differential practices of action, making comparisons across different languages and health systems where possible. They highlight the evidence that, although patients have multiple ways of voicing their own agendas, ideas, and concerns, their success in terms of getting them addressed wholly relies on physician collaboration. This finding runs contrary to the professional literature, which recommends that physicians work to discover the “patient’s perspective.” They also argue that CA studies in primary care have helped to expand our methodological reach as a discipline.

Ekberg and colleagues review secondary outpatient care and report their findings in terms of five clinical activities: information gathering and patients’ descriptions of their condition; information delivery, including test results and diagnosis; decision-making about goals, treatment, and future care; interacting about sensitive issues, including patients’ emotions and psychosocial concerns; and, finally, managing the interactional role of accompanying companions. Their commentary includes examples of how the findings of some of the studies they reviewed have fed into national policy and into online training resources.

Riou reports on a decade of CA studies of communication in emergency care, both pre-hospital (calls to emergency medical services and paramedic interactions with patients/companions) and in-hospital (interactions in emergency departments among health professionals and with patients/companions). She demonstrates how CA studies on pre-hospital emergency care—the oldest form of telehealth—have recurrently shown participants both enacting and pushing back against sequential and time constraints, and she makes a case for the contribution made to wider CA research on telephone calls. In contrast, Riou notes that CA research on in-hospital emergency care is still developing and that much remains to be investigated. She also argues for the value of CA studies investigating simulations—a core part of clinical training, given the fast-paced, high-stakes environment of a medical emergency, when patients are at their most vulnerable.

Seuren and colleagues examine telehealth in all its forms: that is, care delivered via telephone, video, or text. Despite the heterogeneity of this field of CA research, they provide an orderly and integrated set of findings organized in terms of the interactional organization, the therapeutic relationship, and the clinical activities of the encounter. Their reflections and commentary include clearly articulated arguments about CA’s unique position in terms of being able to deliver evidence-based recommendations, and they problematize a widely held assumption—arguing that telehealth should not be assumed a priori to be inferior to in-person care.

Jenkins and colleagues review CA studies of communication in pediatric healthcare, examining interactions about, and involving, child patients across a number of diverse settings. Their review highlights features of diagnostic and treatment decision-making discussions between health professionals and caregivers. They also illuminate how caregivers can be supported to deliver crucial therapeutic and clinical care. Equal consideration is given to the tangible practices by which children assert or are invited to demonstrate the role of competent child patient. They closely examine children’s participation, revealing the mechanisms that constrain and enable their involvement. They argue that CA work on children may benefit from a more joined up approach and draw attention to the potential for CA scholars to contribute to wider methodological debates regarding research on and with children.

Dooley and Webb’s review interrogates the notion of “atypical communication” through the lens of the social relational model of disability. One key focus of their findings is on CA studies that have shown that behaviors often medically interpreted as symptoms are, in fact, recognizable as displays of interactional competence. They also examine health professionals’ practices that can reduce interactional challenges in communicating with people who, at least in some circumstances, interact in atypical ways. Their reflections on issues of equity, diversity, and inclusion are relevant for the entire field of CA research.

Parry’s review focuses on CA research to date on palliative care interactions and on research in other settings in which conversations about the end of a patient’s life occur, either with the patient him- or herself or with a close family member. Her review focuses on cumulative findings about the stepwise, cautious practices people use to initiate sensitive conversations about prognosis and end-of-life and to manage emotions. Another theme examines how and why—in contrast to current guidance—practitioners, patients, and close family members rarely use the most direct form of reference to dying and death. Within her reflections and commentary, she notes the important contribution that the reviewed studies make to broader CA scholarship on delicacy, emotion in interaction, and indirect reference.

For practical reasons, this special issue is not representative of all CA research in healthcare. Other areas are ripe for reviewing, for example, maternal care and care for people living with mental illness. We also see room for reviews of CA studies focused on particular recurrent features and tasks of healthcare interactions. Among such recurrent features across multiple healthcare settings are the involvement of third parties, such as interpreters, or patients’ companions, such as accompanying family members. Among such common tasks across healthcare settings are conveying empathy, negotiating shared decisions, and advice-giving.

We hope you enjoy this special issue and that it provides insights and arguments that enhance your knowledge not only of CA research in healthcare but of the wider body of CA research.