Figure 7.3 final.xls

Figure 7-2: Orientations,goals, knowledge, and decision-making analysis Time Turn Who
Transcript
First Level
Second Dr.
B's orientation and goal activation levels
A's orientation and g
Episode Parse
(starting at the beginning of the medical discussion)
(starting at the beginni
(See the description of A's agenda, in the narrative) Orientation legend: Dr. B
Orientation legend: A
(See the description of B's agenda, in the narrative) a. Gather/examine data for evidence-based medicine.
c. Encourage patient to eat properly.
d. Encourage patient to exercise properly.
d. Take doctor’s suggestions seriously, e. Encourage patient to take proper doses of medicines.
f. Take patient’s perspective seriously and interact accordingly, to maximize likelihood of recommendations being taken up.
Goal legend: A
Goal legend: Dr. B
That’s my little recorder, and it’s on…/ a. Go over the most recent test results (and causes; see goal c).
b. Compare these results with those from the previous visit.
Yeah. So here… This is the chapter that I sent you via email and c. Discuss any problematic lab scores.
this is the introduction to the book… [hands two chapters to B] d. Check with the patient regarding current dietary and exercise habits, and ask about changes from the previous visit.
f. Raise issue of test data not arriving.
e. Conduct a brief physical, examining the patient’s feet and anything Oh, very cool. So I can take this and plagiarize it and publish else that comes up in their discussion.
f. Recommend the appropriate diet/exercise regimen.
Of course – though if you publish it fast enough I can plagiarize g. Write lab slip for blood tests A should take before their next visit.
h. Respond to any of patient’s concerns.
k. Get lab slip for the next round of blo /‘cause my problem is that I haven’t gotten it written.
Orientations: Dr. B
Goals: Dr. B
Orientations: A
But then I’d have to understand the equations, that’d be too bad. So, very Um, So let’s look at your numbers.
Yeah. I didn’t get a copy of the report, even though I put on the front of the thing, “please send a copy to me,” I didn’t get it from them, I didn’t get it from your office, so I don’t know the numbers.
and medicines related to A's medical condition(s) Hmm. You had these done like a week ago./ /Last week and then I was out Monday and Tuesday…So you wouldn’t have gotten it from me yet. It was filled out Monday.
B turns to a major goal, a general check-in; Pretty well. I’ve been behaving myself and I’ve lost weight.
Although there’s a pretty strong discrepancy between your scale and ours, so Figure 7-2: Orientations,goals, knowledge, and decision-making analysis 182–183 and I’m about 5 pounds heavier here.
No, I took off my shoes and some stuff, so it’s close. Add maybe a pound or two.
But even by our scale, which is calibrated for here, You were 195 in March and you’re 188 now. So….
B confirms the weight loss mentioned by A Well, I told you I was going to behave myself.
So I’m curious to know about the HbA1C, because that should have gone That’s um….We did a lot of walking in Europe, so the interesting thing is that even though I ate pretty well, I didn’t gain weight and the weight loss makes a difference with regard to the HbA1C.
Yeah, I think the exercise makes a huge difference. I think exercise is actually the most…? You were 6.6 in March and you went down to 5.7. Were 3 weeks. Spent a week in Amsterdam, then had a meeting on the Dutch coast and then a week in Paris.
And did you keep exercising when you came back? B transitions to general discussion of A's exercise.
Well, actually, I had a series of trips and on those I don’t exercise. And then So, the exercise, I mean occasionally I go for a long bike ride ‘cause I know it’s good for me, but otherwise it’s the typical ride back and forth to campus, which is close to a half hour total.
Do you, after dinner, do you go for a walk? Do you think you could. You should take a 15-minute walk right after dinner. You want to work in the evening? You should take a fifteen minute walk after dinner.
Figure 7-2: Orientations,goals, knowledge, and decision-making analysis I actually think there’s something about the exercise right after the meal. I don’t have any proof for this, but there’s some neuro-hormonal thing that happens that lowers your blood sugar.
What I have done is… on an average of once a week. though it’s been screwy because of the travel… I’ll go for a bike ride and I’ll either go from home or from campus along the Alameda up to Moeser.
That’s uphill all the way and pretty steep.
So, that’s the way I get my exercise.
Yeah. And then you know, four times a week, more when the semester starts, I’ll be riding back and forth to campus Right. I think it’s the daily exercise, not even particularly intensive exercise, that’s good for diabetes. [A: umhmmm…] I think there’s something that your body thinks you’re going to be exercising, that it thinks you’re active and moving, it does something different with your blood sugar. [A :umhmmm…] I’m sure there’s a biological explanation for it. That sort of everyday, taking part of your routine [A: umhmmm…] and sort of finishing…. I think if you just went for a 15-minute walk around the block. It doesn’t have to be long. That’s what I would recommend.
[Laughs] That’s my recommendation and I’m sticking to it. Your fasting sugar went from 2 something [looks at chart] … 217 – to 167 167. That’s odd since I tested my blood sugar that morning and it was 129. So how it went from 129 at 6:30 or 7:00 in the morning to 167 when I didn’t eat anything, that’s very strange.
That is strange. Unless your meter’s not accurate.
Could be. The strips are kind of old ‘cause I don’t use them that often. But, that’s an odd disparity.
Yeah. That one, I can believe LabCorp. If anything I would think their numbers should come out lower because the sugar, the blood was in the tube for a while. That should be accurate.
You know what we could do is test your meter against ours here. Although you don’t use it that much….
No. No, as long as I’m feeling decent…Yeah, and the 167 doesn’t quite square with the HbA1C either.
Your cholesterol… The last time we tested your cholesterol was in January. And… (looking) those numbers are better too.
Your triglicerides are down, which is, I think, response to weight loss.
Yeah. Well that, and the other change in my diet is I’m better about lunch because I’ve been staying home more, so I tend to have a light breakfast and lunch and then I eat well for dinner.
Then you especially need to do my post-dinner constitutional… You know, that may be why your fasting blood sugar is high because you’re eating small meals in the morning and afternoon and then your biggest meal Well, they’re not that small. I mean my two typical breakfasts are a mixture of about 5 ounces of cottage cheese with a pear. I cut it up and mix them together/and Figure 7-2: Orientations,goals, knowledge, and decision-making analysis Well, I shouldn’t criticize you. With these numbers, I’m not gonna hassle And the alternative is a large bowl of cereal and some yogurt. So there’s a respectable amount of food. And sometimes for lunch I’ll have one of those breakfasts, and sometimes I’ll have a sandwich. But I used to stop in on the way to campus and get something heavier and I’m not doing that anymore.
Well, today, I’m having a nice lunch, but that’s today.
Just occasionally. Do you notice…well, you’re not taking your sugar. Is it night time you eat the most carbs, do you think? Like pasta.
It varies. Last night was a relatively typical dinner and that was some sautéed halibut, some salad, and a section of baguette. So not that much carbs.
That’s what it is. That’s raising your fasting blood sugar. I betcha. Could you do a little experiment? Go a couple of nights without wine and test your fasting. I bet that’s what it is.
And you’re on the Glucotrol twice—three times a day?  mg three times a day and the Metformin twice. I take that in the morning and at bedtime and I take the Glucotrol with meals.
Do you really have to take the Glucotrol three times a day? You were taking it once a day before. It’s usually a once-a-day medicine.
Well, I was taking 5 mgs. once a day and my sugar was going up. And the problem was we couldn’t raise the Metformin because it messed with my stomach. So we went to the 7 1/2 milligrams of the Glucotrol because of that and then since it was going to be 7 1/2, we decided to do it three times a day./ Cause it seemed like it would spread it out… Oh, that particular one because I can split it. The problem was that you can get the 5 mg.in extended release, but the 2 1/2 one isn’t so if I went to ones I split, then it wasn’t extended release so I had to spread them out during the day.
Oh, I see. And you don’t forget those. They’re hard to remember.
[Taking out a small container]. Here are my pills for the day. I had my morning pills and there are my two 2  mg Glucotrol and that’s my Metformin.
Oh, you put all your pills in there everyday.
I take my morning pills and I put the rest of the day’s pills in there.
Mid-day, I take it out. I just take one Glucotrol. So I’m good on that score.
And your urine protein was undetectable. Um….randomly. I wouldn’t say frequently.
[Personal conversation about a mutual acquaintance] [Personal conversation about a mutual acquaintance] Can you watch this and just put some moisturizer around it? Just this little area of eczema, but I don’t want that to turn into anything. Just moisturizer.
Figure 7-2: Orientations,goals, knowledge, and decision-making analysis [Personal conversation about a mutual acquaintance] [Personal conversation about a mutual acquaintance] I’m so thrilled with how you’re doing. The only thing I want you to do differently is to take an evening constitutional. You can do like Kant. Didn’t the people in his town set the clocks by him? Didn’t he always do his walks See, it’s for your neighbors’ sake not for yours.
You see, the problem is I start behaving and you want me to do more.
No, that’s true. You’re doing so well. I’m not sure about that fasting blood sugar. Yeah, well, the first thing I’ll do is I’ll try the empirical experiment and see what happens.
You’re so hard to convince (laughs). All right try your experiment. You know what I think. We have the walking after meals. It’s in our back pocket. If things start to slide then we can go to that.
OK. So these labs are good, at least for four months. We don’t have to do another set of labs. Then, we’ll have to do another set of labs. I’ll give you a lab slip now. I’ll do a more minimal set in four months. I’ll do the a hemoglobin A1c and a creatinine on your kidneys.
Yeah, since the cholesterol turned out ok and the albumin turned out ok.
There’s no reason to take them. In fact, we don’t have to be fasting for the hemoglobin, although we wanna do a fasting blood sugar.
Yeah, I want that number too. That one really strikes me as strange.
Interesting, huh. You don’t have any neuropathy. Any problems at all. And you get your eyes checked regularly? OK. You know what I’m checking with everyone now? Vitamin D. So I’m putting that down.
So I’ll check it too. So here it is. I’ll have them send you a copy so you’ll have a copy.
Your blood pressure’s kinda high today.
You walked in, sat down, and took your blood pressure.
Well, it was also a chaotic morning. I was trying to get an email out to a colleague before I left and then some other stuff happened. So I ran out It’s best to really rest for a few minutes before.
Oh, sometimes I make people more anxious, which I hate to admit about myself.
Oh, it’s not you. It’s your white coat.
(both laugh) Which I don’t wear. I got a little lower number. I got 144/78.
/I’d love to have your systolic below 140/ /Because I tested it periodically and it had normally been 130 + or – 2 over 80 + or – 2.
Yeah, 80 was the ceiling that I didn’t want to go above and I’ve been 78, 79, 80, 81, 82.
We’ll chalk it up to white coat hypertension for now.
I don’t believe that part. The crazy morning is probably more of a contributor.
It’s still….You know, I’d like to have your systolic below 140.
But if it usually is at home I’m not gonna make a big deal out of it.
Well, what I’ll do which I haven’t done for a while is get back to monitoring my blood pressure.
Figure 7-2: Orientations,goals, knowledge, and decision-making analysis Yeah, I told you over Christmas that I’d eaten too much and it was time to I think it’s neat though. You can see what a difference it makes. It’s kind of nice to have a system like that.
Except it’s unfortunate because that means I do have to behave.
You do have to behave, if you want to be healthy.
OK. I’ll get you copies of the labs.
Let me know what else you need to do with that [the tape]. I think that’s a Yeah. What I’ll do is transcribe it. I had some general ideas. The idea is that just as when I walk into a classroom, I have a set of expectations and things that are technically called scripts. If all goes well, I know what to look at, I know what to do, and I do it. But then, when little things happen that are slightly out of the ordinary, that’s when I go “oh let me check that.” So the little spot of eczyma, for example, was a new one. So I have this notion of how everything proceeds, but I don’t know what the bases are for your proceeding. So what I want to do is transcribe it, see if I can see where I think, based on the fact that we’ve had two dozen conversations through the years, what some of the routine things are and when I’ve got that bring it to you and say now what do you bring that makes you do this this way? OK. Great. We’ll sit down and do that off hours. Let me make a copy of this.
Figure 7.3 Orientations, goals, knowledge and decision making analysis.
Figure 7-2: Orientations,goals, knowledge, and decision-making analysis goal activation levels
Resources and Decision Making
ng of the medical discussion)
Alignments
A's resources and decision-making are in regular type face;
Dr. B's resources and decision-making are in italics.
Synchronization
(Social and other prelminaries are dealt with as usual by both.) diet, exercise, etc. ns subject to orientations a, b, and c.
asting blood sugar.
ues raised by doctor.
As discussed in the text, Dr. B has a large amount of relevant medical knowledge, which is "on tap." Some information about A is triggered by his name on the front of the chart; some will be regenerated as she goes through the data with him. She enters the room with a "type II diabetic" script, tailored to A's personality. A's agenda is aligned with Dr. B's . Generally speaking, he will follow her agenda, adding information he thinks she should have, in response to her lead. As noted, he has some knowledge (of his own habits, etc.) that she does not, and will bring that to bear in the conversation. When she raises an issue that taps into his knowledge or goals, he will insert what he perceives to be relevant. That includes things like the fact that he has not gotten lab results, though it is a week after the blood tests. (They arrived from the lab five days later.) Dr. B. picks up on this and other issues raised by A, inserting them into This is the first, general part of Dr. B's script. As noted above, A chimes in with part of his agenda.
B follows through, inserting A's item into her agenda and then continuing Figure 7-2: Orientations,goals, knowledge, and decision-making analysis (The issue of scales is now taken care of.) B continues with the script, comparing current weight with previous. A chimes in, with a goal high on his stack, but of clear mutual interest: since the "tale of the tape" indicates he's been good, the question is whether the HbA1c score will show the impact of his good behavior.
Seeing the positive lab results leads B naturally to ask about what Once again A chimes in, in response to B, with what he thinks is information that will contribute to mutually getting the "big picture." B continues with clarification regarding A's general diet and exercise A begins to provide data, which he does over the next few turns. B takes a turn toward a recommendation based on the information she Figure 7-2: Orientations,goals, knowledge, and decision-making analysis To pursue the recommendation, A provides an analytical justification A begins to describe his general exercise regime, possibly to provide a larger context and possibly to to say he is getting a reasonable amount of exercise. (From his point of view, time is at a premium, so anything that will cut into scheduled work time is an issue.) B acknowledges the utility of A's regime, but still tried to push for more, using analytic substantiation. (We have to find out whether this is a standard approach, or whether she chooses this argument based on the fact that she's dealing with A.) B recognizes that this is as far as A will go for now; she stops at stating With the exercise goal on hold, B returns to the next item on her goal This unexpected datum - until now, his home testing of fasting blood sugar values has agreed closely with the lab reports - leads A to establish the goal of sorting through the issue.
B takes on A's agenda. (The consistency of test values is important for (interactive, goal-oriented conversation follows) Closure on the issue of different readings for fasting sugar. B moves to the next issue on her stack. Follows B's lead, providing more information abouty diet.
Further dietary information from A leads B to consider possible causes for the high fasting sugar reading, which is still unexplained. Figure 7-2: Orientations,goals, knowledge, and decision-making analysis She can't help herself - even though they've had this conmversation A continues with dietary information, under the assumption that B will want a clear picture of his dietary habits.
Tentative hypothesis and diagnostic suggestion to test hypothesis. Continuing script, moving to next item on the stack. A responds by picking up the thread - obvously B is interested in his pill regine - and providing the relevant information. (More on exercise, prompted by her concerns, and the memory he does Next part of script - problems manifest early in diabetic patients' feet. Figure 7-2: Orientations,goals, knowledge, and decision-making analysis Start of wrap-up, which includes return to topic of exercise With the physical exam done, the next part of wrap-up involves setting up the blood tests for the next visit. A final check, castng an eye over the chart, reveals that blood pressure is an issue - it's not quite time for A to go…Follow-through and discussion, as before: A offers information for joint in Figure 7-2: Orientations,goals, knowledge, and decision-making analysis

Source: http://vocserve.berkeley.edu/faculty/ahschoenfeld/HWT_figure_7.3.pdf