Pål Gulbrandsen

• Ruud, Marte Morønning; Salte, Rebekka; Schaufel, Margrethe Aase; Gulbrandsen, Pål; Fløtten, Øystein & Madebo, Tesfaye [Show all 9 contributors for this article] (2026). Assessing physician performance at contextualizing care in patients with advanced lung cancer. Patient Education and Counseling. ISSN 0738-3991. 153. doi: 10.1016/j.pec.2026.109845. Full text in Research Archive Show summary

  Objectives: Contextualization of care has been well documented as an important process for optimizing health care outcomes. Yet there has been little research on attention to patient life context in care planning in the setting of life-threatening disease. We sought to explore how care is contextualized during medical visits in advanced lung cancer treatment in Norway. Methods: We conducted an exploratory observational study using data from physician-patient dialogues about treatment decisions. The material consisted of consultations with patients receiving treatment for advanced lung cancer from several hospitals in Western Norway. Transcripts and audio recordings were analyzed using the Content Coding for Contextualization of Care (4 C) system. Physician attention to patient context was defined by whether clinicians (a) probed contextual red flags to elicit contextual factors and (b) incorporated contextual factors into care plans. Contextual factors were categorized into their twelve domains. Results: Across 17 medical encounters, clinicians probed 19 of 30 contextual red flags (63%) and formulated contextualized care plans for 21 of 29 contextual factors, a contextualizing care rate of 72%. The most common contextual domains were Skills, Abilities and Knowledge (10 contextual domain assignments), followed by Access to Care (4) and Social Support (4). One contextual factor was assigned to two domains, yielding 30 contextual domain assignments across 29 contextual factors. Conclusion: This exploratory observational study suggests that inattention to contextual factors may hinder effective care for patients with advanced lung cancer.

• Frigaard, Christine; Ofstad, Eirik Hugaas; Delor, Julia Menichetti; Schirmer, Henrik; Bjørnstad, Herman & Simonsen, Tone Breines [Show all 8 contributors for this article] (2026). Optimised heart failure medication in hospital-to-home transitions: An adherence burden for patients? Patient Education and Counseling. ISSN 0738-3991. 149. doi: 10.1016/j.pec.2026.109655. Full text in Research Archive Show summary

  Objectives When patients are hospitalised for heart failure (HF), doctors review and optimise their pharmacotherapy at subsequent care transitions. Studies show that patients, many of whom are old and frail, have adherence rates of only 40%-60%. Few communication studies have examined the burden of optimisation on patients as their regimens evolve. Focusing on prescription changes over multiple care transitions, we aimed to: (1) identify how many changes patients received, (2) characterise the support provided in discharge letters, and (3) assess patients’ implementation of changes at home. Methods We conducted an exploratory, observational cohort study with prospective longitudinal data collection. We recruited 23 older HF patients in Norway, collecting observational data (medical records, discharge letters, interviews, photographs) from their hospital visits (admission, discharge), general practitioner visit, and their homes. We inductively developed a systematic analytical procedure to identify prescription changes and to assess the quality of doctors’ written information about patients’ medication management at home. Results Doctors made a median of six prescription changes per patient (range 2–19) over a median timespan of 25 days, usually leading to more medications. Of the discharge letters patients received, 26% provided clear instructions about all changes and explanations of the benefit. While all patients reported adherence, home visits revealed 17% had discrepancies indicating non-adherence, and 61% dispensed medications from original pharmacy packaging with outdated dosing instructions. Conclusions To adhere to their optimised pharmacotherapy, HF patients needed to implement many incremental changes. Doctors' discharge letters were often unclear or lacked information about the changes. Practice implications To enhance patients’ ability to adhere to treatment, clinicians may consider: (i) improving the quality of discharge letters, including clarifying medication labels (ii) providing updated instructions for old medication packages, (iii) normalising and providing safety-net support for non-adherence to HF regimens. Further research is needed to test these actions.

• Bruun, Andrea; Gulbrandsen, Pål; Fløtten, Øystein & Schaufel, Margrethe Aase (2026). How doctors present treatment options in advanced lung cancer consultations: a conversation analytic study. BMJ Open Respiratory Research. 13(1). doi: 10.1136/bmjresp-2023-002172. Full text in Research Archive Show summary

  Background To facilitate shared decision-making (SDM), it is important that doctors clearly present the decision to be made and the available treatment options to the patient. This study explored how treatment options after first-line therapy were presented in advanced lung cancer consultations. Methods Audio recordings of 12 advanced lung cancer consultations between patients, their companions and doctors in three Norwegian hospitals were transcribed and analysed using Conversation Analysis. Data were collected between November 2019 and March 2022. Results Doctors employed three strategies when presenting treatment options to patients. These were (1) open option presentation, (2) selective option presentation and (3) recommended option presentation. Strategy (1) involved the doctor presenting all the possible treatment options in a balanced manner to the patient. With strategy (2), the doctor presented selected treatment options to the patient, and, for example, did not articulate the possibility of refraining from further therapy. Strategy (3) included the doctor’s explicit preference for certain treatment options. Conclusions Strategies that doctors employ to present treatment options to patients facilitated SDM to different degrees, where some can challenge core principles of SDM, such as creating choice awareness. Doctors must be aware of their strategies to ensure that treatment options are presented to patients in a way that supports SDM.

• Gilani, Sara; Gulbrandsen, Pål; Han, Paul K.J.; Hillen, Marij A. & Ofstad, Eirik Hugaas (2026). First-year residents’ experiences of uncertainty in rural and urban emergency departments. BMC Medical Education. 26. doi: 10.1186/s12909-026-09021-0. Full text in Research Archive Show summary

  Background Uncertainty is an inherent and challenging aspect of medical practice, particularly for first-year residents making the transition from theoretical education to clinical practice. We aimed to identify factors influencing uncertainty experienced by residents practicing within different organizational frameworks, which could serve as potential targets for supportive interventions. Methods A qualitative study was conducted using semi-structured interviews with 20 first-year residents across five organizationally and geographically diverse hospitals in Norway. The reflective interviews were informed by participatory observation during emergency department shifts that provided verbal and behavioral cues signaling uncertainty. Data was transcribed and analyzed using Systematic Text Condensation. Results We found four themes with factors influencing residents’ experiences of uncertainty: 1) Residents’ Competence: level of experience and knowledge affected level of uncertainty and confidence, 2) Clinical Complexity: level of patient complexity affected level of uncertainty and the need for consultative support. 3) Consultative Support: availability and predictability of consultative support from senior physician affected level of uncertainty. 4) Level of responsibility: greater responsibility of residents in rural hospitals, due to limited support, fostered faster learning but with the downside of greater initial uncertainty and suboptimal learning environment. We also found that additional factors outside of physicians control such as the number of concurrent patients, the urgency and severity of clinical cases, and related time pressure, further influenced the residents' experience of uncertainty. Conclusion First-year residents’ experience of uncertainty is influenced by a combination of personal and organizational factors. Rural hospital settings, which offer limited consultative support and greater responsibility, may foster more uncertainty initially but also promote a quicker transition towards autonomous uncertainty management and development of uncertainty tolerance. Urban settings offer more immediate uncertainty management support, but often under higher patient loads and time constraints, limiting residents’ experience with critically ill patients and responsibility in general. These findings can help hospitals, universities and management modify factors affecting residents’ experiences of uncertainty. This can also help in training medical students and residents so they can better understand, tolerate and manage uncertainty.

• Gulbrandsen, Pål; Benth, Jurate Saltyte; Ofstad, Eirik Hugaas & Han, Paul K. J. (2025). The potential of uncertainty tolerance measures to identify specific needs of first-year medical residents: an exploratory study. BMC Medical Education. doi: 10.1186/s12909-025-08449-0. Full text in Research Archive Show summary

  Background: We aimed to explore 1st year residents' responses to five different uncertainty tolerance (UT) measures, varying in their specificity to physicians and medical practice, and to compare their ability to classify residents according to their level of UT in this population. Methods: 202 residents beginning training at two Norwegian hospitals in 2021-2023 completed the Physicians' Reaction to Uncertainty (PRU), a physician-specific UT measure, as well as 4 non-specific measures: Intolerance of Uncertainty Scale (IUS-12), Tolerance for Ambiguity (TFA), Pearson's Risk Attitude (PRA), and Ambiguity Aversion in Medicine (AAM). We described psychometric properties using exploratory factor analysis (EFA). We then applied hierarchical cluster analysis to assess the utility of the PRU and the 4 non-physician-specific measures in classifying residents. Results: Residents' mean length of clinical work experience was 9.6 months (SD 7.6). 137 (68.2%) were female, 125 (62.2%) went to medical schools in Scandinavian-speaking countries. The exploratory factor analysis of all measures together revealed five factors. Factor 1 consisted of all PRU items and four items from TFA and explained 50.4% of the variance. In step 1, the cluster analysis based on PRU alone produced three stable clusters, with high (n = 58, 29%), intermediate (n = 108, 54%), or low (n = 36, 18%) UT. In step 2, a cluster analysis based on all measures produced three clusters, with high (n = 81, 40%), intermediate (n = 67, 33%), or low (n = 54, 27%) UT. Of the 58 with high UT according to PRU, three (5%) had intermediate UT using all instruments combined. Of the 36 with low UT according to PRU, 12 (33%) had high or intermediate UT using all instruments combined. Female residents and residents who studied medicine outside Scandinavia displayed lower UT. Conclusion: PRU appears to be a reliable, discriminatory, and feasible measure for identifying junior physicians who are predisposed to stress or other aversive psychological reactions to the uncertainties of clinical care. High UT measured by PRU indicates high UT according to other measures, while low UT according to PRU is less indicative. Hence, non-physician-specific UT measures appear to assess specific dimensions of UT that could assist supervisors and residents understand different responses to uncertainty.

• Bjørnstad, Herman; Frigaard, Christine; Gulbrandsen, Pål; Gerwing, Jennifer; Schirmer, Henrik & Menichetti, Julia (2025). How hospital doctors respond to contextual factors revealed by older patients with heart failure in hospital interactions: an interaction-based study. BMC Health Services Research. 25. doi: 10.1186/s12913-025-13505-y. Full text in Research Archive Show summary

  Background Patients with heart failure often face individual context-dependent challenges that affect their ability to follow a treatment plan. How hospital doctors recognize and respond to such contextual factors (CF) may influence health outcomes. This study aims to identify adherence related CF disclosed by older patients with heart failure during hospital interactions and to examine how doctors respond to them. Methods Audio-recordings from two key hospital interactions were collected from 42 older patients with heart failure. Occurrences of CF were identified based on a previously developed coding scheme and followed during the hospital interactions. We then analysed doctor’s responses to patient’s CF and categorized them as: (1) Solution-oriented, (2) Exploring (3) No follow-up. Results We identified 58 CF across 113 occurrences in 27 (64%) patients. Medication-related CF (47%) were the most frequently disclosed, followed by patient-specific (34%), condition-related (12%), and healthcare system-related factors (7%). Doctors’ responses varied: 26% (n = 15) of CF received no follow-up, 21% (n = 12) were only explored, 24% (n = 14) were explored and met with a solution-oriented action, and 29% (n = 17) were met with solution-oriented actions without any exploration from the doctor. Conclusions Older patients with heart failure often disclose important CF relevant to adherence during hospital interactions. Roughly half of these factors are not met with a solution-oriented response, with a substantial portion not being followed up by the doctors at all. Future research should explore how to better improve doctors’ ability to recognize and appropriately respond to CF disclosed by patients.

• Elwyn, Glyn; Gulbrandsen, Pål; Leavitt, Hannah; Abukmail, Eman; Clayman, Marla L. & Edwards, Adrian [Show all 27 contributors for this article] (2025). Shared Decision-Making. A Primer for Clinicians. Journal of General Internal Medicine (JGIM). ISSN 0884-8734. 40, p. 3889–3899. doi: 10.1007/s11606-025-09707-z. Full text in Research Archive Show summary

  Importance Shared decision-making is a widely promoted approach, yet clinicians, typically supportive in principle, find it difficult to implement because of concerns and barriers they commonly encounter in practice. Objective To generate a primer that describes shared decision-making from the perspective of clinicians. Methods We collaborated with clinicians, patient representatives, and health service researchers. We invited members of the International Society of Shared Decision Making to co-produce a primer for clinicians using a series of jointly edited online documents. We shared drafts with other clinicians and patients. Finally, we integrated the contributions until we had arrived at a consensus. Findings Twenty-five people from 13 countries contributed; 9 had medical qualifications, 4 had nursing qualifications, and 12 others had a range of backgrounds. A total of 30 patients and clinicians provided further comments. The description differs from previous versions because it addresses the barriers that clinicians frequently mention. It describes how to overcome common challenges by emphasizing the importance of a clear invitation at initiation; it suggests how to manage patients’ resistance to shouldering decisional responsibility; reinforces the need to allow time for deliberation, especially with other stakeholders; and reassures clinicians that consensus, albeit welcome, need not be the goal of shared decision-making. Conclusions and Relevance This primer portrays a reflective clinician who is aware of power asymmetry, patient vulnerability, risk communication, health literacy, agenda setting, and goal clarification. It envisages a clinician who is curious about personal perspectives and who can offer collaborative, iterative, and deliberative steps.

• Frigaard, Christine; Menichetti, Julia; Schirmer, Henrik; Wisløff, Torbjørn; Bjørnstad, Herman & Simonsen, Tone Breines [Show all 8 contributors for this article] (2025). How do doctors address heart failure patients’ disclosures of medication adherence problems during hospital and primary care consultations? An exploratory interaction-based observational cohort study. BMJ Open. 15(4). doi: 10.1136/bmjopen-2025-098826. Full text in Research Archive Show summary

  Objectives To investigate how doctors and self-managing older patients with heart failure (HF) discuss the patients’ potential or ongoing medication adherence problems, and how such discussions evolve as patients transition from hospital to home, with particular focus on: (1) doctors’ communicative actions aimed at addressing patient disclosures of adherence problems and (2) patients’ feedback indicating whether their doctor’s supportive actions were acceptable to them. Design Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient–doctor consultations, audio recorded for each patient at: (1) first ward visit in hospital, (2) discharge visit from hospital and (3) follow-up visit with general practitioner (GP). Setting Hospital and primary care, Norway (2022–2023). Participants 25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs). Results Analysis of 74 consultations revealed that 25 HF patients disclosed 23 practical adherence problems indicating risks of unintentional non-adherence (eg, limited resources to manage medications) and 39 perceptual problems indicating risks of intentional non-adherence (eg, worries, negative experience or stance). Doctors addressed 79% of patients’ disclosures by: (1) exploring the scope of the problem or (2) providing supportive actions to improve patients’ ability or motivation to adhere. We calculated nearly five times higher odds for doctors to address patients’ practical problems to their perceptual problems (OR 4.79, 95% CI 1.25 to 25.83). Unresolved problems included: (1) doctors addressed patients’ disclosures, but patients signalled the supportive actions were unsuitable (37%) and (2) doctors left disclosures unaddressed (21%). Conclusions In this explorative study, the doctors were more likely to address the patients’ adherence problems associated with unintentional non-adherence risks than those associated with intentional non-adherence risks. Even when doctors attempted to address HF patients’ medication adherence problems, half of the problems remained unresolved, usually because patients indicated that the doctor’s suggestion to improve their situation was against their preference.

• Bjørnstad, Herman; Frigaard, Christine; Gulbrandsen, Pål; Gerwing, Jennifer; Schirmer, Henrik & Menichetti, Julia (2025). Contextual Factors Affecting Adherence Revealed by Old Patients with Heart Failure in Hospital and Primary Care Interactions: A Descriptive Study. Patient Preference and Adherence. 19, p. 1075–1087. doi: 10.2147/ppa.s505297. Full text in Research Archive Show summary

  Introduction: Old patients with heart failure are a vulnerable patient group facing various challenges, specifically during the transition from hospital to home. Non-biomedical factors, or “contextual factors”, such as patient attitudes and social support, can influence treatment adherence. However, their role in clinical interactions is not well understood. This study aimed to identify and describe how and when these factors manifest during clinical interactions in the hospital-to-home transition. Methods: We audio-recorded 42 old patients with heart failure admitted to hospital interacting with their physicians at: 1. the first ward visit, 2. discharge visit, 3. first primary care visit after discharge. Based on an umbrella review, we developed a list of 48 factors known to affect adherence among cardiovascular patients. Patient utterances from the recordings containing information on one of these factors (contextual indicators (CI)) were extracted and categorized according to the type of factor, mentioned impact, and being a facilitator or barrier to adherence. Results: From the 105 audio recordings, 742 CI were identified, each interaction containing an average of 7 CI (SD = 4.2; median = 6). CI considered to have a potential impact on patient’s life or adherence were overall evenly split between facilitators (n = 82, 42%) and barriers (n = 115, 58%), and both types of CI appeared in most patient trajectories. The most salient barrier CI was related to patients’ concerns regarding medications side effects and regimen complexity, while CI facilitators were more commonly related to patients’ knowledge, motivation and social support. Discussion: The findings from this study provide insights for clinicians to the main types of non-biomedical factors revealed by old patients with heart failure in medical interactions, which affect their treatment adherence. Clinicians should particularly consider patient concerns regarding medications’ side effects and the regimen complexity as important aspects to discuss, leveraging on motivational and social resources if present.

• Menichetti, Julia; Benth, Jurate Saltyte; Gerwing, Jennifer; Lundqvist, Christofer; Clayman, Marla L & Gulbrandsen, Pål (2025). What influences how physicians frame information for patients? An explorative quantitative study on hospital interactions from different specialties. BMJ Open. 15(9). doi: 10.1136/bmjopen-2024-097474. Full text in Research Archive Show summary

  Background Physicians frame medical information for patients in different ways, impacting patient outcomes. What underlies their framing choices has not been investigated.  Objective To explore the use and function of information framing practices in medical interactions. Design Explorative, quantitative observational study with a mixed-methods design. Setting and participants 28 videorecorded hospital interactions, ranging from short-term/acute (orthopaedic surgery, gynaecology) to long-term/chronic care (oncology, gastroenterology) and involving 14 physicians and 28 patients. Outcome measures Using a previously developed coding system, we analysed physicians’ framing practices. We extracted information sharing functions qualitatively, checking 10% of the analysis with an independent assessment from the physicians. To explore whether variation in physicians’ use of information frames stemmed from individual or clinical specialty differences, we estimated intraclass correlations. To assess how their use of information frames varied at the macro level (across clinical specialties) and micro (the immediate function in the interaction), we estimated linear mixed models adjusted for the number of words. Results Variation in framing practices was mainly observed at the level of physicians nested within the same clinical unit (9.5% of the overall variance explained vs 1.3% for the unit level and 0.7% for the individual level). Physicians from different clinical units differed significantly in how they framed information, with the main differences between the gastroenterology and oncology units (mean difference=1.88; 95% CI 0.97; 2.79; p<0.001). The primary function of their information sharing also varied significantly across clinical specialties (all p<0.001 in χ2 tests). Physicians from more short-term care units were oriented towards shared understanding, from gastroenterology towards inviting and convincing efforts and from oncology towards personal communication. Conclusion Results revealed signature marks of clinical units in terms of information sharing practices. Physicians’ information framing choices were driven both by the macro level (the clinical unit) and micro (the specific function for sharing information at that moment), thus highlighting potential areas for future interventions.

• Larsen, Berit Hofset; Gerwing, Jennifer; Lundeby, Tonje; Gulbrandsen, Pål & Førde, Reidun (2025). More than an extra set of ears: A video-based analysis exploring the role of companions in routine oncology visits. Journal of psychosocial oncology. ISSN 0734-7332. 43(5), p. 682–703. doi: 10.1080/07347332.2025.2457964. Full text in Research Archive Show summary

  Purpose Patients with advanced cancer commonly bring a companion to medical appointments, often a family member. Despite increasing focus on family involvement, few studies are based on observations of real-life consultations. This study aimed to explore how companions contribute to the information exchange process during advanced cancer outpatient visits. Methods Data were ten videos of routine oncology visits. We identified when and how companions participated using microanalysis of clinical interaction. Findings Companion participation varied greatly. They tended to speak up spontaneously, contributing medical, personal, and contextual information that might otherwise have remained unsaid. They both brought information into the discussion and facilitated information exchanged between the physician and patient. Companions displayed few of their own concerns. Conclusions The findings suggest that companions may be an important resource during oncology visits, not only for the patient, but also for healthcare providers aiming for person-centered care to the individual patient.

• Frigaard, Christine; Delor, Julia Menichetti; Schirmer, Henrik; Bjørnstad, Herman; Simonsen, Tone Breines & Wisløff, Torbjørn [Show all 8 contributors for this article] (2024). What do patients with heart failure disclose about medication adherence at home to their hospital and primary care doctors? Exploratory interaction-based observational cohort study. BMJ Open. 14(8). doi: 10.1136/bmjopen-2024-086440. Full text in Research Archive Show summary

  Abstract Objectives: The main objective of this study was twofold: to investigate what kind of information patients with heart failure (HF) tell their doctors about their medication adherence at home, and how often such information is provided in consultations where medication reconciliation is recommended. To meet these objectives, we developed an analysis to recognise, define, and count (1) patient utterances including medication adherence disclosures in clinical interactions (MADICI), (2) MADICI including red-flags for non-adherence, and (3) MADICI initiated by patients without prompts from their doctor. Design: Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient–doctor consultations, audio-recorded at three time-points for each patient: (1) first ward visit in hospital, (2) discharge visit from hospital, and (3) follow-up visit with general practitioner (GP). Setting: Norway (2022–2023). Participants: 25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs). Results: We recognised MADICI by two criteria: (1) they are about medication prescribed for use at home, AND (2) they involve patients’ action, experience, or stance regarding medications. Using these criteria, we identified 427 MADICIs in 25 patient trajectories: 143 (34%) at first ward visit (min–max=0–35, median=3), 57 (13%) at discharge visit (min–max=0–8, median=2), 227 (53%) at GP-visit (min–max=2–24, median=7). Of 427 MADICIs, 235 (55%) included red-flags for non-adherence. Bumetanide and atorvastatin were most frequently mentioned as problematic. Patients initiated 146 (34%) of 427 MADICIs. Of 235 ‘red-flag MADICIs’, 101 (43%) were initiated by patients. Conclusions: Self-managing older patients with HF disclosed information about their use of medications at home, often including red-flags for non-adherence. Patients who disclosed information that signals adherence problems tended to do so unprompted. Such disclosures generate opportunities for doctors to assess and support patients’ medication adherence at home.

• Kvæl, Linda Aimee Hartford; Gulbrandsen, Pål; Werner, Anne & Bergland, Astrid (2024). Implementation of the four habits model in intermediate care services in Norway: a process evaluation. BMC Health Services Research. 24(1). doi: 10.1186/s12913-024-11647-z. Full text in Research Archive Show summary

  Background Intermediate care (IC) services bridge the transition for older patients from the hospital to the home. Despite the goal of involving individuals in their recovery process, these services often become standardised, leading to communication breakdowns. While evidence-based practices, such as the Four Habits Model (4HM), for effective communication are crucial for enhancing high-quality healthcare, research suggests their integration into routine practice remains limited. In this study, we aimed to investigate the implementation process of the 4HM through a two-day course that engaged healthcare professionals and managers in IC. Methods We conducted a process evaluation employing qualitative and quantitative methods: (i) individual interviews with three managers and two course participants pre-course, (ii) two focus group interviews with course participants (N = 11) and individual interviews with the same three managers post-course, and (iii) the NoMAD questionnaire (Normalisation MeAsure Development) administered four months later to assess the short- and long-term impact on course participants (N = 14). Reflexive thematic analyses were guided by Normalisation Process Theory (NPT), which offers insight into how new interventions become routine practices. The analysis of the NoMAD involved descriptive statistics. Results We identified four themes in the qualitative data: (i) Decoding Interactions: Making Sense of the 4HM in IC services, (ii) Fostering Change: Legitimising 4HM Through Staff Engagement, (iii) Harmonising Practice: Integrating 4HM into Complex Situations, and (iv) Embedding Value: Normalising the 4HM into Everyday Work. These themes illustrate the normalisation process of the 4HM course within IC, establishing standard practices. Healthcare professionals and managers highlighted the urgent need to integrate communication skills based on the 4HM into daily care. They noted positive changes in their communication habits following the course. The consistent findings from the NoMAD questionnaire underscore the sustainability of implementing the 4HM programme, as participants continue to utilise it in their clinical practice beyond the initial four-month period. Conclusion The 4HM course programme was deemed feasible for expansion within IC services. Both managers and staff found its focus on addressing communication breakdowns and readiness for change sensible. The study findings may benefit the stakeholders involved in IC service routines, potentially improving services for older patients and relatives.

• Ofstad, Eirik Hugaas; Asdal, Karoline; Nightingale, Bruno; Han, Paul K.; Gregersen, Trine Ammentorp & Gulbrandsen, Pål (2023). LIS1-leger og medisinsk usikkerhet – en kvalitativ studie. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 143(8), p. 702–707. doi: 10.4045/tidsskr.22.0428. Full text in Research Archive Show summary

  BAKGRUNN - Hvordan norske leger håndterer medisinsk usikkerhet, er lite studert. Formålet med studien var å undersøke hvordan leger i spesialisering del 1 (LIS1-leger) opplever og håndterer usikkerhet i en klinisk hverdag.<p> <p>MATERIALE OG METODER - Ti LIS1-leger ved to sykehus ble rekruttert til intervjuer etter svarmønsteranalyse fra et kartleggende spørreskjema. Intervjuene ble analysert med systematisk tekstkondensering.<p> <p>RESULTATER - Analysen avdekket tre hovedtemaer i intervjuene: håndtering av medisinsk usikkerhet, personlig respons på medisinsk usikkerhet samt arbeidsmiljø, tilbakemeldinger og forberedelse. Innen alle de tre tematiske områdene brukte informantene ordene sikker/usikker og trygg/utrygg om hverandre.<p> <p>FORTOLKNING - LIS1-legene strevde med medisinens iboende usikkerhet og kjente på en betydelig utrygghet, spesielt i starten av tjenesten. Mottakelsen og tilbakemeldingene legene fikk på arbeidsplassen var viktige. Den medisinske utdannelsen hadde i liten grad forberedt LIS1-legene på møtet med medisinsk usikkerhet i en klinisk hverdag.

• Menichetti, Julia; Gulbrandsen, Pål; Landmark, Anne Marie Dalby; Lie, Hanne Cathrine & Gerwing, Jennifer (2023). How Do Physicians Frame Medical Information in Talks With Their Patients? An Inductive Microanalysis. Qualitative Health Research. ISSN 1049-7323. 34(1-2), p. 101–113. doi: 10.1177/10497323231205152. Full text in Research Archive Show summary

  During medical consultations, physicians need to share a substantial amount of information with their patients. How this information is framed can be crucial for patient understanding and outcomes, but little is known about the details of how physicians frame information in practice. Using an inductive microanalysis approach in the study of videotaped medical interactions, we aimed to identify the information frames (i.e., higher-level ways of organizing and structuring information to reach a particular purpose) and the information-framing devices (i.e., any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it) physicians use spontaneously and intuitively while sharing information with their patients. We identified 66 different information-framing devices acting within nine information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don’t like where I (or where you are) am going with this, (3) This may be tricky to understand, (4) You may need to think, (5) This is important, (6) This is not important, (7) This comes from me as a doctor, (8) This comes from me as a person, and (9) This is directed to you as a unique person. The kaleidoscope of information-framing devices described in this study reveals the near impossibility for neutrality and objectivity in the information-sharing practice of medical care. It also represents an inductively derived starting point for further research into aspects of physicians’ information-sharing praxis.

• Orstad, Silje; Fløtten, Øystein; Madebo, Tesfaye; Gulbrandsen, Pål; Strand, Roger & Lindemark, Frode [Show all 9 contributors for this article] (2023). “The challenge is the complexity” – A qualitative study about decision-making in advanced lung cancer treatment. Lung Cancer. ISSN 0169-5002. 183. doi: 10.1016/j.lungcan.2023.107312. Full text in Research Archive Show summary

  Introduction The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability. Methods Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway. Results The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy. Conclusion Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.

• Lie, Hanne Cathrine; Gerwing, Jennifer; Bondevik, Hilde; Bostad, Inga; Ellingsen, Dan-Mikael & Frühholz, Sascha [Show all 12 contributors for this article] (2022). Studying clinical communication through multiple lenses: The underused potential of inter-disciplinary collaborations. Patient Education and Counseling. ISSN 0738-3991. doi: 10.1016/j.pec.2022.04.010. Full text in Research Archive Show summary

  In the era of evidence-based medicine, surprisingly little attention is given to the practice of evidence-based communication skills and strategies to provide the best and most efficient patient care, perhaps due to the infinitely complex nature of clinical communication. Multiple models for ‘best practice’ exist, but they tend to focus on what skills and strategies to use, paying less attention to how they should be used in which contexts and situations for best effects [1]. Disentangling the complexities of effective clinical communication would therefore require insights from other disciplines outside medicine, including their theoretical models, empirical knowledge, and research methods, concerning the study of human communication and interaction, as well as medical, ethical, legal, philosophical, existential, cultural, and organizational perspectives. Although several disciplines study clinical communication, this is often done in isolation, without integrating efforts beyond a few selected disciplines, e.g., medicine, linguistics, or social psychology [[1], [2], [3], [4]]. Given the multiple levels of complexity in clinical communication research, we need to move beyond this fragmented approach to answer questions about what works, for what reasons, and in which contexts. These Association Pages aim to provide insights to move forward towards interdisciplinary research of clinical communication. As a primer to help build bridges across disciplines, we have asked experts from medicine, cognitive neuroscience, psychology, philosophy, linguistics, medical ethics, and educational sciences these two questions: “What fascinates you about clinical communication?” and “Which methodological tools do you tend to use to study it?“. We have summarized the responses below and provided a suggestion for how these different experts may work together in an interdisciplinary effort to generate new and needed knowledge of what is effective clinical communication, how it works and why, which can be translated into clinical practice and training.

• Øverby, Caroline Tonje; Sutharshan, Prasanthy; Gulbrandsen, Pål; Dammen, Toril & Hrubos-Strøm, Harald (2022). Shared decision making: A novel approach to personalized treatment in obstructive sleep apnea. Sleep Medicine: X. 4. doi: 10.1016/j.sleepx.2022.100052. Full text in Research Archive Show summary

  Study objectives i) To describe a novel approach of phenotyping by shared decision making (SDM) in obstructive sleep apnea (OSA) discharge consultations ii) to describe correlation between patient and observer based evaluations of SDM and iii) to describe treatment adherence. Methods Consecutive patients referred to the otorhinolaryngology department at Akershus University Hospital with suspected OSA between 2015 and 2016 participated. Patients with body mass index >30 were oversampled. Four male communication-trained doctors aged from 30 to 60 years participated. SDM was evaluated by modified content analysis and by the CollaboRATE self-report questionnaire and the “Observer OPTION (Young et al., 2008) [5]” rating scale. Positive airway pressure (PAP) treatment adherence and weight reduction was assessed by interview at six year follow-up. Results Eighteen consultations were video filmed. The content analysis revealed that the patient perspectives only briefly were explored. PAP was chosen by 17 of 18 patients. Median CollaboRATE questionnaire score was 29 (26, 30). Mean OPTION (Young et al., 2008) [5] score was 65.6 (SD 6.6, range 55–80). The correlation between SDM assessed by CollaboRATE self-report and by the “Observer OPTION (Young et al., 2008) [5]” rating scale was low (Pearson's r = 0.09). At follow up, 11 patients (64.7%) were PAP adherent and no one achieved 10% weight loss. Conclusions Despite a high degree of SDM compared to studies of non-OSA populations, the sub-optimal exploration of the patient perspective by communication-trained doctors precluded identification of patients willing to cope actively. SDM assessed by self-report and by a rating scale may represent two different constructs. PAP adherence was good.

• Elwyn, Glyn; Price, Amy; Franco, Juan VA & Gulbrandsen, Pål (2022). The limits of shared decision making. BMJ Evidence-Based Medicine. ISSN 2515-446X. doi: 10.1136/bmjebm-2022-112089. Full text in Research Archive
• Nordfalk, Jenny Maria; Holmøy, Trygve; Thomas, Owen Matthew Truscott; Nylenna, Magne & Gulbrandsen, Pål (2022). Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial. BMJ Open. 12(3). doi: 10.1136/bmjopen-2021-049817. Full text in Research Archive Show summary

  Objective To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS). Design Single-centre, single-blind, randomised controlled trial. Setting One university hospital in Norway. Participants Thirty-four patients with early-stage MS. Intervention A 3-hour training for neurologists on how to provide complex information about MS escalation therapy. Main outcome measures Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs. Secondary outcome measures Number of information units provided by the physicians. Effects on patient involvement through questionnaires. Methods Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim. Results Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (−0.01 to 0.15)), p=0.099). The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter −0.09 (SE 0.02, 95% CI (−0.13 to −0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter −0.29 (SE 0.05, 95% CI (−0.39 to −0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire. Conclusion A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate. Trial registration number ISRCTN42739508.

• Larsen, Berit Hofset; Lundeby, Tonje; Gulbrandsen, Pål; Førde, Reidun & Gerwing, Jennifer (2022). Physicians’ responses to advanced cancer patients’ existential concerns: A video-based analysis. Patient Education and Counseling. ISSN 0738-3991. 105(10), p. 3062–3070. doi: 10.1016/j.pec.2022.06.007. Full text in Research Archive Show summary

  Objective In a recent study, we explored what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation and how they communicate such concerns. The current study builds on these results, investigating how the physicians responded to those concerns. Methods We analyzed video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. Results We identified 185 immediate physician-responses to the 127 patient existential utterances we had previously identified. The responses demonstrated three approaches: giving the patient control over the content, providing support, and taking control over the content. The latter was by far the most common, through which the physicians habitually kept the discussion around biomedical aspects and rarely pursued the patients’ existential concerns. Conclusions Although the physicians, to some extent, allowed the patients to talk freely about their concerns, they systematically failed to acknowledge and address the patients’ existential concerns. Practice implications Physicians should be attentive to their possible habit of steering the agenda towards biomedical topics, hence, avoiding patients’ existential concerns. Initiatives cultivating behavior enhancing person-centered and existential communication should be implemented in clinical practice and medical training.

• Nordfalk, Jenny Maria; Menichetti, J.; Thomas, Owen Matthew Truscott; Gulbrandsen, Pål & Gerwing, Jennifer (2021). Three strategies when physicians provide complex information in interactions with patients: How to recognize and measure them. Patient Education and Counseling. ISSN 0738-3991. doi: 10.1016/j.pec.2021.10.013. Full text in Research Archive Show summary

  Objective To define and operationalize three taught strategies for providing information in interactions with patients using videos collected in a randomized controlled trial (RCT). Methods This was a qualitative exploratory study embedded in a randomized controlled design, using microanalysis of face-to-face dialogue as an inductive video analysis method to operationalize physicians’ use of three information-provision strategies. Data were 34 video-recorded simulated (but unscripted) interactions between 17 physicians and 34 multiple sclerosis patients collected before and after a brief course on information provision. We operationalized (1) mapping the patient’s preferences and (2) checking the patient’s understanding, and pauses indicative of (3) portioning information. Results Results are detailed analytical definitions, criteria, and assessable, quantifiable outcomes for each of the three strategies. Patients responded to portioning pauses as expected: whereas 91% of these pauses elicited an immediate patient response, only 23% of non-portioning pauses did so. Conclusion Our methods revealed how to define and evaluate information sharing strategies physicians used within the contingencies of clinical interaction. Practice implications Findings provide applicable methods to teach, analyze, and evaluate information sharing strategies and indications for further training.

• Han, Paul K.J.; Strout, Tania D.; Gutheil, Caitlin; Germann, Carl; King, Brian & Ofstad, Eirik Hugaas [Show all 8 contributors for this article] (2021). How physicians manage medical uncertainty: A qualitative study and conceptual taxonomy. Medical decision making. ISSN 0272-989X. 41(3), p. 275–291. doi: 10.1177/0272989X21992340. Full text in Research Archive Show summary

  Background - Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described.<p> <p>Objectives - To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians’ tolerance of medical uncertainty.<p> <p>Design - Qualitative study using individual in-depth interviews.<p> <p>Participants - Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1–3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine–pediatrics), at a single large US teaching hospital.<p> <p>Measurements - Semistructured interviews explored participants’ strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies.<p> <p>Results - Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness.<p> <p>Conclusions - Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

• Iversen, Else Dalsgaard; Wolderslund, Maiken; Kofoed, Poul-Erik; Gulbrandsen, Pål; Poulsen, Helle & Cold, Søren [Show all 7 contributors for this article] (2021). Communication skills training – a means to promote time-efficient patient-centered communication in practice. Journal of Patient-Centered Research and Reviews. ISSN 2330-068X. 8(4), p. 307–314. doi: 10.17294/2330-0698.1782. Full text in Research Archive Show summary

  Purpose: We hypothesized that health care providers would behave in a more patient-centered manner after the implementation of communication skills training, without causing the consultation to last longer. Methods: This study was part of the large-scale implementation of a communication skills training program called "Clear-Cut Communication With Patients" at Lillebaelt Hospital in Denmark. Audio recordings from real-life consultations were collected in a pre-post design, with health care providers' participation in communication skills training as the intervention. The training was based on the Calgary-Cambridge Guide, and audio recordings were rated using the Observation Scheme-12. Results: Health care providers improved their communication behavior in favor of being more patient-centered. Results were tested using a mixed-effect model and showed significant differences between pre- and postintervention assessments, with a coefficient of 1.3 (95% Cl: 0.35–2.3; P=0.01) for the overall score. The consultations did not last longer after the training. Conclusions: Health care providers improved their communication in patient consultations after the implementation of a large-scale patient-centered communication skills training program based on the Calgary-Cambridge Guide. This did not affect the length of the consultations.

• Rostadmo, Martine; Strømme, Siri Lunde; Nylenna, Magne; Gulbrandsen, Pål; Hem, Erlend & Skovlund, Eva [Show all 8 contributors for this article] (2021). How well do doctors understand a scientific article in English when it is not their first language? A randomised controlled trial. BMJ Open. 11(6), p. 1–5. doi: 10.1136/bmjopen-2020-043444. Full text in Research Archive Show summary

  Introduction English is the lingua franca of science. How well doctors understand English is therefore crucial for their understanding of scientific articles. However, only 5% of the world’s population have English as their first language. Methods Objectives: To compare doctors’ comprehension of a scientific article when read in their first language (Norwegian) versus their second language (English). Our hypothesis was that doctors reading the article in Norwegian would comprehend the content better than those reading it in English. Design: Parallel group randomised controlled trial. We randomised doctors to read the same clinical review article in either Norwegian or English, before completing a questionnaire about the content of the article. Setting: Conference in primary care medicine in Norway, 2018. Participants: 130 native Norwegian-speaking doctors, 71 women and 59 men. One participant withdrew before responding to the questionnaire and was excluded from the analyses. Interventions: Participants were randomly assigned to read a review article in either Norwegian (n=64) or English (n=66). Reading time was limited to 7 min followed by 7 min to answer a questionnaire. Main outcome measures: Total score on questions related to the article content (potential range −9 to 20). Results Doctors who read the article in Norwegian had a mean total score of 10.40 (SD 3.96) compared with 9.08 (SD 3.47) among doctors who read the article in English, giving a mean difference of 1.32 (95% CI 0.03 to 2.62; p=0.046). Age was independently associated with total score, with decreased comprehension with increasing age. Conclusion The difference in comprehension between the group who read in Norwegian and the group who read in English was statistically significant but modest, suggesting that the language gap in academia is possible to overcome.

• Menichetti, Julia; Gerwing, Jennifer; Borghi, Lidia; Gulbrandsen, Pål & Vegni, Elena (2021). Saying “I don’t know”: A video-based study on physicians’ claims of no-knowledge in assisted reproductive technology consultations. Frontiers in Psychology. 11, p. 1–10. doi: 10.3389/fpsyg.2020.611074. Full text in Research Archive Show summary

  Introduction The assisted reproductive technology (ART) field deals with consistent and predictable gaps in knowledge. Expressing lack of knowledge with a sentence like “I don’t know” can be challenging for doctors. This study examined physicians’ negative epistemic disclaimer “non lo so” in Italian ART doctor-couple interactions. In particular, it aimed to reveal specific features of “non lo so”: function, topic, temporality, responsibility, and interactional aspects. Methods This was a video-based observational study. We used microanalysis of face-to-face dialogue to analyze 20 purposively selected triadic consultations from a corpus of 85. This inductive analysis focused on the function, the content (topic and temporality) and some selected interactional aspects of the “non lo so”, quantifying and capturing the interaction between these qualitative features. Results We found 82 doctors’ “non lo so” in the corpus (mean = 4.4; range = 0–15). We discovered three main functions of this expression: propositional ( n = 73/82), relational ( n = 6/82), discursive ( n = 3/82). The most frequent topics raising doctors’ “non lo so” were costs ( n = 11/82), treatment-related aspects ( n = 10/82), and timing issues ( n = 9/82). In more than half of the cases ( n = 44/82), present issues emerged. The majority ( n = 70/82) of “non lo so” was framed using the “I,” with doctors’ taking personal responsibility. Patients played a role in these expressions from doctors: Patients initiated more than one third of them, and in one fourth of the cases, patients followed up immediately. Conclusion Our findings may be related to characteristics of the specific field of ART. Doctors in this setting must frequently express a direct lack of knowledge to their patients, and when they do, they mean it literally. Patients contribute to such disclosures, and their responses suggest that they find them acceptable, showing that they may expect limitations in their potential to conceive.

• Lie, Hanne Cathrine; Juvet, Lene Kristine; Jr, Richard L. Street,; Gulbrandsen, Pål; Mellblom, Anneli & Brembo, Espen Andreas [Show all 13 contributors for this article] (2021). Effects of Physicians' Information Giving on Patient Outcomes: a Systematic Review. Journal of General Internal Medicine (JGIM). ISSN 0884-8734. p. 1–13. doi: 10.1007/s11606-021-07044-5. Full text in Research Archive Show summary

  Background: Providing diagnostic and treatment information to patients is a core clinical skill, but evidence for the effectiveness of different information-giving strategies is inconsistent. This systematic review aimed to investigate the reported effects of empirically tested communication strategies for providing information on patient-related outcomes: information recall and (health-related) behaviors. Methods: The databases MEDLINE, Embase, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and relevant bibliographies were systematically searched from the inception to April 24, 2020, without restrictions, for articles testing information-giving strategies for physicians (PROSPERO ID: CRD42019115791). Pairs of independent reviewers identified randomized controlled studies with a low risk of selection bias as from the Cochrane risk of bias 2 tool. Main outcomes were grouped into patient information recall and behavioral outcomes (e.g., alcohol consumption, weight loss, participation in screening). Due to high heterogeneity in the data on effects of interventions, these outcomes were descriptively reported, together with studies’, interventions’, and information-giving strategies’ characteristics. PRISMA guidelines were followed. Results: Seventeen of 9423 articles were included. Eight studies, reporting 10 interventions, assessed patient information recall: mostly conducted in experimental settings and testing a single information-giving strategy. Four of the ten interventions reported significant increase in recall. Nine studies assessed behavioral outcomes, mostly in real-life clinical settings and testing multiple information-giving strategies simultaneously. The heterogeneity in this group of studies was high. Eight of the nine interventions reported a significant positive effect on objectively and subjectively measured patients’ behavioral outcomes. Discussion: Using specific framing strategies for achieving specific communication goals when providing information to patients appears to have positive effects on information recall and patient health–related behaviors. The heterogeneity observed in this group of studies testifies the need for a more consistent methodological and conceptual agenda when testing medical information-giving strategies.

• Gerwing, Jennifer; Steen-Hansen, Jon Erik; Mjaaland, Trond Arne; Jensen, Bård Fossli; Eielsen, Olav V & Thomas, Owen Matthew Truscott [Show all 7 contributors for this article] (2021). Evaluating a training intervention for improving alignment between emergency medical telephone operators and callers: a pilot study of communication behaviours. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 29(1). doi: 10.1186/s13049-021-00917-y. Full text in Research Archive Show summary

  Background Calls to emergency medical lines are an essential component in the chain of survival. Operators make critical decisions based on information they elicit from callers. Although smooth cooperation is necessary, the field lacks evidence-based guidelines for how to achieve it while adhering to strict parameters of index-driven questioning. We aimed to evaluate the effect of a training intervention for emergency medical operators at a call centre in Tønsberg, Norway. The course was designed to enhance operators’ communication skills for smoothing cooperation with callers. Methods Calls were analyzed using inductively developed coding based on the course rationale and content. To evaluate whether the course generated consolidated behavioral change in everyday practice, the independent analyst evaluated 32 calls, selected randomly from eight operators, two calls before and two after course completion. To measure whether skill attainment delayed decision making, we compared the time to the first decision logged by intervention operators to eight control operators. Analysis included 3034 calls: 1375 to intervention operators (T1 = 815; T2 = 560) and 1659 to control operators (T1 = 683; T2 = 976). Results Operators demonstrated improved behaviours on how they greeted the caller (p < .001), acknowledged the caller (p < .001), and displayed empathy (p = 0.015). No change was found in the use of open-ended questions and agreeing with the caller. Contrary to expectations, operators who took the course logged first decisions more quickly than the control group (p < .001). Conclusions This pilot study demonstrated that the training intervention generated behavioural change in these operators, providing justification for scaling up the intervention.

• Larsen, Berit Hofset; Lundeby, Tonje; Gerwing, Jennifer; Gulbrandsen, Pål & Førde, Reidun (2021). “Eh – What type of cells are these – flourishing in the liver?” Cancer patients’ disclosure of existential concerns in routine hospital consultations. Patient Education and Counseling. ISSN 0738-3991. doi: 10.1016/j.pec.2021.11.010. Full text in Research Archive Show summary

  Objective Advanced cancer poses a threat to all aspects of being, potentially causing existential suffering. We explore what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation, and how they communicate such concerns. Methods We analyzed thirteen video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. Results Nearly all patients disclosed how the illness experience included losses and threats of loss that are strongly associated with existential suffering, displaying uncertainty about future and insecurity about self and coping. Patients usually disclosed existential concerns uninvited, but they did so indirectly and subtly, typically hiding concerns in biomedical terms or conveying them with hesitation and very little emotion. Conclusions Patients may have existential concerns they want to address, but they may be uncertain whether these are issues they can discuss with the physician. Practice implications Health professionals should be attentive to underlying existential messages embedded in the patient’s questions and concerns. Acknowledging these existential concerns provides an opportunity to briefly explore the patient’s needs and may direct how the physician tailors information and support to promote coping, autonomy, and existential health.

• Menichetti, Julia; Lie, Hanne Cathrine; Mellblom, Anneli; Brembo, Espen Andreas; Eide, Hilde & Gulbrandsen, Pål [Show all 12 contributors for this article] (2021). Tested communication strategies for providing information to patients in medical consultations: A scoping review and quality assessment of the literature. Patient Education and Counseling. ISSN 0738-3991. 104(8), p. 1891–1903. doi: 10.1016/j.pec.2021.01.019. Full text in Research Archive Show summary

  Objectives: To systematize the scientific knowledge of empirically tested strategies for verbally providing medical information in patient-physician consultations. Methods: A scoping review searching for terms related to physician, information, oral communication, and controlled study. Four pairs of reviewers screened articles. For each selected study, we assessed the quality and summarized aspects on participants, study, intervention, and outcomes. Information provision strategies were inductively classified by types and main categories. Results: After screening 9422 articles, 39 were included. The methodological quality was moderate. We identified four differently used categories of strategies for providing information: cognitive aid (n = 13), persuasive (n = 8), relationship- (n = 3), and objectivity-oriented strategies (n = 4); plus, one “mixed” category (n = 11). Strategies were rarely theoretically derived. Conclusions: Current research of tested strategies for verbally providing medical information is marked by great heterogeneity in methods and outcomes, and lack of theory-driven approaches. The list of strategies could be used to analyse real life communication. Practice implications: Findings may aid the harmonization of future efforts to develop empirically-based information provision strategies to be used in clinical and teaching settings.

• Iversen, Else Dalsgaard; Wolderslund, Maiken; Kofoed, Poul E; Gulbrandsen, Pål; Poulsen, Helle & Søren, Cold [Show all 7 contributors for this article] (2020). Codebook for rating clinical communication skills based on the Calgary-Cambridge Guide. BMC Medical Education. 20. doi: 10.1186/s12909-020-02050-3. Full text in Research Archive Show summary

  Background The aim of the study was to confirm the validity and reliability of the Observation Scheme-12, a measurement tool for rating clinical communication skills. Methods The study is a sub-study of an intervention study using audio recordings to assess the outcome of communication skills training. This paper describes the methods used to validate the assessment tool Observation Scheme-12 by operationalizing the crude 5-point scale into specific elements described in a codebook. Reliability was tested by calculating the intraclass correlation coefficients for interrater and intrarater reliability. Results The validation of the Observation Scheme-12 produced a rating tool with 12 items. Each item has 0 to 5 described micro-skills. For each item, the codebook described the criteria for delivering a rating from 0 to 4 depending on how successful the different micro-skills (or number of used jargon words) was accomplished. Testing reliability for the overall score intraclass correlation coefficients was 0.74 for interrater reliability and 0.86 for intrarater reliability. An intraclass correlation coefficient greater than 0.5 was observed for 10 of 12 items. Conclusion The development of a codebook as a supplement to the assessment tool Observation Scheme-12 enables an objective rating of audiotaped clinical communication with acceptable reliability. The Observation Scheme-12 can be used to assess communication skills based on the Calgary-Cambridge Guide.

• Siddiqui, Tahreem Ghazal; Cheng, Socheat; Mellingsæter, Marte; Grambaite, Ramune; Gulbrandsen, Pål & Lundqvist, Christofer [Show all 7 contributors for this article] (2020). “What should I do when I get home?” treatment plan discussion at discharge between specialist physicians and older in-patients: mixed method study. BMC Health Services Research. 20:1002. doi: 10.1186/s12913-020-05860-9. Full text in Research Archive Show summary

  Background During discharge from hospital, older patients and physicians discuss the plan for managing patients’ health at home. If not followed at home, it can result in poor medication management, readmissions, or other adverse events. Comorbidities, polypharmacy and cognitive impairment may create challenges for older patients. We assessed discharge conversations between older in-patients and physicians for treatment plan activities and medication information, with emphasis on the role of cognitive function in the ongoing conversation. Methods We collected 11 videos of discharge consultations, medication lists, and self-reported demographic information from hospitalised patients ≥65 years at the Geriatric department in a general hospital. Mini Mental State Examination score < 25 was classified as low cognitive function. We used microanalysis of face-to-face dialogue to identify and characterise sequences of interaction focused on and distinguishing the treatment plan activities discussed. In addition to descriptive statistics, we used a paired-sample t-test and Mann-Whitney U test for non-parametric data. Results Patients’ median age was 85 (range: 71–90);7 were females and 4 males. Median of 17 (range: 7 to 23) treatment plan activities were discussed. The proportions of the activities, grouped from a patient perspective, were: 0.40 my medications, 0.21 something the hospital will do for me, 0.18 someone I visit away from home, 0.12 daily routine and 0.09 someone coming to my home. Patients spoke less (mean 190.9 words, SD 133.9) during treatment plan activities compared to other topics (mean 759 words, SD 480.4), (p = .001). Patients used on average 9.2 (SD 3.1) medications; during the conversations, an average of 4.5 (SD 3.3) were discussed, and side effects discussed on average 1.2 (SD 2.1) times. During treatment plan discussions, patients with lower cognitive function were less responsive and spoke less (mean 116.5 words, SD 40.9), compared to patients with normal cognition (mean 233.4 words, SD 152.4), (p = .089). Conclusion Physicians and geriatric patients discuss many activities during discharge conversations, mostly focusing on medication use without stating side effects. Cognitive function might play a role in how older patients respond. These results may be useful for an intervention to improve communication between physicians and older hospitalised patients.

• Gulbrandsen, Pål; Lindstrøm, Jonas Christoffer; Finset, Arnstein & Hall, Judith A. (2020). Patient affect, physician liking for the patient, physician behavior, and patient reported outcomes: A modeling approach. Patient Education and Counseling. ISSN 0738-3991. 103(6), p. 1143–1149. doi: 10.1016/j.pec.2020.01.003. Full text in Research Archive Show summary

  Objective To determine associations between patient affect and physician liking of the patient, and their associations with physician behavior and patient-reported outcomes. Methods Structural equation modeling based on coding of 497 videotaped hospital encounters, with questionnaires assessing pre-visit patient affect, post-visit patient affect and encounter evaluations, and physician liking of the patient, involving 71 physicians. Results In first visits, patient reported outcomes were strongly correlated with physician behavior and less so with physician liking, while in later visits, patient reported outcomes were directly related to physician liking and not mediated by physician behavior. Physician liking predicted physician behavior, more for female physicians in first visits. Patient negative affect before the visit was negatively associated with male physicians’ liking. When acquainted, both patient positive and negative affect were associated with physician liking. Conclusion Physician liking of the patient plays a dynamic role in a consultation, is influenced by patient pre-encounter affect, and influences physician behavior. The dynamics are different in first and later visits, and influenced by physician gender. Practice implications Physicians should be aware how patient affect influences their behavior, and administrators should take any prior relationship between patient and physician into account when evaluating patient reported outcomes.

• Han, Paul K.J.; Babrow, Austin; Hillen, Marij A.; Gulbrandsen, Pål; Smets, Ellen M. & Ofstad, Eirik Hugaas (2019). Uncertainty in health care: Towards a more systematic program of research. Patient Education and Counseling. ISSN 0738-3991. p. 1–11. doi: 10.1016/j.pec.2019.06.012. Full text in Research Archive Show summary

  <i>Objective</i> - To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research.<p> <p><i>Methods</i> - We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research.<p> <p><i>Results</i> - A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated.<p> <p><i>Conclusion</i> - Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community.<p> <p><i>Practice Implications</i> - A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.

• Nordfalk, Jenny Maria; Gulbrandsen, Pål; Gerwing, Jennifer; Nylenna, Magne & Menichetti, Julia (2019). Development of a measurement system for complex oral information transfer in medical consultations. BMC Medical Research Methodology. 19. doi: 10.1186/s12874-019-0788-7. Full text in Research Archive Show summary

  Background Information exchange between physician and patient is crucial to achieve patient involvement, shared decision making and treatment adherence. No reliable method exists for measuring how much information physicians provide in a complex, unscripted medical conversation, nor how much of this information patients recall. This study aims to fill this gap by developing a measurement system designed to compare complex orally provided information to patient recall. Methods The development of the complex information transfer measurement system required nine methodological steps. Core activities were data collection, definition of information units and the first draft of a codebook, refinement through independent coding and consensus, and reliability testing. Videotapes of physician-patient consultations based on a standardized scenario and post-consultation interviews with patients constituted the data. The codebook was developed from verbatim transcriptions of the videotapes. Inter-rater reliability was calculated using a random selection of 10% of the statements in the transcriptions. Results Thirtyfour transcriptions of visits and interviews were collected. We developed a set of rules for defining a single unit of information, defined detailed criteria for exclusion and inclusion of relevant units of information, and outlined systematic counting procedures. In the refinement phase, we established a system for comparing the information provided by the physician with what the patient recalled. While linguistic and conceptual issues arose during the process, coders still achieved good inter-rater reliability, with intra-class correlation for patient recall: 0.723, and for doctors: 0.761. A full codebook is available as an appendix. Conclusions A measurement system specifically aimed at quantifying complex unscripted information exchange may be a useful addition to the tools for evaluating the results of health communication training and randomized controlled trials.

• Hvidt, Elisabeth Assing; Søndergaard, Jens; Hansen, Dorte Gyrd; Gulbrandsen, Pål; Ammentorp, Jette & Timmermann, Connie [Show all 7 contributors for this article] (2018). 'We are the barriers': Danish general practitioners' interpretations of why existential and spiritual dimensions are neglected in patient care. Communication & Medicine. An Interdisciplinary Journal of Healthcare, Ethics and Society. ISSN 1612-1783. 14(2), p. 108–120. doi: 10.1558/cam.32147. Full text in Research Archive
• Lee, Joy; Callon, Wynne; Jr, Carlton Haywood; Lanzkron, Sophie M; Gulbrandsen, Pål & Beach, Mary Catherine (2018). What does shared decision making look like in natural settings? A mixed methods study of patient-provider conversations. Communication & Medicine. An Interdisciplinary Journal of Healthcare, Ethics and Society. ISSN 1612-1783. 14(3), p. 217–228. doi: 10.1558/cam.32815. Full text in Research Archive Show summary

  Objective: To understand the variability and nature of shared decision making (SDM) regarding a uniform type of serious medical decision, and to make normative judgments about how these conversations might be improved. Methods: This was a mixed-methods sub-analysis of the Improving Patient Outcomes with Respect and Trust (IMPORT) Study. We used the Braddock framework to identify and describe seven elements of SDM in audio-recorded encounters regarding initiation of hydroxyurea, and used data from medical records and patient questionnaires to understand whether and how these tasks were achieved. Results: Physicians covered a spectrum of SDM behaviors: all dialogues contained discussion regarding the clinical issue and the pros and cons of treatment; the patient’s understanding and role were not explicitly assessed or stated in any encounter. Yet no patient agreed to start hydroxyurea who did not already prefer it. There was no uniform approach to how physicians presented risk; many concerns expressed by patients in a pre-visit questionnaire were not discussed. Conclusion: In this analysis, patients seemed to understand their role in the decision-making process, suggesting that a patient’s role may not always need to be explicitly stated. However, shared decision making might be improved with more routine assessment of patient understanding and concerns. Standardized decision aids might help fully inform patients of risks and benefits.

• Ammentorp, Jette; Wolderslund, Maiken; Timmermann, Connie; Larsen, Henry; Steffensen, Karina Dahl & Nielsen, Annegrethe [Show all 12 contributors for this article] (2018). How participatory action research changed our view of the challenges of shared decision-making training. Patient Education and Counseling. ISSN 0738-3991. 101(4), p. 639–646. doi: 10.1016/j.pec.2017.11.002. Full text in Research Archive Show summary

  Objective This paper aims to demonstrate how the use of participatory action research (PAR) helped us identify ways to respond to communication challenges associated with shared decision-making (SDM) training. Methods Patients, relatives, researchers, and health professionals were involved in a PAR process that included: (1) two theatre workshops, (2) a pilot study of an SDM training module involving questionnaires and evaluation meetings, and (3) three reflection workshops. Results The PAR process revealed that health professionals often struggled with addressing existential issues such as concerns about life, relationships, meaning, and ability to lead responsive dialogue. Following the PAR process, a communication programme that included communication on existential issues and coaching was drafted. Conclusion By involving multiple stakeholders in a comprehensive PAR process, valuable communication skills addressing a broader understanding of SDM were identified. A communication programme aimed to enhance skills in a mindful and responsive clinical dialogue on the expectations, values, and hopes of patients and their relatives was drafted. Practical implications Before integrating new communication concepts such as SDM in communication training, research methods such as PAR can be used to improve understanding and identify the needs and priorities of both patients and health professionals. Ammentorp, Jette, et al. "How participatory action research changed our view of the challenges of shared decision-making training." Patient education and counseling (2017). © 2017. This manuscript version is made available under the CC-BY-NC-ND 4.0 license.

• Ofstad, Eirik Hugaas; Frich, Jan C; Schei, Edvin; Frankel, Richard M.; Benth, Jūratė Šaltytė & Gulbrandsen, Pål (2018). Clinical decisions presented to patients in hospital encounters: a cross-sectional study using a novel taxonomy. BMJ Open. 8, p. 1–9. doi: 10.1136/bmjopen-2017-018042. Full text in Research Archive Show summary

  Objective: To identify and classify all clinical decisions that emerged in a sample of patient–physician encounters and compare different categories of decisions across clinical settings and personal characteristics. Design: Cross-sectional descriptive evaluation of hospital encounters videotaped in 2007–2008 using a novel taxonomy to identify and classify clinically relevant decisions (both actions and judgements). Participants and setting: 372 patients and 58 physicians from 17 clinical specialties in ward round (WR), emergency room (ER) and outpatient (OP) encounters in a Norwegian university hospital. Results: The 372 encounters contained 4976 clinically relevant decisions. The average number of decisions per encounter was 13.4 (min–max 2–40, SD 6.8). The overall distribution of the 10 topical categories in all encounters was: defining problem: 30%, evaluating test result: 17%, drug related: 13%, gathering additional information: 10%, contact related: 10%, advice and precaution: 8%, therapeutic procedure related: 5%, deferment: 4%, legal and insurance related: 2% and treatment goal: 1%. Across three temporal categories, the distribution of decisions was 71% here-and-now, 16% preformed and 13% conditional. On average, there were 15.7 decisions per encounter in internal medicine specialties, 7.1 in ear–nose–throat encounters and 11.0–13.6 in the remaining specialties. WR encounters contained significantly more drug-related decisions than OP encounters (P=0.031) and preformed decisions than ER and OP encounters (P<0.001). ER encounters contained significantly more gathering additional information decisions than OP and WR encounters (P<0.001) and fewer problem defining decisions than WR encounters (P=0.028). There was no significant difference in the average number of decisions related to the physician’s and patient’s age or gender. Conclusions: Patient–physician encounters contain a larger number of clinically relevant decisions than described in previous studies. Comprehensive descriptions of how decisions, both as judgements and actions, are communicated in medical encounters may serve as a first step in assessing clinical practice with respect to efficiency and quality on a provider or system level.

• Gulbrandsen, Pål (2018). The possible impact of vulnerability on clinical communication: Some reflections and a call for empirical studies. Patient Education and Counseling. ISSN 0738-3991. 101(11), p. 1990–1994. doi: 10.1016/j.pec.2018.07.025. Full text in Research Archive Show summary

  Objective To direct attention to the concept of vulnerability, how it affects interactions in subtle ways and is difficult to detect in studies of clinical dialogues. Methods A reflection on three everyday examples of what seems like insignificant details in physician-patient interaction, enlightened by readings with an emphasis on unacknowledged shame, illness and social bonds, and the physician’s role. Results Physicians are aware of patients’ vulnerability as risk and susceptibility to harm under certain circumstances, but often miss the vulnerability related to perceived or anticipated loss of social bonds. The latter may elicit unacknowledged shame, which leads to subtle behavioral changes that are easy to overlook. Typical reactions are silence or lack of relevant response to questions. Physicians are rarely aware of their own vulnerability. Slight behavioral changes from a clinician may reduce or increase a patient’s ability to partake actively in problem solving and decision-making. Conclusion When physicians or patients are touching upon unacknowledged shame as part of being vulnerable, subtle changes in the interaction may hamper efficient communication. Practice implications We need studies that add participants’ unprompted and prompted reflections on encounter videos, with an emphasis on micro-events and their explanation and impact on the interaction.

• Skjeggestad, Erik; Gerwing, Jennifer & Gulbrandsen, Pål (2017). Language barriers and professional identity: A qualitative interview study of newly employed international medical doctors and Norwegian colleagues. Patient Education and Counseling. ISSN 0738-3991. 100(8), p. 1466–1472. doi: 10.1016/j.pec.2017.03.007. Full text in Research Archive Show summary

  Objective To explore how language barriers influence communication and collaboration between newly-employed international medical doctors and Norwegian health personnel. Methods Interviews were conducted with 16 doctors who had recently started working in Norway and 12 Norwegian born health personnel who had extensive experience working with international medical doctors. Analyses were consistent with principles of systematic text condensation. Results All participants experienced that language barriers caused difficulties in their everyday collaboration. Furthermore, the participants’ descriptions of “language barriers” encompassed a wide range of topics, including semantics (e.g., specialized professional vocabulary, system knowledge), pragmatics (e.g., using language in doctor-patient and interprofessional interactions), and specific culturally sensitive topics. All participants described that language barriers provoked uncertainty about a doctor’s competence. Conclusion Newly employed international medical doctors and their colleagues are concerned by ineffective communication due to language barriers. Experiences of language barriers threaten professional identity as a competent and effective doctor. Practice implications Newly employed doctors who are non-native speakers could benefit from support in understanding and handling the array of barriers related to language. Skjeggestad, Erik, Jennifer Gerwing, and Pål Gulbrandsen. "Language barriers and professional identity: A qualitative interview study of newly employed international medical doctors and Norwegian colleagues." Patient education and counseling 100.8 (2017): 1466-1472. http://dx.doi.org/10.1016/j.pec.2017.03.007 © 2017. This manuscript version is made available under the CC-BY-NC-ND 4.0 license.

• Hvidt, Elisabeth Assing; Hansen, Dorte Gyrd; Ammentorp, Jette; Bjerrum, Lars; Cold, Søren & Gulbrandsen, Pål [Show all 12 contributors for this article] (2017). Development of the EMAP tool facilitating existential communication between general practitioners and cancer patients. European Journal of General Practice. ISSN 1381-4788. 23, p. 261–268. doi: 10.1080/13814788.2017.1326479. Full text in Research Archive Show summary

  Background: General practice recognizes the existential dimension as an integral part of multidimensional patient care alongside the physical, psychological and social dimensions. However, general practitioners (GPs) report substantial barriers related to communication with patients about existential concerns. Objectives: To describe the development of the EMAP tool facilitating communication about existential problems and resources between GPs and patients with cancer. Methods: A mixed-methods design was chosen comprising a literature search, focus group interviews with GPs and patients (n = 55) and a two-round Delphi procedure initiated by an expert meeting with 14 experts from Denmark and Norway. Results: The development procedure resulted in a semi-structured tool containing suggestions for 10 main questions and 13 sub-questions grouped into four themes covering the existential dimension. The tool utilized the acronym and mnemonic EMAP (existential communication in general practice) indicating the intention of the tool: to provide a map of possible existential problems and resources that the GP and the patient can discuss to find points of reorientation in the patient’s situation. Conclusion: This study resulted in a question tool that can serve as inspiration and help GPs when communicating with cancer patients about existential problems and resources. This tool may qualify GPs’ assessment of existential distress, increase the patient’s existential well-being and help deepen the GP–patient relationship.

• Hurlen, Petter; Ofstad, Eirik Hugaas & Gulbrandsen, Pål (2017). Identifying the basis for clinical decisions – a feasibility study. Studies in Health Technology and Informatics. ISSN 0926-9630. 228, p. 509–513. doi: 10.3233/978-1-61499-678-1-509. Full text in Research Archive Show summary

  This study explored the possibility of defining a set of terms to describe and identify the basis for clinical decisions in a set of transcriptions from clinical encounters with previously identified decisions. The paper presents the considerations behind the exploratory study and considerations for further work.

• Kasper, Jürgen; Lager, Anne Regine; Rumpsfeld, Markus; Kienlin, Simone Maria; Smestad, Kristine Hoel & Bråthen, Tone [Show all 15 contributors for this article] (2017). Statusbericht aus Norwegen: Implementierung von Patientenbeteiligung im norwegischen Gesundheitswesen [Status report from Norway: Implementation of patient involvement in Norwegian health care]. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen. ISSN 1865-9217. 123-124, p. 75–80. doi: 10.1016/j.zefq.2017.05.015. Full text in Research Archive
• Skjeggestad, Erik; Norvoll, Reidun; Sandal, Gro Mjeldheim & Gulbrandsen, Pål (2017). How do international medical graduates and colleagues perceive and deal with difficulties in everyday collaboration? A qualitative study. Scandinavian Journal of Public Health. ISSN 1403-4948. 45(4), p. 428–435. doi: 10.1177/1403494817698286. Full text in Research Archive Show summary

  Aims: Many medical doctors work outside their countries of origin. Consequently, language barriers and cultural differences may result in miscommunication and tension in the workplace, leading to poor performance and quality of treatment and affecting patient safety. However, there is little information about how foreign doctors and their colleagues perceive their collaboration and handle situations that can affect the quality of health services. Methods: Individual, semi-structured in-depth interviews were conducted with two groups of informants: 16 doctors who had recently started working in Norway and 12 unrelated Norwegian-born healthcare providers who had extensive experience of working with doctors from foreign countries. The interviews were analysed according to the systematic text condensation method. Results: The foreign doctors described themselves as newcomers and found it difficult to speak with their colleagues about their shortcomings because they wanted to be seen as competent. Their Norwegian colleagues reported that many new foreign doctors had demanding work schedules and therefore they were reluctant to give them negative feedback. They also feared that foreign doctors would react negatively to criticism. All participants, both the new foreign doctors and their colleagues, reported that they took responsibility for the prevention of misunderstandings and errors; nevertheless, they struggled to discuss such issues with each other. Conclusions: Silence was the coping strategy adopted by both the foreign doctors and native healthcare professionals when facing difficulties in their working relationships. In such situations, many foreign doctors are socialized into a new workplace in which uncertainty and shortcomings are not discussed openly. Effective leadership and procedures to facilitate communication may alleviate this area of concern.

• Gerwing, Jennifer & Gulbrandsen, Pål (2017). The perils of information giving: What an accidental incident taught us about messages and roles. Patient Education and Counseling. ISSN 0738-3991. 100(11), p. 2109–2115. doi: 10.1016/j.pec.2017.05.009. Full text in Research Archive
• Gorawara-Bhat, Rita; Hafskjold, Linda; Gulbrandsen, Pål & Eide, Hilde (2017). Exploring physicians' verbal and nonverbal responses to cues/concerns: Learning from incongruent communication. Patient Education and Counseling. ISSN 0738-3991. 100(11), p. 1979–1989. doi: 10.1016/j.pec.2017.06.027. Full text in Research Archive Show summary

  Objectives Explore physicians’ verbal and nonverbal responses to cues/concerns in consultations with older-patients. Methods Two teams independently coded a sample of Norwegian consultations (n = 24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients’ verbal emotional expressions were labeled ‘Acknowledging of patients’ emotional expressions’, and ‘Distancing from patients’ emotional expressions.’ Based on type and extent of nonverbal expressiveness, consultations were labeled ‘Affective’ and ‘Prescriptive.’ Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed. Results Types 1 and 2 consultations were described as ‘Congruent,’ i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered ‘Incongruent,’ i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients’ needs. Conclusions Frequently physicians’ display incongruent behavior in challenging situations. Older patients’ may perceive this as either alleviating or increasing distress, depending on their needs. Practice implications Type 3 consultations may shed light on reasons for physicians’ incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients’ perceptions of incongruent communication should be further explored.

• Hurlen, Petter; Borthne, Arne Sigmund & Gulbrandsen, Pål (2017). The Impact of PACS on Radiograph Interpretations in an Orthopedic Outpatient Clinic. In Gundlapalli, Adi; Jaulent, Marie-Christine & Zhao, Dongsheng (Ed.), MEDINFO 2017: Precision Healthcare through Informatics. IOS Press. ISSN 9781614998297. p. 1364–1364. doi: 10.3233/978-1-61499-830-3-1364. Full text in Research Archive Show summary

  We found no significant change in the accuracy of clinicians' reading of skeletal radiographs before and after PACS- introduction. The level of inter-rater agreement between clinicians and radiologists was high in both periods, but they disagreed in significantly more cases after PACS.

• Elwyn, Glyn; Durand, Marie Anne; Song, Julia; Aarts, Johanna; Barr, Paul & Berger, Zackary [Show all 21 contributors for this article] (2017). A three-talk model for shared decision making: multistage consultation process. The BMJ. 359. doi: 10.1136/bmj.j4891. Full text in Research Archive Show summary

  Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Design Multistage consultation process. Setting Key informant group, communities of interest, and survey of clinical specialties. Participants 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties. Results After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on “team talk,” “option talk,” and “decision talk,” to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals. Conclusions The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences.

• Landmark, Anne Marie Dalby; Svennevig, Jan; Gerwing, Jennifer & Gulbrandsen, Pål (2017). Patient involvement and Language Barriers: Problems of agreement of understanding? Patient Education and Counseling. ISSN 0738-3991. 100(6), p. 1092–1102. doi: 10.1016/j.pec.2016.12.006. Full text in Research Archive Show summary

  Objective: This study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation. Methods: From a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM. Results: Though the physician did extensive interactional work to secure the patient’s understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient’s participation. In ratings of PCC and SDM, this case scored well above average. Conclusion: Despite the fact that this encounter displays some of the ‘best actual practice’ of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement. Practice implications: When facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges.

• Lauritzen, Peter Mæhre; Andersen, Jack Gunnar; Stokke, Mali Victoria; Tennstrand, Anne Lise; Aamodt, Rolf & Heggelund, Thomas [Show all 10 contributors for this article] (2016). Radiologist-initiated double reading of abdominal CT: Retrospective analysis of the clinical importance of changes to radiology reports. BMJ Quality and Safety. ISSN 2044-5415. 25(8), p. 595–603. doi: 10.1136/bmjqs-2015-004536. Full text in Research Archive Show summary

  Background Misinterpretation of radiological examinations is an important contributing factor to diagnostic errors. Consultant radiologists in Norwegian hospitals frequently request second reads by colleagues in real time. Our objective was to estimate the frequency of clinically important changes to radiology reports produced by these prospectively obtained double readings. Methods We retrospectively compared the preliminary and final reports from 1071 consecutive double-read abdominal CT examinations of surgical patients at five public hospitals in Norway. Experienced gastrointestinal surgeons rated the clinical importance of changes from the preliminary to final report. The severity of the radiological findings in clinically important changes was classified as increased, unchanged or decreased. Results Changes were classified as clinically important in 146 of 1071 reports (14%). Changes to 3 reports (0.3%) were critical (demanding immediate action), 35 (3%) were major (implying a change in treatment) and 108 (10%) were intermediate (requiring further investigations). The severity of the radiological findings was increased in 118 (81%) of the clinically important changes. Important changes were made less frequently when abdominal radiologists were first readers, more frequently when they were second readers, and more frequently to urgent examinations. Conclusion A 14% rate of clinically important changes made during double reading may justify quality assurance of radiological interpretation. Using expert second readers and a targeted selection of urgent cases and radiologists reading outside their specialty may increase the yield of discrepant cases.

• Clayman, Marla; Gulbrandsen, Pål & Morris, Megan A (2016). A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter. Patient Education and Counseling. ISSN 0738-3991. doi: 10.1016/j.pec.2016.10.016. Full text in Research Archive
• Lauritzen, Peter Mæhre; Stavem, Knut; Andersen, Jack Gunnar; Stokke, Mali Victoria; Tennstrand, Anne Lise & Bjerke, Gisle [Show all 10 contributors for this article] (2016). Double reading of current chest CT examinations: Clinical importance of changes to radiology reports. European Journal of Radiology. ISSN 0720-048X. 85(1), p. 199–204. doi: 10.1016/j.ejrad.2015.11.012. Full text in Research Archive Show summary

  Objectives Misinterpretation of radiological examinations is an important contributing factor to diagnostic errors. Double reading reduces interpretation errors and increases sensitivity. Consultant radiologists in Norwegian hospitals submit 39% of computed tomography (CT) reports for quality assurance by double reading. Our objective was to estimate the proportion of radiology reports that were changed during double reading and to assess the potential clinical impact of these changes. Materials and methods In this retrospective cross-sectional study we acquired preliminary and final reports from 1023 consecutive double read chest CT examinations conducted at five public hospitals. The preliminary and final reports were compared for changes in content. Three experienced pulmonologists independently rated the clinical importance of these changes. The severity of the radiological findings in clinically important changes was classified as increased, unchanged, or decreased. Results Changes were classified as clinically important in 91 (9%) of 1023 reports. Of these: 3 were critical (demanding immediate action), 15 were major (implying a change in treatment) and 73 were intermediate (affecting subsequent investigations). More clinically important changes were made to urgent examinations and less to female first readers. Chest radiologist made more clinically important changes than other second readers. The severity of the radiological findings was increased in 73 (80%) of the clinically important changes. Conclusion A 9% rate of clinically important changes made during double reading may justify quality assurance of radiological interpretation. Using expert second readers and targeting a selection of urgent cases prospectively may increase the yield of discrepant cases and reduce harm to patients.

• Landmark, Anne Marie Dalby; Svennevig, Jan & Gulbrandsen, Pål (2016). Negotiating treatment preferences: Physicians' formulations of patients' stance. Social Science and Medicine. ISSN 0277-9536. 149, p. 26–36. doi: 10.1016/j.socscimed.2015.11.035. Full text in Research Archive Show summary

  Eliciting patients' values and treatment preferences is an essential element in models of shared decision making, yet few studies have investigated the interactional realizations of how physicians do this in authentic encounters. Drawing on video-recorded encounters from Norwegian secondary care, the present study uses the fine-grained empirical methodology of conversation analysis (CA) to identify one conversational practice physicians use, namely, formulations of patients' stance, in which physicians summarize or paraphrase their understanding of the patient's stance towards treatment. The purpose of this study is twofold: (1) to explore what objectives formulations of patients' stance achieve while negotiating treatment and (2) to discuss these objectives in relation to core requirements in shared decision making. Our analysis demonstrates that formulating the patient's stance is a practice physicians use in order to elicit, check, and establish patients' attitudes towards treatment. This practice is in line with general recommendations for making shared decisions, such as exploring and checking patients' preferences and values. However, the formulations may function as a device for doing more than merely checking and establishing common ground and bringing up patients' preferences and views: Accompanied by subtle deprecating expressions, they work to delegitimize the patients' stances and indirectly convey the physicians' opposing stance. Once established, these positions can be used as a basis for challenging and potentially altering the patient's attitude towards the decision, thereby making it more congruent with the physician's view. Therefore, in addition to bringing up patients' views towards treatment, we argue that physicians may use formulations of patients' stance as a resource for directing the patient towards decisions that are congruent with the physician's stance in situations with potential disagreement, whilst (ostensibly) avoiding a more authoritarian or paternalistic approach.

• Ofstad, Eirik Hugaas; Frich, Jan C; Schei, Edvin; Frankel, Richard M. & Gulbrandsen, Pål (2016). What is a medical decision? A taxonomy based on physician statements in hospital encounters: A qualitative study. BMJ Open. 6(2). doi: 10.1136/bmjopen-2015-010098. Full text in Research Archive
• Gulbrandsen, Pål; Clayman, Marla L.; Beach, Mary Catherine; Han, Paul K; Boss, Emily F & Ofstad, Eirik Hugaas [Show all 7 contributors for this article] (2016). Shared decision-making as an existential journey: Aiming for restored autonomous capacity. Patient Education and Counseling. ISSN 0738-3991. 99(9), p. 1505–1510. doi: 10.1016/j.pec.2016.07.014. Full text in Research Archive
• Dalby, Anne Marie Landmark; Gulbrandsen, Pål & Svennevig, Jan (2015). Whose decision? Negotiating epistemic and deontic rights in medical treatment decisions. Journal of Pragmatics. ISSN 0378-2166. 78, p. 54–69. doi: 10.1016/j.pragma.2014.11.007. Full text in Research Archive Show summary

  Shared decision making has become an ideal in contemporary clinical practice, and guidelines recommend exploring patients’ preferences and providing them with options so they can make informed decisions. This paper examines how the ideal of sharedness is maintained and negotiated through epistemic and deontic resources in secondary care consultations where patients are given a choice between invasive and non-invasive treatment options. The analysis suggests that the physician's presentation of treatment options is often tilted in favor of one proposal over the other, yet giving the patient the right to make the final decision. The patients on the other hand regularly resist this responsibility by claiming lack of epistemic authority (e.g. I know nothing about it) or by making the decision contingent on the physician taking a stronger deontic stance (e.g. if you think so). This may be characterized as an inverted use of deontic authority from both parties: Physicians give patients deontic rights in their pursuit of independent commitment to their preferred option, while patients orient to physicians’ epistemic and deontic rights as a way to resist committing to the physicians’ propositions. These conflicting orientations to epistemic and deontic authority counteract the ideal of shared decision making.

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• Gulbrandsen, Pål & Finset, Arnstein (2019). Skreddersydde samtaler - en veileder i medisinsk kommunikasjon. 2. utgave. Gyldendal Akademisk. ISBN 9788205523968. 181 p. Full text in Research Archive
• Haver, Brit; Berge, Line Iden; Gulbrandsen, Pål & Hannestad, Yngvild Skåtun (2016). Hva gikk galt hos legen? Når dialogen svikter. Spartacus. ISBN 9788243010000. 212 p. Full text in Research Archive

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• Gulbrandsen, Pål; Landmark, Anne Marie; Svennevig, Jan & Teig, Inger Lise (2025). Snakk om usikkerhet. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 145(11). doi: https:/tidsskriftet.no/2025/09/kronikk/snakk-om-usikkerhet. Full text in Research Archive
• Solarek-Gliniewicz, Magdalena; Gulbrandsen, Pål & Lilleslåtten, Mari (2024). Utenlandske leger strever med norske dialekter. Går det på helsa løs? [Internet]. Universitetsplassen - en podcast fra UiO. Full text in Research Archive
• Gulbrandsen, Pål & Widing, Eva (2024). Video om vanskelige samtaler. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 144(3). doi: 10.4045/tidsskr.23.0855. Full text in Research Archive
• Gulbrandsen, Pål (2024). Død i vente. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 144(13), p. 1053–1053. doi: 10.4045/tidsskr.24.0535. Full text in Research Archive
• Larsen, Berit Hofset; Lundeby, Tonje; Gerwing, Jennifer; Gulbrandsen, Pål & Førde, Reidun (2023). Alvorlig syke kreftpasienter kan kamuflere sine eksistensielle bekymringer. Sykepleien Forskning. ISSN 1890-2936. doi: 10.4220/Sykepleiens.2023.93333. Full text in Research Archive
• Egenberg, Herman Escher; Gerwing, Jennifer; Lie, Hanne Cathrine; Gulbrandsen, Pål & Menichetti, Julia (2023). If I say…teach-back. Patient Education and Counseling. ISSN 0738-3991. 116. doi: 10.1016/j.pec.2023.107982. Full text in Research Archive
• Egenberg, Herman Escher; Gerwing, Jennifer; Lie, Hanne Cathrine; Gulbrandsen, Pål & Menichetti, Julia (2023). Erratum: Withdrawal notice to “If I say…teach-back” [Patient Educ Couns 116 (2023) 107982] (Patient Education and Counseling (2023) 116, (S0738399123003440), (10.1016/j.pec.2023.107964)). Patient Education and Counseling. ISSN 0738-3991. 116. doi: 10.1016/j.pec.2023.107991. Full text in Research Archive
• Pieterse, Arwen H.; Gulbrandsen, Pål; Ofstad, Eirik Hugaas & Delor, Julia Menichetti (2023). What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care. Patient Education and Counseling. ISSN 0738-3991. 114. doi: 10.1016/j.pec.2023.107801. Full text in Research Archive Show summary

  Objective Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training. Discussion Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients. Conclusions We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.

• Menichetti, Julia; Gerwing, Jennifer; Landmark, Anne Marie Dalby; Lie, Hanne Cathrine & Gulbrandsen, Pål (2022). Formulations used by doctors to provide information to patients: A video-based study. Full text in Research Archive
• Pieterse, Arwen H; Gulbrandsen, Pål; McCaffery, Kirsten & Henselmans, Inge (2022). Shared Decision Making. In Ho, Evelyn; Bylund, Carma & Weert, Julia Van (Ed.), The International Encyclopedia of Health Communication. John Wiley & Sons. ISSN 9781119678816. doi: 10.1002/9781119678816.iehc0688. Full text in Research Archive
• Gulbrandsen, Pål; Gerwing, Jennifer & Landmark, Anne Marie Dalby (2022). Time to advance the educational model of clinical communication in medicine. Patient Education and Counseling. ISSN 0738-3991. doi: 10.1016/j.pec.2022.04.011. Full text in Research Archive
• Gulbrandsen, Pål & Menichetti, Julia (2021). Avstand og nærhet i klinisk arbeid. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 141, p. 708–708. Full text in Research Archive
• Juvet, Lene Kristine; Brembo, Espen Andreas; Eide, Hilde; Heyn, Lena; Mellblom, Anneli & Gulbrandsen, Pål [Show all 11 contributors for this article] (2021). Communication strategies for providing information in talks with patients: A systematic review. Full text in Research Archive
• Gulbrandsen, Pål (2020). Er pasientene kravstore systemutnyttere? Full text in Research Archive
• Gulbrandsen, Pål; Hyldmo, Ingrid; Fossum, Ingvild Skinstad; Seip, Birgitte Karen Berggreen; Øyen, Lill Anette & Owen, Tanja (2020). En effektiv og trygg vei til bedre spesialistutdanning i sykehus? 140. Full text in Research Archive
• Finset, Arnstein; Bosworth, H; Butow, Phyllis; Gulbrandsen, Pål; Hulsman, Robert L & Pieterse, Arwen H [Show all 9 contributors for this article] (2020). Effective health communication – a key factor in fighting the COVID-19 pandemic. Patient Education and Counseling. ISSN 0738-3991. 103(5), p. 873–876. doi: 10.1016/j.pec.2020.03.027. Full text in Research Archive
• Siddiqui, Tahreem Ghazal; Cheng, Socheat; Grambaite, Ramune; Mellingsæter, Marte; Gulbrandsen, Pål & Lundqvist, Christofer [Show all 7 contributors for this article] (2020). Discharge conversation between geriatric patients and specialists physicians. Full text in Research Archive
• Gulbrandsen, Pål; Hyldmo, Ingrid; Fossum, Ingvild Skinstad; Seip, Birgitte Karen Berggreen; Øyen, Lill Anette & Owen, Tanja (2020). En effektiv og trygg vei til bedre spesialistutdanning i sykehus? 140(2), p. 1–5. doi: 10.4045/tidsskr.19.0639. Full text in Research Archive
• Gulbrandsen, Pål (2020). Flyskam for skriftlærde. Full text in Research Archive
• Lie, Hanne Cathrine; Mellblom, Anneli; Juvet, Lene Kristine; Heyn, Lena; Sundling, Vibeke & Brembo, Espen Andreas [Show all 12 contributors for this article] (2020). Spoken communication strategies for effective information provision in the medical consultation: A systematic review. Full text in Research Archive
• Gulbrandsen, Pål (2020). Shared decision making: Improving doctor-patient communication. BMJ. British Medical Journal. ISSN 0959-8146. 368. doi: 10.1136/bmj.m97. Full text in Research Archive
• Gulbrandsen, Pål (2020). Helseministeren svikter legespesialistutdanningen. Full text in Research Archive
• Gerwing, Jennifer & Gulbrandsen, Pål (2019). Contextualizing decisions: Stepping out of the SDM track. Patient Education and Counseling. ISSN 0738-3991. 102(5), p. 815–816. doi: 10.1016/j.pec.2019.03.024. Full text in Research Archive
• Siddiqui, Tahreem Ghazal; Cheng, Socheat; Mellingsæter, Marte; Lundqvist, Christofer; Gulbrandsen, Pål & Gerwing, Jennifer (2019). Communication about medication use between older patients and physicians in secondary care. Full text in Research Archive
• Gulbrandsen, Pål (2018). #powerblind: hva makten gjør med oss (menn). Full text in Research Archive
• Bjørndal, Arild; Borchgrevink, Christian Fredrik; Frich, Jan C; Gulbrandsen, Pål; Lie, Anne Helene Kveim & Malterud, Kirsti [Show all 9 contributors for this article] (2017). Per Fugelli. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 137. doi: 10.4045/tidsskr.17.0800. Full text in Research Archive
• Gulbrandsen, Pål (2017). Journalopptak og dokumentasjon, Indremedisin I & II. Forlaget Vett & Viten AS. ISSN 9788241207402. p. 25–34. Full text in Research Archive
• Gulbrandsen, Pål (2017). Arnstein Finset's legacy. Patient Education and Counseling. ISSN 0738-3991. 100(11), p. 2074–2074. doi: 10.1016/j.pec.2017.06.020. Full text in Research Archive
• Hurlen, Petter & Gulbrandsen, Pål (2017). Hvor trygg kan pasientjournalen egentlig være? Full text in Research Archive
• Gulbrandsen, Pål (2016). The significance of seconds. Patient Education and Counseling. ISSN 0738-3991. 99(11), p. 1751–1752. doi: 10.1016/j.pec.2016.09.014. Full text in Research Archive
• Gulbrandsen, Pål (2016). Ord dreper! Aftenposten (morgenutg. : trykt utg.). ISSN 0804-3116. Full text in Research Archive
• Gulbrandsen, Pål (2016). Den viktige samtalen: Leger trenger kommunikasjonstrening. Dagens medisin. ISSN 1501-4290. p. 30–30. Full text in Research Archive
• Gulbrandsen, Pål (2016). Om pasientmedverknad. Firdaposten. Full text in Research Archive
• Gorawara-Bhat, Rita; Eide, Hilde; Hafskjold, Linda & Gulbrandsen, Pål (2016). Verbal and Nonverbal Communication in Physician-Older Patient Interaction. Full text in Research Archive
• Gorawara-Bhat, Rita; Hafskjold, Linda; Gulbrandsen, Pål & Eide, Hilde (2016). Verbal and nonverbal communication in physician-older patient interactions. Presentation during Symposium Communication with older persons: Adressing Worries and Distress in Home Healthcare and Hospital. Full text in Research Archive
• Lauritzen, Peter Mæhre; Stavem, Knut; Andersen, Jack Gunnar; Tennstrand, Anne Lise; Stokke, Mali Victoria & Bjerke, Gisle [Show all 10 contributors for this article] (2015). Endringer av klinisk betydning ved dobbeltgransking av CT thorax. Full text in Research Archive
• Lauritzen, Peter Mæhre; Andersen, Jack Gunnar; Tennstrand, Anne Lise; Stokke, Mali Victoria; Aamodt, Rolf & Heggelund, Thomas [Show all 10 contributors for this article] (2015). Endringer av klinisk betydning ved dobbeltgransking av CT abdomen og bekken. Full text in Research Archive
• Gulbrandsen, Pål (2015). Å være utstøtt er verre enn døden. Full text in Research Archive
• Gulbrandsen, Pål (2015). En dansk økonom ser på helsetjenesten. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 135, p. 355–355. Full text in Research Archive
• Førde, Reidun; Gulbrandsen, Pål; Lundeby, Tonje & Larsen, Berit Hofset (2023). Patient autonomy in advanced cancer. A video-based qualitative study of clinical communication in routine hospital visits. Universitetet i Oslo. ISSN 9788234802898. Full text in Research Archive Show summary

  This thesis contributes to the discussion about how to enhance patient autonomy in the case of advanced cancer posing an existential threat to all aspects of being. The aim was to explore 1) what existential concerns patients with advanced cancer disclose during routine hospital visits and how they communicate such concerns, 2) how physicians respond to patients’ existential concerns, and 3) how next-of-kin accompanying the patient contribute to the information exchange. We employed a qualitative research design, studying video-recorded routine outpatient hospital visits involving patients with advanced cancer, using analytic principles from “microanalysis of clinical interaction”. Most patients disclosed existential concerns during the consultation. However, existential concerns were hesitant, subtle, and indirect, typically hidden in biomedical terms. The physicians habitually responded to these concerns by keeping the agenda around biomedical aspects, resulting in that the existential issues remained unaddressed. In most consultations, the patient was accompanied by a next-of-kin, whom the physicians mostly related to as a “supporter on the sidelines” rather than addressing the couple as a team. When claiming the floor, next-of-kin contributed to securing information that would otherwise have been missing. Next-of-kin provided personal and contextual information that can help the physician when aiming to tailor information and care to the individual patient. The thesis points to a potential existential neglect in the physician and in the medical culture. It argues that a narrow focus on patient choice and decision-making may be inadequate, as it does not consider that persons are vulnerable, dependent, and relational. Insights from this thesis can inform the discussion about how physicians can play a role in attending to existential concerns and restoring autonomy in collaboration with the patient, next-of-kin, and the interdisciplinary team.

• Landmark, Anne Marie Dalby; Gulbrandsen, Pål & Svennevig, Jan (2016). Negotiating patient involvement in treatment decision making. A conversation analytic study of Norwegian hospital encounters. Universitetet i Oslo. Full text in Research Archive Show summary

  This dissertation presents an examination of how physicians and patients make treatment decisions in actual encounters in a Norwegian hospital. The overall aim of the study is to identify and describe aspects of the interactional accomplishment of treatment decision making when patients are involved in the decision making, since current guidelines promote patient involvement in making decisions (i.e., shared decision making). The method used is conversation analysis (CA). Based on video recordings of actual interactions, CA is a datadriven approach for examining both how participants in talk accomplish actions and what interactional consequences those actions yield. Article 1 examines encounters where more than one option is brought up. Article 2 identifies one specific practice physicians use to bring up the patient’s stance towards treatment. Article 3 describes a physician’s strategies to secure a non-native speaking patient’s understanding and acceptance of an invasive treatment recommendation. In sum, this study shows how physicians and patients negotiate treatment decisions in at least three areas: (1) Firstly, the participants negotiate what treatment to choose. (2) Secondly, in order to arrive at a treatment decision, the participants negotiate the terms on which the decision should be made. These terms involve negotiating who will make the decision (deontic rights), which is dependent on determining on what grounds the decision should be based, either on the patient’s personal experiences and wishes (epistemics of experience), or on the physician’s medical expertise (epistemics of expertise). (3) Thirdly, negotiation may also concern determining which treatment options are available and appropriate (cf. the Patients’ Rights Act, § 3-1). The study shows that physicians and patients orient to, and indeed expect, a constrained form of patient involvement in decision making, where the physicians set important terms for opportunities and constraints for patient participation. The ways in which physicians involve patients (e.g., providing choice, bringing up patients’ views and securing patient acceptance) seem to curtail, rather than promote opportunities for patient involvement, in that the physicians’ actions primarily work towards bringing the patient ‘on board’ on decisions that correspond to the physician’s view. Nevertheless, patients also have ways of influencing decision making. Article 3 illustrates how a patient can even influence a decision through minimal participation, effectuated by an expectation of patients’ acceptance (or rejection) of treatment recommendations. This dissertation expands previous knowledge about how patients are actually involved in treatment decision making. Such fine-grained descriptions of authentic interaction may contribute to much needed empirical detail and specification that can be the basis for refining and developing recommendations for practice.

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