Discussing care decisions at the internal medicine outpatient clinic: A conversation analysis

•Introducing the precarious topic of care decisions presents several dilemmas.•There is no obvious interactional slot, therefore effort is needed.•Common ground needs to be created, possibly over time.•Framing as relevant in the future but needs to be discussed now creates a paradox.•Physicians’ training should address these dilemma’s. Explore how often, when and how care decisions are discussed during consultations at an internal medicine outpatient clinic, and what we can learn from these observations. Qualitative analysis of 150 video-taped consultations. Consultations involving a discussion of care decisions were analyzed using conversation analysis. 1) Only 21 of the 150 consultations involved a discussion of care decisions; 2) As there is no destined phase for the introduction of the topic of care decisions, the topic is most often introduced at the end of the phase ‘treatment and course of the disease’; 3) A lot of interactional effort is needed to create common ground and make relevance clear with extensive justification. Hesitation markers, repairs and hypothetical talk show the precariousness of the topic. Three dilemma’s need to be addressed: 1) a slot has to be created to introduce the topic of care decisions; 2) common ground has to be created, possibly over time; 3) the paradox of framing the topic as relevant ‘in the future’ but ‘needs to be discussed now’ needs to be attended to. We recommend that physician training should address the three dilemmas. Future research should focus on how to do so.