Self-management support in primary care: enactments, disruptions, and conversational consequences

A common refrain in chronic disease management is that patients and clinicians need to enact new roles: patients as their own caregivers; clinicians as professional supporters of patient self-management activities. These roles are central to self-management support (SMS), an approach that emphasizes a clinical partnership, and promotes patient identification and achievement of realistic and short-term behavioral goals. With SMS, behavior change is the desired end, not the means to a desired biomedical end. Shifting SMS concepts into clinical practice has proven to be difficult and inconsistent, creating potential, unknown risks or harms to patients. We completed a discourse analysis of 16 clinical dialogues between diabetic patients and clinicians, collected during a study of six Ontario Family Health Teams, to explore the questions of risks and harms relating to SMS implementation. We observed varying degrees of incomplete implementation of SMS, as well as interactions that actively negated the core principles. Contrary to SMS principles, clinicians tended to emphasize behavioral changes as means to achieve biomedical ends, though to varying degrees. We present two appointments in detail, highlighting how linking behavior change closely with biomedical measures often elicited face-saving defenses from patients. The subsequent dialogue shifted attention away from problem solving and behavior change into active negotiation of responsibility and identity. Interactions that oriented more to SMS concepts elicited fewer defensive maneuvers from patients. Our analysis helps explicate one additional mechanism by which self-management talk threatens the clinical relationship, and highlights a promising method to mitigate this threat.