When neurologists solicit patients’ treatment preferences:The relevance of talk as action for understanding why shared decision-making is so limited in practice

Shared decision-making (SDM) is now accepted as an ideal within many healthcare systems, but research repeatedly shows that it is often not implemented as proposed by models of SDM – if at all. This is true also of soliciting patients’ preferences, which is a key element of SDM. As part of a wider, conversation analytic study of 223 recordings of UK neurology outpatient consultations, my team identified a collection of 149 turns that we called patient view elicitors (PVEs). In this chapter, I demonstrate two recurrent sequential positions in which these occurred: after the neurologist had made a recommendation or as a preliminary to doing so. Taking the view that to talk is to do something, I argue that we can see how, in both locations, the PVEs and their responses are being used in the service of other social actions. We are not, then, seeing the kind of ‘pure’ exchange of views assumed by SDM models. Rather, PVEs may work against the ideal of SDM even as they enact the requirement to solicit patients’ preferences. I argue that, by understanding talk as social action, rather than information exchange, we see why there’s such a tenacious gap between the SDM ideal and decision-making in practice.