Studying Challenges in Medical Conversation with Structured Annotation (2020)

Abstract: Medical conversation is a central part of medical care. Yet, the current state and quality of medical conversation is far from perfect. Therefore, a substantial amount of research has been done to obtain a better understanding of medical conversation and to address its practical challenges and dilemmas. In line with this stream of research, we have developed a multi-layer structure annotation scheme to analyze medical conversation, and are using the scheme to construct a corpus of naturally occurring medical conversation in Chinese pediatric primary care setting. Some of the preliminary findings are reported regarding 1) how a medical conversation starts, 2) where communication problems tend to occur, and 3) how physicians close a conversation. Challenges and opportunities for research on medical conversation with NLP techniques will be discussed.

## introduction medical conversation is at the core of medical care. through conversation, doctors collect the information needed to form a diagnosis and provide a treatment recommendation for the patient's condition. effective communication is essential for achieving optimal medical outcomes. yet breakdowns in doctor-patient conversation are common in medical practices. for example, the largest proportion of hospital and community health services complaints in the uk were about communications with medical professional in @xcite @xcite . thus, a better understanding of medical conversation (e.g., how it is conducted; what practical problems and dilemmas doctors and patients face) could improve not only the quality of care, but also the efficiency of the healthcare system. in this paper, we first review the major issues that medical conversation research has investigated; we then introduce the data and methods that we use to analyze medical conversation; lastly, we present some preliminary findings based on our analysis of the corpus and conclude with a discussion on implications of the study and our future work. ## research on medical conversation research on medical conversation has a long tradition. earlier studies that use naturally occurring medical conversation data can be traced back to 1970s in the united kingdom and the united states. having audio-recorded and analyzed 2500 recordings of medical conversation, british researchers @xcite were regarded as the pioneers in medical conversation research. at about the same time, american physicians @xcite conducted one of the most influential studies on medical communication, based on 800 audio-recordings of conversation collected in the los angeles children's hospital. these studies showed that medical communication practices significantly affect patient health outcomes. more recently, a substantial body of research using conversation analysis @xcite emerged and investigated a wide range of topics in medical conversation. these topics generally fall into three categories. how is medical conversation conducted? this stream of research examines the process and constituent activities of medical conversation. in other words, how do physician and patient coordinate in this social encounter and how is medical conversation organized? unlike many other types of conversation, medical conversation are treated as having a discernable overall structure. for example, acute primary care encounters in the uk were found ordinarily beginning with an opening sequence, progressing through problem presentation, history taking, physical examination, diagnosis, and treatment recommendations, and then onto a closing sequence @xcite . while this overall structure of conversation can be considered as socialized through physicians' training in medical school and patients' repeated exposure since childhood, it is also considered a product of coordination and negotiation between physicians and patients in local interaction context. therefore, a lot of research in this stream has been done to investigate questions such as how one activity transits toward another in medical conversation, and what constitutes a complete sequence within some particular activity phase. for example, studies find that there are varying expectations for what constitutes a complete diagnosis sequence and a treatment recommendation sequence. while patients' no response or weak response (e.g., mm hmm) is treated as sufficient for a diagnosis sequence to complete @xcite , patients' explicit acceptance of treatment recommendation is oriented as necessary for completing a treatment recommendation sequence @xcite . what are the practical problems and dilemmas in medical conversation? the second stream of research on medical conversation concerns with more concrete problems in medical conversation. for instance, how physicians' and patients' actions are designed and sequences are organized to deal with various kinds of practical challenges and dilemmas in medical conversation. for example, physicians use various forms of questions to solicit patients' problem presentations, and these different action types can afford different opportunities for patients' contribution to medical conversation. specifically, the length of patients' problem presentation is significantly longer if physicians use open-ended solicitation questions, as compared with close-ended questions @xcite . in addition, when delivering a diagnosis to terminal patients, it is found that physicians can deploy a rather complicated form of sequence (the so-called news delivery sequence (nds)), in which patients' perspectives of their health condition are incorporated, in order to prepare them for the bad news @xcite . ## data and corpus in this section, we introduce the the corpus that we construct for medical conversation research. ## costa scheme to enable a systematic analysis of medical conversation in the dimensions that we described above, we developed an annotation scheme that marks up the structure of medical conversation at multiple levels. in addition, application-dependent labels can be created and added on top of the structural annotation, tailored to particular researchers' interests. below we briefly introduce how medical conversations are analyzed using the conversational structures and actions (costa) scheme, in terms of 1) conversational structures, and 2) applicationdependent labels for conversational actions. ## discussion in this section, we discuss several potential use cases of this study. ## conclusion in this paper, we introduced some of the major issues that existing medical conversation research has focused on; we described the data that we use for conducting medical conversation research. to analyze medical conversation more systematically, we proposed an annotation scheme, which can capture the hierarchical structure of the medical conversation and be extended to include applicationspecific labels. based on a subset of the annotated data, we report findings regarding how medical conversation is opened and closed in the chinese pediatric consultations and how one can identify places that problems tend to occur. this study makes several contributions to medical conversation research. first, to our best knowledge, the corpus that we are constructing is the first medical conversation dataset with structural annotation. it is a valuable resource for conducting medical communication research, and can also be used to train nlp systems such as a conversation parser. second, costa is a general scheme for annotating conversational structures and actions. the annotation facilitates systematic analysis of medical conversation and there are other potential use cases as outlined in the previous section. while we use the scheme to build a chinese corpus consisting of medical conversations, costa can be applied to conversation in other domains or in other languages. for future work, we will finish annotations of the corpus and release it to the public. we will start training nlp tools in order to evaluate the usefulness of the corpus for the use cases mentioned above.