Dr. Therne (1898) in response to weakening compulsory smallpox vaccination laws, thus entering one of the most heated debates of the late nineteenth century. With Dr. Therne, Haggard aimed to intervene in the lives of the many working-class anti-vaccinationists who, from the 1850s onwards, mobilised to evade what they perceived as a gross – and targeted – extension of state power at the expense of individual rights. Recovering the novel, which has not yet received scholarly attention from historians of medicine, reveals the way fiction was called upon to change minds during a crucial period of Victorian medicine, one that witnessed a climactic shift in public health intervention. This article will examine the reception of Dr. Therne in various print media – middle-class London papers, medical journals and working-class, anti-vaccinationist publications – to consider some new dynamics of the debate which the disagreement over Haggard’s polemic exposes, including the perceived power of fiction (when properly priced and distributed) to change minds, and the contested role of the evangelical press. Additionally, a discussion of the different iterations of Dr. Therne, and a look at an exceptional anti-vaccinationist response in the form of a competing novel, illustrates that pro- and anti-vaccinationists alike contributed to a moment in late Victorian society when the role of fiction was considered a worthy contender in a debate ostensibly about fact.Henry Rider Haggard, the famed author of adventure romances, wrote the novel  Absit omen! May the prophecy be falsified!’‘Dr. Therne, a largely forgotten pro-vaccination propaganda novel that sought to illuminate the dangers of the burgeoning anti-vaccinationist movement in Britain. Haggard wrote his pro-vaccination morality tale at the end of the era of Victorian reformism, by which time its clear social purpose abutted a nascent scepticism towards professional medicine. The novel responded directly to weakening compulsory smallpox vaccination laws, entering the author into a controversy that had been engrossing doctors, lawmakers, intellectuals, laypeople and activists for over four decades. What can a novel by a preeminent imaginative writer tell us about the vaccination debate?In this foreboding call to arms, acclaimed Victorian novelist Henry Rider Haggard was not warning against the seduction of witches’ spells, Zulu divinations, or any of the other supernatural curiosities his readers would have come to expect from his globe-trotting adventure novels. Rather, his injunction comes at the beginning of Dr. Therne in its historical context, emphasising the social unrest to which Haggard was responding. The article then examines the reception of the novel in various print media – middle-class London papers, medical journals and working-class, anti-vaccinationist publications – to consider what the fierce disagreement over Haggard’s intervention can tell us about the debate. This approach – making sense of Dr. Therne through its reception among various groups of readers – though well-established in histories of medicine, has never been used in reference to studying the vaccination debate. A discussion of the novel’s different iterations, and a look at an unusual anti-vaccinationist response in the form of a competing novel, shows that, far be it from an irrelevant minor novel, Dr. Therne was a lightning rod for public scrutiny. Whether pro- or anti-vaccinationists were able to successfully mobilise fiction to change opinion would be nearly impossible to prove; instead, this article demonstrates that Dr. Therne compelled virtually all parties of the reading public – whether or not they had a devout opinion about compulsory vaccination – to make a consideration until now unexamined: what place fiction had in a debate ostensibly about fact.Using a variety of archival sources – including Rider Haggard’s correspondence with his editor, housed at Columbia University; articles and other materials collected by anti-vaccinationist Alfred Milnes, held by the London School of Hygiene and Tropical Medicine and newspapers from across England – this article details not only how Rider Haggard’s pro-vaccination polemic intervened in the vaccination debate, but also the ways in which the novel’s reception sheds light on some of the complexities of its participants. It begins by situating Since the mid-twentieth century, scholarship on compulsory vaccination in Britain has revealed the immense social, scientific and legal upheavals which both generated and responded to vaccination resistance. The debate captures many of the challenges faced by Victorian governments, which during this period were rapidly reinterpreting the legal frontiers of scientific expertise, state intervention and individual liberty – what public health historian Alison Bashford has summed up as the paradox of liberal governance.preventative measures was a matter for parents to decide themselves.Starting in the late 1960s, historians began focusing on how anti-vaccinationists – often taking cues from abolitionists and anti-vivisectionists – mobilised to evade what they perceived as a gross extension of state power at the expense of individual rights. Roy MacLeod has discussed how changes in compulsory vaccination legislation effectively reinterpreted parental responsibility from the lens of criminal law, and established an influential distinction between treatment and prevention: preventing one’s child from receiving medical treatment amounted to wilful neglect, yet abstaining from Nadja Durbach has, in recent years, both redrawn the map of the anti-vaccination debate and recalibrated our compass for navigating it. Durbach’s articles and book have illuminated the perspectives of working-class members of the movement, on behalf of whose conscience most prominent interlocutors in the vaccination debate deigned to speak. Uneven enforcement of the vaccination laws, which disproportionately penalised working-class people and women, was an important feature of the lived experiences of resisters and explains the composition of the movement more broadly, a dimension which has only recently come to light through her scholarship.Of course, histories of Rider Haggard have similarly changed tack. Hagiographies, biographies and bibliographies abound due to the lasting imprint Haggard has made on generations of British school curricula as well as readers’ psyches – so much so, in fact, that Haggard counted among his most eager readers both Sigmund Freud and Carl Jung. A new generation of Haggard scholarship, largely starting with the work of Wendy Katz, has focused on scrutinising the role and status of empire in Haggard’s work – and, indeed, the role Haggard played in empire, defending its theories of hierarchical difference among people and presenting a stage for the indulgence of heroic fantasies.Dr. Therne gets passing mention in most books and articles that attend to its author  whom the reader could join on an extraordinary civilising mission. The reader breaks bread with Strong’s wife, a woman whose mind, when not engrossed in anti-vaccination literature, ‘occupied itself almost entirely with that well-known but most harmless of the crazes, the theory that we Anglo-Saxons are the progeny of the ten lost Tribes of Israel’.The Star, the East London Observer and the Morning Leader – Haggard was confident that fiction, in his hands, could appeal to the mind of the average Briton where scientific diatribes had failed. By considering Dr. Therne’s reception among three groups of readers – London’s middle-class periodicals, leading medical journals, and anti-vaccinationist literature – we cannot only evaluate whether Haggard succeeded, but also begin to uncover where and how these readers drew lines of demarcation between public health messaging and propaganda, science and mere speculation.‘The A.V. people will abuse it’, Longman continued in his response to Haggard’s draft, referring to anti-vaccinationists, ‘but whether they will buy it largely I cannot say’.The Times was the first to ask the question that remained a leitmotif throughout London’s middle-class press coverage: Why was Rider Haggard publishing a novel about, of all things, the conscientious objector? ‘A novel on the vaccination question seems a curious development even for modern fiction – and it is no less curious that the author should be Mr. Rider Haggard’.In its notice of forthcoming publications, The Spectator – a leading weekly during this period, which stressed ‘morality, good taste and wholesomeness’– located Haggard within the milieu of authors who had warped the novel into a tool of social reform: ‘There was a time when the scope of the novel was too exclusively confined to the full-dress functions. Nowadays we run to the other extreme, and degrade it to the level of a literary maid-of-all-work’.The Spectator, betakes itself ‘to the sphere of the abnormal, to the exploration of the charnel-house of humanity and to the study of mental, moral and even physical degeneracy’.This sentiment was echoed across publications. Haggard responded to this criticism directly, appealing to the virtue of realism in facilitating social improvement. Any person ‘who chances to have the welfare of childhood much at heart’ would be compelled to speak out against these dangerous developments, and that, furthermore, there was ‘nothing reprehensible in such a desire’. It was Haggard’s hope, ‘however futile’, that others will take up the cause and that ‘public opinion may bring about a change in the law’.Manchester Guardian picked up on the exchange to flippantly register appreciation that more novelists did not trouble themselves with social issues, the literary magazine Academy, catering to educated, middle- to upper-class readers, sombrely criticised Haggard’s nonstrategic attempt to educate working-class anti-vaccinators.If Mr. Haggard is really intent on proselytising he will direct that it be issued in tract form at a popular price as well as in its present three-and-sixpenny form. The ‘conscientious objectors’ who now come before the magistrates day after day and waste the time of the Court are not to be reached by three-and-sixpenny pamphlets, but – if at all – by penny ones.The Athenaeum, largely considered the leading journal of literary criticism of the late Victorian period and indispensable to those in both literary and scientific circles, found Dr. Therne little more than ‘a popular means of advertising the lurid ways of a fell disease’.The Times gave their brief review a few days later, confirming their intuition of the novel’s incongruity: Dr. Therne was ‘scarcely calculated to increase the literary reputation of its distinguished author’.While the Dr. Therne’s tepid reception was due, in part, to what the conservative Morning Post suggested was its underlying ‘common sense’.Dr. Therne had neither the adrenaline of adventure nor the fascination of the exotic; for many of these readers, Dr. Therne simply confirmed long-established prejudices.Punch had largely shaken off its radical undertones in exchange for light social commentary.Punch one of the most widely read periodicals of the era. Famous for its bracing satire and political cartoons, as well as its bevy of influential writers and artists, the magazine often featured short parodies, unauthorised sequels and general pastiches of culture both high and low.Although it was started as an outlet for power-homing critiques, by the late nineteenth century, the London satirical weekly Dr. Therne.Doctor’s Dilemma-era Edwardian period, Punch’s re-telling of Dr. Therne painted both physicians – Therne and Merchison – as conniving, selfish and not to be trusted. Not only does Therne, the anti-vaccinationist doctor, vaccinate himself in the dead of night, but also Merchison – the presumptively upstanding fiancé of Therne’s daughter – admits that, although he promotes vaccination for his patients, he would never get the procedure done on himself. In the parody’s final scene, Therne makes Merchison bare his arm, which lacks the token vaccination scar:Merchison . You’ve found me out.Therne . And you’ve found me out, eh? Well, let’s strike a bargain. You say nothing about me and I’ll say nothing about you. You agree?Merchison. I agree.Therne: Very well. Then Donkeyster keeps its Member [of Parliament]. And, by the way, under these circumstances I’ve no objection to your marrying my daughter. We scoundrels ought to have a fellow feeling for each other. (Shaking him by the hand.) Good morning.(Curtain.)In early February 1899, under the banner of ‘Mr. Punch’s Dramatized Novels’, there appeared a two-column, three-act reinterpretation of This conspiratorial back-slapping epitomises what George Bernard Shaw soon thereafter characterised as doctors’ ‘conspiracy against the laity’, which was worse than that of other professional conspiracies only because the medical profession was ‘less suspected’.The Outlook, a weekly conservative magazine that often sounded the trumpet for imperial affairs.The Outlook was confident that Dr. Therne could ‘appeal to the emotions of the uninstructed and to the intellects of those who are better informed’ and ‘prevent the development of many objectionable consciences’.The only outlier to this general middle-class scepticism of Haggard’s proselytising was British Medical Journal, a leading platform for pro-vaccination physicians, applauded Dr. Therne’s strong didactic message and the ‘unsparing realism’ with which it explored Therne’s contradictions.BMJ hoped that by presenting a dystopian, virus-ravaged future, the novel could spark a renewed sense of urgency in otherwise complacent individuals ‘who would never trouble their heads further than to be revaccinated when an epidemic is threatening’, and remind readers of how quickly charlatans could trick communities into losing their hard-won immunity.Under the title ‘A Vaccination Romance’, the BMJ and The Lancet underlined the novel’s relevance by referring to recent episodes, warning readers how urgent, still, was their battle against ‘the honest fanatic, the designing agitator and the ignorant dupe’, each of which appears in the novel and in the debate over vaccination.BMJ maintained that this tale was no mere fiction: ‘The vaccination of the anti-vaccinationist leader in fear of the epidemic is an incident not without historical basis in fact’.The Lancet re-iterated that the novel was sensational for exactly how closely it mirrored reality: the final scene at the town meeting ‘was probably prompted by an occurrence which recently took place in London in connexion with the adventures of a gentleman whose career would have had the deepest interest for Mr. Haggard a few years ago’.Both the BMJ and The Lancet were alluding to remain unknown, a strikingly similar episode (from outside of London though it was) would suggest that stories of fraudulent anti-vaccinationist leaders were not entirely unheard of. In 1895/6, just 2 years before Dr. Therne was published, a smallpox outbreak ravaged the anti-vaccinationist stronghold of Gloucester. As the epidemic loomed, Walter R. Hadwen, one of the leading anti-vaccinationist physicians and voice of the movement, was rumoured to have had himself and his children surreptitiously vaccinated.Although the exact events the Dr. Therne’s apparently plausible story excited the major organs of the medical profession: the book illustrated in striking detail the chicanery of anti-vaccinationists against which doctors had so long warned. Not even Haggard’s portrayal of multiple conniving, self-serving physicians seems to have discouraged the medical community. After all, the doctor of the late-Victorian novel was not uncommonly a character whose growing scientific drive to knowledge was at odds with social compassion.Dr. Therne featured no hand-wringing; rather, a few unsavoury doctors seemed a small price to pay for the bounty of the pro-vaccination moral. As the BMJ had identified in connection with the anti-vaccination debate only a year earlier, the written word itself could act as a type of inoculation: what mattered was that it got the job done.Despite the conflicting accounts of what happened in Gloucester, The Lancet promised that while vaccination ‘does not sound a tempting theme for those who seek oblivion in the perusal of stories’, fewer scenes in all of fiction had been better told, an acknowledgement meant to reassure readers of Dr. Therne’s durability in a debate that often featured more histrionics than scientific rigour.Medical News, a Philadelphia weekly, and Dr. Therne was sure to be a strong ally ‘ – if the “antis” ever read anything except their own lying pamphlets’.Dr. Therne, but, like the medical community, they also saw the novel as a vindication of their own staunch opinions.The Star, a London-based working-class daily and reliable critic of compulsory vaccination, often exposed what it claimed were the devious operations of pro-vaccinators.Dr. Therne, as an intensely dogmatic tract penned by a famous writer, was a symptom of such unchecked power, and The Star devoted a full column to its review.Mr. Rider Haggard has turned from the production of witch’s heads, hot pots, misty people, and other such-like sober actualities, to try his hand at last on a work of pure imagination. The advantages of being vaccinated are now his theme; and there at last he soars to that astral plane whereon fancy roams emancipated from every slightest trammel of mere terrestrial fact.The front page of The Star pilloried Haggard for mixing up the titles of a vaccine-administering doctor and an administrative official: ‘The author of a work of pure imagination cannot be supposed to know the difference between a public vaccinator and a vaccination officer, and Mr. Haggard does not know it’.The Star considered Dr. Therne to be the kind of heedless interjection masquerading fiction as fact which was responsible for mucking up confusion over vaccination in the first place. Likening vaccination to a fairy tale, The Star underscored the potency of both: neither were ‘real’, but both had ‘a very real existence’, a warping influence on the imagination that, in the case of vaccination, could foster reckless belief in an unscientific practice, and thus endanger one’s health.Anti-vaccinationists were especially attentive to Haggard’s factual missteps. For example, The Star further condemned what they saw as an outright injustice in the comparison of the strategies used in England by anti-vaccinationists to those used in Africa. Haggard, The Star accused, writes how ‘“the terrible rule of isolation known as the improved Leicester system” is virtually “the same plan” as that of African savages who surround with guards the kraal in which smallpox has broken out’. This was, The Star railed, a ‘slanderous falsehood’.Vaccination Inquirer – a journal founded in Manchester in 1879 by one of the movement’s leaders, William Tebb, which was the voice of the anti-vaccination movement– took a less hostile approach than The Star, performing mock disappointment at what was, nevertheless, an aggressive and unusually accessible reproach of their side:Dr. Therne in the expectation of a few hours of pleasant amusement. Save when it is enlivened by some really brilliant flashes of ignorance, the book is wearisome to a degree beyond words.The persons who, in respect of this book, are most to be pitied are those who are misled by Mr. Haggard’s reputation as a story-teller into buying The Dr. Therne was not the headline-grabbing success that Haggard saw with titles such as King Solomon’s Mines. It had clearly tested the limits of what a novel – even in the name of public good – should be made to do. By February 1899, Longman told Haggard: ‘We have sold about 4400 of the 3/6 edition of Dr. Therne – it does not sell very fast now, but it does keep moving: 100 have gone in the last 10 days. We printed 10,000, so that we have over 5000 left, and I fear that if a 6d edition were now published nearly all this stock would be rendered worthless’.Dr. Therne reappeared as both a sixpenny edition and, before that, as a lavishly illustrated, widely circulated serial from a parish press.Whereas middle- and upper-class readers shuddered at Haggard’s unexpected attention to local oddities, anti-vaccinationists chastised Haggard for what they saw as his complete departure from reality. The enthusiastic endorsement from medical professionals, including the Jenner Society, met by the dissatisfaction of nearly everyone else, from the literary to working-class worlds, would seem to indicate that Dr. Therne as a sixpenny edition, the Society for Promoting Christian Knowledge (SPCK) serialised the novel in their parish magazine, The Dawn of Day. The ‘interesting tale’ was ‘well suited to the requirements of a parish magazine’, noted the Oxford Times.Dr. Therne in instalments was not entirely routine, since the novel was serialised a year and a half after its initial publication. As we saw above, Haggard’s publisher Charles Longman saw the drawn-out process of serialisation as a losing strategy in the quicksand of public opinion. As much recent scholarship has suggested, however, by the mid-nineteenth century, the initial economical value of serialisation had been partly eclipsed by its triumph as a cultural form uniquely suitable to the age.In 1900, 2 years before the reappearance of The Dawn of Day, founded in 1878, was a parish magazine that counted among its contributors the poet Christina Rossetti.The Dawn of Day’s circulation vary. The society’s own contemporary history stated that the parish magazine started with a circulation of only a few thousand, but by 1898 (the time of the chronicle’s publication) had reached ‘considerably over half a million, which increases year by year’.Tit-Bits and Pearson’s Weekly, had circulations of roughly half a million.Dr. Therne appeared throughout the country, in the Oxford Times, Exeter’s Western Times and North England’s Wakefield and West Riding Herald – the magazine, the latter wrote, contained ‘the second chapter of Mr Rider Haggard’s fascinating story “Doctor Therne”’.The Dawn of Day’s 12-month run featured three pen-and-ink sketches by the water-colourist W.S. Stacey, amounting to thirty-six illustrations of the novel’s most evocative scenes.Notices for the parish magazine featuring East London Advertiser, one concerned reader laid out his credentials for balanced critique. He was a member of the English Church Union, a reader of Rider Haggard (who was ‘clearly a man of genius’) and an avowed believer in the science of vaccination. Thus, he could justify his claim: ‘I am not an anti-vaccinator’, he wrote, ‘But I hate trickery, especially pious trickery’. Why, he asked, ‘publish a severely controversial, one-sided story in a purely (adapted so at least) evangelical, moral and religious print, no doubt “taken in” by thousands of persons who sincerely believe in the curse of vaccination’?The few reader responses to the serialisation captured in the press largely hit upon the same note: church doctrine would do well to keep away from fiction. In an unsigned letter to the editor of the Truth magazine, arguing that a parish magazine should flirt with neither science nor fiction. ‘It is not surprising’, he wrote:that in all parts of the country the subscribers of parish magazines who suddenly find Mr. Rider Haggard’s polemical romance foisted upon them are highly indignant, and many who do not differ from Mr. Haggard’s personal views recognise that this method of disseminating disputable opinions is illegitimate.Not only, this author claimed, were there plenty of church members who would likely disagree with Haggard’s position on the subject, but even those who might actually agree would not approve of this method of persuasion. Additionally, the author notes how the church was already prey to schismatic differences of opinion ‘without the ecclesiastical authorities going out of their way to multiply them by identifying themselves with non-religious controversies’.Another concerned reader wrote his thoughts in Church Sunday-School Magazine had, a few years prior to this episode, maintained that ‘all babies must be registered, vaccinated and christened before they could be considered English Christian children’.Dr. Therne’s serialisation in the evangelical press demonstrates – warrants further exploration.The Dr. Therne: Anti-Vaccinist, published in March 1902 by London’s George Newnes – appears to have been reissued in indirect response to the fallout from the 1898 conscientious objector clause. There was a renewed sense that working-class Britons were again being targeted: critics pointed out that the process of receiving an exemption entailed overcoming significant bureaucratic and financial barriers, which effectively kept the working class in states of noncompliance.sic] the bargain’.The novel’s second edition – The Lancet encouraged its readers to recall that novel with purpose, Dr. Therne. The second edition had just been released, and the author’s new introduction explained why. As Haggard wrote, he was releasing the second edition of the novel after having received an unusual letter from a reader. ‘As our pages are read by an audience already in no doubt as to the benefit of vaccination’, the article opined, The Lancet was unaccustomed to featuring stories of successful conversions from disbelief, but now made an exception.In May, Dr. Therne, George J. Battle, a resident of Rushden, a small village with its own Anti-Vaccination League chapter, had been compelled to abandon his decades-long belief in ‘theories concerning vaccination’.The Lancet was eager to share the words of a convert:In 1898 I was fined for non-compliance with the Vaccination Act and I have since obtained exemption certificates for my three children under the conscientious objector clause in the Act of 1898. Your ‘Dr. Therne’ has made me think that non-compliance with the Vaccination Act is the worst course to take and I shall not only have my children vaccinated but shall submit to the operation myself.After having read Dr. Therne, though well-meaning, was stymied by its inability to reach the right audience. Haggard was moved by readers like George Battle, as well as concerned physicians, like one doctor who wrote, pleading for a cheaper edition of the novel that he could share with anti-vaccinationists: ‘Will you not lift your voice on the side, not merely of right, but of what is almost vital to the people? Could you not bring out this book in a cheap form’?The second edition was prompted by Haggard’s worry that Tit-Bits. Newnes had experience appealing to a wide audience and printed a sizable 200 000 copies of the second edition.Times Literary Supplement presented it, was now, as promised, ‘made available for the million on the strong advice of a medical expert’.Dr. Therne.Despite Longman’s original apprehension, by 1902, it therefore seemed that a sixpenny edition would do more good than harm. Longman obliged by licencing the book to George Newnes, founder of the mass-circulation weekly magazine Dr. Therne can be understood as one prong in a full-fledged campaign to drown out anti-vaccinationists using every tool possible. The second edition was also issued to meet a different challenge. Although publicly framed as a generous response to the demands of concerned readers, the sixpenny edition must also be recognised as a targeted rebuttal of a surprising piece of counterpropaganda authored by a leading anti-vaccinationist.Although there is little evidence of the second edition’s impact in print media besides scant advertisements, I would suggest that this was not the goal. The multiple iterations of Vaccination Inquirer ran a small announcement for a forthcoming novel by the National Anti-Vaccination League’s (NAVL) president. The journal intended its readers to purchase the new book, available at the League’s offices in London, before the Vaccination Inquirer ran a more substantial review: ‘We are reserving our more detailed notice till the next issue of the Inquirer, when we hope many of our readers will be able to follow our appreciation of this happy idea of our President’s with a greater interest because of their own knowledge of the book’.On 2 December 1901, the Lord Dunchester, or the End of Dr. Therne: An Autobiography. This unlicenced sequel to Haggard’s Dr. Therne, written by anti-vaccination league president Lieutenant-General Arthur Phelps, was not printed and distributed by the League, but published by London’s Swan Sonnenschein and Co. The publishers were accustomed to working with authors critical of vaccination, especially when it came to the lack of statistical support for vaccination’s efficacy – an oft-distorted method of persuasion both criticised and weaponised by Phelps in his response to Haggard.The book was Lord Dunchester opens with Dr. Therne pondering the ruins of his life from exile in Madeira, where he realises that, despite his eleventh-hour vaccination, he has fallen ill. After contacting the London pharmacy that supplied the calf lymph to inquire about its purity, the pharmacy threatens to take legal action should he publish any slanderous reports against them. Step-by-step, Therne’s confidence in the efficacy – and ethics – of vaccination unravels. Despite his growing suspicions, and in a last-ditch effort to rebuild his reputation, Therne returns to Dunchester in order to fund a new hospital wing devoted to vaccination. There, Therne learns that Dr. Graunsh, Dunchester’s public vaccinator, had fabricated the morbidity statistics from the smallpox epidemic that closed Dr. Therne and ended the eponymous character’s career. Wyley, Therne’s trustworthy steward throughout the sequel, puts it thus: ‘I believe there was some exaggeration about those figures. You know how enthusiastic Dr. Graunsh is’.Statistics, just like the realist novel, had the power to elucidate complex social problems by positing that a universal could be made out of a particular.Lord Dunchester with references to these statistical debates, signposting for attentive readers the relevant reports and medical research that disproved vaccination’s efficacy. In one passage, Therne reflects, ‘I did not then know that calf lymph was capable, as shown by Mr. Jonathan Hutchinson’s researches, of producing symptoms indistinguishable by experienced surgeons from those of the horrible disease from which I had been suffering’.Phelps packed Dr. Therne for its undisciplined descent into ‘pure imagination’, and hoped that Haggard would ‘make a special study’ of Lord Dunchester: ‘He will find that there is more truth in General Phelps’s fiction than in his own, and that the names of anti-vaccinist authors and of their works are genuine, and will guide him, if he chooses, to the sources of the truth on our question’.The anti-vaccination press had criticised Lord Dunchester was released a mere 2 years after Dr. Therne, giving readers scarcely any time to read the original to which Phelps was responding, why did he bother? There is reason – backed though it is by scant evidence – to believe that Phelps was motivated by personal animus as much as political commitment. During the aforementioned epidemic of 1895/6, Walter R. Hadwen – a leading anti-vaccinationist physician in Gloucester – was rumoured to have had himself and his children surreptitiously vaccinated as the epidemic loomed. Yet, as Hadwen’s biographers contest, it was not Hadwen who betrayed the cause, but ‘another notable anti-vaccinationist of Gloucester, a newspaper proprietor’ who actually did the ‘violence to his staunchly held principles by accepting vaccination’.Citizen.Dr. Therne, and whether this personal indignity prompted his response, certainly adds a layer of intrigue.If The End of Dr. Therne was published, he wrote as much to his sister:The concession of a conscience clause has acted as a narcotic to many, who are content to save their own skins, and leave others to fight for the cause. Our subscriptions have fallen off, and at the Annual Meeting in a fortnight we shall probably make rather a poor show.Phelps was the leader of a movement struggling to maintain its direction and urgency after a long-sought, yet somewhat compromised, victory. After all, most committed anti-vaccinationists felt that the adoption of the conscience clause was one step on the long road to complete abolition of compulsory vaccination. To witness its disappointing results – parents keeping their heads down, getting their exemption certificates and withdrawing the movement’s financial base – may well have driven Phelps to the unconventional results this article has discussed.However, given what we know of Phelps, another explanation may be more likely. Though initially optimistic about the development of the conscientious objector clause, Phelps himself eventually lost faith, sensing that it operated as a release valve that deflated, rather than energised, the movement. A year before Dr. Therne – the Saturday Review, the Speaker, Athenaeum and the Academy – Lord Dunchester provoked almost no response outside of the Vaccination Inquirer. As authors, Haggard and Phelps could not have been more different. For Haggard, Dr. Therne, in content and reception, was a career aberration; Phelps, on the other hand, wrote from the crucible of the vaccination debate, spending the latter part of his life ceaselessly defending anti-vaccination as president of the NAVL, and often coming under fierce personal attack.Dr. Therne to the Jenner Society, and Phelps, tongue-in-cheek, dedicated Lord Dunchester to ‘the sincerity, born of ignorance, of the members of all societies which mind other people’s business’.Despite advertisements placed in many of the same papers as Dr. Therne in England, this article has demonstrated how different groups of readers generally interpreted the book in accordance with their previously held positions in the debate. The London middle-class press was bemused, conceding the importance of the cause but rejecting its presentation in a novel. Physicians, exhibiting enthusiastic support, saw the beneficent power of vaccination reflected back at them, and championed Dr. Therne as the newest weapon in their armoury for converting anti-vaccinationists. The anti-vaccinationist press feigned amusement, identifying Dr. Therne as the excrescence of an overzealous novelist.Whether or not their polemics changed one mind or thousands, Haggard and Phelps both constituted late-Victorian ‘merchants of doubt’ in their attempts to construct and propagate competing world views of medical authority, state intervention and individual responsibility around the vaccination debate. In considering the reception of Dr. Therne may have been, put bluntly, ‘rather poorly received’,Dr. Therne in the United States and continental Europe – where editions were released by Longmans and Tauchnitz, respectively – may portent interesting points of comparison, as would examinations of later British editions.Yet, that does not mean that the novel had no impact. Clearly, there was a perceived need for a strong rebuttal which could challenge Haggard in style, substance and scope. The responses examined in this paper suggest that while Dr. Therne as a unique dimension of the vaccination debate, this article proffers the study of fiction more broadly as a way to trace these complex contours of belief. Although, as authors, Haggard and Phelps were undoubtedly at odds about the merits of vaccination, what emerges from an examination of their books is rather less clear-cut than the epithets ‘pro-’ and ‘anti-vaccinationist’ would suggest. Readers who might not hesitate to get their children vaccinated did pause at the use of fiction to compel others to do so. A follower of the Church of England might not have batted an eye at compulsory vaccination, but found deep disturbance in the Church promulgating such a view. As exhuming Dr. Therne shows, these messy, complicated beliefs may reveal themselves best not when sharpened by fact, but when diffracted through fiction.When it comes to understanding anti-vaccination in this period, long abandoned is the idea that a belief in science was the only factor shaping one’s attitude – although, as Phelps saw it, dubbing something ‘scientific’ could ‘gild any absurdity so as to make the British public swallow it’.


Interactive, mixed reality technologies such as augmented reality, virtual reality, and holographic technology may provide a novel solution to fast-track the translation of evidence into practice. They may also help overcome barriers to both mental health and asthma management service uptake, such as cost, availability of appointments, fear of judgment, and quality of care.This study aimed to investigate if mixed reality technology is an acceptable mechanism for the delivery of a component of cognitive and behavioral therapies for the management of elevated psychological distress among young people with asthma.To explore the perceived acceptability of these technologies, mixed reality tools were evaluated via qualitative, 1-on-1 interviews with young people with asthma and symptoms of psychological distress, parents/caregivers of young people with asthma and symptoms of psychological distress, and relevant health professionals. The Theoretical Framework of Acceptability was used for the deductive coding of the recorded interview transcripts.This study enrolled the following participants: (1) 3 adolescents with asthma and symptoms of psychological distress with a mean age of 14 (SD 1.7) years; (2) 4 parents/caregivers of adolescents with asthma with a mean age of 55 (SD 14.6) years; and (3) 6 health professionals with a mean age of 40.8 (SD 4.3) years. A total of 4 constructs—experienced affective attitude, experienced effectiveness, self-efficacy, and intervention coherence—were coded in all participant transcripts. The most frequently coded constructs were experienced affective attitude and intervention coherence, which were reported a total of 96 times. The least frequently coded construct was anticipated opportunity cost, which was reported a total of 5 times. Participants were mostly positive about the mixed reality resources. However, some concerns were raised regarding ethicality, particularly regarding privacy, accessibility, and messaging. Participants noted the need for technology to be used in conjunction with face-to-face engagement with health professionals and that some patients would respond to this type of delivery mechanism better than others.These results suggest that mixed reality technology to deliver psychological interventions may be an acceptable addition to current health care practices for young people with asthma and symptoms of psychological distress.Australia and New Zealand Clinical Trials Registry ACTRN12620001109998; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380427 Australia has one of the highest asthma prevalence rates in the world , with 11According to a 2018 report, people with asthma were more likely to experience psychological distress  than inDue to the bidirectional relationship between asthma and symptoms of psychological distress , psycholA recent systematic review of 28 studies found that text-based internet searches were the most commonly identified help-seeking approach among adolescents, along with other internet communities . ReasonsInteractive technologies such as augmented reality (AR), virtual reality (VR), and holographic technology  may provide a novel solution to aid in the timely translation of evidence-based treatment into practice. Using a smartphone as a viewing device, AR superimposes digital information into the real world so that content seems to coexist with reality . VR requIn children and adolescents with asthma, a recent scoping review found that digital health interventions (including VR and AR interventions) were a promising option for asthma management and treatment delivery and were perceived positively by health care professionals and patients . MethodoAccordingly, this study aimed to investigate whether mixed reality technology is an acceptable mechanism for the delivery of a component of CBT to manage symptoms of elevated psychological distress among young people with asthma.This paper focuses on the acceptability of mixed reality technology as a delivery mechanism for a component of CBT to manage symptoms of elevated psychological distress among young people with asthma. The mixed reality tools utilized for this qualitative study were preexisting resources, including 1 bespoke AR resource , 1 VR reTo evaluate perceptions of usability and appropriateness, 1-on-1 interviews were carried out with the target audience. Semistructured moderator guides -3 were dParticipants were all identified through a pediatric respiratory specialist at the Women’s and Children’s Hospital. Health professionals were recruited through word of mouth. Purposive sampling was utilized to ensure a good representation of participant characteristics to meet the requirements of the research question.Hospital staff provided potential participants with a copy of the participant information sheet and consent form for their review. If the participants were interested in learning more, consent to contact them was obtained, and the research staff was given contact details to follow up for screening and consenting procedures.Young people were eligible for inclusion in this study if they (1) were aged between 13 and 17 years, (2) were formally diagnosed with asthma by a health professional (inpatients or outpatients), (2) had experienced or were currently experiencing symptoms of psychological distress determined by the Kessler Psychological Distress Scale (K10+) , (3) hadParticipants were eligible for inclusion in this study if they (1) were the parent/ caregiver of an adolescent with asthma (aged 13 to 17 years) who currently had or had reported in the past elevated symptoms of psychological distress (did not need to be a child actively participating in this study), (2) had access to a smartphone and can use smartphone technology (basic level), and (3) were English speaking or able to understand written English.Health professionals were eligible for inclusion in this study if they (1) had been practicing in their respective fields for at least 12 months, (2) had access to a smartphone and could use smartphone technology (basic level), and (2) were English speaking and able to understand written English.Participants with an intellectual disability or cognitive impairment that would inhibit their ability to provide informed consent and participate in the study were ineligible to participate. Young people with a history of epilepsy or other contraindications for the use of VR were also ineligible to participate.Qualitative data were coded using three prespecified lenses to enable insight into different aspects of the mixed reality interventions: (1) the Theoretical Domains Framework (TDF), the TheAll transcripts were coded by 2 independent researchers (authors KS and CM), with discrepancies resolved through consensus or discussion with a third party (author KCC). During the coding process, quotes were determined to be generally positive, negative, or neutral toward the mixed reality technology. A standardized pilot-tested data extraction Microsoft Excel (Microsoft Corp) template was used for data management. This study was conducted following the principles of the Declaration of Helsinki  and receA total of 19 participants were approached to take part in the study, with 13 completing interviews. Two young people and 1 parent withdrew from the project for psychological reasons, and another 2 young people and 1 parent were considered ineligible. Interviews were conducted by 1 of 3 researchers .The 13 participants included 3 (23%) adolescents with asthma, 4 (31%) parents of young people with asthma, and 6 (46%) health professionals, including 2 (33%) psychologists, 1 (16%) psychiatrist, 1 (16%) medical consultant, 1 (16%) respiratory nurse consultant, and 1 (16%) respiratory sleep nurse consultant. The average duration of experience among health professionals was 17.08 (SD 5.87) years. As per the inclusion criteria, all adolescents reported to have experienced or were currently experiencing symptoms of psychological distress determined by the K10+ scale. The technology experience level of participants varied greatly. Full demographic details are presented in A total of 4 constructs, namely, experienced affective attitude, experienced effectiveness, self-efficacy, and intervention coherence, were coded in all 13 participant transcripts. The most frequently coded constructs were experienced effective attitude and intervention coherence, which were reported a total of 96 times, while the least frequently coded construct was anticipated opportunity cost, which was reported a total of 5 times. The remaining categories were coded between 11 and 85 times. Example quotes for each TFA construct are included in Participant groups were similar in their proportion of positive, negative, and neutral quotes across all constructs .Affective attitude is defined as “how an individual feels about taking part in an intervention” . TranscrI think on its own, I would be worried, but if they're also seeing a therapist, counselor, psychologist...or had a trusted adult and health professional to talk to, I think it could be very positive.Health professional #6Young people were also generally positive about the idea of technology:Um, yeah, definitely. It would help. A lot because you know a lot of people spend most of their time on their phones nowadays, having an app like that. Well, you know, it would probably help a lot and you would be more, you know, you would probably use it more.Young person #7Similarly, 96 quotes were identified for experienced affective attitude, with the majority  being positive. “Calming,” “cool,” and “engaging” were terms often used by participants in all groups to describe their experience. However, not all experiences were positive. One health professional suggested:Uh, I probably couldn't be bothered doing it myself, I guess. Um, I think sometimes it's just about grabbing people's attention and to me, I felt that had a sense that young people would say, yeah, yeah, whatever.Health professional #5The comment that the holographic technology did not meet expectations commonly occurred among health professionals and parents of young people, along with disappointment about the size of the hologram. As 1 health professional stated:I think if you kept, like, if you kept it, that kind of size, I think you’d lose engagement. Cause it would just be too little. But if you could have that, so it was, like, a really big thing then that’d be cool.Health professional #2Effectiveness refers to “the extent to which the intervention is perceived as likely to achieve its purpose” . Once agUm, yeah, definitely. It would help. A lot because you know a lot of people spend most of their time on their phones nowadays, having an app like that. Well, you know, it would probably help a lot and you would be more, you know, you would probably use it more.Young person #7As with affective attitude, quotes coded for this domain in transcripts with health professionals focused on the need for technology to be used in conjunction with face-to-face engagement with health professionals. Participants also noted that some people would respond well to information delivered via technology, and others would not. One health professional said:I think it's a really good adjunct because there are some people that will be, like, perfect for… And there are some people that it will be okay with and there'll be some people that won't engage with it or won't have the actual technology resources themselves, like the phone and the iPads...have access to do it. So, I think it just adds another string to your bow, it's some other way that will work. And it's about figuring out that goodness of fit.Health professional #4A total of 85 quotes were coded for experienced effectiveness, among which 56 (66%) were positive, 8 (35%) were negative, and 21 (25%) were neutral. Participants felt that the technologies would be beneficial, particularly for education, given the engaging visual nature of the information. As 1 parent of a young person with asthma stated:So, the goal is to understand as best you can, what's happening either inside your own body or inside your child's body. Okay. So that's, that's the aim. What is the best mechanism for doing that? Well, to see it really, isn't it? And so then to see it in the most representative and the most real and the most, um, sort of engaging way becomes I guess the goal.Parent of young person #2Once again, participants in all groups suggested that some people would respond more positively than others. A young person with asthma said:It would be very beneficial for them. At least, um, or at least some people, depending on if they prefer it this way or that way. It would be very beneficial to the people who absolutely prefer something like this to learn and to discover more about themselves.Young person #3Participants also noted the ease of accessibility of the information. One health professional stated:Yeah, definitely because that's something that they can access at home and it's something that they can access at any time. Um, it's creating that, um, autonomy to the, to the patient, to the family, um, re…reinforcing education that they might want, but in their own time and privacy of their own home.Health professional #3Ethicality is “the extent to which the intervention has good fit with an individual’s value system” . A totalThey might not have access to reliable internet, or they may not have the money or access to a device, then, you know, it’s all very well having that, but they might not have the ability to use it.Health professional #1The issues identified also included questions of privacy:Um, I think I have concerns over privacy and access to data and so on, in particular as most, um, servers seem to be based overseas.Health professional #1as long as you…stick to your mainstream stuff and um, organizations that publish things”) and the importance of human interaction:Participants were also concerned with the accuracy of online messaging , while the negative comment expressed that the technology would not be relevant to her work (“Not for me. No.”)Opportunity costs refer to “the extent to which benefits, profits, or values must be given up to engage in the intervention” . TranscrIn total, 11 quotes were coded for experienced opportunity costs, with quotes identified from all 3 participant categories of participant. Among these, 8 (73%) were positive, and 1 (9%) was neutral. Health professionals commented on whether learning to use and recommend the technology would be a good use of their time:Yeah, definitely because that's something that they can access at home, and it's something that they can access at any time.Health professional #3They also commented on the accessibility of the technology for intervention delivery:Particularly if it's, say, if it's an app you download on your phone, if it's a card box that you can easily access, think what people are looking for is that convenience, just download the app. That's sort of a low-cost, no-cost app or the little cardboard boxes. And that again in my sort of world in education. They're easy recommendations to make.Health professional #4Likewise, young people with asthma and parents of young people with asthma commented predominantly on the accessibility of the technology. One parent noted that the accessibility would depend on the skills and abilities of the user:Um, I would say that if it's on the phone, it's more accessible, probably quicker, but that would also depend on your knowledge [inaudible] accessing it.Parent of young person #6“For me? Yes. For a young person? No.” One parent of a young person agreed:This construct was also separated into anticipated and experienced subcategories, and it is defined as “the perceived amount of effort that is required to participate in the intervention” . A totalProbably difficult for my age group. Um, because you know, we didn't grow up with them, but the kids it's just like, they don't find it difficult at all.Parent of young person #5“Um, in some cases, maybe”), while another parent of a young person with asthma disagreed:Young people with asthma also echoed that sentiment  being positive. Additionally, 7 (15%) comments were negative, and 5 (11%) were neutral. Many participants used the words “easy” and “simple” to describe their experience using the technologies, expressing that it would be easy to use once familiar with the technologies. As 1 parent of a young person with asthma asserted, I think we'd have to say it was moderately difficult. Right? If I didn't have a skilled proponent of the technology…I would have seen nothing cause you, but you could imagine a little arrangement that has a black bit of cardboard at the back and then something that sort of positions that somehow, need a little bit of thought…and kind of got to position it from above, don't you, otherwise you interrupt one of your pictures.Parent of young person #2“I’m not tech savvy,” and 1 parent shared that while some people of his age would adapt well to technology, he found it more difficult:This construct refers to “the participant’s confidence that they can perform the behavior(s) required to participate in the intervention” . A totalLook, uh, certainly there would be a certain amount in my generation. I would think that um, possibly, a little bit more, uh... You know, adaptable to computers and things. There's some pretty smart people out there of my age that, you know, it's. Computers and that, and technology is natural for them. It's never been sort of part of what I've ever done if you know what I mean?Parent of young person #6Likewise, when the young people with asthma were asked if they would use the tools themselves, most answered in the affirmative, and most indicated that they were comfortable using the technology:Yes of course I would. These like, really work, very informative and very, very calming.Young person #7“I have heard of it. I don't sort of understand it too much”), most demonstrated understanding afterward. We also considered that quotes about how the technology could be used outside of this project demonstrated an understanding of the intervention and how it worked and thus were appropriate to this construct. For example, 1 health professional said:Intervention coherence is defined as “the extent to which the participant understands the intervention and how it works” . There wYeah. To be used as, like, a treatment tool for those kids? I guess it depends on what you're actually wanting to deliver, but I can definitely see [the] potential that if you're giving, um, if you're giving education on how like lungs work and how the pathophysiology of it all and the effectiveness and how medications work like um, your bronchodilators or whatever, then that could be really good cause I can actually see what's happening inside of them. So, I think that would then help them kind of put the picture together as opposed to just talking to them. From an anxiety and depression point of view. Um, yeah, I mean, I think that like a guided meditation type thing, like you did with the [VR] one that could, that could be useful in that kind of scenario.Health professional #2The findings of this study suggest that mixed reality technologies are generally acceptable to adolescents with asthma, parents of adolescents with asthma, and health professionals. Participants across all 3 groups largely felt positively toward the mixed reality technology  and consConcerns were raised among all 3 groups of participants surrounding the ethicality of the intervention , but this was mostly discussed by health professionals. Privacy and accuracy of messaging were identified as potential issues, as well as the accessibility of technological interventions for all socioeconomic groups. Issues surrounding privacy and mobile technologies in health care have already been identified in prior research, with some participants expressing concerns about the safety of medical data collected or transmitted via mobile devices ,38. AcceInterestingly, multiple participants—most commonly health professionals and parents of adolescents with asthma—reported being disappointed with the holographic technology due to high expectations based on the portrayal of holographic technology in movies and TV shows. These preconceived perceptions may have introduced bias in the assessment of this type of technology. Future research with a larger budget may consider upscaling this type of resource to meet preconceived perceptions. Participants also expressed concerns about the burden of using holographic technology more so than VR or AR. The feedback comparing the mixed reality technology modalities led us to amend protocols for future studies limiting intervention content to AR.The sample of participants was all recruited from 1 hospital in Adelaide, South Australia, limiting the generalizability of the results to the larger population. While smaller than originally planned, this sample size was considered appropriate for the project timeline. Sim et al  includedFindings from this study demonstrate that mixed reality resources may be an acceptable treatment/intervention delivery mechanism for young people with asthma. Participants reported feeling positive about the technology and the potential efficacy of this delivery mechanism, and the technology was largely considered easy to use. Health care services might consider the use of mixed reality technology in conjunction with existing resources to diversify treatment delivery and increase engagement.The results of this study suggest that mixed reality resources may be an acceptable addition to current health care practices for the purpose of delivering psychological interventions to young people with asthma. Participants were mostly positive about the mixed reality resources; however, some concerns were raised regarding the ethicality, particularly in relation to privacy, accessibility, and accuracy of messaging. Participants noted the need for technology to be used in conjunction with face-to-face engagement with health professionals and noted that some patients would respond to this type of delivery mechanism better than others. Further randomized trials are warranted to explore the effect of mixed reality resources on health and behavior outcomes in this population.


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  and the information-framing devices  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.During medical consultations, physicians need to share a substantial amount of information with their patients.  Physicians talk at least half the time of a consultation . During what information to provide and on aids supplementing the physician talk , a variation in linguistic presentation can generate different results and cause individuals to alter their preferences  and how the speaker has designed, or framed, that content (indicating the function) . Heritagnd force . In the  actions . Interlo actions . Along tferences . Adding ferences , p. 671,ferences . The gaiferences .something—vs. anything—else you want to address in the visit today?”) obtained almost all the times the desired reply from the patients. Finally, different systematic reviews have demonstrated how message design choices like gain/loss framing or tailored visual designs can influence some  disease prevention behaviors . Therefore, we will consider information-framing devices to be any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it, while for information frames we mean higher-level ways of organizing and structuring information to make it more meaningful and useful for a particular purpose. We will therefore apply the more literal meaning of the terms rather than their more frequent use within the traditions of sociology and psychology . MCI is a method for “recognizing, identifying, and characterizing any communication phenomena in clinical dialogues” . It is a). Participants gave broad written consent for using their data for further research on clinical communication.We drew from a corpus of 380 videos of physician–patient interactions available for further research and collected in a Norwegian University Hospital between 2007 and 2008. The videos had been collected in the context of a randomized controlled trial testing a communication skills training for hospital physicians . The stuFor this study, we aimed for interactions that would be particularly rich in information provision and would have included a wide range of manifestations of information-sharing practices. To meet this aim, we selected the consultations that had scored high on shared decision-making, based on the MAPPIN’SDM tool . These 3Due to research ethics requirements, the video recordings had to be deleted at the end of 2020. Therefore, before deletion, the researchers who performed the analysis (JM and JG) supplemented the verbatim transcript with observable details such as gestures used by physicians and patients, notable prosodic features , pauses, and various visible contextual elements. Then, the researcher (JM) conducted analysis, discussing and debating analytical choices regularly (approximately every week or two weeks) with another researcher (JG). These meetings began during the process of transcription and involved quality checks of the speech and particularly the co-speech actions and continued over the entire span of analysis, up to and including formulating the coding manual. In addition, throughout the research process, JM brought key points of analysis to a microanalysis seminar group, specifically of five researchers from different disciplines  all working with video analysis in clinical settings: (1) to discuss examples of what was and what was not an “information-sharing episode,” (2) to ensure that the analyst was not overlooking possible ways of designing messages in the information-sharing episode , and (3) to check on the overall rationale of the approach and consistency of decisions, particularly when the analyst was unsure . Finally, to obtain additional peer feedback from researchers who were less familiar with the research process, the results of the analysis and of the categorization process were presented two times to two different multidisciplinary research groups to check and eventually refine the final categories (the information frames).The analysis proceeded in four main steps, summarized in information-sharing episodes were defined as “physician turns during which they initiate sequences of providing medical information that is new to the consultation and during which the patient is in a listening role.” The formal, granular microanalysis was limited to these episodes, and the interactional context was used to interpret and disambiguate the episodes and the behaviors observed.The first step was selecting the episodes when the physician was in an “information-sharing mode,” so that the detailed analysis could focus on the most relevant excerpts. Such As a second step, the researcher identified all the various information-framing devices in each information-sharing episode. This included any feature of the message that went beyond a basic expression of the same content; thus, the researcher had to examine each utterance/phrase in the episode to derive the most basic, concise version of its propositional content. For example, if the physician said “this is a VERY big operation,” the most basic propositional content was “this is a big operation.” The researcher then used the basic version as point of reference to reveal the observable variations in how the physician actually conveyed that information to the patient. In our example, the physician added “very” and stressed that word  worked together to group the framing devices in categories of broader information frames based on their function. They created post-its with labels for each device and a couple of examples. These were randomly placed on a board, and the two analysts discussed each of them, trying to answer the question: “what may the doctor be trying to accomplish with this framing device?” Information frames were therefore extracted, grouping framing devices with a similar overall function.We identified 66 different information-framing devices. These were grouped into nine main information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don’t like where you are or I 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.Appendix A. The next section provides an overview of the frames. All examples have been translated from Norwegian into English.anchored the message into something mutually known, summarized the main information shared, checked understanding, marked or explored shared knowledge, or narrated what was happening, or marked the message as closed. All these information-framing devices were used within the frame of checking if the available knowledge so far was indeed shared with the patient. For example, with checking understanding, the physicians could conclude an information-giving episode by asking patients whether something was unclear or whether they had questions or doubts. Checking understanding could be done in the form of direct and explicit formulations that offered a clear slot for the patient to confirm or disconfirm understanding  or in the form of indirect and implicit formulations that did not provide a slot for the patient to confirm or disconfirm but instead projected a preference for confirmation of understanding from the patient .In some cases, physicians corrected the patient or themselves, changed framing device mid-course, suspended the utterance, or titrated information. These framing devices signaled that the physician was not satisfied with the current state of the message and was responding by adjusting. For example, when suspending the utterance, the physician decided not to complete an utterance, signaling that where it was going should be left unsaid and that the patient could imagine how the sentence could be completed . Another example is when the physicians self-repaired the framing device: they started designing the message in a certain way, did not complete, and moved to another way. In these cases, we observed a disfluency in the message: the physician self-interrupted and changed in the direction of a new treatment for how to design the same message. For example, “it takes 5 seconds to check it while we are operating on? you, but if we ... if you are unsure then we don’t do it.” In this case, the physician switched from “if we” to “if you,” thereby changing to a frame that gave more knowledge, power, or responsibility to the patient.Physicians clarifying, exemplifying, explicating, or specifying content, using visual displays like pictures or gestures, or adopting verbal analogies or metaphors. By mobilizing such extra effort to explain information, the physicians signaled that it might be otherwise difficult to understand and, by implication, that the patient might need to exert extra cognitive effort to fully understand the message. For example, in some cases, the physician selected and presented aspects of the information using visible modes of communication, such as turning the screen toward the patient and pointing to it rather than just reading something from the screen. Similarly, one physician did not just describe how a ganglion cyst reacts to being drained but represented the dynamics of its shape and relationship to the patient’s body in gesture. Both these choices allowed the patient to perceive part of the message visually and directly and interpret it along with what the physician was saying.We observed physicians comparing, contrasting, providing consequential reasoning (“if...then”), highlighting and valuing one message compared to another, or giving ideas about the number of bits of information on the table or their sequence. With all these devices, the information frame conveyed was that the patient should think about the information. For example, physicians signaled that the patient should put information in context with other related options when they presented two ideas or contents together to highlight their differences (contrasting)  it’s that you don’t have to be stressed, compared to the first option”) or similarities (comparing) .Some framing devices oriented the patient to a reasoning process. We observed physicians accentuating, signposting, using a double negation, intensifying, redirecting, repeating, paraphrasing, anticipating, or reintroducing the message. These framing devices upgraded the importance of a message and directed the patient to be alert and pay extra attention to the information. As an example, with the accentuating device, the doctor used terms or formulations that exaggerated or amplified parts of the information without necessarily changing its propositional content, thereby lifting some information into the foreground, so that it emerged more saliently to the patient. This device could take the shape of amplifying adjectives , of the use of a stronger expression than what was necessary for utterance comprehension . Accentuating could also be a word stressed by using a higher tone of voice or talking slowly while pronouncing a word, or a pointing to some parts of a sentence, just to stress it, like when saying “because I don’t find any clear explanation for what you have (.)” [patient: “no”], and then adding again “I don’t.”We observed physicians minimizing, deferring, justifying an action, or framing the message as certain or obvious. For example, when using the deferring device, the doctor postponed and deferred a discussion to a future time, thus signaling to the patient that there was no need to pay too much attention to that message at that moment .At the opposite, physicians designed the message to downgrade its importance. The information was presented as routine and not needing the patient’s special attention or worry. This information frame was done with the devices of precise, technical terms, using the physician colloquialism, substantiating a medical decision, showing and expressing competence, clearly declaring the professional role, being directive, deciding who has the responsibility for an action, generalizing to the tendencies of the population, showing generic practical implications, or using ways to keep the turn. All these framing devices signaled that physicians were stating that message from the position of their professional role. The most explicit example was when physicians declared their role, thus defining their professional function, expertise, or tasks. For example, an anesthesiologist talking to a patient about what would happen with anesthesia during surgery said, “So you shouldn’t feel that when we are then working with the urinary tract, [patient: ‘ok’] because it is very uncomfortable. (.) [patient: ‘yes’] So that’s why I’m here” [laughter]. In another case, the physician declared the professional role of another person, giving indication of the borders of professional competency, role, or expertise. For example, one physician said, “and then I’m going to fill the bladder with 300 mL of saline, [patient: ‘mhm’] and then you’re going to cough (.) Then we’ll see how much you leak when you cough (.) [patient: ‘mhm’] And then my boss takes over completely and runs a kind of test on you, a little physical activity.”Some ways of designing the information demonstrated an effort to convey the physician’s professional stance, role, and position. We observed physicians framing the information by using very mixed, ambiguous messages, displaying their own reasoning, relating to feelings or emotions, expressing lack, reduced, or approximated knowledge, or showing that the information is subjective and can change from person to person. A frequent example was when the physician inserted the professional self into the reasoning about the present situation, by using a 1st person personal pronoun, followed by verbs indicating a cognitive reflection . With this displaying own reasoning device, physicians offered a glimpse into their mind and personalized the relationship to the information, thus providing a sort of personal accountability and transparency for deliberations expressed in the dialogue.Other framing devices demonstrated that physicians were talking from their personal position, as a unique person with limitations, vulnerabilities, knowledge gaps, uncertainties, emotions, individual reasoning processes, and doubts. Such information-framing devices were providing empowering or reassuring the patient, validating their experience, softening the message, using humor, referring to something in the patient’s life, making the information explicitly personal for the patient, individualizing, or translating the information for the patient. As an example, one physician said, “We’ll fix this [your knee] so you can go climbing on the mountain again.” In this case, the physician was referencing, that is, specifically referring to that person’s specific passion for climbing mountains.Finally, a group of information-framing devices acted within the frame of recognizing the individual person in the patient role, with their own experiences, life circumstances, individual characteristics, preferences, and unique situations. Framing devices used by physicians to signal a recognition that the patient is a unique person involved information-framing devices covering nine main information frames, with the intent to ensure shared understanding, to provide orientation to the information, or to display the relationship to the information. To the best of our knowledge, this is the first study that discerned the details of physicians’ information-framing practice inductively in naturally occurring, routine care.In this study, we analyzed video recordings of hospital interactions to identify the specifics of how physicians frame the medical information they share with patients. We identified 66 A more overarching finding is that information sharing is not “just” about accomplishing the task of making sure the patient correctly receives the information, but it serves different broad communication goals. We found framing devices and frames that covered task goals of shared understanding and orienting about how to treat the information, but also identity and relationship goals. This reflects the multiple goals theory of communication, where high-quality communication is the simultaneous achievement of (1) task goals (completing a task), (2) relational goals , and (3) identity goals (managing self-presentation) .repeating and reintroducing information). Some of the framing devices also resembled Wittgenstein’s examples of language games, like describing an object by its appearance or its measurements, speculating about the event, or forming and testing a hypothesis  influenced patients’ adherence 6 months later. Similarly, substantiating a medical situation when delivering diagnostic information in circumstances when they are dealing with possible resistance by patients, and most importantly, this device can actually encourage the patients to talk. With this study, we therefore provided a sort of kaleidoscope of information-framing devices, which can constitute an inductively derived starting point for further research into aspects of information sharing (or “tell” moments). Each information-framing device can indeed be a starting point for further in-depth exploration. Further research can, for example, identify the different layers of functions of the framing devices, but also describe how information-framing devices are taken up by interlocutors and where or under which circumstances they occur. Previous literature has demonstrated that how messages are framed can greatly influence how listeners perceive the message, thereby shaping their attitudes and opinions 3 D: And it’s … it’s not harmful to take those. But do you have a lot of4 trouble that you bleed very easily or get bruises?5 P: No, I don’t think I bleed easily, because you see … I don’t bleed now after taking [unclear].D: Then you can continue with it.6 7 P: Okay.In this study, we defined information-framing devices by first articulating the most basic, propositional content for the utterance under scrutiny. This approach was based on well-grounded assumptions that there would be observable differences between the basic content and the way the physician stated the information. We observed that there was no instance when a physician’s utterance matched the mere “propositional content.” Consider the following example:providing consequential reasoning framing device. The observation that physicians always shaped information in their utterances reveals a near impossibility for pure neutrality and objectivity in the information-provision practice of medical care  carries a sense of praise, whereas inexact a sense of reproach . This also means that, due to the focus of this study, patients and their contributions were more or less invisible. However, the conversations constituted continuous opportunities for intersubjective understanding and misunderstandings, occurring in and outside these particular episodes. As with all interlocutors, for physicians and patients, intersubjectivity is a practical problem routinely solved and achieved (Schutz, in Some of the limitations of this study include the use of transcripts supplemented with additional notes for the analysis. Therefore, although we included visible actions that were included in the transcripts, the analysis focused primarily on speech. Another major limitation in terms of reliability of findings is the fact that the analysis was mostly performed by one researcher. Hence, we cannot assume that two different researchers would have identified and labelled all the same data segments independently and similarly. This approach precluded creating a reliable coding system; however, creating such a system was not the goal of the study. Similarly, since the study focused on the breadth of information-framing practice, we did not provide an exhaustive collection of examples nor did analyze the entire material. Lastly, although sense-making is “strongly interactive and contextual” and context sensitivity is a universal property of communicative practices , p. 13, Click here for additional data file.Supplemental Material for How Do Physicians Frame Medical Information in Talks With Their Patients? An Inductive Microanalysis by Julia Menichetti, Pål Gulbrandsen, Anne Marie Landmark, Hanne C. Lie, and Jennifer Gerwing in Qualitative Health Research


Open access funding enabled and organized by Projekt DEAL.The article “Red flags for a concomitant giant cell arteritis in patients with vertebrobasilar stroke: a cross‑sectional study and systematic review”, written by Ahmed Mohamed Elhfnawy, Doaa Elsalamawy, Mervat Abdelraouf, Mervat Abdelraouf, Jens Volkmann, and Felix Fluri, was originally published Online First without Open Access. After publication in volume 120, issue 6, page 1389–1398 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2021 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The original article has been corrected.