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recorded transcriptions

of activities

engaged

in by

their colleagues.

The

teachlng hospitals

(university and

Veterans)

in which

my research

was

conducted

were

not

necessarily representative

of

clinic

Ot

hospital

settings where

there

may

be

an

absence

of

House

Staff.

Formal

and

informal

assessments

of

one's

novice

or

expert

status

become

routine aspects

of daily work

settings in teaching hospitals.

A pat1ent's d1agnosis‚

treatment

and

laboratory

and radiologic

conditions

can

become

the

topics of

many

prescribed and

informal

conversations

over

different

time periods and

locations.

Particlpants

of teachlng hospitals normally have

and

differentlally

invoke

officlal

tltles

and

may rehearse

certain

aspects of

the

way

a

cage

1s

described

in

a c11n1c‚

nurse's

stat1on‚

over

1unch‚ during rounds‚

etc.

Impromptu

meetings

can

be

a source

of

a

potentlal shift in a

prlor

tentative

diagnosis

while laboratory

and/or

radiologic evidence

often

does

but

may

not

tilt

a

diagnosis in

a

spec1f1c

directlon.

The

research analyst must remain sensitive to the

way

turns

at

speaking

occur

and

how

participants

with

stmilar

or

different

expertise

respond to

particular suggestions

or

evidence.

The rights

ot

entitlements

of

speakers‚

therefore‚

reflect hureaucratlc

or

institutlonal

conditions, existinq

h1erarch1ea‚

and

their

practical‚ negotiated

realization.

Such

activities

often

are

influenced

by personal relationships

that

can

deviate

from organizational

norms.

The

focus

of

the

paper will be

on the

way

participants of

medical

settings

create or

reproduce t h e knowledge

structures

and diagnostic

14

..

.

_

.

-

„

-

_

.

.

.

.

.

. . _ _

.

-

‚

- _ _ _ _ _ ? _ : _ . {

decision making

that are associated with nedical expertlse

and

organizations

as

practiced and

enforced actlvlties.

Participants of

medlcal

settings

are

quided und

constrained

by

differentially distributed

know1edge‚

authox1ty‚

and

power‚ all

of

which can

influence

who

can

speak‚ when‚

and

for

how

1ong‚

about

certain topics.

A

phys1c1an's

pouer

1s

associated

with

her

or

his ability

Co

create

'object1ve' representatlons cf

the

pat1ent's

health

or

111ness.

These

medical

judgments derive from

a

knowledge

base and

a cultural tradition that

in

its

ideallzed

form

expects

a

patient

to

be

subservient

to

the

phys1cian's

powerful

medlcal

resources

that few

patients can

challenge.

In

Max Weber's(196B; 941)

terms‚ the

professional 1s able

to

dominate

because

of possesslng a

monopoly

of

control

over

information

or

a

constellation of

interests.

The

possession

and use

of

medical

knouledge

by

the

physician 1s similar

to

the "sclentific

author1ty'

described

by

Pierre Bourdieu

(1981).

Communicative

Contexts

The

delivery of

health

c a r e

services

to

patients

always

presupposes

social interaction or discourse

and objectified

summarles

or

accounts of

verbal

und

nonverbal

exchanges.

Discourse

analysis extends

techniques

derived

frcm

t h e

analysis of

linguistic units auch

as sounds‚ words or

sentences

to conversational

or

elicited

material

of

a

more complex

nature

and organization

(e.g. medical histories

or

diagnostic

interviews).

Medical comnunication

and

diagnostic

reason1ng‚

therefore‚ are intimately

linked

to the

relationship

between

oral

exchanges

and

written

documentation.

Participants of

discourse are

said

to rely on Gr1ce's

(1975.

45ff)

notion

of

conversational

implicature; makihg

inferences

that

do

not

always

follou

the

given premises of

utterances.

An

utterance

1s assumed

to activate other

information

or

knowledge

and this

explanation

goes

beyond

the information that

seems

to

be obvious in

a

given setting

and

appears essential for

creating coherence about what

has

been said.

Lanquage can

be used

to perform many

communicative

functions auch

as

conveying

information

of

a factual

or

proposltional

nature‚

establishing and maintaining

social

re1at1onsh1ps‚

and

creating common

ground

during discourse.

Principles of analogy

and

local

interpretation

are

used

hy

participants of

discourse

to

connect

a sequence

of

sentences

and

interpret linguistlc cues.

The

sociolinguist

looks for

recurring patterns of

language

use across

many

records

of

naturally

occuring conversations

while

oriented to the lmmedlate

social

interaction

setting

and

the

expectation

that

the research

ana1yst's characterization

of some

aspect

of conversation is

hopefully conceived

in

a

similar

way

by

participants producing

the

dlscourse.

Knowing

something

about

the

speaker

can help

participants

antlcipate

what

might be said, and knowing

the

topic

can

change

the listener or analyst's

expectations of

the klnd

of

language

that

might be

produced.

Knowing where

the

speech

event

takes

place

and something about

the postur1ng‚

gesturing and

facial

expressions of participants can

also

influence

part1c1pants'

expectations.

Other

familiar

notlons used

in

discourse

analysis

include channel

of cammun1cation‚

the

code

or

language

or dialect or style employed

by

speakers‚ the

message-form or intended form

of

speech‚

and

the type

of

speech

event

involved.

In

medical

and

similar

settings,

parallel

efforts

by

research analyst and lnformants are

tequired

to create

models

16

of

what each

intends

and

seeks

to

convey about

different

statea

of

affairs.

The

local

setting

13

influenced

by

the

kinds

of organizational expectations prevalent and

the

use

of prlor

mental

models and experiences

that

are

activated

by t h e

current

speech

event.

In

the examples that fo11ow‚

we illustrate the

above notiona

of

context and aspects

of

the

knowledge

or

expertise

that contribute and

constrain

the

commun1cat1on

and

diagnostic reasoninq of

physiclan

and

patient.

Contrasting

patient-physiclan Perspectlves

The

prospect

of

a

fatal

lllness can create difficult

emotional

states

in patients

and

physicians.

For

the

patient,

the emotional

consequencea

of symptoms

that

seem

unusual

or

'not

r1ght'

often leads

to an

appointment

wich a physician‚

though sometimes after a

period of

delay that may

suppress

or

exaggerate

the

imaginable

or

imagined

outcomes

of

a medical

examination.

The

feelings

or

emocions

that

precede

an

1n1t1a1

examination

can intensify 1f‚

say‚ a follow-up blopsy

1s

recommended.

The extent to

which

a patient's

thoughts durlng

these occasions

begins

to review

a

11fe—t1me

of personal

re1at1onsh1ps‚

missed

opportun1t1es‚

and

the

prospect of

a

terminal

illness

are delicate

matter:

that

we

know

about

through

indirect

or

reported speech

and

aspects

of

our

personal

experiences.

In

the present

section‚ I review

elements of

earlier work

(Cicourel‚

1982;

1983)

to

illustrate

the interplay between challenges to

bureaucratically

organized medical practices

and a patient's

emotions

and

beliefs

about the

illness

dlagnosed and the

way

t h e

illness

1s

linked

to the

husband's

recent

death

from

cancer.

Br1ef1y‚

t h e case

involves a

62

year

old

white

female

whose

Initial visit to an

oncologlcal gynecoloqist

was

recommended by

her

internist

because

of

'...hav1ng

a problem

17

in

the

uh..

uh‚

I

guess

w-what you call

t h e

bulk

of t h e

outer uh part of the organ.

There's 11ke‚ paper thin

uh cuts‚ just

a

11 t t 1 e b1eed1ng.'

The patient

reported

that

she had

been

told

by

her

lnternist

that her 'uterus

was

klnd

of

spongy

and

also

I had uh‚

very 1ow‚

I was

very

low

in

hormones...'

At

the

end of

this

initial

long

narratlve

of t h e first 1nterv1ew‚

the

patient closed by

saying

'...

I

d1dn't

realise

when

flrst my

husband

died

nine months

ago, but

still, anybody‘d just look

at me

and

you know

I'd

just be‚.. be

uh

the bereavement.

I

don't

know‚

I uh

never

used

to

be 11ke

that..."

The phys1c1an‘s

progress notes

after

this

narrative

stated

the

patient

was

'w1dowed 9 mos‚

-

depressed.

Saw

internist

4

mos.

ago

because

of

vulva irritation."

From

llstening

to the tape

recording of

the inltial

interview,

I

inferred

that the pat1ent's

manner

of

talking

could

be seen

as

emotional

and

confuslng but not

in

a

way

that

would

indicate

an

inabillty

to

conduct

her daily affairs and meet

important

obligations.

After

one

1n1t1a1 vIs1t‚

the

physician

told her:

‘Hell...

from

uh...

uh standpoxnt of uh‚

a gyneco1og1st‚

I

think

everything 1s.

1s

really pretty

good.'

A pap

smear was

obtained

by

the

physician

as

part of

his

physical

examination.

The

pat1ent's

1n1t1a1

confusion

about

her

husband's

recent

death

and

h e r

own

preoccupation

with

breast

soreness

and

vulva

ittitation seemed

to recelve

some

relief

with

the

phys1c1an's

1n1t1a1

diaqnosis.

The patient

was called

a

few

days later

and

told

to return to

the

office

for

biopsies

because

of

a

positive

paps

test.

The

second

v1s1t‚

during

whlch

the

biopsy

was

done‚

proved equivocal.

The

physician

told the

patient

that

only

dilation of

the

cervix

and

scraplnq

or

curettement

18

of

the endometrium would

be

necesssry

lt

ehe biopsies

were

negative.

The

subsequent biopsy

revealed

cancer

of the

endometrium.

Hithin

the period

of

one

month‚

therefore‚

the pat1ent‘s

condltlon

was

descrlbed initially

as

relatively benign

and

then as life

threatening.

Prom

t h e

pat1ent's perspective

(and

partislly documented be1ow)‚

the

phys1c1an's

assessments seemed

to

be simultaneously

doubtful

and expected because

of

several

independent

events

and

beliefs associated

with

these

events.

The

independent

events

had

to

do

with

the pat1ent‘s

husband

and

hls death from

cancer and

her belief that

cancer

was

perhaps

a communicable

disease

and

that

she

and

her two children

had been

exposed

to the dlsease while

caring

for

the

husband in

hospital.

During

the Third interview

conducted by

the

gynecologist

with

the

patient‚

she

noted that after

consulting

her

internist

two

months prior

to the initial

vislt with

the

gynecologist "I

felt there was

something

wrong‚

even

though

they

said

the

second

paps test

was

all

right.

I

could tell

Lt

in my eyes and the way

I,

way

I

fee1‚

there

was

something

wrong."

The

pat1ent's remarks should be understood

as part

of

a

1arger‚ emotionally charged

everyday,

lived

context

that

she had

been experiencing for at least

one

year before

consulting

the

gynecoloqist.

Despite

a lengthy and

some

tlmes formal explanation

of

what would

be

done

medically

by

t h e

phys1c1an‚ the

patient

challenged the

diagnosis

and the surgical

procedures

proposed.

After

responding

to

a question

about

and

problems

associated with the b1opsy‚ the patlent abruptly shlfted

the

topic

as

follows:

(Figure 2 lines 1

—

10).

19

Figure 2.

Pnt1ent's doubts about

diagnosis and

doctor's

explanation of

pap

test 11m1tat1ons‚*

1

Dr:

Did you have

much

proplem

after

we

took

the

biopsy

the

other

day

?

2

Pt:

Not

over

the

weekend.

Not until yesterday

really.

(unintelligible)...

3

but

over

the

weekend I

didn't.

It

just

seemed like

last

night I had

4

quite

a bit.

Do

you

feel

that's

been

there

?

Nov,

as

I

say‚

I

had

this

5