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paps

test


taken‚

taken


one

in September,

and

the


last

one they


took

6

I



asked

the


nurse‚ I

didn't


see the

doctor, and

I

sa1d‚


‘was

that test

7

all right?'Because



I

called


her, and she

sa1d‚


and she

looked


1:

up

8



and

she


sa1d‚ 'Yes‚"

9

Dr:



Yeah‚ I'm-not

surprised

at that because the

pap test


1s

not


at

all


10

good


when lt

comes


to

dlagnosing

this

klnd


of

cancer.


*From

Cicourel


(1982; 61)

The shift

in

toplc


in

11ne


(4) by

the


patient

wich the


abstract

expression

“Do you feel that's been there“ refers

back


to

the


earller

paps


smear

taken


at

the 1ncern1st's

office

when

she asked

the


nurse

about the earlier test.

I

assume

the


patient is

saylng something

like

the


“Do

you thlnk the



cancer

has


been in

the


lining

during


all

of

those times

that

I was given



the

pap


smear

tests?"


This hypothetical expansion

patient's remarks

does not appear remarkable

in

20



followinq:

of

the uterus



earlier

of

the



the context

'of

the third

interview

unless we

view

the


patient's remarks

in

lines (4-8) and subsequent



remark

(not


shown

in

Frgure

2)

few


moments

later


(“uh

and


then the biopsy") as

questioning

the physician's

diagnosis.

I

am

suggesting



that the

patient


found

it

difficult



to

understand



why

the


previous

pap


smear tests could differ from the recent one and the

biopsy


performed.

The

phys1c1an's response in llnes 9-10 did not



seem

to change the patient's



doubts

about the most recent

tests.

It

1s possible



to make such

observations

because

of

the



hindsight

afforded


by

an

interview



I

conducted with

the

patient


many

months

after


her hysterectomy.

The


patient

reported explicit

doubts that

seemed implicit during

the


initial

four


interviews with

the


gynecologist.

The


patient

challenged

the

gynecologist during



the

third interview

by recounting

her


experience of working

at a 1arge‚

private

hospital in Chicago



and recently as a volunteer at the

military


hospital where

her husband

died.

The


following dialogue

occurred:

Figure 3.

Further


indication of patient

doubts about

medical bureaucratic

practices*

1

Pt:


I

have


one question

there.


You're

you're


connected

with


the

university

2

right?


3

Dr:


That's

right.


4

Pt:


Nov, you

do

the surgery?



After that

60 Minute

program

where


I

wonder


5

whether


the doctor does

6

Dr:



Yeah‚

I

get that



asked by

about every other

patient‚

7

Yesterday‚



I

operated on a 1awyer's

wife and,

needless


to say

he

asked



8

me

that



question

about


six

times.


And‚

yes


I

do

the



surgery‚

yes


that's

21


10

11

12



13

14

15



16

17

18



19

20

21



22

23

24



25

— — - - _ — — _ . . - - _ _ _ _ - - _ _ - - - _ . . -

Pt:

Pt:


Dr:

Pt:


Dr:

Pt:


correct.

Uh‚ residents help me and, as a

matter of

fact‚ I


have

a fu11-


time associate

who's

fully tra1ned‚ a

gynecologlcal cancer doctor‚

Dr.


Rob and he

often helps me

too‚ and

we

help



each

other.


Uh‚ that

was


a very unfortunate

program

because‚


in

many respects,

the

best


c a r e

that


anybody

can possibly get in

a

university



hospital.

And


uh

I

wlsh



that...

Hell,


even

in

private



hospitals, see‚

I

worked

in

Queen's

in

Chicago,



and

I,

remember that,



I

worked

t h e desk.

Hhen they called

down

and gave me a



delivery

and


said

Dr.


Frank,

for examp1e‚ delivered

the baby‚ and I'd see

him

walk


in

ten minutes

later.

So, he


wasn't

anywhere

near


the

delivery


Yeah‚ I

fhink


that...

and I

didn't think that



was

right


either

I

agree



For

the hospital records to



say

he

delivered



that baby.

I,

I



agree

with


you.

Because I

worked there‚ and

did


as

I

was

told.

(Dr:


I,

I)

I



was

very


young

.

I



couldn't agree wich you

more


about

s m e t h i n g

like

that.


Cicourel

(1962; 65-66)

22


The

patient's questions

about

t h e

doctor's role during

the operat1on

("whether‘the doctor

does“

( t h e


operation))

and

her challenge

of

the


professional conduct of physicians

111ustrates‚

I

be11eve‚ the



anxiety

that


many

patients


experience

when

facing serious

medical interventions

and

especially

when a

loved one

has recently passed away.

They may recall lncidents

which makes problematic

the


trust

the


physician

expects to have



from

a

patient



before

a

surgical



procedure 1s performed.

The


patient

invokes


her

prior


experiences

in medical

settings

(lines


15-19)

and


the viewing

of a television program

(lines

4-5)


about doctors

to

challenge the phys1c1an's fulfillment



of responsibility.

According

to

the pat1ent‚



doctots

are


said

to fail to

fu1f111

their


obligations

to

patients by allowing



others

to

take



their

place.


The

patient


uses the

TV

program



1n

ozder to questlon

the phys1c1an's

assurances

and

his description of

the

factual


circmstances

of

her condition that



were

presented

to

the


patient in

considerable detail

(not

shown

here‚ but



see

C1coure1‚

1982).

The patient



proceeded to

make

a

more



direct

challenge

to

the


physician

that suggests



she 15 cognitively

alert yet her



remarks

carry considetable emotional force

as

she

notes


the

following:

‘and you put your faith in this doctor‚

and I

put my


faith

in

you‚



because you're

here‚


and

then


1E

someone

else turns around



and does

the


s u t g e r y ‚

I

don't appreclate that



(1aughs)."

The


physician followed

with


a

remark

that


acknowledged

the


pat1ent's feelings and perspective and

also


noted that she

was

free to


consult another

physician.

During t h e

fourth


recorded

interview

between

the doctor



and

pat1ent‚ she asked Lt

he

performed



operationa

at

another



hospital.

The patient

was

unhappy about t h e larqe number

of

medical students



at

University Hospital.

The pat1ent's

23


doubts

are documented

in

detail


elsewhere (C1coure1, 1982),

including

a detailed account of

what had

transpired in the

follow-up tape-recorded interview

at

the pat1ent's



home.

Here


I only wish to report on

an

additional lncident that



did not

insplre


confidence in

the


health care

delivery


system on the part

of

the



patient.

H e r


account

to me of


the four recorded lnterviews included the

expressed

belief


that perhaps she had

been misdiagnosed because of

the


phys1c1an's

initial


rematks

that she


appeared

to

be



in

good


conditlon

and

that this



was

consistent with her

1nternist's

assessment.

On

the



other band, the

patient


also expressed

the


view that

perhaps she believed

something

was wrong

with


her

health for

some time (as

noted in her initial

narrative

to the gynecologist).



The

incldent


that appears to

have been

Central


to

expresslng the belief that



perhaps she

had


been misdlagnosed

1s

associated wich



the

recelpt of

a letter

from

the


hospital

that had arrived

while

she


was

still in hospital.

The

letter


Lnformed

her that a recent pap



smear was

normal.


The

letter


was

a

laboragory

test

report


but

did


not

have


the

pat1ent's

name

on

lt



nor

the


date

it

had

been sent.

The


letter contradicted

the


previous

test results reported

by

the


gynecoloqist and

the hysterectomy

performed.

This


practice

was


observed

by

the



writer

to

be



prevalent wich all

gynecologlcal

patients

at

University Hospital



but considerable

time


elapsed before the

reporting

letter

was


altered.

The

patient


seems

to have


used

the


letter as

grounds


for

thinking


she

may


have been

operated


on

mlstakenly



and

that another

person

was walking

around


with

cancer


of

the


endometrium

but not informed of this condition.

There

1s

more



to

the


story

but


I

do

not have time to continue.



The

oncological

gynecology

case illustrates

several


features

of

health care delivery that



may

be peculiar

to

24


university

clinics


and hospitals

but


can

also


be

applicable

to

all


1arqe—sca1e

medical


care

Systems.


The

private


patient dlscussed

above was

not


seen by the

House

Stafi


but her observations about

physicians



and

the


problems

associated

with

the


bureaucrattc

reporting of

laboratory

results are not



always

rare events.



Hhat

13

rare



13

the


way

the patient challenged the physician

during

several


encounters

and

while


under considerable stress after recently

losing her husband

as a result

of pancreatic

cancer.

The


patient had been

told


by

her


internist and initlally by

the


gynecologist

that she


appeared

to be


'...rea11y

pretty


good" and

then told after

a

second visit

that


a

minor


procedure would probably

be required, and finally

on the

third


vis1t‚

that


a

hysterectomy



was

indicated



because

of

cancer

of

the endometrium.



In

earlier papers‚

I

called attention to the pat1ent's



apparent confusions about the telephone Calls

made


by

the


gynecologist

after each office

visit.

I hesitated,



at

the


time‚

to elaborate on what appeared to

be

a

patlent



who

had experlenced considerable personal and fm111a1

atress‚

includlng some



apparently minor

health


incidents attributed

to

her



two children

ab

the



time

of

her hysterectomy.



The

pat1ent's cognitive

or

comprehension



problems

were


underscored

previously because

of addressing

a

linguistic



audlence.

The


emotional aspects of the pat1ent's

sometimes

confused beliefs need to be conceptualised

in

light



of her

ability to

reca11 personal work experlence that

effectively

challenged the

way

health


care

delivery systems

function.

The emotional stress

of

loslng her



husband

to

cancer



and

being


told of

her


oun

cancerous

condltion



perhaps focussed

more


sharply her

ability


to challenge the

physician.

while

1:

1s



possible to note the

patient's



somewhat

unusual


claims about the transmission

of cancer‚

these

25


beliefs

did not


mitigate

the patient's

ability

to

identify



persistent

bureaucratic



drawbacks

in

health



care

delivery.

The

physician categorized t h e patient



as

"depressed“ but

did

not pursue this



observation‚

perhaps


because he

was

preoccupied

with

the


patient's challenges

to the


professional

integrity of

physicians

rather than

in

the


emotional aspects

of

the case.



The patient

never told

the

physician



that

she

believed


that her husband's

cancer

may

have been transmitted to her



and

her


children.

The

information

was

expressed to me



when I

interviewed the

patient in her home

many

months

later.


The

value


of

tape


recording physlcian-patient

interviews

in

order


to obtain detailed information about health

care


delivery problems

needs


to

be

clarifled.



Single interviews

can


be misleading

unless there

is

adequate


ethnographic

or

organizational



infotmation available

about the health

care

settings and



the views

of patients



and

physicians

of each

other's


activities.

Each constructs mental

or folk

models

of

the



other that

become

influential

in

eliciting



or

withholding

information

during


a speech event.

The patient's

emotionally-driven



thinking

can


exacerbate beliefs about the

causes

and

transmission

of disease‚

but


it

can


also help to

focus

one's


cognitive activities

about health

care

delivery.



The

physician's

dominant position

in medical

encounters

does

not mean


he

or

she



is

free


of having

their beliefs and

practices

cha11enged‚

but

physicians



clearly

enjoy


the

advantage of being

able

to

recode



the patient's

speech

acts


into

a different vocabulary



and

make use of

external


memory

devlces


like

medical


dictionaries‚ textbooks‚

journals,

laboratory reports‚

x-rays and the counsel

of

other


colleagues or

experts.


The

patient's Iiteracy

or

rationa1ity‚



even if

he

or she



is

highly


educated‚

ls

compromised



by

emotional

feelings

26


about illness

and

death and

is

seldom

a match for the

phys1c1an's

language

and expertise

at

band

and accessible

from


other

sources.

In

order

to

understand



t h e

asymmetrlcal communicative



power

of

the



physlcian-patient

re1at1onsh1p‚ the

misunderstandings

that


can occur,

the


way

these

f a c t o r s

can


weaken

the


pat1ent's communicational

abillties

to

express

their


v1ews‚ fee11ngs‚

and

emot1ons‚

we

must

examine

more


general

conditions

cf

organized



medical

settings and

the

fact


that health

c a r e

dellvery decisions



must

be negotiated

over their

course.


Medical

health


care

delivery can be

viewed

as

a



microcosm of

the


klnds of

misunderstandings and

power relations that are

inherent in complex

societies where

persons often

rely on different uses

of

literacy



to

comprehend

and

cope with

different



forms

of

technology that can affect



theit lives

and their ability

to

adapt



to acute

and

lonq-term

unpleasant circmstances.

A

medical



novice and

an

expert



The

second a r e a of

health


c a r e

I

want



to

address

shifts


the

focus


of

attention



from

the


physician-patient

encounter

to

speech

events


between

medical


novices and

expert


physicians or

attendings.

Aspects

of

medical



education

can


reveal

elements


of

the


way

the health



c a r e

system


is

influenced

by how

physicians



become

experts


and

the


extent

to which


this acqulsition of dominance

can affect



how

a

patient 15



diagnosed and

treated.


I

shall


focus

on a


small

aspect of

the expertlse ptoblem here.

The research



was

conducted

in

the


area

of rheumatology



and

included


a

medical


expert

from


the

outset.


In1t1a11y‚

this


was

possible


because

of

my teaching duties in



a

course

for


first

year


medical

students


ent1t1ed‚

"Introduction to

27


Clinlcal

Hedicine."

My

duties continue



to include

giving


a lecture

on

medlcal communication and diagnostlc reasoning

to the flrst year medical school class.

During


subsequent

meetings, I

provlde

an

on-11ne assessment



in

the classroom

of

an

attendlng



phys1c1an's

interview with

a

patlent.


The

choice


of

the rheumatology

area

was

a

direct



result

of working wich someone in

this

subspecialty of



internal

medicine.

My colleague

(Michael


we1sman‚ whose

help


was

essential

for

the


remarks

noted


below)

facllltated our

entry

(myself


and

a

postdoctoral fellow worklng wlth



me)

into


a

rheumatological

cllnlc

at Unlverslty



Hospital

and subsequently

at

a Veteran's



Hospital.

The

research

reported hexe

parallels simllar work in

other


clinlcs

in

the



same

hospitals

where

I

also audlo



and

Video


taped

numerous

physiclan-patlent

exchanges.

Medlcal


students and

House

Staff


are tralned

to

supplant



their intuitive

common


sense

knowledge



and

reasonlng about

illness

and

dlsease wlth

basic

and cllnlcal



science knowledge

and


cllnlcal 'hands

on' experlence with

patlents.

The


novice physlcian

must

learn


to convert the

pat1ent's

often

idiomatlc



and

somet1mes'amb1guous

language

and

folk bellefs

or

t h e o r l e s into

unamblguous

declarative

oral

and

wrltten


assessments

uslng


a

systematic

vocabulary

and

notatlon


system.

The pat1ent's language

can

reflect considerable



uncertainty

about


symptoms

and


their

consequences‚



and. as

noted earller,

their


expressions

often


embedded in complicated

emotlons

and

feellngs


about

thelr health.

The

patlent's



conceptual, emotional,

and

linguistlc

problems emerge

in

a



local context

in

which



the physician

seeks to


employ

her


or

his


own

language use



and

elicitation

format.

In

previous work (Cicourel‚



1985;

1986), I


lllustrated

the


lnteractlon

between

"local and



schematized knowledge'

used


by

a

novice physician



who

had

interviewed a

patient

28


referred

to the rhematology clinic at University

Hospital

where

the


research

was


conducted.

The

interviews



between

House

Staff


and patients

are


commonplace and

are


considered

to

be normal



institutionalized functions

by

all



personnel.

The


material in Example (1)

illustrates



t h e

way

a

member



of

the


House

Staff


(a

training


fellow

or

TF)



creates

what


appears to

be

a coherent narrative for



t h e

benefit


of

the


supervising attending.

The


narrative is

about

the medical

status

of

a



patient

that had been seen a few

minutes

earlier.


Examgle

(1)


-

Training


Fellow-Attending Initial

Exchange‘

: 0k,

next


is

Elena


Louis‚ (background

voices)


anyway‚

she's


44 years

of

age and sent here



from

(the


7)

oncology


qroup.

so

the



past

two years



she

has had


episodes initially

of erythema

followed

by

swelling involving



the

second

and


third metacarpal

and

PIP


joints of

both hands‚

a1ternating‚

one

time


this hand‚ one time

this


hand.

She's


also had

arthritis of

her ankles‚

which


includes

redness


on

a lateral border

of

the


iateial

malleolus

followed

by swelling.

p-xocpsnmuva-wuä

O

H‘h‘



Comes

on‚ first the

redness‚

and

she has


pain

and

swelling


within

24

hours.



Lasts for several

days‚


and then

it

goes



away.

I-'


h)

F‘

w



F‘

h

But



when

she

has

1 t ‚


the

pain 15 quite

severe.

I-‘


U1

It

greatly limits her



hand

function


and

her


walking

16

function.



‘Fron

Cicourel (1985;

179)

The narrative



in

Example (1) presupposes

a listener not

only capable of comprehending

American

Eng11sh‚


but

whose

background



knowledge

will


include medical or

nursing training.

Such

training‚



however‚

does

not insure that the TF's



remarks

can


be viewed

as

medically competent‚



nor that

t h e speaker's

(to


me)

confident narrative style

reveals

adequate background



29

knowledge to a listener

(such


as the

supervising

attending)

who


13

considered

to

be



a

highly qualified expett in

the

hospital setting



.

Po:


a

novice‚ including

the present writer

at

the



time

of initiatlng

thls research

in

the



a r e a of

rheumato1ogy‚

the

material


In

11nes

1-16 appears to

be

a series


of crisp,

declarative

utterances that

suggest


a

speaker expressing

confidence about her

ox

his



knowledge of

some state

of

affairs.


The

language


employed

includes a

mixture

of

technical



(“erythema"‚

“third metacarpal



and

P I P


jo1nts‚'

'1atera1


border

of

the



lateral

ma11eo1us')



and everyday

terms


("tedness'

(etythema)‚ '5we111ng").

The

attending physician listenlng



to

these remarks

did not


challenge

them


at the t1me‚ but

seemed

to

assume

that the

TF's


narratlve

was

indexing


appropriate semantic domains.

when I

subsequently



asked

the


attendlng

to review the medical

interview

completed

prior

to the


narrative

in

Example (1), he



was

critical of

the

way

the


TF

had posed

questions

for the patlent.

Spec1fica11y‚

the


attending

stated that the

TF was using

a

data base about



rheumatoloqy

dlseases in.an

inappropriate

manner


and

could


not

link


appropriate concepts

with


the

symptoms

elicited


from

the


patient.

According

to the

attend1ng‚



the

TF's


remarks

in Example

(1)

present information that



implies

or

presupposes background knowledqe that



1s

not


evident

in

the



Original intervlew.

Details about

the

inappropriateness



of

the TF's questlons can

be found

elsewhere

(Cicoure1‚

1986).


The

concepts


employed

by

the



TF in Example

(1)


can

be

linked to material



given

to first year medical students

on

rheumatoid



and

osteoarthritis



and lupus

but not


shown

hexe.


The general point

1s

that the



TF's use of

lanquage can

easily be seen

as demonstrating knowledge

of

key terms



associated

with


rheumatological

diseases but

they

lack


clarity vis-a-vis

their


use

to

elicit



and

interpret

adequate

symptoms

from

the


patient.

30


The

material


in Example (2)

reveals


the

1n1t1a1


part of

the


original

interviews



between

the TF and

patient

that


preceded

the narrative

of Example (1).

Examgle

(2)


-

Initial intetview between

TF

and

pat1ent*


1

TF:


Ummm‚

who

sent you to arthritis?

2

P:

Uh‚



uh‚

oncology.

3

TF:


Oncology.

(unclear)

That's

okay.


(other

voice)


4

Now


let

me

just



get a

piece of


paper

(7 seconds)

5

(closing


drawers)

6

How

old

are


you?

7 P:


44

8

TP:



Okay

(9

seconds) and (do



you?

)

have

any

problem?


9

P:

oooooh‚



the whole

body


10

TF:


whole

body

11

P:



Joints‚

really bad.

12 TF:

Uhuh, yeah okay.



13

P:

and ummm‚

breakout

in

these



big

red spots‚

(mumbling)

14

tops



and

toes.


15

TF:


Uhummm.

16 P:


But only

when

I sit


in the

bot water‚ they



ccme

out


17

quite


a

b1t‚


my hands get‚

like


th1s‚ they stiffen up.

*From Cicourel (1985;

176-177)


The opening lines of

Example


(2)

are


notable for the

deictic


and

anaphoric functions



and amblguous

referents

like

' ( d o you?)



have any problem?"

(line


8)

and the


response of

"the


whole body"

(line


9), and in

lines


13-14

of 'these big

red spots' and

'tops


and

toes."


The opening

line


(1)

asks


“who

sent you to arthr1tis' and the response In 11ne

2

of

'onco1ogy”



and

the TF's repeat of ”onco1ogy' in

line

3 make use of



imaginative

constructions that

are

metanymic by replacing



the

physicians wich whom

the

patient spoke



to

in

the



gynecological

oncology clinic

wich

t h e

terms “arthr1t1s‘

(clinic)

and


"onco1ogy'

(c1in1c)‚

used

respectively



by

the


31

TF und

the


patient.

The use

of ambiguous

referents and

apatial


or

deictic and

pronominal anaphoric

functions is

characteristic

of

medical intervlews



and

all discourse.

what 1s central in the pat1ent's

remarks

are


references to

her


body

in

terms

that are medically unclear and equally

unclear to

someone

attempting



to

use

a

coumon sense



understandlng

of

the



categories employed

by

the



patient.

The

reference to ’Jo1nts, really bad'

in

line


11 of

Example (2) should

have activated

rheuatoid and

osteoarthrltic semantic memory traces for the TF‚ as



we11

as

motivated



questions about

details wich respect

to

the


specific

joints involved.



The

reference

to

'these


big

red


spots"

in

line



13

of Example (2)

could activate

ambiguous



memory

traces


because

they


do

not


seem

to

be connected



to

conditlons

a

rheumatologist



could

llnk


to specific

diagnostic categories

unless additional informatlon

was

ellcited.

The reference

to

‘tops



and

toes" in line

14 is

deictically ambiguous



unless

the


research analyst

was

present


to

observe


the

patient


showlng

the top cf her hands and

pointlng

to

the



area

of

her



toes.

Furthermore‚

the reference to

"they


come

out


quite

a

b1t'



in lines

16-17


appear

to

index



the

"red


spots'

of

line 13, and



the

reference

to 'my

hands get, like

th1s‚


they

stiften


up'

illustrate

the

importance of



local observatlonal

conditions

of

discourse.



The

pat1ent's reference to her ”jo1nts‚rea11y bad'

in

11ne 11 appears to



be diagnostically relevant,

but


lts

possible significance

was

quickly dispelled



when

the


attending

reviewed


t h e transcript

and

tape recording of t h e

TF‘s

intervieu



of

the


patient.

The


attending

also


noted that the

significance of

the

"red spots' and



the

stiffinq of t h e

hands

when they are inmersed in



hot

water


1s of

dountful


significance

for


rheumatology patients.

32


The

reference

to

the 'jointa‚



really

bad'


would

he

of



immediate diagnostic

value if


the

T? had pursued

the

patient's



remarks

by askinq

additional

detailed


questions about

the


hands

and


wrists and

actually


holding

the


hands

in

order to



pinpoint which

joints seem

to

be

involved



and

if they


seemed

"warm?

and in any way



deformed.

Fron


the point of view

of

the expert



(the

attending)‚ the novice

(the Training Pellow)

was


aware

of

the fach



that

'red spots'



and

the hands beconing

stiff could be

significant for

rheumatology patients‚

but the


TF

was

unable


to

enploy the



background knowledge

activated

by

this


reference

to

'red



spota' and 'stiff'

hands

in

an



appropriate and clinically

relevant manner

during

the


local

situation

of

the medical interview.



The attending concluded

that the


TF was

unable


to

employ

effectively the

background

knowledge needed

to pose


appropriate questiona

for


the

patient;


the communicative style

was


not adequate for

pursuing and

nullifying

several hypotheses that



emerged

in

the



opening

lines


of

the interview.

The

expert medical informant frcm wham I received



considerable information about the kinds of

background knowledge

presupposed

by

the TF's


questions in Example (2) and

the


summary

narrative presented to the

attending

in

Example (1).

point

to the


significance of

institutional



and organizational

contexts for

understanding

discourse

oz

conversational



material in

medical as well

as

other


settings.

The

medical


setting

also reminds us Chat we



must

clarify how

to assess

the


expertise of

informants

who

are


uaed

systematically to

confirm references to background knowledge.

The importance

of

the notion



of

communicative

competence

as

discussed in



the

literature

on sociolinguistics

needs

to

be



made

problematic

with respect to

t h e

ethnographic

setting and

the


research ana1yst's experiences

with


the institutional

context.


'

33


Conclusion

In

the



first medical

case‚


I

reviewed


some

of the


emplrical

issues associated with

physician-patient

communication

and


the

possible impact

that bureaucratic

otganization



and

status


or dominance can have

on

the



information

that


is

elicited


or

withheld.

The interaction

of cognitive and emotional elements in

the

gynecological



case

illustrates

aspects of

the


way

health


care delivery

1s

framed



by

the


perspectives of

the participants.

Such

conditions should



be

examined


by

medical


sociologists

because they constitute the bedrock

of

medical


practice.

The

medlcal


Interview

and


medlcal

history


conducted

by

the



gynecologist and TF

could


be

seen


as falrly

typical of



hundreds

of cases I

have

observed


and/or

tape-recorded

over

a number


of

years.


But

the content

of

the


narratives

expressed by

the


patients

and


physicians required

the help


of

expert informants

whose

clinical


experiences

and knowledge

of

medicine


helped

to

clarify



the discourse and

diagnostic

reasoning

reported in

the

examples presented.



The

attending

physician

in

the



rheumatology

case


in

Examples (1) and (2)

told

me Chat


he

was

teluctant

to

challenge



t h e TF

dlrectly


despite feeling

Chat


there were

serlous


problems

wlth


the

content


of

the narratlve

(partially) shown

In Example

(1).

The

issue


was

not so


much

the


TF‘s

lack of


formal

knowledge

about

rheumatological



diseases,

but


a lack

of

clinical experience



and

a

weak ability

to translate the

formal

knowledge

into appropriate questions

that


could ellminate

particular dlagnostic hypotheses

and establish

others that could

be

tested


with laboratory

or radxological

and additional

clinical evidence.

34


The

rheumatological



case

illustratea

a

common practice



whereby patients

are


interviewed by novices

and

t h e

diagnosts

1s

monitored



by

an

expert.



This

case

calls


to

mind the


fact that medical specialista

must

rely on an

interpenetration

of

context-free and local knowledge



during medical

communication



and diagnostic reasoning.

The circumstances

that have

been outlined

for novice



and expert

can


prevail

between a general

practicioner

and


a

specialist and

subspecialist.

The


exercise of

profesaibnal

authority

combines


intuitive,

taken-for-granted and formal knowledge

in

the construction



of

a diffetential

diagnosis.

In

other



related work‚

I

seek



to identify different aspects

of

medical



education and

clinical


practice

that


appear

to

be



associated

wich


the discourse exhibited

1n

physician-patient



and

physician-physician encounters.

Ethnographic

experiencäs

were essential to the

way

I

could identlfy



larger

Lnstitutional



and

1oca1


senses

of context



and background

knowledge that

are

integral


aspects

of

attempts



to engage

in

the



systematic analysis of

medical discourse materials.

In closing,

I underscore the

importance of examinlnq

part1c1pants'

repreaentation

of their


folk, clinlcal

and

basic


science

knowledge



and

the


ways

in which these knowledqe



sources

are displayed in local

setting:

as constrained



and

facilitated

by

the organizational



and

interactional

regularities

and practices of

medical environments.

Aaron

V.

Cicourel



Department

of Sociology

and

School


ot

Hedicine


University of

Ca1ifornia‚

Qan

Dieqo


La

Jol1a‚


CA

92093


35

References:

Bourdieu‚

P1erre‚ "The Specificity of

the


Scientific

Fie1d‚"


in

Charles Lemert

(ed.)‚

French


Soc1o1ogx‚

New

York:


Columbia. University Press‚ 1981,

257-292.


Cicoure1‚

Aaron


V. "Language and

belief


in

a medical

setting,”

in

Heidi Byrnes



(ed.)‚

Contemporary Perceptions

of

Languagg


: Interdisciplinary Dimensions. Georgetown

University



Ruund

Table


on

Languages



and

Linguistics,

Washington,

D.C.


:

Georgetown

University Press‚ 1982,

48-78.


Cicourel. Aaron

V.

"Language



and the Structure

of

Belief



in

Medical Communication‚' in

S.

Fisher


and

A.D.


Todd

(eds.)‚


The

Social Organization of

Doctor—Patient

Communication.

Boston: Routledge

and Kegan

Paul,

1983,


221-240.

C1coure1‚

Aaron

V.

"Text



and

D1scourse.' Annual Revlew of

Antrogo1og1‚

14 (1985),

159-185.

Cicoure1‚

Aaron

V.

'The



Reproduction of

objective Knowledge:



Common

Sense

Reasoning in Medical

Decision

Making‚"


in G. Boehme and Nico

Stehr


(eds.)‚

The


Knowledge

Society‚


Dordrecht:

D.

Reide1‚



1986,

87-122.


Gtice,

H.P.


'Log1c

and

Conversation."

in Syntax and Semantics.

(eds.)‚


P.

Cole and


J.

Morgan


1975,

New


York:

Academic


Press‚

41-58.


Presented

at

the



opening

plenary


address

of

the



BSA

Medical


Socioloqy

Group Annual Conference, University

of

York,


England,

25-27 September

1987.

J6


Abstracts

°f

P ä p e r s



given

at the


1987

BSA

Medical sociology



Conference

PHIIEII


Abhott

mnrtnnt

cf

suclology



Plylnuth

Polytachnic

man


circa

Plymuth.

Devon


I

POLICHB


THE

FAMILY:


THE

CASE


G’

REAL“!


VISITIKI

This

presentation,

mich 1s


video-led,

is

based



on

the one

band


on

interviews

and

obaervation

research

on

the current practices

and discourse

ot

Health Visitors

mich

Anlaott


hgs

carried

out

in

tun health authotity

areas‚_arxi

on

the

on

a

readmg



of health

visitirlfs

histozy

und its


place

m

the



general

lustory of nnternnl

and


paediatric

surveillarlce in

Brjtain.


The vicbo

1s

oometrled chiefl y



with

current

practice,

and the



txxef

paperyhich



acoaupanies

it

draws



out the

historical

origins

of

c u r r e n t



attxttndes,

practioes

und


policy

limitatiotxs

frm a


perspective

influenced

by Fmcault

und by feninist

uork

on

health



provision.

Peter

Allen

a u c h ä v l o u

m a n c h mit

Gutmann


Haiming

‘m:


University

mnterbvxy

Kent.


C17

7 | !

(RIGIN


All)

BVQHPICN

G’ A PRIPBSSIGJ:

‘HE RESIETIAL

(‘ARG


IN

A

E G A L



PIAIDICAP

SERVICE

‘rhis

paper

descrllns

the setting

np

of



a

neu Service Iased

on

staffed



housa

Eor people



with

mental hamicaps

who have


reeently

nach


discharqed

Eran

a

l a r q e

ms

hospital.

‘Ehe Service arxd



the

ideology

hehind


the neu

System

of care are



b r i e fl y

described.

‘rwo

kinds of infomation are

than

presented

to

illuninate



the nechanisrs by

which


specifi c

intentions

are

translated

into social functions.

F i r s t l y, the setting-q:

process

is

analysed

in tems

of

the



ideological and mtivational chnracteristics

of

the personnel. Seoorxdly, operational



constraints

and

f a c i l i t i e s

are

ecanümd within



the new Organisation.

Sole

inplicatiotms

fot

the

future

are

discussed.



allen

Armndnle


um

Iuliml


snclology

mit


6

141mm:


Gardarns

Glasgow


G12

K!)


CHIC! A8

(‘ATCH


CAN:

PRACPICE


EMVIEXR

IN A


BIRTHIE

3711€


‘mis

paper explotes the vay

in Hhich


sets

of

relationships shape



nedical

practice.

Focussirxg

on a


birth

oenter

in

the

USA. I show

thgt


the

interaction of

patients,

their

siqnifi cant

others,


obstetricnags

and


midwives has

a

signifi cant and

Ear

reaching inpact

tpon


natermty

carve.


c r i t i c a l l y infonning the

uay

in

which decisions



are

nade


and

le-vel

of

control



that

patients


have

over


t h e i r

care.

1

addresg



the

tensxops


that

derive from d i f f e r e n t interests, how they are

dealt

wxth‚

lind


Ehen’

355€“


upon

patient care.

37


sara

Arber


Dwaruent 0E

scaciology



University

cf mrrey



Glildford

GU2


sxu

TRANSITIGS IN

CARIIG:

GEMTJR,

LIFE

CQJRSI’.


A M )

CARE


U’

THF}

ELEERLY


Feninist critiqms of

ocmmmity care are widely accepted

-

canmmity

rare


neans unpaid care by unter.

This

portrayal

w i l l be

exanirxed

using

t h e

1980


General

Household

Survey,

mich


contains

data

on

4,500 pecple



over

age

65.

A

unter

of

issms


w i l l

be

addres@:—



1.

A

one-uay



nodel

of

dependent elderly and indepeffient carer



neglects che

dynamic


and negotiated natura

oE

c a r e ,

which

often

involves

reciprocity and mutual

support.

2.

The

dynamic

of

the life course



is

neglected.

Reciprocity and

the

constraints of

care

vary

in different



types of

household

-

among


elderly

spouse

c a r e r s , e l d e r l y siblings,

single child carers



and

narried wonen

caring Eor

a

patent

or

patent-in-law.

3.

09er

a

t h i r d

of

carers



are man.

They have been



neglected nainly

because


men are

found


only

in


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