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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,

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

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IN A

BIRTHIE

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‘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

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CARE

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Feninist critiqms of

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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