Communication in medical care: Interaction between primary care physicians and patients
Edited by: J. Heritage & D. W. Maynard
Cambridge University Press
2006
Pp. vii + 484
ISBN-13 978-0-521-62123-6 (hbk)
ISBN-13 978-0-521-62899-0 (pbk)

Reviewed by: Roxana Delbene

This book is a collection of 14 chapters which address the issue of conversations between patients and their primary care physicians during acute and follow up visits. The data collected in the United States, England, and Finland, include actual tape and video-recording interviews.

Chapter 1. Introduction: Analyzing interaction between doctors and patients in primary care encounters. This chapter presents an overview of the foundational approaches in doctor-patient interaction. One of these approaches is process analysis and the other, microanalysis. Additionally, there is an excellent summary of the methodological principles embraced by Conversation Analysis (CA). The authors describe generic practices of talk-in-interaction in the medical setting and combine it with a granular analysis of interaction. The result is that these theoretical and methodological approaches enable them to focus on aspects of the medical visit with new eyes. For example, they describe the association between interactional variables and medical decision-making; i.e., how physicians’ decisions are particularly affected by the patients’ interactive preferences for orientation for treatment. In conclusion, from a sociological and interactive perspective, this volume presents a cooperative articulation of the medical visit as a real-time interactive product. Cooperativeness is not exempt, however, from levels of conflict, authority, and subordination.

Chapter 2. Soliciting patients’ presenting concerns. Robinson analyzes physicians’ question formats to elicit patients’ concerns. Three types of question formats are identified (What can I do for you? How are you feeling? and What’s new?) as suiting three types of patients’ reasons to visit the doctor’s office respectively. Robinson shows how subtle differences in physicians’ questions design as well as their failures in identifying the patients’ institutionalized reasons to visit their doctors, have an impact on patients’ responses and can subtly change the course of action that those questions perform.

Chapter 3. Accounting for the visit: giving reasons for seeking medical care. Heritage and Robinson analyze patients’ formats to describe their medical problems to their physicians as “doctorable.” These formats are shaped as an enumeration of symptoms or as a chronological narrative of the illness. When patients’ arguments are at stake for doctorability, the following verbal pattern arises: (1) making diagnostic claims, (2) invoking third parties, and (3) making “troubles-resistant” claims. These arguments show that patients have endured the condition for a while and attempted self-cure before seeking medical assistance. The authors explain the patients’ behavior as motivated by “trouble resistance” (Jefferson, 1988).

Chapter 4. Realizing the illness: patients’ narratives of symptom discovery. Following Sacks, Halkowski analyzes the relevance of the location of the patients’ narratives of illness-discovery and how patients portray themselves by making those narratives. As a pattern, the author finds that the patients tend to normalize their conditions by means of two patterns observed in patients’ narratives of illness-discovery: the structure “At first I thought X” and a “sequence of noticings.” In this manner, patients tend to portray themselves as rational.

Chapter 5. Explaining illness; patients’ proposals and physicians’ responses. Gill and Maynard explore the interactive structure of patients’ “lay” explanations about their possible illnesses and their doctors’ responses to these explanations. In the analysis, the authors also examine the location occupied by the explanations in the sequence of the narrative. This analysis is expected to reveal the communicative actions realized by the patients. The authors observe that patients are rather sensitive to orient their explanations in sequential ways. By so doing, patients secure that they will not disrupt physicians during the phase of the collection of medical information.

Chapter 6. Taking the history: questioning during comprehensive history-taking. Boyd and Heritage examine the phase of history-taking. The authors focus on two types of questions used to elicit the patients’ histories. (a) Optimization, in which questions are oriented to a maximum outcome by means of the use of “negative polarity” and (b) Recipient design. This chapter shows that while physicians’ questions are oriented to get patients’ alignments, patients manage to propose their own alternative agendas instead by challenging physicians’ presuppositions, especially when presuppositions involve patients’ life styles.

Chapter 7. Body work: the collaborative production of the clinical object. Heath analyzes from a semiotic viewpoint the patients’ collaborative display of their bodies as objects of medical inquiry. The study examines the potential for interactive conflict given the disruption that may take place between the patients’ descriptions of their symptoms and their bodies as a source of empirical confirmation.

Chapter 8. Communicating and responding to diagnosis. Peräkylä analyzes the phase in which physicians deliver their diagnoses. An important finding is the strategy called “turn design” which has shown to be very effective when communicating uncertain diagnoses to patients. By means of “turn design” physicians explain to their patients the evidence of their reasoning in order to deliver the diagnosis.

Chapter 9. On diagnostic rationality: bad news, good news, and the symptom residue. Maynard and Frankel discuss the asymmetry observed in the delivery of bad versus good news in medical consultations. While the delivery of good news enhances affiliation between doctors and patients, bad news triggers disaffiliation. Because bad news indicates propensity for emotional loss of control on the part of patients, this type of “response cries” (Goffman, 1978) encourages restraint on the part of physicians. The chapter analyzes the dilemma that doctors face when having to bring patients to the rational side of the bad diagnosis, and gently invites physicians to be able to sympathize with the irrational side of the patient.

Chapter 10. Treatment decisions: negotiations between doctors and parents in acute care encounters. Stivers analyzes patterns of delivering treatment recommendations and parents’/patients’ responses to them. The study confirms that both physicians and parents/patients display an orientation to parent acceptance of the treatment. By default, when parents do not act by showing acceptance, this behavior is problematic for physicians since it is seen as resistance. Stivers observes that physicians’ recommendations formulated as “against treatment” e.g., “antibiotics are not recommended,” recommendations that are unspecific, as well as recommendations that minimize the child’s treatment, tend to trigger patients’ resistance in their interaction with the doctor.

Chapter 11. Prescriptions and prescribing: coordinating talk- and text-based activities. Greatbatch identifies the potential for interactive conflict between the competing demands of interacting with patients and writing, at the same time, prescriptions on a computer. The author describes patients’ and physicians’ verbal, gaze and proxemic strategies to be able to synchronize their prescription-related talk with their computer-related actions.

Chapter 12. Lifestyle discussions in medical interviews. Sorjonen, Raevaara, Haakana, Tammi, and Peräkylä analyze the location and orientation of lifestyle discussions (involving drinking, diet, smoking, exercise). The authors compare the corpus of interviews collected in Finland with their results of the studies done in the United States. While the authors observe differences between physicians’ styles in giving advice to their patients in these two countries they have found common patterns of interaction. One of these patterns is the location of the doctor’s advice (or question about lifestyle). When the advice is performed subsequently to a formulation of a medical problem, the medical problem is likely to be interpreted as more serious and “motivated” than a question that is asked as a part of a larger segment of history-taking and away from any formulation of a medical problem.

Chapter 13. Coordinating closing in primary care visits: producing continuity of care. In this chapter, West analyzes closing phases in primary care visits by comparing the patterns found in closing phases in the United States with those in the United Kingdom. In the United States closing is characterized, first of all, by physicians departing from their patients’ presence (in the doctors’ examining rooms) and, secondly, by patients and doctors ensuring continuity of contact or producing “continuity of care.” According to West, this way of closing which looks for continuity is compensatory to the health care-system crisis in the United States, in which millions are not medically insured.

Chapter 14. Misalignments in “after-hours” calls to a British GP’s practice: a study in telephone medicine. Drew studies “after-hours” telephone calls made to a British GP’s practice, and the physicians’ decision making: to visit the caller/patient at home or to manage the caller’s needs over the phone. Drew reports a patients’ pattern characterized by “misalignments,” which show that the callers tend to intensify the severity of the symptoms in order to get the physician to pay a home visit.

Evaluation: This is a ground-breaking collection. It confirms the essential place that the study of conversational interaction has in the behavioral social sciences. Another salient merit is that this book shifts the paradigm from the perspective of doctor-centered, doctor-authority, and asymmetry in institutional settings to emphasize patients’ agency and the notion that interaction is rather a joint activity coordinated by both parties in interaction. All the chapters are methodologically sustained with a significant amount of data. Additionally, the conversational patterns found in the studies ratify CA principle that “the organization of interaction is fundamentally geared to the joint management of self-other relations” (p.13). However, the reader may wonder how joint management in medical consultations is realized in occasions in which patients are not motivated by “trouble resistance,” do not try to be rational, nor do they try to normalize their illness hypotheses as well as in other possible scenarios of deviance from cooperation. This problem was partially addressed in the collection. Finally, this book is an essential reference for practitioners and medical educators.