Keeping the gate ajar during openings of general practice consultations
Issue: Vol 8 No. 3 (2011)
Journal: Communication & Medicine
Subject Areas: Healthcare Communication Linguistics
DOI: 10.1558/cam.v8i3.235
Abstract:
A deferral of stance during the openings of general practice consultations is discussed in this paper as a possible systematic and important device for accomplishing gate keeping. The paper draws upon video recordings of naturally occurring consultations in Denmark. It is found that doctors defer their explicit stances when patients engage in a visit by requesting a specific clinical service (a prescription, a further test, a referral or a sick note etc). Instead of assuming a stance, doctors begin to ask the patients a series of questions, whilst withholding their ‘yes’ or ‘no’ throughout relatively long periods of time.
Author: Søren Beck Nielsen
References :
Beach, W. A. (1995). Preserving and constraining options: ‘Okays’ and ‘official’ priorities in medical interviews. In G. H. Morris and R. J. Cheneil (eds) The Talk of the Clinic: Explorations in the Analysis of Medical and Therapeutic Discourse 259–289. Hillsdale, NJ: Lawrence Erlbaum.
Bell, R. A., Wilkes, M. S. and Kravitz, R. L. (1999). Advertisement-induced prescription drug requests patients’ anticipated reactions to a physician who refuses. Journal of Family Practice 48 (9): 446–452.
Boyd, E. and Heritage, J. (2006). Taking the patient’s medical history: Questioning during comprehensive history taking. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interactions between Primary Care Physicians and Patients 151–184. Cambridge: Cambridge University Press.
Byrne, P. S. and Long, B. E. L. (1976). Doctors Talking to Patients: A Study of the Verbal Behaviours of Doctors in the Consultation. London: HMSO.
Charles, C., Gafni, A. and Whelan, T. (1997). Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango). Social Science & Medicine 44 (5): 681–692. http://dx.doi.org/10.1016/S0277-9536(96)00221-3
Chatwin, J. (2006). Patient narratives: A micro-interactional analysis. Communication & Medicine 3 (2): 113–123. http://dx.doi.org/10.1515/CAM.2006.014
Davidson, J. (1984). Subsequent versions of invitations, offers, requests, and proposals dealing with potential or actual rejection. In J. M. Atkinson and J. Heritage (eds) Structures of Social Action. Studies in Conversation Analysis 102–128. Cambridge, UK: Cambridge University Press.
Easter, D. E. and Beach, W. A. (2004). Competent patient care is dependent upon attending to empathic opportunities presented during interview sessions. Current Surgery 61 (3): 313–318. http://dx.doi.org/10.1016/j.cursur.2003.12.006
Frankel, R. M. (2001). Clinical care and conversational contingencies: The role of patients' self-diagnosis in medical encounters. Text 21 (1/2): 83–111. http://dx.doi.org/10.1515/text.1.21.1-2.83
Gafaranga, J. and Britten, N. (2005). Talking an institution into being: The opening sequence in general practice consultations. In K. Richards and P. Seedhouse (eds) Applying Conversation Analysis 75–90. Basingstoke: Palgrave Macmillan.
Gallagher, T. H., Lo, B., Chesney, M. and Christensen, K. (1997). How do physicians respond to patients’ requests for costly, unindicated services? Journal of General Internal Medicine 12 (11): 663–668. http://dx.doi.org/10.1046/j.1525-1497.1997.07137.x
Gill, V. T. (2005). Patient ‘demand’ for medical interventions: Exerting pressure for an offer in a primary care clinic visit. Research on Language and Social Interaction 38 (4): 451–479. http://dx.doi.org/10.1207/s15327973rlsi3804_3
Gill, V. T., Halkowski, T. and Roberts, F. (2001). Accomplishing a request without making one: A single case analysis of a primary care visit. Text 21 (1/2): 55–81. http://dx.doi.org/10.1515/text.1.21.1-2.55
Gill, V. T. and Maynard, D. W. (2006). Explaining illness: Patients’ proposals and physicians responses. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interactions between Primary Care Physicians and Patients 115–150. Cambridge: Cambridge University Press.
Glenn, P. (2003). Laughter in Interaction. Cambridge: Cambridge University Press. http://dx.doi.org/10.1017/CBO9780511519888
Goffman, E. (1972). Relations in Public. New York: Harper & Row.
Heath, C. (1992a). The delivery and reception of diagnosis in the general-practice consultation. In P. Drew and J. Heritage (eds) Talk at Work. Interaction in Institutional Settings 235–267. Cambridge: Cambridge University Press.
Heath, C. (1992b). Gesture’s discreet tasks: Multiple relevancies in visual conduct and the contextualization of language. In P. Auer and A. D. Luzio (eds) The Contextualization of Language 101–127. Amsterdam: John Benjamins Publishing Company.
Heinemann, T. (2006). ‘Will you or can’t you?’: Displaying entitlement in interrogative requests. Journal of Pragmatics 38 (7): 1081–1104. http://dx.doi.org/10.1016/j.pragma.2005.09.013
Heritage, J. (1984). Garfinkel and Ethnomethodology. Cambridge, UK: Polity Press.
Heritage, J. and Maynard D. W. (2006). Introduction: Analyzing interaction between doctors and patients in primary care encounters. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interactions between Primary Care Physicians and Patients 1–21. Cambridge: Cambridge University Press.
Heritage, J. and Robinson, J. (2006). Accounting for the visit: Giving reasons for seeking medical care. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interactions between Primary Care Physicians and Patients 48–85. Cambridge: Cambridge University Press.
Jefferson, G. (1972). Side sequences. In D. Sudnow (ed.) Studies in Social Interaction 294–338. New York: The Free Press.
Jefferson, G. (1984). On stepwise transition from talk about a trouble to inappropriately next-positioned matters. In J. M. Atkinson and J. Heritage (eds) Structures of Social Action. Studies in Conversation Analysis 191–222. Cambridge: Cambridge University Press.
Jones, C. M. (2001). Missing assessments: Lay and professional orientations in medical interviews. Text 21 (1/2): 113–150. http://dx.doi.org/10.1515/text.1.21.1-2.113
Kravitz, R. L., Bell, R. A., Azari, R., Kelly-Reif, S., Krupat, E. and Thom, D. H. (2003). Direct observation of requests for clinical services in office practice. What do patients want and do they get it? Archives of Internal Medicine 163 (14): 1673–1681. http://dx.doi.org/10.1001/archinte.163.14.1673
Lewin, K. (1947). Frontiers in group dynamics. Human Relations 1 (2): 143–153. http://dx.doi.org/10.1177/001872674700100201
Lindström, A. (1997). Designing Social Actions: Grammar, Prosody and Interaction in Swedish Conversation. Unpublished PhD dissertation, University of California, Los Angeles.
Maynard, D. W. (2003). Bad News Good News: Conversational Order in Everyday Talk and Clinical Settings. Chicago: University of Chicago Press.
Merrit, M. (1976). On questions following questions in service encounters. Language in Society 5 (3): 315–357. http://dx.doi.org/10.1017/S0047404500007168
Mishler, E. G. (1984). The Discourse of Medicine. Dialectics of Medical Interviews. Norwood, New Jersey: Ablex Publishing Corporation.
Paris, J. J., Crone, R. K. and Reardon, F. (1990). Physicians’ refusal of requested treatment. The case of baby L. New England Journal of Medicine 322 (14): 1012–1014. http://dx.doi.org/10.1056/NEJM199004053221420
Paterniti, D. A., Fancher, T. L., Cipri, C. S., Timmermans, S., Heritage, J. and Kravitz, R. L. (2010). Getting to ‘no’. Strategies primary care physicians use to deny patient requests. Archives of Internal Medicine 170 (4): 381–388. http://dx.doi.org/10.1001/archinternmed.2009.533
Peräkylä, A. (2002). Agency and authority: Extended responses to diagnostic statements in primary care encounters. Research on Language and Social Interaction 35 (2): 219–247. http://dx.doi.org/10.1207/S15327973RLSI3502_5
Pomerantz, A. (1980). Telling my side: ‘limited access’ as a ‘fishing’ device. Sociological Inquiry 50 (3-4): 186–198. http://dx.doi.org/10.1111/j.1475-682X.1980.tb00020.x
Pomerantz, A. (1988). Offering a candidate answer: An information seeking strategy. Communication Monographs 55 (4): 360–373. http://dx.doi.org/10.1080/03637758809376177
Potter, S. J. and McKinlay, J. B. (2005). From a relationship to encounter: An examination of longitudinal and lateral dimensions in the doctor-patient relationship. Social Science & Medicine 61 (2): 465–479. http://dx.doi.org/10.1016/j.socscimed.2004.11.067
Robinson, J. D. (2001). Asymmetry in action: Sequential resources in the negotiation of a prescription request. Text 21 (1/2): 19–54. http://dx.doi.org/10.1515/text.1.21.1-2.19
Robinson, J. D. (2003). An interactional structure of medical activities during acute visits and its implications for patients’ participation. Health Communication 15 (1): 27–59. http://dx.doi.org/10.1207/S15327027HC1501_2
Robinson, J. (2006). Soliciting patients’ presenting concerns. In J. Heritage and D. W. Maynard (eds) Communication in Medical Care: Interactions between Primary Care Physicians and Patients 22–47. Cambridge: Cambridge University Press.
Robinson, J. D. and Heritage, J. (2005). The Structure of Patients’ Presenting Concerns: The Completion Relevance of Current Symptoms. Social Science and Medicine 61 (2): 481–493. http://dx.doi.org/10.1016/j.socscimed.2004.12.004
Sacks, H. (1992). Lectures on Conversation. Oxford: Blackwell.
Sarangi, S. (2001). Editorial. On demarcating the space between ‘lay expertise’ and ‘expert laity’. Text 21 (1/2): 3–11. http://dx.doi.org/10.1515/text.1.21.1-2.3
Schegloff, E. A. (2007). Sequence Organization in Interaction. A Primer in Conversation Analysis. Cambridge: Cambridge University Press. http://dx.doi.org/10.1017/CBO9780511791208
Stivers, T. (2002a). ‘Symptoms only’ and ‘candidate diagnoses’: Presenting the problem in pediatric encounters. Health Communication 14 (3): 299–338. http://dx.doi.org/10.1207/S15327027HC1403_2
Stivers, T. (2002b). Participating in decisions about treatment: Overt parent pressure for antibiotic medication in pediatric encounters. Social Science & Medicine 54 (7): 1111–1130. http://dx.doi.org/10.1016/S0277-9536(01)00085-5
Stivers, T. (2007). Prescribing under Pressure: Parent-Physician Conversations and Antibiotics. Oxford: Oxford University Press.
Stivers, T. (2008). Stance, alignment, and affiliation during storytelling: When nodding is a token of affiliation. Research on Language & Social Interaction 41 (1): 31–57. http://dx.doi.org/10.1080/08351810701691123
Stivers, T. and Heritage, J. (2001). Breaking the sequential mould: Narrative and other methods of answering ‘more than the question’ during medical history taking. Text 21 (1/2): 151–185. http://dx.doi.org/10.1515/text.1.21.1-2.151
Swiryn, S. (1986). The doctor as gatekeeper. Archives of Internal Medicine 146 (9): 1789. http://dx.doi.org/10.1001/archinte.1986.00360210177025