The world’s leading medical schools and journals officially recognize that what doctors and patients say to each other, and how they say it, dramatically affect the welfare of both patients and health-care organizations. Within the discipline of communication generally, and specifically within the sub-field of language and social interaction (LSI), the study of doctor–patient “talk” involves the study of all conductin-interaction between doctors and their patients. “Doctors” include all forms of formally institutionalized practitioners (e.g., medical doctor, acupuncturist), all specialties, and all levels of experience (e.g., residents). “Interaction” typically includes real-time, voiceto-voice or face-to-face encounters, including some mediated ones (e.g., telemedicine). Encounters in which participants are not immediately co-present (e.g., Internet-based forms of textual communication) are studied less frequently because participants do not labor under the standard affordances and norms of interaction. “Conduct” includes all forms of verbal and nonverbal (e.g., artifactual) communication.
Features Of An Lsi Approach
Doctor–patient talk is studied from a variety of LSI perspectives, including conversation analysis, discourse analysis, (socio)linguistics, and some types of ethnography. Although different perspectives are guided by different theories, methods, and proof-procedures, they are all primarily committed to describing and explaining the content, organization, and meaning of conduct-in-interaction. A second-order concern is with the effects of interactional variables on post-encounter outcomes, such as patients’ well-being and adherence to doctors’ medical recommendations.
The focus on conduct-in-interaction entails a commitment to the repeated analysis of (relatively) detailed transcripts of conduct. Patients’ self-reports of communicative events (e.g., from post-encounter surveys) do not correspond highly with their actuality. Although audio and video records can be repeatedly analyzed and coded without transcribing them, the process of transcription helps to ensure that consequential details are recorded that might otherwise not be given attention (e.g., silences, self-corrections, intonation). Furthermore, from an LSI perspective, interaction is the primary data, and transcription allows it to be presented in scholarly publications. Because LSI perspectives treat verbal and nonverbal communication as inseparable, there is a commitment to video-taping when relevant. Universities’ institutional review boards permit video-taping, and participation rates tend to be high even in “sensitive” medical contexts.
LSI research on doctor–patient talk does not focus on any conduct; rather, it focuses on conduct that is organized by participants’ orientations to aspects of the institution being examined, such as its norms, rules, functions, inferential frameworks, goals, tasks, roles, identities, etc. These “institutional” aspects include both professional and “lay” or vernacular conceptions, and thus can be different, and differentially relevant and consequential, for doctors and patients. Research attempts to discover what these aspects are for participants, how they come to be realized and managed in and through interaction, and what their interactional consequences are.
The abovementioned reference to “participants’ orientations” alludes to LSI’s commitment to inductive methods and grounded theorizing. Early research showed that social-structural predictions (e.g., roles) made from pre-existing theory and/or official medical ideology are not always valid during all types of doctor–patient talk (Emerson 1970). Furthermore, even when social-structural arrangements can be shown to be valid, they are not always simply reinforced by interaction; rather, they are frequently negotiated, contested, or otherwise modified in interaction according to the actions and activities that participants are pursuing at the moment. Thus, while recognizing that doctors and patients interact with reference to social structures that are exogenous to interaction (i.e., while recognizing the macro–micro link), LSI studies privilege meanings that are oriented to by participants during actual interaction. Of course, extant theories arising from wideranging disciplines, such as those dealing with information seeking and uncertainty reduction, have proven useful in explaining doctor–patient talk.
LSI scholars are similarly wary about (but not completely averse to) understanding doctor–patient talk through the lens of pre-formulated coding schemas. Code categories of the earliest schemas were established deductively from theories that were insensitive to the nuances of human communication (e.g., theories that conceptualized the function of communication as information transmission vs social action), and were originally designed for non-doctor–patient contexts (e.g., studies of small-group decision-making). Even as sensitivity increased, code categories continued to be operationalized in ways that conflated grammatical form with social action (e.g., coding for statements vs medical advice giving), and in ways that were insensitive to both the organization of interaction itself (e.g., unitizing in terms of the social-psychological notion of thought units vs the conversation-analytic notion of turn-constructional units) and sequential context (e.g., not differentiating between doctor-initiated and patient-sought advice). Additionally, code categories are frequently transformed into variables that are not relevant to participants (e.g., measuring category frequency per encounter). Finally, statistical requirements that categories represent single meanings produced by single speakers can run at odds with the fact that even the most basic units of interaction can be polysemic and interactively co-produced.
At least partially due to technological limitations, research in the 1960s was ethnographic. The primary focus was not interaction, per se, but rather how doctors’ behavior toward patients, as well as doctors’ understandings of patients’ behavior, were shaped by professional socialization, including both its official forms (e.g., medical school) and its unofficial forms acquired as doctors labor under a variety of implicit and explicit organizational pressures (Becker et al. 1961). Within the discipline of communication, there has been a dearth of ethnographic research that intersects with doctor–patient talk, and a lamentable disconnect between health-care ethnography and interaction analysis.
Asymmetries In Doctor–Patient Interaction
In the late 1970s through the 1980s, research was dominated by three interrelated themes dealing with asymmetries between doctors and patients. First, research examined the asymmetry of (largely medical) knowledge and understanding. Research focused on the interactional causes and manifestations of “miscommunication” (e.g., medical jargon), its resolutions (if any), and its consequences (for review, see West & Frankel 1991).
Second, research examined the structure of medical interaction itself and its underlying norms and rules (which, overlapping the first theme, included those pertaining to repairing problems of speaking, hearing, and understanding). Here, researchers were concerned with the asymmetry between doctors’ and patients’ levels of participation. Interaction was found to be restricted with respect to speaker identity and sequence structure, such that doctors predominantly initiated topics and sequences (e.g., doctors asked questions), and patients predominantly responded. Research examined the interactional mechanisms of this asymmetry, such as how doctors design turns in ways that normatively restrict patients’ answers (e.g., yes/no questions that are linguistically designed to prefer noanswers), and how patients (fail to) resist such pressures (for review, see Robinson 2001).
Third, overlapping with the second theme, research focused on the types of contributions doctors and patients made. Here, researchers were concerned with the asymmetry of, and conflict between, a variety of different types of doctors’ and patients’ interactional frames. For example, Mishler (1984) argued that doctors’ voice of medicine dominated patients’ voice of the life-world. Along these lines, a variety of researchers demonstrated that doctors, who largely controlled the flow of interaction, systematically restricted their contributions to biomedical topics, avoided psychosocial topics, interrupted or ignored patients’ psychosocial contributions, and omitted such contributions from medical records. Additionally, it was argued that doctors’ “voices”or frames are biased according to their (Caucasian, male, upper-middle-class) ideologies. Again, researchers examined the interactional mechanisms of frame asymmetry, its negotiation, and its consequences.
The Structure Of Medical Encounters
Although most of the abovementioned research was conducted from the perspective that communication is fundamentally produced and understood to accomplish social action(s), it primarily focuses on interactional structure (e.g., lexical choice, turn design, and sequence organization) and relatively broad characterizations of content (e.g., biomedical vs psychosocial). Based on this necessary groundwork, research in the 1990s focused more intently on medical actions and activities per se. It became increasingly clear that doctor–patient encounters have overall structural organizations, or normatively ordered and organized sets of medical activities. For example, in primary acute care, these activities are opening, problem presentation, information gathering (i.e., history taking and physical examination), diagnosis, treatment, and closing (Robinson 2003). Because medical activities are themselves distinct contexts that shape participants’ understandings, the nature and level of asymmetries of knowledge, participation, and frame differ, and are differentially consequential, in each activity. For over 15 years, research has been explicating the social organization of individual medical activities and their constitutive actions. For example, in a volume by Heritage and Maynard (2006), Anssi Perakyla addresses the activity of diagnosis, including different diagnostic formats (e.g., “You have bronchitis” vs “It seems like bronchitis”), how they embody aspects of doctors’ expertise and authority, how they attribute agency to patients, how their meanings are altered according to their sequential positioning, and how they shape patients’ responses. Complementing this, Douglas Maynard focuses on how diagnosis delivery is shaped according to the valence of the news for patients (i.e., good vs bad).
LSI research on doctor–patient talk is not, in principle, opposed to coding interaction into statistically manipulable variables and testing their association with each other or with post-encounter health outcomes. However, these moves proceed from basic, inductive research establishing that (at least interactional) variables are relevant to, and procedurally consequential for, participants. For example, Heritage and Robinson (2006) found that certain types of doctors’ opening questions are associated with patients responding with an increased number of discrete symptoms, and Robinson and Heritage (2006) found that these same questions are associated with patients’ post-visit satisfaction.
LSI research on doctor–patient talk opens and illuminates the communicative black box of pure survey research. One major consequence is that LSI research promotes efficacious behavioral interventions. For example, survey research indicates that pediatricians’ perceptions that parents desire antibiotics (for their sick children) is a primary predictor of doctors’ inappropriate prescription of antibiotics (e.g., for viral conditions). Until recently, it was unknown exactly how such perceptions were formed during encounters. Stivers (2006) has since discovered a variety of parents’ communication strategies that promote such perceptions, as well as doctors’ strategies for combating parents’ pressure to prescribe.
- Becker, H. S., Geer, B., Hughes, E. C., & Strauss, A. L. (1961). Boys in white: Student culture in medical school. Chicago, IL: University of Chicago Press.
- Emerson, J. P. (1970). Behavior in private places: Sustaining definitions of reality in the gynecological examination. Recent Sociology, 2, 74 – 97.
- Heritage, J., & Maynard, D. (2006). Communication in medical care: Interactions between primary care physicians and patients. Cambridge: Cambridge University Press.
- Heritage, J., & Robinson, J. D. (2006). The structure of patients’ presenting concerns 1: Physicians’ opening questions. Health Communication, 19, 89–102.
- Mishler, E. G. (1984). The discourse of medicine: Dialectics of medical interviews. Norwood, NJ:
- Robinson, J. D. (2001). Asymmetry in action: Sequential resources in the negotiation of a prescription request. Text, 21, 19–54.
- Robinson, J. D. (2003). An interactional structure of medical activities during acute visits and its implications for patients’ participation. Health Communication, 15, 27–59.
- Robinson, J. D., & Heritage, J. (2006). Physicians’ opening questions and patients’ satisfaction. Patient Education and Counseling, 60, 279–285.
- Stivers, T. (2006). Prescribing under pressure: Parents, physicians and antibiotics. Oxford: Oxford University Press.
- West, C., & Frankel, R. M. (1991). Miscommunication in medicine. In N. Coupland, H. Giles, & J. M. Wiemann (eds.), Miscommunication and problematic talk. Newbury Park, CA: Sage, pp. 166 –194.