'Alternative' Medical Interview

My second sample is designed to address such issues of change in medical practice. It is also a medical interview, though of a radically different sort. Short pauses are marked with full stops;

longer pauses with dashes; square brackets show overlap; and unclear material is in round brackets.

145

but she hasbeenvery unfairtome . got

respect for me at

[all

^{and Ithink.}that's one of thereasons hm

why I drank

5[0

much you [know - a[nd em

hm hm hm hm are you

you back are you back on it have you started drinking [again

no

oh you haven't (uncle[ar ..• )

no . but em one thing that the lady on the Tuesday said to me was that. ifmymother did turn me out of the [house which she thinks she

hm may do .CDZ •she doesn't like the way she has turned me o[ut befo[re . and em . she said that.

hm hm

Icould she thought that it might be possible to me for me to go to a council [flat

right [yeah but she

said it's a very em she wasn't [pushingitbecause. my hm

mother's got to sign a whole of and e: . she said difficult [and em . there's no rush over

hm

it . I I don't know whether. I mean one thing they say in AAis that you shouldn't change anything. for a year

hm

hm yesI think I think that's wise. I think that's wise (5 second pause) well look I'd like to keepyouknow seeing you keep. you know hearing how things are going from time to time if that's possible

Text Analysis: Constructing Social Relations

PATIENT:

The doctor in this case belongs to a minority group within the British National Health Service which is open to 'alternative' (such as homeopathic) medicine, and treatment of the 'whole person', which accords weU with the use of counselling tech-niques. This sample lacks the overt structures of doctor control of sample 1, as well the manifest discrepancy and conflict of different voices.

The most striking difference between the two samples in terms of interactional control features is that the question-response-assessment cycle is missing from sample 2, which is structured Text Analysis: Constructing Social Relations

drinking make it worse?'), L interrupts M in I. 29 ('Enough to make me go to sleep') and vice-versa inI.31('One or two drinks a day?'), L interrupts M in I. 42 ('Since I've been married') and vice-versa in 44 ('How long is that?'). The patient continues the turn initiated in I. 45 with a lengthy account of why she needs a1chohol, and why she uses a1chohol rather than just pills, which is again followed by an M question ('How often do you them?', i.e. the pills) from the doctor. In this part of the inter..

view, M and L are in contestation. The doctor repeatedly uses control of questions to reassert M. Nevertheless, the repeated incursions of L appearto disturb the doctor's agenda: notice hesitations which begin to appear before the doctor's questions (ll. 23-4, 27, 37, 41, and 44). Whereas the doctor rarely upon L, the patient uses M extensively, and is far more dating to the doctor in that sense than vice-versa. The evidently contrast in their content: M embodies a technological rationality which treats illness in terms of context-free clusters of physical symptoms, whereas L embodies a 'common sense' rationality which places illness in the context of other aspects of the patient's life. Mishler points out(1984: 122)that the contrast seems to correspond to the distinction made by Schutz (1962) between the 'scientific attitude' and the 'natural attitude'.

Both analysis in terms of the doctor's control of the interac-tion, and analysis in terms of a dialectic of voices, are ways of gaining insight into standard medical practice at a micro-analytical level, and into medicine as a mode of professionalism;

However, medicine like other professions is undergoing rather dramatic changes in contemporary society. Perhaps what course analysis can contribute most is a means of investigating what these changes amount to 'on the ground', in the ways in which doctors and patients really interact.

144

Text Analysis: Constructing Social Relations 147

does so, however, with a reticence which is uncharacteristic ftraditional medical practice and traditional doctor-patient rela-which brings us to modality, politeness and ethos. The sessment inI.29 has an explicit 'subjective' modality marker ('I k'), which makes it clear that the assessment is just the doe-opinion, and tones down its authoritativeness (see the sec-on modality below): 'that's wise' sec-on its own would imply on the doctor's part to implicit, and mystified, sources of fessional judgement. The one question is, as I have already inted out, produced as an aside, and it consists of a vague and initial formulation ('are you you back are you back on followed by a more explicit formulation ('have you started These features of the question minimize its face-reatening potential and in that sense heighten its politeness. The IJggestion of further interviews is also polite in that sense. It is ery indirect: presumably the doctor is asking the patient to make rther appointments, but what he actually says, tentatively ('I'd . e... if that's possible'), is that he wants to see her again. He so formulates the purpose of further interviews as if they were cial visits ('to see how things are going'). And he hedges his ggestion twice with 'you know' and hesitates ('keep. you know earing'), again giving a of disfluency.

These comments can be linked to the notion of ethos. Whereas in sample 1, the doctor's style of speaking accords with a scien-ethos, in this sample the doctor's reticence, tentativeness, and apparent disfluency accord with a lifeworld ethos: doctors in this of medical interview appear to be rejecting the elitism, for-ality, and distance of the medical scientist figure in favour of a (frequently simulated) 'nice', 'ordinary' person, a 'good listener'.

This accords with general shifts is dominant cultural values in our society, which devalue professional elitism and set a high value of informality, naturalness, and normalness.

Sample 2 also differs from sample 1in terms of its intertextual-There is nothing analogous to the dialectic of the voices of medicine and the lifeworld that I noted in the latter. Rather, the doctor appears himself to be drawing upon the voice of the lifeworld for example, in portraying future interviews in terms of 'hearing how things are going' and endorsing the patient's recourse to it by giving her space to give her account in her own words, and encouraging her with extensive feedback.

Nevertheless, the doctor does exercise control, even if in an Text Analysis: Constructing Social Relations

around a lengthy account by the patient, with the doctor great deal of feedback in the form of minimum response ('hm', 'no', 'yes', 'right'), asking a question which is linked to the patient's account (11.6-7), giving an assessment of the patient's answers to questions, as in sample I, course of action recommended by a third party (I. 29), suggesting a further interview

Turn-taking is collaboratively managed rather than being metrically controlled by the doctor. There is evidence negotiated nature of turn distribution in the doctor's 6-7), which is articulated rapidly and quietly as an aside, the doctor's sensitivity to the way he is 'intruding' patient's 'floor'. The question is so treated by the patient, answers it briefly, then immediately resumes her account.

evidence is the long pause by the doctor in I.30 after his assess-' ment, which appears to be making the 'floor' available

the patient to continue her account if she wishes to, before the doctor moves towards terminating the interview.

Control over the introduction and change of topics, that exercized mainly by the doctor in sample I, is here exercized the patient. The mode of topical development is that of conversa-tion and of the 'lifeworld': the patient is 'talking topically' with out to a single topic, but shifting across a series of interconnected topics her mother's unfairness, her drinking, possible alternatives to living with her mother, and so forth.

so doing, she is elaborating in ways which are quite relevant by conversational standards but probably not medically relevant from the perspective of conventional medicine. Throughout, doctor's attentive feedback implies acceptance of this conversa-tional mode of topical development.

Yet one cannot simply conclude that the doctor is surrendering interactional control to the patient. Notice that the initiative yielding a measure of control to the patient in medical interviews of this sort invariably comes from the doctor, which suggests doctors do still exercise control at some level, even if in the paradoxical form of ceding control. In fact, however, there ..

main manifest control features even here: the fact that the doctor does ask the medically important question about the patient's drinking, does offer an assessment, and does control the initiation and termination of the interview (not evident from this sample) and future action.

146

149

oh gosh yeh

colorado beetle

oh good grief mm and rabies er an

er-rabies

yeh cos ifan animal that has rabies spits on the io anyway

plants

really illegal. plants oh yes

Silvie'd got some plants under the seat which were illegal to bring

Sample 3: Conversational Narrative Text Analysis: Constructing Social Relations

ality towards informality, and so forth. Change is not oth, however. For one thing, there are divergent and contra-tllry tendencies at work. Secondly, tendencies in cultural ge can harmonize with tendencies at other levels, or come conflict with them. For example, transformation of medical cice in the direction of sample 2 is economically costly. A tor can 'process' patients far more 'efficiently' and speedily a pre-set routine like that of sample 1, than with tech-lies which give patients the time they feel they need to talk.

ere are currently in Britain and elsewhere huge pressures on and other professionals to increase their 'efficiency', and pressures conflict with dominant tendencies at the cultural (For further discussion of contemporary tendencies in

dis-change see chapter 7 below.)

e third sample illustrates a further dimension of intertextualiry, is an extract from an account by a married couple to another ouple of a close encounter with Customs and Excise on return-g from a holiday abroad. The transcription is orreturn-ganized in ur-line 'staves', with a line ·for each participant; after the first, include lines only for participants who speak. Overlap is as simultaneous speech on two or more lines; pauses are as full stops; an equals sign shows one utterance following immediately on from another; and capital letters show loud speech.

Text Analysis: Constructing Social Relations uncharacteristic manner. We can see this fact in terms of cursiviry (constitutive intertextuality), by postulating a ence of standard medical interview genre with other genres that some of the interactional control features of the maintained, but realized in an indirect and mitigated form the influence of the latter. The acts themselves emanate genre, their realizations from others. What are these other I have referred already to conversation, but conversation is here as a constitutive element of another genre, counselling primary interdiscursive relation in this type of medical seems to be between standard medical interview genre and eo selling, or what ten Have (1989; see also Jefferson and Lee in an analysis along the same lines, calls 'therapy talk'.

ling emphasizes giving patients (or clients) the space empathizing with their accounts (with the counsellor echoing them or formulating them in the voice of the patient) and being non-directive. The search for models for

has not surprisingly led outside institutional discourse to

sational discourse, where such values (manifest here in the doe-tor's reticence and mitigation) widely realized, for instance the lifeworld figure of the 'good listener'.

Different varieties of medical interview do not simply they enter into relations of contestation and struggle, as a of the more general struggle over the nature of medical

Medical interviews like sample 2 are transparently linkedjc values such as treating the patient as a person rather justa case, encouraging the patient to take some responsibility for ment, and so forth. In struggles between varieties of medical interview, it is boundaries within orders of discourse, such as boundary between counselling and medical interview, and interdiscursive articulation of elements within orders of discourse, that are at issue.

The primary direction of change within contemporary medi-cine would seem to be towards interviews .which are more like sample 2. This is a particular manifestation of shifts in cultural values and social relations that I have already referred to - shifts in the construction of the 'medical self' away from overt author-ity and expertise, shifts in power away from the producers of goods and services towards the consumers or clients, away from 148

Text Analysis: Constructing Social Relations 151

In

the penultimate stave, Hl asks Wl to stop interrupting him.

hether one regards what Wt is doing during the account as Hl ' depends upon one's assumptions about the pre-ise nature of the activity here. There are various 'sub-genres' of or story-telling, and one important way in which they iffer is in whether they have single or multiple narrators. Jointly narratives on the part of two or even more persons hose story it is' are not uncommon in conversational story-lling. Perhaps in this case Hl is working on the assumption that is producing a single-narrator story, whereas Wl (as well as ) assumes that they are jointly producing a story, though she see her own role as a 'supporting' one. Wt and H2 also to be working on the model of an interactively produced iory, in the additional sense of a story produced partly through ialogue between narrators and audience. This situation of diffe-ent participants working to differdiffe-ent generic models can be seen another mode of intertextuality, rather like the situation of 1 where the different participants are oriented to different (recall the differentiation of modes of intertextuality at the beginning of chapter 4 above).

The two sub-genres of narrative I am postulating will; of ourse, differ in their systems for turn-taking and topic control.

story-telling 'ascribes rights to the 'floor' for the duration of the story to the one narrator, which implies that other participants have no right to take substantive turns, though they will still be expected to give feedback in the form of minimal responses, and therefore no rights to control topic. The jointly-produced story, however, implies a shared floor, shared rights in turn-taking and topic introduction and shift. Ht's attempt to 'police' his right to the floor comes across as heavy-handed because of its insensitivity to the orientation of Wt and H2 to jointly-developed narrative.

To what extent is the issue of gender relevant here? The fact H2 shares with Wt an orientation to jointly-produced narra-tive is itself evidence against any straightforward equation of the latter with women speakers, and single-narrator genre with male speakers, even if that were not implausible on other grounds.

Nevertheless, this sample does approximate to what my experi-ence tells me is a widespread pattern in story-telling by married

go' a couple of packets of Gitanes which I'd been smoking mvselfe over but one pack I WISH STOP INTERllUprin

=yeh but they were open

me there'sone packet which er was unopened.(tapecontinues) hmhm

well- . no that was within the limit. butIforgot. that I'd also no

that-Martin, and Mary of course yknow heh and

er-heh was that over as they're cheaper over there than it's like when you buy watches

. a bought er . a pack of 250 grams of tobacco yknow . for you combinedbirthdayand christmas present

no combined binhday

would have stretching its cred credulity somewhat I'd mm

good leaves lying on the floor some other animal could catchit

and er . Silvie"s

and that also ought to have been declared =

.why=

christmas present

importduty onit.erm so w we gotgotquite a lot of gear mm bought me this telescope for a . birthday present yeh well was

ohyeh

optical instruments you've got to declareitbecause you good grief

grief

so heh heh plants are really out heh heh heh

allsmall but cu cumulative and my air of innocence

mm yeheh

Text Analysis: Constructing Social Relations

HI:

In document Fairclough 1992 Discourse and Social Change (Page 77-81)