Framing medical discourse

The idea that the doctor’s consultation is ‘framed’, and that everyday discourse is transformed through this framing, is implicitly recognised as demonstrated in this stand-up routine by comedian Andy Zaltzman1:

Extract 3.1

AZ: So, hello, how are you all?

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Audience: [whoops and cries of „yeah‟]

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AZ: I hope you‟re more specific than that when you go to see the doctor.

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Audience: [laughter]

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The joke works because the audience are aware that the question ‘how are you?’ carries different expectations of response when framed as part of a comedy performance than when framed as part of a medical setting. This awareness is sufficiently widespread to work on an international audience and be generally understood.

1

Extract of comedy performance in Trondheim, May 2013, featured on The Bugle podcast, 31st May, 2013 - http://thebuglepodcast.com/bonus-bugle-andy-in-norway/

Goffman himself used a wide array of examples from medical settings, including psychiatric settings, to demonstrate his argument. Despite this, framing has rarely been discussed explicitly in studies of doctor-patient interaction. In Chapter Two, I provided an overview of some key research findings from previous studies of medical interaction. These studies have focused on different aspects of medical discourse, often in a way that nods to the concept of framing. Despite this, and perhaps because studies tend to focus on one aspect of the discourse at a time, few explicitly apply the concept of frame, though similar concepts can be seen in Mishler’s work on ‘voices’, defined as “relationships between talk and speakers’ underlying frameworks of meaning” (Mishler, 1984: 14) and Wodak’s ‘disorder of discourse’, described as ‘frame conflict’, in which “worlds of knowledge and interests collide with one another” (Wodak, 1996: 2).

There are however, a few studies of medical discourse that explicitly apply Goffman’s models of interaction and framing (Ainsworth-Vaughn, 2003). In the next section I give a brief review of some of the key studies using frame analysis to explore medical discourse.

3.5.1 Institutional discourse

Much frame analysis work has focused on institutional settings of various sorts, ranging from Hutchby’s analysis of how participation is mutually ratified at the beginning of calls into talk radio shows, to Coupland’s (1994) study of ‘How are you?’ type exchanges at the start of geriatric patient-doctor consultations. Ribeiro and Hoyle argue that frame analysis provides a valuable way of reassessing the nature of institutional discourse by revealing the way in which institutional activities are constructed by participants.

“It is increasingly noted that institutional talk *...+ is institutional not because of the setting in which it is produced or because of the pre-existing institutional identities of its producers. Rather, participants themselves construct its nature by displaying their

orientation to institutionally relevant activities and identities on a moment-to-moment basis.” (Ribeiro and Hoyle, 2009: 83)

Van Dijk (1997) highlights the challenge of identifying institutional discourse. Institutional interaction is not confined to easily identifiable institutional settings, nor is discourse in institutional settings such as hospitals, schools and offices necessarily institutional discourse. Van Dijk argues that institutional discourse is that which is oriented to institutional roles and identities. Thus sociable chat between doctor and patient, including those pleasantries often exchanged at the start or end of an appointment, generally remains within an understanding of discourse that is appropriate for the identities of doctor and patient.

Institutional discourse can thus be seen as the product of framing. Interaction takes place within an institutional frame that informs participants as to which identities and roles they are expected to orientate towards. Deeper frames, such as an informal, social frame within an institutional interaction, do not occur in isolation of the larger one but are layered over it, producing additional but not contradictory levels of expectation.

3.5.2 Medical and social frames

Some frames have been considered in detail by previous researchers of medical discourse, in particular frames of bio-medical and socio-relational concepts of health and illness (Fisher, 1991, Coupland et al., 1994, Coupland and Coupland, 2001). These frames or discourses have been found in numerous studies and have generally been considered to create an asymmetry in doctor-patient relationships. Ribeiro and de Souza Pinto (2005), in exploring psychiatric interactions, identify two broad frames: medical inquiry and narrative or personal frames. These are closely associated with topic and schema, and discussed above. They argue that in a standard psychiatric interaction, there is a shared expectation that the doctor will control the structure and topic of the consultation. The doctor therefore introduces officially sanctioned

topics through medical inquiry frames. The patient uses narrative frames to dictate the topic of the interaction and introduce new themes and information.

3.5.3 Framing meaning

Peräkylä (1989) used Goffman’s work on frames to examine models of understanding death in a hospital. In his ethnographic fieldwork he identified four frames: medical, psychological, lay and practical, and he explored why and how each frame is employed by the staff members and patients. He argued that parties to an encounter negotiate a frame around it. This frame leads to expected identities and roles. Any deviance from these identities and roles causes participants to shift the frame they are applying in order to fit the behaviour into predetermined expectations. He concludes that:

The crucial point lies in the relationship between different discourses, or frames. The meaning of discourses, of frames, and the workings of power mediated through them, cannot be understood if they are taken separately. It is in the relationship between discourses, 'where effects of power are constituted and challenged' (Silverman 1987:135). Instead of arguing for or against the use of social-psychological models in medicine, sociology should explicate the way those models are used, the circumstances that they are applied in, and the intended and unintended consequences of their use. These are social issues, permeated by power relations. (Peräkylä, 1989: 121)

Further evidence of this use of different frames in medical consultations come from Nessa and Malterud’s (1998) investigation of a single interaction between a patient with depression, her doctor and her husband. They highlight the use of different models to explain her depression, with the husband and doctor collaborating to produce a medical model, which is only partially accepted by the patient. Mishler also identifies similar frames in his study of medical discourse where he finds the ‘voice of medicine’ and the ‘voice of the lifeworld’ (Mishler, 1984: 14). As

noted above, Silverman (1993) has cautioned against perceiving these as simplistic, dichotomous voices, whereby the doctor speaks in a medical frame and the patient in a ‘lifeworld’ frame (Mishler, 1984, Fisher, 1991). Instead, these discourses should be seen as interacting, with either participant able to employ either frame.

3.5.4 Framing participation and roles

Tannen and Wallat (1987) used interactive frames and schema to understand an interaction between a paediatrician, a child with cerebral palsy and the child’s mother. They demonstrated how different frames are used with different participants, and particularly how these are influenced by the differing knowledge schema they possess. In exploring this they demonstrate how conflicting frames can create unsatisfactory and emotionally distressing results.

“According to this mother, many doctors have informed her in matter-of-fact tones of potentially devastating information about her child’s condition, without showing any sign of awareness that such information will have emotional impact on the parent. In our terms, such doctors acknowledge only one frame – examination – in order to avoid the demands of conflicting frames – consultation and social encounter.” (Tannen and

Wallat, 1987: 212)

In her analysis of children during medically-themed playing, Buchbinder (2008) identifies three broad frames: clinical, play and personal. She demonstrates how the shift between frames changes the footing between participants, including herself as part of the play. For example, in the clinical frame, children ask Buchbinder, as a clinical expert, to identify the medical toys. In doing so, their alignment to her is as child and adult, or lay and expert. In contrast, during the play frame, Buchbinder is aligned as patient to their doctors.

“Although the girls assigned me to the patient role for much of their doctor play, within the clinical frame, they shifted footing to treat me as a knowledgeable adult who could answer their questions about the medical equipment and supplies.” (Buchbinder, 2008:

144)

Rodham’s frame analysis, which is based on interviews, rather than naturally occurring interaction, focuses entirely on the framing of a professional role. The frames identified are not interactional frames per se, but are labelled by the perceived role in which the

occupational therapist positions herself or is positioned by others. Identified frames include: medical frame, medic with managerial skills, and manager with medical skills (Rodham, 2000: 78).