The clinical interaction
6.2 The clinical interaction II: a sociolinguistic perspective A related, but I believe conceptually and theoretically distinct, approach to the
Critiques of interaction analysis tools that are published from within the dis- cipline of cognitive psychology (or a secondary discipline derived from its the- ories) tend to question the psychometric properties of a particular instrument or suggest how it might be adapted or refined.30More fundamental critiques of these tools, which generally come from disciplines outside psychology, ques- tion the worth of any psychometric instrument in assessing the complexity of clinician–patient interaction or meaningfully influencing it. Scambler and Britten, for example, have criticised psychologically driven research on doctor–
patient consultations for being both under-theorised (studies are driven by a somewhat na¨ıve and positivist search for a list of ‘factors’ that predict par- ticular ‘outcomes’) and de-contextualised (the consultation is taken as a fixed unit of analysis without regard to the social or institutional context within which it is embedded).31Ong et al.’s review, for example, undertaken from a cognitive perspective, discusses such psychometric constructs as ‘privacy be- haviour’, ‘controlling behaviour’, ‘use of medical vocabulary’, ‘patient recall of information’ and ‘patient satisfaction’.25But such constructs do not allow for ‘upstream’ questions such as ‘what is the nature of the social context that engenders the use of controlling behaviour?’, ‘what is not being said here and why?’ and even ‘who has not consulted the clinician at all, and why?’.
In other words, if the research question concerns the interaction within the clinical consultation and nothing more, the approaches described in this section are ideal for addressing it – but they have less utility in other contexts. In the next three sections, I will consider some alternative approaches to analysing clinical interaction – using sociolinguistic, psychodynamic and literary per- spectives – which offer the opportunity to move the level of analysis of the con- sultation from the clinical dyad itself to the context in which that dyad is nested.
6.2 The clinical interaction II: a sociolinguistic perspective
theory and developed it into one that had depth and coherence. In Blumer’s words:
‘The term ‘symbolic interaction’ refers, of course, to the peculiar and distinctive char- acter of interaction as it takes place between human beings. The peculiarity consists in the fact that human beings interpret or ‘define’ each other’s actions instead of merely reacting to each other’s actions. Their ‘response’ is not made directly to the actions of one another but instead is based on the meaning which they attach to such actions.
Thus, human interaction is mediated by the use of symbols, by interpretation, or by ascertaining the meaning of one another’s actions. This mediation is equivalent to inserting a process of interpretation between stimulus and response in the case of human behavior’.32,p.180
The theory of symbolic interactionism rests on three core concepts. The first is that of meaning. Humans act towards people and things based upon the meanings that they have given to those people or things. Meaning is thus cen- tral to human behaviour. This may not seem so surprising, but when Mead originally introduced this idea, psychology (including social psychology) was still focusing mainly on stimulus–response theories. The concept of meaning required the ‘stimulus’ to be interpreted before the response was initiated. The second core concept is language. Language gives humans a means by which to negotiate meaning through symbols. This meaning is assigned through nam- ing and engaging in ‘speech acts’ – that is a socially meaningful act that a speaker performs when making an utterance (such as conferring a knighthood with the command ‘rise, Sir Lancelot’, or terminating a consultation with the words ‘here’s your prescription Mrs Brown’). It is by engaging in speech acts with others (symbolic interaction) that humans come to identify meaning and develop discourse. The third core concept in symbolic interactionism is that of thought. Thought modifies each person’s interpretation of symbols. Thought, which is of course based on language, is a mental conversation or dialogue that requires role taking or imagining different points of view. Whilst remarkably few research studies in primary care draw explicitly on the theory of symbolic interactionism, the notion that clinical talk is imbued with symbolic meaning (and must be studied closely, and in context, to draw out that meaning) is fundamental to the sociolinguistic study of the consultation.
Another theory that can be applied to the sociolinguistic study of the consul- tation, for example, by sociologists Nicky Britten and Graham Scambler,31,33is the theory of communicative action developed by the German philosopher and social theorist Jurgen Habermas. Like the symbolic interactionists, Habermas believed that talk must be interpreted within its wider social context and was especially interested in the power relations of the interpersonal relationship and in the wider social system that generated and legitimated these power relationships. He is not the easiest of modern philosophers to comprehend (in- deed, he has been described as one of the most impenetrable) but I believe that his theory of communicative action is crucial to understanding the primary care consultation, so I will spend some time explaining it here.
In the theory of communicative action, Habermas makes three important distinctions:
rBetween communicative and strategic action;
rBetween lifeworld and system;
rBetween ‘micro’ (interpersonal) and ‘macro’ (socio-political) levels of analysis.
Communicative action is talk that is sincere and which has mutual under- standing and consensus as its goal. Strategic action, on the other hand, has a more devious purpose. It occurs when at least one party instrumentalises speech for what might be called an ulterior motive. There are two types of strategic action: (a) open, in which a speaker openly pursues an aim of influ- encing the hearer(s), and there is an associated claim to power (as in giving an order to a subordinate) and (b) concealed, in which there is confusion between actions oriented to understanding and actions oriented to success, resulting in what Habermas calls communication pathologies. It usually involves either conscious or unconscious deception.
Let’s assume for the moment that an instance of communicative action is occurring. The parties will make various claims whose validity is criticisable – that is, it will be possible to claim for each communication that it is true or not true, appropriate or inappropriate, justifiable or unjustifiable (all of which can be argued out through counter-claims), and also that it is sincere or not sincere (which may require practical demonstration or some other external evidence). In other words, if (and only to the extent that) talk is characterised by genuine communicative action on both sides, in a context in which each trusts the sincerity of the other, the questions and statements exchanged are likely to increase mutual understanding and bring the parties towards consensus (even if that consensus is agreeing to differ).
Let me give you some hypothetical examples. When I telephone my mother, who is a churchgoing 80-year-old, and ask what she has been doing today, I’m pretty sure I can count on her to tell the truth, and also to select aspects of her day that I would be interested in. That’s because I know from years of phoning up my mother that she has never yet misled me about her activities, nor do I know of any reason why she might do so. Most of the time, our conversation can be described as communicative action – with an exception being perhaps when my mother has been out to buy me a birthday present but does not want to spoil the surprise, so she pretends to have been at home all day. On these rare occasions, she would be engaging in strategic action (not by lying, but by steering the conversation away from things she doesn’t want me to ask about).
When I ask my son what happened to him at school today, I am less confident that I will hear an account that he views as the whole truth and nothing but the truth. He might, for example, wish to cover up the fact that he has flunked a test. He would then engage in concealed strategic action (‘concealed’ because I am not aware of his motives or strategies – but he is) by telling me all sorts of irrelevant news and deliberately withholding the fact that he has taken a test.
If I later discover (perhaps from checking his books) that my son has indeed
flunked a test, I might order him to his bedroom, thereby using my power as a parent to engage in open strategic action (‘open’ because both he and I are well aware that I am instrumentalising speech for the purpose of inflicting a punishment).
There is one more type of strategic action, which is especially important to the study of communication between doctors and patients, which is when there is deception going on but the deceiver is not consciously aware of it. Let’s say my mother has been having some chest pains, but as someone who lived through the Second World War, she holds the view that one should not bother the doctor unnecessarily and, more generally, that one should not make a fuss about trivial matters. When my mother attends the doctor for a blood pressure check, she might be asked very explicitly if she has been having any chest pain, and might say something like ‘Oh no dear, nothing serious’, believing this statement to be entirely genuine. This is an example of unconscious deception, also termed ‘systematically distorted communication’ by Habermas. It occurs when at least one party is deceiving themselves that they are acting with an attitude oriented to the success of the conversation – and, as you might imagine, it is more common when there are large power differentials and when people’s perceptions have been influenced by wider social forces.
Now, let us consider Habermas’ distinction between ‘lifeworld’ and ‘system’, which has had considerable influence in primary care research. ‘The lifeworld’
represents family and household and is generally characterised by commu- nicative action. ‘The system’ is the world of economy and state, characterised by strategic action oriented around money and power, respectively. When economy and state intrude in inappropriate and unaccountable ways into the lifeworld, they can be said to ‘colonise’ it.
The final contribution of Habermas’ theory of communicative action is its ability to bring together the ‘micro’ of interpersonal relationships with the
‘macro’ of society and state. In other words, a Habermasian analysis of the consultation looks at both the clinician–patient interaction and the wider socio- political context within which that interaction is nested. I discuss this in more depth in Section 6.5 in relation to interpreted consultations. For a more in- depth analysis of the work of Habermas in relation to primary care, see Graham Scambler’s excellent book.33
If we accept that conversation is not always what it appears to be and that there are situations where the researcher should ‘zoom out’ from the text of the consultation and ask what might be called political questions, how might he or she go about this? One technique that is becoming popular in primary care research is conversation analysis (which is one application of a wider technique called discourse analysis). Conversation analysis was first applied to clinical consultations by sociologist Elliot Mishler, whose elegant demonstration that the patient’s lifeworld is partially colonised by the ‘voice of medicine’ (an example of encroachment by the state into the personal world) is one of the all-time great studies in medical sociology.34A subsequent paper by Barry et al.
both confirmed and refined Mishler’s original model.35
Box 6.2 An example of conversation analysis.
001 M1 D Hm Hm. . . now what do you mean by a sour stomach?
002 P . . . .what’s a sour stomach? A heartburn, like a heartburn or something
003 M2 D [Does it burn over here?
005 P Yea:h. It li- I think I think it like- if you take a needle and stick
006 ya right . . . there’s a pain right here
007 D [Hm hm Hm hm [Hm hm
009 P and and then it goes from here on this side to this side 010 M3 D Hm hm. Does it go into the back?
. . . . 016 M D How- how soon after you eat it?
017 M P . . . Wel:l 018 . . . probably an hour . . . . maybe less
[
019 M D About an hour?
020 P Maybe less
021 L . . . I’ve cheated and I’ve been drinking which I 022 L shouldn’t have done
[
023 M D . . . Does drinking make it worse See Box 6.3 for a glossary of notation.
From Mishler34(page 84), reproduced from original citation in Barry et al.37
Box 6.3 Symbols used in conversation analysis.
rBrackets containing a stop ( . ) indicate a pause of less than two seconds rNumerals in round brackets indicate the length in seconds of other pauses rSquare brackets [ ] contain relevant contextual information or unclear phrases rItalicized square brackets [.] describe a non-verbal utterance
rThe symbol [ in between lines of dialogue, indicates overlapping speech rUnderlining signifies emphasis
rAn equal sign=means that the phrase is contiguous with the preceding phrase without pause
rA colon : indicates elongation of the preceding sound rD is the doctor
rP is the patient
Mishler uses the notation ‘L’ for the voice of the lifeworld and ‘M’ for the voice of medicine.
Reproduced with original authors’ permission.38
A characteristic of conversation analysis that distinguishes it from the inter- action analysis systems described in Section 6.1 is the level of detail required for coding and analysing each utterance, which Mishler saw as essential to the quality of the research.36Box 6.2, for example, shows a consultation frag- ment originally published in Mishler’s early work on conversation analysis and subsequently quoted by Barry et al., who comment as follows:
‘. . . the [apparently] unremarkable interview, while appearing coherent and fluent on the surface, fragments meaning by means of frequent interruption, lack of acknowl- edgement of responses and shifts of topic with no reason given. The doctor is in control as both first and last speaker in each exchange. Only the doctor is involved in devel- oping the topic of talk, by asking a series of seemingly (to the patient) disconnected questions. This inhibits the patient from playing a role in maintaining conversational flow. Through these structures the doctor maintains a strong control over the devel- opment of the interview. However, the cost is a loss of context in terms of how the problem developed (the history and course) and the effects on the patient’s life.37 This commentary illustrates how a sociolinguistic analysis of the consulta- tion can reveal a political (i.e. relating to power) dimension to the consulta- tion. Such a dimension is largely, though not entirely, inaccessible using the more conventional interaction analysis described in Section 6.1. I discuss the power dimension again in Section 6.5 when I talk about interpreted consul- tations. The technical detail of how to undertake a sociolinguistic analysis of a transcript of an interaction – and even how to transcribe the interaction in the first place – is beyond the scope of this book, but if you are interested in pursuing this approach, I recommend Elwyn and Edwards’ introductory chapter,38Mishler’s methodological textbook36and the paper by Barry et al.
which offers a perspective that builds on Mishler’s original approach.37If you are confused by the idea of a political analysis of the consultation and are look- ing for a very basic introduction to sociolinguistic conversation analysis, try the recent paper by Maynard, which was written for an audience of medical educators.39
6.3 The clinical interaction III: a psychodynamic