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Conversation Analysis

4. CA and the Medical Encounter

Sequence Organization

At the next level down is sequence organization which, as previously noted, concerns how sequences of actions are put together. For example much of primary care question-answer sequences are punctuated by clinician acknowledgements that indicate a willingness to see the patient continue with a response (such as "yes" or "mm hm"), or, alternatively, acknowledgments that indicate a preparedness to shift to some new topic, or activity (such as "okay" or "right"). Because of these differences in inviting sequence expansion or sequence closure, these acknowledgments have the effect of compiling questions into topical 'blocks,' treating their topics as remaining to be further clarified or, alternatively, as closed.

 

Example 3

For example, in the following pediatric history, the clinician treats the mother's initial response to his question as sufficient (line 4) but, following her elaboration, he does not intervene again until line 9 when he pursues the matter of how the child's cough sounds.

Dialogue Example as discussed in the text

After his subsequent question at line 12, he boundaries off the mother's inconclusive response (at line 17), and then resets the terms of his question at line 19, finally gaining a clear response.

Physician-initiated sequences in medicine can vary significantly in terms of the conditions under which they may be closed. Clinicians can proceed from diagnosis to the treatment plan without the necessity of explicit acknowledgement of these findings by the patient (Heath, 1992; Peräkylä, 1998; Stivers, 2007). This observation, however, does not apply to the treatment plan: it is difficult to leave the treatment phase of a medical encounter without some overt sign of acceptance by the patient, and this can be exploited by patients who can and do deploy a form of 'passive resistance' to medical recommendations as a means of influencing clinicians to revise the treatment plan (Stivers, 2005, 2007).
Stivers, T. (2007). Prescribing under pressure: Parent-physician conversations and antibiotics. New York: Oxford University Press.
Heath, C. (1992). The delivery and reception of diagnosis and assessment in the general practice consultation. In: Drew P., Heritage J., Ed, Talk at Work. Cambridge, UK: University Press, 235-267.
Peräkylä A. (1998). Authority and accountability: The delivery of diagnosis in primary health care. Social Psychology Quarterly 61(4): 301-320.