Volume 4, Issue 2

In this issue of Communication & Medicine a number of themes across a range of sites are reported, including an overview of communication studies in the domain of mental illness, ethical decision making in end-of-life consultations, frame ambiguities in simulated primary care consultations, as well as the mediating role of whiteboards in the organisation of professional practice. Other contributions move outside the clinical/institutional sphere to explore narratives of bereavement experience and lexical formulations in popular health writing associated with nutrition. In what follows I offer a trailer—hopefully, nutritionally rich—to stimulate the reader's appetite.

Good communication in EOL (end-of-life) discussions is described at a general level in the literature, but there are few studies of EOL discussions at the level of interaction, with data drawn from the actual talk between physicians and families. In this article I present a discourse analysis of EOL discussions from an American ICU (intensive care unit) where the decision to withdraw life support is situated in a hybrid ethical frame co-constructed as the final phase of the EOL discussion. In Mishler's (1984) terms, the final phase of the EOL discussion merges the voice of medicine and the voice of the lifeworld, with both physicians and families initiating, developing, and repeating particular topics that encompass not only the logistics of death but also the ethics of the end-of-life decision. Physicians index their ethical accountability in terms of medical futility, and families express their accountability in terms of an ethics of consciousness. The hybrid ethical frame that is co-constructed ultimately centers upon consensus that the ‘right’ decision has been made from both ethical perspectives.

The quality of the professional–patient relationship in the treatment of mental illness predicts patient outcome. Hence, we conducted a review of recorded professional–patient communication to identify existing research, methods, and findings. Sixteen studies focused on (i) how psychiatric symptoms are manifested in patient communication; (ii) the role of therapist communication in patient improvement; (iii) the influence of sociodemographic characteristics on doctor–patient communication; and (iv) how patients and professionals jointly construct therapeutic interactions. The findings were disparate and included (a) patient nonverbal communication is impaired in depression and schizophrenia; (b) the use of specific therapeutic skills led to improvement in depression; high expressed emotion (criticism and emotional over-involvement) in treating schizophrenia was a state rather than trait characteristic of therapists; (c) patient gender, income, and education influenced communication about depression, anxiety, and medication; and (d) psychiatrists' varying institutional agendas, which sometimes competed with patients' agendas, strongly shaped their consultations. Few studies investigated two-way professional–patient communication, with most focusing on either patient or therapist communication in isolation from the other. Finally, methodological advances in linking communication processes with treatment outcomes in large-scale observational studies and trials are a challenge for research on medical communication.

Communication is believed to hold a central role in recreating an individual's sense of meaning and well-being after a loss. Narrative theory in particular points to ways that people create meaning and connection with others. Literature on bereavement suggests that the formation of connections with others, or building community, comprises an important part of the healing process. For this study, the content of bulletin board postings commemorating deceased children was studied quantitatively and qualitatively. Data were examined to learn how contributors used the Web site to connect with others who shared experience of losing a child, engage in meaningful shared activities, and create community. Findings from the data analysis suggest that the Web site contributors are able to discuss topics that might be restricted in other communication scenes. The discussion of these topics allows them to serve as ‘witnesses’ to truths learned as a result of the loss of a child and enables the participants to keep the memory of the child alive. By participating in this scene of meaning negotiation, we argue that the participants actively construct a counterplot to societal narrative expectations for bereavement that facilitates the creation of some positive meanings.

In this paper we argue that whiteboards in clinical settings play a hybrid role: communicating inter- and intraprofessional directives, mediating professional tensions, and mitigating potentially face-threatening acts. The data upon which this paper is based emanate from two independently conducted ethnographic studies: the first explored a range of nurse–nurse and nurse–doctor communication practices in operating rooms, while the second explored work routines and communication methods in oncology wards. Data collection included fieldwork using observations, interviews assisted by photographic methods, and in the first study, a personal diary. A deconstructive analysis was independently undertaken. As a communication method, the use of whiteboards in clinical settings provided a focal point for the coordination of clinical work activities and for the dissemination of information to large groups of people. Whiteboards were a conduit for potentially face-threatening information in that they facilitated the policing and disciplining of staff, while distancing communicators from one another. We conclude that whiteboards are ‘pseudo-synchronous’ in nature, enabling ‘communication at a distance’. In doing so, whiteboards may facilitate and economize clinical communication but they also perpetuate the invisibility of nurses' contribution to ensuring safe care, and they mask the symbolic violence that is committed within and between health professionals.

We report an investigation of the sociolinguistic characteristics of simulated encounters (role plays) in medical education, focusing in particular on frame negotiation. The role played by context in influencing the nature of out-of-frame activity is noted through comparison with another published study of simulations (Linell and Thunqvist 2003). While in general sustaining a role-playing frame that involved an orientation to exact mimicry of clinical situations, the interactional work done to sustain this appearance of ‘authenticity’ at certain moments was revealed by out-of-frame utterances. One participating doctor in particular used humor to exploit the ambiguous realism of the role-playing frame. The success of this doctor in acquiring and applying new communication behaviors problematizes the view that ‘realism’, achieved through mimicry, is solely responsible for the success of training interventions. The implications for studying other kinds of simulated encounters, including an outline for a program of research into the sociolinguistics of acting tasks in general, are outlined. Sociolinguistic researchers involved in observational studies of talk would benefit from adopting the view that role-played, rehearsed, and even scripted talk of the sort used in dramatic performance is a variety of naturally occurring data and therefore worthy of study.

Examination of lexical items in naturally occurring vernacular prose shows patterns of ambiguities in how Americans discuss health issues. Samples from the Freiburg–Brown corpus of American English and varied registers of popular health writing found online reveal two principles of naming beliefs that crosscut the uses of many ambiguous terms: the semantic principle of ‘lexical conflation’ and the semiotic principle of ‘edible iconicity’. Both are shown to reflect sources of nutritional conceptualizations. Lexical conflation is illustrated by uses of fat, cholesterol, sugar, oil , and germ , with modifiers shown to help disambiguate terms. Edible iconicity, where meaning is attached to the visible form of what is ingested and characteristics of a food are believed to transfer to the person who eats it, is illustrated through aspects of hard, white , and hot . Applications are suggested that take into account the influence on nutritional choices that can occur when lay people misinterpret specialized information as signifying a nonspecialist sense. Recognition of these two principles has the potential to affect public health policy by helping practitioners to identify and modify ambiguous words, and to take into account tendencies to interpret metaphors literally, especially regarding iconic ingredients and their presumed effect upon the body.