Band 3, Heft 1

This issue of Communication & Medicine coincides with the return of the COMET conference to Cardiff (29 June–1 July 2006). I would like to extend my warm welcome to all participants—local and international—at the 4th COMET conference. While writing this welcome message on a dark, wintry morning in early February as this issue goes into production, my earnest hope is that it will be read in bright and sunny Cardiff in June/July. There seems to be a very good reason to look forward to the arrival of COMET!

As a case study, this article describes a nurse's communication activity, focusing on change talk during lifestyle counseling in primary healthcare. All videotaped counseling sessions with a single patient within a period of two years were transcribed verbatim. In the analysis, an emphasis was placed on the nurse's communication activity that produced change talk, how the nurse initiated change talk, and how the patient received it. The observations provide evidence that the dilemma of simultaneously maintaining professional authority and patient perspective leads to sensitivity in lifestyle counseling. Three categories of change talk were identified: rejected, restrictive, and expansive change talk. Producing change talk is a very demanding task for counselors. It is best produced when the nurse stays within the patient's frame of reference with a combination of reflective, change-inducing questions, encouraging assessments and conversational space. On the basis of our results, we suggest that nurses need training to identify and to encourage patients' change talk and to communicate flexibly according to patients' values during lifestyle counseling. In addition, in order to insist on change talk, we need to demonstrate how change talk could be carried out so that nurses could orient to it.

HIV and hepatitis C are blood-borne viruses that cause chronic diseases and affect (in parts of the developed world) predominantly groups that are marginalized and discriminated against: gay men and injecting drug users, respectively. This paper compares the representation of people with HIV and hepatitis C in editorials of medical journals between 1989 and 2001. Analysis is informed by critical discourse analysis and systemic functional linguistics. Hepatitis C editorials draw almost exclusively on the discourse of biomedicine, and patients are either absent or objects in medical procedures. In HIV editorials, a variety of other discourses are integrated into the discourse of biomedicine, thereby creating multidimensional representations of people with HIV as patients and agents in medical procedures, involved in decision making, affected by economic factors, social and cultural issues. The paper discusses the role of the gay community in discursive change and argues that discursive diversity in the representation of people infected with HIV and hepatitis C in medical journals is necessary for health policy, the professional development of healthcare providers, and media reporting to the general public.

Psychotherapists sometimes disclose personal information to their clients during therapeutic sessions. We report here our analysis of how these ‘therapist self-disclosures’ are done. In a sample of 15 sessions involving four therapists, we find that all therapists use them sparingly and some not at all. When they do, they ‘match’ something in the client's preceding turn. Vehicles for the match can range from comparatively simple agreements to more complicated ‘second stories’, which use analogies from the therapists' own current life. We find that these ‘personal’ disclosures are invariably rather ordinary but are made to bear visibly on the therapeutic business at hand, though not always in obvious ways. The ordinariness of therapist's self-disclosures underpins what seems to be one of their main actions—to ‘normalize’, for a number of disparate local interactional contingencies, the clients' experience. We discuss the practice of using one's own life experiences to bear on one's client's troubles, noting the recurrent features of extreme case formulations and explicit recipient design. We conclude with a brief discussion of the relation between our analyses and those which might be oered by members of the therapeutic community.

Ethnographic research was conducted in the thoracic ward of a Norwegian university hospital in order to study collaborative medical problem solving. As a general principle, evidence-based medicine is supposed to lead the process of medical problem solving. However, medical problem solving also requires evidence of a different kind. This is the more concrete form of evidence, such as X rays and other representations, that guides medical practice and makes sure that decisions are grounded in sound empirical facts and knowledge. In medicine, ‘evidence’ is on the one hand an abstract category; on the other hand, it is a tool that is practically enacted during the problem-solving work. Medical evidence does not ‘show itself’. As such it has an emergent quality. Medical evidence has to be established and made practically useful in the collaborative settings by the participants in order to make conclusions about diagnoses and treatment. Hence, evidence is an interactional product; it is discursively generated and its applicability requires discourse. In addition, the production of medical evidence requires more than medical discourse and professional considerations. This paper looks at the production processes and use of medical evidence and the ambiguous meaning of this term in practical medicine.

This paper considers the problematic role of the science–media symbiosis in the dissemination of misleading and emotionally manipulative information regarding services offered by CordBank, New Zealand's only umbilical cord blood banking facility. As this case study illustrates, the growing reliance of health and science reporters on the knowledge capital of medical specialists, biogenetic researchers, and scientists potentially enhances the ability of ‘expert’ sources to set the agenda for media representations of emerging medical and scientific developments, and may undermine the editorial independence of journalists and editors, many of whom in this case failed to critically evaluate deeply problematic claims regarding the current and future benefits of cord banking. Heavy reliance on established media frames of anecdotal personalization and technoboosterism also reinforced a proscience journalistic culture in which claims by key sources were uncritically reiterated and amplified, with journalistic assessments of the value of cord banking emphasizing potential benefits for individual consumers. It is argued that use of these media frames potentially detracts from due consideration of the broader social, ethical, legal, and health implications of emerging biomedical developments, along with the professional, personal, and increasingly also financial interests at stake in their public promotion, given the growing commercialization of biogenetic technologies.

In this paper, we investigate two scientific articles at opposite ends of the MMR debate—Wakefield et al. (1998) (which started the debate) and Taylor et al. (1999)—and four media articles published to inform the public of the results of these two scientific studies. Because people need to assess truth claims about health risks, communicators seek to establish their believability in two ways: authority (i.e., the attribution of scientific claims to sources that may be perceived as believable because of their status) and factuality (i.e., the moderating, limiting, or highlighting of truth claims). The importance of authority was confirmed by the media texts' preference for direct quotes and messages about what people ought to do, especially at the beginning of the debate. Our most significant find, however, relates to two important indicators of factuality: avoidance of vague references and high use of epistemic modals, where Wakefield et al. displays a pattern not at all different from the media texts and opposite to that expected from a scientific text. That Wakefield et al. stands out in the majority of indicators investigated is of interest in view of its controversial position in the MMR debate and worthy of further study.

Healthcare students learn to manage clinical uncertainty amid the tensions that emerge between clinical omniscience and the ‘truth for now’ realities of the knowledge explosion in healthcare. The case presentation provides a portal to viewing the practitioner's ability to manage uncertainty. We examined the communicative features of uncertainty in 31 novice optometry case presentations and considered how these features contributed to the development of professional identity in optometry students. We also reflected on how these features compared with our earlier study of medical students' case presentations. Optometry students, like their counterparts in medicine, displayed a novice rhetoric of uncertainty that focused on personal deficits in knowledge. While optometry and medical students shared aspects of this rhetoric ( seeking guidance and deflecting criticism ), optometry students displayed instances of owning limits while medical students displayed instances of proving competence . We found that the nature of this novice rhetoric was shaped by professional identity (a tendency to assume an attitude of moral authority or defer to a higher authority ) and the clinical setting (inpatient versus outpatient settings). More explicit discussions regarding uncertainty may help the novice unlock the code of contextual forces that cue the savvy member of the community to sanctioned discursive strategies.

Ruth Chadwick's piece covers a great deal of thought-provoking ground. She considers that one reason why genomics science has attracted much interest in public engagement is because of its relations to Kant's three basic questions of philosophy: What can I know? What ought I do? What may I hope? With the last question especially, Chadwick argues that there is a potentially large role for public engagement, and suggests that genomics science might develop its own distinct service ideal, springing from a conception of the good that is internal to it.

Knowledge production is never simply about increasing the reservoir of information. It is also and equally about answering what Kant called the quid jure : By what right? Who is allowed to speak authoritatively on a subject? There are any number of people who have made a self-study of law, history, or medicine, or who for one reason or another quit their studies just before being awarded their final certification. These individuals may be quite able to competently address issues within a particular domain of knowledge. But only those who have passed the bar, been awarded the Ph.D., or have passed their medical boards have standing, are considered proper experts who are authorized to pronounce on a subject. These experts form closed groups that perpetuate their power by establishing chokeholds over access to and the dissemination of information in their fields—via peer review, journals, and professional associations.

The issue Ruth Chadwick addresses in her paper is an important and interesting one. Until recently, while medicine as a profession was guided by a ‘service’ ideal, the moral ideal of biologists (and other scientists) was more or less oriented toward free enquiry and scientific creativity. Although they tended to see themselves as serving societal interests in the longer run, their agendas were oriented toward biological questions rather than toward societal demands.