Band 3, Heft 2

In this paper, I use nexus analysis framework to examine how one quadriplegic man from Oman, named Yahya, directs the course of his present (and his future) through anticipatory discourse. In particular, I analyze conversations between Yahya and me regarding his future as they relate to actions I undertake on his behalf to effect a social change: to secure Yahya, an unmarried man, a permit to hire his own resident nurse/assistant (permits for such hirings are reserved only for married couples in Oman). I demonstrate how Yahya influences me to follow his agenda through constructing a helpless identity in narrative discourse. Reciprocally, I suggest that through the actions Yahya's caregivers subsequently undertake, they succeed in giving him a sense of control over an important aspect of his life (being able to hire his own assistant), and I demonstrate how Yahya subsequently displays agentivity in his narratives. I thus illustrate the interconnectedness of Yahya's anticipatory discourse and his caregivers' (macro-level) actions that cause societal change, as well as the interconnectedness of these actions and the kinds of selves Yahya constructs through anticipatory discourse in private (micro-level) interactions.

The use of narrative as a therapeutic tool is well established in many forms of counseling and psychotherapy. Similarly, it forms a significant element of many holistic consultation approaches. The value of patient narratives are recognized by many practitioners working in primary care too, but opportunities for its utilization can be limited by the practicalities of working within conventional healthcare structures. This article presents a micro-interactional analysis of the ways in which patients routinely frame and self-manage their narratives in the context of primary care encounters, and explores some of the behavioral motifs utilized by practitioners in the management of narrative-based interactions.

We studied media discussions of end-of-life decision making to find out how the doctor–patient relationship is portrayed and what types of positions the media takes and how it is represented by other discussion participants in this context. The significance of the end-of-life decision making is related to the fact that it forms a contested site for the realization of patient autonomy. Our material consisted of two newspaper discussions and one television program. In all three samples, the consumerist physician–patient relationship model was promoted in the context of end-of-life decision making by the media representatives and the laypeople (patients, relatives, and a patient advocate). In the first, the media representatives make use of the romance narrative, which presents physicians as villains, and constructs patients as knowledgeable and competent ‘ordinary heroes’. This justifies public scrutiny of healthcare. In the second sample, the relatives stress their competence but now by appealing to their knowledge and caring for the patient. This promotes their right to make decisions for patients. In the third sample, the journalist again pictures patients as ‘ordinary heroes’ who acquire their knowledge from the media. Patients are now empowered as consumers of healthcare. In conclusion, the consumerist doctor–patient relationship is promoted and the media's position as the source of information and as patient advocate is stabilized.

Nontherapeutic genetic testing in childhood raises many ethical concerns within and beyond the clinic. We examine six key position statements from Canada, the United Kingdom, and the United States that present ethical guidelines for good practice in clinical nontherapeutic childhood testing. Using a discourse-analytic perspective that focuses on the use of rhetorical contrasts, we identify how these statements argue for recommendations with distinctly different modalities for different types of nontherapeutic genetic testing. This comes about because of the interaction between a number of contrastive descriptions. It is dependent on how the genetic information resulting from testing is differentiated on a cline of seriousness, how such an evaluation is premised on a network of assumptions about the status of reproduction in people's lives, and the related selective deployment of ethical principles that foregrounds the self over others.

It has been argued that being able to utilize expertise in discourse is as important as having expertise (C. Candlin and S. Candlin 2002). From a constructivist perspective, knowledgeability does not exist outside of social interaction: being expert involves performing knowledge and skills effectively in social practices (cf. Butler 1990; Lave and Wenger 1991). It is, then, crucial that novice professionals develop the interactional competence to construct themselves as experts in interaction. This study brings together perspectives from research on expert–lay communication, social interaction, and situated learning to examine how a pharmacy intern performed his professional knowledge in the practice of patient consultation over time. Using conversation analysis complemented by the interactional competence framework (Hall 1995; Young 2002), I demonstrate that as the novice pharmacist gained more experience over the course of one internship, he was able to employ professional knowledge in ways that were sensitive to the sequential organization of talk, and to share the patients' lifeworld perspectives (Mishler 1984) more effectively, thus successfully managing the transactional and interpersonal functions of the consultations. This study contributes to research on expert–lay interaction, particularly in pharmacy, and to the under-studied area of interactional competence development in the professions.

The objectives of this study were to examine patterns of resident–patient communication and the relationship between resident patterns of speech with patient satisfaction. Forty consultations, ten in each of the four gender combinations (male resident/male patient, male resident/female patient, female resident/female patient, female resident/male patient) were audiotaped and microanalyzed using the Roter Interaction Analysis System. Several findings depart significantly from previous studies with physician-only or physician–resident-mixed samples. First, the average length of the 40 consultations was 19.5 minutes, 11.3 minutes longer than consultations in a physician-only sample drawn in the same clinic previously. Second, male residents engaged in twice as much psychosocial talk as female residents and conducted longer consultations. Third, residents asked 80% of the total questions while patients asked 20% of the questions. Previous studies with physician-only or physician–resident-mixed samples reported that physicians ask 89–99% of the total questions. Finally, patients' overall satisfaction and communication satisfaction were negatively correlated with residents' positive talk, which constitutes 31% of a given resident's total utterances. In the study conducted in the same clinic with a physician-only sample, physician positive talk was 26% and physician positive talk was not correlated with patient satisfaction. Is this a signal that residents should reduce the amount of positive talk? Apparently more studies with resident-only samples are needed to answer this and other unanswered questions in the field to offer directives to resident training.

This article examines the constructions of loss of self-control by male perpetrators of intimate violence in therapy-group conversations. It looks at discursive strategies used by therapists and clients in therapy-group negotiations concerning the issue of self-control. The data are part of a larger corpus of videotaped and transcribed recordings of treatment groups for male perpetrators and consists of four treatment group processes. The analysis concentrates on episodes of self-control talk where a participant referred to loss of self-control when accounting for his violent behavior. The loss of self-control was found to be a fundamental constituent of excuses and was used to account for the clients' behavior in past violent situations. It allowed the speaker to admit the reprehensible character of his behavior, while denying full responsibility for it. It also permitted the speaker to be portrayed as a responsible person in the present conversational group therapy context. These different representations of the past and present selves gave those presentations the appearance of inconsistency. The therapists used this inconsistency in the clients' talk to challenge the use of loss of self-control as excuse, and thus called for more responsible accounts.

This paper considers the nonmedical status of patients in end-of-life decisions. Considering nonmedical factors is not yet routine, particularly in decisions to withhold or withdraw treatment. The paper advocates that non-medical factors—the capacity and willingness to withstand continuing treatment—are essential to ensure that decisions taken are in the patient's best interest. We argue that including this dimension of patient care not commonly considered gives balance to decisions about continuing treatment where its benefit is diminishing. Drawing on a qualitative study of intensive care nursing in a large public hospital in Sydney, Australia, the paper exemplifies and interprets the tendency of some clinicians to not disclose the medical and nonmedical status to conscious patients, and the environment of mistrust and conflict that can result. We propose a process of ‘conferencing’—a regular, inclusive, ongoing, and dynamic process of communication begun early in the patient's admission—to allow multidisciplinary clinicians to manage their differences, agree on patient-care goals, and prepare the patient and their family for the experience of dying. By integrating both medical and nonmedical factors, conferencing becomes the means of enacting and embedding a multidisciplinary, multidimensional approach to end-of-life care.