Volume 21, Issue 1-2

This editorial coincides with the double special issue of TEXT on ‘lay diagnosis’. Each special issue comes with a biography of some sort— how a particular theme focus evolves over time and how different key players in the field become identified and invited to engage (sometimes in a dialogic format) in a debate of intellectual fervor. This special issue is no exception, except that it has a recoverable subplot surrounding an influential backstage character, Robert Hopper, to the memory of whom this issue is dedicated. Bob was the founder architect of this special issue, but sadly he did not live to see his dream realized in ‘text’.

Textual and discursive analyses of various institutional and professional sites have been a mainstay among this journal's priorities. This special issue, with its focus on interaction in health care settings, quite clearly connects with this objective. Conversation analysis in particular has been a visible strand of inquiry in this field, and this is further borne out by the contributions to this special issue. As the title ‘Lay diagnosis’ suggests, we have here a wide range of perspectives on lay participation in medical discourse. The guest editorial (Beach) and the two retrospective commentaries (ten Have and Drew) capture in clear terms the scope and remit of the special issue. Many of the contributors are well known for their previous work in health care communication. Here they extend their ongoing work to focus on the patients' perspective. This is the point of departure from mainstream discourse analytic and sociolinguistic studies—as well as previous conversation analytic studies—which have been predominantly doctor-focused. As Drew points out, the paradox is that ‘in censuring medical practice for silencing the voice of the patient, such research has itself largely ignored the role of patients in their interactions with doctors’.

The studies herein offer previously unarticulated insights about physician–patient–family relationships. Primary attention is drawn to interactions comprising medical interviews, though conversations among family members are also addressed: i. How do patients initiate and solicit social actions during clinical encounters? ii. Outside of the clinic (e.g., in home environments), how do patients and family members deliver and update news about an illness?

This article deals with one form of interactional asymmetry in doctor–patient consultations, that of initiative: Doctors primarily initiate actions and solicit responses, whereas patients primarily respond to doctors' initiatives. This article argues that the variable of initiative actually contains two dimensions: speaker initiative and utterance constraint . It then reviews and critically evaluates prior accounts for these asymmetries. These accounts are almost exclusively ‘professional’ in nature, relying upon features of the social organization of the profession of medicine, medical contexts, or institutionalized medical activities. This article argues that asymmetries of initiative can and should initially be accounted for in terms of the everyday social organization of action. The primary organizing sequential structure for action is the adjacency-pair sequence, which embodies an intersubjective set of normative standards for producing and understanding behavior. This article supports a ‘mundane’ account of asymmetry with a conversation analytic, single-case analysis of a patient request for a renewal of a prescription.

Physicians and other care-givers need to recognize the various and often subtle ways that patients make initiatives, such as requesting medical interventions, in medical encounters. Prior research on patients' requests and physicians' responses has limited real-world relevance because it treats ‘requesting’ and ‘responding’ as straightforward, discretely codable categories. In this study, we use conversation analysis to investigate how a primary care patient delicately hints that an HIV test is warranted and how her physician recognizes (and responds to) her implicit request for this diagnostic test. Our findings provide an empirically grounded and detailed account of some of the subtle interactional dynamics involved in making and responding to medical requests. By documenting the diversity of patients' and physicians' practices, we will gain a more comprehensive understanding of patients' initiatives, physicians' responsiveness, and patient-centered behavior.

Patients' understanding of the origins and consequences of their medical problems (self-diagnosis) has historically been viewed by social scientists as either an asymmetry in role relations (physicians are high status and have access to technical understanding; patients are of variable status and do not really understand what is wrong with them), or as an effect of cognition (health beliefs) on health care processes and outcomes. Recent efforts to understand the medical encounter as a speech event have yielded important insights about how physicians and patients communicate with one another. The role of patient self-diagnosis in the encounter remains under-researched, however. Using a case example, in which an unstated difference in perspectives between a patient and provider regarding her diagnosis was followed by the patient's suicide, three social psychological theories of physician–patient communication are reviewed to see how they deepen understanding of the case. Based on interactional evidence from the third approach, micro-interactional analysis, two key observations are offered. The first comes from evidence based on the initial data gathering segment of the encounter. Here, in an experimental manipulation involving standardized patients being interviewed by second-year medical students, it is shown that eliciting patients' self-diagnosis (attribution) systematically leads to more complete and accurate diagnoses. The second observation is that physicians' delivery of diagnostic ‘information’ at the conclusion of the visit is contingent upon the patient's initial statement of concerns, including attribution whether stated or unstated, and the range of questions and topics pursued by the clinician between the statement of the problem and the delivery of diagnosis. A lack of agreement or alignment between the problem statement and the proposed solution can result in outright or unstated rejection of the diagnostic news, as detailed analysis of two cases reveals. From the evidence provided, the article concludes that interaction analysis is a useful tool for understanding the importance of patient self-diagnosis in the medical encounter. It also provides the best insight to date on the costs and consequences of not addressing self-diagnosis issues at the beginning and the end of the encounter.

This study extends conversation analytic research by Frankel and colleagues on the occurrence (or nonoccurrence) of assessments in physician–patient interviews. As assessments are regularly offered after hearing news or information just asked for in everyday talk (often displaying alignment and as liation for the news bearer), and as reportings commonly occur in both mundane and medical interaction, the post-question–answer slot (after newsworthy answers) was identified as one interactional environment to investigate. Analysis revealed that lay and professional orientations do not mesh. At these points, assessments are absent, unlike in everyday talk. Instead, physicians offer (a) no response, or (b) an acknowledgment token. Patients subsequently exhibit, through pausing and withholding speaking, that they expect a different type of response from physicians. Hence, gaps occur when assessments might be due (from a mundane perspective), marking them as missing. After these gaps, the participants react differently. Physicians disattend the lack of assessments, instead continuing with ‘business at usual’. Patients display an orientation to the absence, using various strategies ‘unsuccessfully’. Implications are discussed in relationship to as liation and social support, important in the delivery of health care. Several explanations for absent assessments in medical interviews are also explored.

This article uses conversation analysis focusing largely on a single unremarkable primary care doctor–patient encounter. In the relatively restrictive context of comprehensive medical history taking, this article investigates some of the ways in which a patient expands her answers—volunteering more information than was asked for. This article draws on previous work to establish that comprehensive history taking is designedly a restrictive environment for patients' responses, and is oriented to by patients as such. In this context, patient expansions are accountable in various ways, and are built to implement specific projects. We review a range of examples of these expansions, and examine their design and import for the interaction. The implication of this research is that while doctors may not routinely as liate with patients' lifeworld narratives as interactants in ordinary conversation might, these narratives can nonetheless be treated as resources for learning more about patients and ultimately facilitating their care and education.

This article presents an analysis of laughter as an interactional device in doctor–patient interaction. The article starts by reporting some findings of a larger study on laughter in Finnish primary care encounters. In the database, it is typically the patients who laugh. Furthermore, they laugh alone, i.e., the doctors do not reciprocate their laughter. The article presents some typical examples of the patients' laughing practices and shows that there are activities that are recurrently done with laughter. For instance, if the patients reject the doctor's candidate understandings with more problematic descriptions, or if the patients problematize the doctor's directives, they recurrently laugh in performing these activities. Through laughter the patients display that the activity at hand is delicate and by showing their awareness of the problem, the laughter also functions as a remedying feature in different kinds of interactional problems. The latter part of the article concentrates on a specific activity environment, the very beginning of the medical agenda where the patients deliver the reason for the visit. The article analyses the cases in which the patients laugh in this slot. In giving the reason for the visit, laughter is used in specific cases: it occurs when the patients present their problem as somewhat ‘untypical’ or ‘strange’. By laughing—and other means—they deal with the delicate interactional business of presenting a problem that is not typical or likely, and thereby may need extra legitimizing as a reason for the visit.

Drawn from a series of 54 phone calls over a 13-month period, excerpts are analyzed from five phone calls involving family members talking through a mother's diagnosis and treatment for cancer. In three of these instances, occurring across three phone calls in a two-day period, the son delivers and updates news to his (recently) divorced wife about the stability of ‘mom's’ condition. As emerging news is shown to be an upshot of prior informings, including reconstructions from other family members' and health professionals' reportings, several distinct features and problems enacted through these cumulative ‘news delivery sequences’ are identified. Behaving ‘as if’ mom would soon be dying, announcing and elaborating upon the news is shaped by (a) inherent and practical ambiguities associated with uncertain illness trajectories (e.g., arranging travel plans), and (b) displayed frustration and fatigue at being a primary family member preoccupied with mom's changing health status. Responding to and assessing news updates is also problematic. Displaying concerns for mom and the son, yet also distancing from reported troubles, require different interactional solutions. The achieved character of social relationships (e.g., closeness and distance) is thus evident as speakers demonstrate being variably affected by the news. Understanding the social organization of family cancer journeys requires both episodic and longitudinal examinations of fundamental quandaries of communication in everyday life: managing relationships during periods of illness, practical decision making and plans, and the ongoing volativity of illness diagnoses by lay persons.

This article starts with a discussion of the somewhat paradoxical character of the concept of ‘lay diagnosis’, as it suggests that lay persons could fulfill such a specific professional task. It is used here as indicating any kind of verbal contributions patients could make to the diagnostic process. Within the research on doctor–patient interaction, two different trends are distinguished, one focussing on how physicians' behavior is inviting, allowing, or discouraging patients from expressing their ideas and feelings, while the other presents an overall structural view of medical encounters ‘as a genre’ in itself. The latter perspective is elaborated at some length as offering at least a partial elucidation of the findings of the first concerning the effects of physicians' conduct of the consultation. The interactional significance of ‘lay diagnostic’ contributions seem to differ according to the phase of the consultation in which they are offered. In the conclusions, some implications for future research and practice are suggested, including an extension of the research agenda to include both pre- and post-clinical lay discussions of diagnostic concerns.

This article reviews the contribution which papers in this collection make to a changing focus in the study of medical interactions—one which pays closer attention to the role of the patient and patient perceptions, both within the medical consultation, and beyond that in the everyday world in which symptoms are first experienced by patients. What emerges from the studies reported here is a less simplistic picture than the one represented in research about the medical interview, as though that is a standard, unidimensional form. We begin to see instead how patients actively participate in medical interactions and in decisions about treatment. We see also how medical interviews unfold according to the communicative choices made by both doctors and patients—a more genuinely interactive approach than hitherto. A number of inter-related themes are identified, in which the patient's role is foregrounded: these include the initiatives which patients make; how they break free of the medical agenda in order to express their concerns; how delicate issues are handled in the interview; patients' lay theories and self-diagnoses (this from a more ‘holistic’ view of the patients' experience); and misalignments between lay and medical perspectives.