Diagnosis as Cultural Practice (eBook)

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Judith Felson Duchan, State University of New York at Buffalo, USA; Dana Kovarsky, University of Rhode Island, USA.

Contents 7
Contributing authors 9
Chapter 1. Introduction 11
Chapter 2. Diagnosis as an aid and a curse in dealing with others 27
Chapter 3. A diagnosed life in an institutional setting: Can the dancer walk? 43
Chapter 4. From diagnostic to aesthetic: Moving beyond diagnosis 75
Chapter 5. Revisiting authority in physician-patient interaction 93
Chapter 6. "I just wanna know why": Patients' attempts and physicians' respronses to premature solicitation of diagnostic information 113
Chapter 7. Aggravated resistance to problem formulations in therapy 147
Chapter 8. Learning to diagnose: Production of diagnostic hypotheses in problem-based learning tutorials 163
Chapter 9. Emotion and objectivity in medical diagnosis 189
Chapter 10. The diagnostic practises of Speech-Language Pathologists in America over the last century 211
Chapter 11. The diagnosis of deafness in Nicaragua 233
Chapter 12. Documenting awareness of the cultural process of diagnosis: Letters of recommendation for medical school faculty 251
Chapter 13. Speaking about menopause: Possibilities for a cultural discourse analysis 273
Chapter 14. The diagnosis of the constituents of communication in everyday discourse: Some functions, enabling conditions, consequences, and remedies 287

Charlotte M. Jones and Wayne A. Beach (S. 103-104)

Picking up on the issue of authoritarianism raised by Heritage in the previous chapter, Jones and Beach examine how authoritarianism gets enacted throughout physician–patient encounters. A collection of instances are analyzed where patients solicit diagnostic information during initial moments and phases of medical interviews. In response, doctors treat such actions as premature and generally avoid addressing patients’ concerns.

The authors then examine instances where patients take the initiative, despite discouragement, to pursue diagnostically relevant responses. For the most part physicians continued to not respond willingly to patients’ pursuits, revealing their dispreference for ongoing patient-initiated questions (and related actions). But the authors also describe interactional environments wherein patients shape their initiations in ways that doctors treat as acceptable.

After exploring specific features of interactions resulting in more positive responses by physicians, it becomes clear that mutual involvement and decision-making can be enhanced through collaborative approaches to medical care.

During medical interviews patients seek assurance, solicit diagnostic information from physicians, and even proffer their own diagnosis of an illness. We examine a range of soliciting techniques employed by patients as they pursue understandings about their medical condition, and in response, how physicians treat such contributions with hesitation and indirectness. At times, physicians are also shown to disattend patient-initiated topics by moving back to biomedical agendas.

Acting as though patients’ contributions are untimely and/or altogether inappropriate, physicians appear to treat patients as resisting adherence to a biomedical model in which physicians address diagnoses, and only subsequent to data-gathering and physical examination. The result is a marked contrast in orientations to communication in medical interviews, where patients’ lay concerns and diagnoses get raised but only minimally acknowledged by clinicians (Beach 1995, 2006, Beach and Mandelbaum 2005, Jones 2001, Lutfey and Maynard 1998, Peräkylä 1991). Moments where patients solicit, and physicians withhold providing “premature” diagnostic information, are deserving of close analytic inspection. We begin by overviewing five central issues underlying the need to examine these interactional involvements.

First, while clinicians are traditionally understood to be the “officially” designated participants responsible for regulating emergent phases of a biomedical encounter (Byrne and Long 1976, Drew and Heritage 1992, McWhinney 1989, ten Have 1989) – (a) opening, (b) data-gathering or question-answer, (c) physical examination, (d) diagnosis and treatment, and (e) closing – such phases are interactionally produced and thus not necessarily linear nor constrained by role (see Heath 1992, Modaff 1996a, 1996b, Peräkylä 1997, Robinson 1998, ten Have l991a).

Just as medical professionals predominantly ask more questions, offer “formal” diagnoses, and prescribe treatment regimens, so too has it become increasingly clear that patients should be treated as active collaborators throughout interviews (Beach 2001a, Drew 2001, ten Have 2001). At times patients extend and may even abandon physicians’ attempts to constrain answers focusing on lifeworld experiences (Beach and Dixson 2001, Heritage and Stivers 1999). More commonly, however, patients avoid intruding on the prescriptive judgment of a physician (Robinson 2001), hint at rather than directly state their requests (Gill et al. 2001), and limit their questions to provided opportunities such as “Is there anything else today?” (Frankel and Beckman 1988).