Dr. G: You had made an appointment to see the eye doctor. Have you seen him?

Mom: Yeah, no I didn’t.

Dr. G: How come?

Mom: ‘Cause of transportation. I have to make another [appointment

Dr. G:                                                                  [You need to make an appointment because you know with his eye situation—

Mom: They keep wandering.

Dr. G: Especially with the eyes wandering off--. . . ((long discussion of wandering eye))

Dr. G: So you need to make the appointment with the ophthalmologist as soon as possible, and again, I’ll dictate it, but I think they should be making-- I’ll tell ((V)) to make an appointment.

Although both sequences fulfill the communicative responsibility of explaining a referral, note the symmetrical features of (1a) such as the validation of the mother’s expertise, in contrast to the asymmetrical features of (1b) such as the staccato questions, interruptions, and the transfer of responsibility from the mother to a member of the clinic staff. In this paper, I was trying to build a more comprehensive description of the context of the medical encounter and the nature of the physician-patient relationship, arguing that expertise and compliance are key dimensions underlying very specific discourse practices, such as the reference to family expertise, the use of interruption, and the patterns of questions and answers.

One of the most exciting opportunities of this fellowship has been to think about new and interdisciplinary research questions that would be of interest both to the field of linguistics and the field of medicine. For example, one of my upcoming rotations will be in the Hollings Cancer Center, where I will observe the Multi-Disciplinary Clinics in lung, breast, and other kinds of cancer. The communicative situation I will focus on is clinical trial enrollment and consent: how do physicians and other medical professionals, in particular nurses, present the basics of medical research to patients and families? how do medical professionals present specific clinical trials to patients and their families? how do patients and families express their understanding of medical research generally and clinical trials specifically? how do patients and families bring up their concerns? how do medical professionals review informed consent with patients and families? how does the formal process of informed consent repeat some crucial information for patients and families? how do patients and families refuse to participate in clinical trials? what can we learn from looking at clinical trial enrollment across medical specialties—do medical professionals present clinical trials differently in lung cancer, for example, as opposed to breast cancer or some other cancer? All of these questions can be investigated by a linguist who observes, records, and transcribes specific communicative sequences and then analyzes them for subtle features of communication at the micro-level (long and short pauses are an example of a micro-feature that linguists investigate: how do long pauses indicate problems in communication? how do short pauses function as a request for repetition? what other subtle purposes do pauses serve in communication?). And the answers to these questions are likely to be of interest to medical professionals who are looking for ways to increase enrollment in clinical trials (right now, only 3-5% of eligible cancer patients actually enter clinical trials). I hope to use my observations in the Cancer Center to set up a larger project on this communicative problem of interest both to medicine and linguistics.

Other questions that are of interest to both linguistics and medicine include the study of what can be very sensitive and difficult conversations: for example, how do physicians and other medical professionals discuss the transition to palliative and hospice care to patients and families? how do physicians discuss other end-of-life decisions, such as DNR orders and withdrawal of support? how do ethics consultants explain the concept of medical futility to families? how do family support coordinators work with families to understand the concept of brain death and the decision to donate organs? how can medical professionals come to recognize the subtle signs that families use to ask for reassurance as well as information? how does the gender, race, and class of the patient and family affect communication with medical professionals? Again, the investigation of questions like these is likely to be of great interest to linguists as well as medical professionals.

Another part of the interdisciplinary perspective developed in the fellowship program concerns research methods and methodologies. At some times, it can seem as though the quantitative research perspective of medicine and its focus on outcomes in clinical research is antithetical to the qualitative research perspective of linguistics and its focus on detailed analysis of specific instances of communication. Yet both fields have something to learn from the methodological practices of the other. Linguistics can begin to develop research projects that have closer connections with outcomes: for example, the project of clinical trial enrollment described above should certainly keep careful track of patients who ultimately do or do not enroll in trials. Medicine can begin to understand that the close analysis of specific cases has much to offer the general understanding of medical communication. I believe that the key to establishing methodological appreciation is based on the thorough understanding of the methodological practices of the different disciplines attempting to forge a connection in the development of interdisciplinary research. The fellowship has done much to increase my understanding of the assumptions and practices of medical research. I hope I will be better able to explain the assumptions and practices of my own field in return.

In short, the fellowship has been an exciting opportunity to consider and develop interdisciplinary research on medical communication. I will return to my home institution with many new ideas about formulating research questions and choosing research methods.

References
1.  Frankel, Richard. 1979. Talking in Interviews: A Dis-preference for Patient-Initiated Questions in Physician-Patient Encounters. In Everyday Language: Studies in Ethnomethodology, ed. George Psathas, 231-62. N: Irvington.
2. ten Have, Paul. 1989. The Consultation as Genre. In Text and Talk as Social Practice, ed. Brian Torode, 115-35. Dordrecht: Foris.
3.   Heath, Christian. 1992. The Delivery and Reception of Diagnosis in the General Practice Consultation. In Talk at Work: Interaction in Institutional Settings, eds. Paul Drew and John Heritage, 235-67. NY: Cambridge University Press.
4.  Maynard, Doug. 1992. On Clinicians' Co-Implicating Recipients' Perspective in the Delivery of Diagnostic News. In Talk at Work: Interaction in Institutional Settings, eds. Paul Drew and John Heritage, 331-58. NY: Cambridge University Press.
5.  West, Candace, 1984. Routine Complications: Troubles with Talk between Doctors and Patients. Bloomington: Indiana University Press.
6.  Barton, Ellen, (in press). The Interactional Practices of Referrals and Accounts in Medical Discourse: Expertise and Compliance, In Discourse Studies, forthcoming.

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