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Asymmetriesofknowledgeinpatient-providerencounters:Threestudiesadoptingconversationanalysis

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Patient Education and Counseling 92 (2013) 1–2

Editorial

Asymmetries of knowledge in patient-provider encounters:Three studies adopting conversation analysis

Contents lists available at SciVerse ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

The present issue of Patient Education and Counseling containsthree papers that adopt the sequentially focused approach ofconversation analysis (CA) as a methodological framework. Allthree address asymmetries of knowledge in patient-providerencounters and the consequences, difficulties and miscommunica-tions that result from these asymmetries. This association betweenmethodology and content is surely not a complete coincidence, ifonly because the primacy of turn-by-turn analysis that is thehallmark of CA [1] tends to shine a bright light on the gaps inassumptions, understandings, knowledge, and knowhow thatfrequently inhabit medical encounters [2].

In the first of the three, Leydon et al. address a simple butprofound and far reaching problem in medical communication:establishing agreement about assumed common ground [3] at theoutset of an interaction [4]. In primary care, this is typicallyaccomplished in an opening sequence [5] and, as Robinson hasshown, it can be the object of quite nuanced practices. For example,‘‘How are you feeling?’’ conveys the physician’s belief that thepatient is most likely presenting for a follow-up rather than anacute visit [6]. The information asymmetry that Leydon et al.describe emerges in the opening moments of telephone callsbetween cancer patients and specialist nurses at a cancer helplinecall center. Telephone call openings have been much analyzed interms of identification and agenda setting processes [7,8] and havebeen shown to have significant associations with medical out-comes [9,10]. In the context described by Leydon et al., the caller isrouted from a frontline call taker to a specialist nurse who thenopens the conversation.

The paper convincingly shows that the nurse’s opening shouldcontain four major elements in which she (i) identifies the caller byname, (ii) identifies herself, (iii) summarizes her understanding ofthe information the caller has already given to the frontline nurse,and (iv) invites the caller to elaborate using a question format (e.g.,‘‘How can I help’’) that is frequently used in soliciting patients’presenting concerns in acute visits [6], and is also quite common inservice encounters more generally. If any of these features aremissing from the nurse’s opening, significant difficulties emerge.Some of these are relational: a nurse who identifies the caller butnot herself establishes an asymmetry of information, andeffectively anonymizes herself in the context of a conversationwhere a caller’s life and death concerns are to be discussed. Notsurprisingly some callers insist that the nurse identifies herself byname. Other problems have to do with the management ofcommon ground about the patient’s condition. A nurse who fails tosummarize her understanding of the information the caller has

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http://dx.doi.org/10.1016/j.pec.2013.05.003

already provided leaves the caller with a dilemma about whetherto repeat what she has already said to the frontline call taker.

This latter dilemma is also encountered by US primary carepatients who, having described the presenting concern to a medicalassistant, can be uncertain about whether to repeat it to theirphysician [11]. The dilemma is the product of a very general norm inhuman communication that one should not tell others what theyalready know [12]. This norm clearly influences many forms ofmedical communication [13], including the cancer helpline de-scribed by Leydon et al. Conversation analysts have identified twobasic communication strategies in contexts where there is uncer-tainty about pre-existing knowledge. The first – ‘undersuppose andovertell’ – systematically underestimates the knowledge of therecipient and results in a very complete process of communication,but at a cost of potential redundancy which may be sanctioned by therecipient. The second – ‘oversuppose and undertell’ – supposes therecipient to be possessed of a certain level of knowledge and, inkeeping with the norm, avoids its repetition. The second strategy isone that is unlikely to attract immediate sanctions from irritatedsuperiors, co-workers and others, but involves the risk of inadequateor misleading communications between patients and providers and,perhaps even more importantly, in provider–provider communica-tions about patient care. The Leydon et al. study instantiates a tellingexemplification of this extremely widespread problem.

Lehtinen’s domain of study – genetic counseling – is one that isrife with uncertainties of every kind [14]. The science of genetics isnew and evolving, patients encounter information that is oftenpresented (at best) in terms of statistical probabilities and thusexperience deep needs for resolution of consequent uncertainties,and in general misunderstanding and miscommunication aboutthe meanings and significance of test results and prognoses arecommon [15]. Lehtinen’s study focuses on the use of ‘hedges’ –linguistic resources that reduce the speaker’s commitment to aclaim of some kind. Thus when a clinician, in response to amother’s claim to have seen white spots in the back of herdaughter’s throat, says ‘‘Yes. You definitely might have seensomething like that,’’ his initial agreement (‘‘Yes’’) is later dissolvedin the flurry of subsequent hedges that make up the rest of thesentence. Lehtinen’s study focuses primarily on occasions whenpatients offer theories, observations or generalizations about theirown condition or that of others. It matters comparatively littlewhether these observations are framed as statements or questions.As a long literature has attested, in circumstances where one partyis conventionally held to be more knowledgeable than the otherregarding a particular domain, any proposition concerning that

Editorial / Patient Education and Counseling 92 (2013) 1–22

domain will be heard as requesting, and indeed requiring, aninformative response [16–18]. This condition certainly applies inthe field of primary care [19,20], and of course genetic counseling.Lehtinen’s examples are richly furnished with hedged responses topatients’ observations in search of corroboration. A patient’sattempt (in Extract 1) to explain her fatigue in terms of ‘bloodsedimentation’ is padded away with the generalized, but hedged,claim that the disease ‘‘as such’’ is linked to ‘‘a tendency fortiredness’’. Here the physician uses a hedged generalization tocover uncertainties about how this particular symptom maymanifest in this particular patient, and the hedge also mitigates hisindirect rejection of the patient’s theory.

In other cases however, patient descriptions invite physicians tospeculate about other patients and symptoms to which they haveno clinical access (Extracts 2 and 3). Here physicians once againencounter a dilemma: patient observations that are clearlyoccupied with the search for meaning and understanding invitephysicians to respond in a context where responding wouldabrogate basic tenets of medical practice and the scientific method,and also risk misleading the patient. Hedging is one way out of thisdilemma, though it remains an open question as to whether, orunder what conditions, it is to be preferred to other solutions.

An underlying problem that may inhabit some of the sequencesdiscussed by Lehtinen is that the terminology used in theencounter (terms like risk and probability, for example) may atcertain moments be insufficiently shared between patient andprovider. In medicine this problem is familiar from studies ofmedical jargon. With every use of a descriptive term, a physicianmust decide whether the use of some specific term is appropriatefor this particular patient: for example, is an area of the patient’slower torso to be referred to as his ‘tummy’, his ‘stomach’ or his‘abdomen’, or is diarrhea and vomiting to be described as‘gastroenteritis’ or not. In this area the alternative strategies of‘undersuppose and overtell’ and ‘oversuppose and undertell’ alsocome into play. As before, the first strategy risks risks patronizingthe patient with oversimplified language, while the second risksconfusing patients with language that they don’t understand andmay be reluctant to query. Every use of a medical term involvesthis dilemma, whose difficulty may be exacerbated when theclinician does not know the patient very well.

In the Kang and Zayts study of prenatal screening conversationswith older patients, however, a different order of asymmetry isdocumented: one in which the very language of the encounter maynot be shared, or may be insufficiently shared between patient andprovider [21]. With this asymmetry, come multiple otherasymmetries concerning cultural norms, interactional styles,medical knowledge and others. These asymmetries are nowwidely documented, but Kang and Zayts’s study raises questionsabout what can possibly be meant by patient consent or shareddecision making when some of the most basic resources forunderstanding the decision are absent. In Kang and Zayts’ secondcase, for example, a non-native speaker of English is told that ‘‘theblood test... involves sonographic measurement of the baby’snuchal translucency and also take blood from arm and then we cangive you an estimation of whether your risk of having Downsyndrome baby is high or low.’’ During the 21 lines of transcript inthis example, the mother utters only one complete sentence ‘‘whatis that?’’ (about a previous blood test). It is hard to know how muchthe patients grasp of what is told them in encounters like this,though one suspects very little. In part this is because patients,perhaps embarrassed by their lack of understanding, or overlyrespectful of authority figures, or perhaps anticipating that theexplanation may be more challenging to understand than whatthey have heard already, simply avoid showing their lack ofunderstanding by initiating repair [22–24], and just nod and smileand issue simple ‘continuers’ [25]. In an increasingly globalized

world characterized by increasing migration and multilinguisticand multicultural populations, this can only be a growing problemfor medical providers.

In sum, all three of these studies present difficulties incommunication that center on establishing, or failing to establish,common ground between provider and patient. While the Leydonet al. study addresses a problem that is, happily, soluble withappropriate training that the authors identify, the Kang and Zaytsstudy indexes a worldwide communication problem that willundoubtedly take much time and effort to resolve.

References

[1] Schegloff EA. Sequence organization in interaction: a primer in conversationanalysis. Cambridge, England: Cambridge University Press; 2007. 1.

[2] West C, Frankel RM. Miscommunication in medicine. In: Coupland N, Giles H,Wiemann JM, editors. Miscommunication and problematic talk. NewburyPark, CA: Sage; 1991. p. 166–94.

[3] Clark HH. Using language. Cambridge, UK: Cambridge University Press; 1996.[4] Leydon GM, Ekberg K, Drew P. How can I help? Nurse call openings on a cancer

helpline and implications for call progressivity. Patient Educ Counsel 2013;92:23–30.

[5] Robinson JD. Getting down to business: talk, gaze, and body orientation duringopenings of doctor–patient consultations. Human Commun Res 1998;25:97–123.

[6] Robinson JD. Soliciting patients’ presenting concerns. In: Heritage J, MaynardD, editors. Communication in medical care: interactions between primary carephysicians and patients. Cambridge, England: Cambridge University Press;2006. p. 22–47.

[7] Schegloff EA. Identification and recognition in interactional openings. In: deSola Pool I, editor. The social impact of the telephone. Cambridge, Massachu-setts: MIT Press; 1977. p. 415–50.

[8] Schegloff EA. The routine as achievement. Human Stud 1986;9:111–51.[9] Boyd EA. Bureaucratic authority in the ‘‘company of equals:’’ the interactional

management of medical peer review. Am Sociol Rev 1998;63:200–24.[10] Jean YA. Inclusive intake screening: shaping medical problems into specialist-

appropriate cases. Sociol Health Illness 2004;26:385–410.[11] Heritage J, Robinson J. The structure of patients’ presenting concerns: physi-

cians’ opening questions. Health Commun 2006;19:89–102.[12] Terasaki AK. Pre-announcement sequences in conversation. In: Lerner G,

editor. Conversation analysis: studies from the first generation. Amsterdam:John Benjamins; 2004. p. 171–223.

[13] Heritage J. The interaction order and clinical practice: some observations ondysfunctions and action steps. Patient Educ Counsel 2011;84:338–43.

[14] Lehtinen E. Hedging, knowledge and interaction: doctors’ and clients’ talkabout medical information and client experiences in genetic counseling.Patient Educ Counsel 2013;92:31–7.

[15] Timmermans S, Buchbinder M. Saving babies?: the consequences of newborngenetic screening.. Chicago: University of Chicago Press; 2012.

[16] Labov W, Fanshel D. Therapeutic discourse: psychotherapy as conversation.New York: Academic Press; 1977.

[17] Kamio A. Territory of information. John Benjamins: Amsterdam; 1997.[18] Heritage J. Epistemics in action: action formation and territories of knowledge.

Res Lang Social Interact 2012;45:1–25.[19] Gill V. Doing attributions in medical interaction: patients’ explanations for

illness and doctors’ responses. Soc Psychol Q 1998;61:342–60.[20] Gill V, Maynard D. Explaining illness: patients’ proposals and physicians’

responses. In: Heritage J, Maynard D, editors. Communication in medicalcare: interactions between primary care physicians and patients. Cambridge:Cambridge University Press; 2006. p. 115–50.

[21] Kang AA, Zaytz OA. Interactional difficulties as a resource for patient participationin prenatal screening consultations in Hong Kong. Patient Educ Counsel 2013;92:38–44.

[22] Schegloff EA, Jefferson G, Sacks H. The preference for self-correction in theorganization of repair in conversation. Language 1977;53:361–82.

[23] Schegloff EA. Repair after next turn: the last structurally provided for place forthe defense of intersubjectivity in conversation. Am J Sociol 1992;95:1295–345.

[24] Jefferson G. Preliminary notes on abdicated other correction. J Pragmatics2007;39:225–61.

[25] Schegloff EA. Discourse as an interactional achievement: some uses of ‘uh huh’and other things that come between sentences. In: Tannen D, editor. Analyz-ing discourse (Georgetown University Roundtable on Languages and Linguis-tics 1981). Washington D.C: Georgetown University Press; 1982. p. 71–93.

John Heritage*UCLA, Department of Sociology, University of California,

264 Haines Hall, Los Angeles, CA 90095-1551, USA

*Tel.: +1 310 206 5216E-mail address: heritage@ucla.edu (J. Heritage)