Health

14(5) 505–522
Patient resistance towards © The Author(s) 2010
Reprints and permission: sagepub.
diagnosis in primary care: co.uk/journalsPermissions.nav
DOI: 10.1177/1363459309360798
Implications for concordance http://hea.sagepub.com

Taru Ijäs-Kallio and Johanna Ruusuvuori

University of Tampere, Finland

Anssi Peräkylä
University of Helsinki, Finland

Abstract
This article reports a conversation analytic study of patients’ resisting responses after
doctors’ diagnostic statements. In these responses, patients bring forward information
that confronts the doctor’s diagnostic information. We examine two turn formats –
aligning and misaligning – with which patients initiate resistance displays, and describe
conversational resources of resistance the patients resort to: their immediate symptoms,
their past experiences with similar illness conditions, information received in past
medical visits and their diagnostic expectations that have been established earlier in the
consultation.Through the deployment of these resources, patients orient to the doctor’s
diagnostic information as negotiable and seek to further a shared understanding with
the doctor on their condition. The results are discussed with regard to concordance
as a process in which patients and doctors arrive at a shared understanding on the
nature of the illness and its proper treatment. Our analysis illuminates the mechanisms
in interaction in and through which concordance can be realized. Thus, we suggest that
concordance can be seen to encompass not only treatment discussion but also the
process where participants reach agreement about the diagnosis. The data of the study
consist of 16 sequences of patients’ resisting responses to diagnosis and is drawn from
86 Finnish primary care visits for upper respiratory tract infections.

Keywords
concordance, conversation analysis, diagnosis delivery, doctor–patient interaction,
primary care

Corresponding author:
Taru Ijäs-Kallio, Dept of Social Research, University of Tampere, Kalevantie 5, Tampere, 33014, Finland.
Email: taru.ijas@uta.fi

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Introduction
Current health policies in Europe and North America encourage patient participation
and emphasize the importance of concordance between professionals’ and clients’ views
(Collins et al., 2007; Vermeire et al., 2001). A concordant doctor–patient relationship
involves mutual information giving and shared decision making in which the doctors’
medical expertise and the patients’ experience-based knowledge are considered equally
important (Bissell et al., 2004). Mutual understanding between doctors and patients has
been regarded as potentially significant in terms of the outcome of the consultation.
Stevenson et al. (2002) have found that discordance may lead to non-adherence, while
on the other hand, it has been suggested that patients’ involvement in decision making
increases the positive outcomes both in terms of effective care and patient satisfaction
(Elwyn et al., 2003; Kerse et al., 2004). Thus, the concept of concordance refers to a model
of doctor–patient relationship that has evolved as an effort to solve the problem of non-
compliance in health care. The term concordance advocates a shift towards equality in a
doctor–patient relationship instead of mere patient compliance, and stresses the validity of
the patient’s knowledge in doctor–patient communication (Vermeire et al., 2001).
Concordance refers to a consultation as a shared process rather than to a certain patient
behaviour during or after the consultation (Weiss and Britten, 2003). Therefore, while
concordance has still mostly been used in reference to prescribing and taking medication,
here it is extended to encompass the activity of diagnosis delivery and its reception. We
see the slot following the doctor’s diagnosis as a potential place for the patient to seek to
further a shared understanding with the doctor on the diagnosis. In our view, agreement
on diagnosis is also a prerequisite for arriving at a shared understanding of the proper
treatment. Moreover, in our data with patients with upper respiratory tract infection
discussion about diagnosis and treatment decision are closely linked. For instance, once
a doctor diagnoses sinusitis, a prescription of antibiotics typically ensues without explicit
reference to treatment decision.
This article describes how doctors and patients go about their interaction when their views
on the diagnosis differ. First, we depict how the patients bring forward that their views on their
illnesses diverge from that of the doctors’. Second, we consider the resources that the patients
rely upon in resisting the diagnosis. We discern the focal components of the process within
which patients and doctors work to achieve a shared understanding on the patient’s medical
condition. In more general terms, our aim is to illuminate the mechanisms in and through
which concordance emerges in face-to-face interaction between the doctor and patient.

Interaction and concordance in diagnosis delivery

Patients rarely resist the diagnosis given by a doctor. Research has shown that patients
usually receive diagnoses with minimal reception tokens or even with silence (Heath,
1992; Peräkylä, 1998). However, patients have means to further the shared understanding
with the doctor on the diagnosis. Heath (1992) found that should discrepancy between
patients’ and doctors’ views occur, patients are more likely to respond extensively.
Peräkylä (2002) described patients’ extensive responses to diagnosis and showed that
in cases of incongruence, patients can offer additional symptom descriptions as indirect

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Ijäs-Kallio et al. 507

non-acceptance, or they may reject the diagnosis more overtly by explicating another
diagnostic proposal or by offering an alternative to the diagnosis given by a doctor.
Nevertheless, the patients cautiously oriented to the difference between their and their
doctors’ ways of reasoning and to the doctors’ ultimate authority as a medical expert.
They did not question the evidence on which their doctors grounded the diagnosis
(Peräkylä, 2002). Furthermore, in the context of non-routine consultations and serious
diagnoses, Maynard (1991, 1992) showed the ways in which the doctors can further
shared understanding on diagnosis by eliciting the clients’ view before the delivery of the
diagnosis, and by tailoring the diagnosis delivery accordingly.
This article focuses on a particular ailment, upper respiratory tract infections. Within
this illness category, patients and parents often have implicit or explicit expectations
towards diagnosis and treatment and these expectations, whether real or perceived,
may affect the physicians’ prescribing behaviours inappropriately (Elwyn et al., 1999;
Macfarlane et al., 1997; Stivers et al., 2003). A guideline for Finnish general practitioners
is that antibiotic treatment for viral illness should be avoided, and the pros and cons of it
considered also in some spontaneously curing bacterial conditions (www.kaypahoito.fi).
As patients with upper respiratory tract infection may have strong views with regard to
their illness and its proper treatment, this illness category provides a fruitful environment
for describing the patients’ methods and resources to resist a diagnosis.
Our method of study is conversation analysis (CA) (Heritage, 1984a; Schegloff,
2007). From the CA point of view, social actions and relationships are managed in
and through sequences of interaction, not in one person’s conduct but in two (or more)
interlocutors’ concerted actions (Sacks et al., 1974; Schegloff and Sacks, 1973). CA is a
method to study social activities (such as a medical interview) and their interpretations as
participants’ co-constructed activities. Thus, CA focuses on the participants’ orientations
and reasoning processes as these unfold momentarily in interaction. In this study,
our focus is on the sequences of doctors’ diagnostic statements followed by patients’
resisting responses. We investigate these activities to unravel participants’ orientations
towards the diagnostic decision making. As the term concordance, by definition, involves
paying attention to the doctors’ and patients’ mutual involvement in sharing information
and decision making on the treatment (or diagnosis), CA offers a potent method for
investigating the constituents of concordance in face-to-face interaction.
Our data are drawn from a corpus of 86 video-recorded primary care consultations
with 11 doctors. The data were collected in nine municipal health centres in Finland
in 2005–2006 for the purposes of a larger study on patient participation and decision
making in primary care. This article reports one part of this study. All participating
doctors, patients and parents were informed about the purpose of the study and gave
their permissions for video-recordings. The study is approved by the Ethical Board of
Pirkanmaa Health Care District (R04143).
In 10 out of 86 consultations, the patients brought forward that their diagnostic views
differ from those of the doctors’. In these 10 consultations there were 16 sequences
of such patient resistance, which form the data of the present study. The analysis of
these sequences is based on the video-recordings supported by the original language
transcripts. Data extracts presented in this article are translated from the original data.
The transcript notation is given in Appendix 1.

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Patients’ responses to diagnosis

Doctors produce diagnostic statements typically in two locations of the medical
consultation: as pre-diagnostic commentaries on clinical findings in examination phase
(Heritage and Stivers, 1999) and as actual diagnosis deliveries after the examination.
In CA terms, a doctor’s diagnostic statement is an information delivery (Maynard,
2003; Silverman, 1997), after which a relevant next action would be its reception –
an acknowledgement (Schegloff, 2007: 120–123) or a change of state token from the
patient (Heritage, 1984b; Schegloff, 2007: 118–120). A patient’s typical next action
after a diagnosis delivery is its minimal acknowledgement (Heath, 1992; Peräkylä,
1998). Consider extract 1.

Extract 1: Consultation 12

01 Doc °>yeah< put the shirt on°=the lungs are #qui:te# by

02 listening they are clear so,
03 (.)
04 Pat [KRH] ((coughs))
05 Doc [it’d] be more in the sinuses it’s dripping from there
06 and you, (0.4) get it down on your throat then.
07 (.)
08 Pat --> yea:h? ((mutual gaze))
09 Doc <go ahead put your shirt on then.>
10 Pat khhhhh (0.2) hhhhhhhh ((starts getting dressed))
11 Doc I’ll put you on antibiotics, (0.3) that’s what one
12 has to do,

This illustrates a typical diagnosis delivery–response sequence. First, the doctor provides
evidential basis for the diagnosis by explicating the clinical findings (ll. 1–2) (Peräkylä,
1998). Thereafter, the doctor explains the patient’s symptoms and offers a diagnostic
statement it’d be more in the sinuses (l. 5). The patient acknowledges this with a minimal
response token yeah (l. 8). The doctor interprets this acknowledgement as accepting the
diagnosis as he initiates a new activity first by asking the patient to get dressed, with
which the patient aligns (l. 10), and thereafter by introducing a new topic (l. 11). Thus,
the participants orient to the minimal acknowledgement as an unproblematic response
to the diagnosis.
In extract 1, the participants displayed no detectable incongruence between their
views. In what follows, we examine patients’ resisting responses that do not share the
doctor’s view on the diagnosis but argue or imply a different possibility. First, we describe
two turn formats through which the patients’ resisting turns can be initiated: the first
format conveys the patient’s overt misalignment with the action of giving and receiving
information. This is done by initiating a new information giving sequence instead of
acknowledging the doctor’s information. In the second turn format the patient first aligns
with the ongoing sequence by producing a conventional reception token after the doctor’s
diagnostic statement (as in extract 1). Only thereafter, the patient proceeds to resist the

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Ijäs-Kallio et al. 509

doctor’s diagnostic information. Second, we examine the resources of knowledge that

the patients resort to in resisting a diagnosis. These include the patients’ immediate
symptoms, their past experiences with similar illness conditions and information they
have received during past medical visits. Finally, we show how the patients may rely
on these resources as they re-invoke their own diagnostic expectations that have been
established in the consultation.

Composition of the patients’ diagnosis-resisting turns

Patient resistance, although often implicit or hidden instead of an overt disagreement, is
initiated and conveyed in turns with which the patients give information that confronts
the preceding diagnostic information given by a doctor (Peräkylä, 2002). Sometimes such
resistance is quite visibly displayed in turns in which the patient, instead of producing
conventional information reception markers such as yes or okay after the diagnostic
statement, overtly misaligns with the ongoing action. Such misalignment becomes visible
as the patient does something else than what was projected in the doctor’s preceding
turn (Schegloff, 2007: 21), that is, it breaks the flow of diagnostic information giving–
reception sequence. Consider extract 2.

Extract 2: Consultation 68

01 Doc it would require antibiotics because the ear is infected

02 and it might be that it’s been (.) lingering there since
03 the previous?, (0.2) infec[tion,
04 Mom --> [they did examine her ears
05 --> then and said that she doesn’t have it.,
06 Doc yeah when (0.2) you [visited,
((talk about the previous visit continues))

The doctor’s diagnostic information is delivered in two parts. The first is an assertion
(Peräkylä, 1998) it would require antibiotics because the ear is infected (l. 1). The
latter part of the doctor’s diagnosis delivery offers a tentative etiological explanation
for the baby patient’s long-prevailing illness it might be that it’s been lingering there
since the previous infection (ll. 2–3). It means the ear infection that is diagnosed in this
visit, the previous infection refers to the baby’s previous ailment the mother had talked
about earlier in the encounter (data not shown). The mother misaligns with the action
as she omits the acknowledgement of the doctor’s etiologic explanation and initiates an
information delivery that challenges it they did examine her ears then and said that she
doesn’t have it (ll. 4–5). This information provides an alternative interpretation for the
baby’s current condition as the mother implies that the doctor’s explanation of the baby’s
symptoms is not adequate. Thus, with this turn structure the mother counters the flow of
the sequence (cf. Schegloff, 2007: 17) by giving new information that contradicts a part
of the information the doctor just provided.
In extract 2, the mother’s resistance became observable in terms of the sequential
structure of conversation, as she withheld the expected second pair part of the information

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giving–reception sequence (Maynard, 2003: 98–107). In a number of other cases, however,

resistance is displayed in less overt ways. In these cases, the patient maintains the structure
of the information giving–reception sequence by receiving the diagnostic information as it
is given. Only thereafter, the patient proceeds to resistance display by initiating information
giving that confronts the doctor’s diagnostic statement. Consider extract 3.

Extract 3: Consultation 8

01 Doc [so ] the pressure inside the ear changes then but
02 the ear itself is not infected ac[tually?,]
03 Pat --> [  yeah. ]
04 (0.4)
05 Pat --> it’s just because it feels exactly the same as it
06 --> did here when the infection started, (0.4)
07 --> I [got it in the sinu]ses first but when £I finally
08 Doc [ mm, ]
09 Pat --> visited a doctor when I realized£ it won’t
10 --> heal so now it has gone to the ear already?
11 (1.1) ((mutual gaze))
12 Doc yeah:?, (0.3) I guess (0.5) it’s wisest to put you on
13 some antibiotics and [ see ] how it (.) .hh works,

The doctor’s diagnostic statement the ear itself is not infected actually (l. 2) is a negative
formulation ruling out a diagnosis. The patient aligns with the information delivery as
she receives the diagnostic news with a response token yeah (l. 3). With this token the
patient acknowledges the diagnostic information as heard. Importantly, following the
patient’s response token the doctor could start a next topic as in extract 1. However,
this does not occur and after a short silence the patient initiates a new turn that calls
into question the doctor’s no-problem diagnosis: it’s just because it feels exactly the
same as it did here when the infection started (ll. 5–6). Thus, within this structure the
patient aligns with the preceding action of information giving by producing the relevant
acknowledgement token. However, her resistance becomes evident as she initiates a new
sequence where she gives information that is at variance with the diagnostic information
the doctor just gave.
In these sequences, by producing a new first pair part in the form of information
giving after a diagnosis delivery, the patients communicate their resistant views about
the diagnosis (cf. Stivers, 2007: 104). Initially, the patients can either misalign with the
ongoing action by withholding the reception of the diagnosis and moving directly to a
new utterance of information giving, or align with it by first receiving the diagnosis as
information and challenging it only in the next utterance. Nevertheless, both choices
of action enable the patients to avoid agreement with the doctor’s opinion, while not
showing open disagreement either. By offering alternative or additional information after
diagnostic news, patient resistance emerges as a co-operative action seeking to further
the participants’ shared understanding of the patient’s condition, rather than as a flat
rejection of the diagnosis. Through these actions the patients are able to call into question

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the doctor’s diagnostic information. Next we turn to examine the resources of knowledge
that the patients draw upon in resisting their doctors’ diagnostic statements.

Patients’ resources for resistance

Three sources of knowledge that the patients may draw upon in resisting the doctors’
diagnostic opinions were found in the data. These include: (1) present symptoms; (2)
past experiences in similar symptoms; and (3) information received in previous medical
visits with similar illnesses. Drawing from these epistemic resources, patients and parents
are able to contest the doctor’s diagnostic information. In this section we describe each
resource, respectively.

Present symptoms.  Extract 4 illustrates a case in which a patient resists a doctor’s

diagnostic information by describing her present symptom.

Extract 4: Consultation 21

((Doc examines patient’s sinuses with ultra sound))

01 Doc this doesn’t now ↑give (0.8) the kind of sign that
02 there’d be,
03 (.) ((exam continues))
04 Pat --> how come it hurts so much.
05 Doc °nii-ih?,°
06 (0.5)
07 Pat it couldn’t be in my fore°head could it, °

In her problem presentation, the patient assumed sinusitis to cause her current
symptoms (data not shown) (Gill, 1998; Stivers, 2002). In this extract from the
physical examination phase, the doctor gives pre-diagnostic commentary (Heritage
and Stivers, 1999) that rules out this possibility: the ultra sound examination does
not indicate the existence of sinus infection (ll. 1–2). Instead of acknowledging this
as information, the patient initiates a new sequence (l. 4). In her question, the patient
provides information that confronts the doctor’s preceding statement. She evokes
her present symptom (sinus pain) that only she has access to as a piece of evidence
for infection. Thus, the patient’s question brings up an undeniable indication of an
apparent problem. The doctor responds with nii (l. 5). The meaning of this Finnish
response particle is context-dependable and thus difficult to translate. In this sequential
context, following an assertion by the patient that encodes puzzlement about having
pain although there is no sinus infection, with nii the doctor recognizes the patient’s
symptom experience as being possible, even claims to share the puzzlement, but does
not contemplate its relevance any further (Sorjonen, 2001: 140–142). Following a
gap of 0.5 seconds the patient goes ahead to propose a possible explanation for her
symptoms by asking whether the infection could have spread to her frontal sinuses
(l. 7). Thus the patient evokes her present experience of symptoms to confront the
doctor’s observation of the non-existent infection.

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Past experiences in symptoms.  Patients can also refer to their past symptom experiences in
resisting the diagnosis. Consider extract 5.

Extract 5: Consultation 82

01 Doc so because you have that joint pain it’s better

02 to #take the blood sample#. (.) but otherwise the
03 impression is quite that you have a viral illness (.)
04 .hh that will indeed cure on its own #as long as you
05 just keep resting a bit and,#
06 --> (1.3)
07 li°ke [that°.
08 Pat --> [but this is indeed I mean this is indeed notably
09 --> worse than what I’ve had like let’s [say
10 Doc [mm::.
11 (0.4)
12 Pat --> for twenty thirty years so,
13 Doc mm:.

After recommending the blood sample as further examination, the doctor delivers a
diagnostic statement: the patient has a viral illness (l. 3). Although the doctor finishes
her turn with a continuer and, her creaky, lower tone of voice (ll. 4–5) indicates that
she has arrived at the completion of her turn (see Ogden, 2001 on turn-taking in
Finnish conversation). However, the patient does not take the turn. A long gap of 1.3
seconds follows (l. 6) that anticipates a possible problem in the patient’s reception of
the diagnostic news (Pomerantz, 1984). Following the gap, the doctor produces a new
completion to her turn with like that (l. 7), after which the patient launches a resisting
response by initiating a new sequence (ll. 8–12). The patient’s resistance is displayed in
his turn-initial contrast-marker but, after which he offers additional information on his
symptoms. He grounds his resistance on his past experiences with similar symptoms
claiming his present symptoms to be the worst in 20–30 years.
In extracts 4 and 5 the patients relied on their subjective, ‘life-world’ experiences
regarding the symptoms of illnesses (Mishler, 1984). This is a resource of knowledge
that is available only to the patients themselves. They did not rule out the doctor’s
diagnostic opinion but provided information so far unknown that challenged the doctor’s
diagnosis. In the following extract 6 (same as extract 2 above) the parent relies not
so much on her experience of symptoms, but rather on the information received from
another medical authority. By ‘borrowing’ another doctor’s medical authority, the parent
is able to challenge the doctor’s diagnostic statement.

Information received in previous visits

Extract 6: Consultation 68

01 Doc it would require antibiotics because the ear is infected

02 and it might be that it’s been (.) lingering there since

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Ijäs-Kallio et al. 513

03 the previous?, (0.2) infec[tion,

04 Mom --> [they did examine her ears
05 --> then and said that she doesn’t have it.,
06 Doc yeah when (0.2) you [visited,
((talk about the previous visit continues))

As recalled from extract 2, the doctor here ponders whether the baby’s long-prevailing
symptoms could be caused by an ear infection that has not been detected until now. The
doctor presents her diagnostic opinion as an option it might be (l. 2). By delivering new
information on the problem (ll. 4–5), the mother insists that the doctor’s suggestion on
the ear infection explaining the baby’s illness is not adequate: the diagnostic information
she has got from another medical authority, and not her life-world knowledge only,
proves that the baby did not have an ear infection back then. Thus, the mother implies
that the explanation for the baby’s ill condition remains open.
In sum, extracts 4–6 showed how patients and parents may deploy different epistemic
resources in resisting doctors’ diagnostic statements. In extract 6, the parent’s ‘life-
world knowledge’ and her ‘medical knowledge’ got intertwined. This is perhaps most
overt in the resource of resistance we will focus on in the last section of this article: the
patients re-invoking their initial diagnostic expectations. In using this resource, patients
draw upon the preceding course of consultation, also deploying the above mentioned
epistemic resources in arguing for their own point of view.

Re-invoking the patient’s own diagnostic expectations

The very beginning of the consultation, following the doctors’ opening question, is an
opportunity for patients to present the reason for the visit (Robinson, 2006; Ruusuvuori,
2000). These initial problem presentations may include candidate diagnoses that
encode patients’ own diagnostic expectations (Gill, 1998; Stivers, 2002). These
expectations can be re-invoked as a resource to resist a diagnosis in a later phase of the
consultation. The patients’ references to these expectations bring to the fore that they
have arrived to the consultation with particular anticipations concerning the course
and the result of the consultation and that they are willing to promote these agendas
even in the face of the doctor’s different view. Consider extract 7a from a problem
presentation phase.

Extract 7a: Consultation 8

01 Doc [.h]hh (.) right, (.) .h how’s it going,

02 (0.4)
03 Pat .hhh well (.) thanks otherwise it’s going very well but
04 (0.9) now I’ve had like (.) this winter I’ve felt that
05 I’ve had (0.3) a kind of flu that I haven’t had for many
06 years=I had terribly (.) bad sinus and ear infections
07 and I was on medication (.) .hh I finished it a ↑week
08 ago?, (.) .tch now I feel that I have symptoms in the
09 other ear that was supposed to be fine back °then°,

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In presenting her problem, the patient produces an implied candidate diagnosis (Stivers,
2002). First, she refers to her previous sinus and ear infections she had just suffered
and to the antibiotic medication she took because of these infections. After this, she
describes her current symptom (Robinson and Heritage, 2005) by creating a link between
her previous and current ailments: now I feel that I have symptoms in the other ear that
was supposed to be fine back then (ll. 8–9). The problem presentation creates a particular
context and expectation for the ensuing consultation (Stivers, 2002): it is not just any
ear pain she is seeking explanation for, but it is the pain in the ear that was supposedly
healthy during the recent infection. Later on, the patient re-invokes this expectation on
having a recurrent ear infection as she resists the doctor’s diagnostic statement. Extract
7b was initially presented as extract 3.

Extract 7b: Consultation 8

01 Doc [so ] the pressure inside the ear changes then but
02 the ear itself is not infected ac[tually?,]
03 Pat [ yeah. ]
04 (0.4)
05 Pat --> it’s just because it feels exactly the same as it
06 --> did here when the infection started, (0.4)
07 --> I [got it in the sinu]ses first but when £I finally
08 Doc [ mm, ]
09 Pat --> visited a doctor when I realized£ it won’t
10 --> heal so now it has gone to the ear already?
11 (1.1) ((mutual gaze))
12 Doc yeah:?, (0.3) I guess (0.5) it’s wisest to put you on
13 some antibiotics and [ see ] how it (.) .hh works,

In his diagnostic statement the ear itself is not infected actually (l. 2), the doctor
disconfirms the patient’s candidate diagnosis that was presented earlier on (extract
7a). The doctor’s use of the turn-ending word ‘actually’ indicates the contrast
between the views (Hakulinen, 2001). The patient resists the doctor’s diagnostic
statement by re-invoking the element she presented in her problem presentation:
the implied suggestion of a recurrent ear infection. In doing so, she employs several
epistemic resources: references to current and past symptoms (ll. 5–6) as well as
the authority of another medical professional who had diagnosed an infection (ll.
7–9). Thus, the patient maintains the idea that the current and the past conditions
feel the same. Thereby, she implies the current ailment being the same or similar
to the previous one, even though the doctor had just ruled out this possibility. By
returning to her initial diagnostic suggestion the patient re-invokes her expectation
of the result of the consultation, that is, that she has an ear infection and will be so
diagnosed. Importantly, after the patient has displayed her resistance towards the
doctor’s diagnosis, the doctor admits an antibiotic prescription even though this is
contrary to his prior diagnostic statement in line 2. This decision was not overtly
requested but still, as it appears, mutually oriented to.

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Ijäs-Kallio et al. 515

Our last example shows another case in which a patient’s diagnostic expectation is re-
invoked as resistance towards diagnosis. Consider extract 8a from a verbal examination
phase in a child patient consultation.

Extract 8a: Consultation 76

01 Doc .hh (.) can you describe it more precisely how

02 your throat’s aching,
03 (0.3)
04 Pat #w-# (.) well it feels like (0.9) well it feels like
05 when I had laryngitis the [re#
06 Doc [yeah,
07 (.)
08 Pat in the summer so it feels exactly the sa°me°. (0.8)
09 so I #thought that I have laryngitis# °a[gain°.

After the doctor has asked the patient to describe her sensation of pain, the patient (a
12-yearl-old girl) explicates a candidate understanding on a possible cause of her current
symptoms. She mentions her current symptom being equivalent to the sensation she had
during a previously diagnosed laryngitis (ll. 4–5). With her response the doctor posits
herself as a recipient of the patient’s symptom description (l. 6). After this, the patient
completes her turn (l. 8) and produces yet another unit with which she answers ‘more
than the question’ (Stivers and Heritage, 2001). There, she suggests laryngitis (l. 9). This
diagnostic expectation is re-invoked later on as the doctor and the patient’s mother talk
about the diagnosis (extract 8b).

Extract 8b: Consultation 76

01 Doc .hhh erm: (.) #e-# (.) so it doesn’t look like a

02 bacterial infec[tion but a] viral one but
03 Mom --> [ nii:, ]
04 Doc [it’s ] worth to check it with the throat cul[ture.
05 Mom --> [mm. ] [nii.
06 (.)
07 Doc this situation.
08 (0.6)
09 Mom --> .thh well the last time she had it exactly like such a
10 --> way #that erm# .hh it didn’t show (.) b[ut the]n erm::
11 Doc [ mm. ]
12 (.)
13 Mom .hh tho- (.) anyhow she was prescribed th- (.) #n# the:
14 antibiotics .h (.) and (.) then erm: .hh (1.2) we waited<
15 (.) perhaps until the next #day too (.) s- still#
16 (.)
17 Doc mm[:. ]

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18 Mom [and] only then we fill[ed it in and (.) to]ok it

19 Doc [ yeah:. (.) yes. ]
20 Mom so that not right away.#
21 (.)
22 Doc yeah I think it’s worth to make sure with that
23 cultu[re now] so that’s where you’ll see it then.
24 Mom --> [ nii. ]
25 (0.4)
26 Mom --> .thh (.) because it was just her larynx
27 --> that was in [fected. ]
28 Doc [yeah. nii]
29 so otherwise not but now that it seems to be there in
30 the (.) you said it feels the same but there in the
31 edge of the palatine tonsil it seems to be the worst (.)
32 on the #left side the# worst redness at the moment. (0.9)
33 .hhhh so (.) now you’d go to the lab and make the call
34 tomorrow since that [cultur]e takes that #much time.#
35 Mom [ yeah.]

The mother re-invokes her daughter’s candidate diagnosis as she resists the doctor’s
diagnostic statement it doesn’t look like a bacterial infection but a viral one (ll. 1–2). The
mother receives this statement with response particles nii (l. 3) and mm (l. 5). The mother’s
nii (l. 3) treats the diagnostic information as expected or already known to her (Sorjonen,
2001: 246–247), while mm (l. 5) offers a minimal acknowledgement of the information.
After this, the doctor adds a recommendation for further examination but it’s worth to check
it with the throat culture (l. 4). Again, the mother responds with nii (l. 5). As a response to
a recommendation, nii treats it only as one possible option, implying that there are other
available options (Sorjonen, 2001: 118). Therefore, this response token implies the mother’s
resistance towards the doctor’s diagnosis and recommendation. Also the doctor does not
seem to treat the mother’s response as adequate as she completes her recommendation with
an increment (l. 7) thereby pursuing the mother’s acceptance (Stivers, 2007: 109–114).
Instead of producing the projected response (acceptance), the mother initiates a new
sequence with which she resists the doctor’s diagnostic opinion (l. 9). In resisting, she
draws from various resources: the patient’s present symptoms, their experience with her
previous symptoms and the information they had received during the previous medical
visit. These resources re-invoke the diagnostic expectation that was established earlier in
the consultation. With her turn design well the last time she had it (l. 9) the mother treats
the previous and current ailments as being similar, even though the doctor suggested a
different diagnosis. Second, she juxtaposes the diagnostic uncertainty in the previous
and present consultations by linking the doctor’s failure in diagnosing with the same
difficulties they had last time she had it exactly like such a way that it didn’t show (ll.
9–10). Thereafter, the mother proposes an alternative for the next action plan by telling
about the doctor’s procedure in the previous visit: the doctor had prescribed antibiotics
to be used later if necessary (ll. 13–15, 18, 20). The doctor acknowledges the mother’s
information with a minimal response token yeah (l. 22) after which she reproduces the

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Ijäs-Kallio et al. 517

recommendation to take a throat culture (ll. 22–23). Negotiation on the diagnosis is

explicitly going on as the doctor addresses the benefits of the throat culture in diagnosing
the child’s condition so that’s where you’ll see it then (l. 23).
Again, the mother receives the recommendation with nii (l. 24), treating it as only one
possibility and withholding affiliation (as in the similar context in line 5). And again,
she initiates a new sequence delivering information about the child’s previous laryngitis
(ll. 26–27). With her turn because it was just her larynx that was infected the mother
treats the current diagnosis as insufficient and her own contrary knowledge about the
previous diagnosis as relevant. The doctor acknowledges this expectation by addressing
the patient’s symptoms: you said it feels the same (l. 30). However, by explicating her
clinical findings the doctor opposes the candidate diagnosis of laryngitis and argues
for the throat culture once more (ll. 33–34). As a result of this lengthy negotiation, the
mother seems to accept the recommendation (l. 35).
In sum, one resource that the patients may use in resisting the diagnosis given by a
doctor is to re-invoke their diagnostic expectations that have been established earlier in
the consultation. By referring to their candidate diagnoses, the patients bring to the fore
their own understanding of the expected result of the consultation. In insisting upon the
validity of their own diagnostic expectations, the patients deploy the other resources of
resistance: present and past experiences of symptoms and information received from
other medical authorities. As examples 7b and 8b showed, the patients’ participation in
the discussion about the diagnosis was consequential for the conduct in the consultation:
granting a prescription even though it was against the doctor’s diagnosis (extract 7b) or
resulting in a lengthy negotiation on the next action plan (extract 8b).

Discussion
After the patient’s resistant turn the doctor is in the position of information receiver, not
vice versa (cf. Schegloff, 2007: 16–19). In US data, Stivers (2007) showed how parents
initiate resistance by inquiring about the symptoms and diagnoses. Through questioning,
the parents display their reluctance to accept a diagnosis that indicates no-treatment
decision. In Finnish data, Peräkylä (2002) has shown that patients resist diagnoses by
offering additional or alternative information to the diagnosis presented by a doctor. The
results presented here support both observations. Patients have available both sequential
and epistemic resources to further their own diagnostic views. Here we have specified
the grounds of some of these resources and shown how in deploying these resources
patients’ life-world and medical knowledge get intertwined. This is perhaps most evident
when patients re-invoke their initial diagnostic expectations. Within this resource patients
regard their views on the nature of their illness as strong enough to compete with their
doctors’ diagnostic statements. As we have seen, insisting upon retaining the patient’s
own agenda may also have consequences for the actual medical decision. This suggests
that at least some patients consider their experience-based knowledge on the illness as
adequate as the diagnostic knowledge offered by a medical expert, and as a valid basis
to plan future treatment of their illness. Medical expertise that is invested in the doctor’s
examination-based diagnosis delivery may not be sufficient to convince patients of the
benefits of the recommended treatment or further examination. However, despite that

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518 Health 14(5)

some patients challenged the diagnostic information and insisted upon an alternative
view on the diagnosis, resistance was displayed cautiously and accounted for. Instead of
plainly rejecting the diagnosis, the patients introduced more and alternative information
for the doctors to re-evaluate their medical decision. Nevertheless, they oriented to
diagnosis as something that can be negotiated and that is based on their own knowledge
as well as the doctor’s view on the situation.
These observations have implications for how we understand concordance in medical
interaction. As the previous studies have shown, patients rarely, if ever, contest their doctors’
views in terms of medical reasoning (Gill, 1998; Peräkylä, 2002). However, as we have
seen here, patients may orient to the diagnostic information given by doctors as negotiable,
as something on which they have a say also upon hearing the doctor’s diagnosis. Further,
in giving grounds for their alternative views on the diagnosis patients may not only resort
to their symptom experiences but also on medical knowledge received in previous visits.
Through these practices patients and doctors negotiate, and gain a shared understanding on
the patient’s illness. We suggest that these practices can be seen as ‘interactional constituents
of concordance’ (cf. Peräkylä and Ruusuvuori, 2007). They seem to corroborate the
definition of concordance as ‘an agreement reached after negotiation between a patient and
a healthcare professional that respects the beliefs and wishes of the patient in determining
whether, when, and how medicines are to be taken’ (Dickinson et al., 1999). Further, the
patients’ introduction of new information seems to contribute to the possibility of making
‘choices that are as well informed as possible about diagnosis and treatment’ (Dickinson
et al., 1999). By responding to their patients’ initiations of information exchange, and by
giving grounds to their own view on the diagnosis in light of the new information presented,
the doctors also orient to the diagnosis as negotiable.
Further, our findings on the negotiability of the diagnosis suggest that in order to
achieve a concordant view on treatment decision, doctors and patients take steps to
achieve agreement on the nature of the medical problem itself (diagnosis) before seeking
a solution to treat it (treatment decision). Therefore, we suggest that the concept of
concordance could be stretched to concern not only treatment decision making and
medicine taking, but the whole consultation. Concordance is something that starts to
emerge from the very beginning of the medical encounter, as a result of doctor–patient
interaction where the participants work to reach a shared understanding of the reason for
the visit, the diagnosis, as well as the treatment decision (Stevenson et al., 2004; Weiss
and Britten, 2003). This observation has potential for application in medical training. The
knowledge of patients’ often implicit ways of resisting diagnoses may help to observe and
take into account potential threats to maintaining shared understanding of the treatment
decision in the consultation, and thus also to later adherence to treatment (Stevenson et
al., 2002). In pursuing concordance with their patients, it could be profitable for doctors
to pay attention to patients’ diagnostic expectations, however implied, and address rather
than disregard them during the consultation (cf. Perrin et al., 2000).
What remains unresolved is whether the seemingly unproblematic cases of the patient
simply acknowledging the diagnosis as information actually constitutes its acceptance.
This calls for further research on different formats of responding to the diagnosis
and treatment decision compared with the rates with which patients actually take the
medication prescribed. As we pointed out, the diagnosis itself (that forms a basis for

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Ijäs-Kallio et al. 519

treatment options) can be a negotiable matter between a doctor and patient. Thus,
research on the ways of achieving agreement on the diagnosis and the description of the
patients’ range of accepting vs rejecting responses, together with investigating these with
regard to the patients’ subsequent use of medicines, would contribute to our knowledge
on ‘best practices’ in terms of health outcomes. Combining CA with relevant outcome
measures offers a potentially fruitful way to investigate these questions. It should also be
noted that patient resistance towards diagnosis was analysed here in a particular setting
of upper respiratory tract infections. Many people experience these illnesses perhaps
even several times a year, and gain experience-based and medical knowledge on the
ailment. Available resources for patient resistance could be different in unfamiliar acute
conditions or in chronic illnesses the patients have learned to deal with (Perrin et al.,
2000). However, investigating the specific context with patients who are knowledgeable
on their illness may help to unravel the questions of increasing consumer orientation in
health care (Hardey, 1999).
There is currently some debate on the ways in which the term concordance fits the
models of decision making. Horne et al. (2005: 113–114) point out how concordance
embodies characteristics from both shared decision making (decisions made together
by doctors and patients) and informed decision making (the patient is responsible for
decision making). In our data, overwhelmingly, the interaction between the doctor and
the patient in diagnostic and treatment decision making better fits with the former than
the latter model. Even the consultations where the patient rather overtly resisted the
doctor’s diagnosis and treatment decision (extracts 7b and 8b), depicted negotiations
that resulted in the doctor making the decision either pro or against the patient’s opinion,
rather than the patients’ informed decisions.
Horne et al. (2005) suggest that the multifaceted nature of the term concordance would
be difficult to operationalize for scientific purposes. However, we have found it useful
as it encompasses not only the interactional process of decision making but also points
at the importance of unravelling the role of lay vs medical expertise in this process.
Concordance means partnership between a doctor and patient and considering the patients’
views as equally valid as the doctor’s opinion as a medical expert. Here we have offered
one viewpoint to concordance in practice – what sort of actions amount to efforts towards
shared understanding and agreement on the proper diagnosis and treatment for the patient.

Appendix 1:Transcript notation

word. period marks lowering pitch (turn-ending)
word, comma marks level pitch (turn-ending)
word? question mark marks rising pitch (turn-ending)
<word> talk produced on slower pace than surrounding talk
>word< talk produced faster than surrounding talk
↑word word/sound uttered with higher pitch
↓word word/sound uttered with lower pitch
°word° talk/sound produced in silent voice
.word word/sound uttered while breathing in
[word onset of overlapping talk
word] offset of overlapping talk

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520 Health 14(5)

#word# talk/sound produced with creaky voice

=word utterance started immediately after preceding one ends
WORD capital letters mark talk/sound uttered in high volume
word underlying marks stressed words/sounds
wo:::rd colons mark prolongation of words/sounds
word< word/sound cut-off or ended abruptly
£word£ smiley voice
wo(h)rd talk/sounds uttered with laughter
(word) word/sound unclear for transcriber (the best guess in brackets)
(5.5) pause in talk in seconds and tenths of seconds
(.) micro-pause (less than 0.2 seconds)
.hhh inhale
hhh exhale
((note)) transcribers notes, e.g. gestures ((nods))

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Author biographies
Taru Ijäs-Kallio, M. Soc. Sc, is a graduate student in social psychology in the Department of Social
Research, University of Tampere. She is writing a doctoral dissertation on diagnostic and treatment
decision making in Finnish primary care consultations. Her research interests include interactional
constituents of patient participation and professional–client relationship in health care.

Johanna Ruusuvuori, Dr. Soc. Sc, is a senior assistant professor in social psychology in the
Department of Social Research, University of Tampere. Her research interests include medical
interaction, emotion in social interaction, changing professional–client relations in various contexts
of health care, and the role of facial expression in face-to-face interaction.

Anssi Peräkylä, PhD, is a professor of sociology in the Department of Sociology, University

of Helsinki. His current research interests include interaction in medical consultation and
psychotherapy. He is also studying facial expressions in emotional interaction, and interaction and
emotion between a baby and care-taker.

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