___________________________________________________________________________

APPENDIX ONE
An example chapter from a BA project
Ghita (2012)
CHAPTER THREE
RESEARCH METHODOLOGY AND DATA COLLECTION

3.0 Introduction

The main purpose of this chapter is to will deal with the description of the research I
conducted in a Clinic County Hospital on doctor-patient interaction. This is meant to show the
connection between the theoretical framework of this paper and the research I chose to carry
out. This chapter sheds light on the following methodological issues: topic of the research, the
hypothesis and research question, the type of data and data collection method, access to data
and ethical issues, the setting and subjects of the research.
Although the stages of my research methodology are somewhat clear, I must confess that
there is a constant smoothening of my research questions so as to achieve the highest degree
of reliability possible in this project.

3.1 Topic

The topic of this research deals with the unequal distribution of power in the doctor-patient
consultation and attempts to explain how existing conventions according to which doctors
interact with patients linguistically actually entail hierarchisation. The exercise of power in
the modern society is increasingly achieved through language and therefore, developing a
critical consciousness of domination is required. The prevailing sociolinguistic order that
places the doctor in a position of power in relation to his/her patient is sustained by the
linguist Fairclough (1989) and by Cordella (2004) who conducted a study on the analysis of
doctor-patient discourse. In the introductory chapter of his 1989 book, Fairclough makes the
following statement:
‘My main focus in this book will be on trying to explain how certain conventions are the outcome of
power relations and power struggle. My approach will put particular emphasis upon ‘common-sense’
assumptions which are implicit in the conventions according to which people interact linguistically, and
of which people are generally not consciously aware. An example would be how the conventions for a
traditional type of consultation between doctors and patients embody ‘common-sense’ assumptions
which treat authority and hierarchy as natural – the doctor knows about medicine and the patient

1
 doesn’t; the doctor is in a position to determine how a health problem should be dealt with and the
patient isn’t; it is right (and ‘natural’) that the doctor should make the decisions and control the course
of the consultation and of the treatment, and that the patient should comply and cooperate; and so on.’
(Fairclough, 1989: 2)

This excerpt that I provided in support of my research basically treats the doctor-patient
interaction as an example of social conventions that generate a certain social order which at its
turn is mainly accomplished through language. This is enough to prove that this topic is
worthy of attention as in our contemporary society, language seems to cater to a wide variety
of purposes in a wide variety of domains, including the medical one. Citizens should not
neglect the power and the effect of language and that it can discretely operate within the
society so as to create communicational gaps. However, this exercise of power can be twice as
damaging as the mistreated part does not have any visible trace of the abuse (i.e. physical
violence) and thus, his awareness of the phenomenon is compromised.

A patient who does not possess health literacy skills may think that he has no right to question
the doctor’s decisions or to gain additional information about the diagnosis or treatment plan
imposed on him. This occurrence is due to the fact that from the very beginning of his verbal
exchange with the doctor, the patient assumes that he is not on an equal footing with the
doctor and that it is his duty to adhere to everything that the doctor says. Most patients do this
unconsciously because they do not realize that they are dealing with constraints that are the
result of social norms.

What is more, this repetitive pattern that places the patient in an inferior position in
connection to the doctor is ‘ a means of legitimizing certain existing social relations and
differences of power simply through the recurrence of ordinary, familiar ways of behaving
which take these relations and power differences for granted.’ (Fairclough, Norman, 1989: 2)
Not to mention the fact that laymen are not aware of the hidden factors that lead to the
creation of the asymmetry in this type of event and for this reason, this manner of interacting
is perpetuated in the same way as with a habit. The question is whether we can state for sure
that this type of interaction, where the participants know their standing beforehand is a good
or bad habit.
Furthermore, Cordella (2004:6) adopts a less vehement approach to medical discourse as she
provides the following definition:
‘Doctors and patients find themselves engaged in a discourse in which the manner whereby the
technical information is conveyed may be as important as the information itself. The doctors’ forms of

2
 talk may either help or hinder the patient’s understanding and cooperation and the exercise of power is
representative of this asymmetrical interaction in discourse.”

From her perspective, we can deduce the fact that the superior-inferior relationship that gives
rise to hierarchisation in its linguistic form can be attenuated provided the doctor carefully
selects the way in which he speaks to his patients. This is a matter of language adaptation to
serve the needs of the patient and to help him take in the information he is given as well as a
matter of receiving appropriate feedback with a view to mutual contentedness with the
consultation. This cautious construction of meaning on the part of the doctor is meant to have
a conciliating effect and enable cooperation in talk that will ultimately lead to efficient
communication.

3.2 Research Questions

• RQ1. How do doctor and patient create meaning in interaction?

The aim of this research question is to analyze how meaning is created by looking at the
language used by the doctor and his patients within their consultations and to see whether the
doctor’s use of medical jargon or the patients’ level of health literacy create
misunderstandings. To offer a response to this research question I will rely on Chapter 3, but
mainly on sections 2.1.2 and 2.2.3.4. Therefore, the following sub-questions derive from the
above:
a. How does a patient’s level of health literacy influence on the degree of
understanding? What are the signs of low health literacy?
b. Can the doctor detect the patient’s level of health literacy and adapt to it?
c. Is the patient’s low health literacy a cause of miscommunication?
d. Do the participants use error handling and recovery strategies?

These questions are particularly relevant because the subjects on whom I chose to conduct my
study are elderly hospitalized patients. As research has shown, there is a linkage between low
health literacy and hospitalization (Baker, 2003), and since the elderly are known to have an
inadequate health literacy mainly due to their decreasing cognitive abilities, it is extremely
important to see whether the doctor is aware of these aspects and succeeds in adapting to the
patient’s type of exposing suffering.

3
 • RQ2. What is the prevalent communication style adopted by the doctor in the
consultations?

My second question seeks to further examine the manner in which the doctor approaches the
patient to see whether he can adapt to the patient’s narrative patterns and specific way of
exposing suffering. Moreover, as healthcare professional a doctor must have at all times an
attitude that can engender patient trust and confidence. Actually, this research question is
meant to detect the doctor’s interactional style and to discover whether he preserves it, or on
the contrary, he changes it from patient to patient. For this purpose, I will bring into
discussion the notions of patient-centered communication and non-verbal behavior as I will be
trying to answer the following sub-questions:

Ø Is the patient an active or passive participant?

Ø Does the doctor allow the patient to elaborate his suffering?
Ø Does the doctor show empathy?
Ø Does the doctor show a tolerant or moralizing attitude?
Ø How important is non-verbal behavior in terms of doctor-patient cooperation?

• RQ3. Is medical history taking a form of institutional talk?

The aim of this question is to reveal whether the question-answer sequence is dependent on
the type of activity in which both doctor and patient are engaged. To answer this question, I
will revisit my analytical framework. Basically, I will go back to Heritage’s (2004) concept of
‘institutional talk’, namely section 2.2.4 and to Levinson’s (1992) notion of ‘activity type’
that can be found under section 2.1.1 so as to clarify the way in which the participants are
‘goal-driven’. Apart from looking at the doctor’s and the patient’s agenda in the medical
interview, I will also try to uncover the overall structure of the interaction and go into detail
about turn design and lexical choice. In this way, I want to see whether the participants are
oriented towards their institutional identities and whether the inferences made in the
interaction are specific to the context in which the participants are involved. What is more, my
other endeavor is to bring to light the stances, ideologies, identities and asymmetries that
emerge within medical history taking.

3.3. The type of data and data collection method

4
The data I used in my research are naturally occurring conversations that can reveal a wide
variety of interactional features. As a matter of fact, the natural conversations that I collected,
i.e. conversations where the researcher is an observer, are particularly interesting for
conversation analysts and interactional sociolinguists. The data I used for my research are
directly linked to the research questions I have raised in the previous section of my paper and
the hypothesis according to which medical discourse is an example of asymmetrical
interaction. Moreover, my data type is relevant for the emphasis I decided to put on context
by choosing to collect my data in an institutionalized setting that is a clinical county hospital.

In addition, my interest in finding out how interaction is organized in this social setting (i.e. a
hospital) urged me to consider recording natural conversations that I turned into my object of
analysis. My decision to collect natural conversations has been of real value to my study as I
could portray the healthcare delivery process and its interactional features. This is also the
main reason why Conversation Analysis became a legitimate method of analyzing my data
since its role was to help me comprehend the unfolding of the doctor-patient interaction and
how communication influences the outcome of the consultation.

The above aspects are extremely valuable as the conversations (see Appendix I and II) I
recorded in the hospital render the process of medical history-taking of a patient by a
physician. In fact, the doctor-patient conversation is the methodological foundation for the
process of medical history-taking as Boloșiu (1993) explains, because this medical history or
anamnesis (abbr. Hx) is information received by a doctor after a series of questions meant to
help the physician in the formulation of his diagnosis and choice of treatment plan. I will
expand on this issue in Chapter 3, where I will expand on the features of this type of
consultation that make it a structured inquiry similar to an interview.

Furthermore, out of seven recordings of natural conversations that I prepared for my corpus, I
have only used four as I consider them to be the most relevant to my present study and
because they best serve as an example for the unfolding of a medical-history taking. The four
conversations (see Appendix II) that I have selected to be at the core of my study proved to be
a reliable source of information as they are illustrative for the relevance of my research
questions and for revealing important interactional features within a consultation.

5
In order to record the data I used a state-of-the-art digital voice recorder incorporated with
voice recognition software whose features proved an asset to the quality of my data. Apart
from its small size that didn’t distract patients’ attention and thus, the flow of the medical
inquiry, the sound quality was another invaluable advantage when it came to the process of
transcribing the data. In order to transcribe the data, I transferred the compressed audio files in
an mp3 format to my computer and downloaded an audio editor programme that gave me the
possibility to obtain a maximized sound clarity and perform a series of tasks such as level
balancing.

3.4. Setting and participants

Initially, when I thought about analyzing medical discourse, a lot of ideas of where I could
seize and exploit instances of medical language in use sprang to mind. I came to think about
studying the discourse in popular medical drama television series such as House MD or
Grey’s Anatomy because it was easy to gather the data as I could have
used the transcripts available on-line as the object of my analysis. Soon, I came to realize that
this is to a great extent, artificially created language and thus, I excluded this possibility
because it didn’t pose a challenge to me as a researcher. Therefore, I immediately directed my
attention towards naturally occurring language and this stimulated me to go searching for an
institution where medical discourse (i.e. doctor-patient interaction) is a daily practice. This is
how I came to take into consideration the following settings:
• a student dental office in a student complex;
• a family practice medical office;
• a hospital such as an emergency hospital, children’s hospital, geriatric hospital,
psychiatric hospital, a teaching hospital etc.

By analyzing them one by one, I came to the conclusion that there is a low chance of
gathering sufficient data and thus, extracting relevant instances of language in use for analysis
from the dentist- patient verbal exchange. After leaving out this option, my next attempt to
record the conversation between a family practice physician and its patients proved hard to
accomplish due to a series of social factors. The ties between a Romanian family physician
and its patients are very close knit and the relationship they develop is personal to the extent
to which a researcher’s participation as mere observer to the consultation would have been
obtrusive and both deliverer and receiver of care would have perceived me as an intruder. Of

6
course, this would have had a negative effective on the accuracy of my research findings and
on the quality of my data because my presence would have probably instigated the doctor and
the patient to alter their language. After weighing this aspect, I excluded this possibility as
well and finally, I opted to gather my data in a hospital.

However, I must state that both methodologically and practically the choice of setting was
limited and gaining access to the emergency county hospital where I decided to conduct my
research was even more difficult (see section 5.5.). Because I was looking for an institutional
setting where the creation of medical discourse comes with the job of being a doctor and with
the laymen’s need to see a doctor, the final decision of the setting was adequate for the
purpose of my research. Conducting my research in a hospital provided me with a multitude
of possibilities for my chosen setting had many units such as emergency unit, neurology,
pathology etc.

However, my work has been considerably improved by the fact that the hospital had an
outpatient and especially, an inpatient department. This latter department where patients are
admitted to the hospital and stay for an undetermined period of time in which they receive
inpatient care (i.e. treatment and diagnosis) became my point of interest. Therefore, my final
decision was that of recording doctor-patient consultations in the inpatient department ward as
doctors would take patients’ medical history during their rounds. Furthermore, because I
noticed that the vast majority of the hospitalized patients in the inpatient department were
elderly, I immediately decided upon recording conversation between a doctor and some of his
elderly patients so as to attempt to obtain homogeneity of variances to my study that would
further enable me to analyse and compare somewhat similar data.

Given the above mentioned, the participants in my study are four elderly patients and their
doctor who is a Romanian internist. The patients who are referred to as P1, P2, P3 and P4 are
all retired and their ages vary between 58 and 84 and the doctor who is referred to as D is a
man about 40 years old. In addition, P1, P2 and P4 are female participants whereas P3 is a
male participant and surprisingly, his medical history taking took approximately 14 minutes
to complete. The consultations in the case of P1, P2 and P4 correspond to 5, 8 and 9 minutes
long recordings.

7
The linguistic collision between the doctor’s choice of lexical items and that of the patient
became obvious from the first consultation that I recorded. This clash between the
professional and the layman, respectively the deliverer and receivers of care became obvious
in all four conversations that I chose for analysis and the legitimacy of my research questions
became clear as there is a visible discrepancy between the vocabulary used by the doctor and
the vocabulary that his patients use. Therefore, the participants of my study offer the external
validity of my study as their interaction in a formal setting creates a reality where ‘discourse
constitutes the social’ (Fairclough, 1992:8) and thus, the language they use becomes worthy
of analysis. Not to mention the fact that ‘discourse is shaped by relations of power and
invested with ideologies’ (Fairclough, 1992:8). Therefore, the participants of my study who
are Romanian native speakers embody these ideologies and help me reflect the relations of
power that come into existence whenever they interact linguistically.

3.5 Access to data and ethical issues

In this section I will give a thorough explanation of each step I took in order to gain access to
the clinical county hospital where I conducted my research and to my data. Moreover, the way
in which I managed to obtain access to the participants is explained with the awareness that
‘the researcher is responsible for protecting ALL participants against any harm that might
arise from their participation’ (Allwright, 1992, cited in Coposescu, 2003).

The key ethical principles that I adhered to during the process of data collection in a
healthcare institution were the following:
ü to respect the participants’ autonomy and their right to choose whether they wanted to
be recorded or not;
ü to refrain from any type of coercion or manipulation that could deceive the patients or
the doctor into becoming participants of my study;
ü to obtain informed consent from participants;
ü to assure the participants of their anonymity and privacy in the research;
ü to inform truthfully the participants about the purpose of my study and the goals of my
research ;

Having these ethical principles in mind, I asked for the help of a professor who teaches at a
Faculty of Medicine, but unfortunately I cannot reveal his name for reasons of confidentiality,

8
although I am overwhelmed with gratitude for his help. Not only did this professor approved
of my idea which to put it in his words ‘It’s brilliant because you can reveal the amount of
physical and psychical energy a doctor invests when dealing with hospitalized patients’, but
he also gave me an insight into hospital practices and informed me about the difficulties of
communicating with elderly hospitalized patients. This was the main reason why I decided to
deal with elderly hospitalized patients as they are part of the vulnerable population and they
often complain of being neglected or that their needs are being paid little attention to none,
especially by clinicians.

This professor directed me towards an influential figure in a clinical county hospital who had
the benevolence of allowing me to record some conversations. Of course, I assured him of the
confidentiality of the setting, data and participants after he expressly cautioned me that
revealing details of a medical history could make me and the hospital liable to legal charges.
Between the two of us, we arranged for a week in the month of February when I could be
allowed to the hospital’s wards so as to gather my data. Therefore, on the pre-arranged days, I
went to the hospital and accompanied the internist who was on call and recorded the
consultations he performed during his clinical rounds.

After a couple of days, when I started transcribing my data, I realized that I could only use
two of them because the sound clarity of the others made the process of transcription
practically impossible. Consequently, I went back to the hospital in the month of March to
complete my data, but this time my request was met with a polite refusal. However, I was
fortunate enough to meet the internist whose talk exchange with his patients I had previously
recorded and he gave me the support I needed. He gained his superiors’ consent to record his
conversations with his patients and after I told him that the data would be confidential and
that his name as well as those of his patients would remain anonymous, he agreed to give me
four more recordings out of which I selected only two for analysis.

Therefore, two of the four conversations that I chose to use as my data and are conventionally
marked as Data1 and Data2 had me as an observer, in my quality of researcher, and the other
two, namely Data3 and Data4 were not recorded in my presence. As a consequence, Data1
and Data2 allowed me to transcribe non-verbal information (see Appendix II, Data1, lines 23,
25) and non-verbal behavior (see Appendix II, Data1, lines 35,74), whereas Data3 and Data4
do not include any of the two categories. Actually, this is what prompted a subsequent

9
research question as I realized that non-verbal information and non-verbal behavior is
extremely useful for me as a researcher since the former explains the pauses and the latter can
account for a valid answer, but these are all aspects that I will further analyse in Chapter four,
section 4.4.2.

As I mentioned before, I assured the participants of their anonymity in this research paper, by
using a neutral notation (i.e. ‘D’ for the internal medicine doctor, ‘P1, P2, P3, and P4’ for the
patients) instead of using the initials of their real names or even more unethically, their real
names. Due to ethical issues, I decided to start recording the conversations after the internist
had established the initial rapport (i.e. the doctor greeted the patient, introduced himself,
asked the patient for his name) and after I had introduced myself and clarified my role, giving
the patient an outline of what my goals were.

Another ethical issue I was confronted with was when P3 gave one of his doctor’s name and
the hospital where she works. When transcribing the data, I decided to use this symbol ‘~’
that replaces confidential data such as the doctor’s workplace and name (see Appendix II,
Data3, lines 43, 44). But after dealing with this situation, I realized that certain details in the
transcripts could harm the confidentiality of the setting so I had to hide some other deleterious
information with an ‘~’. Moreover, so as not to harm my participant’s privacy in the slightest
I have also decided not to reveal any information that related to their address (see Appendix
II, Data1, lines 29, 31), workplace (see Appendix II, Data3, line 74) etc.

Furthermore, I informed the participants of my willingness to communicate to them the

findings of my research, but the internist alone proved to be interested in the topic and wanted
to read my final paper as he believed my findings could actually help him be a better
communicator. In what the patients are concerned, they all expressed their desire to help me
in my quality of research student, but they all felt that my findings would not make doctors
change the way they interact with them. This judgment together with limitations of space and
time were the reasons why patients were unwilling to offer their feedback at a later date.
However, all elderly patients advised me to try to obtain feedback for my analysis from the
doctors as the general comment was that doctors should learn to speak “patient language”.

3.6 Conclusion

10
This chapter was meant to shed light on important aspects of my research methodology such
as research questions, the type of data and data collection method I have used and also on the
ethical principles that have guided my research. Also, it is extremely important to mention
that I tried to preserve the privacy and anonymity of the subjects by not revealing their names,
and concealing any detail that might reveal their true identity. Moreover, I have also made a
diligent work to preserve the confidentiality of the institutional setting where the recording of
the data took place.

11
___________________________________________________________________________
APPENDIX TWO
Cover and front pages
UNIVERSITATEA TRANSILVANIA DIN BRASOV
FACULTATEA DE LITERE
PROGRAMUL DE STUDII UNIVERSITARE DE LICENŢĂ:
Limba şi literatura română – Limba şi literatura engleză
Forma de învăţământ: la distanţă (ID)
(size: 18 points)

LUCRARE DE DIPLOMA
(size: 20 points)

Absolvent
(size: 18 points)

Coordonator
(size: 18 points)

Brasov
2013 (size: 18 points)

12
TRANSILVANIA UNIVERSITY OF BRASOV
FACULTY OF LETTERS
DEPARTMENT OF DISTANCE LEARNING
ROMANIAN - ENGLISH
(size: 18 points)

BA PROJECT
(size: 24 points)
(example title)

THE SYMBOL OF THE SEA IN

E. M. HEMINGWAY’S NOVEL
‘THE OLD MAN AND THE SEA’
(size: 18 points)

Candidate

(size: 18 points)

Supervisor
(size:18 points)

Brasov
2013 (size: 18 points)

13
 ___________________________________________________________________________
APPENDIX THREE
Example Contents pages

Ghita (2012)
The Convergence of Language and Authority in Healthcare
Communication: Medical discourse and the distribution of power in doctor-patient
interaction.
TABLE OF CONTENTS

Table of contents ………………………………………………………………....

Abstract …………………………………………………………………………..

CHAPTER ONE: Introduction ………………………………………………….

1.1 Purpose of the study………………………………………………………
1.2 Outline of the study…………………………………...........

CHAPTER TWO: Analytical framework

2.0 Introduction ……………………………………………………
2.1 Achieving understanding as linguistic cooperation………………
2.1.1 Meaning in context…………………………………………………
2.1.1.1 Sociolinguistic approaches to context…………………..
2.1.1.2 The pragmatic perspective on context………………….
2.1.2 From cooperation to miscommunication…………………………..
2.1.2.1 Types of miscommunication and error handling…………
2.1.2.2 Repairs as error recovery strategies…………………..
2.2 Conversation analysis and institutional talk…………………………………….
2.2.1. Ethnomethodology and the origins of CA………………………………
2.2.2 Generalities on CA ……………………………………..
2.2.3 The extent of studies in healthcare interaction………
2.2.3.1 CA research on the medical interview……………
2.2.3.2 Non-verbal behavior in doctor-patient interaction…
2.2.3.3 Patient-centredness in the medical interview……..

14
 2.2.3.3.1 Patient-centredness vs. the biomedical approach……
2.2.3.3.2 Approaching the patient and ‘examiner’ qualities……
2.2.3.3.3 Patient narrative patterns…………………
2.2.3.4 Health literacy as a demand in the healthcare dialogue……….
2.2.4 Defining institutional talk…………………………………..
2.2.4.1 The overall organization of institutional talk………………….
2.2.4.2 Power and asymmetry in institutional talk……………
2.3 Conclusion……………………………………………………………..

CHAPTER THREE: Research methodology and data collection…………….

3.0 Introduction …………………………………………………………………
3.1 Topic of the research
3.2. Hypothesis and Research Questions
3.3 Data collection type and method …………………………
3.4 Access to data and ethical issues…..
3.5 Setting and participants …………………………………...
3.6 Conclusion

CHAPTER FOUR: Analysis of data

4.0 Introduction………………………………………
4.1 The process of transcription…………
4.2 Features of talk represented in the transcription………….
4.3 Transcription conventions………….
4.4 The construction of meaning in doctor-patient interaction
4.4.1. Elderly patients and the level of health literacy
4.4.2 The doctor’s communication style
4.5. Medical-history taking as institutional talk
4.5.1. The overall organization of medical history taking
4.5.2 The Question-Answer sequence
4.5.3 Turn design and lexical choice
4.6 Conclusion

CHAPTER FIVE: Conclusions

5.0. Introduction

15
5.1. Summary of findings………………………………………….
5.2. Limitations of the study…………..
5.3. Implications for further research

References
Appendices ………………………….
Appendix 1 - Romanian Transcription of Conversations
Appendix 2 – English Transcription of Conversations
Appendix 3 - Foaie de observatie clinica
Appendix 4- The Calgary- Cambridge guide to the medical interview

16
_____________________________________________________________
APPENDIX FOUR
An example Literature review chapter
Ghita (2012)
CHAPTER TWO
ANALYTICAL FRAMEWORK

2.0 Introduction
The aim of this chapter is to shed light on some important theoretical aspects that I have
chosen to discuss about in my paper due to their relevancy to my research. Therefore, this
chapter is organized into two main sections according to which I have performed the analysis
of my data. As a matter of fact, section 2.1 deals with three main concepts such as meaning,
meaning in context and miscommunication. Thus, I have tried to explain how meaningful
interaction is created and then maintained by handling and recovering from all sorts of errors
that occur while communicating. On the other hand, section 2.2 focuses on two important
concepts such as conversation analysis and institutional talk. Actually, section 2.2 starts with
a presentation on CA, its features and its contribution to the field of healthcare interaction
research and ends with a global overview on institutional talk (i.e. overall structure, power
and asymmetry).

2.1 Achieving understanding as linguistic cooperation

First of all, I have started this section from the assumption that all people want to obtain
something by communicating and for this purpose they use a lot of linguistic strategies. In
Wardaugh’s (2006:9) view people use a code when communicating, and this code is actually
what we call language. This language actually represents shared knowledge when
communication happens between individuals that speak the same language. Consequently,
language becomes a ‘communal possession’ (Wardaugh,2006) and this is relevant for my
paper because the participants of my research are native speakers of Romanian, that is they
use language and understand each other’s utterances because they had access to and learned
how to appropriately use the same language.

Moreover, this shared knowledge of language combines with knowledge of how to use
language. As a matter of fact, Chomsky (1968) made a distinction between ‘competence and
performance’ in a language, the latter referring to what speakers choose to do with it.

17
Performance or ‘communicative competence’ as it is also called brings forth the social aspects
revolving around language. In addition, sociolinguists such as Hudson (1996) conclude that
language is made up of ‘linguistic items’, such as sounds, words, grammatical structures and
so on and it is on these aspects that Chomsky focuses in his ‘asocial view’ of language
(Wardaugh, 2006:10). On the other hand, sociolinguists try to understand how societies are
structures and thus, work with concepts such as ‘power’, ‘class’, ‘ideology’, ‘status’,
‘solidarity’, ‘face etc.

But, critics such as Cameron (1997) who adopts an ‘interventionist approach’ suggest that
sociolinguists should ‘deal with such matters as the production and reproduction of linguistic
norms by institutions and socializing practices; how these norms are apprehended, accepted,
resisted, and subverted by individual actors and what their relation is to the construction of
identity’(cited in Wardaugh, 2006:12). This work has been called ‘linguistics with a
conscience and a cause, one which seeks to reveal how language is used and abused in the
exercise of power’ (Widdowson 1998, in Wardaugh, 2006:15).

Actually, this view is adopted by Fairclough (1996) and Van Dijk (1993) who developed the
branch of ‘critical discourse analysis’ in order to reveal how the conventions that people use
to interact linguistically are the outcome of power relations. As my paper is entitled ‘The
convergence of language and authority – medical discourse and the distribution of power in
doctor-patient interaction’, I will expand on the works of Fairclough and Van Dijk so as to
enlighten the reader on the ideology behind medical discourse because “the conventions for a
traditional type of consultation between doctors and patients embody ‘common-sense’
assumptions which threat authority and hierarchy as natural” (Fairclough, 1996:2). The
inference that we can draw form this statement is that the doctor has the ‘right’ to control the
course of the interaction whereas the patient should cooperate no matter what.

Furthermore, when we speak or write, we try to make our contribution to an act of

communication as appropriate as possible to the particular situation in which we are
communicating, and, at the same time, how we produce those specific utterances is extremely
important to the very “birth” of the situation: ‘We fit our language to a situation or context
that our language, in turn, helped to create in the first place’ (Gee, 1999: 11). What is more,
we try to recreate the structure of reality each time we speak, leaning on the upgraded version
of language, i.e. language as discourse. The latter one refers to language used in tandem with

18
non-linguistic cues and symbol systems, tools, actions, interactions, technologies, and
particular ways of thinking, feeling, or believing.

In face- to- face interaction or spoken discourse what one will utter in a particular situation
and how his utterance will be interpreted depends on aspects such as knowledge of what the
encounter is about and what its purpose is. As a result, meaning in language depends on the
social and psychological conditions that force it into existence. Thus, individuals’ beliefs,
attitudes, opinions are expressed by means of language use. For example, my data that
consist of doctor-patient conversations encompass the constitutive meaning (i.e. attitude,
opinion about medical consultations) that manifests itself in every utterance as well as the
descriptive meaning that is the result of interaction, describing the norms and conventions
entailed by a consultation.

Taking into consideration the fact that meaning both shapes and is shaped by social reality, it
becomes obvious that my attempt to reveal what the level of understanding in a doctor-patient
interaction is and whether misunderstandings or other form of failed linguistic cooperation
occur should consider a variety of implications. Moreover, my interpretation of
misunderstandings or other possible form of miscommunication demands an accurate
description of what is going on at that precise moment. Only by keeping in mind that
‘meaning is dynamically generated in the process of using language’ (Thomas, 1995;
Verschueren, 1995, in Coposescu, 2003) will I be able to give solid explanation of what
linguistic failure shows us and what caused its occurrence.
It may be that failing to achieve cooperation and thus, bringing about miscommunication is
the outcome of a variety of social factors

Finally, the reader should bear in mind that the patients from my data are elderly people, a
fact which might mean their linguistic cooperation could be seriously hindered by their
cognitive abilities, health literacy level, etc. Moreover, the doctor might be equally
responsible for the occurrence of miscommunication as he/she may use a highly specialized
vocabulary that obviously poses ‘understanding’ problems to the layman. Therefore, looking
at how doctor and patient create meaning and attempt to understand each other (even when
types of miscommunication appear) is sufficient proof of the complexity of meaning and its
implications.

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2.1.1 Meaning in context
Since I have previously put emphasis on issues of meaning, I will continue to offer
information about aspects of context as means by which we achieve understanding.
Consequently, by looking at these two interdependent notions, namely meaning and context, I
am trying to offer an explanation to my rationale according to which meaning and context are
the pillars that support social reality and its development through cooperation.

Cooperation in talk can be observed within a conversation that makes use of utterances. No
matter how hard we try to classify and to analyse these utterances from a syntactic,
morphological and semantic point of view, the result will still be unsatisfying as utterances
are a reservoir of possible interpretations. Perhaps the most exhaustive way of interpreting
language in use, is by taking into account the wider context as well. This is an interpretative
path above sentence level that can guarantee meaning will not be lost.

Although context is not a clear notion, it has been divided into co-text, namely an extension of
utterances that CA has taken full advantage and the larger context perceived as the natural
‘habitat’ where utterances take place (Mey, 1993; in Coposescu, 2004: 71-74). When
considering the natural ‘habitat’ of utterances we must approach the social context because a
conversation cannot be understood without it. This way of understanding social context as
keeper of values, beliefs, norms and rules that are manifest on a particular social occasion (i.e.
medical consultation) has come to me regarded as ‘discourse’ whose element of newness is
the examination of how people use language in a particular social context.

Nevertheless, other classifications of context I can mention are those of Schegloff andDuranti
and Goodwin, both cited in Coposescu (2003). Schegloff (1992) makes a distinction between
‘extrinsic context’ (i.e. information outside the context about the setting, social role etc.) and
‘intrinsic context’, which stands for chunks of text. In addition, Duranti and Goodwin (1992)
divided context into ‘focal’, that is, setting and behavioral environment - verbal and non –
verbal communication and ‘extrasituational’ (wider social, political and institutional
discourses). Duranti and Goodwin’s treatment of context is indispensable to my interpretation
of data because one of my research questions is: How important is non-verbal behavior in
terms of doctor-patient cooperation? With this question, I am assigning value to non-verbal
communication as ‘contextual particular’ that can enhance cooperation and improve the
outcome of interpersonal communication, aspects that I will be dealing with in chapter four.

20
As indicated above, literature has expanded on elements of context such as the setting where
the interaction occurs, shared knowledge held by participants, and also through CA,
pragmatics adopts a more extended perspective by analyzing context as made up by language.
Pragmatics’ twofold perspective sees language as being not only an imposition from the
outside (i.e. physical or social context) but also as the leading factor that can create as well as
change the context. Therefore, I will basically be looking at several sociolinguistic approaches
to context, including the ethnography of speaking, ethnomethodology, as well as pragmatics
to show how speakers benefit from context and how context becomes the main framework
they use to achieve understanding and construct meaning.

2.1.1.1 Sociolinguistic approaches to context

Sociolinguists have investigated context in its connection to social aspects encompassed by
talk such as gender, ethnicity, age etc. Nevertheless, naturally occurring data extracted from a
particular social occasion showed that these aspects are dependent on the setting in which the
interaction unfolded and also on the verbal actions that speakers perform (Goffman, 1967).

Hymes (1967) initiated an ethnographic framework which is made up of all the factors that
are involved in a communicative event and that are essential to both the understanding of
participants and to the achievement of their goals. As a matter of fact, Hymes created the
SPEAKING grid, a word that is the acronym for the various contextual elements which
govern ‘talk’. These factors are the setting and scene (S) that refers to the physical
circumstances in which speech takes place, the participant (P) who can be speaker-listener,
sender-receiver, the ends (E) that refers to the expected outcome of the exchange as well as
the personal goals of the participants, the act sequence (A) that is the form and content of
what is said, the key (K) that refers to the tone or register in which a message is
communicated (i.e. light-hearted, serious, sarcastic etc.), the instrumentalities (I) that refer to
the choice of communication channel, norms of interaction and interpretation (N) that refer to
who usually speaks and for how long and finally, genre (G) that refers to clearly demarcated
types of utterances (i.e. poems, novels, advertisement). Therefore, Hymes’ SPEAKING
formula acts as proof of the complexity of the communicative act and tries to prompt
awareness to both speakers and listeners of the fact that they have to be sensitive to context so
that nothing goes wrong in their conversation.

21
‘In ethnographies of speaking, the focus is on the language the participants are using and the
cultural practices such language reflects. They very often deal with issues of identity and
power.’ (Wardaugh, 2006: 249). Therefore, it is clear that there is more to understanding how
language is used than describing the sentences from at a pure linguistic level. Consequently,
‘communicative competence’ (Gumperz, 1972) is given as a notion that reflects people’s
ability to do things with language:
‘Communicative competence extends to both language and expectations of who may or may not speak
in certain settings, when to speak and when to remain silent, whom one may speak to, how one may talk
to persons of different statuses and roles, what nonverbal behaviors are appropriate in various contexts,
what the routines for turn-taking are in conversation, how to ask for and give information, how to
request, how to offer or decline assistance or cooperation, how to give commands, how to enforce
discipline and the like- in short, everything involving the use of language and other communicative
dimensions in particular social settings.’(SavilleTroike, 1996:363, cited in Wardaugh,2006:250)

Actually, ‘communicative competence’ is needed to use the language and it is due to it that
we know how to cooperate linguistically as well as non-verbally on a particular speech
occasion. This is what makes communicative competence essential to the creation and
transmission of a message, regardless of its contents, means of diffusion etc. Nevertheless, the
competence we possess when communicating is also the result of knowledge about other
important aspects such as social status, the formality or informality of the talk we are engaged
in, as well as knowledge about the turn-taking specific to a certain conversation (i.e. question-
answer sequences in the medical consultation).

A different perspective is Goffman’s notion of ‘frame’ (1974:8, in Coposescu, 2003), which

imparts the fact that any type of interaction is controlled by rules emerging from the
‘definition of the situation’, making all social occasion governed by a set of rules, norms of
interaction and this particular concept similar to Levinson’s constraints on participants in his
‘activity type’. Goffman (1981) analyses shifts in the frame of talk and the participants’
alignment to the interaction showing a keen interest on ‘footings’, reflecting the stance that
individuals take in relation to what has been previously said.

Based on Goffman’s concept of ‘frame’, Gumperz (1982a) has contrived the

‘contextualisation cues’. Thus, ‘he demonstrates that any aspect of linguistic behavior
(lexical, prosodic, phonological and syntactic choices) may function as a contextualization
cue’ (Coposescu, 2003), pointing to those aspects of context that can serve to the
interpretation of a speaker’s utterance.

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2.1.1.2 The pragmatic perspective on context
The pragmatic approach to context or otherwise called Levinson’s (1979b: 367) ‘activity
type’ is based on the idea that the way we use language shapes a certain speech event. In his
pragmatic approach to context, Levinson draws on Wittgenstein (1958) and his ‘language
game’ (i.e. Sprachspiel) which has come to mean the study of any form of use of language
against a background context of a form of life’ (Kenny,1973:166).

Thus, Levinson gives the following definition to his ‘activity type’ due to his desire to surpass
the merits of sociolinguists:
‘…a fuzzy category whose focal members are goal- defined, socially constituted,bounded events with
constraints on participants, setting, and so on, but above allon the kinds of allowable contributions.
Paradigm examples would be teaching, a job interview, a jural interrogation, a football game, a task in a
workshop, a dinner party and so on. (Levinson 1979b:368)

Actually, Levinson build his ‘activity type’ notion in his urge to bring into prominence the
idea that in order to draw a correct inference for something that has been previously said we
have to possess knowledge of the ‘language game’ in which it occurs. This ‘language game’
has its own rules and norms of interaction and thus, failing to observe them would lead to
failing to make sense out of an utterance, or at least grasp the correct meaning of what one
speaker intended the other speaker to infer.

However, ‘the reduction of meaning to moves within a language game is not going to provide
us with any account on the key intuition that sentences have meanings partially independent
(not totally of course) on the circumstances in which they are used’(Levinson, 1979b:366-
367). Therefore, the language that is being used by speakers is embedded in the ‘language
game’ and as Levinson puts it, ‘over and beyond whatever meaning the words or sentences
may have in vacuo’ (Levinson, 1979b:367). As Levinson himself explains it, his ‘activity
type’ is somewhat similar to the notions of ‘speech event’ and ‘episode’ (Hymes, 1972;
Gumperz, 1972), but his notion is to be more desirable and have more value as it refers to
‘any culturally recognized activity, whether or not that activity is extensive with a period of
speech or indeed whether any talk takes place in it at all’ (Levinson, 1979b:368).

On the other hand, Levinson talks about ‘totally prepacked activities’, where our linguistic
intervention is futile for the organization and unfolding of the event and ‘largely unscripted
events’, where we basically talk about casual, ordinary conversations. In the case of casual

23
conversations, speakers shape the interaction as they go; each time they utter a sentence or a
new turn follows the speech event acquires shape. Due to these two types of activities, with a
strict and less rigid structure, Levinson portrays his ‘activity type’ as a ‘fuzzy category’.

Furthermore, the following two constraints on participants are of chief concern for the
‘activity type’:
a. ‘the structure of the event’ (Levinson, 1979b:369);
b. ‘the set of inferential schemata’(Levinson, 1979b:371) .

The constitutive elements of a speech activity in terms of structure include:

- episodes, for example a court case is divided into a statement of the case, cross-
examinations, the passing of a sentence etc. (Levinson, 1979b:369);
- pre-structured sequences governing the allocation of turns, the role of the interactants,
the time and the place at which the activity can occur;
- topical cohesion and the functional adequateness of contributions that reflect how
speakers adapt their speech so as to accomplish their goals that must be tied to the type
of activity involved.
-
Furthermore, in what the ‘inferential schemata’ is concerned, we are dealing with the
constraints that force the speaker to bring an appropriate contribution to each activity. As a
matter of fact, the type of activity in which language is used will help the interlocutors decide
on the meaning they have to assign to utterances and as a result, differentiate between what is
a correct inference and what is not on a particular social occasion. This is the reason why we
should rely on knowledge about the type of the activity we are in so that our utterances fit the
context in which they are produced. This is what can be called contributing to the speech
activity as due to their contextual dependence, our sentences demand a careful selection
before they will actually be uttered.

Then, the goals of the participants deserve attention too since they use commonsense
knowledge to identify the goal of the event and as a result, shape their individual goals so as
to act in accordance to them. Moreover, although the goals of the participants may be
different, the speakers must find a way to cooperate so as to fulfill the goal of the entire
speech event. As goal-driven individuals, speakers can be perceived as performers of social
functions. Actually, the minute they initiate a conversation having a firm and pre-established

24
goal in mind, in accordance with the overall goal of the ‘activity type’, they will orient their
talk in the direction of achieving their goal.

Furthermore, I have to bring to light the fact that my data is governed by an institutional
frame where re-framings occur and the indicators of these occurrences are changes of modes
of talk cued by laughter, ‘proof-procedures’ or as I have called them ‘errors’ in the unfolding
of the interaction. My choice of the term ‘errors’ is meant to encompass anything that can go
wrong in the conversation and to show the cues that signal the production of errors. These
cues can be repairs, delayed or dispreferred responses, hesitations, repetitions, frame-shifts
etc.

The notion of activity type is of invaluable assistance to my paper since I will be looking at a
type of activity (i.e. medical history taking) that Heritage includes in the category of
‘institutional talk’ (Heritage,2004:103), the latter putting more emphasis on the distinctive
feature that makes this particular conversation institutional, thus formal in character. In what
formal activity types are concerned, other concepts worthy of analysis power, status, stance,
identity and ideology, notions more clearly demarcated in works that expand on institutional
interaction.

2.1.2. From cooperation to miscommunication

It is generally assumed that the purpose of any interaction is achieving understanding so that
this will result in achieving a common goal. As a matter of fact, speakers must orient their
talk towards successful communication and for this, they should strive to cooperate whenever
they engage in a conversation.

The work of sociolinguists, Wardaugh (2006) being one of them, clearly indicate that human
communication is effective because we are able to recognize certain principles and rules of
the verbal exchange. Moreover, the most notable work in the field of cooperation is that of
Grice to whom communication is logical, a fact that transpires from our way of managing
discourse and giving it a structure. The cooperative principle (CP) he has created shows how
participants are able to observe and act according to ‘a mutually accepted direction’ (Grice
1975:45, in Ladegaard 2008:649). Grice’s view has been adopted by Levinson(1979) who
admitted CP is a universal rule of human interaction and incorporated it, with its four maixms
of quantity, quality, relation and manner, as basic element in the definition of his concept of

25
‘activity type’. We can deduce from here that any human activity which entails linguistic
interaction has to be cooperative. However, Grice is aware of the fact that people can
cooperate to a greater or lesser extent and to account for these variations he also gave
examples that demonstrate how this CP can be violated. But, the fact that the four maxims are
flouted does not reflect the fact that a breakdown in communication has occurred. Instead, for
Grice flouting the maxims is a way of generating implicatures, that is, meanings beyond the
level of the utterance whose producer forces the interlocutor to figure out the implicit
meaning of his utterance. By flouting the maxims, the participants in a verbal exchange are
still cooperative as they consider their interlocutor perfectly capable of interpreting their
utterances at a deeper level.

A speaker’s certainty that his interlocutor will be able to make sense of his intentional
irrelevant, ambiguous, obscure message comes as the result of the awareness that his
interlocutor has the same social, educational background (i.e. shared knowledge). Maybe, this
lack of shared knowledge is the explanation of why people coming from different cultural
backgrounds misinterpret one another with such high frequency (Gazdar 1979). It may be that
they have different perceptions of what a cooperative behavior is and how it should manifest
itself. This would entail that ‘‘communicators must have the same discoursal and pragmatic
rights and obligations to take turns and to avoid silences and interruptions, and, most of all,
they must have equal control over what for interactional purposes counts as ‘truthful’,
‘relevant’, ‘adequate’ and ‘sufficient’ information’’ (Sarangi and Slembrouck, 1992:125, cited
in Ladegaard, 2008:652).

Actually, according to Coupland (1991b:1, in Ladegaard, 2008:650) the problem is that

research meant to evaluate the state of language and communication failed to adopt the notion
of miscommunication. Moreover, Ladegaard (2008:650) mentions that miscommunication
can be applied to ‘cases of abuse of language/communication’ and ‘it may refer to
communication mishaps or to deviations of communicative norms’. What is more,
miscommunication ‘may be a consequence of low levels of communicative competence in
certain domains’. According to this latter statement, the health illiteracy of lay people is a
contributing factor to the forms of miscommunication that might occur during a medical
consultation.

26
As Coupland et al. put it, researchers have used a ‘Pollyanna’ point of view by looking only at
what is considered to be ‘good’ communication and ignoring the ‘bad’ one. Moreover they
add the following:‘communication is itself miscommunicative, although the motivating force
behind many research paradigms is the recognition that language and communication
underpin and enact more specific social problems, divisions, inequalities, and
dissatisfactions.’ (Coupland et al. 1991b:3, in Ladegaard, 2008:650). Therefore, it is clear that
we must use a different perspective to account for errors in communication. Obviously, we
should enlarge the spectrum of research that is committed to examining only rational and
logic conversation and instead redirect our attention towards the flawed and problematic
communication, examples of which have existed forever and can be noticed all around us.
Why look only at ‘good’ communicators and refuse to correct the behavior of the ‘bad’ ones?

In what the linguistic aspect of the CP is concerned, this has to deal with linguistic goal-
sharing, that is abiding by the same turn-taking rules as not committing faults in what the
semantic, syntactic, prosodic, pragmatic aspects of an utterance are concerned. Actually,
violations of the turn-taking rules (i.e. overlapping talk) and faults occurring at a semantic,
syntactic, prosodic, pragmatic level of an utterance are all subject to ‘corrections’. Therefore,
in the next section I will try to identify some types of miscommunication and look at various
ways in which these types of miscommunication can be handled and recovered from.

2.1. 2.1 Types of miscommunication and error handling

Many people speaking the same language are at pains when having to communicate
efficiently what they have in mind and this combined with the ambiguity of the language will
often result in unclear utterances that may confuse the hearer. The hearer’s inability to make
perfect sense of the speaker’s utterance and thus, linguistically cooperate is what we term as
miscommunication.

Therefore, one of the greatest challenges we face when having a dialogue is recognizing
errors that often go unnoticed, although all humans have a system of identifying errors and
recovering from them at the stage at which they occur or at a later stage. Even with the
recognition of the errors that have occurred in a conversation and with their repair,
‘apparently satisfactory communication may often take place between humans without the
listener arriving at a full interpretation of the words used’ (Skantze, 2005:325).

27
Furthermore, due to the redundancy of language, speakers often opt for repeating a word, sets
of words or entire informational clauses so as to make sure that their interlocutors will achieve
understanding. This can count as an unconscious process of handling errors by preventing
their appearance.

Therefore, the notion of miscommunication covers a wide range of phenomena that may
occur in a verbal interaction. Miscommunication refers to misunderstandings, non-
understandings and misinterpretations. Firstly, a distinction is made between
misunderstandings and non-understandings (Hirst et al., 1994; Weigard, 1999, in
Skantze,2005:326). The former would refer to being given a response that it is not in
conformity with one’s intended meaning or with the effect the utterance was supposed to
produce, whereas the latter points to receiving no response at all or too many interpretations
of the same utterance. What is more, Skantze points out that misinterpretations, added to the
list of miscommunication types by McRoy (1998) occur when the interlocutors have different
beliefs about the world. There is a variety of ways to deal with miscommunication, that is, to
prevent it, detect it or recover from it. Error handling procedures include rephrasing,
reformulations etc.

Fortunately, conversation analysts such as Sacks, Schlegloff and Jefferson (1977) realized the
importance of looking at errors in communication and not only did they develop the concept
of ‘repair’ (see chapter 2, section 2.1.2.2) to recover from miscommunication, but also came
up with a classification of repairs. However, as Coposescu (2004:120) continues, ‘the turn-
taking system has its own means of repairing faults’. This is the case of overlapping talk when
one of the speakers has to forcedly complete his turn earlier due to the interruption of another
speaker who goes on with his turn at talk after the completion of the previous turn.

2.1.2.2 Repairs as error recovery strategies

In general, CA work has put more emphasis on the micro-structure of conversations and this
is why its application to my data is in compliance with the focus I have decided to put on
smaller excerpts of talk and to investigate into matters that pertain to the micro-level of
conversations (i.e prosodic features of utterances, hesitations, pauses, overlapping talk,
repairs). This means that I am trying to capture every aspect that Fairclough has called
‘moment of crisis’. Actually, these ‘moments of crisis’ (Fairclough, 1992:230, cited in
Coposescu,2003:32) are clear indicators of the fact that there is something out of place within

28
the conversation. Thus, these indicatorsdraw our attention to the occurrence of a deviation in
the normal and untroubled flow of communication.

Moreover, indicators of ‘moments of crisis’ are ‘repairs’defined as ‘a generic conversational

practice through which all types of interactionaltroubles can be managed and repairables
corrected’ ( Schegloff et al. 1977, in Arminen 2005:129). As a matter of fact, this concept of
repair is extremely important in the correction of misunderstandings, non-understandings,
mis-hearings, slips of tongue and incorrect lexical choice. Moreover, repairs cover any kinds
of errors that can be identified in a verbal exchange: semantic, syntactic, prosodic, pragmatic,
etc. Nevertheless, the repairable items must be faulty in the context of that particular activity
otherwise the repair is invalid.

In addition, the area of repair is quite extensive and I have previously stated it also
encompasses overlapping talk. But in this case, where the ideal of speaking at a time is
infringed, the turn-taking system has its own ways of rectifying the trouble in communication.
In all conversations, regardless of whether they are formal or informal, when two speakers
have begun to speak in the same time, almost every time a speaker abandons his right at talk,
while the other continues with his turn until the completion of his utterance. Therefore, here
we have a speaker who interrupted his interlocutor’s talk and is considered the source of the
trouble and the other speaker is the initiator of repair. Another distinction is that repairs can be
initiated by self (the speaker who produced a fault), and repair initiated by other. What is
more, a repair can unfold within a turn or sequences of turns and as Schlegoff et al. (1977)
have noted, there seems to be a preference for self-repair initiations.

According to the work of ethnomethodological conversation analysts such as Jefferson, Sacks

and Schlegoff (1977) there are four types of repair. The examples I will give so as to illustrate
these varieties of repairs are taken from my own data.

§ Self-initiated self-repair. Repair is both initiated and carried out by the speaker of the
fault. Below is an example taken from Appendix II, Data2:
D: when did this happen? =
10 P3:= on Thursday night.
D: a::nd=
P3:= until then I’d never experienced such a crisis.

29
 →ehh (.) now I’ve had. I mean (.) I’ve been having asthma for a long time now.
since I had that crisis ((stifles a cough)) I could only breathe like this,
15 I couldn’t breathe. =

In the example I have provided, the repair occurs at line 13. The turn starts with back-
channeling that indicates uncertainty, afterwards the patient hesitates and abruptly ends a
clause that makes no sense. Then, the patient tries to reformulate his answer (i.e. “I mean”)
and introduces his repair “I’ve been having asthma for a long time now.” The nature of the
fault is an incorrect lexical choice on the part of the patient.

§ Other-initiated self-repair. Repair is carried out by the speaker of the trouble

source but initiated by the recipient. The following example is taken from Data4:
D: why were you hospitalized? (2)
P4: when?
D: →WHY WERE YOU HOSPITALIZED?

In this example, the speaker of the trouble source is D because P4 has a hearing
disability so he has to speak louder. Repair is initiated by P4’s question (i.e. when? )
in line 8 indicating a misunderstanding as a result of her hearing deficiency and in the
same time a demand to repeat the question addressed to D. The repair is done by D in
the next line by repeating his question, but this time speaking louder so that P4 can
hear him.

§ Self-initiated other-repair. The speaker of a trouble source may try and get the
recipient to repair the trouble – for example if a name is proving troublesome to
remember.
and then I had lung ┌ X-rays ┘done. and I had (.)
err ‹ VIRAL INFECTION › inter (.) costal or ∞intertitial∞. I don’t know the name. =
D: →=interstitial. =
35 P3: how? =
D: =→interstitial.
P3: = correct. because my daughter knew it, interstitial.

30
 P3’s turn in line 35 illustrates a ‘next-turn’ repair initiator (NTRI). Other NTRIs may
be words like ‘What?’, or even non-verbal gestures, such as a quizzical look. In the
above example, P3’s trouble in remembering the correct pronunciation of a word (i.e. I
don’t know the name) is repaired by the doctor in line 34. Moreover, another repair is
initiated by P3 in line 35 because he has mis-heard the repair. The doctor double
repairs the same trouble source in line 36. Finally, P3 is able to correct his error in line
37, but firstly he admits that the word repaired by D is the correct one, stressing the
word “correct”.

§ Other-initiated other-repair. The recipient of a trouble-source turn both initiates

and carries out the repair.
10 P1: = aches and (.) suffocations.
D: →so ‹ shortness of breath ›. =
P1: =shortness of breath. I couldn’t walk.

In this case, D has previously asked P1 what was the condition she had been hospitalized for
and P1 gives account of her symptoms in line 10. In line 11, D clarifies that it was his
intention to find out the name of the condition instead of the symptoms. Thus, he initiated and
carried out the repair by uttering the name of P1’s condition. P1 realizes her misunderstanding
and shows this by repeating D’s repair.

2.2. Conversation Analysis and Institutional talk

Ever since it emerged as a method of analyzing ‘talk-in-interaction’ (Hutchby and
Wooffitt,1988:13, in Coposescu, 2004:102), the field of Conversation Analysis dealt not only
with everyday conversations, but also with the study of conversations with an institutional
character. However, it was not until 1970 that conversation analysts started to examine
naturally occurring language as institutional talk. Institutional talk with its distinctive
institutional features was first analysed by Atkinson and Drew (1979) in their work on courts.

Regardless of its name, ‘Conversation Analysis’ is engaged in more than the study of ordinary
or casual conversations. CA wishes to discover how social roles are accomplished and how

31
the interactional organization of a particular speech event is managed by the participants. Due
to this fact, CA proved to be my best choice when it came to finding a method for the analysis
of my data (i.e. naturally occurring doctor-patient conversation).

2.2.1 Ethnomethodology and the origins of CA

Ethnomethodology, which is a branch of sociology, is a science interested in the processes
people use to give an interpretation to the world surrounding them and thus, make sense of
everyday existence. Ethnomethodology’s aim is to look at how people understand the social
reality and how they cooperate so as to shape it. Also, ethnomethodologists want to discover
the mechanisms that people use when interacting with each other. According to Fairclough
(1989:9):
‘Ethnomethodologists investigate the production and interpretation of everyday action as
skilled accomplishments of social factors, and they are interested in conversation as one
particularly pervasive instance of skilled social action.’

Therefore, apart from seeing how people interact, how they pass knowledge on to each other,
ethnomethodology aims at revealing how social relationships are maintained and how routine
activities are performed (Wardaugh, 2006:252). All these aspects argue that
ethnomethodology is opposed to Hyme’s SPEAKING grid. In fact, ethnomethodologists
argue that ‘contexts are not pre-established situations consisting of a number of fixed
categories that are indexed or affected by talk, but are locally constituted by participants’
(Coposescu, 2003:27). Obviously, the participants can construct this context and
consequently, manage and organize it as they wish provided they are aware of the fact that
their utterances have a certain function and their use at a particular moment is not random.

For my interpretation of particular sets of sentences, having some ‘knowledge of the

categories that speakers find relevant’ is essential (Sacks, 1972a, cited in Wardaugh,
2006:253). These categorizations that we use with a high frequency are actually labels that we
attach to people, places, events etc. This is why, a medical consultation is labeled as ‘formal
activity’ and because of this ‘labeling’ (Wardaugh, 2006:253), there are certain norms and
rules of interaction that doctors as well as laymen must adhere to. Provided that both the
doctor and the patient correctly label or identify the ‘activity type’ they are engaged in, the
conversation is bound to be a success. But, an incorrect view on how language should be used
on a particular occasion is enough to produce disorder. This is the reason why I am looking at

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the distribution of power in doctor-patient interaction, that is, to see whether there is an
enactment of power behind the doctor’s discourse.

The natural phenomena of verbal exchanges are the main concern for ethnomethodological
conversation analysts such as Sacks, Schegloff and Jefferson. The interesting data made up of
naturally occurring interaction is suitable for ethnomethodologists and conversation analysts
alike, since such conversations reveal how individuals achieve certain goals and accomplish
their social roles by saying something. They obey certain rules of cooperation, turn-taking and
they rely on ‘commonsense knowledge’ and ‘practical reasoning’ to understand and then, do
things and perform their daily routines (Wardaugh, 2006:254).

Therefore, doctors and patients must cooperate to sustain ‘the reality’ of the medical interview
(i.e. medical history taking) and must definitely possess a sense of what is normal and
habitual conduct on that particular speech event so as to know when something went wrong
and correct it. Therefore, the sequences of talk in my data are regarded as smaller activities
within the same ‘reality’ due to the fact that the medical interview is composed of several
units of talk, each encompassing certain actions within the same context. Furthermore, I have
started analyzing my data from the CA assumption or hypothesis that conversational
mechanisms are the same in all contexts and that people employ ‘commonsense’ knowledge
so as to account for their actions (Garfinkel, 1967, in Coposescu 2004). If they are able to
account for their actions, this clearly means that participants recognize the overall activity
they are engaged in and the smaller activities they perform while interacting linguistically.

2.2.2 Generalities on CA
As we have seen in the previous section, the origins of CA are represented by Garfinkel
(1967), who realized that analyzing conversations in terms of the rules and the norms that
govern them and impose constraints on participants must be upgraded so as to create an
approach that would focus on the following two aspects:
• the speakers’ utterances are actually a contribution to the speech event as they move it
forward;
• the participants’ linguistic contribution is an indicator of the fact that they understand
the event in which they are engaged.

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What is interesting is that CA ‘links both meaning and context to the idea of sequence’
(Heritage, 2004:105). CA examines the organization of a social action, which is made up of
systems or various episodes that help participants linguistically cooperate through turn-taking,
repairs etc. Basic Conversation Analysis views a verbal exchange as a turn-taking activity that
is related to the following: turns, the prosodic features of utterances, overlapping talk, repairs,
turn distribution, topic control, adjacency pairs and ‘preference’ etc. All these linguistic
resources are ‘the foundation of human sociality as they are systematically biased in favour of
affiliation and social solidarity’ (Heritage, 1984a).

In what the turn construction is concerned, participants’ talk is context shaped as a current
speaker draws on the preceding utterance, that of his interlocutor to make his linguistic
intervention fit the context (Sacks, Schegloff, and Jefferson 1974/1978, in Heritage,
2004:105). When performing a particular action (i.e. uttering a sentence), the speaker
demands that his interlocutor speaks next and thus, ‘create, maintain or renew a context for
the next person’s talk’ (Heritage,2004:105). By producing a subsequent action, speakers
demonstrate the fact that they understood the ‘prior’ utterance and by making sense of a
precedent turn, the conversation can advance untroubled.

Achieving understanding is actually a sign of linguistic cooperation as a particular meaning

can be mutually approved by the parties and this is the case of adjacency pairs, a concept
introduced by conversation analysts. For example, pairs such as question-answer, greeting-
greeting, offer-acceptance are sequences that show the degree of understanding of the
participants. Therefore, the second part of a sequence pair must be relevant to the first. The
‘preference’ feature of adjacency pairs makes a distinction between second ‘preferred’ and
‘dispreferred’ parts. For example, if the first part of an adjacency pair is a question, the
preferred second part would be an answer, whereas a ‘dispreferred’ part would be the absence
of an answer which is treated as a ‘noticeable absence’. Also, not all second parts of an
adjacency sequence come immediately after the first part because there are longer stretches of
conversation that contain ‘insertion sequences’.

2.2.3 The extent of studies in healthcare interaction

Linguists, sociolinguists and pragmaticians alike, have directed their attention towards the
analytical study of doctor-patient interaction since the early 1980’s, making the doctor-patient
encounter become the bedrock for their investigations. Their findings, after studying tape-

34
recorders or video-tapes as their main instrument of research, helped portray the healthcare
system and how it functions as a whole, by revealing important organizational features and
interaction processes.
In the late 1970’s, Richard Frankel, who was a faculty member in a department of medicine,
thought of the exploring of video tapes as a way of offering training to physicians in
overcoming the barriers encountered in doctor-patient communication. At that time, he
realized the importance of CA in the creation of communicational patterns and envisaged its
role in comprehending the unfolding of a medical consultation. Drawing from
ethnomethodolody, whose research interest is the study of the everyday methods people use
for the production of social order (Garfinkel: 1967) and considering that CA came as a form
of response to sociological inquiry, it is understandable why the medical field -a sphere of
human activity functioning in a society- did not escape the scrutiny.

CA is an asset to anyone involved in the healthcare system as its ultimate goal is to improve
communication and health, and make doctors as well as patients more sensitive to the
language. It is due to the fuzziness of society and the imperfection of language in action that
pioneers in this field, like Candace West, considered that if we were to ponder over the
particularities of the naturally occurring interaction between the two participants, the
betterment of the doctor-patient communication would be ensured. As West argues, ‘… it is
only through systematic empirical study of the minutiae of doctor - patient interaction that we
can learn what constitutes the alleged communication “gap” between doctors and patients, and
how it might be transformed ’(West 1983 : 103, cited in Pilnick et al., 2009:788).The CA
approach reveals aspects of asymmetric power in the succession of turns in a medical
encounter with a view to filling any existent gap and enhancing cooperation between the two
participants. The basic purpose is to give answers that would clarify the seemingly
constraining uncertainties in doctor-patient interaction.

CA is extremely productive because research in the sociology of medicine is also a field that
benefits from the findings of conversation analysts. Thus, Silverman, Kurtz and Draper, who
are researchers working in the field of medical sociology created The Calgary-Cambridge
Guide to the Consultation (see website 7). After observing healthcare interaction, the
inequalities in the medical domain and how power was distributed in the doctor-patient
interaction, Silverman, Kurtz and Draper (1998) realized that a consultation model that
incorporates patient centered communication instead of a biomedical approach (i.e. doctor-

35
centered approach) is the best way of successfully talking to patients and thus, obtaining a
good health outcome and improving the health status of the patient. As a matter of fact, their
Calgary-Cambridge Framework (see Appendix IV) is a useful tool that reflects the changes in
what consultation models are concerned and reveals the fact that increasingly, doctors opt for
a consultation model incorporating a communicational style that is patient oriented. The
Calgary-Cambridge Guide to the medical interview with a focus on the patient-centered
communication processis of tremendous support for doctors who wish to efficiently manage
their patients’ disease by understanding them not only at a verbal and non-verbal level but
also from an emotional point of view.

2.2.3.1 CA research on the medical interview

Of particular interest to CA is the organization of different types of doctor-patient encounters
and in my paper I am studying the medical consultation that involves taking the medical
history of the patient. Thus, taking a medical history is one of the most difficult tasks for a
doctor since his interviewing skills, medical knowledge and the ability to create a bond with
the patient are equally important. That is why, in medical school, future doctors learn how to
perform a medical history taking by using the Calgary- Cambridge approach as a model
(Silverman et al.2005, in Washer, 2009).

In addition, communication skills and history-taking are two interdependent notions because
the success of the medical encounter depends on the doctor’s ability to make the patient feel
at ease and not embarrassed to disclose medical information. However, the doctor must ‘pay
attention to both the process and the content at the same time’ (Washer, 2009). This means
that all five stages in the consultation (i.e. initiating the session, gathering information,
physical examination, explanation and planning, closing the session) are of extreme
importance to building a relationship of trust, confidence and cooperation and maintain the
flow of communication (see Appendix V).

Moreover, medical history taking is a structured enquiry where doctor and patient behave as
interviewer and interviewee (Maynard and Heritage, 2005). This entails that the doctor is in a
position to ask questions whereas the patient must provide an answer. From this we can
deduce that the sequence organization of the medical interview is made up of question-answer
pairs and these can reflect the collaborative nature of this type of interaction. The problems
that arise in the conversation and the disruption of its sequentiality have been matters of

36
ardent debates in the field of CA. To offer just a few examples cited in the work of Pilnick et
al. (2009: 789-790), ‘patients face the issue of how to put their concerns on the floor’
(Robinson and Heritage 2005) and doctors think of how to elicit all the problems faced by
their patients and how to prepare patients for difficult diagnostic news (Maynard 2003,
Maynard and Frankel 2006).

Furthermore, research on the medical interview is aimed at discovering issues that pertain to
the social context (i.e. social status, knowledge and asymmetries) and affect or influence the
development of the medical consultation. In order to reveal how certain social practices are
performed and what stances, identities, ideologies are enabled in talk (Heritage, 2004),
conversation analysts look at the way participants use and form sequences that carry all of
these aspects. Sequences display asymmetries as each turn points to the level of health literacy
of the patient and the medical knowledge of the doctor. Of course, CA investigations focus on
the verbal behavior of patients as well as doctors for ‘it is by acting together that doctor and
patient assemble each particular visit with its interactional textures, perceived features, and
outcomes’ (Heritage and Maynard, 2006b:19, cited in Pilnick et al.,2009: 789).

2.2.3.2 Non-verbal behavior in doctor-patient interaction

Maynard and Heritage (2005:428) suggest that the doctor-patient relationship is a ‘co-
construction’ or a ‘collaborative enterprise’. However, analyzing the naturally occurring
conversation requires more than just examining the utterances of the participants. The doctor-
patient interaction consists of more than just stretches of sequences as it also includes non-
verbal behavior and and non-vocal aspects of utterances related to the accomplishing of a
certain social activity that hold crucial information for a researcher.

Thus, medical sociology finds CA an asset to healthcare interaction due to its ‘ability to reveal
and unpack thefundamentally collaborative and contingent nature of medical encounters’
(Maynard andHeritage 2005, Heritage and Maynard 2006a). Actually, CA notes that in all
doctor-patient encounters, both participants are ‘ongoingly attentive to the talk and visible
conduct of their coparticipants’. Indeed, participants ‘rely on each other to make sense of
emergent conduct by virtueof what has happened immediately before’ (Pilnick et al.,2009). In
fact, nonverbal behavior is an indicator of the effectiveness of health services and patient
outcome.

37
Nonverbal behavior is a concept associated with rapport as indicated by Hall et al. (1995) and
by Silverman et al. (1998, 2003). In the Calgary- Cambridge Guide to the medical interview
(see Appendix VI), using appropriate behavior on the part of the doctor is the primary aspect
comprised in the stage of ‘Building relationship’. From this, we can infer that a ‘good’ doctor
must demonstrate adequate eye contact, facial expression, posture, gestures, body movement,
vocal cues (i.e. pitch, rhythm, intonation).

The medical sphere is in a perpetual state of transformation ever since the biopsychosocial
model has been introduced (Engel, 1977, in Hall et al., 1995). Nowadays, with the advent of
patient-centredness, it seems that the process of communication cannot be dissociated of the
quality of care patients receive. Consequently, physicians are trained to look at the personal
side of healthcare delivery and they should constantly be aware of the fact that ‘core clinical
skills are interpersonal’ (Hall, 1995:22). Thus, researchers that studied naturally occurring
language in the doctor-patient encounter realized that their recordings were like a ‘study of
words without music’.

Nonverbal aspects of communication (i.e. clothing, physical appearance, gaze, facial

expression, gestures, body movement) have a lot of implications for human relations and they
can offer quick and important information. Friedman (1979) noted that patients are alert for
the doctor’s nonverbal behavior in order to overcome their anxiety and uncertainty. In this
way, patients want to discover the quality of the physician and his feelings and attitude
towards them. What is more, these indicators that ease the patient due to their lack of power
and control reinforce the spoken content (Fiske 1993, in Halll et al., 1995:22).

In what nonverbal cues on the part of the patients are concerned, most of them are signs of
cooperation, trust and confidence and help to develop rapport. Even the cases where hostile
patients do not cooperate can be explained since patients are angry because of their illness,
which makes them distrustful. However, if the doctor succeeds in developing rapport he will
restore the patient’s trust and confidence, which will result in a further exploration of the
medical history. In addition, nonverbal behavior contributes greatly to the ‘making sense’ of
utterances and they even possess emphatic qualities that betray positive or negative effect.
Actually, smiling and head nodding indicate positive affect and reveal a high affinity,
persuasiveness, sympathy and warmth towards each other (Hall et al., 1995:24). Illustrative
gestures can be interpreted as other signs of cooperation.

38
Moreover, nonverbal indices have been correlated to the degree of support felt by patients.
Therefore, the physician’s tone of voice in terms of pitch, volume, intonation is extremely
important because their voice must not sound dull, uninvolved but warm and relaxed. As a
matter of fact, nonverbal cues (eye contact, gestures, forward lean, smiles) are more salient
than verbal cues (for example, jargon, interpretations, self-disclosure, and reflections). Other
nonverbal skills include finding sensitivity to pain cues such as facial expression. Knowledge
about the patients’ facial expression of pain can help them distinguish between what is real
pain and who makes false claims in connection to their level of pain(Prkachin, 1992b, cited in
Hall et al., 1995:31).

To summarize, we can say that the participants’ nonverbal behavior creates the affective
climate of the encounter since it is correlated to the notion of rapport and thus, can influence
the doctor’s degree of empathy and sympathy as well as the patients’ level of trust and
confidence, which are of significant importance for the disclosure of disease-related
information.

2.2.3.3 Patient-centredness in the medical interview

Many researchers claim that the patient centered communication is the preferred style on the
part of the doctor while interviewing his patient (Swenson et al., 2005:200). Patient-centered
communication includes ‘identifying and responding to patients’ ideas and emotions
regarding their illness,’ and ‘reaching common ground about the illness, its treatment, and the
roles that the physician and patient will assume’ (Epstein,2000, cited in Swenson et al., 2005).
Moreover, patient-centredness, which facilitates the biopsychosocial approach to the
interview according to Frankel et al. (2000), has been linked to better health outcomes, a
decline in malpractice claim as well as with improved patient satisfaction with health services
and compliance to treatment.

Moreover, patient centered communication is said to increase patients’ participation and

involvement in the medical interview as the doctors facilitate their patients’ understanding
and try to educate them from a medical point of view. Patient centered encounters are
considered to be ‘those in which the patients’ point of view is actively sought by the
physician’ (Stewart, 1984, in Zandbelt et al., 2006:396). The focal elements of patient
centered care and thus, those of patient centered communication are the physician’s active

39
listening, encouragement of the patient to express his/her concerns and feelings, checking for
understanding, giving explanation, developing rapport so on and so forth (see Appendix VI).
Not to mention the fact that the Calgary-Cambridge approach puts emphasis on opened
questions and agenda negotiation with the patient. What is more, according to the patient
centered approach the doctor should avoid using medical jargon so as to make his language as
accessible as possible to the patient in order for the two parties to achieve shared
understanding.

In addition, doctor questioning during the interview should take into consideration two
principles, namely ‘optimization’ and ‘recipient design’ (Maynard and Heritage, 2005:432).
The former refers to the way questions are designed so as to receive the most adequate
response and the latter contains the idea that questions must be specifically construed so as to
take into consideration the patient’s expectations, concerns, beliefs etc. This verbal exchange
between the parties contains assumptions about the social reality and this is obvious when the
doctor asks lifestyle questions as part of his medical history taking. The gathering of this type
of information (i.e. smoking, alcohol, drugs etc.) is seen as a threat by the patients who see the
moral element hidden within these questions. Despite the doctor’s neutral stance, patients are
afraid of disclosure as they think they might be judged according to lifestyle matters so they
tend to give evasive or false answers in order to avoid being blamed for their behavior
(Maynard and Heritage, 2005:433).

Actually, patient centered communication has been found to increase patient confidence as
they are more interested and eager to manage their disease and improve their health
status(Zandbelt et al., 2006:397). And since the aim of this paper is to see whether the
clinician’s communication style triggered a high compliance level and active participation on
the part of the patient, discovering the interviewing style adopted in my data is a crucial issue.
To establish active participation I will basically be looking at the duration of patient talk
compared to that of the physician as well as the utterances to see whether they express
concern, anxiety, need for emotional support or medical related information.

2.2.3.3.1Patient centredness vs. the biomedical approach

Although patient-cetredness is the prefered medical approach within the consultation, this
patient centered communication style is contrasted with the doctor-centred approach or the

40
biomedical perspective where communication is disease-oriented and the doctor does not
actively involve the patient in the discussion (Swenson et al., 2005:200).

Therefore, even though the vast majority of patients are in favor of a patient centred
communication style, there is a small proportion of patients that would rather interact with a
doctor centred communication style and this is partly due to the fact that the biomedical
perspective fosters a straightforward approach and a ‘high control interaction style’ (Flocke et
al., 2003, cited in Wong and Lee, 2006). An authoritative manner is believed by some patients
to be adequate for a caring attitude would bring about excessive information, which
wouldstimulate confusion and anxiety. Also, patient-centredness is said to engender
emotional dependancy, whereas the biomedical approach gives concise medical advice and
treatment recommendation, clear explanation and concise information so that the patient can
choose what he considers appropriate for his condition.

In addition, in Swenson’s work (2005), there was supporting evidence in favour of the doctor
centred approach but this relies entirely on the type of patient that the physician has to deal
with. We must shed light on the fact that there are patients who do not prefer a soothing
attitude and this is the direct result of the patients’ own needs and priorities. Patients might
feel at ease with a less caring and sensitive attitude on the part of their doctor.What is more,
the biomedical physician is not disrespectful of his patients, but unlike the patient-centred
doctor he is emphatetic to a lesser degree and this does not mean that his interest is not
genuine. A significant number of receivers of care are inclined to let the doctor decide for
them as they do not want to be responsible for a life-changing medical choice. Another
explanation would be that patients fear their decision-making is not as good as that of the
experienced health professional.

Finally, Swenson et al. (2005) concluded that those who preferred a doctor-centred style were
influenced by the commonsense assumptions concerning the medical consultation. Due to the
ideologies presiding over the medical consultation (i.e. the doctor has authority, medical
knowledge, prevents harm, delivers clear information), people come to the encounter with a
clear picture of how the interview should unfold, what counts as allowable contributions in
terms of lexical choice, attitude, stance etc., who holds the floor and who controls the topic or
establishes the agenda.

41
2.2.3.3.2Approaching the patient and ‘examiner’ qualities
The reason behind an individual’s visit the doctor is a suffering that the health professional
can cure. First of all, the doctor-patient relationship is an interpersonal relationship, where the
patient’s health and life is in the hands of the doctor. The major objective of the doctor-patient
encounter is the alleviation or prevention of suffering, that is, curative treatment. But in order
to treat the patient, which is the finality of the medical process, the doctor must first evaluate
the cause and the mechanisms that triggered the suffering (Bolosiu, 1998).

Actually, the physician has to compare the data obtained from the patient with his own
medical knowledge and previous medical experience so as to be able to frame the suffering
within a system. The purpose of this comparison is reaching a diagnosis, which is strictosensu
exhaustive knowledge. According to Bolosiu (1998:7), a precocious, correct and complete
diagnosis is the key to a therapeutical success (Qui benediagnoscit, benecurat).

The data obtained from the patient are his symptoms, subjective perceptions that the doctor
discovers while linguistically interacting to the patient (i.e. medical history taking or
anamnesis) and also the objective signs that the doctor discovers during the physical
examination. Generally, a tendency to supra evaluate other data coming from complementary
investigations (i.e. X-rays, CT scan) has been observed. However, no matter how many
advances occur in the field of medical technology, the traditional method of approaching the
patient’s suffering through conversation can never be replaced or outranked. By breaking or
eliminating the communication between the doctor and the patient, the profession of being a
doctor would be dehumanized.

When saying medical history taking or anamnesis we think of the data obtained from the
patient (see Appendix III) and the objective of this type of medical consultation is to collect
subjective data concerning the disease (i.e. symptoms, the evolution of symptoms). Not to
mention the fact that other additional information regarding the biological status of the
patient, his affective personality, his emotional attitude are modified as a result of the disease.

Therefore, in this section I have decided to bring to light patient communication styles and
their particular ways of exposing suffering since the methodological ground for the medical
interview is the conversation and an adequate approach of the patient is linked to the outcome

42
of the consultation. As a matter of fact, the information I am putting forward in this section is
a conceptualization of Bolosiu’s work (1998).

As Bolosiu (1998:10) puts it, the patient wants to feel that he is regarded not only as a
‘clinical case’ but also as a human being who has the right to solicit professional expertise as
well as human consideration. Patients are often confronted with the uncertainty of not
knowing the human quality of the physician whom they interact with so they erect an
emotional barrier that engenders a lack of trust and confidence.

Moreover, the qualities of the ‘examiner’, which are partly integrated in the Calgary-
Cambridge guide to patient-centered communication (see Appendix VI) are the following:
a. interest - an interest that encompasses the desire to understand and help the patient not
only medical curiosity;
b. tolerance – refraining from a moralizing attitude and not blaming the patient for his
lifestyle;
c. warmth and sympathy – no two individuals can have the same life experience, but if
the doctor tries to understand the patient, a relationship of trust can be build;
d. politeness and flexibility – the conversation must take place in a relaxed environment,
where there is mutual respect;
e. optimism – the conversation must have at all times an encouraging and constructive
tone.

2.2.3.3.3 Patient narrative patterns

According to Bolosiu (1998: 11), the doctor must be an attentive listener. The cases when a
patient can expose his suffering in an objective manner are extremely rare and most of the
times doctors have to deal with an ‘emotional spectrum’. This is why, each patient is unique
and must be approached differently as there are no standardized patient in real life. As
Trousseau used to say: Il n’y a pas des maladies, il n’y a que des maladies.This guides us to
the conclusion that no one can foresee how a medical history taking will unfold and no one
can give ‘a recipe’ of its unfolding.

However, Bolosiu (1998:11-12) has identified the following types of patients, each one
having a unique way of exposing suffering:

43
1) the intelligent patient narrates the data in a clear, concise, comprehensible manner
and almost with no trace of emotion showing a perfect self-control and ability of self-
reflection. In this case, the doctor must not intervene so as to elaborate a clear view on
the patient’s situation;
2) the confuse patient has memory disorders and language impairments and/ or a low
level of literacy, which makes his narration unintelligible and thus, the doctor must
intervene and ask simple questions that demand a clear answer;
3) the verbose patient gives excessive and irrelevant information and in this case the
doctor will tactfully orient his narration to the essential points, but making sure his
interruptions are not premature for this could suggest superficiality and hastiness;
4) the introvert or taciturn patient is parsimonious in his narration, he exposes the
details of his suffering with a certain reserve and reluctance and has the tendency of
minimalizing the severity of his symptoms due to a feeling of culpability. This attitude
and this reticence to disclose information can be observed in connection with aspects
such as exaggerated alcohol consumption, intimate details or drug abuse. In this case,
the doctor must adopt a neutral stance before approaching these ‘sensitive’ issues. ;
5) the ‘informed’ patientis the patient I have called the health illiterate patient who is
contrasted with the health literate patient. The ‘informed’ patient easily and
correctly uses medical terms, although he may sometimes not understand their entire
meaning. Hence, the doctor must not be misguided by the correct use of medical
jargon and see whether this type of information is real. Another difficult situation is
when the patient communicates the exact diagnosis established by other doctors;
6) the insincere patient adapts his narration in conformity with exogenous goals and lies
in connection with his symptoms so as to obtain certain advantages (i.e.
hospitalization, retirement, obtaining a job etc.);
7) elderly patients are a category that has been given a lot of attention by researchers
working in the field of health communication (see section 2.3.2.4). Elderly patients
often have low cognitive abilities and they sometimes suppress information
unintentionally or deliberately when they are too embarrassed or shy to give certain
details. Not to mention the fact that elderly patients often exaggerate the manifestation
of their disease so as to prompt the doctor’s compassion and empathy and they often
give answers that they think the doctors would like to hear.

44
Thus, interviewing is the method that doctors use to manage and provide structure to the
conversation. What is more, by questioning their patients, doctors want to bring to the surface
all the aspects that could have been omitted because even the smallest details are relevant for
the health outcome. Therefore, the above particular ways of exposing suffering act as the
principles that guide the health communication inquiry.

Finally, the questions must have a clear formulation and they should take into consideration
the level of literacy and health literacy of the patient as well as other social factors such as
sex, age, gender etc. Actually, doctors must avoid suggestive questions (i.e where the
response is incorporated in the formulation if the question) that could have erroneous answers
or answers that are meant to please the doctor (Bolosiu, 1998:13).

2.2.3.4. Health literacy as a demand in the healthcare dialogue

The definition of literacy in its most basic sense, i.e. the capacity to read, write and have basic
numeric skills (the three Rs’) has shifted towards a more complex one that puts emphasis on
individual empowerment as in our contemporary society, literacy seems to have become a
means of survival. However, literacy varies by context and perhaps the most important
context where literacy is an invaluable asset is the healthcare arena.

Therefore, health literacy is a subtle form of literacy whose positive effects on one’s health
are well known and researched. Healthy People 2010defines health literacy as‘the degree to
which individuals have the capacity to obtain, process, and understand basic health
information and services needed to make appropriate health decisions.’ (see website 5). In
fact, being functionally literate or being functionally illiterate in the context of health can be
analogous to life or death. For example, if an individual does not possess the ability to
understand the prescriptions on a drug bottle he might take a fatal dosage of a medication.

What is more, The AMA Council of Scientific Affairs more specifically defines functional
health literacy as‘the ability to read and comprehend prescription bottles, appointment slips,
and the other essential health-related materials required to successfully function as a patient.’
(see website 6). Health education that leads to health literacy is achieved therefore, through
methods that go beyond information diffusion. Health literacy entails interaction and
participation. In the doctor-patient interaction, health literacy refers to a patient’s ability to
follow doctor’s directions and thus, adhere to his instructions, a fact which is crucial for a

45
good health outcome. Not being able to correctly process and understand health information
coming from a physician can prove to be fatal for the patient.

In addition, health literacy is critical to the empowerment of the patient in his encounter with
the doctor. Possessing health-related information can balance the distribution of power in the
doctor-patient encounter. However, being health literate requires a complex system of
analytical skills as patients are often confronted with the task of taking treatment decisions
and in this case, it would be ideal to know how to evaluate the risks and benefits involving
that particular decision.

In order to function adequately within a consultation, a patient must have an adequate level of
health literacy, this referring first of all to his ability to communicate efficiently for various
purposes using health-related information. During a consultation, a patient is hypothetically
faced with asking for further information, demanding clarifications or suggestions, but the
only impediment here is that his questions must be pertinent. Not knowing how to ask
pertinent questions or being embarrassed to do this for fear the doctor may judge his plain
vocabulary is obviously detrimental to the patient. Also, a patient could feel embarrassed to
admit that he has not really understood the doctor’s instructions. Furthermore, most patients
opt for saving one’s face by not demanding for clarification because they consider their lack
of knowledge, which in this case is totally justifiable, a source of possible humiliation or
shame.

Health illiterate patients experience more communication difficulties and ‘it is not surprising
to find that patients with low literacy skills are less likely to be active participants in the
medical dialogue and in the decision making process’ (Roter, 2011). Being a good decision-
maker in matters that affect one’s health is especially difficult for elderly patients that
represent a vulnerable segment of the population as they are prone to having low health
literacy. One of the possible reasons is that health literacy declines with age and with the
decrease of our cognitive abilities. ‘A study of 3260 elderly by Baker et al. (2002) looked at
hospitalization and literacy. They found that individuals with inadequate literacy were likely
to be older and have less education. They also had a 52% higher risk of being hospitalized
than those with adequate literacy.’ (Rajda and George, 2009).

46
Although, illiteracy has many social stigmas attached to it, physicians must be aware of the
fact that many patients have a low health literacy which they should perceive as normal.
Consequently, the best approach would be for them to assume that the patients with whom
they are interacting have LHL (i.e. Low Health Literacy), and a “universal precautions”
approach should be followed, as suggested by Paasche- Orlow and Wolf (2007), cited in
Nutbeam (2008:2073). By using this approach, the doctor puts emphasis on improving
patient’s knowledge in matters that affect his health, the effect being the attainment of a
positive health outcome.

To conclude with, doctors must be aware of the fact that breakdowns in the dialogue with
their patients can occur any time and that, at a larger scale, an efficient strategy to prevent that
from happening would be to put emphasis on increasing the patient’s level of health literacy.
However, in the short run, a doctor should try to detect the patient’s health literacy level and
adapt to.

2.2.4 Defining institutional talk

According to Heritage (2004:106), institutional talk is ‘the interaction between lay people and
the representatives of professions or public bureaucracies’. That is why the field of medicine
has been given a lot of attention and during the past thirty years, research has been focusing
on the study of doctor-patient interaction. Compared to ritualistic events such as wedding
ceremonies, which have strict norms of interaction (i.e. who speaks, in what order), the
doctor-patient interaction accepts variations. Even though variations may occur in the doctor-
patient encounter, this does not mean that they are not strictly related to the characteristics of
institutional talk. In fact, any type of variation is constrained by the goal of the interaction.

Moreover, other limitations are linked to allowable contributions and the type of inferences
that participants may draw because of the specificity of that particular speech occasion. It is
due to these constraints that doctors refrain from complaining to patients about their own
condition (Heritage, 2004:107). Thus, the elements that render a conversation as
institutionalized in nature (Drew and Heritage, 1992, in Heritage, 2004:106) are the
following:
a. ‘the interaction involves goals that are tied to institutional relevant identities’;
b. ‘the interaction involves special constraints on what is an allowable contribution to the
business at hand’;

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c. ‘the interaction will involve special inferences that are particular to specific contexts’.

However, there has been some criticism to the study of conversations as institutional talk
(McHoul and Rapley, 2001, cited in Heritage: 2004:107) according to which making a
distinction between ordinary conversations and institutional talk is devoid of sense. If we
were to consider this distinction as motivated, then it would seem only normal that we should
engage in the study of any conversation using medical-related information as institutional
talk. After all, family is no less of an institution that science and medicine and persons
interacting in everyday ordinary conversations use the same ‘communicative competence’
that they would employ in a formal situation. Individuals’ medical knowledge is the same
regardless of the formality of the situation. Why wouldn’t a conversation between two
neighborsat a dinner party, one having the profession of a doctor and the other being a
layman, would not be analysed as institutional talk, but as ordinary conversation?

To answer my question, I am bringing as supporting evidence Garfinkel’s maxim (Heritage,

2004:107) that says that ‘a person is 95% conversationalist before entering an institutional
setting’. Consequently, the difficulty of coming with an exhaustive, operational definition lies
in the fact that ‘institutional talk is not confined to particular physical or symbolic setting such
as hospitals’ (Drew and Heritage, 1992, in Heritage, 2004:107). As a matter of fact,
institutional talk can be encountered everywhere and this is the case of ordinary conversations
too. In fact, I am perfectly aware of the fact that as a researcher, it is my duty to take all these
aspects into consideration.

More precisely, due to these opposing concepts that arise when trying to offer a valid and
reliable definition to institutional talk, I found it difficult to analyse my data from a unilateral
perspective. Generally, the doctor and the patient have to accomplish their institutional task
and their institutional identities are observable throughout the transcriptions. Nevertheless, the
participants come to the point of dealing with matters in a manner that is considered ‘merely
being sociable’ (Heritage, 2004:108). Although the doctor and the patient may orient their talk
in a direction that accounts for their institutional identities, the encounter can switch between
institutional and sociable talk. Furthermore, the medical encounter and the discourse of
participants is bidimensional, passing from the professional-client interaction to ordinary
conversation.

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In sum, although there are no clear boundaries between casual and institutional talk, the
institutional type has distinctive features such as lexical choice, turn-taking system that are
connected to one or the other. To better understand this contrast between mundane and formal
talk, we can presume that the concept of institutional talk is the result of social change.
Moreover, the only notable difference would be the limited range of interactional practices
and constraints that happen within an institutionalized setting, aspects that are often perceived
as threatening or troublesome to the lay people.

2.2.4.1. The overall organization of institutional talk

First of all, in what their structure is concerned, the majority of interactions have distinctive
organizational features. This is why all types of interaction are unique and this is what makes
medical consultations different from a news interviews, classroom interactions, and even
dinner party interactions. Given these facts, the problem is to demonstrate how these different
organizational features manifest themselves.

Whatever types of conversation are under scrutiny, the researcher’s task is to shed light on the
specific actions involved in a particular verbal exchange but also to identify the existence of
inequalities between the participants (i.e. status, stance, identity). However, an individual can
have multiple identities that enable him to function adequately within a community and
finally, in society. These identities, which manifest themselves together with other possible
variables (i.e. age, gender, sex, ethnicity, social role) give us clues of how society works
(Heritage, 2004:110). Therefore, when communicating on a particular occasion, an individual
must carefully select which of his many identities to put into execution. By using the relevant
identity, people show their analytical skills – the outcome of an understanding of the type of
interaction they find themselves engaged in.

Actually, how else can we decide whether an individual is a doctor and a patient is a patient?
Schegloff (1991:50, in Heritage, 2004:110) notes that we must focus on aspects of the
conversation that are relevant to the participants if and only if their relevancy can be proven.
Another issue that must be dealt with comprises the mechanisms by which the identities of the
participants, the setting of the interaction and other aspects that pertain to context can have
consequences for the conversation underway. Thus, the analysis of institutional talk, ranging
from turn-taking mechanisms, sequence organization, turn design, lexical choice can ‘show us

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how particular institutional work-task-related identities are sustained in interaction’ (Heritage,
2004:111).

Additionally, participants’ conduct is an illustration of how they deal with constraints

resulting from the ‘activity type’ (Levinson, 1979) they are engaged in and what are the
allowable contributions they can bring to that particular occasion. Actually, ‘context and
identity have to be treated as locally produced, incrementally developed, and by extension, as
transformable at any moment’ (Heritage,2004:111). Having these norms of interaction into
consideration, the participant must orient and control the course of their conduct in such a
way that would clearly show what is informal and what is formal talk.

Furthermore, turn by turn, people construct the reality of the talk exchange and cooperate to
such an extent that they themselves can figure out the institutional or non-institutional
character of their interaction. For example, if the doctor and the patient stick to the turn-taking
system specific to their encounter ‘they are showing a clear orientation to a specific
institutional identity and the tasks and constraints associated with it (Heritage and Greatbeach,
1991, cited in Heritage, 2004:111).

To summarize, the overall structure of the interaction as well as the turn taking system, turn
design and lexical choice are all domains that require thorough scrutiny because they all
indicate whether a conversation is institutional or not. Although, inconsistencies and variables
are a part of any type of interaction, the overarching structure must be easily identifiable and
the enactment of the elements that I have already mentioned are the aspects that lead to the
creation of the role relationship between participants.

2.2.4.2 Power and asymmetry in institutional talk

As I have already stated in my precedent section, the medical consultation (i.e. medical
history taking) embodies institutional identities, stances, ideologies, all of these aspects
pointing to forms of power and asymmetry encountered in the case of this social practice
where participants accomplish their social roles. Heritage (2004:113) notes that ‘interactional
practices both reflect and embody differential access to resource and to power’. This
statement is enough to show the complexities hidden behind the doctor-patient interaction.
Despite the fact that institutional talk has to do with many actions pertaining to mundane talk,

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where participants share an equal status, in this ‘activity type’ the asymmetry results from the
overarching structure of the interaction.

According to Van Dijk (1993:21), ‘the enactment of power is not simply a form of action, but
a form of social interaction’ and he continues by stating that:
‘The exercise and maintenance of social power presupposes an ideological framework. This framework,
which consísts of socíally shared, interest-related fundamental cognitions of a group and its members, is
mainly acquired, confirmed, or changed through communication and discourse.’

Expanding on Van Dijk’s statement it can be said that in a formal conversation, where lay
people have a reactive role because they have to speak with representatives of a particular
institution for different purposes, the distribution of power is something pre-established.
However, due to the fact that these power relationships have become the “norm”, people can
no longer distinguish between what is ‘normal’ or ‘abnormal’. This is how ideologies become
present in all domains of interaction and people become so ingrained that they modify their
beliefs, aspirations and needs according to these doctrines of thought and conduct.

Moreover, Fairclough (1989) examined certain conventions that he considers to be the result
of power struggle. In his view, these conventions that act as guidance to individuals’ linguistic
interaction are based on ‘common-sense assumptions’ that people employ unconsciously. In
what medical discourse is concerned, the ideological framework that Fairclough (1989:2) puts
forwards is what motivated and forced my research into existence:
‘the conventions for a traditional type of consultation between doctors and patients embody ‘common-
sense’ assumptions which treat authority and hierarchy as natural – the doctor knows about medicine
and the patient doesn’t; the doctor is in a position to determine how a health problem should be dealt
with and the patient isn’t; it is right (and ‘natural’) that the doctor should make the decisions and control
the course of the consultation and of the treatment, and that the patient should comply and cooperate;
and so on.’

This excerpt reflects the fact that power manifests itself throughout the entire unfolding of the
conversation without the participants even noticing. What is more, the control of the
interaction is taken by the doctor who behaves as the initiator of ‘key’ and establisher of the
topic. Taking but a glimpse at my data, which consists of transcriptions of medical
consultations, the first thing that draws the reader’s attention is the fact that the doctor elicits
patients’ answers and not the other way around. Thus, the doctor has a ‘right-to- know’
persona (Verschueren, 1999:153) as his task can be compared to that of an interviewer.
Obviously, the doctor is in a position of deciding the contents and the organization of the
interaction which is a strong factor in the reproduction of this type of ideology.

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Furthermore, although conversations generally entail the existence of equal social roles,
speakers that have institutional roles introduce the notion of asymmetry and status
differences. Actually, in institutional dialogues, speakers display, enact or negotiate hierarchy
and expertise (Van Dijk, 1993: 35). In what the doctor-patient interaction is concerned, Van
Dijk admits that there is an ‘imbalance in the informational exhange’. This means that the
doctor possesses the ability to use medical jargon whereas the patient does not. Not to
mention the fact that the patient needs the doctor’s help and the doctor is the one who can
improve the patient’ health status and not viceversa. During a medical consultation, doctors
question the patients and even providing answers to the physician’s inquiry poses a series of
difficulties, resulting from their inadequate level of ‘expertise’ in the field, also called health
literacy.

To conclude with, medical discourse is an adequate example of domain where social routine
is a source of linguistic power. However, the blunt exercise of power has been linked to the
biomedical approach by specialist such as Treichler, Frankel, Kramarae, Zoppi, and Beckman
(1984), whose works are cited in Van Dijk (1993:36). According to them, the biomedical
approach leaves no room for the patient’s participation that could balance the distribution of
power. Thus, a doctor-centered communication style hinders the patient’s availability to
expose his suffering and concerns.

2.3. Conclusion
My paper draws on a number of approaches, and I have chosen some of these theoretical
concepts and analytical procedures to analyse the content of my data. Thus, the creation of
meaning in interaction, which is an inherent trait in any interaction and the methods people
use to ‘make sense’ of utterances are both worthy of attention. This is what makes
‘contextualization cues’ and ‘repairs’ become important concepts that I will expand on in the
analysis of my data. Moreover, CA and institutional talk provide the resources to my
analytical endeavor, that is, uncovering the structure of medical history taking, finding out
how participants design their turns, the basis on which they select their vocabulary and
discovering the ideology and existent asymmetries in talk if any. As a matter of fact, the
doctor’s approach to the medical consultation and the types of patients, their particular ways
of exposing suffering as well as their level of health literacy have proved to be of tremendous
help from an analytical point of view. I have started from issues of co-text and approached

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aspects of context so as to see whether the participants display orientation to the type of
activity they are engaged in (i.e. medical history taking).

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_________________________________________________________________________________
APPENDIX FIVE
Example BA abstracts
Example 1:
CLIL is a pedagogical project implemented in foreign language learning that has been subject
of global approval because of its many advantages for creating a suitable environment for
learning. Research has shown, however, that while comprehension skills (reading and
listening) are really boosted in a CLIL environment, this may not be the case of productive
skills (speaking and writing). Students seem not to have enough chances to speak or initiate a
conversation, affecting their speaking and writing outcomes negatively.

One solution may be cooperative learning which may help enhance CLIL contexts, catering
not only for the development of comprehension skills and better reasoning, but also for
interaction and communication. In this way, students are given chances both for input
reception and output production. This paper addresses the issue of how teachers can improve
their students’ competences in the foreign language classroom by implementing cooperative
learning structures in content-based environments.

Also, the purpose of this project is to explain how we can try to successfully combine content
learning and language learning in History and Geography classes, respectively, taught in
Romanian High schools. A comparison has been made between how the CLIL approach is
seen and applied in the Romanian teaching system versus how it is seen and applied in the
foreign, European teaching system.
Example 2:
Motivation is defined as the learner's orientation with regard to the goal of learning a
second language. This study investigated the various socio-psychological orientations of
Romanian high school students towards learning English. It focused on the motivation
orientations of the students and their attitudes towards the target language and its community.
A group of students attending intensive English courses at a high school in Braşov was
surveyed using the AMTB (Attitude, Motivation Test Battery). The domains used for the
purposes of the study were: a) integrative and instrumental orientation, b) desire to learn
English, c) motivational intensity, d) attitudes towards foreign languages e) attitudes towards
English-speaking people. The results revealed that these Romanian non-native speakers of
English learn the language mainly due to instrumental motivation and their attitudes towards

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 the target language community and its members were generally found to be highly
ambiguous. The study is based on data collected in eighty-three questionnaires and fourteen
interviews to which the high school students were asked to participate. For the analysis proper
of the data, the Gardner's concept of integrative motivation was brought into discussion.
Example 3:
In the academia, the gendered nature of the political system has constituted a theme since the
1970’s. More recently, Connell (2000) identifies as a source that contributed to the emergence
and continuation of the patriarchal order the modern state and capitalism. Therefore, since its
beginning the state is a gendered institution. However changes occurred and masculinity of
the state has been challenged. As a result women entered politics. Yet they do not hold high-
office jobs such as the Presidency of a state. In Romania, the masculinity of the state was
challenged less than in other countries because of the communist regime that lasted 50 years.
The topic of this paper is the interplay between hegemonic masculinity and the Romanian
state in the 2009 electoral presidential debates. The purposes of this research are, first, to
analyse in what ways hegemonic masculinity pervades two presidential debates and, second,
to reflect critically on the analysis in order to identify ways to overcome the hegemonic
masculinity. The method used to carry out these two purposes was critical discourse analysis.
Fairclough’s critical discourse analysis framework invests the researcher with great
autonomy, thus it was combined without major difficulties with conversation analysis,
rhetoric analysis and content analysis in order to analyse hegemonic masculinity. The findings
of the research revealed that the candidates use conversation and rhetoric strategies - such as
interruptions, overlaps, and latched utterances to control the floor, portraying the debates as a
fight and appealing to emotions in order to revive a daddy state - in order to win the electorate
(Messner 2007). The conclusion is that hegemonic masculinity pervades both the ideological
and individual level of the discourse of presidential debates.

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