How does ordering a test fit into "new problem" medical consultations? Responding to calls for st... more How does ordering a test fit into "new problem" medical consultations? Responding to calls for studies of the overall structural organization of consultations beyond primary care, this article depicts the organization of new problem consultations observed in two large neuroscience centers in the UK. This shows that-in addition to Robinson's widely cited four main activities (establishing the reason for the visit, gathering information, delivering a diagnosis, recommending treatment)-test ordering is oriented to as an additional, normative activity. We show this numerically (tests were ordered in over 60% of our 65 new problem consultations) and by analyzing how participants orient to the activity of test ordering even when neurologists decide against testing. We argue that test ordering is a distinct activity, which, despite being treatment-oriented, displaces treatment in the here and now. Test ordering is thus consequential for progressivity, serving as both bridge and barrier to accomplishing the overarching medical project. Data are in British English. In his hugely influential paper on the structure of acute, primary care consultations in the United States, Robinson (2003) showed that doctors and patients orient to four core activities: establishing the reason for the visit, gathering information through verbal and/or physical examination, delivering a diagnosis, and recommending treatment. Unlike previous attempts to capture or prescribe how the consultation typically does/should progress (notably, Byrne & Long, 1976), Robinson did not conceptualize this structure as a linear set of phases or an ideal type. Rather, he argued that those consultations in which a new medical problem is presented as the reason for the visit are oriented to-by doctors and patients alike-as an "interactional project" with the primary goal of treatment (i.e., addressing the presenting problem). To accomplish this overarching project satisfactorily, doctor and patient must complete the four core activities listed previously. Moreover, each of these is directed toward achieving the next (e.g., information gathering is in the service of producing a diagnosis, which is in the service of making a treatment recommendation). This conceptual shift accounts not only for the recurrent phase-like structure of such consultations but also for often-observed deviations from this. For if either participant deems that one of the activities has not been satisfactorily accomplished, they may hold up progress to the next activity (e.g., from diagnosis to treatment if, say, the patient is concerned the doctor might have missed something) and may revert to earlier activities (e.g., the doctor may initiate further information gathering in response to such a concern) (see Monzoni et al., 2011a, for an illustration in neurology). Progressivity toward the CONTACT Merran Toerien
BackgroundNHS policy emphasises shared decision-making during labour and birth. There is, however... more BackgroundNHS policy emphasises shared decision-making during labour and birth. There is, however, limited evidence concerning how decision-making happens in real time.ObjectivesOur objectives were as follows – create a data set of video- and audio-recordings of labour and birth in midwife-led units; use conversation analysis to explore how talk is used in shared decision-making; assess whether or not women’s antenatal expectations are reflected in experiences and whether or not the interactional strategies used (particularly the extent to which decisions are shared) are associated with women’s postnatal satisfaction; and disseminate findings to health-care practitioners and service users to inform policy on communication in clinical practice.DesignThis was a mixed-methods study. The principal method was conversation analysis to explore the fine detail of interaction during decision-making. Derived from the conversation analysis, a coding frame was developed to quantify interactions...
The Addenbrooke’s Cognitive Examination (ACE-111) is a neuropsychological test used in clinical p... more The Addenbrooke’s Cognitive Examination (ACE-111) is a neuropsychological test used in clinical practice to inform a dementia diagnosis. The ACE-111 relies on standardized administration so that patients’ scores can be interpreted by comparison with normative scores. The test is delivered and responded to in interaction between clinicians and patients, which places talk-in-interaction at the heart of its administration. In this article, conversation analysis (CA) is used to investigate how the ACE-111 is delivered in clinical practice. Based on analysis of 40 video/audio-recorded memory clinic consultations in which the ACE-111 was used, we have found that administrative standardization is rarely achieved in practice. There was evidence of both (a) interactional variation in the way the clinicians introduce the test and (b) interactional non-standardization during its implementation. We show that variation and interactional non-standardization have implications for patients’ underst...
Classification and classification systems organize everyday life and do so in ways that are incre... more Classification and classification systems organize everyday life and do so in ways that are increasingly automated. Classifiers classify the classifiable and are highly political. Yet, ironically, it is precisely through devising new forms of classification that social scientists can also intervene and develop new modes of resistance in everyday life
Seeing Silenced Agendas in Medical Interaction: A Conversation Analytic Case Study
This paper examines the use of "just"-formulated advisings in ordinary, naturally-occurring seque... more This paper examines the use of "just"-formulated advisings in ordinary, naturally-occurring sequences of unsolicited advice-giving when produced in response to troubles-tellings. Drawing on two examples from our broader collection, we demonstrate that such advisings are employed in response to advice-resistance and function to minimise proposed courses of future action, attenuating their imposing nature. We show they place an interactional bind upon advice-recipients which contributes towards further resistance. This paper explicates this bind and its categorial, epistemic and moral implications. Data are in American and British English. In their seminal research on the rejection of advice, Jefferson and Lee (1980; 1981/1992) demonstrated that advice-giving is oriented to as a misaligned response to troubles-tellings, and routinely occasions resistance from troubles-tellers. They explain this resistance on categorial grounds; namely, if a troubles-teller were to accept advice from an interlocutor, this would proposedly transform their discourse identity from that of a "troubles-teller" to an "advice-recipient", substituting the categorial perquisites (e.g. entitlements, rights, obligations, etc.) that are normatively afforded by the incumbency of the former category with those associated with the latter. Likewise, the previously positioned "troubles-recipient" would proposedly transform their discourse identity to that of an "advice-giver", claiming the perquisites that are implicated, normatively, by the incumbency of the latter category. As Jefferson and Lee (1980; 1981/1992) observe, this disrupts the progressivity of the troublestelling. The previously positioned troubles-recipient hasby misaligning with their categorial positioning as suchinitiated a transformation of the interaction from a "troubles-telling" to a "service encounter", focusing off the troubles-teller and his/her experiences, and focusing on the trouble as a 'problem to be solved' (Jefferson and Lee, 1981: 416). The production of advice-giving in response to a troubles-telling thus engenders 'interactional asynchrony' (Jefferson and Lee, 1981: 402), with interlocutors pursuing two diverging interactional trajectories. In this paper, we revisit the period of interactional misalignment to hone in on a peculiar feature that recurs in responses to advice resistance; namely, the delivery of "just"-formulated advisings. Examples of this practice include the following.
The Royal College of Surgeons (2016) has argued that health professionals must abandon a 'paterna... more The Royal College of Surgeons (2016) has argued that health professionals must abandon a 'paternalistic' approach to consent in favour of 'informed choice'. We engage critically with these guidelines through analysis of neurology consultations in two UK-based neuroscience centres, where informed choice has been advocated as good practice for over a decade. Based on 223 recorded consultations and related questionnaire data, we used conversation analysis (CA) to identify two practices for offering choice: patient view elicitors (PVEs) and option-lists. This paper reports further, mixed-methods analyses, which combined CA with statistical techniques to compare the two 'choice' practices with recommendations. We demonstrate that recommendations were overwhelmingly more common. There was little evidence that patient demographics determined whether choice was offered. Instead, individual neurologists tended to have a 'style', making it partly a matter of chance which decisional practice(s) patients encountered. This variability matters for the perception of choice: neurologists and patients were more likely to agree a choice had been offered if a PVE or option-list was used. However, these practices were associated with a risk: while recommendations nearly always ended in agreement to undertake the proffered course of action, option-lists and PVEs did so only about two-thirds of the time. We argue thatinsofar as neurologists tailor their approachthey are engaging in a complex balancing act between their 'duty of care' and the demand for patient choice. We question the appropriateness of a 'one size fits all' model of consent.
Background We report follow-on research from our previous qualitative analysis of how neurologist... more Background We report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another. Objectives To (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making. Design A mi...
This article discusses the changing nature of girlhood over the last century as it is depicted th... more This article discusses the changing nature of girlhood over the last century as it is depicted through an empirical study of all editions of Girl Guide handbooks since 1910. The article describes three strands of change, which we describe as ‘stringy’, insofar as they are co-occur together and are difficult to untangle from one another; yet they are also stories of change that are nevertheless visible as strands in and of themselves through the empirical material. We illustrate the importance of incorporating children and childhood into more general theories of social change, in order to better understand how they are intrinsic to the mechanisms of intergenerational change.
Discourse, Culture, and Extraordinary Experiences: Observations from a Comparative, Qualitative Analysis of Japanese and UK English Accounts of Paranormal Phenomena
In this paper we address Hasting and Manning's (2004) call for analysis of relational aspects of ... more In this paper we address Hasting and Manning's (2004) call for analysis of relational aspects of the performance and production of social identity, and in particular acknowledgement of the role of the other, or alterity, in identity work. Drawing from methods in the micro sociological study of social interaction, we examine a corpus of video recordings of stage demonstrations of mediumship. These video clips were posted on the internet by the participating mediums. Our analyses focus on various communicative practices in the setting of the demonstration by which a particular other-in this case, the spirits-are invoked, and the rhetorical and inferential consequences that follow for the mediums' claims to authenticity and authority.
Communication during labour is consequential for women's experience yet analyses of situated ... more Communication during labour is consequential for women's experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate 'decisions' during labour. Interactions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction. HCPs initiate decision-making using interactional practices that vary the 'optionality' afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through 'assertions'. An 'assertive' turn-design (e.g. 'we need to…') conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions. The expectation...
The landscape of human thought over the last two millennia has often considered the world discove... more The landscape of human thought over the last two millennia has often considered the world discoverable through an understanding of its timeless defining features. In psychology this developed into a dominant focus on the individual's inner life of thoughts and memories, faculties for information processing, and evolutionary heritage of hot emotions and cool reasoning. This internalized or 'cognitivist' focus has become one of the unquestioned premises for most forms of psychology. Mainstream psychology, then, often takes personhood to be constructed through supposed fundamental internal features and processes such as personality, gender, cognition and emotion. Treating these features as natural, discoverable and measurable warrants psychology's claim to be a science, with all the associated characteristics of an objective, apolitical and benign scientific endeavour. As emphasized throughout this book, psychology's individualistic notion of personhood and mind leads to individualizing explanations of human conduct that can undermine the potential for social change and social justice. By locating 'causes' of behaviour inside people, psychologists often miss the deeply situated, social, political and cultural contexts in which human behaviour is produced. Fox et al-3779-Ch-11:Fox et al-3779-Ch-11.qxp 9/2/2008 8:44 PM Page 176
This article examines communicative practices in Japanese and UK English accounts of extraordinar... more This article examines communicative practices in Japanese and UK English accounts of extraordinary experiences. We compare the way in which specific narrative features are handled: description of the actual experience, and the completion of the narrative. We also examine some ways in which the accounts are rhetorically designed to address skeptical alternatives. The perspective is informed by an ethnomethodological focus on communicative competences in description. This comparison identifies differences between Japanese and UK English narratives. This focus on interactional features of the data is contrasted to macro cultural or psychological perspectives on the relationship between national culture and language.
ABSTRACT In this paper we address Hasting and Manning’s (2004) call for analysis of relational as... more ABSTRACT In this paper we address Hasting and Manning’s (2004) call for analysis of relational aspects of the performance and production of social identity, and in particular acknowledgement of the role of the other, or alterity, in identity work. Drawing from methods in the micro sociological study of social interaction, we examine a corpus of video recordings of stage demonstrations of mediumship. These video clips were posted on the internet by the participating mediums. Our analyses focus on various communicative practices in the setting of the demonstration by which a particular other – in this case, the spirits – are invoked, and the rhetorical and inferential consequences that follow for the mediums’ claims to authenticity and authority.
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Papers by Clare Jackson