Title: Pre-emptive resistance: patients’ participation in diagnostic sense-making activities
Abstract: Sociology of Health & IllnessVolume 32, Issue 1 p. 1-20 Free Access Pre-emptive resistance: patients’ participation in diagnostic sense-making activities Virginia Teas Gill, Virginia Teas Gill Department of Sociology and Anthropology, Illinois State University, USASearch for more papers by this authorAnita Pomerantz, Anita Pomerantz Department of Communication, University at Albany, SUNY, USASearch for more papers by this authorPaul Denvir, Paul Denvir Albany College of Pharmacy and Health Sciences, USASearch for more papers by this author Virginia Teas Gill, Virginia Teas Gill Department of Sociology and Anthropology, Illinois State University, USASearch for more papers by this authorAnita Pomerantz, Anita Pomerantz Department of Communication, University at Albany, SUNY, USASearch for more papers by this authorPaul Denvir, Paul Denvir Albany College of Pharmacy and Health Sciences, USASearch for more papers by this author First published: 25 January 2010 https://doi.org/10.1111/j.1467-9566.2009.01208.xCitations: 50 Address for correspondence: Virginia Teas Gill, Department of Sociology and Anthropology, Campus Box 4660, Illinois State University, Normal IL 61790, USA e-mail: [email protected] AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract In medical clinic visits, patients do more than convey information about their symptoms and problems so doctors can diagnose and treat them. Patients may also show how they have made sense of their health problems and may press doctors to interpret their problems in certain ways. Using conversation analysis, we analyse a practice patients use early in the medical visit to show that relatively benign or commonplace interpretations of their symptoms are implausible. In this practice, which we term pre-emptive resistance, patients raise candidate explanations for their symptoms and then report circumstances that undermine these explanations. By raising candidate explanations on their own and providing evidence against them, patients call for doctors to restrict the range of diagnostic hypotheses they might otherwise consider. However, the practice does not compel doctors to transparently indicate whether they will do so. Patients also display their ability to recognise and weigh the evidence for common, easily remedied causes of their symptoms. By presenting evidence against them, they show doctors the relevance of more serious diagnostic interpretations without pressing for them outright. Introduction A medical clinic visit can be seen as a sense-making event. There are various ways of understanding how the participants make sense of patients’ health problems. It can be viewed as a cognitive process wherein doctors, who have a specialised stock of knowledge about physiological processes, systematically gather information about patients’ presenting problems by soliciting information about their medical and social histories and current symptoms, performing physical exams and ordering laboratory tests. In this model, doctors develop and test hypotheses as information emerges in the investigation and finally arrive at diagnoses and plans for treatment. A widely used medical textbook describes the process in the following manner: Appropriate medical care depends on the physician’s knowledge of the patient’s abnormalities … best described as a diagnosis. Each recognizable disease possesses distinguishing features that serve as clues. So the physician embarks on two parallel courses: (1) a search for clues to develop a list of problems, leading to (2) the generation and selection of hypotheses to reach a diagnosis. Clues are sought by taking a history, performing a physical examination, obtaining laboratory tests and imaging, and ordering other special procedures. The clues that are found suggest a list of problems from which is generated hypotheses to explain the cause of the problems in terms of diseases in a list called the differential diagnosis. The clues or facts obtained during the diagnostic examination are used to support or refute each hypothetical disease in the differential diagnosis and finally to arrive at the diagnosis (DeGowin and Brown, 2000: 2). Social scientists, however, have argued that this sense-making process is more than a cognitive one; it has many social dimensions. Studies have shown that a number of socio-demographic factors, such as the participants’ gender and race, influence doctors’ interpretations of patients’ symptoms (Cooper-Patrick et al. 1999, Lorber and Moore 1997, Lurie et al. 1997, Rathore et al. 2000, Rathore and Krumholz 2004, Smedley et al. 2003). Moreover, patients as well as doctors try to make sense of illness; investigations of lay understandings of illness reveal that patients draw upon culturally prescribed models to make sense of their own health problems (Angel and Thoits 1987, Blaxter 1983, Hunt et al. 1989, Keller et al. 1989, Kleinman 1981, 1988). Some social scientists have also argued that it is important to examine social interactions between doctors and patients to see why certain interpretations of illness prevail. In some classic studies, sociologists have called particular attention to the socio-political dimensions of these interactions, such as the ways in which institutional identities and attending asymmetries in power and authority infuse the conversations and lead doctors to subordinate patients’‘life-world’ understandings of illness in favour of biomedical interpretations (Mishler 1984: 6; also see Cicourel 1983, Waitzkin 1979, 1991). Although diverse in nature, these social scientific studies have treated the sense-making process as a social process. Specifically, they have focused on the influence of external forces on sense-making in medicine and they have treated doctors’ and patients’ interpretations of illness as products, outcomes or results of these forces. This article has emerged from a different stream of social scientific research on medical sense-making. Rather than focusing on the social forces that influence doctors’ and patients’ interpretations of illness, this body of research uses conversation analysis (CA) to investigate the concrete social practices the participants themselves use in interaction to display and negotiate interpretations of what patients’ symptoms mean. Numerous CA studies have revealed that the sense-making process in clinic visits is not only a social process but is one with its own orderly features. It is accomplished in and through the participants’ collaborative engagement in an array of actions, such as soliciting and providing information, which figure in broader activities such as testing diagnostic hypotheses. The ways in which these actions are performed can shape what information emerges in the visit, when it emerges and how it emerges, all of which has implications for what can be discovered about the symptoms in question. For example, when patients provide information to doctors during clinic visits they may do much more than convey information about how they are feeling: they often slant this information, meaning that they take positions vis à vis their problems and what is causing them to occur. Furthermore, when doctors and patients offer and respond to each others’ interpretations of symptoms, they can perform a diverse array of social moves in addition to showing how they have made sense of illness, including inviting or pressing the other participant to interpret the illness in a certain manner, casting certain interpretations as probable or improbable and positioning themselves as reliable and authoritative sources of medical knowledge. Our investigation is part of a subset of CA research that focuses on the interactional resources that patients (and their representatives, such as parents of paediatric patients) employ during clinic visits to display their interpretations of illness and thereby draw their doctors’ attention to particular candidate explanations, cast themselves and their illnesses in a particular light, push for and resist particular interpretations, and in various ways suggest how doctors should view and handle the problems at hand. In this article we analyse a practice patients use to draw doctors’ attention to ways in which their problems could be interpreted and portray these interpretations as implausible, thereby suggesting to doctors that it would be relevant to pursue other diagnostic angles. Background Outpatient medical clinic visits generally proceed in phases that encompass different tasks or activities. Doctors collect data (information about patients’ problems and symptoms) through verbal and/or physical examination, analyse these data and present their diagnoses, and then offer advice about how the problems should be treated or managed (see Byrne and Long 1976). These activities occur over the following six phases: (i) opening; (ii) presenting complaint; (iii) examination; (iv) diagnosis; (v) treatment; (vi) closing (Heritage and Maynard 2006: 14). These phases offer different opportunities for patients’ participation in the sense-making enterprise and they impose various constraints upon that participation. In the following section, we provide a background for our study by reviewing the literature on phase-specific resources that patients employ to display their interpretations of illness and accomplish a variety of actions, including exerting pressure on doctors to interpret and treat their problems in particular ways. Patients’ responses to diagnoses The environment following the delivery of a diagnosis11 We reserve the term ‘diagnosis’ for doctors’ final specifications of conditions, diseases or injuries that cause patients’ problems and symptoms. We use the more general terms, ‘explanation’, ‘candidate explanation’ or ‘interpretation’ when referring to patients’ displays of sense-making in regard to illness and to doctors’ more general causal attributions. These encompass both overt and tacit attributions for symptoms, which are done by attributing symptoms to hypothetical conditions (for example, hormone deficiencies), to particular organs in the body (for example, the heart), and to various circumstances (for example, insufficient sleep). It also encompasses reports, speculations and inferences that something ‘brought on’ a symptom (Gill and Maynard 2006). provides patients (and/or their representatives, such as parents of paediatric patients) with opportunities to display interpretations of their health problems. After the diagnostic informing the patient may indicate alignment with the doctor’s interpretation by providing an agreeing assessment (Peräkylä 2002, 2006). Doctors also treat patients’ minimal acknowledgments (yeh’), continuers and silence22 An exception is the ‘stoic’ response (Maynard 2003: 120) where non-vocal behaviour accompanying a silence – such as crossed arms and certain facial expressions – can be used to indicate resistance to a diagnosis. in this sequential location as an indication of alignment and willingness to move to the next phase of the visit: management or treatment of the condition (Peräkylä 1998, 2002, 2006, Heath 1992, Robinson 2003, Stivers 2005, 2006). Patients also may also challenge doctors’ diagnostic interpretations in this location. They may disagree outright (Gill and Maynard 1995, Maynard 2003), or suggest diagnoses that are different from the ones that the doctors have offered (Peräkylä 2002). Patients may also resist doctors’ diagnoses in a tacit manner by reporting information about bodily states and symptoms that are inconsistent with these diagnoses. For example, patients may report that they have symptoms that are discrepant with the diagnosis (Peräkylä 2002, 2006) or that their symptoms have changed (Heath 1992), or they may describe a state of suffering that is incongruent with the condition that has been diagnosed (Heath 1992). By positioning these reports just after doctors’ diagnostic informings, patients invite their doctors to hear the reported circumstances against the contextual backdrop of the diagnostic news, and thus to hear the reports as diagnostically relevant – specifically, as evidence that the diagnoses are incorrect and should be reconsidered. When patients display disagreement with diagnoses in the post-informing environment they encourage doctors to delay the progression of the visit to reconsider their diagnoses, rather than move on to the management or treatment of the condition (Heath 1992, Peräkylä 2006). Frontloading: patients’ displays of sense-making before doctors deliver diagnoses Patients may also frontload the medical visit, meaning that they may present their own interpretations of their problems in early phases of the visit where doctors are, broadly speaking, collecting information. This environment provides patients with a number of opportunities not only to describe their problems but to show how they have made sense of them. By offering their own candidate explanations for illness early on, patients can draw doctors’ attention to potential causes for their illnesses and hint, suggest, or forthrightly ask doctors to consider their relevance during the visit (Gill and Maynard 2006). Patients routinely offer causal explanations for illness as they present their problems and in the course of replying to doctors’ questions about them (Gill 1998, Gill and Maynard 2006). Some frontloading initiatives (for example, ‘Do you think it’s X?’) make it relevant for doctors to reveal their own sense-making in return – specifically, to respond by assessing the explanations. The design of other frontloading initiatives provides for a wider range of doctors’ responses. For example, patients may speculate about possible causes of their problems, they may sandwich their explanations within multiple-component turns or they may juxtapose symptom descriptions with reports of circumstances in ways that imply causal connections. Using these types of practices, patients can hint to doctors that they should investigate particular candidate causes while they are working up their problems, and do so without calling for them to assess these causal explanations then and there. That is, these initiatives do not firmly establish the conditional relevance of doctors’ immediate assessments, such that they would be ‘officially’ or ‘notably’ absent if they did not occur (Schegloff 1968, 1972: 76). Rather, they allow doctors to continue gathering information about patients’ symptoms with patients’ candidate explanations (possibly) in mind (Gill 1998, Gill and Maynard 2006). When patients frontload the visit they also may be engaged in the more general work of showing that they have the types of problems that warrant medical visits (Heritage and Robinson 2006) and should therefore be taken seriously. Additionally, they may be working to cast themselves in a particular light – for example, as ‘reasonable’ patients who can be trusted to take an appropriate stance toward their bodies –‘neither too lax, nor hyper-vigilant’ (Halkowski 2006: 90). When patients provide their own interpretations of illness in the early phases of the visit they also may be angling for particular treatments. For example, in paediatric visits parents may offer candidate explanations at the beginning of the visit to suggest not only that their children’s problems are worthy of medical investigation but that they also worthy of treatment such as prescriptions for antibiotics (Stivers 2002). In this article we reveal another dimension of frontloading in medical visits. We have found that in early phases of clinic visits, patients not only put forward interpretations of illness but also occasionally exhibit resistance to particular ways in which their illnesses could be interpreted. While intuitively it might seem that this would have to occur in response to doctors’ diagnostic informings, this is not always the case. Our analysis focuses on a practice patients use to discount commonplace interpretations of illness pre-emptively, during the phases of clinic visits where doctors are gathering information about their problems and symptoms. In this practice, the patients themselves raise candidate explanations for their problems and then report circumstances that call the explanations into question, showing doctors that these interpretations are unlikely to be worthy of investigation. By working to block certain avenues, the patients also suggest that it would be relevant for their doctors to look elsewhere for the source of their problems. Data and methods Data for this study are videotapes of primary care medical consultations in the USA. We drew upon three sets of data recorded in three different decades in three different clinics: one set was collected in the late 1980s in an internal medicine clinic in a mid-western teaching hospital, the second was collected in the early 1990s in an ambulatory clinic located in a teaching hospital in a large eastern city and the third was collected in the early 2000s in a family practice clinic located in a mid-sized eastern city. The three collections include 50 consultations in total. All recordings were made with the participants’ informed consent. We use conversation analysis (CA) to analyse the data. CA has intellectual roots in the discipline of ethnomethodology (Garfinkel 1967) and shares with that discipline a fundamental interest in culturally available practices, understandings and other resources that members of society draw upon to achieve and reproduce a known-in-common social order. Conversation analysts describe how members employ these shared resources in interaction to accomplish a range of social actions and activities (see Clayman and Gill 2004, Heritage 1984, Pomerantz and Fehr 1997, Sacks 1992). Following this approach, we closely examined the recordings of the medical consultations along with detailed transcripts of the recordings and analysed how the participants used and responded to the practice of pre-emptive resistance during the consultations. Organisation of the practice The practice of pre-emptive resistance is organised in the following manner: In an environment in the medical visit where the doctor is gathering information about the patient’s health problem and the patient is introducing or describing the problem or symptom: 1 Explanation: the patient raises a candidate explanation (X), showing that he or she has already considered the possibility that X causes the problem 2 Counter evidence: the patient resists the candidate explanation (X) by (i) reporting circumstances that serve as evidence that X is not the cause of the problem, or (ii) implying there is no evidence that X caused the problem. This is the base, or generic, practice. The patient may also add an upshot that explicitly rules out X: 3 Upshot: the patient asserts that X is not the cause of the problem. Any particular example of this practice can be placed on a continuum in regard to how explicitly the patient resists the candidate cause that he or she has raised. The most explicit examples include an explanation, counter evidence in the (i) format and an upshot. Those that are the least explicit include an explanation and counter evidence in the (ii) format. In the article we consider examples across the spectrum. We term this practice ‘pre-emptive’ because of its location in the medical interview: it occurs in advance of diagnostic informings, in environments where doctors are still gathering information about the nature of patients’ health problems. Patients make use of the opportunities the information-gathering environment affords: in response to doctors’ symptom-related queries they offer not only descriptions of their problems but also interpretations of what could potentially cause them and evidence that this is not what is causing them to occur. This positioning sets up an interpretive backdrop, enabling doctors to make sense of patients’ symptoms in light of the evidence they have provided. An important dimension of the examples we consider in this article is that the patients display resistance to the possibility that their problems have ordinary, relatively benign causes.33 See (Pomerantz et al. 2007) for an investigation of how patients show that more serious conditions are unlikely. In doing so, they expose the relevance of alternative interpretations of their illnesses – that they are potentially more unusual or serious – yet without openly promoting those possibilities and therefore without displaying that they entertain worst-case scenarios. They present themselves as ‘reasonable’ patients (Halkowski 2006: 90) who have already used their own common-sense reasoning to consider the types of ordinary, mundane causes for their symptoms that doctors might also consider and who can recognise when evidence points away from mundane illness (Heritage and Robinson 2006, Sacks 1984). However, the practice permits doctors to continue the medical workup rather than calling for them to actually reveal whether (or how) their own interpretations of the problem have been affected. Unlike other frontloading initiatives such as ‘Do you think it’s X?’ which establish the conditional relevance of an assessment (Gill 1998, Gill and Maynard 2006), the practice of pre-emptive resistance allows doctors to continue the primary task of this part of the medical interview: gathering information about the nature of patients’ problems. When doctors respond in this manner, it does not amount to an official absence, in sequential terms (Schegloff 1968, 1972). However, in these cases patients may do additional work to show that their problems are unusual, suggesting that they have received insufficient evidence of whether the doctors registered their concerns. Analysis We will show four examples of the practice of pre-emptive resistance. In the first example, the patient, a 59 year-old woman, is visiting her new doctor for a check-up. Just prior to the extract shown below, the patient raised several health concerns including an ongoing problem with migraine headaches. She suggests she is puzzled about what causes the headaches, reporting, ‘they come and go so badly I just have to really wonder what triggers that’. Then she offered two additional concerns, problems with her bowels and fatigue. Taking up migraines first, her doctor began a series of questions by asking what medicines she takes for them. In lines 1–2 (Extract 1a, below) the doctor continues gathering information about the problem, asking the patient how long she has had migraines. She responds that she has had them since she was three years old and then underscores that they have been a chronic problem (lines 3, 6–7). Our analysis will focus on lines 9–30 where the patient makes use of the opportunity that the environment of symptom description provides to present information about her problem. She indicates that she has considered two candidate explanations for the headaches, allergies to foods and to chemicals. She then reports a circumstance that serves as evidence against these explanations, discounting the possibility that the food and chemical allergies are the sole cause of her migraines and suggesting it is relevant for the doctor to look elsewhere for the cause. (1a) [3: 175 (3:23)] 1 Dr: How long have you had this problem with these 2 migraines. 3 Pt: Oh- since I was three. 4 (0.2) 5 Dr: ( ) Since age three. 6 Pt: Yeah. I’ve always had migraines. Al::ways had 7 migraine[s. ] 8 Dr: [Hm.]= 9 Pt. =And they’re never?. hh (.) I- I don’t know what 10 triggers them. I kno::w that decaffeinated coffee. 11 I knowthat. ((snaps fingers)) Boy I’ll get that just 12 like that. 13 Dr: >M hm?< 14 Pt: .hh [Ah:: ] so I think there are some food= 15 Dr: [°>M hm?<°] 16 Pt: =°allerg[ies and ] that° and I’ll also: (.) there= 17 Dr: [M hm. ] 18 Pt: =are some chemical °a- (.) allergies if I get ahold 19 of something that has biSULfites in it.°. hh But you 20 see when I was three (0.4) there weren’t those kinds 21 of things. [So what] triggered that .hh (1.2) at= 22 Dr: [M hm? ] 23 Pt: =THAT time(0.4) I d- I don’t °know (n:: that).° 24 (0.8) 25 Pt: So it’s something that I’ve always had and I 26 [cer ]tainly can’t blame all those chemi[cals ] = 27 Dr: [Hm ] [>M hm?<] 28 Pt: =for it [because ] I had it long before .hh= 29 Dr: [>M hm< ] 30 Pt: =°we had all those chemicals an (1.5) (food)° 31 Dr: Have you tried things for the migraines such as- (0.5) 32 caffergot .h (0.5) ergotamine (.) things to- things 33 to headoff that (0.3) thee ah (.) the pain from the 34 headache. After projecting and then aborting further description of her symptom (‘And they’re never?’ line 9), the patient broaches the issue of causality by inserting a claim that she doesn’t know what ‘triggers’ the migraines and then reporting ‘I kno::w that decaffeinated coffee’. By virtue of its positioning, this report invites the doctor to hear decaffeinated coffee as one such trigger (see Gill and Maynard 2006). She emphasises her certainty with ‘I knowthat’, snapping her fingers and reporting the immediacy of the reaction to the coffee (‘Boy I’ll get that just like that’ lines 11–12). She then provides a more general upshot of her interpretation, framing her reaction to coffee as evidence for ‘food allergies’ (‘so I think there are some food allergies’, lines 14 and 16). In this way she raises a candidate cause for her problem (food allergies) and exhibits that this is an obvious explanation for her to raise, given her experience with decaffeinated coffee. However, via her initial claim that she does not know what triggers the migraines, she suggests that allergies are not the sole or primary cause. On the heels of this, the patient raises the possibility of a related candidate explanation, ‘chemical allergies’. As with ‘decaffeinated coffee’, she provides a specific example of a substance that gives her trouble, ‘bisulfites’ (lines 18–19). Thus, in a context of symptom description the patient raises the spectre of two related candidate causes for her migraines. Note that both of these interpretations of the problem posit a relatively benign condition that she could manage without the doctor’s help: if these substances were causing her migraines, she could potentially cut them out of her diet to avoid the headaches.44 In lines 18–19 the patient suggests that she already avoids the consumption of a substance that triggers her allergies by framing any intake of ‘bisulfites’ as accidental: ‘if I get a hold of something that has biSULfites in it’. In lines 19–21 the patient more explicitly challenges the possibility that food and chemical allergies are the only cause of her migraines by reporting circumstances that are inconsistent with that interpretation (Peräkylä 2002, 2006). She reports, ‘But you see when I was three (0.4) there weren’t those kinds of things’. She displays her reasoning that, given the absence of these substances when she was young, her migraines could not have been brought on by food and chemical allergies at that time (‘So what triggered that. hh (1.2) at THAT time (0.4) I d- I don’t °know’, lines 21 and 23). Having produced this counter evidence, she goes on to provide an upshot where she explicitly rules out the possibility that allergies could be the sole cause of her current headaches: ‘So it’s something that I’ve always had and I certainly can’t blame all those chemicals for it because I had it long before °we had all those chemicals an (1.5) (food)°’ (lines 25–26, 28, 30). To summarise, in the environment of symptom description, the patient discounts two related candidate explanations for her migraine headaches. She does this by raising the explanations herself and then giving evidence that they are unlikely to be the only cause of her migraines. The migraines, she suggests, cannot be solely attributed to food and chemical allergies because they began before she had been exposed to these substances. Having raised these possibilities, the patient shows she is oriented to benign interpretations for her problem and that she is a ‘reasonable’ patient (Halkowski 2006: 90, Heritage and Robinson 2006). By providing evidence against them, she provides the doctor with the materials to let him see for himself that there is reason for concern, and that it is relevant for him to look elsewhere for the cause of her headaches – possibly to a cause that is relatively less obvious, less benign and less amenable to self-management.55 As Halkowski (2006: 98) explains about the device ‘at first I thought “X” and then I realised “W”.’‘Rather than having looked for the dramatic or outrageous explanation for an event, we demonstrate ourselves to have looked for the most obvious and mundane account. Only if those fail do we broaden our search and include more dramatic hypotheses’. See also Sacks (1984), Jefferson (1986), Pollner (1987). While the patient has shown that it is relevant
Publication Year: 2010
Publication Date: 2010-01-01
Language: en
Type: article
Indexed In: ['crossref', 'pubmed']
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Cited By Count: 120
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