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A basic overview of the medical interview The Lucky One with special attention given to the techniques used by the doctor to keep the medical agenda on track

By Edited Jun 12, 2014 0 0

Doctor-Patient Communication

Problems in doctor-patient communication have been occurring for many decades, but it has not been until recently that scholars have begun to focus on these problems. It is common in medical interviews to see the doctors doing specific verbal and nonverbal actions to move the medical interview along without showing concern for the patient’s feelings and concerns.  The typical biomedical model “encourages [doctors to bypass] the patient’s verbal account by placing great reliance on technical procedures and laboratory measurements” (Engel, 1977, p. 132). The doctors will often decline any patient elaboration because this strays away from the doctors’ medical agenda (Drew & Heritage, 1992, p. 32). Medical symptoms seem to take the front seat over the patient’s emotionality in medical interviews (Felitti, 1997). What communication scholars are working to do is find ways in which the doctors can pay more attention to “the patient’s verbal account of his illness” (Engel, 1977, p. 132).

Communication scholars have been arguing that the doctors whom provide the best cancer care are the ones with effective communication skills (Fallowfield & Jenkins, 1999).  The patients are more willing to provide useful information for the doctor to determine the patient’s diagnosis when the doctor treats the patient “as a person rather than a case” (Ben-Sira, 1980, p. 173).  The patients are better cared for when their emotionality is cared for in addition to their biomedical problems. The best care results from doctors treating the whole patient as opposed to just the disease separate from the person.

Many medical interviews, including the following interview, demonstrates that many of the doctors’ verbal and nonverbal actions suggest he was trying to move the medical interview along to keep with his agenda, in order to arrive at the official business of the interview.  Communication scholars argue that the medical agenda of the doctor should not be the primary concern in medical interviews. The questions in the interview should be “co-constructed as routine (or not) through the actions of both doctors and patients” (Boyd & Heritage, 2006, p. 19).  The best communication in medical interviews will occur when the doctors and patients work together to create a medical interview agenda that stresses both the biomedical and psychosocial aspects of the patient’s disease.

Conversation Analysis

The method used to examine the following medical interview is conversation analysis. Conversation analysis is the study of  “how people talk with one another in everyday casual encounter[s]” (Beach, 2008, p. 1). Conversation analysis (CA) is a method done on naturally occurring conversations between people, which makes this method of study so effective. The data collected is never “idealized or hypothetically construct[ed]”, the recordings are of actual communicative unaltered interactions (Beach, 2007, p. 83). The study of conversation gives the opportunity to explain the way humans “do things and the kinds of objects they use to construct and order their affairs” (Sacks, 1984, p. 24). Conversations are collected “by means of audio- and video-recording equipment or film” (Heritage & Atkinson, 1984, p.2). These conversations are always naturally occurring. The recordings and the” carefully produced transcriptions” of the naturally occurring conversations are then analyzed (Beach, 2008, p. 1). Studies done on conversations using conversation analysis have “proved to be highly distinctive both in methodology and findings, from a range of linguistic, social psychological and sociological approaches to the data of interaction” (Heritage, 1984, p. 234).

Preview

This paper examines a conversation between a doctor and a patient that occurred at the Moore’s Cancer Center in the early 2000’s entitled The Lucky One.  The conversation is an interview that consists of a male doctor and a female patient speaking of the patient’s past medical history concerning melanoma. The patient explains that she first had a melanoma removed in 1999 and that she was the first in her family to be diagnosed with a malignant melanoma. The patient concludes with referring to herself as “the lucky one” in her family.

Many verbal and nonverbal cues from the doctor suggest that the doctor was not concerned with the patient’s emotions and primarily concerned with moving the interview along. It is important to note that not all of the doctor’s verbal and nonverbal cues demonstrate this need to move along the interview.  The doctor did attend to the patient’s emotionality at certain points, but most of his verbal and nonverbal responses suggest that this was not his primary concern.

The following medical interview is primarily controlled and guided by the doctor. The doctor uses the comprehensive medical history model to conduct the medical interview. The use of “okay” from the doctor is a common response to the patient’s answers to keep the flow of the interview going. The doctor will also use specific verbal and nonverbal cues to direct the patient to respond in specific ways to guide the interview.  Patient elaboration past what the doctor originally asked is seen in this interview, which takes the medical agenda off track, but the doctor quickly guides the interview back on track. Basic and expanded formulation sequences are also used by the doctor to guide this interview.

This paper will first show what the comprehensive medical history is and why it is so important to doctors. Second, this paper will explain how “okay” is used in medical interviews to stay on track with the medical agenda and keep the patient from straying away with their expanded answers. Next an overview of the medical interview The Lucky One is provided with special attention to the doctor’s use of verbal and nonverbal cues to keep the medical interview on track.  Lastly, this paper will provide a brief discussion on the findings and discuss weaknesses and possible topics for further research.

Comprehensive Medical History

The series of the doctor asking of questions and the patient answering is what Bates, Bickley, and Hoekelman (1995) refer to as the “comprehensive medical history” (as cited in Stivers & Heritage, 2001, p. 152). Most of the questions asked in this series are in the form of a “yes/no” question and typically include wh-inquires (Stivers & Heritage, 2001, p. 152). Heritage and Sorjonen (1994) found the questions are formatted in such a way to get a “’no problem’ response from the patient” (as cited in Stivers & Heritage, 2001, p. 153). The questions are designed to “discourage movement beyond the immediate agenda set” (Stivers & Heritage, 2001, p. 153). This infers that doctors treat minimal answers as sufficient and they prefer for the patient not to expand beyond the minimal answers. When patients stray away from briefly answering the questions, interactional problems occur. Doctors begin to demonstrate dismissive behaviors towards the patients’ answers with their elaborated responses. The use of the comprehensive medical history is important to doctors because it keeps the interview on track, which keeps the doctors within their time limit and ultimately saves them money.

The Use of “Okay” in Medical Interviews

“Okay” is defined as “approval or endorsement” by Webster’s Dictionary (as cited in Beach, 1995a, p. 264). Yet, in medical interviews the word “okay” does something different than it means (Beach, 1995a).  The use of “okay” is not random, and is used by speakers, e.g. doctors and patients, to achieve “particular kinds of actions at specific moments of involvement” (Beach, 1995b, p. 154). The word “okay” is typically used in medical interviews to control and shape “topical progression” throughout the conversation between the doctor and patient (Beach, 1995a, p. 286). The word “okay” is described as “remarkably repetitive”, according to Beach’s (1995a) examination of “okays” in medical interviews (p. 264). The word “remarkable” refers to the finding that “okays” are “used and relied on almost exclusively by medical authorities and only in specific cases by patients” (Beach, 1995a, p. 264).  The word “repetitive” refers to how frequent the word “okay” is used “to achieve particular kinds of tasks” (Beach, 1995a, p. 264). “Okay’s” are most commonly used by the doctor for topic shifts, reaching doctor medical agenda goals, moving away from negative topics,  and pre-closing topics. 

Topic Shifts

Unlike the dictionary definition of “okay”, the word can be used to achieve many different tasks. Most commonly “okay” is used as an introduction to the doctor’s next question (Beach, 1995a). A doctor may use “okay” as an attempt to “close down some or all feature’s of prior turn” before moving onto the next topic (Beach, 1995a, p. 266).  The common use of a question, answer, and then an “okay” plus topic shift is demonstrated frequently in medical interviews (Beach, 1995a, p. 274). An “okay” response from a doctor may work to “[condition] and [prepare] patients to wait for the doctor’s next question” (Beach, 1995a, p. 267).  An “okay” in a medical interview will primary be used to “acknowledge, close down, shift, and move to [the] next matter” (Beach, 1995a, p. 273).

Reaching goals

Doctors use “okay” to ultimately shift from “preliminary matters to official business” (Beach, 1995a, p. 272). The patient explains what medical troubles they are experiencing and that will shape the “eventual focus” of the conversation (Beach, 1995a, p. 272). Doctors will commonly use “okay” to attempt at bringing back the topic of the conversation to particular points that “are deemed relevant and worthy of pursuit en route to achieving professional goals and priorities” (Beach, 1995a, p. 283).

Negative Topics

Jefferson (1984) found “okay” can be used to transition to a new topic when the topic at hand is negative (as cited in Beach, 1995b, p. 138). Jefferson (1984) found the use of “okay” moves from troubling-tellings into closings or the completion of a topic (as cited in Beach, 1995b, p. 138).  Doctors will use “okay” to shift topics when the patient’s topic at hand is negative.

Pre-closing

Schegloff and Sacks (1973) found “okay” could be used as a pre-closer to change topics (as cited in Beach, 1995b, p.146). That meaning “okay” may be used to set up the conversation for a change of topic, but may not end the topic at hand. There may be more conversation after the “okay” is stated about the topic, but that conversation will transition from the old topic into the new topic. The use of “okay” is frequently neither forward nor backward looking “in character” (Beach, 1995b, p. 142). Instead, “okay” is used as “a state of readiness”, as in ready to change to a new topic (Beach, 1995b, p. 142).  “Okay” used as a pre-closing device can “close down a given interactant while eliciting comments from [the] next speaker” (Beach, 1995b p. 129). 

Resistance

Patients may “reject doctors’ attempts to close down and shift topics” with the use of “okay” (Beach, 1995a, p.280). A patient may continue their thought, story, or whatever they may be speaking of to finish their topic. Research has found that this resistance is only “momentary” and patients will eventually “adhere to [the] doctor’s attempts to shift topics toward what they prioritize as more important and relevant [to] ‘official’ matters” (Beach, 1995a, p. 280).

The Lucky One

            Example One

            The following excerpt consists of the first five lines from the medical interview entitled The Lucky One.  This excerpt consists of the doctor asking the patient when she had her melanoma removed. The doctor begins this excerpt with a topic shift to move along the interview, then he attends to the patient’s needs with providing a summary.

1) OC: The Lucky One: 1-5

1  DR1:            Okay. No::w a:h the area on your back, u:h when was that a:h

2            removed (.) that melanoma.

3 PAT:                        Uh May of ninety-nine.

4 DR1:             May of ninety-nine.=

5 PAT:                        =°Mm hm.°=

 

The doctor begins this interview with saying, “okay” in line one indicating a topic shift from a prior topic in the interview (Beach, 1995a, p. 266). This is the first demonstration of the doctor moving the medical interview along with his use of “okay” plus a topic shift. The new topic presented by the doctor in line two is melanoma.  The doctor asks in line one and two when the melanoma was removed. The doctor does a gesture where he uses his pointer finger to make an inward circle and points to his body and then down to the floor as he says “on your back” in line one. The doctor previews the word “back” with his gesture that points to his body because the gesture starts about a half second before he says “back” in line one. This gesture possibly demonstrates he understands that a “back” is a part of the patient’s body. So, the melanoma is not separate from the patient, but it is apart of the patient’s body.

The patient responds with “Uh May of ninety-nine” in line three. She gives a simple response verbally to the doctor’s question, but responds more complicated with her nonverbal cues. The patient looks up to the left as she says “uh”. The gaze to the left indicates that she is thinking about the past when the melanoma was removed (W. Beach, personal communication, January 27, 2009). She then rolls her eyes completely around and looks back at the doctor when she says “May of ninety-nine” in line three. The patient also begins to nod her head up and down when she says “ninety-nine” to confirm her thinking process on the word “uh” was correct and the melanoma was removed in “May of ninety-nine”.

The doctor then responds in line four with repeating what the patient said in line three. The doctor repeats what the patient said to provide a summary and to attend to the patient’s emergent problem of when she had that melanoma removed (Beach & Dixson, 2000). The doctor probably noticed the patient thinking about the questions when she said “uh” in three, and he wanted to make sure the patient was confident with her answer. This summary also shows the doctor understands that the patient had the melanoma removed in May of ninety-nine.

The patient confirms the information she and the doctor provided was correct in line five when she says “Mm hm”. This time the patient does not take any thinking time, for she answers right away. The patient is still nodding her head up and down continuously from when she gave her first answer of “May of ninety-nine” in line three. This nod gives further confirmation that she gave the correct answer in line three and the doctor understood her answer correctly in line four.

Example Two

The next excerpt consists of the doctor asking the patient if any melanoma has recurred around the same site that melanoma occurred before. The doctor uses specific wording and head nodding to guide the patient toward answers that he predicted the patient to give. Beach’s and Dixson’s (2000) basic formulation is also used to move along the medical agenda. The patient uses resistance to the topic change at the end of this excerpt.

2) OC: The Lucky One: 6-9

6 DR1:                        And there’s been nothing that recurred around that site.=

7 PAT:             =°Hm¯mm.°=

8 DR1:                        =O¯kay.

9 PAT:             Just that one.

First the doctor asks the patient if she has had any more melanoma that has recurred around where her past melanoma appeared in line six. This question is meant to further move along the the doctor’s medical agenda.  The wording of the question suggests an answer the doctor wants from the patient.  The doctor says, “there’s been nothing” instead of asking “if there has been anything” that recurred around the site.  This wording suggests he is looking for a “no” answer since he words his question with negative words. The doctor also shakes his head from side to side as he asks this question in line six. This confirms that this is a “no” preference question. Doctors use “no” preference questions to control the outcome of the interview (W. Beach, personal communication, January 29, 2009).  The doctor assumed the patient’s answer to his question would be “no” so he demonstrated his thought through his verbal wording and his nonverbal movements.

The patient responds with “hmmm” in line seven to show she agrees with the statement the doctor previously made in line six.  The patient confirms the doctor’s original assumption that there is no melanoma reoccurring at the site when she says “hmmm”.  The “hmmm” acts as a confirmation answer in this position. The patient is actually saying, “no nothing has recurred at that site” by saying “hmmm” in line seven.  The patient also nods her head from side to side mirroring the doctor’s movement from the original question as she says “hmmm”.

The doctor responds in line eight with an “okay” to confirm he understands the patient has not had any more melanoma occurring in that same area as the last one.  The “okay” in line eight also works as a closure to the topic of reoccurring melanoma.  The “okay” was also meant to give the doctor the opportunity to move onto the next question in his series of questions.  The “okay” also functions as a closure to a negative statement made by the patient. During this “okay” the doctor starts to nod his head up and down to confirm nonverbally that he understands the patient has not had any more melanoma in that specific spot.  This nod could also represent that the doctor predicted the patient would confirm there was no more melanoma reoccurring in that area.  The doctor nods his head to show satisfaction of the answer from the patient.

The patient does not understand that this “okay” in line eight functions as a closure to this topic because she offers more explanation beyond what the doctor asked. The patient adds the commentary “No more melanoma. Just that one” in line nine.  The patient demonstrates resistance because she offers commentary after the doctor initiates the topic shift (Beach, 1995a, p.280).  The patient is confirming verbally that she has not had any more melanoma because in her previous answer she only gave the head nod and the short “hmmm” in line seven. The patient could be providing more information past what the doctor originally requested to make sure the doctor understood her original response.

The patient continues to nod her head from side to side as she says “no more melanoma” but then switches to nodding her head up and down when she says “just that one” in line nine.  The doctor gives a small smile and nods his head up and down after the patient says “no more melanoma” and continues nodding until she says “just that one”. The doctor’s intention behind the smile is meant to close the patient down.  Often doctors smile and then look down at the medical records. This gives the doctor the opportunity to move on with the medical interview without actually responding to the patient’s concerns (W. Beach, personal communication, February 3, 2009). The smile works as a sufficient response to the patient’s concerns for the doctor, but often leaves the patient feeling ignored.  The doctor continues looking at the patient in this case, but then continues to clear his voice to possibly indicate a frustration because the topic shift did not successfully work.

The patient once again mirrors the doctor’s nonverbal motions from the previous question and his current nonverbal motions when she starts to nod her head up and down when she says “just that one”. The patient is confirming to the doctor that she is answering as he predicted with her head nod.  The patient is also demonstrating she possibly feels as if her concerns are being ignored because she gives a smile and then turns it into a grimace as she is nodding her head up and down.

This section demonstrates Beach’s and Dixson’s (2000) basic formulation process. The following three steps: doctor’s formulation, patient’s confirmation, and doctor’s topic shift, create the basic formulation organization process (Beach & Dixson, 2000). The doctor gives his formulation in line six when he says, “there’s nothing that recurred around the site” (Beach & Dixson, 2000).  The patient then gives her confirmation in line seven when she says “Hmmm” (Beach & Dixson, 2000). The doctor then presents his topic shift when he says “okay” in line eight (Beach & Dixson, 2000).

Example Three

The following excerpt shows the doctor initially ignoring the patient’s commentary from the end of the last excerpt. The use of repetition is used by the doctor to confirm that the patient is “the first” in her family to have problems with melanoma. This section uses Beach’s and Dixson’s (2000) expanded formulation sequence to move along the interview.

3) OC: The Lucky One: 10-14

10 DR1:             ((Clears voice.)) °Alright.° Uh any family history of uh melanoma?

11 PAT:            I’m the first.

12 DR1:            You’re the first.=

13 PAT:            =­Yeah.=

14 DR1:            =Okay.

 

The doctor clears his voice in line ten after the patient provided additional commentary past what the doctor requested. The doctor uses “alright” plus the topic shift “Uh any family history of uh melanoma” in line ten. The doctor uses “alright” as a substitution for the word “okay”. The use of  “okay plus topic shift” is a common method used by doctors to move the medical interview along to reach the official business of the interview (Beach, 1995a, p. 266).    Therefore the “alright” represents a conclusion to the past topic and works as a transition between the old and the new topic. The new topic in line ten is the family history of melanoma.

The patient continues in line eleven with saying “I’m the first”. She is referring to herself as being the first in her family to have melanoma. The doctor responds in line twelve by repeating what the patient said prior. The doctor says, “You’re the first”. The doctor presents a summary of what the patient just said in line twelve and this shows that he understands and comprehends the answer. The patient then says “Yeah” in line thirteen to show confirmation to the doctor’s prior summary in line twelve.  “Yeah” is used in line thirteen by the patient to claim epistemic authority (W. Beach, personal communication, October 9, 2008).  The patient is demonstrating she is “the first” and only she can understand what it is like to be the first in her family when she says “yeah” in line thirteen.

The doctor responds in line fourteen with “okay” to the patient’s prior response of “Yeah” in line fourteen. First the “okay” functions to show he understands that the patient was the “first” in her family to be diagnosed with a melanoma. The doctor could also be saying, “okay” to acknowledge that he understands that only this patient can fully understand what it is like to be the first one in her family to be dealing with melanoma. Finally this “okay” functions to close down the prior topic of the patient being the first in her family to deal with melanoma.  The “okay” is closing down a negative topic because the patient is presenting sad news when she says she is “the first” in her family to be diagnosed with melanoma (Beach, 1995b). The news that she is “the first” is a case of troubled-tellings that cause for the doctor to shut it down (Beach, 1995b). The doctor hopes for no more commentary on this topic past the “okay” in line fourteen, but the patient resists.

This entire section also demonstrates the expanded formulation process as described in Beach’s and Dixson’s (2000) Revealing Moments article. The following four steps: doctor’s formulation, patient’s confirmation, focus on emergent problems and doctor’s topic shift, make up the entire expanded formulation process (Beach & Dixson, 2000).  The doctor first speculates that the patient did not have any history of melanoma in her family in line ten. This is the doctor’s formulation (Beach & Dixson, 2000). The patient then tells the doctor that she is “the first” to have melanoma in her family in line eleven.  This is the patient’s confirmation to the doctor’s original formulation (Beach & Dixson, 2000). The doctor then focuses on the patient’s emergent problem by confirming that she is the first in her family in line twelve (Beach & Dixson, 2000).  The patient then confirms her emergent problem in line thirteen with “yeah”. Then the doctor does a topic shift with his “okay” in line fourteen.

            Example Four

            This excerpt consists of the doctor and the patient confirming she is the first one to have problems with melanoma in her family. The patient refers to herself sarcastically as “The lucky one” and the doctor ignores the patient’s attempt to get the doctor to care for her emotionality. The doctor moves on to more biomedical questions to keep the interview moving.

4) OC: The Lucky One: 12-16

12 DR1:            You’re the first.=

13 PAT:            =­Yeah.=

14 DR1:            =Okay.

15 PAT:            The lucky one.

16 DR1:            And uh did you have prior history of s:- uh sun exposu::re.

The doctor comments that the patient is the first one in her family to be diagnosed with a malignant melanoma in line twelve. The patient responds in line thirteen with “yeah” indicating she agrees with the doctor’s summary. The doctor then says “okay” indicating an attempt to “close down some or all feature’s of [the patients’] prior turn” before moving onto the next topic of sun exposure in line five (Beach, 1995a, p. 266). The patient offers voluntary information that is beyond what the doctor asked for when she delivers the essentially good news in line fifteen that she is “the lucky one” (Stivers & Heritage, 2001).  This is voluntary information because the doctor attempted to shut down this topic in line fourteen with his response of “okay”, yet the patient still continues this topic by offering the information that she is “the lucky one” in line fifteen.

The patient delivers what appears to be good news with her response that she is “the lucky one” in line fifteen.  The patient’s body movements however, suggest this is bad news. The patient moves her leg and gazes up into the left corner while making an unpleasant face when she says “the lucky one” in line fifteen. The patient’s bodily movements appear squirmy and awkward, which suggests she is overall uncomfortable with mentioning she is “the lucky one” (Beach, Easter, Good, & Pigeronc, 2004, p. 897). The patient’s bodily movements also suggest she is not only “concerned with, but impacted by, a familiar and potentially fearful experience with cancer” (Beach et. al., 2004, p. 897).

The patient’s gaze indicates interesting finding about her feelings toward the melanoma. First of all, she looks over to the left when she says “the lucky one” in line fifteen.  Patients often look to the left when they are thinking about the past (W. Beach, personal communication, January 27, 2009). This gaze possibly indicates the patient was thinking about her past cancer journey as she said she was “the lucky one”.  The patient could be thinking of all the terrible things she has had to go through since she has been dealing with the melanoma.  The patient clearly has negative feelings about her past cancer journey because she comments to the doctor in a sarcastic voice when she says she is “the lucky one”.

Sarcasm is obviously used in fifteen when the patient refers to herself as “the lucky one”.  Sarcasm used in medical interviews shows the opposite of what is being said is the true meaning (W. Beach, personal communication, February 19, 2009). The patient refers to herself as “the lucky one” when clearly she feels that she is the unlucky one.  It is clear that she feels she is the unlucky one by her nonverbal movements. Her body is very uneasy and her gaze moves across the room. This indicates she is uncomfortable about the situation and she is using sarcasm to make the situation easier to talk about. 

Clearly the patient is concerned, impacted and scared of dealing with the cancer. The patient tells the doctor she is “the lucky one” possibly looking for some sympathy from the doctor. The doctor does not acknowledge the patient’s response.  He instead moves on to his next topic of sun exposure in order to keep on track with his medical agenda. The doctor successfully stays on track with his medical agenda by ignoring the patient’s response for emotional attention and moving onto more biomedical questions. The doctor efficiently moves away from “any possibility that the patient will hear his query as asking for personal reactions to his question-responses” with his non-response (Beach, Easter, Good, & Pigeronc, 2004, p. 899). The doctor ignores the patient’s emotional response and moves onto more biomedical questions that will potentially result in biomedical answers to figuring out why she was diagnosed with cancer.

Discussion

Findings

 This paper demonstrated the doctor was the primary leader of this medical interview. The patient tried to elaborate past what the doctor was asking a few times, but the doctor ignored the extra commentary and continued with his biomedical questions. The doctor used a variety of techniques to stay on track with is medical agenda and successfully executed them.  This doctor demonstrated in this interview that he is primarily concerned with the biomedical issues of the patient, and not with her emotionality.

Future Research and Weaknesses

This paper attempted to provide a basic overview of  “The Lucky One”. Although many important aspects of the conversation were looked at, there are still many other aspects that could have been examined.  Only the most prominent aspects that stood out to me were examined to attempt to give an overview of the whole excerpt rather than just focus on a few specific moments in the interview.

Many other aspects of this interview could be examined for future research.  The first aspect includes the patient’s constant and almost unusual use of blinking.  The patient’s gaze was constantly changing throughout the interview, and this paper only went into minor detail about a few instances of her gaze. Another aspect that could be examined in more detail is the doctor’s gestures. The doctor’s gestures are only spoken of once in this paper.  The doctor’s use of repetition of the patient’s words could also be further examined, for they were only briefly spoken of in this paper.  The patient gives a smile, which turns into a grimace at least twice in this interview.  Facial expressions were only grazed upon in this paper. This paper primarily focused on the doctor’s techniques used to move along the interview without attending to the patient’s emotional needs. The doctor did however attend to the patient’s emotional needs at certain points along with moving the interview along. This aspect of the interview could also be examined in future research.

References

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Beach, W. A. (1995b). Conversation analysis: "Okay" as a clue for understanding consequentiality. Theconsequentiality of communication, 21-162.

Beach, W. A. (2007). A natural history of family cancer: Interactional resources for managing illness. San Diego: Montezuma Publishing.

Beach, W. A. (2008). Conversation analysis [Electronic version]. The international encyclopedia of communication.

Beach, W. A., & Dixson, C. N. (2000). Revealing moments: Formulating understandings of adverse experiences in a health appraisal interview. Social Science and Medicine.

Beach, W. A., Easter, D. W., Good, J. S., & Pigeronc, E. (2004). Disclosing and responding to cancer "fears" duringoncology interviews. Social Science & Medicine , 60(5), 893-910.

Ben-Sira, Z. (1980), "Affective and instrumental components in the physician-patient relationship: an additional dimension of interaction theory", Journal of Health and Social Behavior, Vol. 21 pp.170-80.

Boyd, E. &, Heritage, J, (2006) Taking the history: questioning during comprehensive history taking'. In: John Heritage, Douglas W. Maynard, eds. Communication in Medical Care: Interaction Between Primary Care Physicians and Patients. Cambridge: Cambridge University Press: 151(84).

Drew, P & Heritage, J (1992) Talk at Work, Cambridge, England: CUP. Chapter 1

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.

Fallowfield, L., Jenkins, V. (1999). Effective communication skills are the key to good cancer 

care. European Journal of Cancer, 35(11), 1592-1597.

Felitti, V. J. (1997). Caring for patients (review). The Permanente Journal, 1, 19-20.

Heritage, J. (1984). Conversation analysis [Electronic version]. Garfinkel and ethnomethodology, 233-244.

Heritage, J., & Atkinson, J. (1984). Introduction [Electronic version]. Structures of social action: Studies in conversation analysis, 1-15.

Sacks, H. (1984). Notes on methodology. In John Heritage & J. Maxwell Atkinson  [Electronic version]. Structures of social action: Studies in conversation analysis, 21-27.

Stivers, T., & Heritage, J. (2001). Breaking the sequential mold: Answering `more than the question' during comprehensive history taking. Text, 21(1/2), 151-186.

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