Expansion of Answers

            Stivers and Heritage (2001) found patients expand their answers in three different ways.  All three ways consist of first addressing the question at hand and then expanding to address any “possibly problematic feature of the response” (Stivers & Heritage, 2001, p. 154). One way the patients expand is that they show difficulty in “giving definite answers to some questions” (Stivers & Heritage, 2001, p. 154). Another way is the patients will provide “support answers by adding details” (Stivers & Heritage, 2001, p. 154). And finally, patients will “preempt negative inferences which might arise from unelaborated answers” (Stivers & Heritage, 2001, p. 154). These expansions allow the patient to progressively move “away from the agenda of the physician’s question” and given opportunity for the patient to “introduce [his or her] own agenda of concerns” (Stivers & Heritage, 2001, p. 155). The patient will address topics “in ways that are designed to preempt doctor responses that would pursue the matter” with more question asking or with advice and/or criticism  (Stivers & Heritage, 2001, p. 176).

Difficulties in responding

            Patients will provide expanded answers when he or she feels “uncertainty about information” that the doctor is inferring about (Stivers & Heritage, 2001, p. 155). The patient will respond with answers like “I don’t know” or “I think”. Heritage (1988) found an “inability account”, like using of the words “I don’t know”, is itself routinely accountable (as cited in (Stivers & Heritage, 2001, p. 155). Meaning, the patient will follow up an inability account with some sort of explanation to explain the account at hand.

            Below Example 2: “Well it seems uh um what is the word ambiguous” demonstrates a situation where the patient has difficulty in responding to a doctor’s question:

Example 2: “Well it seems uh um what is the word ambiguous”

1               Patient:             And then I’d go back every six months for blood

2                            work. Actually I changed doctors. I think um right

3                            after Dr. Scotty did that ( ) procedure we changed

4                            insurances so I had to change doctors.

5                Doctor:             Okay.

6                Patient:             And that’s when I was referred to Dr. Kim.

7                Doctor:             That was in two thousand and three I think so you

8                            saw Dr. Scotty approximately every six months for

9                            those few years.

First in line one the patient is elaborating on a question about a biopsy she had in the past. The patient demonstrates uncertainty in line two when she says “I think um”. The patient finishes her thought in line four and the doctor then responds in line five with an “okay”. The doctor is not inviting any more elaboration about changing doctors, yet the patient decided to give more details in line six when she says she was referred to a new doctor. The patient was compensating for the inability account in line two by giving more complete details about switching doctors in line six.

Adding details

Patients may provide supporting details to explain their answers (Stivers & Heritage, 2001). These details are often used to “offer documentation for responses to questions in which the patient gives some estimation or judgment” (Stivers & Heritage, 2001, p. 158). These additional details are “strictly volunteered” and are not solicited by the doctor (Stivers & Heritage, 2001, p. 159). They will often suggest “external expert opinion” by the patient to “enhance their objectivity and credibility” (Stivers & Heritage, 2001, p. 159-160).

            Below Example 3: “Well it seems uh um what is the word ambiguous” demonstrates a situation where the patient adds details to support a response:

Example 3: “Well it seems uh um what is the word ambiguous”

1               Doctor:             Any back pain.

2               Patient:             I have back pain.

3               Doctor:             Okay. So tell me about that.

4               Patient:             I have back pain um in the area. I’ve been treated for

5                            back pain for a long time through a chiropractor.

6               Doctor:             Mmhm.

7               Patient:             Um I also have a lot of back pain in the area where

8               they have taken the biopsies.

9               Doctor:             Mmhm.

10            Patient:             And then I have a pain right here. But I don’t know if

11                         it’s a bone or a muscle pain. But it’s right here.

12            Doctor:             Okay.

13            Patient:             And sometimes it hurts to stretch. So it’s under my

14            mus rib.

15             Doctor:             Okay. How long have you had that pain for.

First the doctor asks in line one if the patient has any back pain. The patient responds with the expected short answer in line two, and then the doctor asks the patient to expand on her pain in line three. The patient then gives details of her back pain in line four and five. The doctor responds with “Mmhm” in lines six to show that is sufficient information. The patient volunteers more information about her back pain in lines seven and eight without being asked by the doctor. The doctor once again in line nine responds with “Mmhm” to show that the information the patient provided is sufficient. The patient still feels the need to continue with her details.  She speaks about her back pain and provides information about other pains to show her credibility in lines ten and eleven.  The doctor responds in line twelve with “okay”, which stronger signal than “Mmhm” that it is time for a topic change and the patient’s information provided is more than sufficient. The patient gives one last detail in line thirteen saying that it “hurts to stretch” This information can only be known to the patient and therefore demonstrates an external expert opinion. The doctor responds with an “okay” in line fifteen and moves onto the new topic of the duration of the pain. At this point the patient stops providing details of her back pain.

Preempting negative inferences

            A patient may expand on his or her answers to make up for a 28“‘medico-moral’ deficiency” in his or her initial response (Stivers & Heritage, 2001, p. 161). Most commonly, these responses are used when referring to preventative health care, and are used to avoid a negative evaluation from the doctor (Stivers & Heritage, 2001). Patients may use words such as “I should” to show they know they have an “insight into the nature of her health problems and knowledge of what should be done to address them” (Stivers & Heritage, 2001, p. 161). These responses can be volunteered by the patient or solicited by the doctor.

Below Example 2: “Based on your presentation unfortunately is uh uh cancer” is a demonstration of an extended response using preempted negative inferences:

Example 2: “Based on your presentation unfortunately is uh uh cancer”

1               Doctor:            That are pretty concerning as well. And do you have

2                                        a a history of tobacco use.

3               Patient:             No.

4               Doctor:             Not really okay.

5               Patient:            I smoked it until I was 25 but um

6               Doctor:            Okay and

            In line one the doctor asks the patient about tobacco use. The patient responds “no” in line three with sound of apprehension in his voice. The doctor picks up on the apprehension in the patients voice and response in line four with “Not really okay”. This triggers the patient to give more details by saying in line five he “smoked it until [he] was 25 but um”. The doctor cuts the patient off by saying, “okay” in line six. The patient sensed the doctor was giving a mental negative evaluation to him in line four. That is when the patient gave an extended response in line five that he smoked until he was in his twenties referencing that he used to smoke but he did the right thing and quit. The patient said this in line five to avoid the negative evaluation by the doctor. The patient was going to continue on with his insight but the doctor cut him off and he was unable to complete his sentence.