Conversation analysis of 33 videotaped consultations at two US clinics. It examined how doctors reported readings such as blood pressure, and how patients responded.
33 consultationsRoutine visits were videotaped at a general medical clinic and a family practice clinic in the US.
Four readingsFour consultations included reported readings, three of blood pressure and one of temperature, all normal or borderline. One more case came from a 2002 study.
Audio during examsCurtains or camera covers during physical examinations meant only the audio could be analysed.
Turn by turn analysisBoth authors examined how doctors built each report and how patients sought information in reply.
BWhat the study found
How doctors reported readingsthe roles each way of reporting proposed
•In these consultations, a verdict without the number cast the doctor as the sole authority.Saying a reading was fine, without the number, positioned the patient as relying on the doctor's judgement. The paper calls this the paternalistic role.
•In these consultations, a bare number treated the patient as able to interpret it.When the patient showed no understanding, the doctor could explain the standard, such as normal temperature. The paper calls this the independent expertise role.
•In these consultations, number and verdict in one turn proposed roles in between.With both in one turn, the patient had no room to respond to the number first. The roles were neither fully paternalistic nor fully independent.
How patients respondedaccepting or contesting those roles
•One patient told his blood pressure was high normal pursued the actual reading.The paper argues that asking for the number and the basis of a verdict is one way patients can resist a paternalistic role.
•One patient given only a number treated the report as falling short.With no interpretation following, the patient asked how high the reading was.
•The paper argues patients may decline expertise by disregarding or quickly forgetting technical details.Technical details such as a normal range would let a patient interpret readings without the doctor.
Roles in talkthe paper's conclusion
•The paper argues doctor and patient roles are built turn by turn.An opening turn positions each person's knowledge, interest and responsibility, and later turns accept or contest it. All readings studied were normal or borderline.
CKey takeaway
Doctor and patient roles, from paternalism to independent expertise, can be negotiated turn by turn over test results. Giving the actual reading can invite patients to interpret their own health, since each report implies what they should know.
Made for this site with AI assistance from the verified research brief. It is not the paper's own figure.
Abstract
When physicians take readings of health indices such as temperature or blood pressure, the practices that physicians and patients employ in discussing the readings both reflect and propose a set of expectations regarding the level of technical medical information the patients should acquire and understand. In this article we demonstrate how physicians’ reporting practices reflect and propose the roles of paternalism or independent expertise and how patients’ responding practices either ratify or contest the roles cast by the physicians’ practices. In contrast to the usual assumption that roles are relatively stable for individuals over the course of encounters, we treat role enactments as matters that are negotiated turn by turn in interaction. Physicians’ practices for reporting test results implicate various sets of expectations about the knowledge, interest, and responsibility state of each participant; patients employ responding practices that ratify or contest the expectations implicated by the physicians’ prior report. In each subsequent turn within the information exchange sequence, a speaker indicates (explicitly or implicitly) whether the level and kind of information being exchanged is appropriate/inappropriate and sufficient/insufficient for the participants.
Research brief
By Anita Pomerantz and Sean Rintel.
Takeaway: Doctor and patient roles, from paternalism (relying on the doctor's verdict) to independent expertise (reading one's own results), are negotiated turn by turn. Giving the actual reading, not just a verdict, invites patients to interpret their own health, because each report implies what they should know.
Why this matters
What was known
Conversation analytic studies show that doctors and patients orient to an asymmetry of medical expertise, while newer models of the active, informed patient contrast with paternalistic expectations. Roles are usually treated as stable across an encounter. (Introduction, p. 3)
What this paper adds
Informing had been studied when doctors give diagnoses and treatment options. We add a third context (routine reports of test readings) and treat roles as enacted in each turn rather than carried fixed into the encounter. (Introduction, p. 5)
Who it matters to
Researchers of doctor-patient interaction and health communication, and those interested in active patient roles, which prior studies we cite link to satisfaction, compliance and health outcomes. (§Discussion, p. 16)
Research questions
How do physicians' practices for reporting the results of readings of health indices reflect and propose paternalistic or independent expertise roles?
How do patients' responding practices ratify or contest the roles cast by the physicians' reporting practices?
Method and data
Design
Conversation analysis of naturally occurring medical consultations.
Setting
Videotaped consultations from a general medical ambulatory clinic and a family practice ambulatory clinic in the US. Curtains or camera covers during physical examinations meant only audio was analysed.
Participants / data
33 videotaped consultations, of which 18 included physical examinations and four included readings of health indices (three blood pressure, one temperature), all reported as normal or borderline. Plus one instance from ten Have (2002).
Analysis
Both authors analysed the sequential organisation of physicians' reports of readings, the methods patients used to elicit information, and how patients' roles were constituted in providing and soliciting information.
Findings
A verdict without the number. In routine consultations at US clinics, when a doctor gave only an interpretation of a reading (that blood pressure was fine, say) without the number, the doctor was positioned as the sole authority. The patient was positioned as someone who relies on that judgement, which is the paternalistic role. #
(Analysis, p. 7)
Patients can ask for the number. A patient can resist being positioned that way by pursuing the actual reading, as one patient did after being told his blood pressure was 'high normal'. #
“Patients who have been cast in a paternalistic role may negotiate that role by seeking further information and by asking for the basis upon which the physicians' interpretations were made.”
A bare number invites the patient to interpret it. When a doctor reported only the number, as a turn on its own, the patient was treated as able to make sense of it. When the patient showed no understanding, the doctor could explain the standard, such as normal temperature, building the patient's ability to interpret readings. #
“Patients who have been cast in an independent expertise role may contest or disconfirm that role by disattending to, and/or rapidly forgetting, any technical information that would allow them to independently interpret readings”
Number and verdict together sit in between. When a doctor gave the number and the interpretation in one turn, leaving the patient no room to respond to the number first, the roles proposed were neither fully paternalistic nor fully independent. #
(Analysis, pp. 11–12)
A bare number can fall short. When a doctor gave only a number and no interpretation followed, the patient treated the report as deficient and asked how high it was. #
(Analysis, p. 14)
Roles are built turn by turn. Roles become visible in two steps. The first is how the opening turn positions each person's knowledge, interest and responsibility. The second is whether the following turns accept or contest that positioning. #
“the physician-patient relationship is difficult to articulate without reverting to talk about how the role of the physician and the role of the patient are played out”
Questions this paper answers
What does it mean when a doctor says my blood pressure is fine without giving the number?
Giving only an interpretation casts the doctor as the sole authority and the patient as someone who relies on that judgement (a paternalistic role). Patients can push back by asking for the actual reading. (See Analysis, p. 7; §Discussion, p. 15.)
What happens when a doctor gives a test number but doesn't explain it?
Giving just the number invites the patient to interpret it. If the patient shows no understanding, the doctor may explain what is normal. In one case where no explanation came, the patient treated the report as deficient and asked how high it was. (See §Discussion, p. 15; Analysis, p. 14.)
Are doctor and patient roles fixed before a consultation starts?
Not on the evidence of recorded consultations. Each report proposes roles, and each response ratifies or contests them. So whether a patient is treated as relying on the doctor or as independently informed is negotiated turn by turn. (See Analysis, pp. 11–12; §Discussion, p. 16.)
Contributions and implications
Patients showing interest in, and understanding of, readings of health indices can be added to the actions that make up an active patient role. patients showing an interest in, and displaying an understanding of, readings of health indices cast the participants in independent expertise roles(§Discussion, p. 16)
Whether a shift from paternalistic to independent expertise roles is worthwhile depends on whether independent expertise leads to better health outcomes.
The analysis gives empirical footing to the view that roles and relationships are difficult to separate and are made manifest in interaction.
Limitations
Only audio could be analysed during physical examinations, so gaze and facial expression were not available. As a result, the analyses relied on only the audio channel.(§Methods, p. 6)
All readings were reported as normal or borderline. The study makes no claims about reporting serious results. We make no claims about practices used to report the results of readings indicating serious medical problems.(§Methods, p. 6)
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Concepts
Paternalism
The traditional expectations, as characterised in prior work: the physician provides information only as needed, makes decisions in the patient's interest and leads the consultation, with the patient relying on and following the physician. (Introduction, p. 4)
Independent expertise
Our term for the alternative to paternalism, in which patients can still rely on physicians when needed: By 'independent expertise', we mean that they gain the knowledge to analyze the test results of indices of their health without relying exclusively on the physician's analyses.(Introduction, p. 5)
Role enactment
Practices seen as consistent with the expectations of a role. Rather than fixed on entering an encounter, we treat role enactments as matters that are negotiated turn by turn in interaction(Abstract, p. 2)
How to cite
Anita Pomerantz and Sean Rintel. 2004. Practices for reporting and responding to test results during medical consultations: Enacting the roles of paternalism and independent expertise. Discourse Studies. https://doi.org/10.1177/1461445604039437
This brief was prepared with AI assistance and published by Sean Rintel. It is not the authors' published text. Page numbers refer to this PDF.
BibTeX
@article{pomerantz2004practices,
author = {Pomerantz, Anita and Rintel, Sean},
title = {Practices for reporting and responding to test results during medical consultations: Enacting the roles of paternalism and independent expertise},
year = {2004},
month = {February},
publisher = {Sage},
url = {https://doi.org/10.1177/1461445604039437},
journal = {Discourse Studies},
edition = {Discourse Studies},
doi = {10.1177/1461445604039437},
}