On structures in medical interactions : a conversation analytic study of general practice consultations.
This thesis addresses from within the research paradigm of Conversation Analysis (CA)
the question "How are interactions between patients and general practitioners
organised? ". CA is a relatively recent tradition within the "interpretative paradigm" of
sociology, growing out of the ethnomethodology of Garfinkel. The thesis first reviews
the relevant literature of CA and medical interactions, and critically discusses the
The empirical analysis used naturally occurring consultations in British general practice,
video-recorded in five practices, involving 14 doctors, and about 50 hours of recording,
made between 1987 and 1992. Recordings were observed first in an unmotivated way, to
note occurrences of interesting interactional phenomena. Objects for further study were
copied onto secondary "collection" tapes, which were then examined in depth, and
transcribed in detail using conventions developed within CA.
The analyses described here are: the use of time in the consultation; the impact of
medical records on the interaction; prescribing and associated talk; the phenomenon of
"facilitation", how doctors appear to enable patients to talk; patient-initiated questions,
and rejection of patients' ideas by doctors; and finally the use of the word "we". The aim
was to describe and explore, but not necessarily to explain, although in describing the
mechanism of interaction in these areas of activity, empirical evidence is advanced for
The phenomenon of patients raising new topics at the end of consultations is described,
with its interactional implications: the "by-the-way" phenomenon is explored and
documented. Case-notes are seen to contribute to consultations in a complex way, and
like talk, are both context-dependent and context-forming. Utterances such as "right",
"uhuh", "mmhm" which appear on the face of it to be facilitatory, can be the reverse.
The phenomenon of dispreference for disagreements by patients is re-examined, and
contexts in which patients do disagree are explored. Doctors' rejections of patients' ideas
are described, and implications for teaching about the consultation are drawn. Finally
the various ways in which the word "we" is used by doctors are described and critically
appraised, in the context of a philosophical understanding of "intersubjectivity".
The study adds to the body of transcribed interactions drawn from general practice, and
sheds some light on ways in which general practitioners and patients structure their
consultations. It has implications for the way medical students learn how to consult, and
for how research on the consultation can be conducted. Conversation analysis is shown
to be a powerful qualitative analytic methodology, relevant to the study of medical