Douglas W. Maynard

Conversation analysis, doctor-patient interaction and medical communication

Introduction  This paper introduces medical educators to the field of conversation analysis (CA) and its contributions to the understanding of the doctor−patient relationship.

Prosodic features of bad news and good news in conversation

Recent work suggests the importance of integrating prosodic research with research on the sequential organization of ordinary conversation. This paper examines how interactants use prosody as a resource in the joint accomplishment of delivered news as good or bad. Analysis of approximately 100 naturally occurring conversational news deliveries reveals that both good and bad news are presented and received with characteristic prosodic features that are consistent with expression of joy and sorrow, respectively, as described in the existing literature on prosody. These prosodic features are systematically deployed in each of the four turns of the prototypical news delivery sequence. Proposals and ratifications of the valence of a delivery are often made prosodically in the initial turns of the prototypical four-turn news delivery, while lexical assessments of news are often made later. When prosody is used to propose the valence of an item of news, subsequent lexical assessments tend to be alignments with these earlier ascriptions of valence, rather than independent appraisals of the news. (Bad news, good news, conversation analysis, prosody, sequencing).* Conversational news deliveries are rarely neutral; instead, they are usually accomplished as valenced, as being either good news or bad news. By displaying an evaluative stance toward the news, participants orient to information in terms not only of its status as news, but also of its perceived affective significance for the individuals involved. As shown by Maynard 1997, valence is not determined by some intrinsic goodness or badness of the news but rather is achieved by the interactants. Ascribing valence to an item of news may be done lexically ,a s in pre-announcement forecasts, e.g. I have some bad newsfor you, or more frequently, in post-announcement assessments, e.g. Oh that’s terrible (Terasaki 1976, Maynard 1996a). However, valence may also be ascribed usingprosody; the term is used loosely here to cover aspects of talk such as pitch, intonation, loudness, and speech rate, as well as more properly paralinguistic features such as voice quality. Prosodic phenomena are employed as devices that propose a particular affective orientation to the news. In this paper, we explicate methodic aspects of the use of

Bad News in Oncology: How Physician and Patient Talk About Death and Dying Without Using Those Words

We focus on the socialization of patients to the process of death and dying by examining actual interactions among medical practitioners, patients, and their family members. Our data consist of three medical interviews. In each one, the oncologist delivers the news that the patients cancer is no longer treatable. Although not stated, the implied message is that the patient will soon die. Because, in these episodes, the same doctor is attempting to convey a similar message to three different patients, we can compare the ways in which the patients respond to the message and thus affect the delivery of the news. In various practical ways, both physician and patient exhibit interactional caution in discussing death and dying.

Physicians of western medicine : anthropological approaches to theory and practice

Section I: Introductions.- 1. Among the Physicians: Encounter, Exchange and Transformation.- 2. Including the Physician in Healer-Centered Research: Retrospect and Prospect.- Section II: Core Medicine.- 3. A World of Internal Medicine: Portrait of an Internist.- Section III: Medical Specialties.- 4. Models and Practice in Medicine: Menopause as Syndrome or Life Transition?.- 5. Mary Patient as Emergent Symbol on a Pediatrics Ward: The Objectification of Meaning in Social Process.- 6. How Surgeons Make Decisions.- 7. Gentle Interrogation: Inquiry and Interaction in Brief Initial Psychiatric Evaluations.- 8. Reflexivity, Countertransference and Clinical Ethnography: A Case From a Psychiatric Cultural Consultation Clinic.- 9. The Once- and the Twice-Born: Self and Practice Among Psychiatrists and Christian Psychiatrists.- Section IV: Interrelations of Medical Specialties.- 10. Discourses on Physician Competence.- 11. Consultation-Liaison Psychiatry: Medicine as Patient, Marginality as Practice.- 12. Disease and Pseudo-Disease: A Case History of Pseudo-Angina.- List of Contributors.- Author Index.

Language, Interaction, and Social Problems

This paper addresses the question of why the study of language and interaction matters to the sociology of social problems. The proposed answer is that such study lends to understanding what Goffman called the “interaction order.” Language studies, that is, have a first-order concern with how talk and interaction work; as a byproduct, they offer a different standpoint for a social organizational understanding of such traditionally-identified social problems as subcultures, conflict, power, troubles, and institutional processing. The appeal here is not for investigating micro-analytic dimensions of abstractly-defined social problems, but for approaching the interaction order as a substantive domain in its own right.

Good reasons for bad testing performance: The interactional substrate of educational exams

This paper was originally published in 1992. It arose out of a project to study how clinicians tell parents a diagnosis of a developmental disability. That specific project was part of a larger one conducted in 1985-1986 to study the delivery of bad and good news in both ordinary and medical settings (Maynard, 2003). As part of the developmental disabilities study, we also examined how testing was done as a precedent to deciding on diagnosis (Marlaire and Maynard, 1989), and the paper here about the “interactional substrate” was meant to show the orderliness of testing interactions – the basic structures that made it possible to generate valid and reliable examination scores that could lend to the official assessment. More recently (2013-2015), a research team and I returned to the same clinic with a grant from the U.S. National Science Foundation, to study more intensively the testing and diagnosis of Autism Spectrum Disorders (ASD). In the time between the 1985 study and the recent one, the prevalence of ASD had skyrocketed in the U.S. from 1 in 5000 children to the current rate of 1 in 68. A study of the micro-interactions surrounding testing and diagnosis does not explain the increase in prevalence but it does say just how testing is done and how clinicians use results and other information to diagnose children. With regard to testing, in particular, we have come back to the paper on the interactional substrate again and again because probing this substrate and the practices by which it is constituted remains as an avenue in to understanding ASD as not just a condition of the child but as something that is manifested as a feature of social interaction. There are ways in which ASD as a child’s condition is co-produced by way of (i) the orderliness of interactions between clinicians and children, and (ii) how tests constrain both the clinician and the child in terms of what is visible as “competence.” Thus, in current work, we distinguish between what we call first-order, or concrete competence, which, by way of the interactional substrate, allows testing to be done, regardless of what the official results may be, and second-order displays of abstract competence (Maynard and RESUMO Este artigo foi originalmente publicado em 1992. Ele surgiu de um projeto para estudar como os médicos apresentam aos pais um diagnóstico de deficiência no desenvolvimento infantil. Tal projeto específico fazia parte de outro mais amplo, conduzido entre 1985-1986, para estudar a comunicação de boas ou más notícias tanto em cenários cotidianos quanto em cenários de tratamento de saúde (Maynard, 2003). No estudo das deficiências de desenvolvimento, também examinamos o modo como eram realizados os testes que precediam a decisão sobre o diagnóstico (Marlaire e Maynard, 1989), sendo que o artigo aqui apresentado, sobre o “substrato interacional”, visava a mostrar o caráter ordenado das interações durante os testes – as estruturas básicas que possibilitavam gerar escores de exames válidos e confiáveis que pudessem levar à avaliação oficial. Mais recentemente (2013-2015), retornei à mesma clínica com um grupo de pesquisa, com financiamento da Fundação Nacional de Pesquisa dos EUA (U.S. National Science Foundation), para estudar mais intensivamente a testagem e o diagnóstico dos Transtornos do Espectro Autista, TEA, (Autism Spectrum Disorders, ASD). Entre o estudo de 1985 e o mais recentemente realizado, a prevalência de TEA nos EUA disparou de 1 em 5000 crianças para a taxa atual de 1 em 68. Um estudo das microinterações envolvidas nos testes e diagnósticos não explica o aumento na prevalência, mas revela, sim, como os testes são realizados e como os médicos usam os seus resultados e outras informações para diagnosticar as crianças. Em relação à testagem, em particular, retomamos inúmeras vezes o artigo de 1992 sobre o substrato interacional, pois o exame desse substrato e das práticas que o constituem continua sendo um caminho para que se compreendam os TEA não só como condição da criança, mas também como algo que se manifesta como traço da interação social. Há, pois, maneiras de se coproduzir os Transtornos do Espectro Autista como uma condição da criança, as quais se prendem a: (i) o caráter ordenado das interações entre médicos e crianças, e (ii) o modo como os testes cerceiam tanto o médico como a criança em termos do que é visível como “competência”. Assim, no trabalho atual, distinguimos entre, primeiro, o que chamamos de competência concreta ou de primeira-

STANDARDIZATION VS. RAPPORT: RESPONDENT LAUGHTER AND INTERVIEWER REACTION DURING TELEPHONE SURVEYS

Laughter emerges naturally in interaction. In the context of the telephone survey interview, however, laughter threatens standardization. Consequently, some survey research centers prohibit interviewers from laughing during the administration of surveys. The data for this study are recorded telephone interviews from one such survey research center. How interviewers handle the laughter invitations of respondents is analyzed. Because these interviewers are not taught what to do when laughter occurs, they rely on their tacit knowledge, either accepting the invitation, declining it, or engaging in pseudo-laughter: Interviewers most often decline or use a pseudo-laughing response. Laughter patterns in a survey research center that does not prohibit interviewer laughter are examined for comparison, and generally much more reciprocation and laughter are observed. Respondent laughter exhibits a central tension in the telephone survey interview: How can interviewers maintain both standardization and an appropriately affiliative social relationship with respondents? The differential management of this tension is explored in terms of survey methodology, the sociology of (social) scientific knowledge, and the organization of talk in institutional settings

Inside Plea Bargaining

The empirical materials presented in preceding chapters can be tied together by treating a theme sketched at the outset—plea bargaining as an “inside” activity. Such treatment also flags other issues to be explored.

Defendant Attributes in Plea Bargaining: Notes on the Modeling of Sentencing Decisions

Previous research on how defendant attributes affect sentencing decisions has relied mainly on “variable analysis.” This paper argues that such research improperly models the decision process. In plea bargaining, defendant descriptions are selected from an array of possible attributes. They are related to other descriptions and “facts” of a case, in a contextual manner, to justify a defense or prosecution position regarding sentence. To properly model the relation of defendant attributes to case dispositions, a gestalt framework is required. This would allow the investigation of commonsense reasoning practices and typifications involved in decisionmaking. The question of whether all defendants receive “equal treatment before the law” is related to what kinds of typifications are employed by lawyers and judges. Where “variable analysis” uses a standard of formal rationality to measure how well the courts administer justice, the standard displayed in plea bargaining is substantive rationality.

Narratives and Narrative Structure in Plea Bargaining

Recent interest in oral language and law (Atkinson & Drew, 1979; Danet, 1980; Levi, 1985; O’Barr, 1982; Pomerantz & Atkinson, 1984), repeating a characteristic of earlier research on criminal justice (cf. Newman, 1966:xiv, Rosett & Cressey, 1976), gives disproportionate attention to trials and formal proceedings rather than informal processes such as plea bargaining, even though it is in the give-and-take of the more casual setting that practitioners settle the bulk of cases coming before the courts. To be specific, the “explosion” of ethnographic research on plea bargaining during the last 15 years (Maynard, 1984:1) makes it abundantly clear that attorneys often present “facts” by telling stories about “what happened.” However, although investigators have explored various dimensions of storytelling in the courtroom (Bennett & Feldman, 1981; O’Barr & Conley, 1985), narratives in the negotiational arena are unstudied and unexplicated.