The Interpenetration of Communicative Contexts: Examples from Medical Encounters Author(s): Aaron V.

Cicourel Source: Social Psychology Quarterly, Vol. 50, No. 2, Special Issue: Language and Social Interaction (Jun., 1987), pp. 217-226 Published by: American Sociological Association Stable URL: http://www.jstor.org/stable/2786753 . Accessed: 27/06/2013 19:27
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Social Psychology Quarterly 1987, Vol. 50, No. 2, 217-226

The Interpenetration of Communicative Contexts: Examples fromMedical Encounters

University of California, San Diego is related to the task at hand. Language and other social practices are Verbal interaction will concedethat Not all students interdependent. of languageuse and social interaction, however, andpatterns that are constitutive ethnographic material, participant attributes, ofsocial organization of or discourse. The researchercan exercise talk need to be includedin studies of conversation " In the or toldabout "context. considerable discretion in whatthereaderwillbe shown present paper, I discuss two senses of "context"as it involvesconversational interaction in a bureaucratic Thisuse oftheterm"context" includes an institutionalized or ways environment. framing ofactivities norms and/or channel that group-derived prescriptive pressure people with designated titles, presumed times or responsibilities intocertain in orderto engage duties competencies, physical spaces at certain activities. Within context orframing in a finite number thisinstitutionalized ofspecifiable ofactivities, viewof "context" in thesenseoflocally createsa morenarrow emergent processesoftalkappearthat I have chosena conversation interaction. between three in a organizedand negotiated physicians theimportance at different levelsof analysis.The medicalcenter to underscore university of context notionsratherthan the interrelationship analyst'sdecision to focus on particularsociolinguistic and broader and narrow sensesofsocial structure willframe between discourse different expectations substantive conclusions on thepartoftheresearcher. for thereaderand different

AARON V. CICOUREL

in ways we would like or expect.The meanings researcher's questions can create contextual A researcher's decisionto tape recordconver- framesthatmay not be consistent with inforsation or discourse creates a contextualframe mant's everydaypractices. A similarproblem as relevant exists in laboratory experimentsof social thatlimitswhat is to be identified data, their organization, and the kinds of interaction where status and role relationsare to whichthesedata will foci of attention. analysisand inferences The investigator's and subbe subjected. Research on conversationand jects' conceptions and role relations of status are discourse varies considerablyin the extentto contingenton implicit and formallydefined will describethe circum- notionsof "context"createdfortheexperimenwhichan investigator and her or his tal occasion. We seldom know the extentto stancesof tapinga conversation involvement with those taped. Similar condi- which simulatedsocial relationsreflector are tions exist in othertypesof researchon social contrary to the kinds of experiencessubjects interaction. For example, in field research,a have in their everyday encounters. mustbe sensitive to thefact participant observer While many researchers will agree thattalk thatelicitation can forceinformants and some notionof "context"shape each other procedures to become aware of issues or conditionsabout as part of an emergentprocess that changes are not aware, or may be whichtheynormally throughtime and space, not all studentsof aware of only in the local contextof everyday language use will concede that ethnographic settings.Silverstein(1981) notes thatmuch if attributes, and patterns of is material,participant to researchers not mostof whatis of interest that social are talk organization constitutive of beyond the informant'sability to articulate need to be includedin studiesof thestructure of conversation or discourse.For example,converat theInvited sation analysts(Sacks et al., 1974; Schegloff, Parts presented ofthepaperwereinitially 'Context':Languageas an Interac- forthcoming) Session "Rethinking to focus on such thingsas prefer tive Phenomenon,Part I" (Society for Linguistic and how thatorganizasequential organization, and General Anthropology Division), Anthropology in converelements American Association annualmeeting, tioncreateslocal contextual Anthropological use of social categories to sation.The researcher's Philadelphia, PA, December, 1986. I am grateful invaluable in any analysis mustbe linked to participants' CharlesDavis and Elizabeth Zieglerfortheir supportand advice, and to Douglas Maynard,Hugh recognition of the categoriesas integralto the Wertsch and twoanonymous referees for eventsbeing studied.This researchattitude Mehan,James can substantive drafts of their suggestions on earlier helpful in a result very formal of type analysis. the paper. Douglas Maynardalso provided veryuseful editorial for reprints maybe sentto Linguistic approaches to discourse analysis suggestions. Requests therole AaronV. Cicourel, of Sociology, University (Brown and Yule, 1983) also minimize Department of California, San Diego, La Jolla,CA 92093. of ethnographic and organizationalconditions
INTRODUCTION

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thatcan resultin a formalanalysisof utterance may or may not begin with the investigator's to directexperiencewiththe ethnographic unclearis theextent sequences. Whatremains setting which the decision to tape or use particular in whichthe speech eventswere recorded. When the investigator includesor excludes explicitand tacit materials knows littleor nothing ethno- about the speech event,and the eventis rather and unreported knowledge aboutreported attributes, and short-lived graphic conditions,participant and apparently notviewed as partof that can selec- or influencedby existing institutionalized pattemsof social organization or analysis.The researcher bureaucratic tivelyshape subsequent activities,what gets identified as in whatthe contextcan be more easily located in the talk discretion can exerciseconsiderable said to be attendedby the participants. readerwill be shownor told about "context." The can begin her or his analysis by The content of conversationor discourse investigator transpar- examining can be made to appearrather theway theconversation is initiated, material ent when we use brief, formal or informal the way intonationand stress are used, the exchangesamongpersonswe do notknow,who content of lexical items and phrases, the in a limited in settings described way, or occurrence interact of pauses or hesitations, tum taking conver- moves, and the way topics are introduced, everyday whenwe use casual, mundane and alteredor changed.The focusof sations among friends during informal ex- sustained, can become thesequential abilityto compre- attention changes. The investigator's organization materialthat presupposesthat hend these exchanges is assumed to be of conversation and is seldom if ever an aspect of participants, self-evident investigator and readerall share a the analysis. But if a fuller analysis of commonknowledgebase thatis largelytacitor and ethnographic un- unstated,but which becomes partiallyarticuconversation participants' about activities,objects and ideas latedby theway theinvestigator derstandings beginsto make is desired, and thatunderstanding presupposes claims about the categories to which the technical,scien- participantsare said to be attending. The priorsocial experience,and/or training, thenotherstrate- investigator and reader presumablycan each tific,or professional local analysismustbe examine the same data and make claims and gies besides a completely counterclaims abouttheclarity and substance employed. of is related to the task at the analysis. Verbal interaction For many studentsof language and social hand. Language and othersocial practicesare about the interaction, Knowing something therefore, thenotionof context interdependent. need to the participants' and ethnographicsetting, the perception of and not include references to others,and broader researcher'spersonal, kin, and organizational attributed characteristics and otheraspects of complex or conditionsbe- relationships and local social organizational of institutionalized settings. Casual, fleeting speech comes imperative for an understanding and nonlinguistic aspectsof communi- events, however, can also contain abstract linguistic institutionalized features thatwe associate with cativeevents. in publicplaces, described in general In thepresent paper,I show severalorganiza- encounters thatcontribute to two senses of butvivid terms tional settings by Goffman (1959; 1963; 1971) interac- among others.These briefexchangescan also "context"as it involvesconversational This use of carry considerable cultural and interpersonal environment. tionin a bureaucratic because of long-term the term"context"includesan institutionalized "baggage" forparticipants or ways thatgroup-derived social relationships unknownto or unattended of activities framing prescriptivenorms pressure and/or channel by the investigator.The investigatorwho attend to compe- examinesa speech eventcan therefore titles,presumed people withdesignated into certain its several senses of context narrowly or tencies, duties or responsibilities physical spaces at certain times in order to broadly. The present with paper is identified explicitly engage in a finite number of specifiable context the view thatboth a broad and local sense of activities.Withinthis institutionalized of activities, or framing processes of contextare needed even if we are dealing with emergent I examinea complexenvirontalk appear thatcreatesa more narrowview of singleutterances. "context"in the sense of locally organizedand mental setting in order to underscore the levels of importanceof context at different interaction. negotiated knows analysis. The following pages begin with a The extentto which the investigator and everyday in which threepersonsemergeas events conversation about the institutionalized and analystscategorizeby the speakers.Subsequent sections thatparticipants providethereader use of specifictermsvaries. For example, the with a brief overview of the organizational and the ethnographic in settings may or may notbe settings analystof particular circumstances present when speech events are recorded. whichthe data were obtained.AfterinvestigatWithinthis more narrowsense of "context," ing additionalspeech events,I close the paper how both immediateand other the analysis of a tape and transcript by illustrating therefore,

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COMMUNICATIVE CONTEXTS aspectsof context mustbe takenintoaccountif we are to understandlanguage and social to interaction in everydaylife. It is important locate the analysis of language and social in a wide variety of social activities interaction known to the thatare implicitly and explicitly participants and investigator. Example (1)-A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 A RoutineConversation

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The speech event presentedin Example (1) can be viewedas a routine conversation between three unidentified personswho will be identified laterin thetext.

conversation betweenthreephysicians

PA: (?) (low voice level) Is thisthe same one (we?) (ya?) did yesterday? IDA: No. This is theeye lady. PA: (?) IDA: Cellulitis PA: Oh. IDA: WithgroupA strep..inshock PA: In shock. (Slightrise in voice level) How about that. [if she didn't IDA: I[t?] was gonnabe moreinteresting MR: I'm(?) IDA: have bacteremia but (laughingand voice level increasing) now she's had Ibacteremia so MR: There's a little,there's little(voice level increases)problemwiththat thatI'll, will go intomoreas far IDA: Yeah. MR: how muchshock she really[was in, was in, right. IDA: MR: comparedto what [abrupt she's a liverlady, shift] sits you know, an' I don't know whatherblood pressure with. at. It may notbe real highto [start IDA: Right. Right. PA: So she didn'thave peripheral, evidenceof shock really?[Just a low blood pressure. MR: No, she wasn't, she wasn't ever clamp, you know PA: Uh huh MR: clampeddown or flushedor anything PA: OK MR: I can..and, and she doesn't one thingthatargues [abrupt shift] againsta lot of neuropathy, you know, fromdiabetes,for one, she's only had it forthreeyears,but two, you know, her neuroexam an' her an' herperipheral vascularexams, is reallynormal,is normalsensory, good pulses distally, and stuff, and I just have a hardtime, PA: Yeah MR: there'dbe a lot of sy-sympathetic, you know PA: Right MR: phonecalls. IDA: Have theygot sinus filmson yeryet? we be sure if the patient is nearby, is an inpatientor an outpatient. We know nothing aboutthephysicians'genderor personalcharacnortheir teristics specialties.Nor do we knowif thisinformation is relevant to the analysis. The opening lines do not mentionthe term "physicians"nor is thereany indication in the openingthreelines thata "patient"is involved.

(Each dot betweenwords = one second) Telling the reader that threephysiciansare at penetrating involvedis an initialattempt what in thisencounter. is occurring Sayingthatthree physicians (theyalso could be otherhealthcare providers) are talking implies that they are in a medicalfacility probably of some kind,but thereis no indication of preciselywhatkindor partof a healthcare facility theyare in. Nor can

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SOCIAL PSYCHOLOGY QUARTERLY not tell the reader that there is medical talk takingplace, nor who is doing the talkingand withwhatcredentials. But claimingthe participants in a given speech event are physicians talking abouta particular "patient"orients us to categories we associatewithparticular members of a medical settingand a basis for making claims about theuse of thesecategoriesin their talk. The Research Setting and Typesof Participants The case material I present in this paper a small portionof data fromfield represents in two teaching research hospitals.The material is part of routineinstitutionalized bureaucratic activities that are typically associated with health care deliveryin westem countries.My observationsand tape recordingof activities involved mostly doctor-patient,physicianphysician, or physician-technician interaction. The medical settings observedare typicalof teaching hospitals but are not necessarily of otherclinic or hospitalsettings representative in which there is an absence of House Staff (intems, residentsand trainingfellows). The inclusion of House Staff adds hierarchical and hence additionalbureaucratic relationships thatdifferentiate conditions teachingfromnonteaching hospitals. Additional details about of status organizational theinfluence conditions, and role relationships,and the expertise or backgroundknowledge associated with such designationswill be provided as the paper unfolds. The range of speech eventsin these settings can be diverseand can includea quick exchange of greetings,brief exchanges of gossip or rumorsabout patientsor staff,and discussion about the local baseball or football team's fortunes. There also can be briefand lengthy techexchangesbetweenphysicianand patient, nical discussionsamongphysicians and between physicians and nurses or technicians, and somberor emotionally charged exchanges betweenfamilymembersand healthcare personnel. The exchanges can occur in a varietyof such as the patient'sroom, in a clinic settings an empty examiningroom, a hall or corridor, at the x-rayfacility, the elevator,the cafeteria, nurse's station, or a laboratory. Over a periodof months, I observedand then began to tape recordvariousclinicalexchanges. These exchanges included outpatientclinics where patientsmay be seen initiallyor as a visitsor inpatient followup from service.I prior also accompanied the resident or attending on wardrounds,or visitsto thex-ray physician facility, to daily laboratoryrounds, and to roundswherecases of weeklygrandor teaching are presented unusual interest beforeattendings

Having identified the three participantsas "physicians," we can also say that they are talkingabout a "patient"who has been dubbed the "eye lady," forsome unstated reason, or a patientwho is experiencing difficulty withher eye. Although thecontent of lines 1-3 of Example (1) ("Is this the same one [we?] [ya?] did No. This is the eye lady") does not yesterday? and a suggesta healthcare facility, physicians, witheye problems,the term"cellulitis" patient in line 5 might be recognizableenoughto send us to a medical dictionaryas we begin our analysis. Altematively,we might seek help frominformants or examine further sequences in the hope that otherlexical of conversation of the talk,or items,phrases,prosodicfeatures thus far unstatednonverbalperceptionsmight of this encounter. increase our understanding For example,noticetheremark by IDA in line 7 to ("groupA strep..in shock") whichcould refer an infection.The commentor observationby PA in line 8 ("In shock. How aboutthat")could as expressing interestin the be interpreted categoriessupplied by IDA and perhaps mild surprise.The subsequentremarksby IDA in lines 9, 11 and 12 of Example (1) (I[t?] was if she didn't have gonna be more interesting but now she's had bacteremiaso") bacteremia with suggestthatPA and IDA are bothfamiliar the terms "cellulitis," "group A strep," "in shock," and "bacteremia." Clearly, including this additionalpart of the interaction suggests are engaged thatthe participants more strongly the medical condition in a discussionregarding control of some otherparty.The investigator's will be shownthe over when and whatmaterial and can readercan, therefore, varyconsiderably createdifferent frames. interpretive If we do not invokesociocultural detailswith which to identify the participants of conversation,the analysisof meaningis nearlyimpossible. The significance the analyst attributes to utterances or to theirsequentialorder particular may have little validityvis-a-vis participants' of the speech perception and understanding event.The focusof thepresent paper,therefore, but also buildson conversation differs from and withthe discoursetheorists concerned primarily structuralfeatures of conversation such as cotum-taking, side-sequences,topicalization, herenceand relatednotions. I will now abruptly shift mymode of analysis by telling the reader something about the in Example (1) and about how the participants data were obtained. The settingis generally known to the reader and investigatoralike of because of a commonsenseunderstanding categorieslike "healthcare facility,""medical center," "hospital," and "medical school." does Statingthatthetalkis in a medical setting

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COMMUNICATIVE CONTEXTS from the county and residentsfrom several hospitals. The ethnographic activitiesalluded to above to exobviously provided many opportunities press my ignoranceabout medicineand to ask The fieldresearch questions of different experts. witha was facilitated by my official connection school of medicine. Knowing some of my of theresearchsetting informants independently in theSchool of activities because of committee in the research Medicine made participation settingeasier, and enabled me to ask many "dumb" questions as a nonmedicalspecialist. with the settings and with But familiarity suchas my can also createproblems, informants thatI am not a physician colleagues forgetting yet speakingto me as if I were fullycapable of thatwere distechnicalmatters understanding in to seem informed cussed. I oftenpretended the speech event,but later orderto not disturb would have to ask forhelp. My ethnographic experiences,consultations with persons called "physicians," and occasional uses of a medicaldictionary enable me to take a number of libertiesin describingthe material in Example (1). I can tellthereaderthat thereis a femaleinpatient located in a medical as well as teaching hospitalwithan eye problem additionaldifficulties associated withthe terms "groupA strep" (line 7), "shock" (line 7) and "bacteremia"(line 11). I claim, and relyon the reader'scommonsense understanding to comprehend, that the physicians are talking about someone with an infection and perhaps somethingmore serious (as may be evidentby the references to "shock" and "bacteremia"). Less here is the remarkby IDA (lines transparent 9-12) that the case would have been more if the patientdid not have bacterinteresting
emia.

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the Conversation Reexamining in Example (1)

some familiar aspects of the studyof language in social interaction. The opening question by PA ("Is this the in line 1, same one [we?] [ya?] did yesterday?") Example (1), can be seen as topicalizingan unidentified but particular type of object that other participantspresumably recognize as fittinginto a specific subset of a general category.We can subsequently categorizethis object as a "patient" by assumingthe participants are health care providersof some kind. The responseby IDA in line 3, Example (1), rejects a particularsubset of the unidentified hypothesized category, but does allude to another "thisis theeye lady." subsetby stating In lines 5, 7 and 12 of Example (1), IDA seems to clarify the hypothesisabout the category patient such as "celluby describing particulars litis," "group A strep," "in shock," and " "bacteremia. The opening question by PA in line 1, Example (1), mightalso be loosely interpreted as one part of an adjacency pair (e.g., question-answer sequence) in whichthe second part consists of the "No" of line 3 by IDA. be stretched Perhapsthistypeof analysismight even moreif we ignorethe "No" of line 3 and the "Oh" of line 6 and say thatthe second part of theadjacencypair consistsof fragments from lines 3, 5, 7 and possibly12 of Example (1). To paraphrasethe exchange, the PA's questionin line 1 askingif "thisis thesame one (we?) (ya?) did yesterday" is answeredby the IDA in lines 3, 5, 7 and possibly 12 ("No. This is the eye lady," "Cellulitis," "With group A strep..in shock," and "now she's had bacteremia"). If we go beyondthisloose illustration of sequentialanalysis,we can ask how muchlocal context is the analystrequiredto construct in orderto convinceherselfor himselfand the readerthat the interpretations being claimed are adequate forsome sequence of text?

The exchangein Example (1) does not state that the three participants are attached to a WhatCountsas Relevant healthcare facility of some kind, nor is there Ethnographic Details? any mention of a patient. The conversation of a topic I observed the exchange in Example (1). begins in line 1 withtheintroduction ("Is this the same one . . .") and a reference to Consequently, I can assert that PA turned some object or someone that had something directly to IDA whenposingthequestionabout done to it the day before. the "same one" in line 1. The speech eventcan In an earliersectionof thepaper,I alluded to be further clarified thatPA refers by noting to a thepossiblecontent of lines 1-7 of Example (1). PathologyAttendant who is the Chief of the An analyst might choose to ignore further Microbiology Laboratory, and IDA is the discussionof contentat this point and instead Infectious Disease Attending. MR is the infeccould focus on who speaks first and how tious disease Medical Residentfor the rotation someone responds,identifying turns, the selec- periodduring whichtheeventoccurred. tion of next speaker, topicalization,side seThe exchange reported in Example (1) quences, adjacency pairs, registers used, topic occurred after the MR and IDA had both and comment,and deictic, anaphoric, meta- interviewed the patientand had discussed the phoric,and metanymic expressions, to mention case. Their participationin the encounter

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reported in Example (1) had already been was in"), seems to be questioning thepatient's anticipated because of the expected earlier "shock" and thesedoubtsare related to theissue exchange. The PA is the expert here and of bacteremia withor without shock. methodically examinesa seriesof small slips of The remark by theIDA in line 18 of Example paper each moming at 11:00 A.M. in which (1) repeatsthe last two termsused by the MR new or additionalinformation about a patient's and adds "right" as if to supportthe MR's culturesis noted. The IDA is also an expert observation.Earlier, I was with the IDA and about microbiological aspects of each patient, MR when the two discussedthe case and knew particularly the clinical ramifications of the that there were doubts expressed (in two the IDA, the PA asks the separatemedical histories)by otherphysicians case. By addressing responsibleclinical expert about the case in aboutthepatient's"shock." The MR's compleorder to contextualize the laboratory findings. tion of his remarkfrom line 17 (stated as There are othersin the comer of a large room "comparedto what" in line 19) was followedby (whichis actuallyone partof the suitein which an abrupt shiftin the topic. Presumablythe the Microbiology labs are located). There often patient's"shock" was to be contrasted withan is a fourth-year medicalstudent doinga month's unstatedsomething else "compared to what") in infectious rotation disease cases, a pathology whentheMR decidedto abruptly shift thetopic residentwho assists the PA with laboratory to the patient'sliver ("she's a liver lady, you details, includingthe culturesfor each patient, know"). So in additionto being "the eye lady" slides, and petrie dishes to be examined that of line 3, the metaphor shifts to thatof "liver moming, an infectiousdisease residentfrom lady." The reader'stechnical knowledge maybe and one or two teaching strained by the phrase "a liver lady." My fellows. pediatrics, In a teachinghospital, the IDA may begin participation in the setting tells me we have a witha few comments on the case but normally patientwitha current eye problemand a prior tums it over to the MR for the details. After liver problemattributed to a history of alcohol this,the PA first examinesthe slide or cultures abuse. and eitherdirectly describesthe morphology of On the basis of previousconversations with theorganism(s) or invites themedicalstudent or informants, I can report thatone clinical signof fellow or a residentto tell the group what shock is very low blood pressure.The MR's in line 21 ("It may not be real high to organism(s) is/are involved. The PA then remark to the timeof admissionfor invariably gives the group additionalinforma- start with") refers tionabout thenature of theorganism, thekinds the patient, when her blood pressure was of disease and/or associatedwiththe observedto be low butwhereno one (including symptoms laboratoryfindings,and the patient's likely the patient) was aware of her normal blood withdifferent prognosis typesof treatment. pressure. The inference of possible shock, can be problematic The openingline of Example (1), therefore, therefore, on the depending assumes coherenceby reference to a presumed patient'snormalblood pressure.The IDA had others contributed activity done with thus far unidentified to the MR's remarks their through theday before.As notedabove, theunidentified previousconversations the day before,and the in thepresent others case are theMR and IDA. "Right" utteredtwice by the IDA in line 22 The responseby IDA in line 3 shifts thetopicto could signal agreement withthe presentobsersomeone called "the eye lady." The inaudible vation by the MR and/or the IDA's prior After comment by PA in line 4 of Example (1) could contribution. howreadingthe transcript, thatthe intent have been a requestfor details about the case. ever, the IDA reported of saying The IDA provides one detail ("cellulitis"). "Right" twice was to hurry the MR into his delivery and remarks. From my watchinghis facial expressionand expediting In lines 23-24, the PA provides some theintonation hearing of his voice ("Oh" in line thatthe termis of interest of thepatient's to thePA. clarification 6), I infer alleged shockby his thatthe patientapWhen the IDA providesadditionalinformation "declarative-interrogative" thePA repeatsthelast phrase parently"didn't have peripheral,evidence of about thepatient, ("in shock") and with a slightlyrising voice shock really? Just a low blood pressure." level seems to be expressing mild surprise Although appearingto be a question,the PA's are spoken authoritatively the ("How about that"). Then the IDA, in lines 9, remarks through 11 and 12, refers to how muchmoreinteresting use of a somewhat "matter of fact" or had not "self-confident"intonation and the mildly the case would have been if the patient had "bacteremia" "I[t?] was gonna be more assertive nature of thecontent. Thereis also the if she didn'thave bacteremia butnow ethnographic element that he is the primary interesting she's had bacteremiaso"). The MR, however, experthere and can be indirectly this asserting in lines 23-24. in lines 10 and 13-17 ("There's a little,there's expertise by his remarks in lines 25-36 of The MR's rambling remarks littleproblemwith that that I'll, will go into more as farhow much shock she really,really Example (1) addressseveralpossible topicsthat

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COMMUNICATIVE CONTEXTS

223

diseases can presupposesbackgroundin clinical medicine. student'sknowledgeof infectious can become be tracedto one or two courses (dependingon For an attending, theMR's remarks of the the quarteror semesterbasis of the medical assessment thebasis foran organizational I attended some of the diseases. Stu- school) in microbiology. residentor novice in infectious the as lectures in microbiologyand interviewed dents of language use in social interaction, of thecourse,who is also thePA in the nonmedical specialists, can only superficially director in Example (1) conversation of Example (1). With the help of assess theimport of thematerial it is possible to traceaspects of the and have informants, unless we seek the help of informants information basic science concepts and clinical medicine access to the kind of ethnographic thatmedical students are exposed to experience providedthusfar. before they enter an intern or residency program.Knowing something about the physician's priorexperiencesin medical school and Context ExpandingtheEthnographic as a House Officer can providethe analystand I have presented a partialdescription of the readerwithpossible aspects of the background ethnographic or knowledge tacitly or explicitly assumed or way the selectionof different organizational settings and types of speech employedduringa speech event. I do not have events or social interactioncan affect the space to present all of the content of my materials interview with the PA in his role as the of theresearch analyst'sinterpretation course director, but instead will presentedto a reader. In this paper, I have microbiology thatcan and providethereaderwitha fewhighlights ignoredseveraladministrative, professional in Example (1). technicalmattersthat affecthow patientsare be linkedto the conversation Trying to tracethekindsof basic and clinical are diagnosed admitted into a medical setting, and treatedby different health care delivery science concepts that medical students and the House Staff are exposedto beforetheyattain personnel. is notmeantto implythat of "attendings" The present case involvesa 48 yearold white status so-arce knowledgeis theprimary female whose chief complaintwas recordedin such codifiable and physicalexamination of background necessary for the diagnostic her admissionhistory directedat patients.In as "swellingof thelefteye." Additionaldetails reasoningand treatment can be found in Cicourel (forthcoming). Of my work on medical communication and I have stressed reasoning, theimporinterest here is her primary diagnosis of diagnostic as tance of tacit clinical experience and the "periorbital cellulitis,"or whatwas described cellu- everyday understandingof mundane social a "right-upper-lid abscess withperiorbital as aspectsof a worldpresumed this interaction to be litis." My informants helped me translate last phrase into an infected,swollen-shut left knownin commonbutnotnecessarily examined withpurplish in themedicalor any by participants coloringof reflexively eye, highlyinflamed, the skin around the eye apparently caused by other area of life (Cicourel, 1982; 1986; blood seeping into the skin. The patient'sleft forthcoming).I call the reader's attention, side of her face was swollen as well as her eye however, to the necessity of incorporating and ear. Therewas pus oozing out of thearea of systematically codified knowledge (textbooks, theeyelids. detailed laboratory apprenticelectures, practices, I accompaniedthe MR whenhe first wentto like experiences) into our understanding of the medical ward to see the patient. Before bureaucratic and nonbureaucratic language use the patient,the MR went to the and social interaction. Inasmuchas sociolinguisinterviewing nurse's station to reviewthe patient'schart.As tics tendsto addressvariouskinds of everyday is often thecase withinfectious disease patients, events in which the analystcan "pass" as an an attendingphysician other than the IDA expert because of her or his backgroundin to themedical languageuse and social interaction, admitted theanalysis usuallywill see a patient is oftenviewed as fairlystraightforservice.In thepresent had of content case, two attendings the patientand had orderedlabora- ward. By calling the reader's attention interviewed to the testsbeforeaskingforan infectious disease role of multipleethnographic tory and/or organizaI underscore and informants, consultation.The results of these tests were tional settings the of theterm"context"or "local" and reportedin the chart. The MR's infectious complexity disease-oriented interview of the patient,there- more abstract senses of culture or social forunderstanding fore,was in partinfluenced by his havinghad organization languageuse and access to thepatient'smedical chart.The MR's social interaction. to themicrobiology questionsreflectaspects of these priorexpericoursedirector According ences. in an interview obtainedearly in my research In addition, thisinterview is influenced by his and notedabove, students shouldremember the prior medical school training. The medical following:

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224 Example (2) 2

1
".

SOCIAL PSYCHOLOGY QUARTERLY

what are the importantbacteria, and, in terms of human The streptococci can be differentiated

4 5 6 7 9 10 11 12
13 14 8

unique microbiologic disease, and whatare their

characteristics....

bacterial pharyngitis. .

ones and ones and the nonhemolytic intothehemolytic make green greenones. Those thatare alpha-hemolytic ones we have the colonies. And amongthebeta-hemolytic groupA strep,whichis reallytheonly acceptedcause of
.

are gramnegative thepseudomonasand the enterobacteriaceae rods, and theylook a lot alike on thegramstrain. ... the group fora minute, And if you look at the streptococci because of A strep,is able to cause sore throats primarily out let's say right me to recognizethisorganism, permit of theblood culture bottlelike you've seen us do up have cellulitis,or lymphangitis? Did thispatient there?.... Yes. Well, thenit's probablya groupA strep. Example (2) are not merelyaspects of textbook butare training, associatedwithprior knowledge expelaboratory also partof a medical student's notedin Examrienceswiththemicroorganisms based this knowledge background ple (2). Without to lecturesand listening textbooks, on studying itwouldbe rather setting, in a laboratory working to display her or his for a participant difficult in theconversation of Examgroupmembership there ple (1). In the case of a medical resident, in as an intern will have been priorexperiences in Example (1) will whichaspectsof thematerial have been discussed. that knowledge sourceof background Another is in medicalsettings can influence speechevents are exposed to an novicephysicians theway that initiallecture(also given to themas a written The foltraining. whenthey begintheir handout) lecture notesdevelopedby lowinglinesare from I quote physician. an infectious disease attending givento the thewritten handout from selectively House Staff.
the M protein. . .. . . . what are the unique microbiologic characteristics that

. The streptococci are in chains,

15 16 17 18

made by thepathologist remarks The technical beforethe comconducted the interview during of conversation laboratory pletelyindependent to the clinical consequences Example (1) refers from are expectedto remember medicalstudents courses in microbiology. The references to ones" "streptococci"(line 3), "beta-hemolytic (line 6) and "groupA strep"(line 7) in Example relatedto the "sore throats"of (2) are directly aspect of the diagline 12 and are a significant nosticreasoningemployedin the presentcase. to "cellulitis"and its assoNotice thereference ciationwith"groupA strep"in lines 17-18. The provideclear evidence of remarks pathologist's plays that on thepartof physicians training prior speechevents.Such training a roleinjob-related but not only to participants, may be important of medical also to the analyst's understanding aspectsof diagnosand semantic communication tic reasoningin the case underreview and in generally. medical settings in by thepathologist The conceptsmentioned Example (3) 1 "I. 2 3 4 5 6 7 8 9 10 11 12 13

Septicemia-microbialagentsin thebloodstream. B. One is led to thediagnosisof bloodstream by a suddenchange in clinical infection state. but, can cause hypotension, All sortsof organisms in theabsence of hypoxia(pneumonia)or heart withendotoxemia bacteremia failure,gram-negative is by farthe mostcommoncause of sustained hypotension.. shock D. Othercauses of infectious shock (groupA strep),oftenin 3. Streptococcal associatedwithsoft the absence of bacteremia, (usuallysevere) . . ." tissueinfections

by a sudden change in to "microbialagents bloodstreaminfection are references Of interest in the bloodstream"(line 1), "the diagnosisof clinical state" (lines 2-4), and organismsthat

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COMMUNICATIVE CONTEXTS
bacteremia with endotoxemia . . ." (lines 5-7).

225

maynothave been in shock. such as "gram-negative claimedthepatient can cause hypotension The presence of shock was never confirmed. contained in Example (3) and given A suddenchangein clinical statecan be a drop The remarks which in tum to House Staffat the two hospitalsin which I in blood pressure(hypotension) can be linked to the release of bacteria or conductedmy researchdirectlyassociate this thatcan lead to background in the bloodstream materialto specificaspects of the endotoxins can be found exchangein Example (1). shock. The most succinctremark I will close this section by quoting a brief in lines 10-13 of Example (3) because it comes with fairlyclose to the case describedin Example excerptfromthe MR's originalinterview was found to have groupA strep the patient. The interviewoccurred prior to (1). The patient in Example (1). as notedby theIDA in Example the speech eventreported and bacteremia (1). The case revealed bacteremiabut the MR Example (4) 1 2 3 4 5 6 7 8 I wanna take (?) yourblood. (?) blood pressure (?) (5 sec.) (mumbling) A lot of people get, bacteria in their blood, and ya get uh shock. [Low monotone intonation] When yourblood pressure goes down because it means (?) thebacteriareleases certain on (?) area (?) [raisedintonation] toxins,depending Has your,blood pressure always runkindof on thelow side, ma'am? I chose as the pointof departure setting forthe present paper was the source of a conversation between three physicians. The material presented in Example (1) can be subjected to different types of interpretation, on contingent the analyst's orientation to language use and social interaction, and the extentto which the notions of backgroundand context are employed. The analyst'sdecisionto describethematerials in Example (1) as an exchangebetweenthree health care deliveryworkersor professionals creates a culturalcontextfor the analyst and readerand simultaneously calls attention to the use of social categoriesthathopefullycan be attributed to participants'recognition of their relevanceforthe speech eventbeing examined. The analyst's decision to focus on particular sociolinguistic notions (topicalization, turntaking,speech act categories,coherence,types of deixis, frozen expressions, preferredsequences, etc.) ratherthan the interrelationship betweendiscourseand cultureor the interrelationshipbetween discourse and linguistictheory, can trigger different expectationson the partof thereader. Tellingthereaderthat thethree participants of Example (1) are physicians,thatthe exchange tookplace in a hospitalmicrobiology laboratory while discussing a patient with suspected bacteremic shock,and preparatory to examining the patient'sblood cultures,creates a cultural context within whichthe analystand readercan understand what transpires. Our understanding deepens when thephysicians as a are identified pathology an infectious attending, disease attending, and an infectious disease medical resident. Not onlyare theexpressive styleand thecontent

Beforethe MR and I entered the ward to see the patient,the MR had reviewedthe patient's chartand was aware of the two priormedical and hence was also aware of histories therein, the suspected diagnosis of bacteremicshock. The MR was also aware of manyothermedical factsand hypotheses about the patient'scondishown tion. The MR's explanation (only partly about her medicalproblems here) to the patient (linking a drop in blood pressureto a prior release of "certain toxins") can be linked directly to the prior medical histories that existed in the patient's chart, the infectious disease attending'swrittenhandout, and the pathologist'sdescription of what medical studentsshould remember of theircourse workin In turn, microbiology. all of thesematters, plus the MR's interviewwith the patient,had an effect on the remarks by the PA, the IDA and theMR in Example (1).
CONCLUDING REMARKS

The paper has presenteda few of the large numberof interpenetrating medical eventsthat formthe local contextfor language use and in any givenencounter. I have social interaction soughtto discuss the topic of local contextin terms of those cultural and organizational and immedinormative expectations constraints, ate conditions thatsurround local speech events as theyunfold. The notionof interpenetrating medical communicativecontexts seeks to place the local mutual shaping of talk and context into a frameworkthat incorporates structuraland processual aspects of social organizationand reasoning during social interaction. The medical

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226

SOCIAL PSYCHOLOGY QUARTERLY face practicalcircumstances thatare an integral part of all research or everyday living. As researchers, we obviously privilege some aspects of a context while minimizing or ignoring otherconditions.The observeris obligatedto justifywhat has been included and what has been excluded according to stated theoretical goals, methodological strategies employed,and the consistency and convincingness of an argument or analysis.Meaning and understanding in everyday life are contingent on cognitive and linguisticactivities,i.e., a knowledgeof how to use language structures that we call metonyms,metaphorsand other imaginative constructions associated with particular lexical items, phrases or utterances, and personal experiences. Therefore,some specification of the environmental conditions in which these language practicesemerge, are embedded and evolve should guide the researcher'sdepiction of context.I have triedto indicatesome of the conditionsthat can be identified in a medical to illustrate the way different setting senses of theterm"context"can be pursuedconceptually and empirically.
REFERENCES Brown, Gillian and George Yule. 1983. Discourse University Press. Analysis. Cambridge: Cambridge Cicourel, Aaron. 1982. "Language and Belief in a PercepMedicalSetting." Pp. 48-78 in Contemporary Dimensions, tions of Language: Interdisciplinary Georgetown edited by Heidie Burnes. Georgetown: Press. University in MedicalDecision Sense Reasoning edge: Common Making." Pp. 87-122 in The KnowledgeSociety, editedby Gernot Bohme and Nico Stehr.Dordrecht: Co. ReidelPublishing in Medical DiagnosticReasoning."To be published DiscourseProcesses. of Self in Goffman, Erving. 1959. The Presentation Everyday Life. GardenCity, New York: Doubleday Anchor Books. The FreePress.
. 1963. Behavior in Public Places. New York: . 1971. Relations in Public. New York: Basic . 1987. "Cognitive and Organizational Aspects of . 1986. "The Reproduction of Objective Knowl-

conon organizationally observed contingent that can strainedstatus and role relationships whose views will be who speaks first, influence or will prevailvis-a-visaction to be influential taken,but the analyst's and reader's abilityto comprehendthe significanceof broader and issues may requireextensive local sociocultural withmedical experts. consultation case actuallybegan withthe MR The present of goingto thenurse'sstation and theresearcher medical centermedicine ward to a university suspected of a patient examinethemedicalchart of having bacteremic shock. The MR was performingan organizational obligation of a consultation requestedof the Diviinitiating sion of Infectious Diseases. course The materialfromthe microbiology medical presentedabove reflectsinformation students are expectedto know, and theexcerpts from the lecture given to new House Staff reflectthe kinds of knowledge experiencesa is or resident physician novice such as an intern likelyto possess whenreadinga patient'schart thepatient. and theninterviewing By thetimethecase reachedthemicrobiology roundsdepictedin Example (1), the laboratory by the IDA; patienthad also been interviewed the MR and the IDA had discussed the case in some detail; the IDA had interviewedthe thepatient's and theIDA had consulted patient; chart, added to it, and had consulted two on microbiology. standard textbooks The analysisof materialin Example (1), the course (Example excerptson the microbiology 2), the infectiousdisease attending'slecture notesfornew House Staff(Example 3), and the from the MR's interviewwith the fragment a small partof a patient(Example 4) represent contexts.In the complex set of interpenetrating presentpaper, I have documentedonly minihelpedme understand mallytheway informants organizational conditions,local speech events the meaningof complex and social interaction, basic and clinical and procedures from concepts, medical science and practical experiences. I have, however, employed several types of and textualmaterialsin order to ethnographic as unavoidwhatI have characterized underscore able aspects of organizationaland local constraints and processes that are integral to " "context. rethinking remainsfor A naggingissue thatundoubtedly one thatan infinite manyreadersis the familiar theobserver can occur,whereby presumregress ably must describe "everything" about a context.Such a demandis of course impossible because no one could claim to have to satisfy all of thelocal and largersociocultural specified or analysts, like aspectsof a context.Observers of speech events,mustcontinually participants

Books, Inc. and Gail JefferSacks, Harvey,EmanuelA. Schegloff fortheOrganizason. 1974. "A Simplest Systematics for Conversation."Language tion of Turn-Taking 50:696-735. EmanuelA. Forthcoming. "BetweenMacro Schegloff, and Other Connections." In The and Micro:Contexts B. Giesen, Micro-Macro Link, edited byJ.Alexander, and Los Angeles: R. MunchandN. Smelser. Berkeley of California Press. University of Awareness." Michael. 1981. "The Limits Silverstein, Working Paper84, Austin, Pp. 1-30 in Sociolinguistic Texas.

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