Talk and Social Institutions
Talk and Social Institutions
Popular in Course
Popular in Sociology
verified elite notetaker
This 183 page Reader was uploaded by Nina Khar on Saturday May 17, 2014. The Reader belongs to a course at University of California - Los Angeles taught by a professor in Fall. Since its upload, it has received 265 views.
Reviews for Talk and Social Institutions
Report this Material
What is Karma?
Karma is the currency of StudySoup.
Date Created: 05/17/14
Talk and Social Institutions 51714 1104 PM 010614 Talk and Social Institutions Approaching Institutional Interaction Origins The Discovery of Everyday Life Background 1940 s 1960 s Sociological positivism a predictive science Focus on relationships between observable and measurable variables eg social isolation and suicide Durkheim Durkheim focus on external relationships Cognitions of persons their thoughts and feelings are inherently unobservable and have no place in a deterministic science we don39t really know about peoples thoughts and feelings in a subjective and meaningful way Moreover social interactions are chaotic and impossible to predict Therefore they are not worth working on Society and its institutions are built up out of actions are meaningful and involve meaning making They do so through a combination of their context or position and their content or composition They involve intersubjectivity which may not always be perfect but which are normally good enough for the participants to keep going Meanings are unique and singular Actions function in particular ways to create meanings that are also particular Erving Goffman The Interaction Order Interaction is a social institution that is motivated by face It is made up of social rules of various kinds What is face o In social interaction persons take a line Line what they do in the situation will affect their view of the situation view of themselves and other people Taking a line is unavoidable Other people will judge you and judge the line your taking Ex What are people trying to say in the situation based on the line they are taking 0 Persons will infer a line from your actions whether you like it or not You become accountable for your behavior 0 Therefore you will find yourself accountable for the line you are inferred to have taken whether you like it or not Therefore you will have to consider the line you will be inferred to have taken before committing to an action Face is the positive social value of person claims by virtue of the line they take Face is something that we positively value and identify with Humans have two main kinds of face wants 0 Positive Face Wants acknowledgement of personal characteristics 0 Negative Face Wants The desire to be unimpeded not having other people impose from you Ex anytime you ask to borrow something from someone you are impeding their freedom to use that item right away Interaction is a social institution organized by ritual rules Mediates other institutions in society All institutions transact their business through talk A core layer of organization in society Harold Garfinkel Ethnomethodology How do people reason things together Sense making is fundamental Made possible by shared procedures or methods Knowing the same things is due to having the same methods of reasoning about things These methods of reasoning allow people to make joint sense of objects actions and situations Shared Methods The Trust tictactoe Experiment 253 Subjects strangers friends all ages same sex different sex Subject asked to make first move Experimenter erases that mark and moves it to a different cell Then experimenter makes hisher own mark Reactions Most subjects 95 reacted Most 73 blamed the experimenter for playing wrong A small minority did not They played along Subjects emotional reactions were scored how emotional were they Very disturbed moderately or not really disturbed Disturbance was not associated with demographic factors like age sex or degree of acquaintance It was associated with uncertainty the ones who played along were the least disturbed The cause of disturbance is cognitive But How is this so Rules of tictactoe are methods for producing action Rules 9 Action standard sociology belief Rules of tictactoe are methods for understanding action Rules 9 understanding garfinkell adds Conclusion Rules of tictactoe are methods for producing action and for interpreting action the same set of rules produce both Conversational Analysis Goffman UCB Interaction Rules Garfinkel UCLA Sense Making 9 Sacks Schegloff 9 Conversation Analysis Studies the institution of conversation Turn taking and interruption Action Sequences Repair of failures in interaction Gaze and body posture The Burning Question Why That Now Conversational Structures Adjacency Pairs Goffman The interaction order Interaction is a social institution interaction order infrastructure that all institutions use Organized by ritual rules Mediates other institutions in society A core layer of organization in society Garfinkel s View of Rules tictactoe Rules are methods for producing action Rules are methods for interpreting action rules are how we make sense of actions Ex you can39t watch football unless you know the rules of the game bc you won39t know whats happening If these rules are shared the parties will understand one another s actions If the rules are not shared they will not understand those actions Interpretation 6 Rules 9 Action Sacks and Shegloff Burning Question Why That Now Adjacency Pairs 1 on Handout Sequence Organization A Where39s Bill B There39s a yellow VW outside Sue39s apartment 9 B does not directly answer A39s question But A will try to see B39s response as an answer A will see B39s response as an answer if he knows that Bill has a yellow VW If A does not know this he may infer it Why does A do these things Tightquot sequence organization Adjacency Pairs Adjacency Pairs are 1 A sequence of two actions which are 2 Adjacent and 3 Produced by different speakers and are 4 Ordered as first pair parts and second pair parts even when the parts are identical as in greetings heo heo 5 Typed so that a particular first pair part requires a particular second pair part Examples of Adjacency pairs Boundary actions hellohello goodbyegoodbye Questionanswer Invitation Adjacency Pair Rule After a speaker has produced a first pair part that speaker should stop and a second speaker selected by the first should respond with an appropriate second pair part What does this rule amount to Statement of Invariance Statistical Prediction Social Norm something which we are normatively accountable for implementing Evidence for rule Large number of cases where it is clearly implemented Deviant Cases Private Inferences from departures we reason about these things think Why did he do that Public Responses to departures public behaviors in responses to departures from rule Adjacency Pairs from Departure Anything longer than 10 sec break in speech is a long break Ex 2 in Handout Therapist and person Rules 9 Action A Is there something bothering you or not B person is now accountable for responding 9 10 seconds go by A Yes or no treat themselves as entitled for a response and treat B person as accountable for response By repeating the question A person is saying that you are willfully withholding a response 9 15 seconds go by A Eh further pursuit of an answer finally gets a response B No Ex 3 in Handout 25 year old girl A I have to cut these mommy 15 secs A Wont we mommy 15s A Wont we B Yes Sequence not product of power differential but is the norm being used to influence a recipient to do a normatively accountable action Normative obligation for the recipient to do something and is accountable for Ex 4 Handout Rules 9 ActionAccounts A What happened at work At Bullock39s this evening B hhh Well I don39t know B39s response is not an answer B s response is an account for not answering Ex J But the train goes Does the train go on the boat M Ooh I39ve no idea Account for not answering She hasn39t said Account for not knowing Adjacency Pairs General Implication for Action For 2quot Speakers rule indicates how to respond normally without 1 generating special inferences often negative ex they are rude not paying attention or 2 having to explain themselves For 1 Speakers rule enables the exercise of agency and social influence Can insist on a particular response Adjacency Pairs Resources for Understanding Ex 7 Nurse talking to a friend about a patient Scenario 1 A Why don39t you come and see me sometimes could be understood as an invitation or complaining B I would like to B person accepted invitation means B understood A person remark as an invitation to be accepted Scenario 2 A Why don39t you come and see me sometimes B I39m sorry I39ve been terribly tied up lately apology and excuse things we do when responding to complaints B39s response shows her analysis of A39s action Invitation or complaint A now know whether B understood correctly or not But B does not know whether she understood correctly Adjacency Pairs Understandinq Ex 10 A Which ones are closed and which ones are open B Most of em This this this A I don39t mean on the shelters I mean on the roads B39s response shows her analysis of A39s action A now knows how B understood him and knows it was incorrect At the arrowed turn A corrects B B now know that and how he misunderstood Ex A Why don39t you come and see me sometimes B I would like to A I would like you too Confirms that B bet right as it being an invitation Ex A Why don39t you come and see me sometimes B I would like to A Yes but why don39t you its not an invitation but a complaint A consists that B doesn39t come to see them very often A39s response shows B that B understood A incorrectly A did not intend to invite B but meant to complain Adjacency Pairs Conditions of Intersubjectivity Primitive Level 1 I have to know that you mis understood what I said Turn 2 2 You have to know that you mis understood what I said Turn 3 MetaLevel 3 I have to know that you know that you mis understood what I said Turn 4 4 You have to know that I know that you know that you mis understood what I said Summary Adjacency Pairs Understandinq Parties have used shared methods for producing action They used those same methods to make sense of one another s actions They achieved a shared understanding of the actions they had produced They knew where they were in the interaction They made sense together They were normatively accountable for implementing the adjacency pair rule Adjacency Pair sequences The engine room of interaction Guide the production of action Enable the exercise of agency and social influence Guide the interpretation and understanding of action Are the means by which understandings come to be shared thuse generating a sense of mutual understanding Emergency Calls Basic Organization 51714 1104 PM Recap from last lecture Shared methods for producing and understanding action Methods for institutional talk are distinctive o Orientation to roe based tasks o Constraints on allowable contributions narrower and more focused than normal conversation 0 Special patterns of inference A fingerprint of practices institutions are talked here and now existence through such methods through these methods of talking that we bring these institutions to life and activate them This fingerprint is best seen by contrast with ordinary conversation 9 1 1 Researchers Don Zimmerman UC Santa Barbara Jack and Marilyn Whalen U Oregon formerly Jorg Bergmann U Bielefeld Background on 911 Centers A Brief History most developed countries have an emergency call line that dispatches help Economics A public service Inside the 911 center o Some call centers both tasks are done separately by different people o Many call centers both tasks are done by people in close proximity and work in teams 0 ExCaerHe s got a gun and he39s comin back o 911 He39s got a gun If there is a crime in progress and a weapon is on the scene then the emergency caller repeats this so that the others listening in can become aware of the weapon Call takers have to take down certain information ex location type of problem and other supportive details Asymmetries between Callers and Ca Takers Many people will never have called 911 in their life but Ca takers will take many calls as it is theirjob Different levels of knowledge for the institution Callers may not have all of the necessary information that call takers need to move forward Problem may be directed at the caller or someone with the caller while the ca taker is not directly involved in the problem Overall Structure of Emergency Calls 1 Opening 2 Request Interrogative Series Response Closing U39Ilgtw Adjacency pair sequence when the first pair part is introduced it makes the next person accountable for response Basic Organization 1 Zimmerman 1984 214 1 911 Midcity Emergency 2 1 opening 0 3 Cir Um yeah 4 somebodyjust vandalized my car 2 Request 5 03 6 911 What39s your address 7 Cir three oh one six maple 8 911 Is this a house or an apartment 9 Cir It39s a house 3 Interrogative Series 10 911 Uh your last name 0 11 Clr Minsky 12 911 How do you spell it 13 Clr M I N S K Y 14 911 We39ll send someone out to see you 15 Clr Thank you 4Response 16 911 Umhm bye 17 Clr Bye 5 Closing Ca taker asks the questions Division of labor Call taker asks caller answers Caller makes the request and the call taker decides whether to grant or refuse that request which they do based off of the information they obtain Caer made a request does not get a granting of the request right away which must be because the ca taker must need more information that is relevant After of which the request can usually be granted Dispatcher Fire Department Caller Yes I39d like tuh have an ambulance at 4139 Haverford please Dispatcher Whats wrong Caller I don39t know I wouldn39t be calling you ifI did Questioning the dispatchers question showing he is distressed Dispatcher OK is this a house or n apartment Caller It39s a home Shows that he is emotional Same basic structure for the most part in a completely new institutional environment 2 Zimmerman 1984 216 1 CT Federated Airlines Reservations Joanne 1 2 C Hi 3 Could you tell me what your cheapest fare would be 2 4 from Portland to Washington DC 5 CT Mhm You39re travelling one way or round trip 6 C Round trip 7 CT And when are you planning on travelling 8 C Uh probably in the summer sometime 3 9 CT Okay So it would be after the fifteenth of June 29 you39d be leaving C Yes CT All right About how ong39r you planning on staying C Um two or three weeks CT Okay Okay I can tell you right away the lowest rate that we can offer um would be our Super Saver fare 4 You would have to make your reservation at least a week before you travel C Mhm CT Okay for the lowest fare you39d have to stay at least seven days and not more than fourteen days C Okay CT Kay An that39s going to be a round trip of three ninety nine C Kay an what is your cheapest fare one way 2 CT On a one way 3 C Yeah CT That would be three oh nine 4 C Okay Thank you very much 5 CT Uh huh bye bye Even in normal casual conversation parts of this basic structure are present when a request is made 3 Schegoff 1990 5657 1 B hhh 39n I was wondering if you39d let me borrow your gun Request 2 12 3 J My gun 4 B Yeah 5 10 6 J Mhat gun 7 Repair sequence omitted 8 J What I meant was Lhich gun 9 05 10 B tch hhh Qh 04 uhm 04 t hhh 05 11 D39j39have a really ong one 12 08 13 J A really ong one hhh 14 B Yeah 15 02 16 B 39t doesn39t matter what kind 17 10 18 J Why would you like a gtreay long one 19 repair sequence omitted 20 B I am doing a p a thing 03 hhh in drama 21 22 More talk about the play B39s part within it etc 23 24 B Yeah you can use 39t Response Everything in between the request and response is the interrogative series In this way institutions overlap with ordinary talk that involves a service request Institutional Service calls vs Conversational calls containing a service request Conversational calls often involve more than a service request institutional service calls are focused on the request In the casual conversation there is a lot of other talk within it Ex if you call a friend to ask a favor that request and dealing with it wont be the only thing that you will talk about You don39t want your friend to think that the only purpose for the call was for a favor You have to acknowledge the whole social relationship Conversational calls have built in opportunities for more unplanned chit chat At the opening How are you How are you At the closing OkOk 9 ByeBye o OkOk means that there is nothing left to say so it39s ok to end the call But one of the people have more to say then they wont say ok but will keep talking Thus conversational calls don39t have a standardized overall phase structure These differences index a social relationship more developed than service seekerservice provider Contrast Standardized phase structure embodies the participants continuous orientation to a singular overarching task securing help and impersonal roe based identities service seeker provider 0 In 911 call there is one task to enact and so the talk is limited The Opening Phase of 911 Call Constraints on Action First contrast to ordinary calls Openings in Ordinary Conversation 1 Summons answer sequence Ring Hello 6 responding to the summons 2 Identificationrecognition Can have voice sample recognition or sef identification 3 Greetings 4 How are you s 5 1 topicreason opening is the only standardized part of ordinary conversation 4 Schegoff 1986 115 1 ring Summons 2 R Hallo Answer 3 C Hello Jim Identification 4 R Yeah Recognition 5 C 39s Bonnie Caller self Identifies 6 R Hi Greetings 7 C Hi how are yuh Greeting How are yous 8 R Fine how39re you How are you 9 C Oh okay I guess 10 R Oh okay 11 C Uhm 02 what are you doing New Year39s Eve 1st topic reason for call 91 1 Emergency Calls 5 Midcity 21 Midnight100am 5a ring Summons Answer below 1 911 Midcity emergency Sef Identification 2 Cir Yes uhI need a paramedic please Recognition Reason for call Identification process involves these two parties aligning one another according to these institutional roles Caller is just someone who meant to call 911 and this is portrayed through the Yes 3 911 Where to Missing components Greetings howareyou39s 6 Midcity 21 Midnight 100am 37 1 911 Midcity emergency hh 2 Cir Uh it39s not an emergency I was just trying tuh reach the 3 police Caller is not sure whether they reached the right person so they did not say OK or YES Yes projects themselves as a person who intended to call 911 Call From Someone They Know 7 Whaen and Zimmerman 1987 177 1 911 County patch Answer 2 04 3 Clr Hi Greeting 4 10 5 911 Hi 02 How are jg Greeting How are you s 6 Cir hh Fine howya doin39 7 911 Fine Not standard for 911 call but more like an ordinary call After line 1 the conversation became casual and moved away from the institutional call So the absence of greetings and how are you s constructs the interaction as institutional Task focused rather than open ended Impersonal rather than sociable Anonymous occupational identities rather than sociable calls Requests for Help Special Patterns of Inference Requests can come in various forms Explicit Requests 0 I need a paramedic please Please send an ambulance to Descriptions of trouble 0 Somebody just vandalized my car In 911 this is always treated as a request for help Descriptions get filled in based on the context and who they are calling Ambient noise silence hanging up o In 911 calls this is heard as a virtual request for help Special process of inference that is distinctive to this kind of process Example 8 Whaen and Zimmerman 1987 179 II 1 911 Nine one one emergency 2 pause 3 911 HELLO Nine one one HELLO 4 gt What39s thuh problem 5 click Example 9 Whaen and Zimmerman 1987 179 1 911 Nine one one emergency 2 Loud voices in the background screaming and arguing 3 Cick 4 911 gt Oops Sounds like a domestic 5 Dispatcher calls phone number from which call originated 6 911 gt This is thuh Sheriff39s Department Is there a problem Example of unusual call 10 Zimmerman 1992a 40 1 911 8 9 Clr 10 911 11 Clr 12 911 Nine one one emergency 06 Yes I need a towing truck for one car away they did park in my parking space the whoe day and overnight 06 39n they won39t move 05 gt I39m I39m sorry Call taker can39t make sense of it in terms of an appropriate action They expected a more serious problem to report 12 Okay I need a towing truck 06 for towing gt You need a TOW TRUCK Yes Then call a tow company Concluding Remarks A fingerprint for 911 Calls Standardized phases organized around the singular task of securing help Reducedspecialized openings fitted to the identitites of 911 call taker and citizen caller Special inferential procedures try to understand the reason for calling in caller39s 1539 turn as a request for help Emergency Calls Gatekeeping and Entitlement 012214 Lecture Outline 1 Gatekeeping Why calling 911 is not like ordering a pizza 2 The Genuineness Issue Is there really a problem 3 The Relevance Issue Is it the responsibility of the service org 4 Wrap up CallTakers as Gatekeepers Not all requests for help are granted Requests should be justified by a real problem that warrants policefireparamedic help 1 2 request for help on lines 8 amp 9 If the caller calls into 911 and doesn39t specify why that help is needed then they are going to be asked a question like what s the problem Issue ofjustifying the request for help 3 Request and immediately the caller gives description 4 Just description of problem Caller must justify the reason for there call So calling 911 is not like ordering a pizza but why is this Public service provided through the tax system your not paying for it directly Critical and scarce resource 1 MCE 21 121 22 1 911 Midcity emergency 2 CLR Ye s uh if you gotta squad care could you send one 3 over to Wake Street and Lowen Avenue keyboard 4 911 Whatsa problem there 2 Zimmerman 1992 43637 1 CT Police Department 2 3 Cir Yes This is the Ambassador Hotel Em Ambassador Hotel 4 echo Hotel 5 Cir Do you hear me 6 7 CT Yeah I hear you 8 Cir Uh they have an emergencyThey want thuh police to thuh 9 kitchen right away 10 CT What kind of an emergency 11 Clr I don39t know honey They hung up I don39t know what39s happening 12 CT Well find out 13 We don39t send out without 14 Clr I beg your pardon 15 16 CT We have to know what we39re sending on 3 Zimmerman 1992 436 1 Cir Can you get somebody over here right away 2 We39ve got a gal that39s just ready to pass out 4 Zimmerman 1992 438 1 Cir Somebody jus39 vandalized mycar 2 03 3 911 What39s your address Genuineness Is there really a problem Training manual for 911 call center Citizens report all types of events to the police when they think that something illegal is going on Usually the event is innocent Callers who say I see a suspicious personcaretc should be questioned as to WHY they feel it is suspicious Reasons for faulty reports 0 they make a call knowing its false but because they want to cause trouble Ex wanting their neighbor to get arrested or they don39t like the police 0 People who always think that there39s something strange going on Calltakers look for signs that the problem is genuine esp how the caller knowsquot Ex 5 illustrates this process dramatically Routine questions ex what is your address Investigative questions trying to determine if the problem is genuine Routine problem questions get put on hold as the investigative questions get used Once the routine questions come back then the 911 ca taker believes the problem is genuine and can send help Caers have to indicate how they know there is a problem 5 Whaen and Zimmerman 1990 473 edited 1 911 2 Cir 3 911 4 Cir 5 911 6 Cir 7911 8 Cir 9911 10 Cir 11 911 12 Clr 13911 14 Cir 15 16911 17 18 19911 20 Cir 21 911 22 Cir 23 911 Midcity emergency Would you send thuh police to eleven six oh Arvin Avenue north Eleven six oh Irving Avenue north Yes there39s been raping goin39 on WHERE Eleven six oh Inside ur outside Inside thee house There39s somebody being RAPED Yup How do you know this I live next door Two ladies bein raped eleven six oh Di How do you know they39re BEing raped inside that house Because they was shoutin They was shoutin quotrapequot They was shoutin quothelpquot What is yur address Okay wull get some They were shoutin quotrapequot and quotfire helpquot Da you know are you sure they39re not just playing around No I I I know they39re cryin Okay wull get somebody there Thank you for calling Callers often indicate their relationship to the problem their stance from the start 6 0 Line 6 answers her motivation Physical Social 6 MCE 121 34 1 911 Midcity emergency 2 Cir hhh Yes would you send th39poice please to 3 thirty four twenty two Jones north hhh downstairs 4 911 Whatsa problem ma39am 5 Cir gt Uh Ijust went by there 6 gt and my son lives there an his wife an thuh famiy 7 Clr Uh huh 8 911 An39 uh there39s some kids throwin39 knives at their house Displaying stance communicates How caller knows there is a problem Callers motives for getting involved Ex 7 line 2 the caller shows that he has acceptable motives for being in that situation 7 Meehan 1989 127 1 911 Bigcity police three five seven 2 Cir gt Yeah this is just a good neighbor callin up and I39d 3 I39ll advise you to send a pa crowd car over here to 4 the Green Street playground in Subcity 05 to stop 5 these kids because I think they39re gonna have a big fight 6 over here Explicit displays of stance seen thus far I live next door Ijust went by there and my son lives there This is a good neighbor calling up Conveying stance implicitly 0 I d like to report Ex 8 9 10 o tend to be used when a caller is calling about a problem that is not their problem Ex its not their house that is being burglarized o Ex 10 a caller uses report format to report a break in but she is a little hesitant about how to formulate the request 0 it happened to the home she39s in but it39s not her home Complicated relationship why she was hesitant 0 We have aquot We39ve got a quot Ex 11 12 cf 13 14 0 occurs at business establishments 0 Problematic case 13 on handout I39ve got a quot Kind of institutionalkind of personal 9 confusion Call taker responds is this a house or business 0 Ex 14 They have an emergencyThey want the police to the kitchen right away She doesn39t really know what39s going on so using they have aquot distances herself from the institution 8 MCE 17 1112 20 1 911 Midcity p39ice an fire 2 05 3 Cir gt Yes I39d like to report an acciden39 08 igh augh 4 I was just walking up University Avenue an jus39 seen 5 two cars coide 9 MCE 21 121 24 1 911 Midcity emergenhy 2 Cir gt Yes I39d like to report a loud party 3 911 keyboard Where is it ma39am 4 Cir Forty eight twenty seven thirty fourth avenue south 5 911 Forty eight twenty seven thirty fourth avenue 6 southIs that a house or an apartment building 7 Cir A house 8 911 hh Okay And your address 9 Cir A neighbor 10 911 hhh We39ll send someone out 10 MCE 21 121 23 1 911 hh Midcity emergency 2 Cir h Yes um I would like to uh port uh 3 hhh a break in 4 911 To your home 5 Cir Yes Well we39re babysitting 11 Whaen and Zimmerman 1990 480 1 Cir This is thuh Maplegrove Care Home uh 2 gt we we39ve got a man here who we believe is having 3 a seizure er something 12 Whaen and Zimmerman 1990 481 911 Midcity emergency Clr Yes uh I need thuh paramedics please Clr gt We have an unconscious uh diabetic 28 911 Are they inside of a building Clr Yes they are 10 911 What building is it 11 Clr It39s thuh adult bookstore 1 2 3 4 5 911 What39s thuh problem 6 7 8 9 13 Midcity 21 CALL 29 1 911 Minneapolis emergency 2 Cir gt Yes sir I got a couple guys over here an man they 3 911 Clr Clr KOCIJlOU39B 10 11 12 13 14 15 Clr Clr 911 911 911 think they39re buncha wi se background noise 05 Are they in your house or is this a business hh They39re over here at Qgk Stop They mckin39 come over here an pulled up at thuh Quick Stop sammin39 their doors intuh my tick Quick Stop Yeah Okay uh were you a gtomer at that store Yeah What39s the address there the um 14 Zimmerman 1992 43637 CT no CT kO00lOU39IlgtUoIJI t CT 10 Clr Police Department Yes This is the Ambassador Hotel Em Ambassador Hotel echo Do you hear me Yeah I hear you Clrgt Uh they have an emergencyThey want thuh police to thuh kitchen right away What kind of an emergency I don39t know honey They hung up I don39t know what39s happening Elaborate displays of stance The narrative format See 15 on handout she thinks that her house has been burglarized but she is not certain so she starts her call with a story 9 she doesn39t have to label the problem o We noticed the door was open shows that she was certain that she locked the door before hand She doesn39t think that she39s overly paranoid or that she made a mistake Zimmerman notes when callers begin with a story they tend to do this when there is doubt from the caller They are uncertain if there is a genuine problem By telling a story it enables the caller to not actually label or name the problem Narrative Format Enables the caller to o Avoid namingcategorizing the problem o Display physicalsocial relationship including process of discovery o Self presentation as reliable observer 15 Zimmerman 1992 440 1 Clr hh Yeah hi uh this is Mary Cooper hh um my sister and I 2 left our house earlier tonight and we were certain we 3 locked thuh doors and hh when we came back hh oh about a 4 half hour ago oh twenty minutesago hh we noticed thuh 5 front door was open hhh an so we jus39 didn39 feel like uh 6 checkin39 aroun so I thought we39d call you Relevance Is it the Responsibility of the Service Organization Even if the problem is real it may not be a relevant problem for that service organization Reader Fire Department Calls marginal cases ex 16 calls for plumbing issue not related to fire 17 o apologies 16 Bergmann FD Clr FD kO00lOU39IlgtUoIJI t Clr ex 16 excuse me 0 accounts for calling ex 16 produces an elaborate explanation for why he is calling the fire department for a plumbing leak says he called plumber cant find owners and cant open door himself 0 Prior attempts to solve the problem 0 Diffusion of responsibility for calling Ex 16 blames plumber p 15 Fire department hh Yes this is Bessler market place Good morning 06 Excuse me could you open a door for us because of the following we had water dripping down that is it comes from the sun bathing studio hh and I don39t have a key for that and even privately I can39t reach them mhm Now I called the plumber and he will come in a minute but he said h hh he39d prefer if y uh 3 would open the door 17 Bergmann 1 FD 2 Clr 3 4 FD 5 Clr 6 FD 7 Clr 8 9 10 Fire department Yes good morning my name is Kelcher 05 the following matter this morning I drove past Mainsteig I am nearby Mhm hh and I saw h that two swans were tormenting a third one wel and at first I thought maybe they were mating in spring evidently you think of something like that hh but that was not the case obviously violated their territory hh and h thus I had the impression they were really going to kill it hhh and 11 12 13 14 FD 15 Clr 16 17 it always had one of these swans always tried to push the weaker one underneath the water and the weaker one just couldn39t get away mhm could only escape to the shore hh Now I called the vet and he suggested that I call the fire department they could help in cases like that 911 Emergency Calls marginal case ex 1822 Expressions of concernfear as justifications Ex 18 caller hears emergency but he39s not quite sure but when he hears police then he feels the right to move forward 0 Emergency conveys urgency and so some people may not feel justified to make the call Ex 19 from the beginning the caller gives a disclaimer there39s conflict that may result in a bar fight Caller gives description cautiously 0 Uses word afraid shows fear Callers do this to justify them calling 911 when a problem hasn39t occurred yet but it might Ex 20 I m afraid that someone is really going to get hurt expression of concern 18 MCE 21 midnight 37 1 2 3 4 5 6 911 Clr 911 Clr Midcity emergency hh gt Uh it39s not an emergency I was just trying tuh reach the police hh This is police Okay There seems to be some sort of argument or potential fight uh about to happen in the alley 19 MCE 21 midnight 16 Clr Clr Clr kO00lOU39IlgtUoIJI t 911 911 911 Midcity emergency Uh yeah hi This is uh hh thuh Vaey b Mmhm An d hh I39m thuh manager here tonight an mmhm hh there39s not reay any tgble going on except that I39ve asked a few people tuh eave they aren39t dink they39re just belligerent gt I don39t really wanna have any trouble with39em but gt I39m afraid if they don39t go I wm have trouble with them 20Meehanp128 CT Clr CT Clr 00lOU39IlgtwIJI t Bigcity Police three oh eight Yeah at the corner of uh Walton Way and Beaumont Street there39s a kid there Harry O39Donnell in fact there39s a whole group of kids but this one kid in particular has got a gun He39s gotta gun Yeah and they39re startin39 a fight up there and gt I39m afraid that someone39s really gonna get hurt Requests are mitigated shows low entitlement I was just wondering Ex 21 I was just wonderingShe s an old lady over 80 justification Ex 22 I was just wonderingocked keys inside my car 0 Use I was just wondering when we don39t really feel that we are entitled to ask bc the problem isn39t very urgent or an emergency 21 Sharrock and Turner 176 1 CT Newton Police 2 Cir Eh my neighbor ah up the street ah thirty o ne 10 3 forty five has locked herself out 4 gt I was jus39 wonderin39 if you could send a man up to 5 help her to get in she39s an old lady over eighty 22 Midcity 17 11 midnight Call 2 1 CT Midcity p39ice an fire 2 02 3 Cir gt hhh Hello I39m wondering if you could send somebody 4 to open up my car door cz my keys are locked inside WrapUp Genuine amp Relevance Call takers will demand that callers display the genuine and relevance of the problem Callers by stance indicate that there problems are real Problematic 911 Cals DocPat opening 51714 1104 PM Problematic Emergency Calls Why study problematic calls Practical Payoffs Management of Emotions there has to be a priority for getting the issue addressed so that help can be sent Illuminate routine 911 calls Hystericaquot Callers the caller is so effected by the situation that they are unable to participate efficiently because they are distressed ex 1 Whalen and Zimmerman How do Callers Display Emotions Verbalizations exclamations pleading remarks o Ex 1 God oh my God exclamations o Pleading remarks please send help line 4 0 Ex 2 line 2 and 10 exclamations Paralinguistic behaviors gasping sobbing screaming o Ex 1 SHE JUS SHOT HERSELF howlingshrieking o GOD MY WIF JUST SHOT HERSELF howling voice o Paralanguage behaviors can coincide with the informational content and may compete with it so that the caller is difficult to understand Sequential placement of these where do these displays occur within the unfolding structure of the call 0 Ex 2 line 910 answer then exclamationpleading remarks o The caller puts a priority on answering the question and the display of emotion is second place The caller presents themselves as relatively attentive to the interaction o The different placements portray different levels of emotion o Line 2 oh my god gunshot caller is more taken by the emotion that they are experiencing in the moment Outward display of emotion vs Inner experience of emotion ex2 lines 910 the caller can without their inner emotions to respond to the call taker people to work to shape their displays of emotion to the interaction Emotion displays reflect Internal psychological states External interactional demands how callers balance these two influence how they are perceived in control vs unable to control their emotions How do Ca takers Realiqn Callers to the task at hand Summing the caller 0 Sir Ma am stressed rising intonation disjoined from subsequent talk 0 Ex 3 L21 Sir Sir We re we re getting Urging calm o Ex 3 L19 Please stop shouting sir Reassuring that help is on the way 0 Ex 3 L21 22 we39re gettin an ambulance there 0 Zimmerman reassurance does not happen very often bc they want to keep the caller on the line Ex 5 amp 6 people hang up once they know that help is coming o If you are going to issue a reassurance you have to immediately ask the next question or ask them to stay on the line there is not much sympathy from 911 call takers 9 taking control of the call Call takers keep records of improperly handled calls for training new hires Implications Emotions as Socially Organized Displays of emotion sensitive to the demands of the interaction We express emotions depending on the social situation Labeling of Emotion sensitive to frameworks of accountability 0 Ex Caller is Hysterical tells how in control the caller is of their emotions 0 Call takers may use Hysterical when there is missing information in other areas of report call takers way of being accountable for why other areas were blank Angryquot Callers Anqry versus Hysterical callers Emotion anger emerges over the course of the call Callers perceived as unwilling not unable to participate o The questions asked make some people angry o Ex 7 L15 impatience with the questions being asked Ex Dallas Call excerpt 8 call turned into an argument and an ambulance was never sent 9 woman died Ex 910 Opened with a request and the call taker responded with Whats the problem sir The caller responds I don39t know and ifI knew I wouldn39t be calling you all 6 challenges the relevance of this question angry What went wrong Misunderstanding may think they want a medical diagnosis of the problem Frame mismatch clash between different understandings of the 911 call itself This caller takes position that he shouldn39t have to justify his request 0 Common Request forms 1 questions ex could you send x 2 statements of need I need an ambulancepolice Both recognize that help is not available on demand 0 Ex 9 I d like tuh have an ambulance at forty one thirty nine Haverford please entited expects the ambulance to come Doubt Ex 131415 0 Ex 13 nurse asks to speak with the person who has the medical problem 6 evidence of doubt When the nurse asks investigative questions she gets blocked by the caller I don39t know what the problem is The Runaround asking investigative questions after asking routine questions even when investigative questions are asked at the beginning Activity Contamination Ex 1617 0 Argument activity contamination Argument sequence of action and counteraction which oppose each other 0 Ex 16 She is having difficulty in breathing She seems like she39s incoherent Well this is a life threatening emergency She39s dying She can39t breathe Sh having difficulty in breathing things said over the course of the convo 0 Ex 17 What if it was your mother in there and can39t breathe What would you do contributions to an argument 0 Once an argument starts it takes work to get back to the focus Final Thoughts The Emergency Call As an Achievement Phase 1 Opening Phase 2 Request Phase 3 Interrogative Series Phase 4 Response Phase 5 Closing 012913 Week 4 Wednesday lecture 12914 Doctorpatient Interaction The first 22 seconds Regular doctor visits emergency room therapy sessions etc every single one of these areas involves people communicating with one another performing tasks through language Primary care is the single most largest medical experience that we have Average time that medical doctor spends with a patient is quite small We will focus on the legitimacy of medical visits how patients justify the reasons for their visits We will also focus on medical authority of the medical doctor how is this authority implemented in there interactions Types of Medical Visits 1 Acute care visits for new problems 2quot Follow up visits for current treatment of an existing problem 3 Routine visits for chronic problems like diabetes or hypertension etc 4 Well visits check upsannual visits Each of these visits have different and distinct structures Acute medical visits 6 phase structure Opening Presenting complaint problem presentation phase Examination history taking or Hx made up of verbal history and the physical examination Diagnosis or Dx Treatmentcounseling Rx Closing Phase 2 Problem presentation significance of problem presentation it is an important source of information where patient may give information that doctor might not have asked about environment for patient to express theories about problem doctors believe this problem presentation gives patient environment where they may express their fears connected to illness probem presentation gives piece of mind to patients knowing that they have been heard by the doctor Beckman and Frankel discovered that problem presentation is short average length is 18 seconds they found that if doctor says anything in response besides Mhmm or Okay then the patient will derail or shut up in terms of the problem presentation Why is problem presentation so short Doctors are short of time Doctors believe that first few sentences patient say are the most important or main problem like a newspaper headline Doctors may just be trained to get to the point Bottom line Doctors deliberately interrupt patients or cut them short doctor is interrupting the patient if the patients problem presentation is completed patient never gets to the point where they say can you help me or that s why I39m here today how big of a problem are patient problem presentationsinterruptions A repeat of the Beckman and Frankel study found that physicians are interrupted after 321 seconds if they were allowed to complete statements patients used on average 6 seconds more study made by medical doctors An alternative assumption problem presentation involves a process of collaboration between doctor and patient both actively involved in building that piece of interaction together doctor s problem figuring out when the patient is done patient s problem justifying the medical visit can treat it as justified when doctor initiates history taking by asking questions doctor acknowledges there is a problem The Doctors Problem doctor has to ask even after the patient finished hisher first sentence ask themselves and figure out if the patient is done presenting the problem example of patient who had foot problem doctor assumes that patient was done after first sentence but patient was not derailed by it and continues giving explanation Beginning the problem presentation 1 One liners example 2 on handout can be seen as patient wanting shots 2 Preface Detailing 3 Narrative One liners often done as ONE liners are summative have period intonation has specificity doctors more likely to come in quickly Prefaces hearably prefatory Well prefaced indicating to be longer than one sentence headlines loose granularity too general to be heard as the complaint itself doctor generally holds off to interrupt Narratives Well prefaced indicated more than one sentence usually start at a point in the past usage of past tense describes a series of events that wind up in the present doctor also likely to hold off Ending the problem presentation Think of Verizon Wireless commercial can you hear me now as an analogy Transfer of speakership need be done seemlessly initiative being passed from patient to doctor Doctor39s solution use acknowledgement tokens to respond to the patient three levels of acknowledgement continuers Mm hm uh huh shift implicatives indicates person is ready to move on to something else like okay or aright with comma intonation or period intonation like a doctor being done with hearing what patient has to say Ending the problem presentation doctors intervene after patients have described one or more symptoms example 7 and 8 on handout patients have resources to do ending the problem presentation example 10 and 11 Patients can manipulate doctors by providing symptoms or not if you don39t get doctor to intervene after describing problem patients are in the zone where they are done with the problem presentation patient can re summarize example 10 speculate about diagnosis or treatment example 11 and may ask for help explicitly Conclusion problem presentation is a co construction length of presentation negotiated by doctor doctorspatients may drop the baton patient may give clue for how long presentation will be see PowerPoint for additional comments Medical Visit 51714 1104 PM IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IlIIIUIUIlIIIIIUIlIUIIIUIIIIIIIUIIIIIIIUIIIIIIIU Week 5 Monday lecture 2314 Talk and Social Inst DoctorPatient Interaction Recap Doctors are interrupting patients and it is the reason why problem presentations are so short Problem presentation is a cooperation between doctor and patient Doctor39s problem is knowing when to interrupt Patient can control the length of their presentation Whenever you get into the present tense doctors understand that it is the time to move in The patient39s problem justifying the medical visit Must give some kind of good reason to be there When doctor starts history taking it means that the doctor is ratifying the visit The Sick Role Concept that originated with Talcott Parson39s when you become sick your entry into a sick person has to be ratify by other people and gives you access to rights of a sick person Rights entitlement to some exemption depending on how ill the person is from normal duties I feel sick to my stomach I think I39m going to skip cass free from personal responsibilities and personal responsibilities for getting better when one enters the sick world we don39t say It s all your fault or we don39t expect a person to get better right away through act of will Obligations for being sick one must view being sick as undesirable Person must strive to get better They should also not try to take advantage Patient should seek competent help and co op in the treatment process Reasons for inappropriately entering the sick role Patient wants to get off work or midterm known as maingering Patient wants to be the focus of care and attention from family and friends according to Parson39s these are secondary gains Patient wants to be focus and attention from medical profession Baron Munchausen s syndrome Patients that go to the doctor all the time or patient is over anxious or the worries well hypochondriac When we go to see the doctor we will work to show that we are not entering the sick role for the wrong reasons justification The Patients Problem Justifying the Doctor39s Visit Achieving doctorability For patients a doctorable problem is one that is worthy of medical attention of evaluation as a potentially significant medical condition and worthy of advice or treatment when necessary Example of patient who discovered a bump or mole in the back of her neck 1 on the handout after having one removed Orientation to legitimacy by the patient Line one she is undermining her own reason for being there might be undermining doctorability Problem is presenting problem as a narrative doubting if they have a problem or if it39s a kind of problem doctor or 911 emergency should deal with Patient also invokes 3rd party husband is made to be the reason for the reason Something weird or leads to diffusion of responsibility Patient fighting by overlapping the doctors questions to downgrade the problem Injects of breathy laugh particles at places where she talks about deciding to visit this kind of move is used when a person is not doing what they were supposed to do or doing something wrong In this same example patient agrees with no problem evaluation she also re invokes her husband 3rd party as telling the doctors that she told him it wasn39t anything patient uses breathy particles again when describing her decision to make the appointment at the end doctor validates her decision to come Patient orients to legitimate the doctor visit once again Is the issue of legitimacy always a problem Unconditional Legitimacy where doctorability is not a problem Medical problems vary examples 2 and 3 I ve gotten bitten by a dog treat their situation as giving them a right to walk into the doctors office without explaining Patient s attitudes to medical problems vary example 4 Conditional Legitimacy where doctorability may have to be worked 1 Patient downgrades seriousness example 5 patient wouldn39t normally go into the doctor with just a cold Doctor validates decision to make the visit example 7 patient didn39t go to the doctor right away but waited for it to get worse and doctor validates by saying she39s a tough cookie and doctor validates her reason as being good enough to be there Different presentation problems different problem presentations Three cases o Routine problems colds a cough fever etc o Recurrent problems specific problems patient has had before like cancer o Newunknown problems Patient just doesn39t know what39s going on and if what they have is a problem or not Dealing with doctorability Routine problems Patient downgrades seriousness but finds some special reason for the visit example 9 patient says that they waited a while before coming in troubles resistance examples 10 and 11 Past experience claims just aches and sore throat but patient has more reasons based on the past treat me now before I get worse example 12 Dealing with doctorability Recurrent problems Patient thinks they have a recurrent problem state that they have had something before and think they have it again this is a risky route to take because it is the doctors job to determine diagnosis Patients sef diagnose sef diagnosis are dispreferred sef diagnosis is often indirect example 1314 still indicating a recurrence of something they have had more direct self diagnosis is previous condition was serious example 15 and 16 patient feels something coming on but is flat wrong Dealing with doctorability New problems Descriptions of uncertain symptoms lead to subjectivized accounts of pain and discomfort example 17 patient at a bind of how to describe the scope of the symptoms feelings of pain are used to further justify visit Descriptions diffuse responsibility by invoking 3rd parties as reasons for the visit example 18 Descriptions are often narrativized example 19 Narratives often contain troubles resistant elements patient reported how long they39ve waited to come in to doctor and all the steps that he took to resist the problem and treat it on his own attempt at sef medication or waited example 19 20 and 21 Troubles resistance narratives contain turning points Why would the person wait so long to come into the doctor39s Patient must have an explanation for this Usually patient and condition have a turning point example 19 20 21 patient doesn39t understand what the problem is and goes through the above stepsphases before reaching her turning point Acute problem presentations conclusions are co constructions doctor negotiates length of presentation patients may prefer brief presentation to get their visit as validated validation occurs when Hx questions are taken problem presentation varies with type of illness and strategies to legitimize vary with type of illness IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IlIIIUIUIlIIIIIUIlIUIIIUIIIIIIIUIIIIIIIUIIIIIIIU Week 5 Wednesday lecture 2514 Communication in Medical Care Question Design We are moving into history taking and question design in medicine When doctors ask us questions they want good accurate responses in order to be able to give proper treatment We don39t see survey questioning from doctors Why is questioning in medical care not like a social survey Because we communicate information to individuals and expect that back Doctors questions are not meant to communicate beliefs or assumptions about a person Essentially anonymous interactions between doctor and patient asked like so in example 1 on handout doctor had two tries at asking about relationship status doctors questions are conveying his beliefs about the patient Four features of question design 1 Questions set agendas to be responded to Topic agendas o What is the topic Action agendas o What response does it solicit 2 Patients responses conform or not to those agendas see example 2 2 Pt conforms with action and topic agenda 1 DOC Tkhh hIs your father alive 2 PAT hh No 3 DOC How old was he when he died 4 PAT hh hhohh sixty three I thinkhh 5 DOC What did he die frgmhh 6 05 7 PAT He haduhm He had high blood pressure 8 9 PAT And he ad uh heart attack 10 40 11 DOC Is your mother alive Example 3 doctor sets action agenda for a yes or no answer but patient instead of answering question in the beginning answers at the end of her answer more cautious and in control 3 Deferred conformity with action agenda 1 DOC Do you have any drug aergies 2 07 3 PAT hh huNot that I know of no Example 4 before she responded to the agenda of the question she inserts a sneaky remark about her working life taking over Same patient for example 5 patient is answering another different where question to get a story launched about how her mother put off visiting the doctor doctor registering that a narrative will be launched by saying mhmm 4 Deferred conformity with action agenda 1 DOC How long have you had that 2 08 3 PAT hhhuhhh How long has it had mehhltNg it 4 DOC Yeah 5 PAT We had it aba We built thuh building about 6 ten years ago I think 7 DOC Mm Example 6 quotbad footquot patient has not met the topic or action agenda she is going to get out her theory about how she got the problem eventually answers where it is hurting her now and re launches into narrative again known as deferred conformity in examples 5 and 6 5 Pt 39conforms39 with action agenda but not topic Conforms at 1415 1 DOC Is your mother alive 2 PAT No 3 10 4 PAT No she died in her like late fifties or 5 I39m not sure 6 7 DOC gt Where was her cancer 8 PAT 9 PAT gt hhh Well she lived in Arizona an she 10 wouldn39t go tuh doctor much She only went 11 to uh chiropracter hu 12 DOC Mm hm 13 PAT gt And she had t 14 gt like in her stomach somewhere I guess but 15 thuh even that guy had told her tuh go into 16 uh medical doctor 17 DOC Mm hm 18 PAT hhh An she had Years before her m uh 19 hh mother in law had died from waitin too 20 or Lmtever ya know on in surgery hh an 6 Bad Foot Deferred conformity 1 DOC Whatcha up toh 2 02 3 PAT I39ve gotta bad foot that I can39t get well 4 02 5 DOC gt Which part 6 PAT gtOkaylt About five weeks ago I went to Disneyland 7 and I wore uh pair of sandals that weren39t very 8 supportive 9 10 PAT hh And after that I started tuh have trouble 11 12 PAT gt It hurts in here 13 14 DOC Mm hm 15 08 16 PAT Now sit s uh lot better than it was because I39ve 17 been wearing an ace bandage 0 further examples of deferred conformity are 7 and 8 in 7 there are two questions about breasts and breast feeding and the first question is accepted and answers the topicaction agenda second answer does not conform exactly to the topicaction agendas as this mother inserts what the doctor exactly the doctor is asking about 2 Presupposition questions embody presuppositions example 9 3 assumptions to the questions and knocks out as she answers that she cannot have a baby example 10 patient had operation to not have a baby example 9 is more presupposing than example 10 patients39 responses confirm or not those presuppositions 9 Cassell 1985b101 1 DOC What kind of contraception do you use 2 PAT None since my menopause 10 1 DOC Are you using any contraception Is that 2 necessary for you 3 PAT Huh uh not now 4 DOC Okay Interrogatives grammatical term Questions an action term as it is requesting information interrogative don39t always question and some non interrogative s do ques on 3 Epistemic Gradient each example is performing the action of questioning depending on degree of knowingness example 11 question is fully interrogative and doctor doesn39t know about the baby or not deep epistemic gradient 11 DEC 1205 1 Doc 1 gt Right Did you have any problems 2 with your baby 3 4 Pat No 5 Doc 2 gt Dih delivery was alright was it 6 Pat Right 7 Doc 3 gt Didn39t have any operations 39 8 Pat No 9 Doc Right it doesn39t sound anything toom too serious Wed 020514 Medicine 3 Data Handout Communication in Medical Care Question Design when asking questions we communicate assumptions Introduction Why questioning a patient is not like a social survey 0 Bc don39t want to be bias Essentially anonymous interactions 0 Communicating that you don39t have any beliefs about them all that you want is the information Doctors questions give patients information 1 Pt conforms with action and topic agenda 1 DOC Are you married 2 3 PAT No 4 5 DOC You39re divorced currenty 6 PAT Mm hm 7 22 8 DOC Tl You smgke h 9 PAT Hm mm This question is designed for a yes answer Doctor has communicated a belief that this patient is likelyshould be married He takes a chance because she has a 28 year old daughter so he makes that assumption Doctors questions convey information about his belief about the patient Four Features of Question Design 1 Agenda Setting 1 Questions set agendas 0 Topic agendas Ex1 LN1 Doc Sets her marital status 0 Action Agendas 2 Patients 0 EX2 o EX3 Answer yes or no Ex1 LN3 patient disagrees responses conform or not to those agendas 3 Deferred conformity with action agenda 1 DOC Do you have any drug aergies Setting action agenda 2 07 3 PAT hh huNot that I know of no Patient deferred conforming to the action agenda by saying No at the end She doesn39t know that she39s not allergic to everything More cautious than just saying Not that I know of and she has more control by adding no at end 4 Deferred conformity with action agenda 1 DOC How long have you had that 2 08 3 PAT hhhuhhh How long has it had mehhltNg it Before she responded to agenda of question she makes a joke indicates that life isn39t so great for her 4 DOC Yeah 5 PAT We had it aba We built thuh building about 6 ten years ago I think 7 DOC Mm 0 Ex 5 5 Pt conforms with action agenda but not topic Conforms at 1415 DOC Is your mother alive PAT Non 10 PAT No she died in her like late fifties or I39m not sure DOC gt Where was her cancer PAT PAT gt hhh Well she lived in Arizona an she wouldn39t go tuh doctor much She only went 11 to uh chiropracter hu She uses the word where to expand on a story without answering the question shows her mom waited too long to go to I I t okO00lOU39IlgtUuIJI t doc 12 DOC Mm hm doc expects answer to question 13 PAT gt And she had t 14 gt like in her stomach somewhere I guess but 15 thuh even that guy had told her tuh go into 16 uh medical doctor 17 DOC Mm hm 18 PAT hhh An she had Years before her m uh 19 hh mother in law had died from waitin too 20 or whatever ya know on in surgery hh I an o EX6 6 Bad Foot Deferred conformity 1 DOC Whatcha up toh 02 3 PAT I39ve gotta bad foot that I can39t get well 4 02 5 DOC gt Which part 6 PAT gtOkaylt About five weeks ago I went to Disneyland 7 and I wore uh pair of sandals that weren39t very 8 supportive 9 10 PAT hh And after that I started tuh have trouble 11 12 PAT gt It hurts in here 13 14 DOC Mm hm 15 08 16 PAT Now sit s uh lot better than it was because I39ve 17 been wearing an ace bandage 2 She sees an opportunity in the question so start with a story and then answer the question 2 deferred conformity of the topic agenda 0 EX78 7 HV 5A1 HV Health Visit 1 HV How about your breasts have they settled 2 down now Implies that there could have been some period of not settled down 3 M Yeah they ave now yeah She responds to the topic and action agenda immediatly 8 HV 1c1 1 HV Are your breasts alright Does not acknowledge any previous problems 2 07 3 M They39re fine now I39ve stopped leaking so Uses the answer to inject what the problem was and uses a question that does not conform to the topic and action agenda your question doesn39t fit to my circumstances 2 Presupposition 1 Questions embody presuppositions 2 Patients responses confirm or not those presuppositions Ex 9 9 Cassell 1985b101 1 DOC What kind of contraception do you use 2 PAT None since my menopause Doctor assumes that patient is on contraception is sexually active she doesn39t want a baby she is heterosexual and is able to have a baby 6 not cautious More presupposing than Ex 10 Patient says she can39t have a baby anymore Ex 10 10 1 DOC Are you using any contraception Is that 2 necessary for you 3 PAT Huh uh not now 4 DOC Okay Doctor more cautious about patients situation Epistemic Gradient Background Point 1 Questions and Interrogatives 1 Interrogative is a grammatical term and describes the grammatical form of a sentence or other turn constructional unit tcu 2 Question is an action term and describes a particular type of action requesting information that a sentence can do 3 Interrogatives don39t always question and some non interrogatives do quesHonZ 4 In particular questions can be done as declarative sentences as well as interrogative ones 3 Epistemic Gradient 1 Questions are designed to convey degrees of a K position Greatest gradient least knowledgeable Has he had a fever He hasn39t had a fever has he He39s not had a fever Least gradient most knowledgeable most fat 11 DEC 1205 1 Doc 1 gt Right Did you have any problems 2 with your baby Interrogative deep epistemic gradient 3 4 Pat No 5 Doc 2 gt Dih delivery was alright was it Statement plus tag question flat epistemic gradient 6 Pat Right 7 Doc 3 gt Didn39t have any operations quotfull declarative question epistemic gradient even flatter doctor more sure that there weren39t problems 8 Pat No 9 Doc Right it doesn39t sound anything toom too serious 12 DEC 1112 1 Cir And it39s d it39s bringin39 up its mik 2 Cir Its face is comin39 out all in spotsI wondered 3 if it w39jus be the heat or 4 Cir I39ve tried givin39 39im water but 39e spits that out 5 Doc Is 39eHow long as this been going on for then epistemic gradient 6 Cir U h we basically since dinner itha39 39e39s actually bringin39 7 the milk up 8 Cir You know it39s sort39us comin39 up all the while at the minute 9 Doc gt Is it Whatw it39s just milk coming up no 39hhh no blood or 10 anyt39ing green or anything 39 Declaratively framed question to recomfirm that the caller has not said anything that would signal sickness 11 Clr No reasonably sure about something and he just reconfirms it with the caller 4 Preference 1 Questions are designed for anticipate expect or prefer particular answers Yes no questions 2 Patients respond or align with those questions Methods for Building Preference Grammatically Yes Preferring 1 Straight interrogative questions eg Are you married 2 Statement negative tag eg your married aren39t you inviting yes 3 Declarative questions Your divorced currently 4 Negative interrogatives eg Aren t you married some positively polarized Grammatically NoPreferring 1 Negative Statement Positive tag your not married are you 2 Negative Declaratives your not married 3 Straight interrogatives with negative polarity items Have you ever had children Do you have any children Negative polarity items include words like any ever at all etc Are there someany other concerns you want to deal with today Patients has more than one medical concern Yes Some 90 Any 53 No some 10 Any 47 Background Point 2 Grammatical vs Social Preferences A questions can be designed to reinforce a personal or social preference or to cut against it 1 Reinforcing A doesn39t want to have to pay for prescription medication Do you have some samples wants yes answer and designed for yes 2 Cross Cutting A doesn39t want to have to pay for prescription medication You don39t have any samples do you framing question is for no answer but desire is for a yes answer contradicts one another 3 In each of these cases the objectivesocial preference of the question is for yes but the grammatical preference is yes in the first case but No in the second 4 Cross cutting cases can also involve positively framed questions in search of negative answers Do you want that last piece of cake Grammatical structure can reinforce or cross cut the objectives or the social preferences indexed by a question 13 1 DOC gt Are your bowel movements normal Straight interrogative reinforcing preferences want normal bowel movements 2 40 patient nods 3 PAT Yeah 4 70 5 DOC Tlk Any ulcers Looking for No answer bc any reinforcing preferences bc don39t want ulcers and question supports no answer Positive optimization 6 05 patient shakes head 7 PAT Mh no 8 25 9 DOC gt Tl You have your gall bladder Declarative question preference for gall bladder design of question yes preferring reinforcing preferences 14 1 DOC gt Tlk You don39t have thma do you Reinforcing preferences 2 3 PAT H mm 4 11 5 DOC gt hhh hh Any chest type pain Reinforcing preferences 6 PAT Mm mm 7 34 8 DOC Shortness of breath Reinforcing 9 10 10 PAT Some but that39s cuz I should lose weight I know that Complicated delayed answer to a yes preferring question 11 I thin39ltNot much Two Principles of Medical Questioning Optimization optimizing a question means designing it for a favorable social or health outcome Is your father alive Doctors always use this version positive optimization Is your father dead Grammer of question is inviting a yes answer to something that people don39t want to say yes too 9 doctors don39t ask this question unless they think they know Is your father alive or dead Makes the doctor appear cold and unconcerned seems like survey question treats life and death like they are equal Optimized cases 13141617 Optimization is departed form when the patient s circumstances make it inappropriate eg 18 16 4A117 1 HV gt Uhm hh So your pregnancy was perfectly 2 gt normal Positively optimized question geared towards yes outcome want normal pregnancy Declarative question flat epistemic gradient So inference 3 M Yeh 4 HV gt And did you go into labour all by yourself Positively optimized people don39t want to be induced prefer natural methods 5 M No I was started off because uhm 08 the blood 6 HV Induced 7 M pressure 07 went up in the last couple of weeks 8 9 Segment dealing with why mother was induced 10 l 11 HV gt And was he alright when he was born Positively optimized reinforcing preference 12 F Mm 13 M Yeah 14 HV gt He came down head first Positively optimized reinforcing preference 15 F Mm hm 16 HV gt Norm norma deiveryDecarative reinforcing optimized 17 M Yeh 18 22 19 HV gt And did he stay with you all the time optimized 20 gt He didn39t go to special care baby unit Reinforcing optimized 21 M No 18 1C125 1 HV gt Qidju have a normal pregnancy 2 M Yes a very good pregnancyI carried her we 3 12 4 HV And uh 15 how long were you in labour for then 5 10 6 M Uhm thirteen to fourteen hours 7 10 8 HV W39 that39s pretty average actually for a first 9 baby 10 12 11 HV And didju 06 push her out yourself or did 12 you have to have forceps then 13 M Pushed her out mesef 14 42 15 HV gt And she 05 cried straight aw y Declarative question 16 05 17 HV gt Did she Moved from declarative form and pushes interrogative bc she is less certain that baby cried right away bc mom paused 18 M Ng 19 M She didn39t no it took er 03 coupe v minutes 20 actu y 21 HV Yeh 22 M They had to give er uh she come out blue 23 04 they gave her oxygen 1 think it was a 24 Linute before she cried 25 HV Yeah 26 06 27 HV gt But she didn39t have to go to special care 28 unit or anything 29 M No no Recipient Design involves tailoring a question or other action to the circumstances of a particular recipient The two principles optimization and recipient design are sometimes in tension Ex 192021 19 1 DOC gt Tlk Do you exercise at all Negative polarity going for no answer Cross cutting preferences Exercise is good but patient gained weight since previous visit so doctor doesn39t think its likely that she exercizes Doctor tilts question to fit particular circumstances she doesn39t have time to exercise and she gained weight 2 25 guilty silence 3 PAT No uh huh huh huh hhhh huh huh hh huh huh 4 DOC Hm Not your thing 5 ah 6 PAT gt hh Woud you believe me ifI saihd yhehs Doctor pitched question exactly to the circumstances question fits situation Conflict 20 1A114 1 HV So you had a uh She is stalling on the word norma and stops before saying it Bc five minutes before husbandwife described complications of labor baby stuck in birth canal It would be unfitted to use normal 2 10 3 gt You didn39t Did you You didn39t have forceps you had a re states question with new direction Optimized going from no answer Cannot find a way to frame this question II 4 M Oh no nothing 5 F 6 HV An and did she cry straight away 7 M Yes she did didn39t she 8 F Mm hm 9 10 Wood cracking 10 HV Uhm you didn39t go to scboo you know the 11 specia care unit 12 M Oh no no Pay offs from studying question design 1 Analyzing how patients understand physician questions 22 2 Seeing reversals in specific areas 23 in lifestyle questions 3 Seeing where optimization can become a problem 24 22 This girl presents with ear pain 1 DOC gt Which ear s hurting or are both of them hurting 02 GIR Thuh left one DOC Okay This one looks pgfect hh MO Uh DOC And thuh right one also ooks 02 even more perfect OU39lgtUd 8 GI 9 10 11 12 13 14 15 16 17 18 19 DOC gt Does it hurt when I move your ears like that Yes design gt 05 GIR gt No DOC No DOC gt hh Do they hurt right now gt 20 GIR gt Not right now but they were hurting this morning DOC They were hurting this morning 02 DOC Mkay MOM gt You ve had uh sore throat pain Mom justifies visit by coming up with another problem 20 21 22 23 24 25 26 MOM Yes DOC Let39s check your throat lthhIuhm there s I don39t really see uh lotta fluid build up Sometimes you MOM Yeah DOC see that ya know MOM Uh huh DOC But I don39t see it right ngw 23 MidWest 346 1 OU39lgtUd 8 DOC Are you married No You39re divorced currenty Mm hm PAT DOC PAT 22 DOC gt tch D39you smgke h Yes polarity so non optimized so most likely to get truthful answer 9 10 11 PAT Hm mm 50 DOC Alcohol use 12 13 14 15 16 17 18 19 20 21 22 23 PAT DOC PAT DOC PAT DOC PAT 10 Hm moderate I39d say 02 Can you define that hhhehh aughing outbreath Uh huh hah hh I don39t get off my 02 outa thuh restaurant very much but awh gt Daily do you use alcohol orh Pardon gt Daily or Oh huh uh hh No uhm 30 probably I usually go out like once uh week Conclusion 1 Back to Ex 1 how conforming was the patient s answer a Are you married No conforms to the idea that you have to respond with yes or no 2 Literal questions vs inferred purposes a A yes No question is only literal if the answer is yes but is inferred if the answer is no Acute Medical Visits 51714 1104 PM Steps in acute medical visit Opening Problem Presentation Exam history and physical Diagnosis Treatment closing Talcot Parsons people take on the sick roe Certain rights and obligations associated with it Free from responsibility of your normal tasks 0 Free from responsibility for being sick in the first place Obligation o to want to get better 0 to not malinger o to not take advantage of being sick the benefits of coming with it ex can39t skip school all the time 0 To seek help doctor I m sick so I don39t have to come to work etc But I do have to try to get better Problem Presentation Doctors problem when to step in and start asking questions when can I start talking Patients Problem Presentations 1 One liners I broke my leg 2 Preface plus detailing one statement to start off but that person needs to say more to understand ex my breathings shocking doctor waits for her to expand well I was fluffing piows 3Narrative long story describing symptoms When does the doctor know that the patient is wrapping up When they use present tense to start talking about current symptoms Patient39s problem justifying their visit Why they are there is meaningful To justify their visitdoctorability If it is a routine visit talk about past experiences find a special symptom waiting a long time troubles resistence showing that you tried to wait out deal with the problem yourself but it didn39t work If it is a recurrent visit for a problem they think they had before self diagnosis usually more often with recurrent problems For new problems diffuse responsibility by bringing in a third party into the conversation ex my boyfriend said I should go to the doctor describe uncertain symptoms talk about pain subjectively I feel this bringing up past experiences if it is similar to something that they have had before the descriptions are narrative when they are not sure what they have narrative will often contain a turning point something prompts them to come in troubles resistance 021914 4 Features of Question Design 1 Agenda 2 what type of action is the questioner seeking from the respondent o Ex how come you don39t have any kids expecting an explanation response 2 Presuppositions a question that you ask may or may not presuppose certain information 3 Epistemic Gradient what degree of K is the person asking the question How much does the questioner actually know based on the way that they are structuring the question Ex You have children Declarative displays most certainty Certainty Decarativegt Declarative negative tag gt negative interrogative gt straight interrogative Negative Certainty negative declarative gt negative declarative positive tag gt interrogative negative polarity item 4 Preference YesNo 0 Yes Do you have children straight interrogative Don39t you have children negative interrogative You have children declarative soliticiting confirmation You have children don39t you declarative negative tag 0 No You don39t have children Negative declarative You don39t have children do you Negative declarative positive tag Do you have any children Negative polarity any ever at a 2 always relevant what is preferable generally 0 When would you want to ask a question with crosscutting preferences when grammatical contradicts with social If you have a reason to believe the answer Ex Is your father dead could be asked because your friend said things in the past for you to believe that they are dead Do you have children 1 Topic agenda kids Action agenda yes or no 2 Presuppositions that they are old enough to have children 3 Epistemic Gradient 4 Preference Grammatical 2 Principles of Medical Questions 1 Optimization When the question is designed towards a favorable health outcome similar to social preference Ex Are your bowel movements normal it39s good to have normal bowel movements 2 Recipient Design Tailoring your question to previous knowledge about the patient similar to presuppositions and social preference Week 7 Discussion Handout Do you have brothers and sisters Ln3132 Action YesNo question Topic siblings Grammatical prefers yes straight interrogative Epistemic most uncertain Optimization can39t say anything about optimization Recipient Design The line before They could have helped her maybe the doctor took that as an indicator that the patient had siblings However structure of question Do you have brothers and sisters doesn39t display any certainty Response Ah there was eight in our family doesn39t conform to action agenda doesn39t give a yesno answer but does conform to topic agenda Pg 6 Ln42 How many hours uh week do you work Action number Topic work hours Grammatical NA bc not yesno Presuppositions presupposes that the patient does work Epistemic Optimization Recipient Design He knows that based on other things that she said that she does work Response Eh I don39t know doesn39t conform to the action agenda It39s an account for why she can39t answer 022614 Online commentary often used to forecast a no problem diagnosis 0 Ex someone comes in thinking they are dying the doctor will use this to support that the patient just has a virus Happens during the exam Often describes symptoms that are normal or mild Review Quiz 2 Doctor Patient Interaction Intro The Nature of Medical Authority Paul Starr Medical Authority involves the surrender of private judgment You over come your private fearsreservations and follow the doctors orders 1 Social Authority based on the dependency of patients your dependent on the doctor 2 Cultural Authority based on the role of science in modern society not on whether it works but that the things that scientists due tend to be right Involves rights to name the world to say what the components of the world are and how they relate to one another Ultimate authority certain organizations have rights to say in the end what something is 0 Ex NASA determines whether someone s account of a UFO is real o Ex High power religious authorities medicine Intro The History of Medical Authority Before 1870 Medical authority low medical training is bad patients see doctors mainly to get strong drugs many forms of medical treatment are counter productive Ex Heroine pain reliever cocaine tooth ache drops 187090 Changes in medical training spread through US universities They teach the new germ theory of disease and organic pathology Doctors start to receive uniform and effective medical training 190020 Improved methods of identifying disease and stethoscopes x rays etc permit physicians to examine internal organs Advances in surgery hygiene and anesthetics Aspirin and Tylenol are invented Doctors can now diagnose patients illnesses accurately and forecast their course but can39t treat them effectively Rising authority and status of medicine in society 194060 Invention of wide range of treatments for illnesses including antibiotics the miracle drug and vaccines for devastating illness like polio Doctors can now diagnose accurately and treat effectively High poin of medical authority The golden age of medicine Information Giving in Medicine in reader Information Giving 1 Doctors use too much jargon medical terminology that patients don39t know a Patients don39t want to appear stupid so they don39t ask them to clarify what the medical terms mean 2 Doctors underestimate how much information patients want 3 Doctors overestimate how much information they give Factors Impacting Information Giving Patient Factors Age older get more info than younger Gender females get more info than males Social Class higher class gets more info than lower class Situation Factors Time patient has been with doctor the longer your with a doctor the more likely they will give you more info v Doctor case load the shorter the medical visit the less info patients get Medical Authority in Interaction Three Studies of Diagnosis 1 Did the doctor name and explain the diagnosis and treatment 2 Did the doctor design hisher statements so as to invite patient questioning or participation How patient centered was the doctor Focused on Doctors 1 Byrne and Long Styles of Diagnosis and Treatment Introduced notion of patient centered care 1 The doctor makes a decision about the patient and Doctor centered his treatment and then instructs the patient to see some service31 o 2 The doctor makes a decision and announces it36 o 3 The doctor sells his decision to the patient4 o 4 The doctor presents a tentative decision subject to change 14 5 The doctor presents the problem seeks suggestions and makes decisions 8 o 6 The doctor defines the limits and requests the patient to make a decision 4 o 7 The doctor permits the patient to make his own decision 1 o Patient centered Style 1 Diagnosis is not named treatment is not explained 31 Doc Well now take this along to the chemist Take them three times daily after meals Bye bye Doc I39ll make an appointment for you to have an X ray Now don39t worry We39ll be in touch Doc hasn39t explained anything to the patient Style 2 Diagnosis is named but not explained Treatment is not explained discussed or negotiated 36 Doc Well now you seem to have nothing more than a bout of flu Take this to the chemist on your way home Go to bed for a few days and I39ll look in from time to time Doc This is an infection of the lung I want you to go upstairs and have an X ray now When you39ve had that come back here and I will detail some more treatment Doc is instructing the patient Doesn39t elaborate on treatment The patient is not being invited in to discuss the treatment recommendation or diagnosis Style 4 Diagnosis is presented and explained treatment options are given in a more exploratory tentative fashion Doc Now then you appear to be having some more trouble with that leg of yours This is I think a consequence of the fact that you39re still trying to work as you did ten years ago Now you are fifty five and you ought really to start taking things a little easier I think you ought to have a long rest Now then how do you think you can cope with that The patient is invited to discuss whether they think this is a good thing or not Focus on Patient Responses to Diagnosis 1 Mainly minimal Responses No Response Acknowledgement tokensgrunts Response 0 None of the following Oh Really Is It Are you Sure Is it dangerousinfectious 2 Bigger Responses when Doctor shows doubt Diagnosis is counter to patient expectations No problem diagnoses 2 Heath 1992239 1 Doc gt Er Yeas 03 this one39s blocked the other 2 one39s not 3 gt 12 long silence 4 Doc Well when would you like to have them done 5 6 Doc Next week sometimez 7 Pat Yers yes please Ex of No response 3 Heath 1992240 1 Doc gt hhhh You39ve got erm 08 bronchitis 2 Pat er Barely a response 3 gt 45 Dr begins to write prescription 4 Doc hhh 03 I39ll give you antibiotics to take for a 5 week mh 6 08 7 Doc How long are you here for 4 Heath 1992247 1 Doc gt hhh g not a totally typical story of a 2 gt wear and tear arthritis but I think that39s 3 gt what it39s going to turn out to be 4 Pat We that but 5 that en right woudn39 LE and se says hhhh 6 Doc Oh 7 well I think we ought to get an X ray as a check 8 Pat hh heh 9 Pat Yers 10 Doc You39ve not had this done on that ankle before 11 Pat No Doctor is not certain about the diagnosis Patient starts to say a sentence or too in response to this uncertain diagnosis 5 Heath 1992250 1 Doc gt It39s not a vein it39s a muscle in spasm 2 Pat gt Is it 3 Doc Yeah 4 Pat gt Oh 5 Doc And I think what39s causing it to be in spasm 6 Pat gt I39ve had it for about 7 gt three or four weeks and now or something like that 8 Doc Yeah Yeah 9 Doc You39ve got a low grade inflammation of the eye 10 03 the front of the eye and this is probably 11 making the spasm come The doc is overruling the patient s theory 9 Patient responds with Oh bigger reaction Biggest responses with no problemquot diagnosis questions legitimacy of visit Wastes the doctors time 6 Heath 1992 255 1 Doc Well yer chest is absolutely cear today 2 10 3 Doc which is helpful 04 and your pulse is 07 4 only eighty thhhh which is er 12 not so bad 5 12 6 Pat Right it39s there night time uh it39s ts 7 not clear there I39ve got er 14 8 03 I39ve more or less gone to bed when it starts on us 9 25 10 Pat I wake all the way through the night without getting 11 any sleep un open 12 05 13 Doc Mm 14 Pat I don39t know what39s fetchin it up during the nights but 15 it comes in at the nights Doctor can39t detect symptoms but patient says that symptoms are there at night Bottom Line These behaviors reflect an orientation to the doctor as an authority figure Patients just sit there and listen to doctor Only more interactive when the doctor is uncertain or questions the legitimacy or patients expectations But is the patient there for diagnosis or for treatment Authority and Accountability Authoritativeness of the diagnosis is balanced by an orientation to the accountability of the doctors judgment and clinical findings Focus on Desi n of Dia nostic Statements 1 Ex 7 2 Ex 8 Ex It looks red That smells off This seems to be an infection They interposing a description of how you arrived at a conclusion by smell sight sound Evidential verbs looks sounds seems 9 evidence assuring the doctors statements prevents them from contradicting themselves 3 Ex 9 The tells you how they arrived at their conclusion II 7 Perakyla 1999 quotStraight factual assertionquot Doc Here39s luckily the ne quite intact Guy goes into a lake picks up a stone and then accidentally drops it on the his foot 8 Peraikylai 1999 quotEvidentia formulationquot 1 Doc Now there appears to be an 10 infection at the 2 contact point of the joint below it in the sac of 3 mucus there in the hip 9 Perakyla 1999 quotEvidence formulating patternquot 1 Doc As tapping on the vertebrae didn39t cause any pain and there aren39t any actual reflection symptoms in your legs it corresponds with a muscle h hhhh complication so hhh it39s only whether hhh 04 you have been exposed to a draught or as it otherwise 6 Pat Oh yes 6 Doc hh got irritated Doc lays out the kind of tests he39s done and he hasn39t seen anything Lays out evidence for his judgment U393Ud 10 FREQUENCY OF TYPES OF DIAGNOSTIC TURNS Turn design Freq Percent 1Pain assertion 31 44 2Incorporated reference to evidence 12 17 3Expication of evidence 28 39 Total 71 100 How are these different designs used 1 Straight factual assertions Embodies both authority in the design of the statement and accountability to evidence by its contextual placement Doctor shows where his conclusions come from 2 Evidential Used when there is a big gap between examination and diagnosis inferential distance 0 When a lot of time elapses between physical exam and diagnosis 0 When the physical exam was complicated or arcane unsure 3 Evidence Formulating Used when there is a lot of inferentia distance ex 12 0 When the physical exam was complicated or arcane 0 When the diagnosis is one that the patient may disagree with eg a no problem diagnosis or is less than what the patient thought 11 Peraikylai 1999 Expansion of 8 Before this extract the doctor conducted the physical examination after which he workied on his computer telling the patient that he was preparing a referral to the X ray ab ll l l l l l l l l Nn ouoooIowu1gtooNn o 39 quotquotgt 39quot Doc Has your hip ever been X rayed before 05 Dr takes papers in his hands Pat hhhh erm hhh 10 I don39t really rememb I don39t think it has 08 Pat I don39t think it hashh My gee has been X rayed as it erm years 02 hh years ago as riding a bicycle was so painful that it couldn39t put up with it h but then nothing was found thereAs far as I remember there has never been an X ray of my hip hh 12 Pt mth Doc Now there appears to be an 10 infection at the contact point of the joint below it in the sac of mucus there in the hip Pat Oh right hh that39s what I thought myself too that ltit probably must be an infectiongt hhhhh Doc And because you have had gouble this long we will Pat hhhhh Doc make sure and take an X ray Pat Xes 12 Peraikylai 1999 The doctor has just examined the patient39s foot kO00lOU39IlgtUoIJI t Doc Qkay h fine do put on your Doc the pulse can be felt there in your foot so Pat Thank you Doc h there39s no in any case no real circulation probem Pat Yes I don39t understand then really hh I was wondering whether I should Doc is ltinvovedgt Bottom Line Authority in medicine is balanced to some extent by accountability Accountability is partial limited by gap between physician and patient competence Medical Authority Conclusion How do we explain the difference between Byrne and Longs findings and Perakylas Historical decline in medical authority o Doctors are more accountable for their conclusions than in the 197039s They need to explain themselves more now Different countries 0 Britain vs Finland Maybe Fin s expect more accountability Different medical care payment systems o Maybe if you pay for your medicine you are more assertive No real difference between Finland and Britain medical care relatively free Return to the History of Medical Authority Before 1870 Medical Authority Low 187090 Improved medical training 190020 Improved diagnoses increase cultural authority of medicine 194060 Golden Age of medicine 1960 Rising medical costs increase pressure on medical care Growth of HMOs and utilization review Consumer movement among patients who shop for information on the internet 9 declining medical authority Organizational Cost Based Pressure Frequency in which doctors order tests and make treatment orders are monitored and must be kept low Every individual doctor can no longer order what ever test or treatment they want They have to think about the insurance company and what they will allow Patient Pressure patients use internet Patient shopping 9 doctors must treat patients the way that they want to be treated Increases negotiation between doctor and patient Conclusion difference between Byrne and Longs and Perakya s findings Rise of consumerism among patients Rise of patient centered medicine Rise of managed care 0 Erosion of medical authority 021214 Talk and Social Institutions Medical Authority and Online Contrary W OPENING PRESENTATION T TnE CLOSING I This linear model illustrates Byrne and Long39s 1976 overall phase structure for the acute medical visit Progressivity is the temporal forwarddriving movement from one rity to a next sud as the movement from problem presentation to physical examination PHYSICAL EXAMINATION PROGRESSIVITY However patients treat themselves as responsible for accepting or rejecting treatment recommendations after all they are going to have to fill the Rx or show up for the surgery This clearly emerges in the interaction Diagnosis patients tend to be unresponsive or only minimally responsive Treatment patients almost always respond Dx vs Rx Recommendations Ex 1 Mom responds alrright to treatment recommendation Ex 2 minimal response okay Ex 3 Let s do that Ex 4 when the doc doesn39t recommend any treatment the mother agrees Ex 5 A little delay on the treatment recommendation the patient holds off on the response until the doctor gives an exact name of medication Ex 6 Once the doctor recycles his treatment recommendation then the patient responds By the time they get to the treatment phase the medical visit is near ending TREATMENT 4 s 1 PATIENT ACCEPTANCE PATIENT NONACCEPTANCE TREATMENT RECOMMENDATION DIACNosIs J5 I pURSUT TR1gt Fig 3 If patients dioose not to accept the treatment recommendation physicians routinely modify their treatment recommendations to pursue patient acceptance TR39 When patients repeatedly dedine acceptance broken lines physicians can modify their recommendations iteratively TR39 39 until the patient accepts solid line and the physician can move to a next activity dotted line Next activity some special procedures for the medication application side effects etc If the patient does not accept the treatment recommendation the doctor may offer some reasons of why the patient should accept the treatment recommendation Im sure it39s the best thing for you If the patient still doesn39t pick it up then the physician will readjust their recommendation 9 alternative option The patient not responding to treatment recommendation passive resistence Important Bottom Line Because patients tend to receive dx passively if they want to resist the dx they have to positively object Doctors treat silence as acceptance for diagnosis However because patients actively accept rx recommendations if they want to resist the rx they don39t have to positively object although sometime they do They can just react passively Doctors treat silence as nonacceptance for treatment In practice how authoritative are doctors really Patient pressure on doctors for treatment recommendations Medical Authoirty Susceptible to patient influence Antidepressants Fake patients gave different treatment recommendations Major Depressive Disorder Brand Specific request 53 General Request for Anti depressant 76 No Request 31 Adjustment Disorder Brand Specific Request 55 General Request for Anti Depressant 39 No Request 10 Getting a treatment recommendation from a doctor involves a negotiation between the patient and the doctor When patients ask for medication they get it half of the time Impact of Perceived Parental Expectations on Diagnosis and Treatment of Pediatric Upper Respiratory Infections lManqione Smith et al 1999 Physician believes Physician believes parent parent expects abx does NOT expect abx Otitis Media Dx all cases 49 13 plt001 Sinusitis Dx all cases 38 5 plt001 A5 prescribed 62 7 pltOO1 viral cases Physicians make diagnostic decisions depending on what they think the parents want In viral case the doctor still prescribes antibiotics when they think the parents want antibiotics Introduction Demand and Antibiotics Prescribing Inappropriate prescribing is the primary factor causing the spread of antibiotic resistant bacteria Inappropriate prescribing is common Prescribing rates for the common cold is 30 for bronchitis and other viral illnesses is 60 5065 of parents expect antibiotics for their kids URI conditions Varies with class and ethnicity What is Online Commentary Online communication is communication to the patient about what the doctor is doing or seeing or about to do during the physical examination of the patient Three types of online communication Directions Open wide Ex 1 line 1 Online Explanations J s gonna check your thyroid Ex 1 line 2 Online commentary That feels norma Ex 1 line 5 1 1 Doc An we39re gonna have you look straight aheadh online direction 2 05 3 Doc J39s gonna check yer thyroid right now online explanation 4 95 5 Doc gt hh That feels normal Online commentary 6 08 7 Doc gt I don39t feel any lymph node swelling hh in yer neck area 8 Doc hh Now what I39d like ya tuh do I wantchu tuh 9 breathe with yer mouth openNice slow deep breaths Features of online commentary 1 Simultaneous with physical exam 2 Mainly used to describe patient signs that are absent or mild 3 Absent signs are described evidentiallyEvidentially It looks red it feels swollen it sounds Absent Evidence I don39t feel anyit doesn39t sound 4 Can be in report or assessment form 5 Subordinated to the physical exam 2 Well visit check up 1 Doc hh Now again uh lot uh pressure 2 98 3 Doc gt You c n hardly even feel the ovaries Report form bc the patient doesn39t know if it39s good or bad 4 gt an that39s good Assessment 5 Pat That39s good 6 Doc Yeahhh That39s real goodhh 7 10 8 Doc gt hh An yer uterus is uh 90 it39s fine 9 20 10 Doc Okay 11 Pat It39s still there 12 Doc It is definitely still there 13 Pat hah hah hah hah The patient was worried about her ovaries Features of online commentary Some problem significant sign patient sign assertion that s quite inflamed physician online comment No problem Non serious sign patient Patient Signs and Physician Responses during Examination Patient Sign Physician Online Comment Significant Sign Assertion quotThat39s quite inflamedquot Factual Assertion minimizer eg Non serious Sign quotThere39s a little redness therequot Table 1 Diagnosis Online Commentary and Prediagnostic Commentary Content Position Inferences and conclusions After physical examination Diagnosis from medical observations tests etc are complete Statements about what Online the physician observes During physical examination Commentary feels etc Pre diagnostic Inferences about possible Any point prior to the Commentary diagnoses delivery of the diagnosis How Frequent is Online Commentary Aggregate Range Exclusively no problem 52 0 100 Some problem 18 0 43 o No online 30 0 73 Table 1 Diagnosis Online Commentary and Prediagnostic Commentary Content Position Inferences and conclusions After physical examination Diagnosis from medical observations tests etc are complete Statements about what Online the physician observes During physical examination Commentary feels etc Pre diagnostic Inferences about possible Any point prior to the Commentary diagnoses delivery of the diagnosis Table 2 Features of Online Commentary Simultaneous with physical examination or occurring between successive actions in physical examination 2 Mainly used to describe patient signs that are absent or mild Present but mild or non serious signs are described in terms that are 3 downgraded qualified or mild eg quotThat s a little bit red back therequot 4 Absent signs are described using evidential terms eg quotI don39t see any fluid therequot Online comments can be presented as reports of observations eg 5 quotYou can hardly feel the overiesquot or as assessments of what is observed eg quotAn39 yer uterus is uh 90 it39s finequot The second type contain overtly evaluative components Online commentary is delivered by the doctor and received by the 6 patient as subordinate to the activity of examination that is under way Online Commentary Well visits vs Acute visits Well Visits Online used to reassure 2 Acute Visits Online used to forecast a no problem diagnosis 10 Two Problems Faced by Physicians in treating patients with upper respiratory Infections 1 Doctorability 345 Resistance to No treatment recommendation 67 Remember the difference between resistance to diagnoses and resistance to treatment recommendations 2 The Quick fix 89 Resuk Patient resistance to physician diagnoses and treatment recommendation that don39t involves antibiotics r U0 MOM hhh Uhm Uh We re thinking she might have an ear infection in thuh left ear DOC Qkay DOC Okay MOM Uhm becauseuh she39s had some pain DOC Arighty MOM over thuh weekend hh SkO00lOU39IlgtUoII t 11 DOC Let39s see your ears first Okay 12 MOM 13 DOC Which ear s hurting or are both of them hurting Negatively optimized question 14 02 15 PAT Thuh left one 16 DOC Okay This one looks pgfect hh online commentary 17 MO Uh 18 DOC And thuh right one also ooks 02 even more 19 perfect No sign of infection online commentary 20 PA 21 DOC Does it hurt when I move your ears like that 22 05 23 PAT Non 24 DOC No 25 DOC hh Do they hurt right now 26 20 27 PAT gt Not right now but they were hurting this morning 28 DOC They were hurting this morning 29 02 30 DOC Mkay 31 MOM gt Do you have uh sore throat pain Mom is pulling another symptom out of thin air to validate the visit 32 MOM Yes 33 DOC Let39s check your throat 4 1 Doc Anything hurt 2 15 3 Boy No 4 5 Doc Your ears don39t hurt 6 03 BOY shakes head ateray 7 Doc Your throat doesn39t hurt 8 06 BOY shakes head ateray 9 Doc Your tummy doesn39t hurt extra rise at the end 10 05 BOY shakes head ateray 11 Doc No 12 02 13 Doc Has he been coughing uh lot 14 02 15 Mom hh Not uh othh 16 Doc Mkay 17 Mom gt But it it ltsoundsgt deep 18 10 19 Mom gt An with everything we heard on tee vheehhhh 20 gt we got scare mom is defending their reason for visiting 21 Doc Kay An fer i It sounds deep 22 23 Mom Mm hm r U39 DOC gt So it looks like she has an acute gastroenteritis DOC gt Doesn39t look like it39s too significant MOM gt Okay th hh th 1 was concerned cause uh DOC And expect 39er MOM gt Qsually if she when sheif she vltmits she gt 08 it it doesn39t last as long or as gften MOM gt Last night was DOC 39ts jus jus39 uh few throw ups an that39s thee end of it Yeah thee MOM gt Yeah Like I gt say she was probably at easth DOC It was uh little u MOM gt It was at list ten times MOM gt more like ten to tweve yeah DOC gt Sh uhyeah well she had very significantuh 17 18 19 20 21 22 23 24 25 26 27 gt 55 Significant threw up but ituh MOM Yeah DOC gt hh there wasn39t uh whole lot of mle in it so gt she39s not obstru I don39t wanta thsay MOM No DOC gt h likely be obstructed it MOM No No it was just ence that I saw that DOC mh Or uh 28 MOM Butuhh 05 DOC gt Okay every An everything checks out fine 6 Reference to quotthis guyquot line 1315 is Mom39s other child who is also in the doctor39s office 1 DOC h Uhm h So lots to drink and then uhm mk 2 if he gets fever agein 02 though uhm h 3 in thuh next two or three deys h uhm 02 we 4 may need to see him back in case he n dees 5 come down with something secondariy 6 MOM gt See c cuz what I 7 gt was werried about I woud39vewoudn39t 8 DOC Mm hm 9 MOM gt normay 09 10 DOC m Bring him in 11 MOM gt interpreted this as a co ya know 12 DOC Mm hm 13 MOM gt uh thing that would run its course but this 14 DOC Mm hm 15 MOM gt guy had thuh same thing and wound up on antibietics 16 gt cuz he got an infection Resisting no treatment recommendation 17 MOM hhh 18 DOC Where 19 MOM gt How can I prevent that from heppening Lines 13 treatment recommendation Uses her other son as an example to resist no treatment SSkO00lOU39IlgtwIJI tS 13 14 15 16 17 18 19 20 21 22 23 DOC Unfertunately like mest viruses we have to wetch it DOC gt hh because you know she cancould have uh fever for another few days and mthin39 ese gt DOC and jus an be fine DOC hh Or else if she got uh fever an got werse and started limping actually at thet time we39d probably need er tuh come back DOC gt hh But at this mement since there39s no sweing or there39s no hh you know ltnothing else t uh most important thing t39 do is tuh watch her DOC gt hh So we39ve had a fgw people right now that have had uh few of our kids are having tlk h fevers for a few days and not much other symptoms DAD So can she go to preschool now 9 lines omitted DOC She doesn39t have enything right new any symptoms of mucus or vomiting that39s contagious DAD gt Are you gonna give her ana antibiotics Preference for no answer 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 DOC Yeah uh amp I don39t have anything tuh treat right now for antibiotics Her ears look really good hh she has gt no sign of bactgial infection right now DOC gt tkh and that39s what she39d get antibiotics fer DOC hh So uh letta times you can start out with uh virus like uh cgld h and if you it goes on for uh while uh bacteria should set in you can get uh secondary gt bacteria infection and thet39s when you need antibiotics DOC hh But y etherwise since she doesn39t have any seurce of an antibi of uh bacterial infection thatuhwe just gt watch her 03 DOC right now ltHer ears look really good ltan39 her tebes are gt in teo DOC gt h And they39re not dreining or enything DAD gt It just means that gt ya know if she gets anether fever we hafta bring her bgck DOC hh Well what I39ll de is she might still get uh fever in thuh next couple uh days because h that39s th39 way 43 viruses wgrk you can have you know how haveyou 44 if you have uh cgld you can get a fever for uh few days 45 hh And thgt Since she39s oder h if something39s 46 uh she would compain thuh symptom 47 GIR 48 DOC then she would need tuh come back 49 DOC hh But what you cgn do is 50 GIR Guess whgt Doctor knowingly prescribes due to parent pressure Example of The Quick Fix 8 1 MOM gt I39m looking for uh uh I39m leoking for a miracle Miraceantibiotics 2 gt from yeu 3 DOC Okay heh heh 4 MOM Martin has uh his very first jor five year old 5 birthday party tomerrow 6 10 7 MOM And his temperature39s beenhh UH hundred an FIVE 8 DOC His birthday or is he going tuh huh hah hah hah hah 9 MOM His birthday Tomerrow And he39s sg 10 gt sick and I NEED UH MIRACLE hhha ha huh huh 11DOC Ah 12 MOM I need 13 a miracle 14 MOM gt hh I39m h hh I kno he probably jest has thuh common 15 gt cold but I39m like preying he has a horrible bacterial 16 gt infection in his Qrs and YOU39RE GONNA CURE IT 17 gt WITH TWO DOSES OF ANTIBIOTIC ha ha ha ha ha ha ha ha High parental pressure 18 DOC Ha ha ha ha ha ha ha ha 19 MOM hh But I know it39s not gonna hhappehn 20 MOM hh But I just said you know what hh Befere 21 I cancel this party 10 22 DOC hh 23 MOM Tkhahhh 24 DOC Yeah I I i hh I I39m afreid I cen39t 25 MOM Ahhh h a h a h a h a hih hih hihs 26 DOC dho thhuh mirhace 27 DOC I mean I39d ah cause he I think he39s gonna probably 28 come down with the fig ya know 9 1 DOC gt Well you know it39s sort of one of those geod news 2 gt bed news scenarios On ene hand thuh geod news is 3 gt that she doesn39t have any serious infection I 4 GIR 5 DOC mean her ears are fine so she can fly an hh 6 MOM an 7 DOC gt everything else looks okay Thuh bed news is that 8 gt it39s probably viral so we can39t make it go awey any faster 10 11 12 13 14 15 16 17 18 19 20 MOM MOM GIR MOM DOC MOM DOC MOM Mkay 04 hh h Now should I 04 just as uh preventative thing should I give them some antibigtics or does that do anything for this An39 if anything it39d make her diarrhea worse Okay No It wouldn39t huh huh 10 II II tI tI tI t t tI tI tI t owuIIgtooNn ouoooIou1Igtwn o 39 quotquotgt quotquot 27 28 Doc Can you op39n your mouth for me again online commentary 03 Doc 39ats it 07 Doc gt gtte bit red hm 16 moving sounds Doc Ari ghth 28 more moving sounds 39393932 lines omitted Doc Aright Michael Can I ook gtin yourlt ears 03 Mom This one Doc 39ank you 09 Doc gt 39ats fine the other one 45 Doc ktch okha yh 05 Doc gt They39re alri ghth I mean there39s a just a itte gt redness in his thrt and and just a little pinkness there gt which means he39s got one of those cglds that make them gt cough a lot hh Because his chest is perfecty all right gt he certainy doesn39t need penicillin Mom No Doc gt 39r anything like that hhhh hh I think the goughing tak continues Doctor did the exam described what he saw and as he moved into the diagnosis eh resummarizes Online Comentary and Patient resistence 10 1 Validates doctorability the patient has some signs of illness 2 Reassures that they are mild 3 Shapes patient expectations away from an antibiotics outcome 4 Commits clinician to a non antibiotic outcome 5 Diagnosis builds off online commentary 6 Extension of evidence formulating diagnoses Perakyla 11 1 Doc How are you in today 2 Pat 39hhhhh Better hhhhhhhhhh 3 Doc And your sinus es 4 Pat 39hh 39 hh 5 6 Pat gt We they39re still they39re about the same 7 8 Doc Bout the same okay why don I have you sit up here for a 9 second 10 11 11 Doc I gave you a lot of medicine over the ast 05 general 12 month or so fer yer sinuses 13 04 14 Doc But the heemobi d an the cena se an then the antibigic 15 the augmentin 16 0739hhhhhhh 17 Doc And you should be noticin a pretty big erence 18 Pat gt Compared to the first visit a lot When people say they notice something then it would say that it just came to their perception that the patient should be better patient must be overworried 19 20 Doc Okay 21 Pat gt It39s sti 39hhhh sniff gtyou knowlt it39s not a hundred 22 gt percent patient continues Developing conflict between the physician and patient 12 1 2 Sk00OlOU39IlgtUo 12 13 14 15 16 17 18 19 20 21 22 Doc Pat Doc Pat Doc Doc Doc Doc Doc Pat Doc good 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Doc Pat Doc Pat Doc Pat Doc Doc 13 A nd you should be noticin a pretty big erence Compared to the first visit a lot 0 Okay It39s sti 39hhhh sniff gtyou knowlt it39s not a hundred percent 5 Talk about medications moving to physical exam deleted Yeah because one you usually you need to take a little bit onger 34 1 gt We I don39t see any fuidyour ears look good 36 1 gt This one does too 56 2 gt Let39s see if we see any drainage 09 Say ah Ahh 02 2 gt An that looks real good too Compiling evidence that he39s 08 Are you havin any real specific problems with the cou gh er anything like that gtwith your sinuseslt Uh m the only thing every once inna while I get a uh a really wid 02 extreme tickle in my throat An Ive gotta cough cough cough fer 02 seconds 0 Nkay An then I clear my throat a couple times an it goes away 0 ooOkayoo But it just reoccurs 04 gttwo a threelt times a day 3 gt We let39s check your sinuses an see how they look today 10 3 gt That looks a ot betterI don39t see any inflammation today 1 Doc That looks a ot betterI don t see any inflammation today 2 08 3 Doc Good 4 Pat Good 5 6 Doc gt That39s done the trick 7 10 8 Doc gt So you should be just about over it I don t I39m Lot 9 gt really convinced you have an ongoing in1 ectionit seems 10 gt like the augmer1tin really kicked it she presents this as though he tried to convince her 11 Pat Good 12 Doc Okay An what E did we need to address your EKG The doctor did three physical exams checks the ears throat and sinuses She summarizes the whole thing with That s done the trick Why is online commentary effective 1 Forecasts upcoming no problem diagnosis 2 uses cultural authority of medicine physicians can name the world she can say whether there is or isn t an infection 3 At the time they are made online comments are not yet conclusive They build up incrementally There39s nothing for the patient to oppose Diagnosis isn t final until the last online comment is down 4 Exploit physician39s ecological advantage you can t look up your own nose real well Doctors are trained and know what to look for that the patients can t do 14 How Frequent is Online Commentary Aggregate Range Exclusively no problem 52 0 100 o Some problem 18 0 43 o No online 30 0 73 o 15 What situations is Online Commentary used in No online Problem No Problem Online Pressure but bacterial 86 829 85 No Pressure but bacterial 189 509 302 Pressure but viral 274 101 624 No Pressure but viral 277 152 571 Pressure patients say things that make the physician think that they want antibiotics 16 How Effective is Online commentary Odds of Inappropriate Abx Parent perceived to want ABX 18 times higher Problem online 7 times higher No online 475 times higher Conclusion How authoritative are doctors Patients Bargain with doctors over antibiotics 0 Doctors aren39t as authoritative Doctors often prescri patient pressure be against their better judgment in response to 0 They are worried that the patient will defect Or go somewhere els field E Online commentary is one means that they can level the playing This suggests that doctors often cannot rely on authority alone when dealing with patient preferences 0 They need to e reasoning ducate patients on how they come to their Week 5 Monday lecture 2314 Talk and Social Inst DoctorPatient Interaction Recap Doctors are interrupting patients and it is the reason why problem presentations are so short Problem presentation is a cooperation between doctor and patient Doctor39s problem is knowing when to interrupt Patient can control the length of their presentation Whenever you get into the present tense doctors understand that it is the time to move in The patient s problem justifying the medical visit Must give some kind of good reason to be there When doctor starts history taking it means that the doctor is ratifying the visit The Sick Role Concept that originated with Talcott Parson39s when you become sick your entry into a sick person has to be ratify by other people and gives you access to rights of a sick person Rights entitlement to some exemption depending on how ill the person is from normal duties I feel sick to my stomach I think I39m going to skip cass free from personal responsibilities and personal responsibilities for getting better when one enters the sick world we don39t say It s all your fault or we don39t expect a person to get better right away through act of will Obligations for being sick one must view being sick as undesirable Person must strive to get better They should also not try to take advantage Patient should seek competent help and co op in the treatment process Reasons for inappropriately entering the sick role Patient wants to get off work or midterm known as maingering Patient wants to be the focus of care and attention from family and friends according to Parson39s these are secondary gains Patient wants to be focus and attention from medical profession Baron Munchausen s syndrome Patients that go to the doctor all the time or patient is over anxious or the worries well hypochondriac When we go to see the doctor we will work to show that we are not entering the sick role for the wrong reasons justification The Patients Problem Justifying the Doctor39s Visit Achieving doctorabilitv For patients a doctorable problem is one that is worthy of medical attention of evaluation as a potentially significant medical condition and worthy of advice or treatment when necessary Example of patient who discovered a bump or mole in the back of her neck 1 on the handout after having one removed Orientation to legitimacy by the patient Line one she is undermining her own reason for being there might be undermining doctorability Problem is presenting problem as a narrative doubting if they have a problem or if it39s a kind of problem doctor or 911 emergency should deal with Patient also invokes 3rd party husband is made to be the reason for the reason Something weird or leads to diffusion of responsibility Patient fighting by overlapping the doctors questions to downgrade the problem Injects of breathy laugh particles at places where she talks about deciding to visit this kind of move is used when a person is not doing what they were supposed to do or doing something wrong In this same example patient agrees with no problem evaluation she also re invokes her husband 3rd party as telling the doctors that she told him it wasn39t anything patient uses breathy particles again when describing her decision to make the appointment at the end doctor validates her decision to come Patient orients to legitimate the doctor visit once again Is the issue of legitimacy always a problem Unconditional Legitimacy where doctorability is not a problem Medical problems vary examples 2 and 3 I ve gotten bitten by a dog patients treat their situation as giving them a right to walk into the doctors office without explaining Patient s attitudes to medical problems vary example 4 Conditional Legitimacy where doctorability may have to be worked on Patient downgrades seriousness example 5 patient wouldn39t normally go into the doctor with just a cold Doctor validates decision to make the visit example 7 patient didn t go to the doctor right away but waited for it to get worse and doctor validates by saying she s a tough cookie and doctor validates her reason as being good enough to be there Different presentation problems different problem presentations Three acute cases Routine problems colds a cough fever etc Recurrent problems specific problems patient has had before like cancer Newunknown problems Patient just doesn39t know what s going on and if what they have is a problem or not Dealing with doctorability Routine problems Patient downgrades seriousness but finds some special reason for the visit example 9 patient says that they waited a while before coming in troubles resistance examples 10 and 11 Past experience claims just aches and sore throat but patient has more reasons based on the past treat me now before I get worse example 12 Dealing with doctorability Recurrent problems Patient thinks they have a recurrent problem state that they have had something before and think they have it again this is a risky route to take because it is the doctors job to determine diagnosis Patients sef diagnose sef diagnosis are dispreferred sef diagnosis is often indirect example 1314 still indicating a recurrence of something they have had more direct self diagnosis is previous condition was serious example 15 and 16 patient feels something coming on but is flat wrong Dealing with doctorability New problems Descriptions of uncertain symptoms lead to subjectivized accounts of pain and discomfort example 17 patient at a bind of how to describe the scope of the symptoms feelings of pain are used to further justify visit Descriptions diffuse responsibility by invoking 3rd parties as reasons for the visit example 18 Descriptions are often narrativized example 19 Narratives often contain troubles resistant elements patient reported how long they39ve waited to come in to doctor and all the steps that he took to resist the problem and treat it on his own attempt at sef medication or waited example 19 20 and 21 Troubles resistance narratives contain turning points Why would the person wait so long to come into the doctor39s Patient must have an explanation for this Usually patient and condition have a turning point example 19 20 21 patient doesn39t understand what the problem is and goes through the above stepsphases before reaching her turning point Acute problem presentations conclusions are co constructions doctor negotiates length of presentation patients may prefer brief presentation to get their visit as validated validation occurs when Hx questions are taken problem presentation varies with type of illness and strategies to legitimize vary with type of illness IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IlIIIUIUIlIUIIIUIlIUIIIUIIIIIIIUIIIIIIIUIIIIIIIl Week 5 Wednesday lecture 2514 Communication in Medical Care Question Design We are moving into history taking and question design in medicine When doctors ask us questions they want good accurate responses in order to be able to give proper treatment We don39t see survey questioning from doctors Why is questioning in medical care not like a social survey Because we communicate information to individuals and expect that back Doctors questions are not meant to communicate beliefs or assumptions about a person Essentially anonymous interactions between doctor and patient asked like so in example 1 on handout doctor had two tries at asking about relationship status doctors questions are conveying his beliefs about the patient Four features of question design 1 Questions set agendas to be responded to Topic agendas Action agendas 2 Patients responses conform or not to those agendas see example 2 Example 3 doctor sets action agenda for a yes or no answer but patient instead of answering question in the beginning answers at the end of her answer more cautious and in control Example 4 before she responded to the agenda of the question she inserts a sneaky remark about her working life taking over Same patient for example 5 patient is answering another different where question to get a story launched about how her mother put off visiting the doctor doctor registering that a narrative will be launched by saying mhmm Example 6 quotbad footquot patient has not met the topic or action agenda she is going to get out her theory about how she got the problem eventually answers where it is hurting her now and re aunches into narrative again known as deferred conformity in examples 5 and 6 further examples of deferred conformity are 7 and 8 in 7 there are two questions about breasts and breast feeding and the first question is accepted and answers the topicaction agenda second answer does not conform exactly to the topicaction agendas as this mother inserts what the doctor exactly the doctor is asking about 2 Presupposition questions embody presuppositions example 9 3 assumptions to the questions and knocks out as she answers that she cannot have a baby example 10 patient had operation to not have a baby example 9 is more presupposing than example 10 patients39 responses confirm or not those presuppositions Interrogatives grammatical term Questions an action term as it is requesting information interrogative don39t always question and some non interrogative s do ques on Epistemic Gradient each example is performing the action of questioning depending on degree of knowingness example 11 question is fully interrogative and doctor doesn39t know about the baby or not deep epistemic gradient IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IlIIIUIUIlIIIIIUIlIUIIIUIIIIIIIUIIIIIIIUIIIIIIIU Week 6 Monday lecture 21014 DoctorPatient Interaction Last two lectures on this topic will concern the question of medical authority doctors as a classic example of authority Paul Star Implementation of medical authority involves the surrender of private judgment in other words when you go to the doctor and heshe makes a recommendation for you chances are you will take that advice you have overcome any fearsworriesdoubts and followed doctors orders first kind of authority that doctors implement is social authority or that which is based on the dependency of patients the second kind of authority is a deeper form known as cultural authority or one that is based on the role of science in modern society involves rights to name the world that is to say what the components of the world are and how they relate to each other bit by bit you learn the differences between swans and ducks it is kind of an ultimate authority where certain people or organizations have the right to say in the end what something is parishioners say they see the Virgin Mary on a tree and if the Vatican comes in they rule out whether it is or is not a miracle Before 1870 medical authority was low training was bad patients sought strong drugs and many treatment were counter productive From 18701890 changes in training spread through US universities They taught the new germ theory of disease and organic pathology From 19001920 improved methods of identifying disease stethoscopes x rays etc Advances in surgery hygiene and anesthetics Asprin and Tylenol invented Drs can now diagnose patients illnesses accurately and forecast their course unable to treat them directly 19401960 invention of wide range of treatments for illnesses including antibiotics the miracle drug Doctors can now diagnose accurately and treat effectively High point of medical authority 1960 the peak and the golden age of medicine Information Giving in Medicine number of ppl have argued that doctors have kept patient in the dark Ch 6 in reader Information giving Doctors use too much jargon complicated medical terminology patients tend to not ask what these terms mean because they don39t want to seem dumb or the doctors might think they are smart enough to know what it is Doctors underestimate how much information patients want Doctors overestimate how much information the actually give Factors impacting information giving patient factors Age older more info than younger gender females more info than male and social class higher socioeconomic standing more info than those at the bottom situation factors Time patient has been with the doctor Doctor case load Medical Authority in Interaction Three studies of Diagnosis Medical Authority 1 Byrne and Lonq 1976 1 Did the doctor name and explain the diagnosis and treatment 2 Did the doctor design hisher statements so as to invite patient questioning or participation how patient centered was the doctor They produced a table of how patient centered the doctor was on handout common styles listed below Stye 1 doctor does not give diagnosis or explain the treatment not told anything and just kicked out Stye 2 diagnosis is named but not explained Treatment is not explained discussed or negotiated Stye 4 diagnosis is presented and explained treatment options are given in a more exploratory tentative fashion Medical Authority 2 Heath 1992 Focus on patient responses to diagnosis 1 Mainly minimal responses No response look at example 2 on handout Acknowedgement tokensgrunts response look at example 3 on handout BUT they do none of the following oh really is it are you sure is it dangerous Heath notices that when patients receive diagnosis they either don39t respond at all or make slight noises 2 Bigger responses when doctor shows doubt diagnosis is counter to patient expectations example 5 on handout quotno problem diagnosis biggest reactions made in these situations legitimateness of the visit is not there example 6 on handout Bottom line according to Heath these behaviors reflect an orientation to the doctor as the authority figure but is the patient there for diagnosis or treatment patient may be there for treatment waiting for the antibiotics or something to fix their problem so they nod through the doctors talk patients do not respond to them they sit there and take it in patients not in the position to argue with the doctor Medical Authority 3 Perakyla 1998 Authority and accountability A Authoritativeness of the diagnosis is balanced by an orientation to the accountability of the doctors judgment and clinical findings Focus on design of diagnostic statement a Straight factual assertion example 7 b Evidential example 8 it looks red or that looks off or this seems to be an infection evidential verbs reduce the certainty of how the doctor gives the diagnosis c Evidence formulating example 9 doctor lays out what their reasoning is based on Example 10 tells us the frequencies of these 3 types How are these different designs used 1 Straight factual assertions embodies both authority in the design of the statement and accountability by its contextual placement you39ve got a broken bone while the doctor points to the evidence on the xray 2 Evidentials used when there is a big gap inferential distance between examination and diagnosis examples when a lot of time elapses between physical exam and diagnosis or when physical exam was complicated 3 Evidence formulating used when there is a lot of inferentia distance example 12 on handout example when the physical exam was complicated or when the diagnosis is one the patient may disagree with like in no problem diagnosis Perakyla bottom line Authority in medicine is balanced to some extent by accountability AND that accountability is partial look at slides Conclusions Byrns and Longs findings vs Perakya s Perhaps there was a historical decline in medical authority Perhaps they were just differences in different cultures Or perhaps there were different medical care payment systems 1960 look at last slides Medical authority may be falling in the US healthcare costs put pressure on medical care get more HMO s trying to impose cost control so doctors try to keep the treatment and tests within certain boundaries hence the pressure on medical authority occurs other pressure comes from patients themselves printing out their own information and pressurizing doctors to treat them the way they believe they should be negotiations of treatment recommendation Explain the difference btw Byrne and Long and Perkya s rise of consumerism rise of patient centered medicines rise of managed care IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IlIIIUIUIlIIIIIUIlIUIIIUIIIIIIIUIIIIIIIUIIIIIIIU Week 6 Wednesday lecture 21214 Medical Authority and Online Commentary Fundamental differences on how patients respond to diagnosis vs treatment recommendations Rough rule patients treat diagnosis as within the doctors realm of knowledge and responsibility Patients however treat themselves as responsible for accepting or rejecting treatment recommendations Example number 01 on handout as soon as doctor says his treatment recommendation antibiotics there is an uptake from the patients mother in this case Example number 02 another example treatment recommended and doctor receives an uptake Example number 03 a bit more complicated uptake Example number 04 another complicated uptake situation Example 05 there is a bit of a delay on the uptake from the patient in this case until doctor gives further information about the medication in terms of its name Example 06 doctor mentions antibiotic no uptake states it again and we receive an uptake Think of the doctor patient medical visit interaction as split into phases treatment phase is expanded next activities section of this phase a doctor will talk about the doses special instructions etc doctors may try and alternate their treatment recommendation until the patient shows uptake and accepts it important bottom line silence after a diagnosis is common by the patient and doctors treat this silence as acceptance however because patients accept treatment recommendations and if they want to resist they don39t have to positively object although they can doctors treat silence here as non acceptance study concerning major depressive disorder vs adjustment disorder adjustment disorder does not normally receive antidepressants patients may just describe their symptoms straightforwardly see a commercial and say that they feel the same way as described this study found that half the time patients that ask for a specific medicine will receive it Doctors believes a parent expects antibiotics vs when a physician does not believe a parent expects antibiotics physicians diagnosis correlate with that they feel a parent is expecting if physician feels that parent is expecting antibiotic they will more likely prescribe it for viral infections although not needed when compared to when a doctor does not feel this parent expectation Inappropriate prescribing is the primary factor causing the spread of antibiotic resistant bacteria We are beginning to move towards a post antibiotic bacteria as doctors are pushing to reduce prescriptions of antibiotics Inappropriate prescribing is common prescribing rates of antibiotics for the common cold is about 30 for bronchitis and other viral illnesses is about 60 5065 of parents expect antibiotics for their kids URI conditions which varies with class and ethnicity What is online commentary Online communication is communication to the patient about what the doctor is doing or seeing or about to do during the physical examination of the patient three types of online communication directions open wide onine explanations quotjust gonna check your thyroids while wrapping hands around necl onine commentary quotthat feels normalquot stating what the doctor feelsexplains IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IlIIIUIUIlIIIIIUIlIUIIIUIIIIIIIUIIIIIIIUIIIIIIIU DOC hhh Uhm his efth earh is infected 15gt 02 DOC h is bglging has uh little pus in thuh 15gt backh DOC gt Uhm an it39s red DOC hh So he needs some antibiotics to treat that DAD gt Alright DOC Mkay so we39ll go ahead and treat him lthe has no a uhm allergies to any penicillin or anything 51714 1104 PM Week 7 Wednesdayy lecture 21914 No school on Monday 217 14 The Justice System Trial examinations talkinteraction does have affects on judicial outcomes in everyday life Leqal Formalism talk should be inconsequential only facts and law matter involved this is the textbook view The alternative view Leqal Realism talk has an independent influence on judicial outcomes There are a few distinctive features of trial examinations as follows o tak made for an overhearing audience o specialized turn taking system question and answer o formality Why is there such a special turn taking system o Managing interactional traffic with many participants o Talk for overhearers o Justice ideals The Dynamics of Examination How is directcross examination shaped by the turn taking system o Goal is to establish guiltinnocence o Must be done step by step via questionanswer o QA sequences are produced and understood in light of this larger project Excerpt 1 illustrates these points o Each Q nominates a specific fact but also advances a larger accusatory line of questioning o The line of questioning has a direction and trajectory from relatively factual to interpretiveaccusatory o More accusatory Qs exert pressure for confirmation o Answers to such Qs often resist confirmation 1 Atkinson and Drew 1979 108109 DG1CU1o5UNl39 14 15 16 17 18 19 20 A w W Then a message from you Deputy Comissioner Ask people in Percy Street to go hame as they can39t stand therequot Yes Did you send that message Yes Were those people you were referring to there Protestant people Presumably they were Were they in fact a Protestant mob that was attempting to burst into Divis Street Prior to sending this message I must have known that there was a crowd of people there I want to ask you about the phraseology there Ask people in Percy Street to go home as they can39t stand therequot Was that your message Yes that is my message That was a rather polite way of addressing a mob who had burned and pillaged a Catholic area was it not I did not know that Resisting Attorneys Questions Rape trial excerpt 2 there is a tug of war over level of familiarity resistance as questions propose familiarity How might the witness contest the version of events contained in the Q Expicit rejection no contradictory version Impicit rejection does not contain no version contrasts but does not contradict PROBLEM what makes these accounts hearably in conflict with the Q SOLUTION the maximal property of descriptions Examples Why don39t you come over for drinks AND Why don39t you come over for dinner 2 Rape Trial D U39IhUJN0 D D Now 07 February fourteenth of nineteen seventy five you were 03 you were down a in Boston Is thae Is that right Yes An youwent to a uh 09 uh youwent to a bazr in Boston 06 Is that correct 10 It39s a club 03 Ac1ub 10 There was liquor served there wasn39t there said fast Yes 05 You had some liquor didn39t you Yes 31 It39s a uh singles club Isn39t that what it is sound of striking mallet 09 No youmay have it 11 It39s where uh uh 03 girls and fellas meet Isn39t it 09 People go there in during that evezning 06 uh didn39t Mister Oulette cme over to sit with you 00 Sat at our table 11 Did39t he sit next to you 06 No he sat across fromxme 03 Acrozss frnyou 07 D39e never sat next to you 03 No 21 Did you daznce with Hister Oulette No 10 D 39 y ever dance with 39 im on that evening No 09 D39yquotave any conversationwith39im S3 54 S5 S6 S7 S8 S9 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 05 YeahI was talkin39 to in 20 He take you out to the car 13 no he walked outside with us 05 He walked outside 09 uh hmml 05 With the group Yes noncha1ent tone of voice An a thazt tizme 03 did39e ask ya to go out with You 04 isn39t that correct Yeah with him that so 20 I don39t remember 14 W 1 didn39 he azsk you uh on that night that uh he wanted you to be his gizrl 05 Did he ask you that 25 I dn39t remmber what he said to me that night 12 Well he has uh sme uh uh fairly lengthy conversations with the defendant uh didnf you 07 on that evening u February fourteenth 10 well we were all ta1kin39 00 well you knew at that time that the defendant was interested in you didn39 you 13 He asked me how a39 bin un 11 j just stuff like that Just asked you how 05 you39d bin 03 But he kissed you goodight 05 Izzat right YeahHe asked me if he could 14 He asked if he could 04 Uh hmm kiss ya goodnizght 10 An you said okay 06 Izzat right Uhhmm 3 Rape Trial Implict Contrast Excerptsll Ol0U39uhUNi39 An you went to a uh 09 uh you went to a bar in city 06 Is that correct 10 It39s a cluzb It39s where uh uh 03 gizrls and fellas meet Isn39t it 09 People go there An during that evening 06 uh didn39t Mister nme come over to sit with you Sat at our table Well yuh had some uh uh fairly lengthy conversations with the defendant uh didn39 you 07 on that evening u February fourteenth 10 Well we were all talkin Well you knezw at that time that the defendant was gterested in you didn39 you 13 g asked me how a bin un 11 j just stuff like that Resisting Material Evidence The Rodney Kinq Trial Many who saw the tape thought the officers would be found guilty Chief Prosecutor What more could you ask for You have the videotape that shows objectively without bias what happened that night It can39t be rebutted But none of the officers were convicted Why O O The Defense Strategy Events on the tape must be understood in the context of professional police practices regarding use of force Cateqorizinq police behavior should be understood as follows Escaation De escaation Assessment Significance of this coding system It functions as a guide for perception for jurors and people within the courtroom As a guide for seeing this coding system tends to exonerate the police In other words it has the effect of partitioning the activity into three distinct phases It portrays police conduct as controlled and methodical It portrays each phase as responsive to something King has done Cateqorizinq Kinq s behavior Cooperative Uncooperative Prosecution once knocked down King was cooperative Defense even on the asphalt King remained uncooperative 5 Goodwin 1994 617 H There were ten distinct 10 uses of force rather than one single use of force In each of those uses of force there was an escalation and a de escalation 08 an assessment period 15 and then an escalation and a de escalation again 07 And another assessment period 6 Goodwin 1994 617 D W DO39iU Ib0Nl39 Pour oh five oh one we see a blow being delivered Is that correct That39s correct The force has again been escalated 03 to the level it had been previously 04 and the de escalation has ceased And at at this point which is for the record four thirteen twenty nine 04 we see a blow being struck and thus the end of the period of de escalation Is that correct Captain That39s correct Force has now been elevated to the previous level 06 after this period of de escalation 7 FH hosocoainauai I II I V Goodwin 1994 619 So uh would you again consider this to be a nonaggressive mvement by Mr King At this time no I wouldn39t 11 It is aggressive Yes It39s starting to be 09 This foot is lying flat There39s starting to be ahend in uh 06 this leg 04 in his butt 04 The buttocks area has started to rise which would put us at the beginning of our p gtrumagain 07 Conclusion Both studies Drew Goodwin suggest that talk is not merely epiphenomenal bears on facts and material evidence Both studies also suggest that ways of formulating events also involve ways of seeing those events IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII The Justice System Trial Examinations Legal Realism talk influences judicial outcomes Legal Formalism only facts and law matter Distinctive Features talk for an overhearing audience specialized turn taking system QA formality Why 0 Managing interactional traffic with many participants Talk for overhearers Justice ideals Dynamics of Examination Atkinson and Drew 1979 How is directcross examination shaped by the turn taking system Goal is to establish guiltinnocence Must be done step by step via QA QA sequences are produced and understood in light of this larger project Excerpt 1 1 A Then a message from you Deputy Commissioner 2 Ask people in Percy Street to go home as they 3 can39t stand there 4 W Yes 5 A Did you send that message 6 W Yes 7 A Were those people you were referring to there 8 Protestant people 9 W Presumably they were 10 A Were they in fact a Protestant mob that was 11 attempting to burst into Divis Street 12 W Prior to sending this message I must have known 13 that there was a crowd of people there 14 A I want to ask you abut the phraseology there 15 Ask people in Percy Street to go home as they 16 can39t stand there 17 W Yes that is my message 18 A That is a rather polite way of addressing a mob 19 who had burned and pillaged a Catholic area 20 was it not 21 W I did not know that Excerpt 1 illustrates these points Each Q nominates a specific fact but also advances a larger accusatory line of questioning The line of questioning has a direction and trajectory from relatively factual to interpretiveaccusatory More accusatory Qs exert pressure for confirmation Answers to such Qs often resist confirmation Resisting Attorney39s Questions A Rape Trial Drew 1992 Tug of war over level of familiarity Qs propose familiarity A39s resist 2 Rape Trial 1 D Now 07 February fourteenth of nineteen seventy five 2 you were 03 you were down a in Boston Is 3 tha Is that right 4 W Yes 5 D An39 you went to a uh 09 uh you went to a bar in 6 Boston 06 Is that correct 7 10 8 W It39s a cub 9 03 10 D A cub 11 10 12 D There was liquor served there wasn39t there said fast 13 W Yes 14 05 15 D You had some liquor didn39t you 16 W Yes 17 31 18 D It39s a uh singles club Isn39t that what it is 19 sound of striking maet 20 P 21 09 22 J No you may have it 23 11 24 D It39s where uh uh 03 girs and fellas meet 25 Isn39t it 26 09 27 W People go there 28 29 30 31 D An during that evening 06 uh didn39t Mister Oulette 32 come over to sit with you 33 08 34 W Sat at our table 35 11 36 D Didn39t he sit next to you 37 06 38 W No he sat across from me 39 03 40 D Across from you 41 07 42 D D39e never sat next to you 43 03 44 W No 45 21 46 D Didn39 you dance with Mister Ouette 47 W No 48 10 49 D D39y39ever dance with 39im on that evening 50 W No 51 09 52 D D39yquotave any conversation with39im 53 05 54 W YeahI was talkin39 to 39im nonchaent tone of voice 55 20 56 D He take you out to the car 57 13 58 W No he walked outside with us 59 05 60 D He walked outside 61 09 62 W uh hmm 63 06 64 D With the group 65 W Yes 66 67 68 69 D An a39 that time 03 did39e ask ya to go out with 70 you 71 04 72 D isn39t that correct 73 W Yeah 74 D with him that so 75 20 76 W I don39t remember 77 14 78 D W39 didn39 he ask you uh on that night that uh 79 he wanted you to be his gir 80 05 81 D Didn39 he ask you that 82 25 83 W I don39t remember what he said to me that night 84 12 85 D Well he has uh some uh uh fairly lengthy 86 conversations with the defendant uh didn39 you 07 87 on that evening u39 February fourteenth 88 10 89 W Well we were all takin39 90 08 91 D Well you knew at that time that the defendant was 92 interested in you didn39 you 93 13 94 W He asked me how a39 bin un 11 j just stuff like 95 that 96 D Just asked you how 05 you39d bin 03 But he kissed 97 you goodnight 05 Izzat right 98 W YeahHe asked me if he could 99 14 100 D He asked if he could 101 04 102 W Uh hmm 103 D kiss ya goodnight 104 10 105 D An you said okay 06 Izzat right 106 W Uh hmm How might the witness contest the version of events contained in the Q Explicit rejection no contradictory version o 36 D Didn39t he sit next to you 0 37 06 o 38 W No he sat across from me Implicit rejection does not contain no version contrasts but does not contradict D you went to a bar Is that correct W It39s a cub D It39s where uh uh 03 girs and fellas meet Isn39t it W People go there D E didn39t Mister name come over to sit with you W Sat at our table Problem What makes these accounts hearably in conflict with the SE Solution the maximal property of descriptions Why don39t you come over for drinks Why don39t you come over for dinner Resisting Material Evidence Goodwin 1994 Professional Vision The Rodney King Trial Many who saw the tape thought the officers would be found guilty Chief Prosecutor What more could you ask for You have the videotape that shows objectively without bias what happened that night It can39t be rebutted But none of the officers were convicted Why The Defense Strategy Events on the tape must be understood in the context of professional police practices regarding use of force Categorizing Police Behavior Escalation De escaation Assessment Significance of this coding system It functions as a guide for perception As a guide for seeing this coding system tends to exonerate the police It partitions the activity into phases It portrays police conduct as controlled and methodical It portrays each phase as responsive to something King has done Categorizing King39s Behavior Cooperative Uncooperative Prosecution once knocked down king was cooperative Defense even on the asphalt King remained uncooperative 7 Goodwin 1994 619 1 P So uh would you again consider this to be a 2 nonaggressive movement by Mr King 3 W At this time no I wouldn39t 4 11 5 P It is aggressive 6 W gt Yes It39s starting to be 09 This foot is lying flat 7 gt There39s starting to be a bend in uh 06 8 this leg 04 in his butt 04 9 gt The buttocks area has started to rise 07 10 which would put us 1 1 gt at the beginning of our spectrum again Concluding Remarks Both studies Drew Goodwin suggest that talk is not merely epiphenomenal bears on facts and material evidence Both studies also suggest that ways of formulating events also involve ways of seeing those events The Justice System News Interviews Jury Deliberations Recap Trial examinations general features talk for overhearers QA turn taking system formality Cross examination lines of questioning factural to accusatory pressure for confirmation o Preference for confirmation for a yes answer increases in time How witnesses resist that pressure How witnesses resist material evidence o Ex Rodney king Implication Talkinteraction impacts judicial outcomes Today Jury Deliberations We39ll see how talkinteraction bears on 1 Facts of the case 2 Law that applies 3 Procedural rules for deliberation itself The Mystery of Jury Deliberations Jurors have two primary objectives To reach a verdict unanimously To do so in an accountable way may include showing proper regard for o 1 The facts of the case o 2 the law that applies o 3 various procedural rules o 4 the ideal of justice Accountability informs The decision of each individual juror The collective jury verdict Note Factslawproceduresetc are important not as rules to be followed but as resources for accountability Problem for accountability What if the jurors are in disagreement 0 Sensitivity ofjuror conversion when a juror changes their minds it shouldn39t be because of pressure to do so or because they are tired and want to go home PostVideo Analysis Different jurors hardlinerssofties articulate different bases of accountability Hardliners letter of the law approach guityjustified by 3 fact based criteria 0 easier for them to say that they were guilty according to the law Softies not guityjustification is initially more difficult to articulate 0 Had a hard time finding legitimate rationality that he was not guilty Some key elements in the process Softies treat the issue of proper procedure as unsettled Softies attack the hardliners approach 3 criteria as mechanical a computer could do it Alternative approach 1 Justiceinclusive rationale accountability by reference to the ideal ofjustice o Achieve a just outcome 9 more interpretiveflexible view of the law Alternative approach 2 knowledgefocused rationale accountability by problematizing key criterial facts in light of defendant39s intelligenceknowledge Argued that really the guy didn39t understand himself to be buying a gun but to be following the requirements of the detective course For the jurors who initially said guilty 9 nonguilty they used 2 approach to change their minds Converting the last holdout he argued throughout the discussion that the person was meeting the 3 criteria for guilty according to the law 0 The other jurors don39t take a final vote until the last person can better justify that he is guilty 0 He changes his vote when trying to understand the 3 criteria in relation to one another He thought the defendant couldn39t understand the 3 laws in relation to one another Did the jury nuify ignore the law Depends on the juror and the specific argument being advanced 0 Ex Justice argument I m wiling to disregard the law in the pursuit ofjustice 0 Most arguments however were in the framework of the aw did he really understandknow that he purchased and was in possession of a gun Reasoned about the law and facts to find him not guity but within the law Final Thoughts formalismrealism revisited Factslaw don39t speak for themselves import depends on how they39re selected formulated definedinterpreted But decisions aren39t arbitrary either Jurors show themselves to be accountable to the facts law and also the broader ideal ofjustice o They are loosely constrained to these frameworks of accountability IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 022614 The Broadcast News Interview Turn Taking Prototypical news Interview Interviewer IR is a professional journalist Interviewee IE has some connection to recent news events Discussion concerns those current events Lecture Outline 1 Background 2 The Turn Taking System in Overview 3 Constructing Questions 4 Constructing Answers 5 Departures from the QA Framework 6 Why This System in This Context Functions of the Turn Taking System News Interview as a Form of Talk Talk for an overhearing audience anyone who watches news 0 Contrast to trial jury where audience only jury Specialized turn taking system 0 Similar to trial examination Formal in character 0 people are highly constrained in what they can do Significance of the turn taking system TTS ITS is the basic architecture of talk distributes action opportunities to participants o Tells the participants who has the right to speak at what moment ITS affects the actions themselves ITS is constitutive of the news interview as a recognizably distinct form of talk The Turn Taking System in Overview Turn Taking in Conversation Turn Taking is essentially unscripted you don39t know in advance how the order of speakership should be At most grammatical completion points the parties negotiate who speaks next Turn order length content are not predetermined Turn Taking in the News Interview Turn taking follows a planformat and it39s known in advance Turn order length content to some extent predetermined The format can be summarized in terms of a simple rule IRs Interviewers ask Qs IEs Interviewees answer them 0 Interviewers should restrict themselves to just asking questions and interviewees should restrict themselves to just answering questions that they get from the interviewer Other Activities are packaged as QsAs EX 1 Have a conflict but still to questionanswer format 1 US Meet the Press 8 Dec 1985 Bob Dole Senate majority leader 1 BD and uh I I I think when we start advocating in 2 advance at we39re goina increase taxes hhhh it39s a 3 big big mistake 4 IR1 SENator I39D like to go 5 IR2 is not advocating but 6 at thuh same time recognizing the possible inevitability 7 of it Why can39t you just say it 8 BD I I 9 03 10 BD Well I39m not sure it39s inevitable 11 Let39s let39s take a look 12 IR2 Well then WHAT OTHer WAY can you do it 13 05 14 BD You can get it outta federal spending every question from the interviewer assumes that a tax increase is inevitable and every response proposes that a tax increase is not necessary disagreement but they work to package it as a QA format 2 UK World At One 13 March 1979 Arthur Scargill mineworkers union 1 AS i it39s the press that constantly call me a Marxist when 2 I do not and never have er er given that 3 description of myself hh I 4 IR But I39ve heard you I39ve heard 5 you39d be very happy to to er hhhh er describe youself Statement disagrees with interviewee statement is adversarial 6 as a Marxist Could it be that with an election in the 7 offing you39re anxious to play down that you39re a 8 Marxist 9 AS er Not at all Mister DayAnd I39m sorry to 10 say I must disagree with youyou have never heard me 11 describe myself hhh er as a MarxistI have only 12 4 lines omitted 13 IR Do you ascribe to Marxist economic phiosophy 14 AS I would say that there er the philosophy of Marx 15 as far as the economics of Britain is concerned is one 16 with which I find sympathyand would support itYes 17 18 IR Well that makes you a Marxist doesn39t it 19 AS NOt necessarily Disagreement over whether he is a Marxist in terms of his philosophy every response is an attempt to resist that presumption of him being a Marxist lines 9 he explicitly says that he disagrees All actions are designed as an exchange of QA Is that all there is What is required to actually follow this QA rule Constructing Questions What Counts as an allowable question in the news interview Restrictions are looser here than in trials 0 In trials question design in very tight very simple Most were one turn constructional unit Occasionally one statement followed by a statement IRs can preface their Qs with statements Statement prefaces can be Innocuous background info ex 3 Hostile to the IE ex 2 4 3 MacNeiLehrer 22 July 1985 South African State of Emergency 1 IR gt tch hh Two two members of your organization 2 supposedly arrested today Statement is necessary to provide context for next question 3 D39you feel in some danger when you go back 4 04 5 IE hh There is always danger 4 Nightline 72285 45 IR As Peter Sharp said in that piece it is a lot easier to impose a state of emergency than it is to lift it gt hhh You still have the root cause when you lift it gt And black leaders in that country have made it very clear hhhh that this kind of situation there39s no way of stopping this kind of situation unless there is an end to apartheid gt It seems to me hh that by doing this by eh imposing I guess this kind of repression you hh you really set up uh system where you can do nothing it seems to me hh when you lift it except to change the system that exists there gt the basic system gt hhh Is that unfair er HB Uh I I would think it39s unfair what is being said saiduh because if thuh government is committedh to bring eto bringing about those reforms hh uh to start ay dialogue h then at east 02 those people who are p to be part of thuh process h they should participate in it hh Now what do we have here at thuh moment h Those people who39ve become thuh victims h uh of thuh violence h they are actually thuh people who39ve come to thuh fore many of them h who say that they want to participate hh Now the moment th t they start participating in some kind of uh political process h uh they39re being made outh to be anuh collaborator h When that is being said all of a sudden they become uhtheh theh uh i there39s uh license out hh to kill them hh And in order to to prevent that h we have taken some ratherharsh measures eh wereor extreme measures h but let me also remind you h h this is not something unique to South Africa because of our own puh peculiar political system there hh Uh ihb ehb a state of emergency h uh many countries in thuh western world democratic countries have been used to it hh Uh eh I39m reminded that earlier 39n this year in some of thuhin a very prominent uh western country h a state of emergency was declared h So it is known in thuh world very elaborate position is being laid out in that preface It39s adversarial it directly disputes what the interviewee has said It argues that the root cause of the violence of South Africa is the Apartied it attacks the whole institution that the governor represents At the end is that unfair closes the circle of the adversarial statements each 9 signifies where the interviewer finished the sentence and the interviewee can respond But most pass on the opportunity to speak until the interviewer asks a question Insertions should be seen as leading up to a question Qs as collaboratively Constructed IRs normally withhold speech until a Q is complete EX 4 Withholding includes 0 1 Substantive responses and o 2 receipt tokens mhm yeah oh right Withholding is conspicuous at the nonvocal level This is all part of the work of following the QA rule Constructing Answers Answers are normally elaborated across multiple sentences or TCUs This differs from law courts Ex 4 very long response and the interviewer waits for him to finish o Where witnesses can be held to limited answers ex yesno If a witness tries to say more it can be objected to or stricken from the record No elaboration is treated as problematic Ex 5 5 US Meet the Press 24 Oct 1993 1 IR hh Madam Attorney General you39ve testified this 2 week u in front of Congress about h violence 3 and television hhh And said that if the TV 4 industry didn39t in effect clean itself up 5 clean its act up hhh there may be government 6 intervention Government regulation 04 7 Thuh New York Times in an editorial said that 8 you embarked ona quote ltdangerous embrace 9 of censorshipgt 03 Didju 10 IE gt No Short response unusual non cooperative May be registering a kind of protest 11 02 12 IR hhhh What kind of government intervention 13 are you thinking about Would you ban programs 14 like NYPD Law and Order would you uh he is taken off guard and pursues a more detailed response 15 IE gt No 16 17 IR W What are we talking about 18 IE We39re talking about asking the media 19 to stop talking about what it promises 20 to do and do it IR keeps pushing her to elaborate on her responses IE registering a protest for the content of the question IRs avoid all receipt tokens duringafter IEs answers As these context are being produced by the interviewees the interviewers withhold their response Ex 4 The only response that an IR gives is another questionstatement they don39t say naked talk yeah Oh Departures From the QA Framework IR initiated departures from questioning Are neutralistically framed via 3 part attribution not interrogatives and not recognizable as questions Ex A Quantitative studies the vast majority of IR turns are Qs or neutralistically framed assertions Heritage and Roth 1995 6 8 o of IR turns are unattributed assertions 0 Found that interviewers ask questions or make unattributed assertions Tolson 2012 4 5 o of IR turns are unattributed assertions Example A JS says that nuclear waste is bad IR 9 You heard what doctor yalow said earlier in this broadcast 9 shell have an opportunity to express 9 her own opinions again but she seems to feel that it is an Eminently soluble problem and that ultimately that radioactive material can be reduced to manageable quantitaties n put in thuh bottom of a salt mine Flat out disagreement in declarative form but maintains neutral posture bc blames it on the doctor JS Thuh point that she was making earlier neutraity maintained by linking statements to third party IE initiated departures from QA IRIE1IE2 multiple interviewees come in to respond Requests for permission to speak Ex 6 o Ex May I say something Token requests for permission Ex 7 0 Ex Can I make a point about thatwhich is that doesn39t wait to be granted permission to speak Addressing the IR Ex 8 0 One of the interviewees speaks out of turn but continues to address the remarks to the interviewer as if there is a question on the table 6 MacNeiLehrer 12489 1 EB as long as the two systems exist and we need them for 2 stability h we will have no h uh unification 3 This is absolutely clear 4 HK gt May I say something asks permission to speak SIR Yes sir 6 HK gt on the subject 7 IR Yes sir 8 HK uh ahem I think it is a big mistake to equate the 9 NATO alliance and the Warsaw Pact 7 Greatbatch 1988 419420 1 LL there was no evidence whatever that stiffer penalties 2 di diminish crime 3 MW gt Can I make a point about thathhh which is that P Y token request for permission interviewee doesn39t wait to be granted for permission but just starts talking 8 Greatbatch 1988 420 1 SB The most important thing hh is that Mister Healey h 2 should stick to his guns 3 PJ You see 4 IR Well I 5 6 PJ gt I disagree with with Sam Brittan on a in a most 7 fundamental way about this because 02 it may 8 gt well be soI mean he would arg Sam Brittan PJ comes in without waiting for a question Indirectly addresses Sam Brittan Acts as if he is responding to the interviewer even though there is nothing to respond to Institutional Function of the Turn Taking System It constitutes a solution to some of the basic problems that the parties face in broadcast journalism Interviewer Neutralism o Journalist must be neutral questions on the surface are designed to solicit information Talk for an Overhearing Audience Final Thoughts 51714 1104 PM Week 9 Monday lecture 3314 Question design in the news interview Intro The news interview contract Interviewer needs newsmakers to come on to the show higher profile and the perkier the better Interviewee needs to get the message across more popular shows the better to get publicity Norms of Interviewing Norm of Objectivity their professional job is not to be biased of particular intervieweespolitical views Adversarialness your job is not to just let the interviewee to just give a speechsimply their opinion interviewer asks questionschallenges them in order to ask what the public wants to know Number 1 on handout The Attlee Interview 1951 election campaign questions only no topic shifts simple questions questions are open ended questions are conventionally indirect polite non committa answers are not pursued interview style is deferential interviewer is careful not to anger the interviewee interviewee is brusque and treats himself as non accountabe to the TV audience 1 BBC Interview with Clement Attlee British Prime Minister 194551 SkD00lOU39IlgtUoIJI t IR IE IR IE IE Good ning Mister AtteeWe mpe you39ve had a good jou y 02 Ygs excellent h 02 Can you now you39re gck hhh having cut short your lgture tour tell us something of Mm how you 02 w the election prospects 02 Oh we shall go in t39give them a good ght 02 very 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IR IE IR IE IR IE good 04 very good chance of gtwinningWe shall go in fidentyWe always dglt 07 Uh And on Lmt will Labour take its stgnd 04 We that we sh39 be announcing shgtly 02 What are your immediate j3jns Mister Attee My immediate plans are ltt39go downgt to a committee t39decide on Est that thing hhh gtsoon39s I can get away from relt 02 hhehhh Uhm hh Anything else you woudgt gre g y agt th39 coming election amp Number 2 on handout The Scargill Interview 1979 questioning him about being a Marxist questions are complex questions are narrow yesno questions questions are direct answers are pursued and disagreed with interview style is accusatory interviewer is brusque and adversarial 2 BBC Radio Interview Robin DayArthur Scargill 1979 1 2 KOCIlOU39hbd 10 AS IR AS IR hhh er hat39s the difference between your Marxism and Mister McGarhey39s Communism er The difference is that it39s the pLess that constantly call me a Marxist when I do Lt and never have er er given that description of mysefhh I But I39ve E you I39ve heard you39d be very happy to to er hhhh er deg yourself as a Marxist Qould it be that with an election in the offing you39re anxious to play down that you39re a Marxist er Not at all Mister DayAnd 11 I39m grry to say I must disagree with youyou have Ever 12 heard me describe my lf hhh er as a MarxistI have ony 13 been put in the position 0 of swering that question when the 14 sgific point has been ppt to me hhh about whether or not er 15 I would call myself a Marxist hhh or whether or not h I 16 subscribe to xist gonomic phiosophy 17 IR Do you aribe to Marxist economic phiosophy 18 AS I would say that there er the j osphy of Marx as far as 19 the ecogics of main is concerned is one with which I find 20 s3pathyand would suppci itYes 21 22 IR Well thit makes you a xist doesn39t it 23 AS Not necesiy makes me a 24 Marxist in the deg pjive sense Simple and prefaced questions 3a simple question with no context given normally formed as an interrogative and 3b prefaced with background info conveyed to audience examples on handout 3a Simple question format Question 1 IR d39you feel in some danger when you go back 3b Prefaced question format Statement Question 1 IR S gt hh Two two members of your organization supposedly 2 arrested today 3 Q gt d39you feel in some danger when you go back uses of prefaces 0 giving background info example 4 on handout o justifying why a particular question is asked of this particular IE example 5 we know that police has been shot at thanks to preface and 6 0 building a more complex and insinuatinq context for a question example 7 4 UK BBC Radio World at One 25 January 1979 1 2 3 IE IR hhh The price being asked for these letters is three thousand pounds Are you going to be able to raise it hh At the moment it seems not 5 UK BBC TV Newsnight 21 Oct 1993 1 OU39lgtUU IR IE You as I say have been shot yourself in thuh in thuh line of duty ahm let39s just look at thuh question of ing thuh police first of all Is it your view that the police should now be armed hhh But definitely hhh Ahm we w have no rights as a society to expect young men to enter situations 6 UK BBC TV Nationwide 15 October 1980 1 2 LDmlOU39gtUd 10 IR GR GR Mister Rippon I must ask youyour name has come up as you know in connection with the possibility of standing against Mrs Thatcher for the hh leadership er Are you likely to be a candidate to challenge Mrs Thatcher hhh Well I du I think it39s very unikeyBut I I I think what has happened hhh is that er it39s a reflection of the anxiety part of the pressure quite spontaneous pressure to urge her to hhh er change her hh attitude er uhm direction of policy before it is too late 7 Face The Nation 041695 Senator Phil Gramm Texas R 1 2 IR Ijust wanta get to thuh jgtcitics of this McNamara book hh agt Ah President Clinton avoided thuh draft LDmlOU39gtUd 10 IE 11 bgt and he seemed to suggest that this book in some way ah indicates that draft avoidance and almost removes Vietnam as a political issue now and forever more cgt hh avoided thuh draft h dgt do y feel h that this ih this book is gonna help inoculate you from say Bob Dole who has this war record in your own competition I don39t think so I don39t I don39t think I Ed vindication 03 and I don39t think gks vindicate you News interview questions Neutral or Neutralistic News interview questions can never be neutral but instead naturalistic Three features of question design questions set topical agendas they involve presuppositions questions YN or polar preference tilts Neutral questions are not really possible Topical agendas o 1 Questions may set topical agendas that the interviewee would rather not talk about o 2 Questions may incorporate presuppositions that the interviewee would rather not deal with may have a big preface leading to the question o 3 Questions may be embody preferences that are tilted towards a response that the interviewee may not want to give applies to yesno questions Questions set agendas Topic and action agendas that IE s responses conform to those agendas or not example 9 interviewee is sensitive to the topical agenda that has been set AND IE failure to provide a straight answer permits IR s to pursue answer 9 BBC TV Panorama 28 January 1981 1 IR 2 Roy Hattersley hhh is it right to interpret this as a move back hh to the ghtThis er Lictory by such a narrow occurring AND setting up an insinuating question example 12 attributing intelligence to the American public when question insinuates they are not 11 UK BBC TV Newsnight1989 1 IR 2 OU39I500 IE Now turning to the exchange rate mechanism you have consistently said or the government has said hh that you will join when the time is right but people are saying hh that that means never Could you define the kind of conditions when you we would go in Uh no I would Lt say it means never For the policy 12 US PBS MacNeiLehrer 21st Oct 1993 1 IR 2 KOCIlOU39hut 11 12 13 14 15 16 IE Let me turn now to our two professionals here in media in media wars gt Mister Castellanos hhh Uh you of course produced thuh gt Republican National Committee ad If you Lere designing the entire ad campaign for opposition to this plan hhh what would you say are the two or three most important things it has to do What does it have to tap in the American public to be successful 05 I think we39r that39s what we39re trying to do in the ah in thuh Republican ad Margaret hh We ah we want people to read thuh pan And when they do I think ah they39ll understand that this is not a plan for tter health care hhh we just want them to know that this is a plan for mgger government Presupposition Questions assert things about the world through presupposition and prefacing 0 questions embody presuppositions examples 1316 0 IE s confirm to those presuppositions or not o prefaced question asserts background facts that IE s have to deal with Questions assert propositions and embody presuppositions with varying levels of explicitness 13 US PBS MacNei Lehrer 21 October 1993 Health Care the IR addressed by name at line 6 is Margaret Warner OU39IlgtUoIJI t IR IE Mizz Jenckes let me start with you Ah you39ve started all of this I think thuh health industry associationgtHeath insurance association hhh Why so early in this debate when there39s not gonna be a yote on it ih f39r maybe a 3Lear Margaret health care reform is H under way 14 US MacNeiLehrer 21 October 1993 Simpified Let me Let me just ask Mandy Grunwald one other How do you explain that public support for thuh President39s plan has dropped off rather sharply since he announced it a month ago We haven39t seen those sharp drops at all In fact we39ve seen So your internal poing doesn39t Our our internal poing 1 IR question 2 3 4 5 IE 6 7 IR 8 IE 9 has seen sustained ah support for thuh plan 15 UK BBC Radio World at One 13 March 1979 1 IR hhh er hat39s the difference between your marxism and 2 Mister McGarhey39s communism 3 IE er The difference is that it39s the pLess that constantly 4 call me a marxist when I do Lt and never have er 5 er given that description of myself 16 US ABC Nightline 15 October 1992 On the 1992 US Presidential campaign 1 IR gt hhh Mister Carville should Governor Clinton39s 2 gt character now be off limits somehow 3 IE Well I don39t know anything about his character being 4 off limits thuh man has magni1 icent character Preference 0 questions prefer particular answers examples 1719 0 IE responses align or not 0 prefaces can add extra to preference example 20 pilling up of facts pushes towards a certain answer regardless if the actual question is or is not tilted to a yesno or counter balance the preference of the question example 21 question is balancing itself as the preface hints for a yes while the actual question is a straight interrogative with a negative polarity item and thus leading towards a no answer Questions can be designed to 39prefer39 particular responses 17 BBC TV Newsnight 14th October 1981 1 IR gt But do you accept that Sir Geoffrey this afternoon said 2 he Ln39t going to change 3 02 4 IE I accept that yes 5 IR gt But you think he39s gally wrong 6 IE Yes 18 BBC Radio Today 1 IR Now there39s talk that thuh cabinet will announce some 2 sort of amgty for people who39ve committed crimes 3 ah gially motivated crimes presumably hh Uhm under 4 thuh ah over thuh last few years 5 gt E wouldn39t be acceptable to thuh ANC would it 6 IE hhh Question of amnesty39s a very difficult situation Q 19 US McNei Lehrer Newshour 18th September 1992 1 IR Alright n let39s talk about some of the things you propose 2 Raising the tax on gasoline tel cents a year for the next five 3 years fifty cents 4 RP Yes 5 RP Yes 6 IR A h a gllon after five years 7 RP After five years 8 IR Eh taxing all but fifteen percent of the social security 9 benefits of recipients that earn over twenty five 10 thousand dollars a year 11 RP Exacty 12 IR Now 3ltu re endorsing that 13 RP Yes 14 IR gt Do you Eiously believe that President Bush g Bill 15 gt Clinton again is going to endorse either E of those 16 RP I thought E1 feel 17 the American people don39t have the stomach for 02 shared 18 sacrifice 12 The fags are the American people doThat s 19 the point we39re trying to make 20 US CBS 60 Minutes Topic is whether US troops could have been exposed to Seron gas during the gulf war causing gulf war syndrome IR Secretary Deutch you say there is no evidence hh You39ve got gses where khh theh Czechs say that they lfound seron Yeu say they didn39t they say that they Qd hh You have Lldiers saying that they experienced ning sensations after explosions in the eir That they became guseous that they got hh headaches hh You have two hundred fifty gallons of chemical agents that were feund inside Kuwait 10 hh You had scgs that had Eon in the werheads 11 10 12 IR If that39s not evidence what is it kO00lOU39IlgtUoIJI t 21 UK BBC Radio Today Bosnia Camps 1 IR gt hhh People have used thuh phrase concentration camps 2 gt and thuh Bosnians themselves have used that phrase Do gt you believe there39s any justification for that at all IE hh I think in thuh case of some of thuh larger camps there are that39s certainly accurate hh ah if you count h gture and execution as hallmarks h of concentration camps h then thuh reports we39ve received ah would seem to suggest that is an accurate description for some of them KOCIlOU39hbd 8 Three Main Features of News Interview Questions and Answers IR Questions IE Responses Set Agendas EngageDecline to engage i Topical agendas i Topical agendas ii Action agendas ii Action agendas Embody presuppositions ConfirmDisconfirm presuppositions Incorporate preferences AlignDisalign with preferences Questions that don39t Questionquot Negative interrogatives are treated as making assertions by IE s are the only interrogative form so treated can be the focus of game playing about the limits of questioning and journalistic standards Accusatory questions How could you kind of questions present the question as unanswerable and therefore is hearably an accusation Questions that don39t 39question39 22 PBS MacNei Lehrer 22nd July 1985 1 IR gt But isn39t this d glaration of thuh state of 2 emergency an admi39ssion that the eh South African gger39ment39s J3cicies have not ked an in fgt that the um United S es administration39s policy of constructive enggement has not worked IE gt I do no c agree with you hhhh that the approach we have taken toward south africa is a is an incorrect apprgch lOU39I500 23 Presidential Press conference 7th March 1997 1 IR W39 Mister President in your z l for funds during 2 gt the last campaign hh didn39t you put the Vice President 3 an Maggie and all the others in your 04 administration 4 top side hh in a very vulnerable position hh 5 05 6 IR gt I disagree with thathh u How are we vulnerable because 24 ABC This Week October 1989 Darman 1 IR gt Isn39t it a fact Mr Darman that the taxpayers will 2 pay more in interest than if they just paid it out of general revenues IE No not necessarily That39s a technical argument IR It39s not a may I sir It39s not a technical argument gt Isn39t it a fact IE No it39s definitely not a fact Because first of all twenty billion of the fifty billion is being handled in gt just the way you want through treasury financing The 10 remaining 11 IR gt I39m just asking you a question I39m not expressing my 12 gt personal views 13 IE I understand KOCIlOU39hbd 25 CBS Evening News February 1887 1 IR hhh Can you explain how jg were supposed tuh be the 2 eh you EL you39re an anti terrorist gpert hhh we 02 I was officially a grorist te hh OZU went around telling eh eh ehr IE I39ve already expljined that Dan I wanted those hostages I wanted Mister BLckey outta there IR Mist Vice President thuh gLtion is IR But 03 10 IE before 39e was ied which he 11 IR gtYou39ve you39ve made us hypocrites in thuh fag o39 thuh mrld 12 IR gtkl couldja gr ho coudja sign Q to such a policy 13 IE That was bad 14 IT hhh And thuh gLtion is what does that tell us 15 IE Well haf thuh same reason 16 IR about your cord 17 IE thuh Eident signed on to it 02 Thuh same reason thuh 18 esident signed on to it hh When a CIA agent is being gtured KOCIlOU39hbd 19 tuh death h maybe ya g on the side of a human iife Really Nasty Questions 1 Forks or when you give IE two alternatives that are BOTH undesirable example 26 on the handout 2 Contrasts or when you portray the IE as falling short by references to higher standards of behavior represented by the contrasts number 27 on the handout comparing the person to some sort of gold standard and that the person is not living up to those standards Really Nasty Questions Question Prefaces and the construction of 39forks39 and 39contrasts39 26 Meet the Press December 1985 1 IR Senator 05 uh Pgident Reagan39s elected thirteen months 2 ago an engmous landslide 3 08 4 IR a gt It is s that his pLograms are in trouble though E seems 5 a gt to be terribly popuar with the American people 6 06 7 IR b gt It is said by some people at thuh Lme House we could gt 8 b gt those programs thgh if only we had perhaps more hh 9 b gt uhffective leadership up on thuh hill an I suppose 10 IE hhhheh 11 IR b gt indi39ly that might relate t39you as Le 12 13 IR q gt Uh whaddyou think thuh problem is rilly Is it 02 thuh 14 q gt lgdership as it might be claimed up on thuh hill er is 15 q gt it thuh pmgrams themLves 27 CBS Evening News 12588 Bush Rather 1 IR Mister Vice President thank you for being with us tonight 2 a gt hh Donald Gregg still serves as your gusted advisor 3 a gt He was dgply inmlved in running arms to the contras 39n 39e 4 a gt didn39t inform you 5 b gt hhh Now when President agan39s 03 trusted advisor 6 b gt Admiral mindexter 05 failed to inform hi 07 7 b gt thuh President 04 ed 39im 8 05 9 IR q gt Lhy is Mister Gregg sti 02 inside thuh White House 10 q gt 39n still a trusted adLBor 11 IE Because I have confidence in him hh 39n because this matter 12 gm as you well ow f 28 BBC Radio 1960 Hastings Banda soon to be President of Malawi formerly Nyasaland 1 IR Doctor Banda what is the purpose of your visit 2 IE Well I39ve been asked by the Secretary of State to come 3 here 4 IR Have you come here to ask the Secretary of State for a 5 firm date for Nyasaand39s independence 6 IE I won39t tell you that 7 IR When do you hope to get independence 8 IE I won39t tell you that 9 IR Doctor Banda when you get independence are you as 10 determined as ever to break away from the Central 11 African federation 12 IE Need you ask me that question at this stage I DO IR Well this stage is as good as any other stage why do 14 you ask me why I shouldn39t ask you this question at 15 this stage 16 IE Haven39t I said that enough for any everybody to be 17 convinced that I mean just that 18 IR Doctor Banda if you break with the Central African t KO Federation how will you make out economically after all your country isn39t really a rich country is it CD 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 IE IR IE IR IE IR IE IR IE IR IE IR IE IR I39m not Don39t don39t ask me that Le leave that to me Which way is your mind working Which way I won39t tell you that Where do you hope to get economic aid from I won39t tell you that Are you going to tell me anything Nothing Are you going to tell me why you39ve been to Portugal That39s my business In fact you39re going to tell me nothing at all Nothing at all So it39s a singularly fruitless interview Well it39s up to you Thank you very much Concluding thougm No matter how many questions an interviewer asks the interviewee can take the heat and just not answer IIIIIlIlIIIIIIIlIIIIIlIlIIIIIIIlIIIIIlIlIlIIIlIIIIIIIlIIIIIIIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Week 9 Wednesday lecture 3514 Answers and Evasions Resistance Interviewees can deal with or resist pressures of the design of the question with their responses Benefits of resisting the Q o avoiding undesirable topicstasks o avoid alienating segments of the public 0 staying on message talk about the things they want to talk on them on their terms Media advisers tell their politician clients to take the above steps In clip exchange Al Gore was forced to shift his position on abortion to match his running mates viewshealthcare plan was questioned on this and was drawn by his adviser to turn the question around today I want to talk about Costs of resisting the Q o monitored by viewing audience through audience inferences or unflattering because the second pair part did not answer the given first pair part we as audience will try to think about why a Q was not answered and they are not to be good 0 IR or journalists frequently try to use followup questions when IE side steps the initial question may also sanction himher expose the resistance to the question implicit or explicitly first 3 examples on handout If you had to address you mind to the question which you put off 1 Greatbatch 1986 451 Unilateral nuclear disarmament 1 IR 2 PS KOCIlOU39hbd 10 11 IR 12 13 14 15 PS You wouldn39t serve in a Cabinet committed to lu ilateral nuclear disarmament of ritian would you Mister Shore hh hat I do beieve er Mister Day which I will not answer that question I39m not de erately answering that question What I do believe is this I do actually genuinely believe ong believe d hhh that unilateral gives can as multilateral disarmament 3 further lines on the benefits of uniateraism gt wu wu Would it er mlp you if you had to er hhhh address you mind to the gu1e stion which you put off for one moment as to whether you would serve in a Cabinet hhh committed to unilateral disarmament of Britain hhhh I would nehver mysef 2 Nightline 6685 7 Nuclear waste disposal RY a scientist and defender of the nuclear industry has been arguing that the amount of radioactive waste is smaller than many believe IR 3 RY IR RY If one can gparate the nadiogtive material from thit which contains it then you39re absolutely right C a n you separate it sneeze 15 u You ngd not have 05 this egmous volume The actual Lolume hh of 06 radioactive material 05 proged 02 if we were to get 04 aH of our elec ity from nuclear power h would be the e Loume equivalent of Qe aspirin h per son per year hh This is Lt an enormous volume of magia thet would have tuh be dealt with gt You re you39re fecglging my brain Doctor Yallow what I asked you is is it possible tuh separate thuh radioactive matgial from thuh gt of thuh ystance gtin other wordslt h if we can gparate it an we then have smaller quantity tell me about it hh An if we can39t wud The answer is yes we c39n rege these volumes enormously 3 9News 22 May 2012 Mike Coffman 1 IR 2 KOCIlOU39hbd 10 11 IR 12 13 MC IR MC Let me ask you after your comments about the president d39you feel that voters are owed a better explanation than just I misspekeh 20 I think that 12 uhm as I s I stand by my statement 07 uh that I misspoke and I apologize hh Okay And who are you apologizing te 05 hh gtY39know I stand by my statement that I misspoke and I apologize h Eh gtI apoogizelt w we talk to ya all thuh timeyer a gt very forthcoming gey who39s telling you not to talk 39n to hande it like this 14 MC Ya know I I 02 stand by my statement that I 15 wrote 02 that you have 06 and I misspoke and I 16 apologize Subsequent news coverage example 4 on handout interviews covered the next day on newspapers etc When a politician has been evasive that very fact is highlighted win such news 4 LA Times 112286 Twice Discussed Overture Toward Iran Shultz Says Later asked specifically whether he was present when a gt decision was made Shultz declined to answer How do IE s manage acts of resistance so as to reap the benefits of not answering the questions while minimizing the costs Basic forms of resistance 0 Overt openly acknowledge that the Q is not being answered straightforwardly o Coverty do not acknowledgeadmit that they are not answering the questionresisting act as if nothing unusual is going on Overt resistance They are either not going to answer the question or shift the agenda in some way and they let this be known Forms of damage control 0 to the IR or interviewer examples 58 on handout precede movements away from the question 0 downplay and suggested that something else they have to say is not a big deal example 7 8 o examples 711 they can provide an explicit account as for why they are not explicitly answering the question or why they are going to begin addressing a different topic good illustration in example 9 justification is this is what is really important not the other question OR example 10 is a 2 part account effective way or IE making it known that heshe wil never answer that question there is a GOOD reason for not anwering the question or turns it into a positive light 5 UK Newsnight Civil Unrest in China 1 IR DH Well what do you think do you think this strengthens 10 a great deal the hand of Zhao Ze Young and the regmers the radicals I think that 02 Jao Ze Young just as he was responsible for bringing China out of the turbuleng which followed the hhh uh resiggtion of Hu Yao Bung as General Secretary inuh Jiuary nineteen eighty seien Hhh just as he brought China out of thit turbulence he will bring China out ofthi turbuleng hhh and I think his stature has almy been increased by recent events h and ah I39ll go Lt on a limb and say I think it39s likely to be increased Qther hh by future events 1 gt but I would like to make two very quick points IR 2 gt y quickly if you would DH There39s a genegtional thing here Hhh Uum 04 ih Dung Zhao Peng is going to be eighty file on the twenty second of August this year Hh he joined the communist party 03 h in nineteen twenty four Hh When Mister Baldwin had become Prime Minister for the first time in this country Hhh 03 gondly 03 cormption Hh A ot of what is caed corruption hh is in fact the byproduct 01 of a system of multiple pricing hhh which I think is going to i to be reaxed 6 UK Afternoon Plus Abortion 1 2 3 IR JK Jill Knight may I ask you how far that39s going to be put into practice and what who is going to degide what Ye s 4 IR is serious and what is a substantial 5 JK Yes hh uh 6 JK Well of course the tor and u h thuh 7 in other areas whhere medica th39medica profession 8 9 JK is piiticed hhh tors39ve been guite capable of 10 deciding what39s gious and what substantial ms 11 gt hhh And can I also point out hh that uh 12 Professor Huntingford whom you md on hh 301 13 program in Degben hh supjooiting the abortion act 14 hhh uh eh said really again quite gcently 15 there39s no dohubt abohut itwe got abortion on 16 AregLt hhh and this is what parliament did LOT ask for 7 US 21 Oct 1993 MacNeiLehrer Health Care Ad War LJ Let me may just make one comment in terms of what Ron says 8 UK Today Child Support RH Can I say just to set the context 9 US 5 June 1985 Nightline Corporate Mergers IR hhhh Senator Metzenbaum take me back to the to that ference that uh Mister Forbes made a moment ago between monopolies and what we have todiy which it seems in in gme instances is ing hh at least 02 graduay in the digtion of a monopoly is it not 04 HM Well I think thet gme rgers don39t have any element of monopoly in them at aH hh Uh for example General Motors buying Hughes Aircraft I39m not at all certain that there39s any monopoly issues there gt On the gther hand I think the gal concern tha at gt been addressed previously in this program HAS to do with the fact that parenthetica comment omitted when you have a major merger of this kind of the KINd that we39ve been talking about on this program hh you f to worry A does it eliminate competition and therefore what does it do to the consumers uh gondly you have to be concerned as to the impact on the shareholders and thiid but certainly not lgst of the three is the impact upon the communi 10 US 6 June 1985 Nightline Nuclear Waste 1 IR Continuing our conversation now with Doctor Rosalyn Llow 2 Doctor Yalow uh ehh l me put it in very simple terms If it39s doable if it is lly disposable y m we 10 RY gt Well frankly I cannot ANswer aH these gt scientific questions in one minute given to me On the other hand there was one rible thing that happened tonight that you have h in addition extlded hh And that is thuh NOtion that there is an ihcreased incidence of 10 cer associated with the Three Mile Island gcident KOCIlOU39hbd 11 US 5 May 1996 ABC This Week With David Brinkley Robert Rubin 1 IR But which way are they going now 2 RR gtgtFor three and a half yearslt hhh Saim I have had for 3 three and a half years a policy of gtnot commenting on 4 Lhat markets are gonna do Covert resistance Side stepping a question while acting as if nothing unusual is going on often involve subtle shifts in the action agendas of the interview Topic agenda may be maintained but the action agenda is not followed example of videointerview about use of chemical use by the military troops playing a game of whack a mole IR can39t quite whack the mole acts as if he is still answering the question Forms of concealment as if they were an answer to the question 0 subversive word repeats and allied practices example 12 IE repeats the phraseology from the question so that they can claim that they are answering the question 12 WAO 31379 Arthur Scargill IR gthhh er hat39s the difference between your marxism and Mister McGarhey39s communism AS gter The difference is that it39s the pLess that constantly call me a marxist when I do Lt and never have er er given that description of myself 13 US 15 Oct 1992 PBS MacNeiLehrer Presidential Debate 1 IR hh Mister Miford ah r your mg Ross Perot is gonna 2 spend at lea st ten miion COEll S hh in TV advertising 3 gtin thuh final two and a half weeks of this campaignlt 4 hhh Is he gtually gonna get out and and meet with 5 voters campaign like the other candidates 6 CM Yeh well let39s talk about this for a second 7 Ah the thuh other two candidates receive over 8 fifty five point two million dollars directly from thuh 9 taxpayers hh Mister Perot is spending his own gney 10 In addition to thuh fifty five million dollars that they 11 gt from thuh federal government hh they get over a 12 hundred million dollars in soft money Thuh Lhole way 13 thuh political process is financed is something we 14 object to HHHH I I imagine he will spend ten 15 million dollars on media cause what we see is something 16 very extraordinary in American politics hh Usually 17 with thuh passage of time independent candidates go 18 Qwn in thuh pos hh Since we have gtered the 19 race according to thuh polls we39ve gone from seven to 20 fifteen pergntm And we think Perot is gonna win Some 20 lines of transcript omitted 21 IR You you gave a gd answerYou never answered my 22 ggstion however hh gtPart of thuh political processlt 23 is for candidates actually to get out and meet with voters 24 03 gtIs he gonna do that 14 The Best of Nightline 0845 IR Uh 05 I told y 04 some days ago when we spoke and I told our audience this evening that I would ask you Qth questions I will ask you thuh first mw just before we tak a meak because I think I know what your swer39s gonna be gt Did you have an affair with Miss Rice GH gt hhhh Mister Koppel 11 if thuh question is in thuh twenty nine years of my marriage including two public separations have I been absolutely and totally faithful to my wife hhh I regret to say thee answer is no 15 BentsenQuayle Debate 10588 0200 JRN hhhh Senator 3Lou have been giticized as me all gm for your decision to stay gt of the Vietnam Lar 03 for your poor academic record hhhhhh but me troubling to so me are gme o39thuh gments that39ve been made by people in your own party tch hhh Just last Leek former Secretary of State g hh said that your pLk 02 was thuh dumbest gll George Bush coud39ve made AUD hhhhxhxhxhxxXXXXXXXXXXXX JRN Your leader in thuh Senate AU D XXXXXXXXXXXXXXXXXX XXXXXXXxxxxxxx 5 8 JRN Your leader in thuh Senate Bob e said that a better qualified person could have been mosen hhh Lher republicans have been far e critical in private hhhh Mhy d39you thik that you have mt de a more subst tial impgssion on some of these people who have been able to observe you up cose 15 DQ gt hhhhhh Thuh question e s 10 to whether I39m qualified 11 to be vice president 08 hhh and in thuh gse of a gagedy whether I39m qualified to be president 06 hhhh 07 QLaifications for 02 thee office of vice president 39r president 10 are not age agne 15 You must look at acgplishments 10 and you must look at experience 11 hh I have re experience 10 than ers that39ve soughth thee office of vice president 16 Invented JRN Why do you think that you have not made a more substantial impression on some of these people who have been able to observe you up close DQ Qualifications for the office of vice president or president are not age alone You must look at accomplishments and you must look at experience 17 BentsenQuayle Debate 10588 02651 JRN Senator I wan I wanna take you back if I gn to thuh question judy as ked you about some DQ o39thee apprehensions people may feel about your being a heartbeat away from thuh presidency hhhh and let us assume if we can for thuh sake of this question that you become vice president and thuh president is incapacitated for one reason or another and you hafta take thuh reigns of pgwer hhhh when that moment Q me w Lhat would be thuh mst steps that you39d take 02 and Lhy 32 hh First I39d first I39d say a prayer 11 tch for myself 23 and for thuh country I39m about to lead 24 and then I would 11 assemble his 11 people and talk 08 hhh gt And I mink this question keeps going ck to 10 AUD thuh qualifications and what kind of 11 of vice president 39n 07 in this hypothetical situation 10 ifI had to assume 08 thuh responsibilities of 03 president what I would be 10 hhh and as I have gid 12 tch age aane 03 hh although I can te you hh after thee experience of these last few weeks 39n thuh campaign I39ve added tan years to my age xxxxxxx 17 Age alane 10 is Lot 02 the mly 05 qualification hhhh you39ve Qt to lack at expgience and you39ve got to look at acQmpishments 18 BentsenQuayle Debate 10588 04550 JRN Senator I wanna take you back to thuh question that I asked you earlier about what would happen if you were tuh take over in an emergency and what you would do first and why hhhh you said you39d say a prayer and you said something about a meeting what would you do next AUD h hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh h DQ I don39t believe that it39s 06 proper for me to hh get into thuh specifics 05 of a hypothetical situation like that 12 gt thuh situation is 08 that if 08 I was called upon 07 to serve 07 as thuh president 04 of this country or thuh responsibilities of thuh president of this country 10 would I be capable and qualified 02 to do that 05 hh and I39ve tried 04 to list thuh qualifications 10 of tweve years in thuh united states congress 19 BentsenQuayle Debate 10588 05630 JRN Senator Quayle I don39t mean to beat this drum until it has no more Ed left in it but to follow up on Brit is question when you said that it was a hypothetical situation hhhh it is sir after all thuh reason that we39re heie tonight hhh because you are DQ Mhm JRN mnning not just for vice j3Lesident AUD x x xxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxx 44 JRN And if you cite the experience that you had in gress 02 my you must have ge plan in mind about what you would dg if it El to you to become gtgesident of thuh united stateslt it has to many vice presidents hh Est in thuh last twenty five 3rs er so 03 DQ tch hhh lemme try tuh answer thuh question one more time I think this is thuh fourth time 10 that I ave had this question h an39 I think JRN this is third time DQ that hh three times 08 that I ave had this question an I39ll try tuh answer it agin for ya 03 as ceary as I gn 07 hh because 1gt thuh gLtion you39re king 13 is Lmt Qd of gualifigtions hhhhhh does n Quayle have to be jopesident 10 2 gt tch Lhat kind of qualifications do I have 3 gt and Lhat would Ido 10 in this kind of a situation And Lmt would I do in this situation hh I would 19 make sure 21 that thuh people in thuh gbinet 09 39n thuh people 39n thuh adgsors to thuh piesident are glled in 02 an I39ll tak to em 05 an I39ll work with 39em 51714 1104 PM Interaction en masse Political Speeches Rhetoric and Applause conversations made by individual speakers to a mass audience Max was interested in the ways lawyers address the jury how am I going to keep the audience from diverting what kinds of things are persuasive to a jury or compelling wanted something more systematic The problem if you are holding a convo with someone the turn taking system provides built in motives for listening people want to take a turn or may be called to take a turn they need to know WHEN to start and WHAT to respond In monologues lectures sermons speeches do not have the same motivations How then does an individual speaker retain the attention of the audience By enabling audience reaction React by booinghissingshoutingshaking fistdisapproval but mostly audience tends to display approvalapplause Significance of applause appause is a display of approval strongy applauded speechesspeakers are seen as popular there is payoff during the live occasionget more animatedcared for and in media reaction Media reaction 1 video one applause from a supporter and another from someone who was attacked I the speech rate of clapping is a very visible index of who is on who39s side one will be accountable for their clapping behavior NORMAL length of applause is about 8 seconds Audiences and Speeches 1 party speaker 2quot party Audience clapping approval and affiliation with what was said booing disapproval and disaffiliation with what was said perceptions of popularity important for career and to stay effective in office Average Applause time 8 seconds 8 seconds strong applause 8 seconds weak applause Max Atkinson Applause structured by the sentences that lead up to it The Problem of Response Coordination How does an audience get to clap how does an episode of applause get started Independent decision making Looking at the graph the applause reaches its peak of intensity at about 1 second most applause begins quickly as a burst most everyone has to agree and therefore applaud pretty simultaneously people must coordinate applause Benefits Expressive audience members show support Instrumental makes recipient appear popular to others whether in same location or on TV clap a lotto show how much bigger and better your support is than the claps of others 0 Important for competitive opera claques cheer for favorite star and in political conventions and debates to drown out disagreements Costs possibility of isolation undesirable acute discomfort embarrassment Atkinson Bursts of applause rapidly increase in volume and then gradually fade 0 Electronic reading of applause intensity and duration for a well applauded passage The shaded area shows the talk the white area the applause From Atkinson 1984a373 IIf39 llelll39H39ill39l39 illlll quotl 7 l e W ifI i ii k 39I39 i ii iiiuE iLlZ ll lll quotLil fill lull ill lllll 39rlll 39Hquot l3939l lilil39lquot lrllllllllljl Applause starting with isolated responders rarely builds to same volume or lasts 8 seconds Instead its weak and dies out quickly POINT audience members prefer to express opinions that are in agreement with others and avoid expressing opinions that seem to be unpopular Thomas Schelling 1960 applauding a speech games of pure coordination Everybody benefits if they can coordinate their actions but they lose if they cannot Problem coordinating applause and avoiding costs of isolation Schelling solution prominence and conspicuousness Atkinson same conclusion 0 applaudable statements were normally made prominent by being emphasized through language rhythm stress intonation and gesture o Applaudable statements need to be projectable audience members must be able to see up ahead when applause might be attempted ppl need to prepare to clap o 9 achieved by creating slots for applause that ppl can anticipate and prepare for Formats for Inviting Applause 1 Contrasts a negative statement is counterbalanced by a positive one most common and diverse involve greater emphasis on the idea embodied in the second half Strongly associated with audience response 9 make it 4x as likely to applaud 1 Contrast GA Gov Zell Miller 1992 Dem Convention 1 ZM He gs 06 he says he39s an outsi der who will shake 2 up the system in Washington 04 But as far back as 1975 3 he was lobbying ggress for tax is 04 He tried 4 to turn fifty five thousand dollars in contributions 5 into a special fifteen lm dollar tax oophoe 6 that was pa taylor de for mm 7 18 ight cheering 8 Sounds to g like 10 9 A gt instead o39shakin39 the system 02 9 10 09 11 B gt Mister Pemt39s been shakin39 it dim 12 AUD xxxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX He sums up his view of Perot in form of a contrast between Perot s claim to be shaking the system up with its connotations of reform and the reality of Perot s shaking it down by engineering tax loopholes with their connotations of sleaze and corruption Contrast signaled with instead and marked by pause at line 10 Word up is emphasized by raised volume and a brief pause line 9 Contrast play on words in which the meaning of the phrase is entirely changed by the substitution of down for up audience has time to anticipate when applause will be due 2 Contrast Clinton 1996 Dem Convention 1 BC I gve and revereh 05 thuh rich and proud 2 history of America 3 07 4 And I am degmined 04 ltto take our best traditionsgt 5 02 into thuh future 6 10 7 A gt But with aH respect 08 we do not need 05 to 8 build a bridge hh to thuh past 9 AU D xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 10 AUD cheering 11 BC B gt WE NEED TUH BUILD A BR1DGETO THUH URE 12 AUD XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 13 BC AND THE IS WHAT I COMMIT TO YOU TO DO 14 AUD XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 15 BC So tonight 3 Contrast Bill Clinton Democratic National Convention 08 Clinton People 05 the world over have aways been more impressed 05 A gt by the power of our exmple B gt than by the example of our power Audience xxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Advocating for soft power not hard power 3a Granholm 2012 Democratic National Convention Granholm But the people who design and build and sell those cars well in Romney39s world a gt the cars get the elevator b gt and the workers get the shaft Audie nce XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Granholm You know what I39m saying Granholm You know what I39m saying Fantastic effort by Granholm Contrast between workers and Mitt Romney39s cars 4 Obama 2004 Democratic National Convention 1 Obama Now even as we speak there are those who are preparing to 2 divide us the spin masters the negative ad peddlers 3 who embrace the politics of anything goes 4 Well I say to them tonight 5 A gt there is not a liberal America and a conservative America 6 B gt there is the United States of America 7 Audience xxXXXXXXXXXXXXXXXXXXXXXXXXX Attack of Republicans use of wedge politics Contrast between divison and unity Types of Contrast Contradictions not this but that Ex Advice is judged by results not by intentions Cicero Ex The house we hope to build is not for my generation but for yours Reagan Comparisons more this than that Ex I count him braver who overcomes his desires than him who overcomes his enemies Aristotle Ex The man who reads nothing at all is better educated than the man who reads nothing but newspapers Thomas Jefferson Opposites black or white Ex Glory is fleeting but obscurity is forever Napolean Ex Injustice anywhere is a threat to justice everywhere Martin Luther King Jr Phrase Reversals Ex Ask not what your country can do for you ask what you can do for your country Kennedy Ex We didn39t land on Plymouth Rock Plymouth Rock landed on us Malcom X Note Rostrum Mino speakers unknown peoplenot national figurespolitical heads do not receive as much applause as platforms when using contrasts 2 Lists three parts both in ordinary convo and speeches Ordinary Convo list associated with emphasis Ex ordinary coversations using lists for emphasis 5 Jefferson 1990 64 1 Carol Did this phone ring I dialed twice and it n 2 rang39n rang39n rang 6 Jefferson 1990 64 1 May I think if you exercise it an work at it and 2 studied it you do become clairvoyant Generalized list completer Jefferson 1990 speakers complete the list with something broad when a list lacks a third item Examples 7 Jefferson 1990 66 1 Ernie I said no I kg his name is something else 2 gt Teddy39r 39r somethin 8 Jefferson 1990 67 1 Rudd Oh they come from Jamaica en South Africa39n 2 gt all over the place 3 ness is a basic norm for lists recipients will wait for a speaker to produce the third item of a list and regularly start to respond on a completed third item even though a speaker may seek to continue the list Lists in Speeches 9 George HWBush Republican National Convention 1988 Bush The congress will push me to raise taxes 1 gt and I39ll say quotNoquot 2 gt and they39ll push and I39ll say quotNoquot And they39ll push again and I39ll say 05 to 3 gt them quotRead my lips 04 No new taxesquot Topic taxes made by Bush 10 Hillary Clinton 2008 Democratic convention Clinton 1 gt No way 2 gt No how 3 gt No McCain AUD xxXXXXXXXXXXXXXXXXXXXXXXXXXXXX Topic republican failure made by Hillary Clinton 11 Tony Benn Attack on Labor Party Leadership 1 Benn and I make not too much of that ale for 2 one thing 3 10 4 If you have a g 03 those who oppi 5 policies 02 don39t mm 02 to qgue 6 02 with conference 04 because they git to 7 the Clause Five meeting and they Q it 8 02 9 1 gt ERETLY 10 02 11 2 gt LRIVATELY 12 02 13 3 gt withLt deltNow MY RESENT 14 Audience x xxXXXXXXXXXXXXXXXXXXXXXXXXX Attack on secret machinations of party leadership Him cutting into applause makes him seem more charismatic Lists are more effective in mobilizing audience response when there is a brief delay before the final item seconds pass or when the final item is longer than the other two 9 gives audience more time to prepare There are three things that make for a successful speech first delivery second delivery and third Three identical delivery Cicero words I shall fight fight and fight again the save the party I love Hugh Gaitskell Veni vidi vici I came I saw I conquered Julius Three different Caesar on his conquest of Britain words No way no how no McCain Hillary Clinton Government of the people by the people for the people Abraham Lincoln Three phrases I stand before you today the representative of a family in grief in a country in mourning before a world in shock Lord Spencer Funeral Oration for Lady Diana Dogs look up to us Cats look down on us Pigs Three sentences treat us as equals Winston Churchill 3 PuzzleSolution 1 speaker presents puzzle or problem 2 Speakers gives solution to puzzle gives audience warning that an applaudable point is coming after solution can combine humor with a political message and generate laughter as well as applause less frequent than lists but have higher success rates 12 Liberals Tape 7 Leader39s Address ST 1 Pol Margaret Thatcher has portrayed her lf 05 as the 2 lnation39s lyse 05 administering 02 nasty 3 but gessary Ldicine to us gtin the belief that 4 whatl erlt E term pain we may suffer in the 5 long run it39s going to do us good 6 07 7 And I39m surpied that as a qualified chgist 02 8 P gt she seems to have forgLHen the warning on 9 gery gm 10 02 11 S gt Eon it is dgqerous to exm the sta ted Qsen 12 Aud Laughter 13 Aud Applause 130 secs Attack on economic policies 13 Hillary Clinton 2008 Democratic National Convention Clinton Now 04 with an agenda like that P gt it makes perfect sense that George Bush and John McCain P gt will be together next week in the twin cities S gt because these days it39s awfully difficult to tell them apart Audience laughter gtappause cheers Made by Hillary Clinton on similarity between George Bush and McCain 13a Bill Clinton 2012 Democratic Convention Clinton Now people ask me all the time how we got four surplus budgets in a row P gt What new ideas did we bring to Washington I always give a one word answer 08 Clinton S gt Arithmetic Audie nce xxXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXX Clinton If Clinton Arithmetic If Audie nce XXXXXXXXXXXXXXXXXXXXXX Made by Bill Clinton on damage to budget Combinations puzzles contrasts and lists can be combined in pairs to enhance emphasis and projectabilityl 14 Combination ListContrast Lloyd Bentsen 1988 VP debate DQ I mve 05 more 07 experience hh than y ers 18 that sought the office of vice president this country 07 I have as much experience in the Congress hhh as Jack Qnnedy did 07 when he sought 05 the gesidency 11 1 will be prepjred 02 to deal with the people 02 in the Bush administration 07 if mat unfortunate event 03 would ger occur 05 OD Senator Bentsen 11 LB hhhh 04 Senator 16 1 gt I served with Jack Kennedy 05 A gt 2 gt I Qew Jack Kennedy 11 3 gt Jack Kennedy was a iend o39mine 13 B gt Senator you39re no Jack Kennedy 02 AU D xxxxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Use of three part list and contrast Puzzles and contrasts 15 Combination Puzzle Contrast Jones on ThatcherHeath Jon s You Know Mister Chairman er Margaret Thatcher and P gt Ted Hgth 04 mth have meat Lbion 07 A gt The difference is that Margaret Thatcher 02 has a Lbion that one day tain will be great again S gt 04 B gt and Ted Heath has a Lbion 02 that one day Ted gth will be great again AU D xxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 194 puzzle is a riddle what could arch enemies Margaret Thatcher and Ted Heath possibly have in common Solution is an attack on Ted Heaths character and integrity Contrasts and Lists 14 Combination ListContrast Lloyd Bentsen 1988 VP debate DQ I mye 05 more 07 experience hh than y ers 18 that sought the office of vice president this country 07 I have as much experience in the Congress hhh as Jack Qnnedy did 07 when he sought 05 the gesidency 11 1 will be prepjred 02 to deal with the people 02 in the Bush administration 07 if mat unfortunate event 03 would ger occur 05 OD Senator Bentsen 11 LB hhhh 04 Senator 16 1 gt I served with Jack Kennedy 05 A gt 2 gt I Qew Jack Kennedy 11 3 gt Jack Kennedy was a iend o39mine 13 B gt Senator you39re no Jack Kennedy 02 AU xxxxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 16 ombination ListContrast Barack Obama Obama 1 gt The road ahead will be long 10 A gt 2 gt Our climb will be steep 10 3 gt We may not get there in one year or even in one term 06 B gt But America I have never been more hopeful than I am tonight that we will get there 05 Pursuit gt I promise you we as a people will get there Audie nce xxxXXXXXXXXXXXXXXXXXXXXXXXXXXX 16a 2012 Democratic Convention Critique of Republican Economic Program Clinton In Tampa 04 the republican argument against the President re eection was actually pretty simple 02 pretty snappy 10 It went something like this Audience Clinton Clinton Clinton Audience We left him a total mess He hasn39t cleaned it up fast enough so fire him and put us back in Laughter scattered appause They want to cut taxes for higher income Americans even more than President Bush did 03 They want to get rid of those pesky financial regulations designed to prevent another crash and prohibit a future bailout 02 They want to actually increase defense spending over a decade two trillion dollars more than the Pentagon has requested 10 without saying what they39ll spend it on 10 And they want to make enormous cuts in the rest of the budget especially programs that help the middle class and poor chHdren 13 hhuh As another President once said 10 There they go again1 Laughter XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 1 quotThere you go againquot was a phrase spoken during the 1980 United States presidential election debate by Republican presidential candidate Governor Ronald Reagan to his Democratic opponent incumbent President immy Carter Reagan would use the line in a few debates over the years always in a way intended to disarm his opponent1 quotThere you go againquot emerged as a single defining phrase of the 1980 presidential election2 The phrase has endured in the political lexicon in news headlines as a way to quickly refer to various presidential candidates bringing certain issues up repeatedly during debates or to Reagan himself3 17 Combination List Contrast Martin Luther King King Like anyone I would like to ive 10 a long life Longevity 08 has its place 10 But I39m not concerned about that now 12 I just want to do God39s will 15 And he39s allowed me to go up to the mountain 05 Audience Go ahead King And I39ve looked over 15 And I39ve En 05 the promised and Audience Holy Holy Holy Holy Audience Amen King A gt I may not gt there with you 05 But I want you to know tonight 10 that we as a piple B gt will t to the pLomised land Audie nce XXXXXXXXXXXXX XXxxxxxxx 1 gt 6 secs So I39m happy tonight A gt 2 gt ltI39m not Lorried 3gt ltI39m not fearing y man 02 B gt egs have seen the gory of the coiing of the Audie nce XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Types of Combinations Third Item of list contrasts with first two We pledge our best efforts to help them help themselves Not because the Communists may be doing it Not because we seek their votes But because it is right John F Kennedy Part 1 of contrast is a list When I was a child I spake as a child I understood as a child I thought as a child But when I became a man I put away childish things 1 Corinthians 1311 Part 2 of contrast is a list And I have a duty a duty that falls upon all responsible politicians to lead others face reality ot a duty to feed the people a diet of compromising pap pig in the sky and false mgs Norman Tebbit Lists of contrasts We observe today not a victory of party but a celebration of freedom symbolizing an end as well as a beginning signifying renewal as well as change John F Kennedy Puzzle with contrastive solution The difference between a misfortune and a calamity is this If Gladstone fell into the Thames it would be a misfortune But if someone dragged him out again it would be a calamity Benjamin Disraeli Puzzle with a list solution There are three kinds of lies Lies Damned lies and statistics Benjamin Disraeli Lists in which all three items contrast You can fool some of the people all of the time and all of the people some of the time but you cannot fool all of the people all of the time Abraham Lincoln This is not the end It is not even the beginning of the end But it is perhaps the end of the beginning Winston Churchill Recession is when your neighbor loses his job Depression is when you lose yours And recovery is when Jimmy Carter loses his Ronald Reagan Rescueing Duds When Delivery Does NOT 9 Applause politicians can re invite audience response by re competing the previous point thus giving audiences a second chance to applaud Ex 20 in book pg 274 Generating Applause The Threestage Rocket Delivery of the Point matters delay and extension of final components volume and intonation shifts rhythmic patterns and eye gaze are involved in the micro management of the audience39s expectations towards the moment when applause is due Occupies a much longer time structure Structuring an audience39s expectations towards a particular slot for applause involves 3 main levels of action Heritage and Greatbatch 1986 1 the argument structure in which positions are staked out often against those of opponents 2 and within 1 structure a level at which particular points are made and are rhetorically structured to build towards a specific slot 3 micro structura level of intonation rhythm timing and gesture which guides the audience towards an exact opening in the talk where response can be initiated Form vs Content BOTH form and content matter Why form matters It enhances applaudability by lowering the perceived risks of applauding to the point at which individual audience members feel able to express their support for positions that they believe in Why content matters ppl applaud with assertions that they approve of different types of content matter too audiences prefer refutation to advocacy Party political audiences tend to be more sure of what they are against than of what they are for They are more united in their response to attacks on others than they are in response to policy advocacy Audiences applaud attacks with a higher overall frequency and at a higher rate than they do advocacy Heritage and Greatbach 1986 game of pure coordination speakers want immediate substantial and hearbly enthusiastic bursts of applause Audience want to show support while minimizing risks of clapping alone The Long HalfLives of Contrasts and Lists Contasts and lists tend to be memorable and repeatable Highly Memorable Soundbites 18 Gettysburg Address 1 Lincoln and that government of the people 2 by the people 3 for the people 4 shall not perish from the earth 19 House of Commons 1940 1 Churchill Never in the field of human conflict has 2 so much been owed 3 by so many 4 to so few 20 Moon Broadcast 1969 1 Armstrong That39s one small step for man 2 One giant leap for mankind Atkinson 1986 Contrasts and lists form the staples of TV and newspaper soundbites that emerge in news coverage and speeches and press conferences Contrast with list essential for long term survival Bc gives them prominence and conspicuousness Scheing 1963 Sustains them as memorable quotable and reproducible elements of human culture Condensed Theoretical Contrasts and Lists Lists As Conceptualizations Christian Trinity Father Son and Holy Spirit Primary Slogan of French Revolution Liberty Equality Fraternity Primary Slogan of Nazi Party Ein Volk Ein Reich Ein Fuhrer Hegel39s Theory of History Thesis Antithesis Synthesis Freud39s theory of the mind Id Ego Superego Turgot39s three stage history of social Hunters Shepherds Husbandmen organization Durkheim39s classification of suicide Egoistic Altruistic Anomicz Booing unshaped by rhetoric and the assertions which prompt it go unremembered booing usually delayed contrasts to applause which is usually prompt Delayed reactions based on mutual monitoring watching another person boo or hiss the next person can go ahead and do the same 9 slowly gets louden Contrasts to applause which is based on convergence in decision making to clap and shaped by rhetorical devices 51714 1104 PM 51714 1104 PM 51714 1104 PM 51714 1104 PM 51714 1104 PM 51714 1104 PM