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A Critical Theory of Medical Discourse: Ideology, Social Control, and the Processing of Social Context in Medical Encounters Author(s):

Howard Waitzkin Source: Journal of Health and Social Behavior, Vol. 30, No. 2 (Jun., 1989), pp. 220-239 Published by: American Sociological Association Stable URL: http://www.jstor.org/stable/2137015 . Accessed: 19/08/2011 16:39
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A Critical Theory MedicalDiscourse: of Ideology, Social Control, the and Processing Social Context MedicalEncounters* of in
HOWARD WAITZKIN
Irvine University California, of

Journal Healthand Social Behavior1989, Vol. 30 (June):220-239 of

thatpatientsbringto doctorsoften The personaltroubles have roots in social issues beyond medicine. While medical encountersinvolve "micro-level" between theseinterpersonal interactions individuals, processesoccur in a social structures society. in context shapedby "macro-level" Examining priortheories to pertinent medical discourse leads to the propositions:(a) that medical tendto conveyideologicmessagessupportive the current social encounters of haverepercussions social control; (c) that theseencounters and order;(b) that for a excludes critical medical The languagegenerally appraisalofthesocial context. as seen by health technicalstructure the medical encounter, traditionally of that may have littleto do with the masks a deeper structure professionals, aboutwhatthey saying are and doing.Similar conscious thoughts professionals of betweenclients and membersof other patternsmay appear in encounters or "helping" professions. Expressed marginally conveyed absenceof criticism by and social control medicaldiscourse in remain aboutcontextual issues,ideology consent. unintentional mechanisms achieving largely for froma Why look at medical encounters theoretical pointof view?
* Directall correspondence HowardWaitzto Community Clinic, kin,UCI/North Orange County CA 300 WestRomneya Drive,Anaheim, 92801. This article one of a seriesof papersfrom is an ongoingresearchprojecton medical discourse. has in The research been supported partby grants fromthe National Center for Health Services Research(HS-02100), the RobertWood Johnson the Clinical Scholars ProFoundation (through gram), the FulbrightProgram, the National on Institute Aging (1-F32-AG05438), and the of AcademicSenateof theUniversity California, Irvine (Honorary FacultyResearchFellowship). Elliot a John Stoeckle, During spanofmany years, of care Mishler, Sam Bloom,members theprimary of researchdiscussiongroup at the University in California, Irvine,and participants the Society of General InternalMedicine have given me abouttheproject.Stephconstructive suggestions J. any Borges,TheronBritt, Hillis Miller,Mark CarlosRowe have Poster, Leslie Rabine,andJohn of to the helpedin my attempts negotiate terrain critical in are My theory thehumanities. errors no fault theirs. of

Morethan quarter a century C. Wright ago, Mills analyzed the relationships between "personal troubles" and "social issues." Mills pointed a out thatthe troubles person experiences arise in the context broader of social problems. Accordingto Mills, an individual'sdifficulties almost always are in interconnected with structures society, although theselinksmay not be obviouson the surface.Mills arguedthatan important withsocial probgoal forpeople concerned lems-those withwhathe called the "socio-is logical imagination" to clarify how perand sonal troubles social issues relateto one another (1959, pp. 3-24). In the intimacy the medicalencounter, of to doctors variety a of patients present their personaltroubles.From Mills' perspective, often in these troubles haveroots socialissues thatgo beyondthe individual level. Yet the tendnot to receive social issues themselves in critical attention conversation between and doctors.In trying help their to patients doctors often find patients, waysthat patients can adjustto troubling social conditions.'

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probably occurin thecommunication Seen from this vantage point, medical patterns clients members other and of are helping encounters "microlevel"processesthat between such as law, psychology, of These professions, involvethe interaction individuals. and however, occurin a social work. Clarifying interpersonal processes, these patternsin whichis shapedby "macro- medicine therefore shedslight professionalon social context, in moregenerally. exploring In level" structures society. For example, clientdiscourse discussproblems the interconnections at betweenpersonaltrouwhenpatients doctors and work, they take their bearings from the bles and social issues,and between micro the organizationof work in society, social and macrolevels,I first buildon theworkof to socialclassrelations prior theorists deal with the issue of expectations aboutwork, to Similarly, medical ideology. I then examine social pertaining work,and so forth. to life in whenproblems pertaining family arise control professionals theirencounters by I in medicalencounters, conversation the must with clients. Afterward, ask how the pertains to deal in some way with such issues as languageof medical encounters women's and men's roles in the family, thesocial context medicine. of and the expectationsabout reproduction and social patmaintenance households, of ternsaffecting children, elderly people, and MEDICAL IDEOLOGY stages of the life individualsat different kindsof social Ideology,while difficult define,is in also to cycle.Patients raiseother whentheytalk withtheir doctors, general an interlocking of ideas and problems set in structures thesociety that the andmacrolevel shape doctrines form distinctive perspective as of a social group.Throughsuch ideas and thecontext thoseproblems well. of has for ideology One challenge socialtheory beento doctrines, represents-on imagian social structures and nary level-individuals' relationship the how macrolevel clarify to microlevel processes affect one another. real conditionsof theirexistence(cf. Al have dealtwiththis thusser1971, pp. 162-165; a criticalapManyschoolsof thought have praisal of Althusser'scontribution theoretical challenge. Some theorists follows of quality of argued for the importance macrolevel laterin thispaper).This imaginary how individuals like power ideology, which patterns structures socialclass andpolitical in in determining happens interpersonalperceiveand interpret experience, what their conprocesses at the micro level. Othershave tributesto ideology's impact in society. claimed that microlevelprocesses are pri- Because ithelpsshapea population's percepand and thatmacrolevel structures emerge tions interpretations, can mary, ideology achieve effect social life. on (similartermsinclude a mostprofound only as a reflection gloss, repetition, As a macrolevel structure society, in integration, aggregation, of and transformation) microlevel processes ideology impinges patients doctors on and as of occurringroutinelyin everyday life. A partof thesocial context medicalencouncompromise positionholds that macrolevel ters. At the micro level of interpersonal structures influence interpersonalinteraction, elements ideologyappear in of profoundly processes, but that microlevel processes doctor-patient communication. Whatpatients reinforce social structures the and doctorssay when theymeet reinforces at cumulatively macrolevel as well (fora critical review,see theirparticular about ideologic conceptions and Knorr-Cetina Cicourel1981). social life. Although ideologyhas received In thispaper,I do nothope to resolvethis wide attentionin social theory, several to theoretical theoretical debate,butrather explorehow previous are contributions helpful themacroand microlevels impinge each for clarifyingideology in medicine. In on theseperspectives ideology,I otherin the single institutional on sphere of presenting medicine.When patientsand doctorstalk emphasize thosetheoretical strands shed that their light on ideologic processes in medical witheach other aboutsocial problems, wordshave muchto do withthesocial order encounters. of around them. Structures society help Ideology,work,and thefamily: perspecin the social context which tivesfromearly Marxisttheory.In classic generate specific The and find patients doctors themselves. talk Marxist theory,ideology is an important thatoccursin medicalencounters also may though inconsistently developednotion.Acbroadersocial structures. Similar cording theprinciple economic to of reinforce determi-

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nacy, the eventsof history emergechiefly idleness. When people become sick, they fromeconomic forces and the conflicting often stopworking, doctors involved and get relations socialclass. Fromthisviewpoint, in this processin severalways. Frequently of economicforcesaffect the ideologiesof a doctorscertify that a patientis physically specific historical period.Despitetheprimacy disabled and thus unable to work. By the of economicforces,ideologyis crucial in certification disability, doctorin effect of a sustaining reproducing socialrelations decideswhena patient and the must return thejob. to of production, especially patterns domina- Whenjudgingthe seriousness a patient's of of tion.Marxcalledattention themechanisms complaints, doctor to a investigates whether the rela- patient's by whichideologyreinforces capitalist with problems interfere work.Doctionsof production the interests the tors write lettersto employers,insurance and of capitalist class (1894, pp. 370-90, 790-94). companies,and government agencies about While ideologies arise in many differentpatients'work limitations and discuss this and to areas,including religion, aesthetics, poli- correspondence a greater lesserdegree or did tics,earlyMarxist analyses notdiscussin with the patientsthemselves. During their talkwithpatients, of depththe ideologiccomponents medicine routine doctors inevitably (Marxand Engels 1846, pp. 3-78). convey attitudesabout work, usually to leads to encourage The Marxist perspective, however, patients' continued on performance in thejob. In theseinstances manyothers, of abouthow elements ideology and questions behav- theimpact thedoctors'wordsis to define medicalencounters relate economic to of of as to ior. Ideologic conceptions work,as they health thecapacity workproductively. in interaction, The familybecomes a second important are transmitted doctor-patient about focus for ideologic elements in medical reflect moregeneralideologicnotions in When encounters, economic activities a givensociety. and theoristsin the Marxist these tradition have emphasizedthe connections theyare spokenin medicalencounters, a ideo- between family economic notions reinforce society'sdominant the and production. of logic conceptions about the nature work For example, the Engelsclaimedthat family, of and of economic production. by "propagation thespecies," playsa key the For instance, amongthe manydefinitions rolein reproducing laborforce.Women's in of "health" thathave appearedduringthe subordinate position thefamily, according the twentieth century,modern medicine has to Engels,helpsmaintain family's reproof emphasizedin practicean interpretation ductiverole (1891). However,the family's to goes beyondthe physicalreprohealthas ability work.Thereare several importance of ways thatthisdefinition healthhas been duction of labor. The familyalso helps in The reproducethe ideologic framework the of reinforced diffused thepopulation. and health of public policiesthat largephilanthropieseconomicsystem.For instance, patterns in andgovernment have initiated the sexualityand child rearingin the family agencies and United Statesand other countries personality characteristics atticonsistentlyreinforce have emphasized importance a healthy tudesthattendto accepthierarchies class the of of work force (Brown 1979, pp. 112-34; and authority. sustaining such patterns, By the becomesan imporFranco-Agudelo1983). Images of health Engelsargues, family for conveyed by the mass media also have tant institution ideologic reproduction, of the symbolism health as the which helpsachievethepopulation's acquiessupported in work (Kelman cenceto and participation current relations capacity to do productive a 1975). These images have communicated of economic production. the Medicinealso mediates family's messagethatthe healthy personis one who reproa produceseconomically. Moreover, widely ductive role. As noted already, medicine health theability work. as standard which judge medicine's tendsto define to to touted by to and is definition cost-effectiveness its contribution pa- However,a secondary related workproductivity health theability reproduce is to tients'subsequent labor. (Wein- is that as steinand Stason1977). Women's activities homemakers, wives, I Doctor-patient interaction, will argue, and mothersare crucial in the family's as Even whenwomen this of activities. reinforces samedefinition health the reproductive do with not workoutsidethe home, theyoftencare abilityto work. In certainencounters doctorscommunicate or forworking husbandsand forchildren who explicitly patients, a to subtly messagethatworkis preferable later will take part in productionand

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This ideologicsystem proportion beliefs,and morality. a Although greater reproduction. the orderand the class the of womenhave entered laborforcesince supports established that it. World War II, they still face the social interests dominate The sameideologic respon- forcesachieve consentand muteresistance remain primarily that expectation they disadvantaged groups. Thatis, from activities. these reproductive siblefor WhileGramsci notconsider did medicine's "healthy" women do these things, and impact, similar a theoretical perspechelp many women in ideologic doctorspredictably For tive would ask to what extent medicine capabilities. their reproductive sustaining the ideologicsystem a of male clients,doctorsalso may interest reinforces dominant their conveyideologicnoin of relations. society.Whendoctors themselves thestability family behavior, especiallyas adequatefunction- tionsaboutdesirable Forbothmenandwomen, thus responsibilities becomes these notionshelp shape patients'roles in ing in familial in of work and the family,medical encounters criterion doctors' assessment another to hegemonic impact of health. As discussed later in this paper, contribute thebroader doctorsare among the expertprofessionals ideology..In this sense, medicine exerts life ideologiceffects thatparallelthose of such have regulated family who increasingly as How doctor- institutions schools, churches,and the century. duringthe twentieth interaction conveysideologicnotions massmedia. patient of Lukacs' conceptions class consciousness about familylife is a question of some also are pertinent mediand reification to interest. of Later theories ideology.The examples cine's ideologic impact. Regardingclass lead ofworkandthefamily to a consideration consciousness,Lukacs, like Gramsci, exideologies of how certain other theorists-Gramsci, ploreshow a society'sdominant In Lukacs, Althusser, and Habermas-have are conveyedand reinforced. discussing and forms cultural of expresthe treated questionof ideology.A unifying literature other all sion, Lukacs emphasizes waysthatthese the positions, themeamongthesetheoretical both reflect and strengthen broad are ofwhich influenced classicalMarxism, materials by mechanism ideologic patterns (1971a, pp. 46-222; 1971b; servesas a subtle ideology is that consent the Jameson to to which 1971b;Taussig 1980). According helpswina population's shape the These theorists Lukacs, such ideologic patterns ways a societyis organized. also emphasizethatideologyhelps maintain consciousnessof individualsand, cumulaof the economic systemand that supporting tively, social classes. In thisprocess,the in of in are society like institutions thefamily keyelements totality social relations an entire and blocked fromcona ideologic becomes mystified reproducing society's dominant to Lukacs argues, the Reification, Although theorists be consid- scious thought. patterns. the with medical involves transformation of socialrelations ered do not deal specifically or these intothings thing-like beingsthattake on one encounters, purposeof reviewing is theories to applythemto the questionof theirown separaterealityin people's consciousness.Shaped by ideology,consciousin ideology medicine. and problems From Gramsci's viewpoint, groups in ness focuseson the concrete economic control objectsof everyday of life,especially poweruse two types sociopolitical thanon the totality rather of relations eco- commodities, of and reproduce to maintain that nomic (1971, p. 123-202,375-77, social relations lies behindtheseroutine production Attention becomesfocusedon the 406-7). In the firstplace, thereis direct concerns. coercion; by holding the legal means of concreteobjects of daily life, and in this of the violence-in the armedforces,police, pris- process of reification totality social state relations escapesconsciousattention. and institutions-the ons,courts, related to through Reification contributes medicine'simthe orderpartly protects established technical stateforce and repression.However, Gramsci pact. In medicalencounters, claims, no regimecan hold powerforlong ments help direct patients' responses to rule. objectified of symptoms, signs, and treatment. by periods timestrictly authoritarian the shifts attention to awayfrom according Gram- Thisreification Ideologic hegemony, of and moreimportant totality socialrelations thesocialissues sci, is a secondandultimately as are root troubles. mechanism control. of Suchinstitutions the that often causesofpersonal of mass media, and family Instead,attention gets paid to problems schools, churches, and pathophysiology personality. inculcate a system of values, attitudes, individual

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helped impleBy reifyingproblematicsocial relations, effects-as when physicians policiesof genocidein Nazi concentrafor medicinereducesthe potentiality effec- ment of Symptoms, tioncamps. Less obviousinstances medithoserelations. tivelycriticizing take on an aura of cine'srepressive impact include doctors' roles signs, and treatment manifes- in involuntary mental hospitalization, prison thansubjective fact, scientific rather (in tations of a troubledsocial reality. The health care, capital punishment some invests cases administering injections otherlethal of or medical processing socialproblems of themwith the symbolism objects, rela- wise assistingin executions),involuntary or and immune from criticism change.This sterilization, so forth. tively the same processconstricts level of attention Medicine's ideologicimpact,however,is rather thansocial doubtless much more important than its to thedisturbed individual, For repressiverole. In their encounters with on impinging the individual. structures of doctors whenthe organization workor patients, mayinterpret personal probinstance, individual behaviors in in creates distress, lems and encourage personal tension thefamily thatare consistent withthe sociexpressionof that distressin a medical directions the Fromthe tendsto reify social structuralety's dominant ideologicpatterns. encounter rootsof the problem.Under these circum- perspectiveof Althusser's theory, when or convey a definition of it symptom sign medical encounters stances, is theobjectified the to encourage thatrequires treatment-not institutionalhealthas theability work,they workers'participation economicproducin of distress. sources individual interaction predictalso by Influenced Gramsciand Lukacs, Al- tion. Doctor-patient of ably transmits notions aboutfamily that life analyzes the structures thusserfurther the in consid- strengthen family'sideologicimpact.In Althusser control modemsocieties. and theseways,medicine exerts among repressive ideologiceffects erstheinterconnections with institutions like as relation- consistent thoseof other institutions,wellas their ideologic and state theeducational (1971). Repressive system mass media. shipsto government Anotherquite different theoreticalapapparatuses(RSAs), Althusserargues, inalso pertains medicalideology. to The courts,and proach clude the army,police, prisons, other that control through "critical theory" of Habermas and other institutions maintain appara- analysts the Frankfurt of School providesa Ideologicstate violence repression. or that instill link betweenideologyand science-and by tuses (ISAs) are institutions scientific medicine. Habdominant Although ideologies in the population.In extension, the theories both have analysis, ISAs include family, ermas's and Althusser's Althusser's thesetwoschools electoral politics,mass media rootsin classicalMarxism, legal system, and of thought education, and communication systems, divergein fundamental ways. In the School usuallyasRSAs are notpurely repres- particular, Frankfurt cultural systems. have the capacityto ideologic.Ideolo- sumes thatindividuals sive, nor are ISAs purely the of critically about societyand to take legitimate actions RSAs. For reflect gies often Althusser diminpolitical action; example,justice and equalityare ideologic "purposive" of criticism the for notions thatlegitimate functioning the ishes the potentiality effective ISAs may use punishment and political action by individuals.Both courts.Similarly, force other approaches, or fordiscipline, however, emphasizethe impact suchas physical forms sanctioning occurin thefamily of ideology.While Althusser of that focuseson the ISAs ideologiceffects varioussocial institutions of or schoolsystem. Althusser arguesthat are especially in class in reproducing relations production, the of important reproducing the structure and the relations of economic Habermasstresses ideologiccomponents many of science. Accordingto Althusser, production. the For Habermas, science is ideology par social institutions-particularly educabecause it claims to be tional system-promulgate ideologies that excellenceprecisely assure the population's acquiescence and above ideology,thatis, objectiveand value in neutral work. (1970). Habermasarguesthatscienparticipation productive Althusser's has an analysis of the wide-rangingtific ideology defined increasing range as solurepressiveand ideologic effectsof many of problems amenableto technical institutions society,though in tends to controversial,tions.In thisway,scientific ideology these social issues by removing pertainsto medicineas well. In rare in- depoliticize repressive them fromcriticalscrutiny. Accordingto stances,medicineexertsdirectly

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Habermas,science legitimates current pat- depoliticize theseissuesby deflecting critical terns of domination,includingthe class attention fromthem. In addition,medical of relations production: interactions show features distorted of communication, fostered instance devices for by Technocratic consciousness on theone is, of languagethat reinforce professional domihand, "less ideological"thanall previous nation.In actualencounters between patients ideologies.. . . On theother handtoday's and doctors, then,one can ask how and to rather dominant, glassybackground ideolwhat extent medical discourse transmits of ogy, whichmakes a fetish science,is scientific ideology. moreirresistible farther-reaching and than ideologiesof the old type. For withthe veilingof practicalproblems not only it PROFESSIONAL SOCIAL CONTROL justifiesa particular class's interest in domination and represses anotherclass's Social control-again to offera simple partialneed foremancipation, affects but definition. a complex concept-refers of to thehumanrace's emancipatory interest as mechanisms achievepeople's adherence that such(1970, p. 111). to normsof appropriate behavior.In mediWhatare the specific processesby which cine, ideologyand social control closely are scientific ideology provides legitimation? One related. When doctors transmit ideologic problemin Habermas' account is that it messages thatreinforce current social patremains on an abstractlevel and rarely terns-at work,in the family, and in other grounds theoretical claims in empirical real- areas of life-they help control behaviorin ity. Habermasconveys an impression that waysthat defined sociallyappropriate. are as scientific creates ideology legitimation through Dealing withproblems outsidethenarrow in cultural symbols the mass media, educa- realmof technical medicine tendsto "meditionalsystem, and technical of organization calize" a widerange psychological, of social, the workplace. also arguesthatideology economic, and politicalproblems.HistoriHe and domination appear in the face-to-face cally, numerous areas gradually have fallen interaction individuals. of Distorted commu- under medical control. Examples include Habermas nication, argues,arisesin boththe sexuality and familylife, work dissatisfacmacrolevel realmof politicsand the micro- tion, problemsof the life cycle (including level realm of interpersonal relationships. birth, adolescence, aging,dying, and death), in Domination creates distortion communica- difficulties theeducational in system (learning and is communicationimpos- disabilities, maladjustment, tion, undistorted and students' to sible, according Habermas,undercondi- psychological distress), environmental pollutionsof domination (1970, p. 113; 1971, pp. tion,and manyother fields.By participating 214-73; 1974,pp. 1-40, 195-282; 1975,pp. in theseareas,practitioners believethat often 33-96; 1985, pp. 273-337). In a majorpart theyare extending caringfunction the the of of his project,Habermasencouragesresis- medicalrole. tanceagainst the domination aimstoward and On the other hand, medicalization has creationof new, less distorted forms of becomethesubjectof a critique thatfocuses communication. Concrete examplesof scien- on heath professionals' expandingrole in tific ideology, however, rarely appear in social control (Conradand Schneider, 1980; Habermas'work;forthisreason,his account Ehrenreich Ehrenreich and 1978; Fox 1977; remains abstract utopian and direc- Illich 1975; Waitzkin1971, 1983; Waitzkin regarding tions of change. On the other hand, his and Waterman,1974; Zola 1972, 1975, analysis causes one to look for specific 1983). As medical management social of of instances scientific and has legitimation dis- problems increased, societalrootsof the in torted communication face-to-face interac- personal troubles become mystifiedand tions. depoliticized.That is, by respondingin are to These considerations pertinent medi- limitedways to some of patients'nontechcal encounters theextent doctor-patient to that nical problems, medicalpractitioners to tend interactions conveyideologicmessagesunder shiftthe focus of attention from societal the rubric of scientificmedicine. From issuesto thetroubles individuals. of Habermas'perspective, suchmessageslegitiThe history professional social control: of matecurrent in and further Foucault. The intrusion the scientific problems society of

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fantasies,intentions, and discourse intomanyareas of social life has ties to thoughts, preoccupiedFoucault in his work on the othermentalprocessesrelatedto sexuality. historyof the professions.Through his Especially during the nineteenth century, notes,surveillance regulation and of studies whathe calls thehumansciences, Foucault of be- mental processespertaining sex became a Foucaulthas conveyedthe connections to of and tween knowledge power(1980). Accord- preoccupation science and particularly ing to Foucault, as such professionsas medicine.Professional practitioners asthen a of overtheactivities law, and social work sumed measure control medicine, psychology, have taken positions and psychological on havedeveloped, they meanings sexuallife. of In discussingsexuality, in life. the Foucaultemphaof control everyday By describing Foucault sizes professional sciences, political roleof thehuman discourseand links dissocial control courseto power.Thatis, whatprofessionals has clarified how professional have said about sexuality has deepened historically. emerged power in everyday While Foucault's early work traces the professional life (1978, diagnostic therapeu- pp. 101-102). Whatpreviously a concern and was history medicine's of tic ideas (1975), his more recent studies for the clergyhas become a challengefor who of degrees emphasize how professionalcontrol has professionals, assumevarious life overtheir clients'sexual expression. widenedintoeveryday (1977). Although control prior Medical doctorsmediatesex, accordingto is than modern punishment morehidden like and social techniques torture publicexecution, Foucault,but so do psychoanalysts, in itselfto surveil- workers,educators,bureaucrats social Foucaultargues,it orients and lance and professionalcontrol over the welfare who agencies, other professionals The new technolo- lay claimto expert deviantpopulation. knowledge. discourse Through gies of power, accordingto Foucault, the throughwhich professionals communicate could create what their special knowledge,from Foucault's criminologic profession over prior perspective, enhancestheirabilityto interappearedto be a humanereform forms grosscorporal of Further, vene in and to control others' behavior. punishment. of he argues, administratorspenalinstitu- Where does one find such professional the of tions have achieved surveillance people discourse? Foucault of course looks for about discourses sex in thebooks, articles, on society's expectations whodeviate from and other documentsthat professionalshave behavior. appropriate from and published.However, for FouMostimportant Foucault'sviewpoint, written has become a standardfor cault, unpublisheddiscourse becomes as criminology as in society. important publications achieving professionalpractices throughout profesto According Foucault,similartechnologies sionalpower,ifnotmoreso. For thisreason, to of also are of surveillance have emerged achieve a variety materials appropriate sources professional power in mental institutions,for study.These sources include the broand and workplaces, schools. chures and files of medical institutions hospitals clinics, Foucault'sexamplesshowthatsocial control treatingsexual disorders,the records of has become more subtle, professionalized,public welfare bureaucracies, therapists' notes, and oriented to surveillanceof deviant and professional correspondence concerning individuals who are considered deviant. behavior. mostimportant thepurposes for AlthoughFoucault's studies of prisons Perhaps here, touch on medicinemainlyby analogy,his one also may look for such discourse, to pertains directly medical whenever workon sexuality talk possible,in theface-to-face of and encounters (1978). Foucault's colorfulac- professionals theirclients.Predictably, what doctors to their count of modernsexualitybegins in the forinstance, say patients Untilthat Foucault about sex comprisesa concreteexpression seventeenth century. time, took institutions an interest of professional discourseand its power in argues,religious in sexuality, the mainly through confessional. daily life, probably a greater to extent than Whenpeopleconfessed sexualactivities, whatdoctors their write aboutsex in textbooks and priests commentedon what liaisons and scientific articles (Poster1984, pp. 131-32). were appropriate whatactions Although and Foucaultalludes to the usefulness positions the and of oral materials, he required penance.After Reformation however, does not use in to himself developing arguments. Counter his Reformation, according Foucault, them concern shifted from On the unintentionalitymedicalsocial bodilyactivigradually of

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and key institutions. control.As notedearlier,social controlin work,thefamily, other process, It does not,even in its moreprogressive an and is medicine generally unintended in versions, foster socialcriticism or dimlyif at all perceivedby participants enlightened Healthprofession- social changeas partof themedicalmission. encounters. doctor-patient There are also situational constraints that as activities viewtheir als seldomconsciously In below the level to to contributing social control. listening leave medicalsocial control clients,doctors of consciousness. from their Whena client in trouble, is wordsof distress as usuallyfeels that something usually do not see theirresponsibility a professional of also organization eco- should be done. Yet the professional the preserving current or nomic production the stabilityof the senses the limitsof what he or she as an on Nonetheless, focusing individ- individualcan do. For instance,when a by family. stressat work,a symptoms reflect rather thansocial issues,doctor- patient's ual troubles the encounters may reinforce social doctor tends to feel that changing the patient or constituted. Whydo these workplaceis beyond the responsibility orderas presently of the capability themedicalrole. With processestendto occur without partici- even the. rare exceptions,such as those involving pants'consciousawareness? of of To help explain the unintentionality physicalabuse, disruption familialrelato tionsis not an appropriate goal of medical one medicalsocial control, maylook first Wantingto help but unable the class origins and position of health intervention. to a Since the beginningof the personally changethe social structure, professionals. the professional typically seeks a solution of twentieth century, vastmajority doctors health families. within the existing institutional context. have come from upper-middle-class In 1920, 12 per cent of NorthAmerican Relaxation techniques, tranquilizers, counselcame fromworking-class ling,family and are therapy, related methods medical students families, and this percentagehas stayed all feasibleapproachesfor the professional in the the time who wantsto do something. a patient For almost exactly sameuntil present recruit- crisis,a doctorcannotdo everything. What limited (Ziem 1977). The extremely families can be done tendsto encourage from working-class mentof doctors copingand despiterecentincreasesin the accommodation. Conscious recognition of has persisted of of proportion women and racial minorities these choices, or consideration more the For seldomoccurs. alternatives, entering profession. the small num- critical These situational to constraints contribute berswithworking-class roots,as fortherest the class position the generallyconservative effectsof the of theprofession, acquired is of physicians one of relativeprivilege. medical role. On the one hand, medical to comfortable lifestyle discourseusuallydoes not attend instituTheir predominantly This orientation to does not encourage professionals criticize tional causes of suffering. to roots of theirclients' leads healthprofessionals overlooksocial the social structural in the of option.On distress, especially sources suffering changeas a possibletherapeutic life the otherhand, when doctorsdo consider class structure. Instead, professionals' in with leads themto help institutional problems their encounters predictably experiences to are. this serves as patients, intervention frequently clients adjustto things they the Professionaleducation and socialization support status quo. Whena professional of mechanisms copingand adjustof to further contribute the unintentionality encourages A of medicalsocialcontrol. critique powerin ment,such communication conveysa subtle modifito of By society needless say, seldompart the politicalcontent. seekinglimited is, On medicalschoolcurriculum. thecontrary, cationsin social roles-at workand in the in for a receive many lessons family, instance-which preserve particprofessionals training overallstability, practithe and about individual pathophysiology treat- ular institution's exertsa conservative instructional pro- tioner ment.Withinprogressive politicalimpact. hearinformation the aboutemo- Despite the best conscious intentions, grams,trainees This practitioner and thus helps reproduce the same tionaldisturbance social problems. structures form rootsof that the emphasizes institutional however,consistently training, is of and social personalanguish.This contradiction one the importance psychological to in knowledge responding theneedsof the sourceof pathosin thehelping professions. Medical social controlalso involvesthe Such an approach seeksto individual patient. in management potentially of troublesome emoarising cope withstresses help thepatient

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deal scheme. In the chief complaint(CC), the tions. Doctors, for instance,regularly elictswhatis bothering patient, the with patients'anger, anxiety,unhappiness, physician possibleterms. The physician and in thebriefest social isolation,loneliness,depression, complaint usually withan distress. Often thesefeelings leads intothechief other emotional from derivein one way or another patients' openingquestionlike: "Hello, what brings such inse- you in today?" or "Well, what's bothering social circumstances, as economic occu- you today?"or "How can I help you?" To racial or sexual discrimination, curity, in life. theseor similar questions, patient the might and pational stress, difficulties family "Headaches" or "My back hurts" or of Such emotions, course,are one basis of answer, political outrageand organizedresistance. "I've gotpainin mychest"or "I can'tsleep" How health managethesesenti- or "I want a check-up"and so forth.In professionals question. One of asking for the CC, the physicianseeks to ments is an interesting of elicitthepatient's foremost concern. medicine'seffects may be the defusing Through present illness(PI), thepatient the Medicineis notthe sociallycaused distress. on He in only institution which such processes elaborates thechiefcomplaint. or she whentheproblem began,what necessarily tellsthedoctor occur, nor do these phenomena of occupya majorpartof medicalencounters. the specificcharacteristics the symptom be, whichmedications othermeaor Still, it is worthasking how such largely might takeplace. sures relieve the symptoms,what prior unintentional microlevel processes he This questionleads us to an analysisof the medicalattention or she has receivedfor the problem,and similardetails that may interaction. structure doctor-patient of to to contribute thedoctor'sattempts reacha to diagnosis. the Guiding patient elicittheCC skill that and PI purportedly the greatest is THE TRADITIONAL FORMAT OF THE a doctors developin taking medicalhistory; MEDICAL ENCOUNTER somecommentators that is themost this argue skill in medicine. Doctors in formatof the medical important The traditional learna comfortable and training presumably is encounter as follows: balancebetween effective listenopen-ended Chief complaint (CC) -* presentillness ing to thepatient's story and moredirective (PH) -* family (PI) -* pasthistory history questioning thatclarifies patient'sprobthe (SH) -* systems lem in terms medicaldiagnoses. (FH) -* social history of examination review(SR) -* physical (PE) Interruptions doctorscommonly by begin -* otherinvestigations -- diagnosis to occur duringthe PI. Such interruptions (OI) (Dx) -* plan (P). to basicallyare attempts cut offstory-telling tries to by patients, thefollowing for the reasons(among a encounter, doctor During typical in to coversomeor all of thesecomponents his others):the storymay not contribute a or herspoken and interaction, byexamination doctor'scognitive a processof reaching In ofthepatient. addition, doctor the provides diagnosis;the patient'sversionof the story a written in versionof the encounter, the maybe confusing inconsistent; or telling the medical record. There, the doctorusually story is maytakemoretimethan perceived to with be available;or partsof thestory labels each component theencounter of maycreate thesame abbreviations I am usinghere. feelings areuncomfortable thedoctor, that that for This traditional formatappears in most thepatient, both.The circumstances or under that textbooks provide instruction clinical whichthedoctor on the interrupts patient's story methodsfor traineesand practitioners to focusthe PI (thatis, what, interrupted, of is commu- whenit is interrupted, reasonis given what medicine. Research doctor-patient on has and so forth) are previously, confirmed for the interruption, nication, reported thatmedicalpractitioners do thatthey actually use the important, especiallyto the extent traditional as structure an organizing frame- cut offconcerns aboutthe social context of work for their encounterswith patients themedical encounter. the Predictably, PI is a criticaljuncture, (Waitzkin 1985).2 duringwhich certaineleTo define to comment each of these ments, and on in though they maybe quiteimportant I on cometo be excluded elements, willfocusfirst thecomponents thepatient's experience, of themedicalhistory (Hx), whichcomprises fromdiscourse,while other elementsare CC, PI, PH, FH, SH, and SR in the above included.

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What is the relationship between the may carry an increased risk in certain spoken PI and the versionthatthe doctor families. Althoughone might expect the social in writes themedicalrecord? Whilewriting a (SH) to be important a contextual for PI comprehensible mayinvolveskillful effort history of it its by a doctor, orderliness invariably givesa analysis medicalencounters, is usuallya listing demographic of data. For falsesenseofwhat happens the during spoken perfunctory "I instance,the doctor typicallyasks about PI. For example,thedoctor neverwrites, the interrupted patient thispoint," or "I birthplace,occupation, educational attainat and status. the patient'scommentsabout his ment,livingsituation, insurance thought concernsthat pertainto a to family hereweren't pertinent hispain,so I The contextual usuallyappear, subjectto asked him about what medications was patient'sdistress he and during PI, rather the to taking,"or "I was in a hurry get my interruption cut-off, child care so I cut off the than the SH. In the SH itself,the doctor from daughter tends not to pursue in much at patient thispoint,"and so forth. Instead, traditionally social circumstances PI thewritten represents doctor's the interpre- depthhow thepatient's might relate thedifficulties which or to for he tation of a disorderlyseries of spoken she is seeking medicalattention. exchanges.The orderliness the written of version belies whatactually gets said during Presumably,the systems review (SR) information about the thePI, whichis mychieffocushere.This is elicits any additional patient thatmight leftout or missedby be notto say that written is uninteresting, the PI and othershave documented enormous other parts of the history.The SR is the very briefand sometimes quite differences content in between spoken the and sometimes lengthy; scuttlebutt medical among practitionwritten versions Hoch(Zuckerman, Starfield, is reiterand Kovasznay 1975). I am mainly ers has it thatthe SR's length inversely relatedto clinical experience. The expectawith spoken in all the concerned, PI however, tion,however, thatthedoctor is will ask the itsdisorderliness. patientwhether or she has experienced he While the CC and PI are almostalways in symptoms more or less each of the in present medicalencounters the (assuming following organsystems: skin,lymph nodes, patient is awake and conversant),other head, eyes, ear, nose, throat, neck, respiraon tory components appearor not,depending may cardiovascular system, system, gastrointime, the doctor's desire to complete a testinal system, genitourinary system, reprocomprehensive evaluation,financialissues ductive system, neurologic endocrine system, such as the patient's insuranceand how system, and bones and joints. For instance, extensive evaluation permits, other underthe gastrointestinal an it and the system, doctor situational constraints. doctor A may choose would question about symptomsof the to defersome or all the remaining compo- esophagus (principally stomach swallowing), nents future to or at visits, notcoverthem all, (heartburn, ulcers, cancer, and so forth), although there is usually some attempt duodenum,small intestine, large intestine to initially developa diagnosis and plan. in (irregularity bowel habits, bleeding, infecIn thepasthistory (PH), thedoctor gathers tions),rectum (hemorrhoids, bleedfissures, information aboutpast medicaleventsin the ing), liver (jaundice, hepatitis, toxic expolife patient's thatare notdirectly to pertinent sures),and pancreas.In other words,theSR the PI. These eventstypically includeprior can be quiteexhaustive, even moreso if the and surgery,other major patient hospitalizations happensto be a "yea-sayer."Then, illnesses,medications, allergies,immuniza- doctorand patient enterpotentially endless tions, smoking, drinking habits,and recre- labyrinths questions of and answers, leading ationalsubstance use. to frustrating excursions a of through welter The familyhistory(FH) includes data symptoms diseasesthathave little do and to about illnesses and deaths in the patient's with the current purposes of the medical immediatefamily:mother,father,sisters, encounter. Gradual recognitionof these brothers, spouse,and children. Additionally, pitfalls a during medicalcareeraccountsfor in this sectionmanydoctorsroutinely elicit the exhaustive efforts thatmedical students information about family occurrencesof devote to the SR, while theirsupervising cancer,heartdisease, hypertension, diabetes physicians oftentruncate SR to a very the mellitus,and othercommonproblemsthat briefseriesof questions, whichtheydo for

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not expect to hear "yes" as a frequent into which a patient's physical problems answer. fall. might Mostpractitioners wouldacknowlthe edge that tendencies interrupt, off, (PE) examination involves The physical the to cut in laying ofhands,whoseimpact medicine orotherwise on redirect patient's the story during intimate thePI deriveat leastpartly touted.Without has been so highly from driveto the would not differ makea diagnosis.Thatis, a doctor touch,medical encounters wantsto othertypesof profes- hear those words that are consistent nearlyso muchfrom with If interactions. timeis available previously sional-client defined diagnostic Parts categories. been done, a doctor of patients' and if it has notalready stories thatdo notfitneatly into will examine the body's entire external thesecategories function unwanted as strangthe surface during PE, as well as its internal ersin medical discourse tendto be shown and Whentimeis notavailable,or ifthe to thedoor(Beckman Frankel orifices. and 1984;West is toward comprehensive-1984). doctor notinclined ness, he or she does a more focusedPE, While the drive to make a diagnosisis on concentrating thosepartsof thebodythat strong, diagnostic reasoning tendsto be both to might related theCC and PI. be limited and exclusionary. True, doctorsand initiates doctors-in-training learnto deal withan sometimes the After PE, thedoctor must (OI)-lab one or more otherinvestigations awesomenumber diagnostic of and categories and so subcategories.Yet this set of diagnoses tests, x-rays, electrocardiograms, aim the corresponds no morethan tiny forth-whose purported is to clarify to a fraction of or datathat maybe useful human diagnosis to gather experience. largepart, cognitive In the OIs or fortreatment prevention. also seemto process of reaching a diagnosis involves communicate They may convey excludinga substantial something. part of a patient's and an impression thoroughness concern. experience of that-no matter how relevant to oriented intervention be thepatient-is notrelevant A scientifically may to thediagnosis. knowledge reassuring becauseofthetechnical Featuresof patients'social context may be whenan OI it presumably reflects. Further, verytroubling patients to and actuallymay leads to a negative finding,it doubtless affect their conditions fairly in physical direct In and of produces feeling relief well-being. a ways. These contextual issues,however, are fact, one research study has shown that almostalwaysdifficult definewithprecito in normallab resultslead to improvement and for sion, are loaded withambiguity, are not even symptoms, whenOIs arenotordered completelyconsistentwith the technical a specific from doctor's a point reason clinical diagnosis. The of view (Sox, Margulies and Sox 1981). categories of differential exclusionarydrive, so much a part of an Thus, a doctor'sact of recommending OI a properdiagnosis,promay have several meaningsin a medical reaching medically affects whatis spokenand recorded foundly results that the aside from specific encounter, medicalencounters. conContextual during are obtained. cerns that do not lend themselves the to With the data gleaned fromthe various possibilities the of components the medicalhistory, PE, technicallexicon of diagnostic tend to gravitatetoward the marginsof and the results OIs, the doctorreachesa of or medicaltalk. diagnosis(Dx), thatmay be provisional The medical plan (P) constitutes the involved confirmed. cognitive The operations interventions thedoctor that suggests, usually are in making a diagnosis undoubtedly the Traditional Essentially toward end of an encounter. complexand poorlyunderstood. aboutthemedicalplan holdsthatit comments the teaching in thedoctor takesthepatients' First,thereis a madeduring the containstwo components. medical history, observations diagnostic plan, whichinvolvesthe OIs that PE, and data from OIs, and shapes this the information into one or more diagnostic the doctorwishesto obtainafter present ends. Second, in the therapeutic encounter categories. recommends medication, the The driveto reacha diagnosis extremely plan,thedoctor is Practitioners doctorsin training surgery,diet, rest, exercise, counselling, and strong. attitude that change,and so forth of categorization relaxation, view thefacility diagnostic as one of the most important professional he or she believes the patient'sdiagnosis skillsin medicine.The "differential diagno- warrants.A substantialpart of medical involveslearning sis" involvesa list of all possiblecategories education and keepingup

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diagnostic BENEATH THE TRADITIONAL vogues of preferred withcurrent FORMAT: PROCESSING IDEOLOGY plans. and therapeutic the AND CONTEXT reasoning, as diagnostic Just it affects is drivealso shapestheplanthat exclusionary By questioning, interrupting, by and by varied Among the infinitely formulated. otherwise the of shifting direction conversafor human action, the limited possibilities tionfrom to nontechnical problems technical relarangeof medicaldiagnosesencourages talk excludecertain ones,doctors topicsfrom tively few options. Usually these options and include others. particular Of interest here data,or are theverbaltechniques divert more technical OIs create involve that that attention or from surgery, that treatments use medication, of in sources personal distress thesocial Alternatively,context. intervention. similartechnical Such techniques offthepossibilcut which ity of considering context nonintervention, a doctor maysuggest the critically, let thata problemis not alone changing How medicalencounters involvesreassurance it. technical action,or convey ideologic messages, and how they enough require to serious to a scheduleof follow-up be sure thatthe invoke social control, sometimesinvolve aboutwhat pronouncements does notbecomeworse.Sometimes, doctors'explicit problem shouldor shouldnot do. It is also such patients othermaneuvers a doctorrecommends and that ideology socialcontrol emerge as dietaryimprovement, changes in habits likely from whatdoctors patients and excludefrom and alcohol consumption, such as smoking their talk,and how it comesto be excluded. or counselling,psychotherapy, behavioral Severalstudies communication mediof in the problems cine have suggested change. In such situations, thatmedicalencounters oftenhave rootsin the contain common structural underconsideration features.In a social context theencounter. of of consociolinguistic analysis doctor-patient rarely versations, becausethemedicaldiagnosis Partly Westhas found typical "troubles" nameforsuchcontextual that a provides technical arisein encounters (1984). Whenpatients abouteventsin their lives call the problems, plandoes notgenerally for expressconcerns Instead,the medi- thatare not amenableto doctors'technical a contextual intervention. West argues, questions and as to cal plantends acceptthesocialcontext a intervention, are interruptions mechanisms whichdocby changes given. Even the limitedbehavioral concerns back to a tors steer patients'* aim that generally at a doctors mayencourage track.As Westnotes,other studies with technical reconciliation less troublesome patient's also have observed that doctors interrupt his or hercontext, rather thanchangein the and morequestions patients frequently initiate For context itself. themedical plan,giventhe thanpatients (Beckman Frankel do and 1984; process, Fisher1986; Fisherand Todd 1983; Frankel power and limitsof the diagnostic the range of the possible becomes quite 1986). In West's tape-recorded sample of restricted. medicalinteractions, male doctors tendedto to Where does giving information the interrupt moreoften thandid female patients format the doctors. West interprets of and patientfit in the traditional interruptions as questioning gesturesof domiRemarkably, this for- frequent medical encounter? control flowof the of mat-as taught generations doctorsin nance,by whichdoctors to She also postulates conneca nicheforproviding conversation. a training-lacks specific tionbetween social powerand sexual differfor It information.is probably thisreasonthat has givinginformation oftenbeen catch-as- ences in language use, in conversations and more specifically profesin the catch-can medicine. in Similarly, absence generally, encounters, sional-client in of a specific place to give information the in of Further, his study medical encounters, has format doubtless contributedMishlerdemonstrates medicaldiscourse encounter's how deficienciesand cuts off contextual to the very problematic issues and redirects the that dissatisfactions have arisenin thisarena focus to technical concerns (1984). Mishler it 1984, 1985). Suffice to say, the presents (Waitzkin from detailedtranscripts recordings also does not guide the of doctor-patient format traditional communication (Waitzkin about 1985) and describes two "voices" that information doctorin communicating issues. compete with each other. The "voice of contextual

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medicine"involvesthe technical topics (of concerns unsaid. In Katz's account,doctors physiology, pathology, pharmacology, so andpatients and tendto remain silent aboutmany in whichconcern doctors their forth) profes- topics, especiallythose that would require sionalwork.Alternatively, "voice of the patients' the informed consent. Similarly, Cassell the lifeworld" comprisesthe everyday, largely interprets confusions, misunderstandings, that with insensitivities, communication and nontechnical problems patients carry lapses in of themintothe medicalencounter. According transcriptsdoctor-patient interaction (1985). a to Mishler'sanalysisof transcripts, patients He reiterates viewpointfrequently exoften to raisecontextual issuesthrough the pressed, thatdoctors training in try shouldlearn voice of thelifeworld. Doctors,however, are bettercommunication skills to avoid such in ill-equippedto deal with such issues and gaffes practice. on Commenting theunsaid return the voice of socioemotional to content medical encounof therefore repeatedly medicine.For instance,patientsraise per- ters, Cassell urges thathealthpractitioners that to sonaltroubles do notpertain technical pay moreattention whatis excludedfrom to relatedto technical conversation, well as thereasonswhy. as problems.Or, although troubles notseem do These accountsof the unsaid in medical problems, these personal amenable to technical solutions. Or, the language do not emphasize enough the leads to discom- pertinence the unsaid for the context of raising personal of troubles of the fort theprofessional, client,or both. professionalencounters.Doctors do not for doctors Underthesecircumstances, typically simplyoverlookor downplayor suppress or contextual introject questions,interrupt, otherwise patients' concerns. The exclusion to from critical attention a is changethe topic, to return the voice of of social context medicine. fundamental feature medicallanguage,a of Mishler'sapproach how featureclosely connectedto ideology and Although conveys medical languageencourages the sayingof social control.Inattention social issues, to somethings theleavingunsaidof others, especially when these issues lie behind and remains rather the"lifeworld" general. Mish- patients' personal can troubles, never justa be ler implies that patients' concerns about matterof professional inadequacy,or the contextual issues in the lifeworld very inadequacy professional are of training. Instead, important themand thatcutting these thislackis a basic part whatmedicine in to off of is concerns undesirable. is When the voice of oursociety. -this medicine achieveWhatelements social context gains sway,however, of helpshape mentalso has muchto do withideologyand the ideologic contentof discourse?Social social control. Divertingcritical attention class, of course,is a keycontextual element. of away from the lifeworld,doctors subtly Relationships social class are crucialparts reinforce ideas thatpattern lifeworld ofthecontext which the the in discourse arisesandin and may help win acquiescence to those whichideologyis transmitted. theextent To features the lifeworld of thatpatients find that doctorsand patientsoccupy different a mostdisconcerting. short, re-reading class positions, In of thisclass difference patterns thatthe the ideologic contentof their discourse. Mishler'smaterials might emphasize not voice of medicine onlytendsto suppress Predictably, doctors sometimes voice explicit thevoice of thelifeworld also reinforces ideologicmessagesthat but legitimate current the the reasonableness and acceptability the class structure society; thetransmission of of or lifeworld itspresent in form. of ideology occursmoresubtly, conveyed by What is leftsilent,unsaid, or hiddenin theabsenceof criticism aboutclass structure medical encountershas fascinated other and its variousinjuries.In medicalencounwho rich researchers, have interpreted textual ters, marginalization constrains opposian materialsbut with little or no contextual tional voice, perhapsthat of a patientin F am izte>t1MQK t% etam a cwt_-,:~t, thesismEmgtQr e lKat Tn_,K&e& extensive account the"silent of world"ofthe de-emphasis. This way of lookingat medical a different theoretdoctor-patient relationship (1984). He shows discourse provides slightly how medical languageoverlooksor down- ical prismto see the same problems uncovof features doctors' and ered by sociolinguists who observea "diffiplayssomeimportant in patients' experience. Thus, Katz argues, dence" of working-class patients medical or doctors often gloss over their patients' encounters, who notecontention between and concerns,and patientstend to leave these the"voice ofmedicine" the"voice ofthe

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lifeworld"(Waitzkin1985; Mishler 1984). CONCLUSION: A CRITICAL THEORY Such observations confirm thatsocial class OF MEDICAL DISCOURSE relations, an elementof context, as pattern ideology within discourse. Now let me turnto threesummaries of But social class is nottheonlycontextual actual doctor-patient encounters. Transcripts were as of thataffects element discourse;othercrucial oftheseencounters prepared part a communication elements includegender,age, and race. All large studyof doctor-patient random from sampling private these contextual elementscan become the thatinvolved and outpatient departments. basis of dominance and subordination, and practices hospital are here they are closely linked to social class. The encounters summarized because theyillustrate typical patterns thesampled in Ideologiesof gender in pertain largepartto (Waitzkin 1985). In each encounthe roles men and women occupy in the interactions deal withpersonal and at work. Through family ideologiesof ter,doctorsand patients troublesthat derive largely from broader gender,expectations about what men and issues (cf. Mills 1959, pp. 3-24). womenappropriately shouldand shouldnot contextual After summaries, tryto reorganize the I the do entereveryday language.Arisingin the elements discourseso thatan underlying of contextof discourse,these ideologiesprostructure become apparent. may Then, after foundly affect whatis or can be said, what reviewing threeencounters, present the I a appearsat thecenter discourse, of and what general structural of medicaldiscourse. view as slips in at the margins. Similarly, people The structural analysis of these particular age, they encountera changing set of materials points also aheadto other papersin and which a expectations demands, vary great thisseries,whichprovide fulltranscripts the deal amongsocieties. theUnited In for and moredetailed States, analyses theseand other of instance, ideologiesof agingcan conveythe encounters. imageof a trash heap, whereelderly people -A man comes to his doctor several actuallyor symbolically move when their monthsaftera heart attack. He is deproductivity, reproductivity, used up. or is pressed.His periodof disability payments Othersocietiestendto be more lenient, or will expiresoon, and his unionis aboutto even respectful,in ideologies of aging. His go on strike. doctor tellshimthat is he Ideologies of race have entereddiscourse able to return workand that to physically whenever societies have encountered the will his working be good for mental health. contrast between and majority minority groups. The doctoralso prescribes antidepresan of Expressions racial ideologieshave ranged santand a tranquilizer. from master-slave the vernacular theonly to -A woman visitsher doctorbecause of moresubtleversions modernity. of slightly in irregularities her heart rhythm. She these contextual Why highlight elements complains palpitations shortness that and of here?Class, gender, age, and race are some breath interfering herability do are with to of the contextual elements that pattern housework. The doctorchecksan electroideologiclanguagein face-to-face discourse, while she exercises,changes cardiogram as well as medicaldiscourse. is notenough It hercardiacmedications, congratulates and to acknowledge thatideologymaybe reproher in her efforts maintaina tidy to duced in medicaldiscourse;the questionis household. -A mangoes to hisdoctor a premarital how this happens. That is, in concrete for blood test. The doctor questions him examples of discourse,the criticalreader closely about his drinking problem,his needsto seek specific places whereideologic his smoking, job, his family, his plans and imreproduction occurs,and wherecontext formarried life. Then the doctorencourpinges on discourse. I propose that these at ages attendance AlcoholicsAnonymous places may become apparent part of an as and orders a test of liver function, in that structure is not obvious or underlying addition thepremarital to bloodtest that the in consciously appreciated surface meanings. patient requested. I Further,expectto find theseplaces, at least in of partly, themargins discourse-in what Figure1 showssomestructural elements of is left unsaid, interrupted, cut off, or discourse thefirst in encounter. Seen in this deemphasized.3 way,thecontextual issueofuncertain employ-

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a Returnto Work After Heart witha Man Anticipating Elementsof Medical Encounter FIGURE 1. Structural Attack A: Uncertain employment B: Depression
-

C: Medical encounter

D: Patient expresses concern aboutreturn brief) to work(very E: Patient repeats concerns; them. doctor de-emphasizes

F: Doctorencourages return work. to patient's -Doctor reassures work that is goodformental health. -Doctor prescribes antidepressant andtranquilizer.

itself (C), the presents (A). Depression tress(B). Whenshe sees herdoctor mentinitially this concern(D). Rather experi- patientmentions thatthepatient trouble is a personal to of ences in anticipation a return uncertain than exploringher concern in depth, the while the (B). Coming to the medical doctordoes an electrocardiogram employment and patient exercises the (C), the patienttentatively (E). Based on theresults, encounter changesthepatient's cardiacmedicaabouthisimpending doctor concern briefly expresses in to her efforts at return workwhenhis unionintends go tions. He also encourages to to a (F). at leasttrying maintain tidyhousehold (D). He repeatstheseconcerns on strike to severalpoints,but thedoctorde-emphasizes The patientthus returns her personal the of in pursuing contextual challenge doinghousework theface of them than (E). Rather heart that serious disease. reassures patient the the problem, doctor elements of health;further, Figure3 gives some structural workis good forhis mental & VI&' tWips zwttwkzl . Wks p tw (C vt. -an fine doctlopltsvbts brAAn the contextual issuethat derives from patternthe (F). and a tranquilizer After medication that men (A). the continues ing of role expectations affect encounter, assumes, patient one for to Like mostmen,thispatient finds he must that to prepare himself a return work. to and of himself his elements thesecondencounter holda job steadily support Structural issue family-to use a convenient term,he must appearin Figure2. Here thecontextual as about women's social earnthe "meansof subsistence." Further, involvesexpectations as he (A). Housework, many he approachesmarriage, also faces an role in thefamily that activityin expectation he stably perform "head" as have noted, is an important which traditionallyof a family.Such expectations about work "reproduction," economic of are however, notsimple ones, is theresponsibility women.Because this andthefamily, is interfere withher sincethepatient something a lush. The of patient'sheartsymptoms therefore a troushe experiences emotionaldis- patient experiences personal housework,
FIGURE 2. StructuralElements of Medical Encounter with a Woman Whose Heart SymptomsInterfere withHer Housework A: Women'srole expectations (homemaintenance; reproduction) B: Distress: heart > symptoms with interfere housework F: Doctorencourages continuing patient's housework. patient's -Doctor changes cardiacmedications. patient -Doctor encourages to in efforts maintain household. tidy C:
-

Medical encounter

D: expresses Patient about concern during symptoms housework. E: states As patient doctor does concern, during electrocardiogram exercise.

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FIGURE 3. StructuralElements of Medical Encounter with a Man Whose Alcohol Problem Potentially withWork and FamilyRelations Interferes A: Men's role expectations (earning means of subsistence; "head"offamily) B: from Conflicts alcoholuse C:
->

D:
-

Medical encounter

Doctorexpresses about concern alcoholuse.

F: Doctorencourages stablefunctioning patient's at workandin family. -Doctor encourages attendance at Alcoholics Anonymous. -Doctor orders of test liverfunction, addition in bloodtest. to premarital

E: Doctorquestions closelyaboutalcohol, plans smoking, family, job, formarried life. -Doctor interrupts frequently.

personal troubles to conflicts same three encounters, ble that pertains actualorpotential distress heart that sympfromalcohol use (B). Duringthe include:depression, deriving with and (C), the doctortakesthe tomsinterfere housework, conflicts medicalencounter alcoholuse.) aboutalcohol(D). from concern lead in expressing cometo closelyabout C. Themedicalencounter: Clients the questions patient The doctor his medical professionals with complaints that alcohol, as well as his heavy smoking, life. In very often(thoughnot always) have ecojob, family,and plans for married interruptsnomic, social, and political roots. Such the thesequestions, doctor pursuing sources of personaltroublesin(E). Beyond voicing contextual the patientfrequently of and attend clude class structure theorganization that strong encouragement the patient family gender life, roles,and sexuality; Alcoholics Anonymous,the doctor also work; the orders a test of liver function.In this agingand the social role of the elderly; of use; and the encourages patient's patterning leisureand substance the discourse, doctor resources dealingwithemotional for at stablefunctioning workand in thefamily limited distress. (F). problemsin thatfollow, reasoning D. Expressionof contextual In the paragraphs I The traditional techniand discourse: encounters,map some medical theseand other from does islands around which medical discourse cal sequenceof the medicalencounter the expressionof contextual these not facilitate seems to flow (Figure4). I interpret own characterin structures theflowof concerns. Regarding patients' islandsas underlying medical discourse, rarely discerned con- istics, the relationsbetweenlanguage and maketheexprespredictably sciously by the doctorsand patientswho social structure concerns moredifficult for sionof contextual travel there. people, women, and racial The economic, working-class A. Social issue as context: humanistic progressive or Certain of social, and politicalcontext societycon- minorities. to These social doctors encourage patients talk aboutthe conditions. tainsmanydifficult of components theirproblems lie issues often behindand help createsome nontechnical to lifeworlds. Thesepatients thatclientsexperi- that pertain their of the personaltroubles and about concerns vent emotions lives (Mills 1959, pp. can express ence in their everyday or above, the such personaltroubles.Less humanistic 3-24). (In the threeencounters doctorstend to discouragepasocial issuesare: uncertain employ- progressive pertinent such concernsor to and women'sroleexpectations, men's tientsfromexpressing ment, them whenexpressed. ignore roleexpectations.) E. Countertextual tensionsderiving from B. Personal trouble: Clients tend to as problems,howthesetroubles privately, their social context:Contextual experience They are unlikely ever, create tensionsin medical discourse. own individual problems. such tensionsthatderivefrom the to recognize consciously social issuesthat Periodically social issues eruptinto the dislie behind theirpersonaltroubles.(In the troubling

236
A: Social issue as context (political/ economic/ social condition) B:

JOURNAL HEALTHAND SOCIALBEHAVIOR OF


C: D:

FIGURE 4. The Micropolitical Structure Medical Discourse of

Personal trouble

Medical encounter

of Expression contextual problems 1. Traditional, technical sequence does notfacilitate 2. Sociolinguistic barriers: class, minorities gender, 3. Humanistic orientation? a. Yes: discuss nontechnical trouble b. No: suppress nontechnical trouble

(consent)

F: of Management contextual problems 1. Offer technical solutions andcounselling 2. Reproduce often ideology, absence conveyed through ofcriticism 3. Excludecollective action to leading socialchange 4. Achievesocialcontrol by consent encouraging

E: tensions Countertextual deriving from socialcontext 1. Manifested margins at ofdiscourse 2. May be suppressed dominance by gestures (interruptions, cut-offs, de-emphases)

course,or appearat itsmargins, createa achievesitsimpact and through absence.Thatis, countertextual reality cannot resolved by a lack of criticism that be directed sources against in the framework a medical encounter. of distressin the social context,medical of Doctors tend to suppresssuch tensionsby discourseideologically reinforces status the dominancegestureslike interruptions, cut- quo. The discourse medicine of thustendsto that offs,and de-emphases get thediscourse excludebasic social changeas a meaningful back on a technical track. alternative. accepting present In the context F. Management contextual problems: as given, and in remainingsilent about of Whethersuch tensions are expressed or collective politicalaction,medicaldiscourse suppressed, languageof medicine the leaves encourages consent rendering by socialchange This latteraccomplishment few optionsforaction. Limitedoptionsfor unthinkable. of actionapplyto bothhumanistic encounters, medicinemay be its main contribution to whendoctors encourage patients talkabout social control. to will nontechnical components theirpersonal of Further studies showhowthisstructure troubles, and to less humanistic encounters, helps us understand what is happening as wheresuchconcerns discouraged. are Gener- doctorsand patients deal withproblems of with ally,doctors technical solutions work, the familyand genderroles, aging, respond how best to adjust to sexuality, and counsel patients leisure,substance use, other"victheir previous roles.The language medical es," and troublesome of emotions. addition, In is sciencecan conveyideologiccontent, espe- medicaldiscoursein whichthis structure social problems into not apparent will become a matter of cially whenit converts technical ones. Ideologiclanguage also arises particular interest. is at the margins of medical discourse or To whatever extent thistheory persua-

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While elaborating medical encounter's the sive, other questions immediately suggest and history pre-historya worthy is enterprise, it themselves:Can the structure medical of is beyondmy scope here and thereis little Can medical disdiscoursebe reformed? doubt that the traditional formatis now of courseincludea criticism the sourcesof in commonplace manyor mosthumansociein of personal distress the social context the ties. That this particular format should have A in professional encounter? critical discourse arisen remarkable is becauseitseffectivepartly medicine, might one argue,wouldno longer ness in improving medical conditions so is encourageconsentto contextual sourcesof Like manyother unproven. aspectsof modem personaltroubles.By suggesting collective medicine, beneficial the of impact themedical action as a meaningful option, medical encounter's organization themorbidity on and of mortality large populations,as well as professionals mightbegin to overcomethe individual is patients, difficult impossible or to impact thatits exclusionexerts.Can thisbe demonstrate (Waitzkin 1983,pp. 3-43; McKedone withoutfurther medicalizingsocial own 1979). This is not to deny thatmodem problems? so, critical If discourse medicine in medicine accomplished has great things. Many wouldrecognize limits medicine's the of also of the medical encounter's most timerole and the importance building of linksto and consuming thus costly components (suchas other forms praxisthatseek to changethe of the FH, SR, and muchof the PE), however, socialcontext medicalencounters. of Moving have never been put to the test of costof beyond the currentstructure medical effectiveness. discourse thenbecomesa majorgoal of this 3. In a companion paper,I have developedthese propositions further throughapplicationsof to attempt analyzeit. NOTES critical theory in structuralism and poststructuralism (Waitzkin 1989b).

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Illness:Clinical,Sociological,and Methodolog- Ziem, Grace. 1977. "Medical EducationSince 76:8-14, 23. Bulletin Health/PAC Flexner," Advances in Psychosoical Considerations." Zola, IrvingKenneth. 1972. "Medicine as an maticMedicine8:180-215. of Institution Social Control." Sociological __ . 1976. "Information Control and the Review20:487-504. of Micropolitics HealthCare." Social Science& I. 1975. "In the Name of Health and Illness: Medicine10:263-76. of Consequences MedOn Some Socio-political 1974. Waterman. Howard,and Barbara Waitzkin, ical Influence." Social Science & Medicine Society. of TheExploitation Illnessin Capitalist 9:83-87. Bobbs-Merrill. Indianapolis: ._ 1983. "The Medicalizing of Society." Pp. Milton C. and William B. Stason. Weinstein, Philadelphia: Inquiries. 243-96 inSocio-Medical Analof 1977. "Foundations Cost-Effectiveness Press. riversity 'Temple h ysis forhealth and Medical Tractices.-'New X., -Lucecrma-n, 'b. S'twaieLd,C.Y>Wenltr, andL )ournal ofMedicineY9bf)\b-z2. Englan& of the West, Candace. 1984. Routine Complications: B. Kovasznay.1975. "Validating Content MedicalRecordsby Means Outpatient Pediatric Troubles With Talk Between Doctors and Encounters." Doctor-Patient Patients. Bloomington: Indiana University of Tape Recording 56:407-11. Pediatrics Press. of HOWARD WAITZKIN is Professor Medicineand Social Sciences,and Chiefof the Divisionof Irvine.His research of Care, at the University California, Medicineand Primary GeneralInternal a he policy. Currently, is finishing book, and communication health focus on doctor-patient interests and of Study How Patients DoctorsDeal With of titled tentatively At theMargins Medicine:A Critical Press,Forthcoming). (Yale University Social Problems