Disorder or difference? How clinician-patient interaction and patient age shape the process and meaning of autism diagnosis.

This article follows Blaxter's foundational call for a sociology of diagnosis that addresses the dual aspects of diagnosis-as-category and diagnosis-as-process. Drawing on video recordings from an autism clinic, we show how the process of attaching the diagnosis to a child involves interactions between clinicians, parents and children, and that in the course of such interactions, a diagnostic category officially defined in terms of deficits can instead be formulated in terms of valuable social and cognitive differences. More specifically, we show that the child's age is crucial for how clinicians formulate the diagnosis: with younger children, clinicians treat autism exclusively as a deficit to be remedied, whereas with older children, clinicians may treat autism either as a deficit or as a social-cognitive difference. Further, because older children are often co-recipients of diagnostic news, we find that clinicians carefully manage the implications such news may have for their self/identity. Finally, we suggest that (1) the equation of a diagnostic category with dysfunction is achieved in interaction; (2) the meaning of a diagnosis may vary with characteristics of its recipients; and (3) that meaning can be worked up by clinicians and recipients in ways that centre difference rather than deficit.

Doing Abstraction: Autism, Diagnosis, and Social Theory.

Recent decades have witnessed a dramatic upsurge in the prevalence of autism spectrum disorder (ASD). As researchers have investigated the responsible sociohistorical conditions, they have neglected how clinicians determine the diagnosis in local encounters in the first place. Articulating a position "between Foucault and Goffman," we ask how the interaction order of the clinic articulates with larger-scale historical forces affecting the definition and distribution of ASD. First, we show how the diagnostic process has a narrative structure. Second, case data from three decades show how narrative practices accommodate to different periods in the history of the disorder, including changing diagnostic nomenclatures. Third, we show how two different forms of abstraction-Type A, which is categorical, and Type B, which is concrete and particular-inhabit the diagnostic process. Our analysis contributes to the sociology of autism, the sociology of diagnosis, the sociology of abstraction, and social theory.

Documenting diagnosis: testing, labelling, and the production of medical records in an autism clinic.

All diagnosis depends on communication between doctors and patients. This is especially so with behavioural disorders such as autism, where structured interactions involving clinicians and children (e.g. standardised tests) play a key role in diagnosing the condition. Although such interactions are collaborative, we find that when reporting test results, clinicians, following administrative protocols, routinely gloss over the embodied interactions constitutive of testing, such that autism is predicated as an inherent feature of the child. In ethnomethodological terms, this is related to the way that "accounts" (Garfinkel 1967), including diagnoses, are reflexively related to the taken-for-granted practices that make them objectively reportable in prevailing professional terms. These practices include how the clinicians themselves interact with children they examine, with other professionals, and with the instruments used to test a child. Examining video footage of a multi-stage autism evaluation, along with the medical report rendering the child's diagnosis, we show how reporting practices, while addressing the administrative features of standardised testing and diagnosis, can also be examined for their grounding in an environment of tacit matters usually unavailable for inspection. We conclude by asking whether, and how, oral and written reports might re-situate children in the concreteness of their social environments.

Creating space to discuss end-of-life issues in cancer care.

OBJECTIVES: Analyze entire oncology clinical visits and examine instances in which oncologists have to break the bad news that patients' treatments are no longer effective. METHODS: Using conversation analysis we examine 128 audio recorded conversations between terminal cancer patients, their caregivers, and oncologists. RESULTS: When oncologists break the bad news that a patient's treatment is no longer effective, they often use a conversational device we call an "exhausted current treatment" (ECT) statement, which avoids discussing prognosis in favor of further discussing treatment options. Analysis suggests that improving and prioritizing patient-centered care and shared decision making is possible if we first understand the social organization of clinical visits. CONCLUSIONS: ECT statements and their movement towards discussing treatment options means that opportunities are bypassed for patients and caregivers to process or discuss scan results, and their prognostic implications. PRACTICE IMPLICATIONS: When oncologists and patients, by fixating on treatment options, bypass opportunities to discuss the meaning of scan results, they fail to realize other goals associated with prognostic awareness. Talking about what scans mean may add minutes to that part of the clinic visit, but can create efficiencies that conserve overall time. We recommend that oncologists, after delivering scan news, ask, "Would you like discuss what this means?".

Delivering bad news in emergency care medicine.

Forecasting is a strategy for delivering bad news and is compared to two other strategies, stalling and being blunt. Forecasting provides some warning that bad news is forthcoming without keeping the recipient in a state of indefinite suspense (stalling) or conveying the news abruptly (being blunt). Forecasting appears to be more effective than stalling or being blunt in helping a recipient to "realize" the bad news because it involves the deliverer and recipient in a particular social relation. The deliverer of bad news initiates the telling by giving an advance indication of the bad news to come; this allows the recipient to calculate the news in advance of its final presentation, when the deliverer confirms what the recipient has been led to anticipate. Thus, realization of bad news emerges from intimate collaboration, whereas stalling and being blunt require recipients to apprehend the news in a social vacuum. Exacerbating disruption to recipients' everyday world, stalling and being blunt increase the probability of misapprehension (denying, blaming, taking the situation as a joke, etc.) and thereby inhibit rather than facilitate realization. Particular attention is paid to the "perspective display sequence", a particular forecasting strategy that enables both confirming the recipient's perspective and using that perspective to affirm the clinical news. An example from acute or emergency medicine is examined at the close of the paper.

Parents as a Team: Mother, Father, a Child with Autism Spectrum Disorder, and a Spinning Toy.

This paper is a single case study involving a visit to a diagnostic clinic for autism spectrum disorder. A young boy finds a toy that he can hold with one hand and spin with another. In order to retrieve the toy and leave it in the clinic, the parents engage in a team effort. We describe this achievement in terms of two styles of practice or interactional routines with differing participation frameworks.We examine not only how the parents work as a team using these styles, but also how they improvise to extract the spinning toy from their son's grasp with minimal protest on his part.

Category attribution as a device for diagnosis: fitting children to the autism spectrum.

The practice of medicine involves applying abstract diagnostic classifications to individual patients. Patients present with diverse histories and symptoms, and clinicians are tasked with fitting them into generic categories. They must also persuade patients, or family members, that the diagnosis is appropriate and elicit compliance with prescribed treatments. This can be especially challenging with psychiatric disorders such as autism, for which there are no clear biomarkers. In this paper, we explicate a discursive procedure, which we term category attribution. The procedure juxtaposes a narrative about the child with a claim about members of a clinically relevant category, in this case, either children with autism or typically/normally developing children. The attribution procedure carries the implication that the child does or does not belong to that category. We show that category attributions are organised in a recurrent interactional sequence. Further, we argue that category attributions encode normative expectations about child development, such that the child is rendered typical or atypical relative to clinical and social norms. Accordingly, such categorisation devices have a moral dimension as well as a clinical one.

'End of life' conversations, appreciation sequences, and the interaction order in cancer clinics.

OBJECTIVE: To address the organization of conversations in oncology visits by taking an "interaction order" perspective and asking how these visits are intrinsically organized. METHODS: Conversation analysis. RESULTS: Using audio recordings of talk in oncology visits involving patients with non-small cell lung cancer, we identify and analyze an "appreciation sequence" that is designed to elicit patients' understanding and positive assessment of treatments in terms of their prolongation of life. CONCLUSION: An "appreciation sequence," regularly initiated after the delivery of scan results and/or treatment recommendations, simultaneously reminds patients of their mortality while suggesting that the treatment received has prolonged their lives, and in some cases significantly beyond the median time of survival. PRACTICE IMPLICATIONS: We explore the functions of the appreciation sequence for cancer care and set the stage for considering where and when physicians have choices about the order and direction the talk can take and how to allocate time for end of life and quality of life conversations.

'What Brings Him Here Today?': Medical Problem Presentation Involving Children with Autism Spectrum Disorders and Typically Developing Children.

Conversation and discourse analyses were used to examine medical problem presentation in pediatric care.Healthcare visits involving children with ASD and typically developing children were analyzed. We examined how children's communicative and epistemic capabilities, and their opportunities to be socialized into a competent patient role are interactionally achieved. We found that medical problem presentation is designed to contain a 'pre-visit' account of the interactional and epistemic work that children and caregivers carry out at home to identify the child's health problems; and that the intersubjective accessibility of children's experiences that becomes disrupted by ASD presents a dilemma to all participants in the visit. The article examines interactional roots of unmet healthcare needs and foregone medical care of people with ASD.

Asking to Speak to Another: A Skill for Soliciting Survey Participation.

This paper is in the vein of applied conversation analysis, dealing with a problem of declining participation rates for survey interviews. When calling a household to request participation in a survey, interviewers may ask for a pre-selected "sample person." We first explore how interviewers design this request in a more or less presumptive way, depending on how and when they identify themselves. Secondly, we analyze different linguistic structures that embody degrees of entitlement. Thirdly, we examine greeting items for their degree of ceremoniousness and in terms of what work they do when not part of an explicit greeting sequence. We examine other features of asking to speak to another as well, including "please" and references to the sample person. Our strategy for analyzing survey interview data is to explore the design of "switchboard" requests in ordinary telephone calls. We relate our analysis to previous research that addresses whether the detailed practices for asking to speak to another matter for obtaining consent to do an interview. We draw implications for obtaining participation in the survey interview and other kinds of phone call solicitations. Data in American English.

An Interactional Model of the Call for Survey Participation: Actions and Reactions in the Survey Recruitment Call.

Previous research has proposed that the actions of sample members may provide encouraging, discouraging, or ambiguous interactional environments for interviewers soliciting participation in surveys. In our interactional model of the recruitment call that brings together the actions of interviewers and sample members, we examine features of actions that may contribute to an encouraging or discouraging environment in the opening moments of the call. Using audio recordings from the 2004 wave of the Wisconsin Longitudinal Study and an innovative design that controls for sample members' estimated propensity to participate in the survey, we analyze an extensive set of interviewers' and sample members' actions, the characteristics of those actions, and their sequential location in the interaction. We also analyze whether a sample member's subsequent actions (e.g., a question about the length of the interview or a "wh-type" question) constitute an encouraging, discouraging, or ambiguous environment within which the interviewer must produce her next action. Our case-control design allows us to analyze the consequences of actions for the outcome of the call.

An interactional approach to conceptualising small talk in medical interactions.

In medical interactions, it may seem straightforward to identify 'small talk' as casual or social talk superfluous to the institutional work of dealing with patients' medical concerns. Such a broad characterisation is, however, extremely difficult to apply to actual talk, and more specificity is necessary to pursue analyses of how small talk is produced and what it achieves for participants in medical interactions. We offer an approach to delineating a subgenre of small talk called topicalised small talk (TST), derived on the basis of conversation analytically-informed analyses of routine consultations involving orthopaedic surgeons and older patients. TST is a line of talk that is referentially independent from their institutional identities as patients or surgeons, oriented instead to an aspect of the personal biography of one (or both), or to some neutral topic available to interactants in any setting (e.g. weather). Importantly, TST is an achievement of both patient and surgeon in that generation and pursuit of topic is mutually accomplished. In an exploratory but systematic analysis, when this approach was applied to a purposive sample of surgeon-patient interactions, TST was much more prevalent in visits with White than African American patients. Accounts for possible ethnic differences in TST are suggested.

Requests, Blocking Moves, and Rational (Inter)action in Survey Introductions.

We draw on conversation analytic methods and research to explicate the interactional phenomenon of requesting in general and the specific case of requesting participation in survey interviews. Recent work on survey participation has given much attention to leverage-saliency theory, but has not engaged how the key concepts of this theory are exhibited in the actual unfolding interaction of interviewers and potential respondents. We do so using digitally recorded and transcribed calls to recruit participation in the 2004 Wisconsin Longitudinal Study. We describe how potential respondents present interactional environments that are relatively discouraging or encouraging, and how, in response, interviewers may be relatively cautious or presumptive in their requesting actions. We consider how the ability of interviewers to tailor their behavior to their interactional environment can affect whether the introduction reaches the point at which a request to participate is made, the form that this request takes, and the sample person's response. Our analysis contributes to understanding how we might use insights from the analysis of interaction to increase cooperation with requests to participate in surveys.

Dialling for donations: practices and actions in the telephone solicitation of human tissues.

Altruistic actions such as the donation of public goods have long been the subject of social scientific debate. While scholars have recognised the importance of analysing the solicitation of donated goods such as human organs and tissues, to date none has examined actual interaction for this fateful event as it unfolds in real time. In this paper, we use data from 186 audio-recorded telephone interactions between donation centre personnel and family members of the recently deceased along with in-depth interviews and observations conducted in the call centre, to examine this particular donation solicitation interaction. Using conversation analysis, we demonstrate the step-by-step sequencing of the interaction that begins with the ringing phone generated by the call centre personnel which eventually leads to the formulation of the reason for the call, the tacit donation solicitation. Our close analysis of the sequential organisation of this interaction shows how solicitation is done cautiously, incrementally, and tacitly rather than overtly, reflecting its status as a dispreferred action. This analysis suggests that configurations in the wording of solicitations may operate interactionally but inadvertently to discourage the act of donation that call centre personnel are attempting to elicit.

"Does it mean I'm gonna die?": on meaning assessment in the delivery of diagnostic news.

This paper investigates how, in the delivery of diagnostic news, participants to the delivery may engage in meaning assessment or interpreting the news. It draws on data from 24 conversations in developmental disabilities clinics, internal medicine clinics and HIV counselling and testing clinics in the USA. The analysis shows that participants initiate meaning assessment sequences whereby one participant proposes what the news means and the other aligns or disaligns with the proposal. When meaning assessment occurs, the preferred way for this to happen is that the clinician initiates and proposes an interpretation. Following the interpretive proposal, a patient or family member aligns or disaligns with the interpretation, with alignment being sought over disalignment. Further practices of meaning assessment are "affirming the positive" and "disconfirming the negative," which work to provide relatively benign interpretations of news. Analysis of a collection of meaning assessment sequences in clinical settings is brought to bear on a single case in which an internist tells a patient that he has stomach cancer. After delivering the diagnosis, this doctor neither affirms the positive nor disconfirms the negative, and the patient ends up asking, "Does it mean I'm gonna die?" At this point, the interview gets disrupted as the patient withdraws. Asking what the news means is a structurally dispreferred way of handling problems of meaning, and as such this patient's exhibition of difficulty is an outcome of orderly social practices. A clinician's withholding of auspicious meaning assessment may undermine the relationship with patients and/or family members and disrupt the encounter.

Conversation analysis, doctor-patient interaction and medical communication.

INTRODUCTION: This paper introduces medical educators to the field of conversation analysis (CA) and its contributions to the understanding of the doctor-patient relationship. THE CONVERSATION ANALYSIS APPROACH: Conversation analysis attempts to build bridges both to the ethnographic and the coding and quantitative studies of medical interviews, but examines the medical interview as an arena of naturally occurring interaction. This implies distinctive orientations and issues regarding the analysis of doctor-patient interaction. We discuss the CA approach by highlighting 5 basic features that are important to the enterprise, briefly illustrating each issue with a point from research on the medical interview. These features of conversation analytic theory and method imply a systematic approach to the organisation in interaction that distinguishes it from studies that rely on anecdote, ethnographic inquiry or the systematic coding of utterances. CONVERSATION ANALYSIS AND THE MEDICAL INTERVIEW: We then highlight recent CA studies of the "phases" of the internal medicine clinic and the implications of these studies for medical education. We conclude with suggestions for how to incorporate CA into the medical curriculum. It fits with biopsychosocial, patient-centred and relationship-centred approaches to teaching about medical communication.