'My computer's asked me...'

Extract 3 shows a transcript of a small part of a consultation. The doctor has finished dealing with the patient's gynaecological problem and goes on to attend to an institutional requirement. The doctor is not using a template here, but responds to an EPR prompt which is displayed at the bottom right of her computer screen throughout the consultation - a 'QOF alert' showing an outstanding QOF item ('Recent Smoking Data').

At 14.32 the doctor re-orients to the screen and points to it as she announces 'now my computer's asked me whether you smoke'. The patient looks towards the EPR and hesitates in her response. Although the QOF alert is not immediately relevant to this patient's reason for attendance, such alerts act as a constant reminder to the doctor of institutional imperatives. Here, the doctor attributes agency for her opening utterance to the EPR, suggesting that the EPR is the author of her words (Goffman 1981). This is effective in introducing some attributional distance between herself and the delicate question she asks of the patient (Clayman 1992) whilst also identifying her professional authority as somehow at issue.

As in the previous example, our ethnographic understanding of the institutional context gives meaning to the micro-analysis and helps to align our interpretation with a specific institutional imperative. The doctor is required within QOF to document whether patients aged over fifteen are 'smokers' or 'non smokers' - although even in this short extract we see that these apparently simple categorisations are often more complex in practice. The EPR not only prompts an activity - and shapes the immediate unfolding interaction - but also mediates the definition of what is important knowledge about patients, reinforcing particular definitions of 'quality' in practice. The gathering of smoking data is an example.

At 15:29 the doctor says 'so (0.2) y'know obviously °< as your doctor > I have to advise you that you shouldn't" She displays what Goffman calls a change in footing (Goffman 1981) namely a shift in the alignment (or

Extract 3 Extract from a doctor-patient consultation

Time

D P

Words spoken/sounds

Bodily conduct

EPR Screen

14.32

D

now my computer's

asked me whether you smoke

(1.2)

D - > EPR. D points to screen D - > EPR, L hand to mouth; P -> EPR;

D -> P; P -> EPR

Medications screen.

QOF alert showing in bottom R corner: QOF Recent Smoking Data (displays throughout consultation)

14.35

P

uhm

(1.0)

P -> EPR

14.36

P

yes (.) no (1.0)

P -> EPR; D -> P P -> D

14.38

D

P

he what's (That mean

[I've had one in the last

three days

D -> EPR, laughing D <-> P

14.41

D

right (.) so (.) very occasionally

D <-> P

14.43

P

yeah (0.2) I'm (.) I'm very much a s:ocial smoker nowadays=

14.46

D

= so with- in a (0.2) in a week uhm how many do you get through °d'you think"

14.49

P

well last week I think I had three

14.52 D right (0.4) right (5.0)

D turns -> EPR; P -> D.

At 14.57 D turns to P again

Transcript not shown - doctor establishes that patient smoked three cigarettes last week and suggests it would be better for patient's general health if she could "ignore them", since although it is not doing "horrendous damage" it is still keeping the "receptors flapping"

15.29 D so (0.2) y'know obviously

° 1 have to advise you that you shouldn't"

(1.6)

D -> EPR; P -> D

D < - > P; D using highly stylised voice

D nods, smiling

stance, or projected self) of participants in interaction. Firstly, she slows down her speech markedly as she says '< as your doctor >' reclaiming her professional authority and legitimising the anticipated advice-giving. She then uses a quiet, highly stylised voice as she seeks to influence the patient: 'I have to advise you that you shouldn't'. This is an example of what Sarangi and Roberts call 'hybrid discourse', in that it is legitimate 'professional' advice on the one hand, but also orients to a higher 'institutional' order. Professional discourse is that which professionals routinely engage in during their practice, whereas institutional discourse concerns the way in which professionals account for their talk (Roberts, Sarangi, Southgate, Wakeford, & Wass 2000; Sarangi and Roberts 1999). Just like the nurse in the previous example ('What I've got here is some questions that I -1 need to ask you') the institutional dimension is conveyed partly through the doctor's words 'I have to’ and partly through the stylisation in her voice which contributes to a 'new' identity as she incorporates institutional business. Goffman refers to this as the 'embedding' function of talk, meaning the way in which animators can convey words which are not their own or which reflect a different aspect of oneself (Goffman 1981).

The consultation as an opportunity for incorporating opportunistic health promotion activity (e.g. smoking advice) is not new; it has long been identified in consultation models (Stott and Davis 1979). But the use of the EPR as a prompt to this kind of talk engenders a shift from professional interaction towards an emphasis on institutional evidence and accountability and is further evidence of the regimentation of the interaction.

This extract is an illustration of the way in which clinicians now have to make new ongoing judgments about whether, when and how to attend to the institutional voice of the EPR, balancing the immediacy ('here and now') of the interaction with the more institutional ('there and then') demands of the EPR. These are 'on-the-spot' judgments about the allocation of involvement (Goffman 1966) and carry the risk that involvement in the interpersonal interaction might be disrupted (Swinglehurst et al. 2012). Attending to the voice of the EPR is not a morally neutral activity, and raises questions about whose interests are being served. Clinicians must accommodate what Blommaert refers to as different 'orders of indexicality' - that is multi-layered, stratified or 'ordered' meanings which incorporate the local and translocal, the momentary and lasting (Blommaert 2005b; Blommaert 2006; Bakhtin 1986). The new 'voices' are not necessarily timely or relevant to the 'here and now', are insensitive to the particular unfolding characteristics of the interaction and challenge very fundamentally the normative model of the consultation as a dyadic meeting of two persons which currently underpins much teaching in clinical consulting (Swinglehurst et al. 2014). In this particular example, the doctor makes the role of the EPR explicit, but in doing so she must engage in additional interaction work, and has to be creative in managing the transition between her professional self and her role as institutional representative.

 
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