Discussion

As a researcher investigating patient participation in decisions about treatment for head or neck cancer, the geography of communication in the clinic presented itself as pivotal to understanding patients' experiences of and involvement in their care. This then required that attention be paid to linguistic and ethnographic aspects of patient- professional encounters.

In conversation analyses of patients' concerns, the focus has been the expression of these concerns within particular phases of the doctor- patient consultation. Heritage and Robinson (2006: 89) write:

Problem presentation is the only phase of medical visits in which patients are systematically given institutional license to describe their illness in their own terms and in pursuit of their own agendas.

A linguistic ethnographic approach, however, extends our understanding of 'the medical visit', highlighting, as in the present study, how much of the consultation takes place without the doctor, and how patients may express their concerns in other, apparently casual or chance encounters, with different professionals. These encounters all complement the formal doctor-patient consultation. This suggests other forms of institutional license and constraint at work - such as the geography of the clinic - in addition to the structures and phases of the consultation.

A broader definition of the consultation, informed by ethnographic observations of the geography of the clinic, therefore leads to more comprehensive understanding of patients' concerns. For example, in the main consulting room, if a patient is not provided with, or chooses not to take, an opportunity to voice their concern, then linguistic analysis of this consultation recording alone will be insufficient to detect the concern, or to account for why it is not presented.

Taking the geography of the clinic into account renders visible, and accessible to the researcher, other forms of 'consultation', and illustrates how different physical spaces in the clinic shape the language used: expansive, reflective talk in the quiet room; corridor conversations indexing concerns in anticipation of the meeting with the surgeon; surgeon-led presentations of diagnosis and treatment in the main consulting room; exchanges in the waiting room through which patients evaluate different treatments and their side-effects, provide one another with encouragements and with information regarding stages of treatment and recovery. This raises the question of how we define the consultation in multidisciplinary health care: not, perhaps, a discrete encounter, but a series of interconnected, overlapping, encounters, which, when taken together, provide the sum of patients' experience of consultations in the clinic and a variety of opportunities for patients' expression of concerns. Goffman's (1959) study of the movements between the kitchen of a hotel and its other, more public, spaces shows how different forms of talk are employed across these to achieve particular goals and maintain certain relationships between workers and guests. Lewin and Reeves (2011) made similar observations about team communication: the ways professionals in health care teams on hospital wards navigate between what they term 'planned, "front-stage" encounters' and ' "backstage", opportunistic encounters' to manage team-working in an acute care setting. With regard to the present study, approaching consultation research with consideration for use and ownership of different clinic spaces invites consideration of multiple forms of participation for patients. For example, limited forms of participation in the main consulting room are augmented by extended opportunities in the quiet room.

Combining linguistics and ethnography, then, challenges dominant medical thinking about how care is provided, where and by whom. By the same token, linguistic ethnography challenges assumptions in health care communication research. By taking the broader environment into account, health care, and the research approach taken in studying it, can be understood as a system of complements. Recognition of spatial dimensions in health care encounters extends the view of the consultation beyond the patient's appointment with the surgeon, and shows how patients' concerns are concealed and disclosed in a variety of locations within the clinic, with different professionals.

Linguistic ethnography affords a wider context - the view that greets the patient in the waiting room, the various contexts in which consultations happen, a longitudinal perspective - for understanding the nature and expression of patients' concerns. This transforms the research: from a study of doctor-patient interaction to one more comprehensive and representative of patients' and professionals' experience. From a researcher's perspective, a more holistic view of patients' concerns can be provided by considering examples from different consultations, research interviews and clinic observations. In future research, questions concerning clinic geography could be extended. For example, though Clinics A and B were similar in configuration, at Clinic B the radiotherapy department was on the floor below in the same hospital, whereas at Clinic A the radiotherapy department was in another hospital three miles away; and this influenced the way in which radiotherapy was presented (at Clinic B, radiotherapy was a more immediate, relevant option, often presented side-by-side with surgery).

In the present study, the combination of linguistics and ethnography broadened the starting points and avenues for discussion regarding the relevance of the research for everyday clinical practice. By providing examples of uses of space, and highlighting the geographical dimensions and constraints at play in the general running of the clinic and in encounters with patients, as well as examples of linguistic features in consultations, the findings became more concrete and accessible to discussion with participating patients and health professionals. We discussed ways existing clinic space could be employed more strategically and with greater awareness of its communication potential: for example, making use of escorting patients to and from the consulting room by engaging in conversation; and at Clinic B, where the main consulting room had a sliding door so that it could adjoin to a neighbouring room, we discussed ways this might facilitate more free-flowing consultations.

Detailed observational studies of different settings using linguistic ethnography have real potential. They can enable further exploration of environmental influences on communication, allow findings to be generalised, and serve a comparative purpose in identifying shared and distinctive features of how different spaces promote, or inhibit, patients' expression of concerns.

Linguistic ethnography offers a route into understanding the relationship between space and interaction: a means to stimulate thinking about these dimensions of institutional communication as they are played out in practice. Above all, the head and neck cancer clinic itself - its environment, the multidisciplinary team, the narratives of its patients, advances in diagnosis and treatment, social contexts of illness - offers a rich fabric of social, linguistic and cultural dimensions for research grounded in everyday experience. The challenge for linguistic ethnography is to remain alive (as discussed in Creese, 2008) to the interplay of these different dimensions, and to maintain its inherent reflexivity, constantly sounding out linguistic observations with ethnographic ones, through constant comparison and dialogue between different sets of data. Thus linguistic ethnography can make a significant and novel contribution to our understanding (in research and practice) of patients' experience of health care.

 
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