Asymmetry in action: Sequential resources in
the negotiation of a prescription request*
JEFFREY D. ROBINSON
Abstract
This article deals with one form of interactional asymmetry in doctor±
patient consultations, that of initiative: Doctors primarily initiate actions
and solicit responses, whereas patients primarily respond to doctors' initiatives. This article argues that the variable of initiative actually contains two
dimensions: speaker initiative and utterance constraint. It then reviews
and critically evaluates prior accounts for these asymmetries. These
accounts are almost exclusively `professional' in nature, relying upon
features of the social organization of the profession of medicine, medical
contexts, or institutionalized medical activities. This article argues that
asymmetries of initiative can and should initially be accounted for in terms
of the everyday social organization of action. The primary organizing
sequential structure for action is the adjacency-pair sequence, which
embodies an intersubjective set of normative standards for producing and
understanding behavior. This article supports a `mundane' account of
asymmetry with a conversation analytic, single-case analysis of a patient
request for a renewal of a prescription.
Keywords: physician; communication; interaction; conversation analysis;
power.
In doctor±patient consultations, there are a variety of practices of communication that are asymmetrically distributed between participants.
One important asymmetry is that of initiative: doctors primarily initiate
actions and solicit responses, whereas patients primarily respond to
doctors' initiatives (Frankel 1990; Linell et al. 1988; Mishler 1984;
PeraÈkylaÈ 1995; Todd 1993 [1983]; West 1984).1 One primary example
is question asking, which is signi®cantly distributed in doctors' favor
(Roter et al. 1988). This has massive consequences for health care in
0165± 4888/01/0021±0019
# Walter de Gruyter
Text 21(1/2) (2001), pp. 19±54
20
Je€rey D. Robinson
at least three ways. First, question asking by doctors is negatively
correlated with patients' adherence to medical advice (Hall et al. 1988).
Second, patterns of communication characterized by high frequencies
of question asking by doctors are negatively correlated with patients'
satisfaction (Roter et al. 1997). Third, patients' questions are a major
vehicle for gaining information from doctors, which is positively correlated with patients' satisfaction, adherence, and recall/understanding
(Hall et al. 1988). Of course, question asking is merely one incarnation
of the asymmetry of initiative. This asymmetry is generally conducive
to doctors' control of the ¯ow of information and topics, which is conducive to the suppression of patients' lifeworld experiences in favor of
doctors' biomedical experiences and the reduction of information relevant
to diagnosis and treatment (Beckman and Frankel 1984; Beckman et al.
1985; Fisher 1991; Larsson et al. 1987; Lipkin et al. 1995; Marvel
et al. 1999; McWhinney 1981, 1989; Mishler 1984; Sankar 1986; Todd
1993 [1983], 1989).
Because of its relevance to health-care outcomes, researchers have
attempted to account for the initiative asymmetry. However, such
accounts must be grounded in experiences that are lived, and oriented
to as relevant, by doctors and patients. In both mundane and medical
interaction, interactants conduct themselves primarily in terms of
action (Drew and Heritage 1992; Scheglo€ 1995a). Although numerous
researchers have coded for doctors' and patients' `questions' and
`answers', these labels are not necessarily adequate descriptions of
actions because interrogatively formatted utterances and their responses
frequently perform a variety of actions other than, or in addition to,
gathering and providing information (Atkinson and Drew 1979; Frankel
1990; Heritage and Roth 1995; Scheglo€ 1984, 1995a). In primary-care
consultations, one common course of action is patients' requests for
non-diagnostic service(s), such as requests for prescriptions. These
requestsÐwhich are frequently interactionally extended and complex,
containing a myriad of component actions, such as taking, advocating,
and resisting positions regarding the decision, and soliciting and providing information in the service of making the decisionÐare socially
organized and provide analytically fertile ground for accounting for the
initiative asymmetry.
This article does four things. First, it argues that prior operationalizations of `initiative' have con¯ated two variables: speaker initiative
and utterance constraint. Second, it reviews and critically evaluates two
types of accounts that prior research has o€ered for these asymmetries:
accounts that are exogenous and endogenous to interaction. These
accounts are almost exclusively `professional' in nature, relying upon
Asymmetry in action
21
features of the social organization of the profession of medicine, medical
contexts, or institutionalized medical activities. Third, it argues that
these asymmetries should initially be accounted for in terms of the
interaction order sui generis. Speci®cally, it argues for a mundane, or lay,
account in terms of the everyday social organization of action, focusing
on the adjacency-pair sequence (Sacks 1992b; Scheglo€ 1968; Scheglo€
and Sacks 1973). Fourth, it supports this argument with a conversation analytic, single-case analysis of a patient request for a renewal of
a prescription, throughout which implications are drawn for research on
asymmetry.
A clari®cation of the initiative asymmetry
Although the initiative asymmetry is sometimes discussed as a single
phenomenon, it actually has multiple aspects. Because all utterances are
simultaneously context sensitive and context renewing (Heritage 1984b),
there are at least two dimensions of initiative concerning an utterance:
1.
2.
the range of initiative that speakers can be said to have when
producing it;
the range of initiative it provides for potential next speakers.2
Along these lines, the production of an utterance can be grossly
categorized along two dimensions: speaker initiative and utterance
constraint. To elaborate, it is necessary to introduce the concept of
the adjacency-pair sequence (Sacks 1992b; Scheglo€ 1968; Scheglo€
and Sacks 1973). In its basic form, the adjacency-pair sequence is
composed of two parts, a ®rst-pair part and a second-pair part, each
produced by di€erent speakers. The ®rst-pair part constitutes an
initiating action (e.g., a request) that normatively obligates the selected
next speaker to produce a relevant and responsive second-pair part
(e.g., a granting). Actions are pair typed, meaning that ®rst-pair
parts make relevant a ®nite range of second-pair parts (e.g., a request
is relevantly responded to with a decision to either grant or deny the
request, not with a greeting, an assessment, etc.).3 The normative obligations of a ®rst-pair part establishes an inferential framework for action
such that the selected next speaker is accountable for immediately
producing a relevant second-pair part (with respect to accountability,
see Heritage 1984b). In terms of the dimension of utterance constraint,
utterances can either normatively obligate a response from a recipient
(as ®rst-pair parts obligate second-pair parts) or not obligate a response.
In terms of speaker initiative, utterances can be either normatively obligated by a prior utterance (as second-pair parts are obligated by ®rst-pair
parts) or not normatively obligatedÐthat is, volunteered by speakers.
22
Je€rey D. Robinson
Prior research has sometimes con¯ated asymmetries of speaker initiative and utterance constraint. The most common operationalization
of initiative has been in terms of adjacency-pair sequence structure (i.e.,
®rst- and second-pair parts; Frankel 1990; Linell et al. 1988; Todd 1993
[1983]; West 1984). Here, the ®ndings are that doctors' turns are primarily ®rst-pair parts (e.g., questions) whereas patients' turns are
primarily second-pair parts (e.g., answers). However, some researchers
have simultaneously operationalized initiative positionally. For example,
Frankel (1990) and West (1984) also coded for `®rst-positioned' utterances that are, in my terms of speaker initiative, volunteered, but that, in
my terms of utterance constraint, do not necessarily obligate a response.4
Here, the ®ndings are that after patients provide complete responses
to doctors' ®rst-pair parts, if patients continue to volunteer additional
talk, they often format that talk as additional responsive components
to doctors' prior ®rst-pair parts, rather than as stand-alone actions
that may or may not obligate a response (Frankel 1990; Gill 1998; Gill
and Maynard to appear; Linell et al. 1988). In sum, the general notion
of initiative embodies at least two analytically distinct concepts,
speaker initiative and utterance constraint, each of which have di€erent
implications for conceptions of asymmetry.
Existing accounts for asymmetries of speaker initiative and utterance
constraint: Exogenous and endogenous
Because of their relevance to health-care outcomes, researchers have
attempted to account for asymmetries of speaker initiative and utterance
constraint. One possible account is in terms of factors that are exogenous
to interaction. For example, some researchers have theorized that the
medical profession contains institutionalized power roles of dominance
and subordination for doctors and patients, respectively (Freidson 1970a,
1970b; Navarro 1976; Parsons 195l, 1975; Starr 1982; Waitzkin and
Waterman 1974). These asymmetries might be conceptualized as a
byproduct of doctors' and patients' subscription to these roles. A similar
account might been given in terms of a variety of sociopolitical structures that are associated with dominance, such as class (Cartwright
1967; Waitzkin 1985), ethnicity (for review, see Roter and Hall 1992),
gender (Pendleton and Bochner 1980), and socioeconomic status (Sleath
et al. 1997).
There are at least two reasons why these exogenous accounts are
insucient. First, there is no necessary relationship between these asymmetries and power or dominance.5 Researchers have coded and counted
®rst- and second-pair parts, as well as ®rst-positioned utterances, largely
Asymmetry in action
23
without characterizing the actions that doctors and patients are
accomplishing with those utterances. Although there is a distinction
between the formal structure of the adjacency pair and the action(s)
being accomplished through it, this is a distinction for analysts, not participants, who orient to ®rst- and second-pair parts in terms of the action(s)
they accomplish. Because the actions accomplished through ®rst- and
second-pair parts can either maintain or challenge traditional power/
dominance relationships, it is con¯ationary to conceptualize dominance
in terms of their aggregated distributions among doctors and patients.6
Second, a large body of research has demonstrated that actual medical
interaction does not consistently embody, and sometimes contradicts,
theoretical, social-structural relationships as they relate to asymmetrical
distributions of communication practices (Anspach 1993; Becker et al.
1961; Beisecker and Beisecker 1990; Bloor 1976; Emerson 1994 [1970];
Strong 1979; Sudnow 1967; ten Have 1991; West 1976). Research has
since demonstrated that interaction has its own, independent order
of social organization (Go€man 1983; Scheglo€ 1987b) and that interactional asymmetries are collaboratively accomplished in and through
interaction (Cicourel 1973; Heath 1992; Linell and Luckman 1991;
Maynard 1991). While not ¯atly rejecting exogenous accounts for
interactional asymmetries, this research argues that any account must
initially be sought in factors that are endogenous to interaction (Drew
and Heritage 1992; Maynard 1991; Mishler 1984).
Prior research has o€ered three types of endogenous accounts: the
speech exchange account, the chaining rule account, and the professional
activity account. According to the speech-exchange account, doctors and
patients organize interaction according to a formal, professional speech
exchange (i.e., turn-taking) system in which patients' ®rst-pair parts
and other ®rst-positioned actions are normatively inappropriate and
avoided (Frankel 1990; West 1984).7 Some have gone so far as to
argue that this turn-taking system preallocates turn order and turn
type into a three-part sequential structure, including (1) doctors'
initiations of actions; (2) patients' responses; and (3) doctors' third-turn
responses, such as (dis) agreements with, and assessments of, patients'
responses (Fisher 1984; Mishler 1984; Todd 1993 [1983]). According to
this account, asymmetries of speaker initiative and utterance constraint
are features of the interactional structure of consultations themselves
as achieved forms of professional social order.8 However, this account
does not hold up. Despite the distributional fact that these asymmetries
exist, there is evidence that doctors and patients structure consultations, unproblematically and without sanction, according to the turntaking rules of mundane conversation (Anderson 1979; PeraÈkylaÈ 1995;
24
Je€rey D. Robinson
ten Have 1991). Furthermore, there is evidence that, even during periods
of asymmetry, doctors and patients display that they are oriented to the
locally managed turn-taking rules of mundane conversation (PeraÈkylaÈ
1995). This evidence rejects the claim that doctor±patient consultations
embody a distinctive turn-taking system (Heritage 1998).
According to the chaining rule account, which Frankel (1990) borrowed from Churchill's (1978) interpretation of Sacks (1992d), the rules
for turn taking in mundane conversation (Sacks et al. 1974) provide
questioners in two-party conversations with a priveledged opportunity
to continue questioning. As Sacks articulated it,
A person who has asked a question [has] a `reserved right to talk again,' after the
one to whom he has addressed the question speaks. And, in using the reserved
right, he can ask [another] question (Sacks et al. 1974: 264).
Although the chaining rule may account for some asymmetry, it is, at
best, only a partial account. Sacks's point was not that the turn slot
for answering is an iron cage. Indeed,
i.
speakers have a variety of practices for securing multi-unit responses
(Goodwin 1996; Je€erson 1986; Scheglo€ 1982, 1996b);
ii. it is not uncommon for patients to provide additional units of
talk beyond their initial answer (Gill 1998; Gill and Maynard, to
appear; Stivers and Heritage, to appear); and
iii. Patients can use these additional units to do other things besides
answering, such as accounting, explaining, and even producing
®rst-pair parts (Stivers and Heritage, this issue; Gill 1998; Gill and
Maynard, to appear; Hughes 1982).9
Additionally, analyses of turn-taking constraints on speaker allocation must be situated within ongoing actions and activities. For example,
when doctors ask questions (particularly during history taking), rather
than immediately asking another question, they frequently engage in
post-answer, nonvocal tasks, such as reading and writing in patients'
medical records (Frankel 1996), and patients sometimes take advantage
of these moments to produce more talk.
According to the professional activity account, consultations are
composed of recurrent sets of professional tasks/activities whose interactional structures, and accompanying normative/interpretive frameworks for action, are conducive to asymmetries of speaker initiative and
utterance constraint. Although this account has existed for some time,
it has more often been alluded to or asserted than demonstrated (e.g.,
Hughes 1982; PeraÈkylaÈ 1995; Sharrock 1979). However, Bloor (1976)
found that patients' levels of participation vary according to doctors'
Asymmetry in action
25
work-related, interactional routines. Ten Have (1991) found that patients'
levels of participation vary according to di€erent phases of consultation, such as opening consultations versus the taking of patients' histories.
And Robinson (1998, 1999) described the normative organization of
the activity of opening consultations and demonstrated that an asymmetrical distribution of ®rst- and second-pair parts can be a byproduct
of constraints associated with the accomplishment of the activity.
A mundane account for asymmetries of speaker initiative and
utterance constraint
Of the three endogenous accounts, the professional activity account is
clearly the most promising, and much more work needs to be done
on describing the interactional structure of speci®cally medical activities, their interpretive frameworks for action, and their e€ects on
interaction generally and asymmetry speci®cally. However, asymmetrical
distributions of communication practices are not unique to professional
contexts. Rather, they are intrinsic features of both mundane and
institutional interaction (Hak 1994; Linell 1990; Linell and Luckman
1991; Scheglo€ 1990; ten Have 1991). As Maynard (1991: 486) has
argued, `the asymmetry of discourse in medical settings may have an
institutional mooring, but it also has an interactional bedrock'. Maynard
criticized studies of asymmetry for focusing on how the participants
`do the institution' at the expense of how they `do the interaction' (1991:
457). Researchers need to take seriously the fact that interactional
asymmetries can and should be initially accounted for in terms of the
interaction order sui generis (Go€man 1983; Rawls 1987; Scheglo€ 1987).
After all, institutional activities are constructed from sequences of
action (Heritage and Sorjonen 1994; Je€erson 1980a) and the production of action is, ®rst and foremost, a mundane a€air. Irrespective of
context (at least as traditionally characterized; see Scheglo€ 1987b),
people produce and understand talk primarily in terms of the action(s)
it performs (Austin 1962; Malinowski 1923; Searle 1969; Scheglo€
1995a; Wittgenstein 1958; for reviews, see Drew and Heritage 1992;
Duranti and Goodwin 1992; Heritage 1984b). Whatever factors condition the production of action (e.g., age, class, sex/gender, race/ethnicity,
psychological variables, etc.), action must be constructed. The construction materials are turns of talk (and other nonverbal behavior), the
construction process is structurally organized, and that organization is
predominantly sequential in nature (Sacks et al. 1974; Scheglo€ 1968;
Scheglo€ and Sacks 1973). The primary organizing sequential structure
for action is the adjacency-pair (Scheglo€ and Sacks 1973), which
26
Je€rey D. Robinson
embodies an intersubjective set of normative standards for producing
and understanding behavior. There is wide agreement across disciplines
and methodological perspectives that doctor±patient interaction is
organized sequentially and that it involves the adjacency-pair sequence
as the main organizing structure of action, medical or otherwise
(Anderson 1979; Coulthard and Ashby 1976; Drew and Heritage 1992;
Frankel 1984, 1989b, 1990; Fisher 1984; Heath 1986; Linell et al. 1988;
Maynard 1991; Todd 1993 [1983]; West 1984). This article provides
a fourth endogenous account for asymmetries of speaker initiative
and utterance constraint: the mundane action account. What follows
is a brief description of the organization of adjacency-pair sequences
relative to courses of action.
Adjacency-pair sequences and courses of action
Although courses of action can be accomplished through single
adjacency-pair sequences, they are frequently accomplished through
multiple adjacency-pair sequences (Scheglo€ 1990, 1995b). This is because
there can be a variety of operations that people can perform on a single
course of action before, during, and after its enactment. For example,
before initiating a request (e.g., `Can I borrow your car?'), the requester
may attempt to forestall rejection, which can be accomplished through
a presequence (e.g., `Are you using your car tonight?'; regarding presequences, see Sacks 1992c; Scheglo€ 1968, 1988c, 1995b; Terasaki 1976).
Before responding to the request, the requestee may need to gather
information in the service of making a decision, which can be accomplished through an insertion sequence (e.g., `How long will you need it?';
regarding insertion sequences, see Sacks 1992a; Scheglo€ 1972, 1990,
1995b). If the request is denied, the requester may attempt to pursue the
request, which can be accomplished through a post-expansion sequence
(e.g., `Please?'; regarding postexpansion sequences, see Scheglo€ 1995b).
Thus, as seen in Figure 1, there is a distinction between a central course
of action, which is accomplished through a base adjacency-pair sequence
(e.g., a request), and actions (and courses of action) that are in the
service of the production and resolution of the central course of
Speaker A: Base ®rst-pair part (e.g., request)
2 Pre-expansion
2 Insert-expansion
Speaker B: Base second-pair part (e.g., granting)
2 Post-expansion
Figure 1. A base adjacency-pair sequence and its potential expansions through which a course
of action can be accomplished
Asymmetry in action
27
action, which are accomplished through a variety of types of expansion
sequences (Scheglo€ 1990, 1995b).
Expansion sequences are almost always adjacency-pair sequences
in their own right (and can themselves be expanded). A majority of
the action in doctor±patient consultations can be isolated and characterized in terms of sequence structure. However, people rarely produce
or understand expansion-related actions apart from their participation
in, and relevance to, central courses of action on which they operate.
Although prior research on doctor±patient interaction has acknowledged that adjacency-pair sequences embody normative frameworks for
the production and understanding of action (Frankel 1989b), it has yet
to take into account the implications for interactional asymmetries of
the distinction and relationship between central courses of action, which
are accomplished through base adjacency-pair sequences, and expansionrelated actions, which are accomplished through a variety of types of
expansion sequences. What follows is an analysis of a central course
of action: a patient request for a medical service. The analysis attempts
to show that, in terms of speaker initiative and utterance constraint, the
distribution and design of doctors' and patients' utterances can be
largely accounted for in terms of the normative organization of the base
adjacency-pair sequence through which the patient's central course of
action (i.e., the request) is accomplished.
Data and background
The datum is a videotape of an actual doctor±patient consultation,
collected in 1995 from a community-based, general practice health
clinic located in southern California. Both participants are Caucasian
males. The patient visits the clinic on a routine basis for a variety of
chronic medical conditions, one of which is gout, a metabolic disorder
that causes painful arthritis, especially in the joints of the feet and legs.
Part of the patient's treatment for gout includes the prescription medication Tylenol 3. Because Tylenol 3 contains the addictive painkiller
codeine, its extended use is not medically recommended. Although the
patient did not see the current doctor during his previous visit, they
have a prior history. During the previous visit, either the doctor or the
pharmacist (or both) questioned the patient's continued use of Tylenol 3,
and although the doctor represcribed the medication, the full prescription was not dispensed. The current visit takes place several weeks
after the previous visit when the patient is almost out of Tylenol 3.
The fragment of interaction to be examined revolves around the
patient's initial medical business: an indirect request to continue using
28
Je€rey D. Robinson
Tylenol 3 (lines l1±12). The doctor's decision is delayed as he gathers
information necessary to make the decision, which is accomplished
through two insertion sequences (initiated at lines 18±21 and 39). The
doctor ®nally makes his decision at line 68. An understanding of the
forthcoming analysis depends on reading, and referring to, the transcript
(see the Appendix for transcription conventions).
(1) Extract 1: TYLENOL 3
((Opening omittedÐdoctor enters room, greets patient, and sits down))
08 DOC: So what's n ew. what can I do for ya.
09 PAT:
(
) heh heh
10
(.)
11 PAT: Well, it± there was some± (.) (d) ± (1.4) discussion
12
about the: the (.) tylenol three:.
13
(0.8)
14 DOC: .mtch~Oh ye:s:.
15
(.)
16 PAT: A:nd uh (.) you know I~(d±) I (doe) ± I don't believe
of it, (.) but it's up to you:.
17
I've used that much
18 DOC: Yer taking it f er go:ut?
19 PAT:
(
)
20
(0.9)
21 DOC: Why are you taking it?
22 PAT: (m) W'll I was wtakin' itv m:ostly fer:: m~my:: (0.3) back
23
problem, an' my: uh hand problem, an' my knee problem, my
ankle problem, my (feet) problem,
24
25
(0.2)
26 PAT: my knee problem,
27
(1.0)
28 PAT: You know it j'st uh (0.2) .hhh (.) it ea:sed the pa:in a
29
little bit, 'n: the rest of the stu€ we took gave me
30
diarrhea.
31
(0.4)
32 PAT: (B't±)~
33 DOC: ~Ri:ght. an' then you also have that problem with
34
your
stomach.
35 PAT:
Yea:h.
So you gotta be ca:reful because certain
36 DOC: .hhhh
37
things
can
bu:rn your stomach.
38 PAT:
Yea:h.
39 DOC: .hhhhh h How ma ny do ya take a day:.
40 PAT:
(
)
Asymmetry in action
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
PAT:
DOC:
PAT:
PAT:
PAT:
DOC:
DOC:
DOC:
PAT:
PAT:
PAT:
PAT:
DOC:
PAT:
DOC:
PAT:
DOC:
PAT:
DOC:
PAT:
DOC:
DOC:
PAT:
DOC:
PAT:
29
(0.2)
(Oh:) (.) I ^do:n't.^
(0.2)
.hhhhhhhhhh
I might take uh : .hhhh the last time I wen' up there
was two weeks ago an' they gave me ten an' I think I got
one~o' those le:ft.
(2.8)
They
didn'
give me the
full prescription:
so: (
)
.hh So you took±
you've
taken
ten in the last two weeks?
Or ni :ne?
(Yeah±)
(.)
Ten in: yeah nine in: maybe ^three^ weeks. I don'
kno:w,
(0.4)
When was the last time I was in here to talk
to 'im about it.
(0.4)
I didn't see you:.
(6.0)
We :ll wI don'
knowv l ast time you were ~
~
two
±
two er±
Two er±
was
july::,
~ here
~ two er three
weeks ago:,
.hhh Okay. (.) I':ll uh± I'll write you another prescription,
Well (i±) (deh±) you know if you'd rather I didn't wtake
itv I c'n: I can live withou:t.
No f:rankly I don' know whatcha gunna do. .h I want± (.) I
wantcha
to be comfortable.
I took that (tyle no:l)~
.hh It's the±
~The only other w± option would be dar:vace:t.~h
(0.2)
hhhh ³I don' know what that is.³
(0.2)
It's another pai:n killer, it doesn't have
the
vaddictionw .hh vpoten tialw
Oh (al right)
30
82
83
84
85
86
87
88
89
90
91
92
Je€rey D. Robinson
PAT: l et's try ^that
then.^
DOC:
as±
co:deine.
as
PAT: Let's try ^that^ the n.
DOC:
A': right.
DOC: 'Cuz there wouldn't be a pro:blem .hh the red ¯a:gs
wouldn't keep wa:ving.
PAT:
O:kay.
DOC: .hh If it was dar:vac et.
PAT:
Al right.
PAT: Now (.) one other thing, .hh uh (0.7) I need eh
e±~summa that (.) face medicine ya gave me.
Analysis
The doctor's o€er to serve
The doctor's initial question, `So what's new. what can I do for ya'
(line 8), displays his orientation to the forthcoming interaction as being
a service encounter in which (i) the parties' roles are service seeker (i.e.,
patient) and service supplier (i.e., doctor); (ii) the business is solving
a problem or dispatching a task (i.e., the patient's medical business);
and (iii) the focal object is the problem and its properties (see Je€erson
and Lee 1981).10 The doctor's question is a member of a more general
class of actions I will refer to as o€ers to serve. O€ers to serve are ®rstpair parts that solicit services/problems to be rendered/remedied by the
o€erer; they solicit either an acceptance, which includes the production
of a service/problem, or a declination, which possibly closes the sequence.
O€ers to serve are not speci®cally institutional actions. For example, see
extract (2), drawn from a mundane telephone conversation between
Christopher and Stephen concerning Stephen's wife, Jennifer, who just
threw her back out.11
(2) Extract 2: BACK PROBLEMS
07
CHR: .h Stephen look ah:: I'm I'm phoni:ng uh on
08
beha:lf of Julie and myse:lf.~We just heard abou:t
poor um (0.4) Jennifer.
09
10
STE:
Yes ma:ddening isn't it.~
11 A CHR: ~Oh:~hh lord. and we were wondering if there's
12 A
anything wecan do to help
13
STE:
Well that's
14
CHR:
I mean
can we do any shopping for her or
Asymmetry in action
15
16
17
18
19
20
21
22
23
31
something like tha:t?
(0.7)
STE: Well that's most ki:nd Christopher .hhh At the moment
no:. because we've still got two bo:ys at home.
CHR: Of course.
(0.2)
STE: Uh but uh now I'm ho ping she'll be better but
CHR:
Well
anyway thank you very much for the o€er.
STE:
Christopher's o€er to serve, `we were wondering if there's anything
we can do to help' (lines 11±12), is declined by Stephen in lines 13 to 18,
and Stephen subsequently moves to close the sequence by thanking
Christopher (line 23; Zimmerman and Wakin 1995).
If a recipient of an o€er to serve accepts and produces a service/
problem, it simultaneously constitutes a second-pair part to the o€er
(i.e., a responsive action) and a ®rst-pair part to be rendered/remedied
(i.e., an initiatory action). For example, see extract (3), a telephone call
from a private citizen to a hotel.12
(3) Extract 3:
01 A Motel:
02
Caller:
03
04
Motel:
05
06
07
08
09
10
11
Caller:
Motel:
Caller:
Motel:
Caller:
ROOM RESERVATION
Star Motel Monte Vista may I help you?
Yea:h I wond'rd~d' you by any chance have a single
room for one person for tomorrow night?
(Uh::) yeah~I~might at this time I don't know the best
thing to do is jus' come by about ten~'leven
in thuh morning~
~Okay:
( ) We usually have some checkouts
You have some checkouts All right
All right
Thanks so much
((End call))
In response to the Motel's o€er to serve, `may I help you?' (line 1), the
caller requests information about room availability (lines 2±3) as a
precursor to reserving a room. This request obligates a response by the
Motel, which occurs in lines 4 and 5.
Returning to extract (1), the doctor's o€er to serve (line 8) both solicits
the patient's medical business and projects that, after the patient presents his business, a resolution will be provided (or at least attempted)
by the doctor. Regarding asymmetry, although the doctor's o€er to serve
is constraining in that it obligates a response, it cannot be conceptualized
32
Je€rey D. Robinson
as embodying dominance (in terms of control over the patient and the
topical agenda). Rather, as an action, it does just the opposite by
soliciting, in an open-ended fashion, a ®rst-pair part from the patient.13
The patient's request to continue using Tylenol 3:
The base ®rst-pair part
Rather than responding to the doctor's o€er to serve with a service/
problem, the patient reports/describes a conversation with the previous doctor during the previous visit: `Well, it± there was some± (.) (d)±
(1.4) discussion about thuh: thuh (.) tylenol three:' (lines 11±12; regarding
such descriptions, see Drew 1984). Although the word `discussion' indexes
di€ering points of view and thus some semblance of a controversy, the
patient does not articulate the description's implications, upshot, or
consequences. The patient orients to his description as a complete,
transition-relevant, responsive actionÐnot only is it a complete turnconstructional unit (Sacks et al. 1974), but the patient stops talking, gazes
at the doctor (Goodwin 1981; Sacks et al. 1974), and waits for almost
a full second (line 13) for the doctor to respond.
Although the patient's description does not constitute an explicit
request for service, I argue that it implicates such a request. First, turns
of talk can perform more than one action (Scheglo€ 1995b) and
descriptions or reports of activities regularly serve as vehicles for
other actions, most notably requests (Drew 1984; Scheglo€ 1988a,
1995a). Second, such descriptions are understood in terms of their consequences for courses of action in progress and thus can implicate
consequences (Drew 1984). Due to its positioning after the doctor's
o€er to serve, and due to the fact that it does not constitute a declination of service, the description is likely to be understood in terms of
its relevance to a service/problem to be rendered/remedied and to implicate a request for help. Third, insofar as `discussions' typically lead to
some form of `resolution', and insofar as the patient's description
does not mention a resolution, the description implicates (Grice 1975)
the lack of a resolution.14 Thus, the patient's description is of `live'
business related to Tylenol 3 that is yet to be resolved and, in this sense, is
problematic. Fourth, in both everyday and service institutional contexts,
reports of `problems' (versus `troubles', see Je€erson and Lee 1981) set up
the relevance of helping. (Drew 1984; Je€erson and Lee 1981; Scheglo€
1995a, 1988a). In fact, members of service agencies routinely treat
customers' ®rst-topic (Scheglo€ and Sacks 1973) descriptions of problems
as soliciting some form of remedy (Bergmann 1993; Frankel 1989a;
Robinson 1999; Zimmerman 1984, 1992).
Asymmetry in action
33
Implications notwithstanding, the patient's description (lines 11±12)
neither explicitly formulates nor requests a service. Drew (1984) noted
that, in response to invitations, one feature of reporting an activity
(versus rejecting the invitation) can be to avoid taking an ocial position regarding the invitation and thus to avoid `intruding on another's
plans, commitment, or routines' (1984: 147). If the patient's description
is implicative of a sensitive request (i.e., a request for an addictive
drug that was questioned by another doctor), he may have produced
a description rather than a request in order to avoid taking a position
regarding the request (i.e., `for' or `against' continuing to take Tylenol 3)
and thus to avoid intruding on the doctor's medical judgement. This is
partially supported by the fact that, after the patient's ®rst request is
resolved, he makes a second request for medication, which is not
as sensitive and made explicitly: `Now (.) one other thing, .hh uh (0.7)
I need eh e±~summa that (.) face medicine ya gave me' (lines 91±92).
Thus, in general, the patient does not appear to orient to the action of
requesting as being normatively inappropriate.
When delivered as reports, descriptions that are informative (as is
the patient's in lines 11 and 12) frequently make relevant some form
of information uptake (Drew 1984; Heritage 1984a; Scheglo€ 1995a).
Without denying that this description implicates a request for service,
the doctor initially elects to treats it as an informative report by claiming
to be informed (with the `Oh'; Heritage 1984a) and to recognize (with
the `ye:s:') the issue at hand (i.e., the `discussion'). The doctor produces
`Oh ye:s:' (line 14) after having gazed at the records for almost a
full second (line 13). It is possible, then, that the doctor's `Oh ye:s:'
communicates that his recognition is the result of having found a speci®c
piece of information in the records that corresponds with the patient's
description.
After the doctor's `Oh ye:s:', the patient produces a turn of talk:
`A:nd uh (.) you know I~(d±) I (doe)± I don't believe I've used that
much of it, (.) but it's up to you:' (lines 16±17). In terms of speaker
initiative, this turn is volunteered. As noted earlier, research has found
that after patients provide complete responses to doctor-initiated
actions, if patients continue to volunteer additional talk, they often
format that talk as an additional responsive component to the prior,
doctor-initiated action (Frankel 1990; Gill 1998; Linell et al. 1988). This
®nding is sometimes used as evidence that patients orient to some form
of social structure exogenous to the interaction that enforces the normative inappropriateness of either volunteering talk or initiating actions.
According to this logic, patients design their voluntary contributions
as `more response' so as to not violate this norm. The patient's turn
34
Je€rey D. Robinson
in lines 16 to 17 is somewhat di€erent. On the one hand, it is volunteered and it is designed, with the turn-initial `A:nd', to be connected
to his initial description, which was a response to the doctor's question, `what can I do for ya' (line 8). On the other hand, it is neither
another response to the doctor's question nor an extension of the
patient's description. In order to account for the production and design
of this turn, we need to examine the action it is accomplishing and
how that action is situated within in the ongoing central course of
action (i.e., the patient's request).
The patient's `I don't believe I've used that much of it' does at least
two things. First, it establishes the relevance of a potential medical
problem: the overuse of Tylenol 3. Here, the patient presupposes or
alludes to at least part of the topic of the previously unelaborated
`discussion' (line 11) and treats his previous description as having
embodied a medical problem. Second, it defends his usage of the drug
by arguing against its overuse. The patient's `but it's up to you:' is
idiomatic for `but the judgment is up to you'. Although this judgment
is explicitly one of whether or not the patient has overused Tylenol 3,
its results bear on the decision of whether or not to allow the patient
to continue using the drug. Thus, the patient retrospectively treats
his initial description (at lines 11±12) as having been produced to implicate a request for serviceÐthat is, he treats it as a ®rst-pair part that
obligated a decision. In doing so, the patient alludes to the request that
was implicit in the description and thus renews both the request and
the relevance of a response. Finally, in light of the patient's `but it's up to
you:', which claims deference to the doctor's judgement, the patient's
preceding defense, `I don't believe I've used that much of it', embodies
a pro-grant position regarding the doctor's pending decision to grant
or deny the patient's request to continue using Tylenol 3. In sum,
with his turn in lines 16 and 17, the patient treats the doctor as
being at the beginning of a decision-making process (involving a request)
and performs actions that are speci®cally relevant to requesting as a
course of action (i.e., advocating a position and providing evidence
to support it).
Regarding asymmetry, the patient orients to producing these actionsÐ
that is, advocating and supporting a pro-grant position through his turn
in lines l6 and 17Ðnot within the normative con®nes of exogenous social
structure, but rather within that of the base adjacency-pair sequence
through which his request is being accomplished. The design of the
patient's turn needs to be accounted for in these terms. If the patient
is treating his description (at lines 11±12) as a request (i.e., a ®rst-pair part)
that obligated a decision by the doctor, then after the doctor's `Oh ye:s:',
Asymmetry in action
35
it is speci®cally relevant for the doctor to proceed to make a decision.
At this point, patient-volunteered talk will, in a variety of ways, be
accountable. The patient's use of the turn-initial `A:nd' (line 16) to
get his actions heard as being connected to his request, which was an
appropriate response to the doctor's question (at line 8), is one way that
the patient mitigates his accountability for volunteering these actions
at this sequential location. Furthermore, the actions of advocating and
supporting a position are relevant to the central course of action in
progress (i.e., a request for a decision).15
Gathering information I: The ®rst insertion sequence
At the completion of the patient's turn in lines 16 to 17, the patient's
request, and the norms of the base adjacency-pair sequence through
which it is being accomplished, obligate the doctor to make a decision
(i.e., to either grant or deny the request). Instead, the doctor proceeds
to gather information in preparation for making a decision, which is
accomplished through an insertion sequence: `Yer taking it fer go:ut?'
(line 18), which is subsequently reformulated as, `Why are you taking
it?' (line 21). These questions project that their answer is a prerequisite
for making the decision. In both mundane and service institutional
contexts, it is not uncommon that the general action of information
gathering precedes the granting or denial of requests (Bergmann 1993;
Frankel 1989a; Scheglo€ 1990; Zimmerman 1984, 1992). The doctor's
question(s) constitute(s) a ®rst-pair part, which obligates an answer from
the patient.
As a reformulation of `Yer taking it fer go:ut?' (line 18), the doctor's
`Why are you taking it?' (line 21) is to be understood as `What medical
condition are you taking Tylenol 3 for?'. There are two ways in which
the patient's initial response in lines 22 to 24 evolves into what
Pomerantz (1986) called an extreme-case formulation. First, the expression `m:ostly fer::' (line 22) projects, at most, a short and selective list
of the most concerning or highest priority conditions. However, the
patient goes on to present a long list of problems (i.e., back, hand, knee,
ankle, and feet), all of which end up being framed as a priority. Second,
lists are typically structured into three parts (Atkinson 1984; Je€erson
1990). Je€erson demonstrated how people can accomplish di€erent
actions by exploiting this structure through weakening or omitting
third parts. Analogously, by adding fourth and ®fth partsÐin this case,
additional problemsÐthe patient underlines the severity of his overall
condition. Thus, the patient presents an extreme case concerning both the
objective gravity of his medical condition and the relevance of Tylenol 3
36
Je€rey D. Robinson
to that condition. According to Pomerantz, extreme-case formulations
are frequently used when justifying and/or defending positions and
are methods of legitimizing claims; they can be used `to assert the
strongest case in anticipation of non-sympathetic hearings' and `to speak
for the rightness _ of a practice' (1986: 227). In sum, through his
answer, the patient continues to advocate a pro-grant decision by
arguing that the legitimacy and severity of his problem warrants the
use of Tylelol 3. The patient's advocation displays his orientation both
to the fact that a decision is in the process of being made (i.e., to the
relevance of an in-progress course of action, that being a request) and
to the fact that the doctor's preceding question solicited information
speci®cally prefatory to making a decision (i.e., to the doctor's question[s]
as initiating an insertion sequence).16
The patient's initial response is possibly complete after `my (feet)
problem' (line 24). The patient orients to his completion at this point by
stopping talking and there ensues a small gap of silence (line 25). This
silence `belongs' to the doctor. That is, after the patient's initial response
(at lines 22 to 24), which answers the doctor's question and possibly
closes the insertion sequence, the doctor is obliged, due to the patient's
live request and the normative constraints of the base adjacency-pair
sequence through which it is being accomplished, to continue to progress
toward a decision. The doctor is, however, writing in the records during
the silence, which is a bureaucratic, documentary form of progression
and thus stands as an account for his lack of talk. At line 26, the patient
recompletes his answer and reinforces the extreme nature of his medical
condition by adding (and repeating) an increment, `my knee problem'.
Throughout the long, one-second silence at line 27, which again `belongs'
to the doctor, the doctor continues to write in the records.
Regarding asymmetry, silence, such as that at line 27, is sometimes
equated with patient's lack of participation and thus used as evidence
that patients orient to social structure exogenous to interaction that
normatively proscribes patient participation (e.g., Heath 1992). However,
in order to validly equate silence with patient's lack of participation,
analysts must demonstrate that, during the silence, it is relevant for
patients to be speaking (e.g., that a patient had just been asked, but not
yet answered, a question). The silence at line 27 follows a re-completion
of an answer by the patient. At this sequential location, due to the
normative organization of the base adjacency-pair sequence through
which the request is being accomplished, it is speci®cally relevant for
the doctor, not the patient, to be participating, and speci®cally to be
progressing toward the decision. Thus, the fact that the patient does
not talk at line 27 is most proximately accounted for in terms of the
Asymmetry in action
37
normative organization of the base adjacency-pair sequence, not
exogenous social structure.
In lines 28 to 30, the patient continues to advocate a pro-grant
position. He does this with two, possibly complete, units of talk: (i) `You
know it j'st uh (0.2) .hhh (.) it ea:sed the pa:in a little bit'; and
(ii) ` 'n: the rest of the stu€ we took gave me diarrhea'. In two ways, the
®rst unit is designed as another response to the doctor's question, `Why
are you taking it?' (line 21). First, the indexical it (i.e., `it j'st') refers
back to this question. Second, the ®rst unit is another type of response
to this question. That is, whereas the patient's initial response at lines
22 to 26 answered the why-question in terms of `What condition are
you taking the Tylenol 3 for?', this unit responds in terms of another
version of whyÐthat is, `How does Tylenol 3 help your condition?'.
Through this unit, rather than simply adding new information onto
the ¯oor, the patient continues to advocate a pro-grant position by
asserting the drug's e€ectiveness in relieving his pain.
The second unit is similarly built as more response to the doctor's
`Why are you taking it?' (line 21). First, it is grammatically tied to
the immediately preceding talk with the word and (i.e., ` 'n: the rest').
Second, it is yet another type of response to the why-question, this time
in terms of `Why are you taking Tylenol 3 as opposed to other medications?'. Through this unit, the patient continues to advocate a pro-grant
decision by ruling out the use of a range of alternative medications (i.e.,
`the rest of the stu€ we took gave me diarrhea'). In doing so, the patient
frames the decision to use Tylenol 3 as the result of a methodic process
of medicinal trial and error. Furthermore, by using the term we rather
than I (i.e., `the stu€ we took'), the patient co-implicates the doctor in,
and thus legitimizes, the decision to use Tylenol 3.
Regarding asymmetry, the patient's talk in lines 28 to 30 is volunteered.
That the patient designs his two units of talk as more response to the
doctor's question is accounted for by the fact that they are produced in
a sequential location where, due to the patient's request and the normative organization of the base adjacency-pair sequence through which
it is being accomplished, it is relevant for the doctor to be talking,
and speci®cally for the doctor to be making a decision. The patient is
accountable for volunteering talk beyond his ®rst complete response
(at lines 22 to 24). Insofar as `responding' to the doctor's question is an
appropriate contribution at this sequential location, designing his two
units as additional responses is a way of mitigating that accountability.
Furthermore, these two units are relevant contributions in that they
perform the action of advocating a pro-grant position, which is relevant
to the central course of action in progress (i.e., a request for a decision)
38
Je€rey D. Robinson
and which continue the patient's advocacy from his initial response in
lines 22 to 26. In sum, across the patient's talk at lines 22 to 30, there
are multiple locations where the doctor is within his interactional rights
to take the ¯oor (especially at lines 25 and 27), and when he does not,
the patient continues. The patient's single, incrementally extended turn
in lines 22 to 30 is the contingent product of multiple e€orts to respond
to the doctor's query (at line 21) and build a case in favor of a decision
to allow the patient to continue using Tylenol 3.
The silence at line 31 again belongs to the doctor, who continues to
write in the records. The doctor's `Ri:ght' (line 33), which interrupts
the patient's continuation, `(B't±)' (line 32), is a third-turn acknowledgement token that (i) claims to be aware of, and con®rms, the patient's
prior informing (at lines 28±30; Heritage and Se® 1992; Scheglo€ 1995b);
and (ii) proposes to close down the patient's answer (and the insertion
sequence that it was part of ) and projects a shift to new matters (Beach
1995a, 1995b). As noted earlier, some researchers have argued that the
speech exchange system of doctor±patient consultations allows doctors
the right to produce third-turn responses and then continue to initiate
more talk (e.g., another question; Fisher 1984; Mishler 1984; Todd
1993 [1983]). However, in the present case, the doctor's right to continue
to produce more talk comes from the normative organization of the
patient's request and the base adjacency-pair through which it is being
accomplishedÐthat is, upon completion of `Ri:ght' it is still relevant
for the doctor to progress toward making a decision.
Proceeding from his `Ri:ght' (line 33), the doctor agrees and aligns
with the pro-grant position constructed by the patient in his answer in
lines 22 to 30. The doctor does this through two units of talk. First, the
doctor reiterates one of the patient's medical conditions: `an' then you
also have that problem with your stomach' (lines 33±34). By prefacing
this `B'-event statement (Labov and Fanshel 1977) with `an' ', by using
the word problem, which was used by the patient at lines 23 to 26, and
by using the word also, which characterizes the problem as an addition
to the patient's previous list at lines 22 to 26, the doctor designs this
statement as being connected to, and building on, the patient's initial
answer in lines 22 to 26. Second, the doctor formulates the upshot of
this statement and cautions the patient: `So you gotta be ca:reful
because certain things can bu:rn your stomach' (lines 36±37).17 Because
Tylenol 3 irritates the stomach less than other medications, the doctor's
reference to `certain things' is to pain relievers other than Tylenol 3. Here,
similar to the patient's utterance in lines 29 to 30, the doctor rules out
a range of alternative medications as a treatment for the patient's
condition and thus indirectly legitimizes the patient's use of Tylenol 3. In
Asymmetry in action
39
sum, the doctor's two utterances in lines 33 to 37 analogously mirror the
structure of the patient's previous response in lines 22 to 30Ðthat is, the
doctor raises a problem and then uses it as evidence for why Tylenol 3
is functional for the patient and his condition. In doing so, the doctor
agrees and aligns with the patient's pro-grant position.18
Gathering information II: The second insertion sequence
At line 39, due to the normative organization of the patient's request
and the base adjacency-pair sequence through which it is being accomplished, it is relevant for the doctor to progress toward making a decision.
Instead, the doctor proceeds to gather more information in preparation for making a decision, which he again accomplishes through an
insertion sequence: ``How many do ya take a day:'' (line 39). As the
doctor completes his question, he prepares to write the patient's answer
in the records (i.e., he holds his pen in position to begin writing and
gazes at the records). The doctor's question obligates a response in
terms of `amount per day' and presupposes that the patient takes
Tylenol 3 daily. The patient initially responds with `(Oh:)' (line 42),
which displays that the doctor's question is inapposite (Heritage 1998),
and continues with `I ^do:n't.^, which emphatically rejects the question's
presupposition. In doing so, the patient continues to support his progrant position by characterizing his usage as less than expected. However,
this response does not answer the doctor's question and thus is not a
complete response. The silence at line 43, then, belongs to the patient,
who is still accountable for responding in terms of `amount'. This is
supported in two ways. First, throughout the patient's silence at line 43,
the doctor maintains his embodied position of preparedness to write
and thus shows that he is waiting for the patient to continue. Second,
in lines 45 to 47, the patient continues to provide an amount-relevant
response.
Several observations can be made about the patient's answer in lines
45 to 47. First, the patient uses `I might take' to overtly design it as a
response to the doctor's question, `How many do ya take a day'. Second,
the patient restarts the utterance and produces an answer that only
indirectly provides an amount per day. Halkowski (1998) observed that
doctors' questions concerning amounts are often sites of con¯ict between
responses formulated in terms of patients' lifeworld experiences (Mishler
1984), which sometimes resist explicit quanti®cation, and calendarbased frequencies (e.g., units per day/week/month; Boyd and Heritage,
to appear; Button 1990; Sacks 1989). The patient's indirect formulation
does, however, allow the patient to table a speci®c piece of information,
40
Je€rey D. Robinson
which is that he was only given ten pills. Here, the patient simultaneously answers the doctor's question (albeit indirectly) and continues
to support his pro-grant position by characterizing his usage as less
than normal.
In order to discuss the patient's utterance at line 49, it is necessary
to provide some context. Simultaneous with the patient beginning to
complete his response at line 45, the doctor abandons his preparedness
to write and shifts his gaze from the record of the current visit to that
of the prior visit.19 Thus, the doctor abandons an e€ort to document
the patient's answer in favor of reviewing the record of the prior visit.
Remember that this doctor was not present for the prior visit and did
not write the previous prescription for Tylenol 3. It is likely that his
e€ort to review the prior visit is motivated by the patient's `(Oh:) (.)
I ^do:n't^' and subsequent pause (lines 42±43), which cumulatively
challenge the appositeness of the doctor's question and thus call the
doctor's knowledge of the prior visit into question. Regardless, the doctor
displays a need to orient himself with regard to the prior visit before he
documents the patient's answer. Notably, the doctor reviews the records
of the prior visit throughout the completion of the patient's answer at
line 47 and a majority of the silence at line 48, which belongs to the doctor
in two ways. First, upon completion of the patient's answer, it is relevant for the doctor to progress toward the decision. Second, the doctor
has projected that he will document the patient's answer in the records,
which he has not yet done. It is in this environment that the patient
volunteers: `They didn' give me the full perscription:' (line 49). This utterance addresses the doctor's nonvocal e€orts to orient himself to the
prior visit and clari®es a speci®c portion of the patient's previous response (i.e., it is an explanation for `they gave me ten'). As a repair-related
action, the patient's clari®cation is a relevant contribution (Scheglo€
1982). Regarding asymmetry, the patient orients to the appropriateness
of volunteering talk that is relevant to the action in progress.
At lines 51 to 53, the doctor requests con®rmation of a slightly reformulated version of the patient's initial answer: `So you took± you've taken
ten in the last two weeks? Or ni : ne?'20 Although the patient begins to
con®rm the doctor's formulation on its own terms, `(Yeah±) (.) Ten in:
yeah nine in:' (lines 54±56), he ultimately con®rms a di€erent formulation by substituting a longer time frame, `^three^ weeks' (line 56), for
the doctor's `two weeks'. With this substitution, the patient diminishes
the frequency with which he takes Tylenol 3 and thus further supports
a case against his reliance on, and for his continued use of, the drug.
However, the substitution, which is additionally modi®ed by `maybe',
makes the patient's previous response (at lines 45±47), as an answer to
Asymmetry in action
41
the doctor's question (at line 39), inde®nite. Furthermore, by adding
`I don' kno:w', the patient claims insucient knowledge and an
inability to address the time frame in an explicit manner (Beach and
Metzger 1997). This is consequential because the doctor's request for
con®rmation was produced to achieve resolution to his initial question,
`How many do ya take a day:', which obligated a response in terms of
`amount' and which was asked as a prerequisite to making the decision.
The patient's answer fails to provide this resolution by problematizing
the sought-for response, that being an amount. In sum, the patient's
response in lines 54 to 57 is equivocal in terms of its status as a complete
answer. That is, although it is both grammatically and intonationally
complete, and although claiming insucient knowledge can constitute
a complete response (Beach and Metzger 1997), it is not a fully, pragmatically complete answer (Ford and Thompson 1996). That the patient is
still accountable for producing an amount is supported by the fact that
he subsequently asks a question in order to gather information (i.e.,
a speci®c date) that will allow him to provide an amount: `When was the
last time I was in here to talk to 'im about it' (lines 59±60). This question
is volunteered and obliges a response from the doctor.
Regarding asymmetry, prior research has used patients' unsolicited
questions as indicators of patients' power, at least in terms of patients'
abilities to initiate topics and agendas and gather information for their
own purposes. It is ironic, then, that the patient's question at lines 59
to 60 serves the exact opposite function in that it is designed to gather
information on the doctor's behalf; that is, on behalf of answering the
doctor's question of amount, which was itself asked in the service
of making the decision. That the patient asks this question is largely
accounted for by the doctor's `How many do ya take a day:' (line 39)
and the normative organization of the adjacency-pair sequence through
which it is being accomplished. That is, this question obligated the
patient to provide a response in terms of a speci®c amount, that obligation was renewed by the doctor's request for con®rmation (lines 51 and
52), and the patient's question is produced in the service of providing
such an amount.
A granting of the patient's request: The base second-pair part
After an extended search through the records, the doctor claims to
not know the date, `We:ll wI don' knowv' (line 64), and then supplies
a month, `last time you were here was july::' (lines 64±66). Notably, the
doctor's answer does not provide the information necessary for the
patient to satisfactorily answer the question of amount, thus leaving it
42
Je€rey D. Robinson
unresolved. It is in this context that the doctor delivers his decision
regarding the patient's request. At line 68, the doctor grants the patient
another prescription: `Okay. (.) I':ll uh± I'll write you another prescription'. This granting is the second-pair part of the base adjacency-pair
sequence initiated by the patient's indirect request (at lines 11±12).
Because the doctor did not acquire a de®nitive answer to his question
of amount (at line 39), and because that information was projected
as being a prerequisite to making the decision, the doctor's decision
to grant the patient another prescription is accountable. Speci®cally, it
can be understood as both a `giving up' on the collection of information
necessary to make a proper decision and a `giving in' to the patient's
pro-grant position, which the patient has taken continuously throughout the accomplishment of the request. This is exactly how the patient
understands it. At lines 69 and 70, the patient o€ers to not continue
taking the medication: `Well (i±) (deh±) you know if you'd rather
I didn't wtake itv I c'n: I can live withou:t'. In formulating the doctor's
position, `you'd rather I didn't wtake itv', and by stressing the word
you'd, which contrasts the doctor's position with the patient's own
position, the patient displays an understanding that the decision was
not made from the doctor's position and thus that the doctor `gave in'
to the patient's position. The doctor rejects the patient's o€er, `No'
(line 71).
The patient's o€er is an attempt to resolve his request as a course
of action. Sequentially, the patient's o€er initiates a post-expansion
sequence (Scheglo€ 1995b) to the base adjacency-pair sequence. Regarding
asymmetry, despite the fact that the o€er is volunteered and obligates
a response from the doctor, it cannot be interpreted as embodying
medical power or dominance. As an action, the o€er threatens to undermine the patient's just-granted request for service and speci®cally does
so under the auspices that the `doctor knows best' (i.e., `if you'd rather
I didn't wtake itv'). If anything, the o€er embodies the patient's
subordination to the doctor's professional judgement.
Although the production of the patient's o€er might be accounted
for in terms of social structures exogenous to the interaction, a more
local and convincing endogenous account is available: the o€er is produced in response to the way in which the patient's request is initially
resolved and the implications that that form of resolution have for the
patient's identity. By granting the patient's request for service in a way
that communicates that the doctor `gave up' his own position and `gave in'
to the patient's position, the doctor communicates that he was somehow
`pressured' into making a decision that he might not otherwise have
made and thus that the decision is potentially medically inappropriate.
Asymmetry in action
43
This particular realization of the doctor's decision puts the patient in
a situation of accepting the prescription and behaving in a dangerous
medical manner in the face of potential medical disapproval and partially as a result of the patient's own advocacy of a pro-grant position.
In sum, the patient's o€er is produced to defray these implications.
The ®nal resolution of the patient's request
At line 75, the doctor produces a counter-o€er, `The only other w± option
would be dar:vace:t.~h', which constitutes a second post-expansion
sequence (Scheglo€ 1995b) of the base adjacency-pair sequence. Space
prevents a complete analysis of this sequence, but the patient's `Alright'
(line 90), like the patient's `O:kay' (line 88), re-accepts the doctor's
counter o€er and possibly closes both the post-expansion sequence and
the central course of action it was modifying (i.e., the patient's initial
request for service). What is notable is that at lines 91 and 92, the
patient continues to make a new request, `Now (.) one other thing, .hh uh
(0.7) I need eh e±~summa that (.) face medicine ya gave me'. Once the
patient is outside of the normative constraints of an ongoing course of
action, he displays his orientation to a right to volunteer an utterance
that initiates a new course of action and obligates a response.21 Here,
the patient does not orient to an inappropriateness of, or general
asymmetry in, participation. The patient's second request, which might
otherwise have been considered to be an outlier in terms of asymmetries of speaker initiative and utterance constraint, can now be
reconsidered as an utterly mundane occurrence.
Conclusion
This article began by critically reviewing and reconceptualizing the
interactional asymmetry of initiative in doctor±patient consultations.
It demonstrated that utterances contain at least two distinct dimensions
of initiative: speaker initiative (i.e., utterances can be either normatively obligated by a prior utterance or volunteered) and utterance constraint (i.e., utterances can either normatively obligate, or not obligate,
a response from a recipient). It then argued that any account for these
asymmetries needs to be grounded in experiences that are lived, and
oriented to as relevant, by doctors and patients.
Like all people, doctors and patients organize their behavior in interaction primarily in terms of action, such as requesting, advocating,
o€ering, advising, agreeing, informing, and so on. During consultations,
action can be simultaneously and di€erentially organized by reference
44
Je€rey D. Robinson
to a variety of larger-order activities. Some of these are `mundane', such
as the activities of story telling and troubles telling (Hak 1994; Je€erson
and Lee 1981; Stivers and Heritage, to appear). Others are `professional',
such as:
i.
medical activitiesÐfor example, opening consultations (Robinson
1998; ten Have 1991), solving (i.e., diagnosing and treating) patients'
new medical problems (Robinson 1999), and gathering face-sheet
data (Heritage and Sorjonen 1994);
ii. institutionalized counseling techniquesÐfor example, the Milan
School Family Systems Technique (PeraÈkylaÈ 1995);
iii. activities associated with professional roles (although researchers
must demonstrate that, and how, such roles are relevant to the
participants and consequential for the interaction; see Scheglo€
1992a).
As PeraÈkylaÈ (1995) put it (borrowing from Levi-Strauss), the shape
of doctor±patient interaction, including the asymmetrical distribution
and design of utterances and actions, is the result of a bricolage of
organizing social structures. However, irrespective of the factors that
condition action, action must be built by doctors and patients with
the bricks and cement of mundane conversation, including turns, turn
taking, and sequences of talk (Drew and Heritage 1992; Heritage and
Sorjonen 1994). In doctor±patient consultations, the fundamental,
organizing structure for action is the adjacency-pair sequence.
This article demonstrated that many asymmetries of speaker initiative and utterance constraint that have otherwise been accounted for in
terms that are either exogenous to interaction (e.g., doctors' power/
dominance) or endogenous to the institutional speci®cs of interaction
(e.g., medical activities, such as history taking) can be more locally and
generally accounted for in terms of the normative organization of
courses of actions, which are predominantly accomplished through
base adjacency-pair sequences and their expansions (Scheglo€ 1995b).
Furthermore, it demonstrated that asymmetries that are not in accordance with prior ®ndings and accounts can also be accounted for in terms
of the normative organization of action. For example, the patient's
question `When was the last time I was in here to talk to 'im about it'
(extract [1], lines 59±60) was voluntarily produced and initiated an
action that obligated a response. Prior research has described these
types of utterances as being inappropriate and thus avoided. However,
its production is not oriented to as such, and can be accounted for by
the doctor's previous line of questioning, which obligated a response
Asymmetry in action
45
from the patient, a response that the patient was not able to provide without asking the question. Finally, this article began to unravel the previously con¯ated conceptions of asymmetries of speaker initiative and
utterance constraint on the one hand, and power/dominance on the
other. For instance, although the question just mentioned was voluntarily produced and obligated a response, it did not embody the patient's
power/dominance, at least in terms of his ability to initiate a topic or
agenda or gather information for his own purposes. Rather, it was
asked in the service of answering the doctor's previous line of questioning
and thus furthered the doctor's agenda. The technical design features
and structures of interactionÐsuch as turn design, turn taking (including
interruption), repair, and sequence organizationÐare not straightforwardly aligned with power/dominance because they are tools and vehicles
for action, which can either maintain or challenge traditional power/
dominance relationships.
Although the term `asymmetry' literally refers to an objective lack
of proportion between the parts of a thing, its use in the literature connotes
a subjective and moral lack of equality. Once the technical features of
interaction, and their proportional distribution between doctors and
patients, are separated from ®xed correspondences to decontextualized
characterizations of action (e.g., theoretical notions of power/dominance),
the term asymmetry becomes a potentially inappropriate descriptor of
proportional features of interactional phenomena. Furthermore, the
goal of analysis shifts from merely tabulating and correlating technical
features of interaction to describing their relationship to the production
of action in situ.
Appendix
The data have been transcribed according to conventions developed by
Je€erson (1984):
DOC/PAT: Speaker identi®cation: doctor (DOC); patient (PAT)
[overlap]
Brackets: onset and o€set of overlapping talk.
~
Equal Sign: utterances are latched or ran together, with
no gap of silence.
(0.0)
Timed Pause: silence measured in seconds and tenths of
seconds.
(.)
Parentheses with a period: a micropause of less than
0.2 seconds.
:
Colon(s): preceeding sound is extended or stretched; the
more the longer.
46
Je€rey D. Robinson
.
,
?
underline
³soft³
wfastv
^pitch^
.h
h
hah/heh
(that/hat)
((Cough))
Period: falling or terminal intonation.
Comma: continuing or slightly rising intonation.
Question mark: rising intonation.
Underlining: increased volume relative to surrounding talk.
Degree signs: Talk with decreased volume relative to
surrounding talk.
Greater-than/less-than signs: talk with increased pace
relative to surrounding talk.
Carets: talk with heightened pitch relative to surrounding
talk.
Superscripted periods preceedings hs: inbreaths; the more
the longer.
Hs: outbreaths (sometimes indicating laughter); the more
longer.
Laugh token: relative open or closed position of laughter
Filled single parentheses: transcriptionist doubt about talk.
Filled double parentheses: scenic details, or an event/sound
not easily transcribed.
Notes
*
1.
2.
3.
4.
A version of this article was presented at the 1997 conference of the National Communication Association, Chicago, Illinois under the title, `The e€ects of adjacency-pair
organization on patient participation'. The author thanks Wayne Beach, Emanuel
Scheglo€, Tanya Stivers, and especially John Heritage for their comments on previous
drafts.
Researchers have also examined asymmetries of interruption (West 1984), knowledge (Drew 1991), and medical experienceÐthat is, the observation that patients'
psychosocial experiences are frequently suppressed in favor of doctors' biomedical
experiences (Maynard 1991; see also Frankel 1996; Mishler 1984).
By ``utterance,'' I am referring to either turns or turn-constructional units (Sacks et al.
1974), each of which can constitute a possibly complete utterance (recompletion,
see Sacks et al. 1974).
Space precludes a discussion of how ®rst-pair parts can be grammatically and/or pragmatically designed to `prefer' or `disprefer' certain second-pair parts and thus a€ect how
second-pair parts are designed (Boyd and Heritage to appear; Pomerantz 1984; Sacks
1987; Scheglo€ 1988b, 1995b; for review, see Heritage 1984b; Levinson 1983).
Frankel (1990) and West (1984) de®ned `®rst-positioned' utterances as
(1) an utterance initiated by a patient that was topically disjunctive, i.e., competed
with an ongoing topic, (2) an utterance initiated by a patient at a phase completion
boundary which either began a new topic tied back to a previous topic or re-started
a just completed topic, (3) an utterance initiated by a patient after a speech relevant
pause that entered new information onto the ¯oor either by a topic initiation,
extension, or modi®cation (Frankel 1990: 260)
Asymmetry in action
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
47
This schema did not include participants' `backward-looking' actions addressed
to `normal troubles', such as `requests for clari®cation, information, etc.' (Frankel
1990: 239).
Although there may be a relationship between these asymmetries and outcome
measures, such as patient compliance (Hall et al. 1988), there is not a necessary
relationship between them and problematic talk during consultations (Linell and
Luckman 1991).
Linell, Gustavsson, and Juvonen (1988) and Linell and Luckman (1991) explicitly
de®ne the asymmetry of utterance constraint as `interactional dominance'. According
to the former, `interactional dominance _ is one aspect of the manifestation of
power relations in dyadic communication' (1988: 437, emphasis deleted).
I am speci®cally using the term `normatively inappropriate' as opposed to `dispreferred',
which was coined by Frankel (1990) and has since been widely adopted. The
conversation-analytic conception of `preference' (see note 3) and the normative
obligations embodied in formal speech exchange systems (Sacks et al. 1974) are distinct
and should not be con¯ated.
The normative inappropriateness of patient-initiated actions has been described as
a feature of entire `medical dialogues' (West 1984: 93), `physician±patient encounters'
(Frankel 1990: 231), and medical 'speech events` (West 1984: 73), and has been
attributed to `overall structural constraints' (Frankel 1990: 234), `presuppositional
grounds upon which the communication situation itself rests' (Frankel 1990: 255),
and `the importance of ritual and deference in physician±patient discourse' (Frankel
1984: 143). In these terms, the speech exchange account is virtually an exogenous
account.
For example, in extract A, after the patient answers the doctor's question, she asks
one of her own, `did you look up there? (.) tuh see?' (lines 73±74).
(i) Extract A
68 Q A
DOC: Do you think it hurts m:ore on one side than the other.
69 A A
PAT: Y:eah.
70
(0.8)
71 Q A
DOC: Which side hurts.
72
(1.8)
73 A+Q A
PAT: M:ore this si:de,it's j's (that±) .hhh (0.3) did you look
74
up there? (.) tuh see?
75 A A
DOC:
Not ye:t.
Actually, the doctor's turn consists of two questions, `So what's new' and `what can
I do for ya'. These two question formats di€erentially communicate doctors' orientations to patients' types of medical business, the former indexing `routine' business and
the latter indexing `new' business (Robinson, to appear). In this case, the doctor replaces
the ®rst question with the second.
I would like to thank John Heritage for bringing this extract to my attention.
I would like to thank Don Zimmerman for making this data available.
See Frankel (1990) for other examples of what he calls doctors' `solicits' (e.g., `Anything else?').
For a discussion of Grice's (1975) notion of implicature, see Levinson (1983).
The implication here is based on Grice's maxim of quantity, which adds `to
most utterances a pragmatic inference to the e€ect that the statement presented is
the strongest, or most informative, that can be made in the situation' (Levinson
1983: 106). Relatedly, see Drew's (1992) discussion of the `maximal' property of
descriptions.
48
Je€rey D. Robinson
15. The patient's turn at lines 16±17 provides evidence that he treats his prior
indirect request (in his description at lines 11±12), which was accomplished through
a single unit of talk, as simultaneously being obligated (i.e., as a second-pair part
response to the doctor's o€er to serve) and obligating a response (i.e., as the ®rst-pair
part of a request). This observation is relevant to the construction of coding schemata
for speaker initiative and utterance constraint. Coding schemata restrict single units
of talk to one code category. Thus, at least one code category would need to represent
units of talk that are simultaneously obligated and obligating.
16. Some researchers have criticized doctors for not explaining to patients the reasons
that motivate their questions (Mishler 1984). Admittedly, the doctor does not explain
the medical signi®cance of gout for his decision and this may be unknown to the
patient. However, the inferential framework established by the ®rst-pair part of
the base adjacency-pair sequence allows the patient to understand that this question,
in that it simultaneously does not constitute a decision and is relevant to making
a decision, is being asked in the service of making a decision. The inferential frameworks of adjacency-pair sequences are not in®nitely elastic. That is, not every question asked after a base ®rst-pair part will be heard as an insertion sequence. Thus, the
inferential frameworks of base adjacency-pair sequences provide patients with
resources for understanding at least some of the motives behind doctors' questions
that are asked prior to base second-pair parts.
17. Formulating the upshot of the prior statement is accomplished by the unit-initial
`So' (Schi€rin 1987).
18. Both of the doctor's utterances solicit a response, which the patient provides at
lines 35 and 38, `Yea:h'. These two sequences of talk at lines 33±35 and 36±38 are
expansion sequences to the insertion sequence at lines 18±30.
19. Evidence that the doctor is, in fact, looking at the records of the prior visit comes
later in the interaction. When the patient asks, `When was the last time I was in here to
talk to. 'im about it' (lines 59±60), the doctor refers to the same page in the records as
he does at lines 45±48.
20. This request ignores, or sequentially deletes (Scheglo€ 1987a), the patient's contribution at line 49.
21. The patient's second request is not an entirely new base adjacency-pair sequence.
Rather, with `one other thing', the patient formats this request as a second response
to the doctor's o€er to serve, `So what's new. what can I do for ya' (line 8).
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Je€rey D. Robinson (B.A., Communication Studies, University of California at
Santa Barbara, 1990; M.A., Communication Studies, University of Southern California,
1992; Ph.D., Sociology, University of California at Los Angeles, 1999) is currently an
assistant professor in the Department of Speech Communication at the Pennsylvania
State University.