Content uploaded by Letizia Caronia
Author content
All content in this area was uploaded by Letizia Caronia on Jul 08, 2019
Content may be subject to copyright.
https://doi.org/10.1177/1461445616683594
Discourse Studies
2017, Vol. 19(1) 30 –48
© The Author(s) 2017
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1461445616683594
journals.sagepub.com/home/dis
Assembling (non) treatable
cases: The communicative
constitution of medical object
in doctor–doctor interaction
Letizia Caronia
University of Bologna, Italy
Arturo Chieregato
Niguarda Hospital, Italy
Marzia Saglietti
University of Bologna, Italy
Abstract
Research on medical interactions shows how the discursive construction of the clinical case
impacts diagnostic reasoning and treatment recommendations. Drawing on an ethnographic study
in an intensive care unit, we illustrate how this process is at play in a ward that adopts an extreme,
guideline-divergent policy as to the use of antibiotics. The article focuses on how physicians
assemble the case as ‘treatable’ or ‘not yet treatable’, and how in doing so they ‘talk into being’
two contrastive policies on antibiotics and position themselves toward the one adopted in the
ward. The analysis identifies the discursive resources displayed by physicians to both project an
infectious disease diagnosis and resist this treatment-implicative trajectory. We argue that the
physicians’ contentious discursive construction of the case has crucial consequences in the way
the ward’s extreme policy is jointly accomplished as a highly reflexive process sensitive to the
contingencies of any particular case.
Keywords
Antibiotic treatment recommendation, co-construction of the medical object, conversational
analysis, diagnostic reasoning, doctor–doctor interaction, medical talk, team decision-making
Corresponding author:
Letizia Caronia, Department of Education, School of Psychology and Science of Education, University of
Bologna, Via F. Re, 6, 40126 Bologna, Italy.
Email: letizia.caronia@unibo.it
683594DIS0010.1177/1461445616683594Discourse StudiesCaronia et al.
research-article2016
Article
Caronia et al. 31
Introduction
Research on medical interactions shows how and to what extent the discursive construc-
tion of the clinical case impacts on diagnostic trajectories and treatment recommenda-
tions, two activities expected to be evidence-based (Timmermans and Angell, 2001) and
dependent upon an ‘objective professional voice’ (Kovarsky et al., 2005: 119–180).
The construction of the ‘clinical object’ (Galatolo and Margutti, 2016; Heath, 2006)
has been widely studied in doctor–patient interaction. This joint activity takes place in
the initial phase of the visit and has a dramatic impact on the subsequent phases, namely
diagnosis delivery and treatment prescriptions (see Maynard, 1992; Stivers, 2002b,
2007). Apart from studies in medical education – where an explicit learning process
between experts and novices is at stake (Hindmarsh et al., 2014; Koschmann et al.,
2011; Mondada, 2007, 2014; Rees and Monrouxe, 2008; Zemel and Koschmann, 2014)
– the clinical case construction between physicians has been relatively underexplored.
Few remarkable studies on doctor-doctor interaction show how physicians collectively
construct the clinical case while reporting it to the team (Anspach, 1988; Atkinson,
1995, 1999; Cicourel, 1985; Ikeda and Okada, 2007), to other professionals (Måseide,
2007) or while taking notes (Hobbs, 2003). These studies converge in underlining that
‘presenting cases is not merely a way of depicting reality but a way of constructing it’
(Good, 1994: 80) that impacts the overall medical diagnosing and decision-making pro-
cesses (Alby et al., 2015; Halvorsen, 2010; Halvorsen and Sarangi, 2015). According to
Anspach (1988), reporting the patient’s condition is a discursive activity that not only
incorporates the physician’s self-presentation, but also embodies the clinical stance
toward the medical challenge at stake and its problematic options (see also Atkinson,
1999). Adding to research on the communicative constitution of the medical object (see
also Alby et al., 2015; Antaki et al., 2005; Cicourel, 1987; Lymer et al., 2014), we con-
sider the case presentation in doctor–doctor interaction as an activity where physicians
construct the ‘assessable object’ (on the analytic concept of assessable, see Goodwin,
2003; Goodwin and Goodwin, 1987). As we will show, this activity is theory-implicative
and praxis-constitutive: in crafting the features of the object they have to assess collec-
tively, physicians index their relevant expert knowledge and channel the subsequent
actions by projecting a clinical trajectory.
Drawing on an extensive ethnographic fieldwork in an intensive care unit (ICU), this
article analyzes physicians’ construction of the assessable object as potentially being a
case of infection. The analysis focuses on how physicians of the same specialty (a)
assemble the clinical object as ‘treatable’ or ‘not yet treatable’ with antibiotics in the
report phase of the team briefings, (b) ‘talk into being’ (Heritage, 1984: p. 290) different
policies concerning antibiotic treatment and (c) position themselves toward them.
Participants’ discursive resources and territories
of knowledge: The case of infectious diseases and
antibiotic treatment
As Stivers’ (2005, 2007) outstanding research shows, the case of antibiotic prescription is
particularly revealing of the kind of struggles that may occur during medical interaction.
The growing evidence of the risks involved in over- or otherwise improper prescription of
32 Discourse Studies 19(1)
antibiotics dramatically changed the physicians’ clinical stance toward antibiotic prescrip-
tion worldwide. Risks concern the selective pressure of antibiotics on the bacteria they are
supposed to fight and the consequent increase of new multidrug-resistant bacteria. The
spread of these germs – responsible for infectious diseases with high morbidity and
mortality rates – is a public health concern all over the world (see Center for Disease
Dynamics, Economics & Policy (CDDEP), 2015; World Health Organization, 2014). The
gap between folk medical notions (e.g. antibiotics as the ‘miracle drug’ and the common-
sensical belief ‘if infection then antibiotics’) and the updated medical expert knowledge
partially explains why patients (or relatives) and physicians often (although mildly) con-
flict upon diagnoses and treatment prescriptions concerning conditions that might be
identified as infections and therefore might be treated with antibiotics.
Drawing on Stivers’ (2002a, 2007) research on doctors’ and parents’ communicative
resources to – respectively – project ‘no need for antibiotics’ and resist this discursive
trajectory, our study focuses on doctor–doctor interactions when there is no ‘socially
sanctioned authority to know’ (Heritage, 2012b: 5) concerning antibiotics,1 and (a)
physicians do not share the same diagnostic trajectory, (b) more than one policy on
antibiotic treatment (ATBT) is locally available (Ten Have, 1995) and (c) they have to
collectively decide in an accountable way whether to treat or not to treat yet. Surprisingly
enough, our data show that some patterns of interaction typically identified in doctor–
patient (or–parent) interaction are at stake even among hospital physicians with the same
epistemic access to the relevant expert knowledge, common technical jargon and heuris-
tics. We advance the hypothesis that the physicians’ discursive oscillation (see Cooren,
2010) between two locally available yet extremely different alternative policies toward
antibiotics accounts for the way decisions are interactively accomplished.
Design and method of the study
The study is part of a larger quantitative/qualitative research project aimed at studying
the nonclinical dimensions that possibly impact the spread of nosocomial infections.2
The overall project involved 40 ICUs. This article reports data from the Central Italy
ICU3 (CEICU) chosen as an exemplar of those having a high rate of infectious diseases
and a very low rate of multidrug-resistant bacteria infections. CEICU follows a policy
toward infectious disease prevention and treatment that both team members and their
colleagues working in other ICUs consider ‘off-label’. Data analyzed here consist of
excerpts from a corpus of nine video-recorded daily team briefings. They have been
analyzed using a conversation analysis approach (Jefferson, 2004; see Appendix). We
focus on the discursive resources deployed by medical staff members during the case
presentation to resist or pursue the ‘no problem/no treatment’ trajectory implied by the
official policy of the ward. These resources make relevant alternative yet not equivalent
courses of action: prescribing, or not prescribing antibiotics yet.
The institutional setting: Alternative policies for
antibiotic treatment
Two policies concerning ATBT are part of the expert knowledge of CEICU’s members:
‘the empirical therapy for suspicion of infection’ and ‘the definite therapy for proven
Caronia et al. 33
infections’ (see Eggimann and Pittet, 2001: p. 2074). The former is totally consistent
with the guidelines and the policy generally adopted in most ICUs that apply ‘early
empirical broad-spectrum antimicrobial coverage for critically ill patients in whom the
development of a N[osocomial] I[nfection] is suspected’ (Eggimann and Pittet, 2001:
p. 2074). This widely used and highly recommended approach consists in (a) collecting
cultures before treatment, (b) treating the patients with first-line, broad-spectrum antibi-
otics at the first relevant symptoms of a suspected infectious disease (American Thoracic
Society and Infectious Disease Society of America, 2005: p. 388) and (c) re-orienting
and tailoring the ATBT as soon as test results are available.
The ‘definite therapy’ for proven infections consists in (a) avoiding the empirical
therapy; (b) tolerating clues that may be but are not necessarily symptoms of infections;
(c) capitalizing, as much as possible, on the patient’s endogenous resources; and (d) pre-
scribing targeted ATBT only when laboratory exams detect the germ(s) responsible for
the disease, the antibiogram reveals the germ’s sensibilities and resistances and the vital
signs of the patient clearly reveal that she or he can no longer resist the infection. Both
policies are accounted for by CEICU members as relying on extant literature and clinical
studies that supposedly provide evidence as to their respective risks and benefits. While
the empirical-therapy approach insists on the positive effects of the early, broad spectrum
ATBT in reducing the seriousness of the patient’s first-order infections, the ‘watch and
stay’ approach focuses on the positive effects of delaying the therapy and avoiding the
use of large-spectrum antibiotics – preserving the ward ecology (and consequently the
single patient) by preventing the occurrence of the rare but far more dangerous and even
fatal infectious diseases caused by multi-resistant bacteria.
Within this typical clinical yet also social dilemma, the CEICU Responsible Clinician
(RC) has adopted the definite therapy – amicably labeled by CEICU members the ‘watch
and stay’ approach4 – as the main therapeutic line of the ward. This approach is held
accountable for an overall reduced use of antibiotics in the ward with respect to those
adopting the empirical approach, and use of less expensive ATBs as well as a low rate of
multidrug resistant (MDR) bacteria. A quantitative analysis of the decisions concerning
patients who display symptoms of possible infection shows that 71% are made following
the ‘watch and stay’ approach: antibiotics are not prescribed that day. The ‘watch and
stay’ approach does not follow the guidelines widely accepted and strictly (defensively)
followed by most ICUs worldwide (although it is coherent with some recent studies; see
Hranjec et al., 2012). Doctors’ and nurses’ oscillating orientation toward these policies is
traceable and analyzable in the ways they participate in the event institutionally provided
for the purpose of taking diagnostic and treatment decisions: the morning briefing (on
the theoretical necessity of implying meaning and culture to make sense of local inter-
action, see the Van Dijk–Duranti debate; Duranti, 2015).
Assembling the case: How physicians project treatability
through reporting
CEICU morning briefings take place each morning from 8 a.m. to around 9 a.m. The
overall scope of the event is to assess the patients’ status and plan the courses of action
for the next 24 hours. As is the case for most institutional talk in health care settings (see
34 Discourse Studies 19(1)
Byrne and Long, 1976; Heath, 1992; Heritage and Maynard, 2006), CEICU morning
briefings are sequentially organized: they consist of a number of macro sections corre-
sponding to the number of inpatients. Each section consists of three main consecutive
phases: the report (i.e. case presentation; Atkinson, 1999; Erickson, 1999), the assess-
ment and the plan. Participants regularly attending the event are the RC in charge of
the clinical line of the ward, the night physician (NP) who is in charge of reporting the
inpatients’ status updated as of 8 a.m. daily, the case manager nurse (CM), the head nurse
(HN), the physiatrist (PH), the physician responsible for the patients throughout the
week (lunghista; L) and other physicians (AP) attending the morning shift.
Members of this team officially adopt a shared decision-making model of teamwork:
Diagnosis and treatment decisions are said (during in-depth interviews and informal talk
with researchers) to be collectively taken (i.e. as one member said, ‘We are a ward. One
ward, one line’). The morning briefings are the institutionally provided locus for that.
The frequent use of the ‘inclusive we’ (O’Grady et al., 2014: 76; for a broader use of the
inclusive ‘we’ in medical talk, see also Brookes-Howell, 2006; Lindwall and Lymer,
2011) in their diagnostic and evaluative talk is one of the cues displaying their orientation
toward this officially declared model of teamwork.5
During the morning briefing, CEICU physicians have the problem of assessing the
patient’s conditions as ‘not yet treatable’ (with ATB) or – if they wish to resist the official
policy of the ward – as ‘treatable’ (for the interactive construction of doctorability and
treatability, see Heritage and Robinson, 2006). The crafting of the assessable object is
therefore crucial as it provides the foundation for both the assessment and the planning. It
is in the report phase that this work begins. The following excerpts illustrate some discur-
sive resources used in the report phase by participants to assemble the assessable object as
‘treatable’ or ‘not yet treatable’.6 The aim of the analysis is to illustrate a typology of the
discursive resources displayed by participants to both project an infectious disease diag-
nosis and resist this treatment-implicative trajectory (see Stivers, 2002a, 2007).
Partial assessments and mitigating no problem conditions
When physicians present a case in ways that are aligned7 to the ‘watch and stay’ approach
(no problem/no treatment today), they can do this in a mitigated way through partial
assessment of specific data concerning the patient’s status.
(1) He is basically a-pyretic [CEICU_Im_9]
1 NP_G: Icola Maurizio.
2 (.)((looks at some papers))
3→[allora lui è sostanzialmente apiretico=
[so he is basically a-pyretic=
4 [((he turns his head to the right))
5 =è salito fino a trentotto, (.)
=it has reached thirty eight, (.)
6 AP_F: ( )
7 NP_G: [sì. ( ) trentotto e uno, trentotto e due=
Caronia et al. 35
[yes. ( ) thirty eight point one, thirty eight point two=
8[((opens the record, leafs through the record))
9 si. ((reads)) trentotto e uno, trentotto e due.
yes. thirty eight point one, thirty eight point two.
10 (.)
11 bianchi, ((reads in the record))
white,a
12 ( ): ( )
13 NP_G: di stama- erano tredici e quattro, stamattina sono,
as of this morn- they were thirteen point four, this morning they are,
14 ((looks at the sheets that nurse N1 is consulting, to his left))
15 CM: ((looks through the papers)) vediamo se ce l’abbiamo se no (.)
let’s see if we have it if not (.)
16 NP_G: non ce l’abbiamo. (va bene.)
we don’t have it there (okay.)
17 ((looks at the sheets that N1 is consulting, then puts his eyes back on the folder that
he has between his hands))
18 e: comunque lui ha un bas con dei cocchi gram positivi, (.)MSSA dieci
a:nd anyway he has a basb with gram positive cocci, (.) MSSAc ten to
19 alla quinta(.) ma non è in terapia antibiotica, (.)il paziente è sveglio
the fifth (.) but he’s not on antibiotic therapy, (.) the patient is awake,
20 (.) e: (.) (emme (tre un emme sei,)
(.) e: (.) a am (three a em six,)
21 ((he turns to the right)) lastra del torace, (.)
((he turns to the right)) chest x-ray, (.)
22 ((he leans forward and turns his head to the right))
23 →è sostanzialmente negativa,
it is basically negative,
24 è un paziente che ha iniziato uno:=
he is a patient that has started a:=
25 ((turning his head to the left, looking back to the papers in front of him))
26 =svezzamento direi da oggi, si
= weaning I would say from today, yes
((lines from 27 to 36 omitted, NP_G continues reporting on the planned beginning of spontaneous
respiration))
37 RC: va bene.
that’s fine.
a.White (bianchi): Elliptical expression for white blood cells.
b.BAS: Elliptical expression for the value of the Bronchial Aspirated Secretions.
c.MSSA: Methicillin-Sensitive-Staphylococcus Aureus.
d. ICP: Intra-Cranial Pressure.
36 Discourse Studies 19(1)
The NP, Gerlando S. (NP_G), provides a partial assessment of the patient’s pyretic
status (‘basically a-pyretic’, line 3) even before giving the numerical information concern-
ing his body temperature. He then continues reporting data about the white blood cells (no
recent data are found), the results from lab tests that detected some (pneumonia inducing)
bacteria in his bronchial aspirates (line 18) and his not being on ATBT (line 19). He then
assesses radiological exam results: the x-ray is ‘basically negative’ (line 23) and reports
information projecting the patient’s relatively good condition: he is awake (line 19) and
ready to be progressively weaned from the mechanical ventilator (lines 24–26).
The case presentation is aligned with the policy of the ward: the simple presence of
a bacterium – in the absence of other relevant conditions – is not enough to suspect an
infectious disease or to prescribe antibiotics. However, the alignment is cautious: exploit-
ing his epistemic right to assess clinical data, he mitigates two ‘no problem’ indexing
conditions. In doing so, he blurs the diagnosis implied in the way he assembled the case
(no-infection at stake): the patient is not a-pyretic, he is ‘basically a-pyretic’ (line 3); the
chest x-ray is not negative, it is ‘basically negative’ (line 23).
This partial alignment provides NP with the opportunity to insert a comment in the
planning phase (not transcribed) through which he will reopen the possibility that the
infectious disease is already established: by stating that the spontaneous respiration can
make it manifest, he implies that the infection is latent. Although the case presentation is
consistent with the ‘no problem/no treatment’ trajectory and therefore aligned with the
‘watch and stay’ policy (no ATBT will be prescribed this day), NP manages to create
some fissures that forewarn of a possible imminent problem.
Selecting and underlining relevant parameters
In the previous case, NP mitigates a (constructed as) not-so-problematic case. The next
excerpt illustrates the minimal form through which physicians project an infectious dis-
ease: selecting and underlining information that could be relevant for a potential infec-
tious disease diagnosis, or that at least may alert toward this possibility. This case
construction orients the diagnostic reasoning toward treatability.
(2) Very very foul-smelling [CEICU_Mart_2]
1 NP_M: Gomez allora, (.)sub-piretico, 37 e mezzo, (.)e eh::m
Gomez then, (.)hypo-pyretic, 37 and a half, (.)and u::hm
2→secrezioni:: maleodoranti, secrezioni bronchiali maleodoranti,
secretio::ns foul-smelling, bronchial foul-smelling secretions,
3→lui ha una sospetto- una storia clinica di sospetta inalazione,
he has a suspected- a clinical history of suspected inhalation,
4 perché è stato trovato a casa con del vomito ed è stat-
because he was found at home with vomit and was-
5 non è stato subito intubato ma posizionato in
he wasn’t immediately intubated but positioned with
6 una maschera laringea.
Caronia et al. 37
The NP, Giovanni M. (NP_M), starts by typically providing information on blood tem-
perature: the patient is hypo-pyretic (line 1). This status is not consistent with infection.
However, he immediately reports a piece of information that is consistent with a possible
infection: the quality of the secretions. The quality of secretions is routinely used to assess a
potential pneumonia; here they are qualified as foul-smelling (line 2). The speaker self-
repairs his previous utterance: he provides a new and more explicit version of the informa-
tion in a more straightforward way. He then goes on by selecting from the patient’s history
two pieces of information that may explain those secretions, and therefore he further points
toward a suspected pneumonia diagnosis. First, the patient has been considered as having
possibly inhaled liquids from the mouth because he has been found at home (unconscious)
with some vomit (lines 3–4). This information from his clinical history is relevant: inhala-
tion may cause endogenous contamination and lead to pneumonia due to the entry of bacte-
ria from the throat into the respiratory district. Second, the patient is reported as not having
been immediately intubated yet positioned with a laryngeal mask (line 6). The known and
implied information here is that the mask does not protect the lungs from inhalation. All the
premises for a possible pneumonia are there as well as a typical symptom: the malodorous
secretions. The sequence is closed by a summary where the NP invites the audience to make
a connection between this information from the patient’s history and his present bronchial
secretions: the turn begins with the discourse marker ‘so’ (line 7) that resumes and ‘indicates
to the hearer that some kind of inferential connection between the two propositions needs to
be made’ (Bolden, 2009: 976). Right after this indication to make a connection, the secre-
tions are referred to again and hyper-qualified: they are ‘very very foul-smelling’ (line 8).
Through this instance of upgraded assessment, NP reiterates the information that projects
a treatable condition and makes relevant a suspicious of infection.
‘Doing nothing’ with information8
In Excerpt 2, RC manages to not provide relevance to or emphasize the NP’s first-hand
information (Heritage, 2012a; Pomerantz, 1980): he does not exploit the pause (line 9) to
a laringeal mask.
7 quindi questa è la sua storia clinica per quanto
so this is his clinical history as for
8→riguarda quelle secrezioni che sono molto molto maleodoranti.
what concerns those secretions that are very very foul-smelling.
9 (.)
10 per il resto, e:: è stato stabile
otherwise, a::nd he has been stable
11 tutta la giornata sotto il profilo
the whole day from the point of view
12 dell’ICP,d un’ICP sempre ben controllata,
of the ICP, an ICP constantly under control,
((The NP_M goes on reporting other information not immediately related to the diagnostic reasoning
concerning infectious diseases))
38 Discourse Studies 19(1)
acknowledge, comment upon, or ratify the marked information, adopting what we call
the ‘doing nothing’ resource (for the sequential meaning of ‘doing nothing’, see Stivers,
2006: 288). Consequently, NP goes on reporting on other aspects of the patient’s status
(acceptable Intra Cranial Pressure, lines 10–12).
Although NP has repeated the same information on the secretions three times, in the
assessment phase (not transcribed) no reference will be made to this potential symptom.
The projected possibility of pneumonia is suspended: not confirmed nor denied. This zone
of indeterminacy is totally consistent with the ‘watch and stay’ approach (on postponing
diagnoses, see Alby et al., 2015): that day, the patient presents only one possible cue of
a hypothetical pneumonia. Although sufficient for the followers of empirical therapy, it
is not enough for a ward committed to delaying the beginning of the ATBT as long as
possible. We suggest that – thanks to the work of the NP to construct the assessable
object as treatable – the possibility is now part of the ‘representational field’ (Heritage
and Raymond, 2005) of the team. The day after, the patient will be assessed again.9
Anticipating and confuting alternative candidate explanations
The following excerpt identifies a more complex case: NP gives more than qualified
information to project an infectious disease problem; he narrows the diagnostic field by
anticipating and confuting an alternative candidate explanation (on candidate diagnosis,
see Stivers, 2007).
(3) It is not a withdrawal symptom [CEICU_Gug_6]
1 NP_F: al letto dieci Gagliotta
at bed ten Gagliotta
((inaudible exchange between researcher and case-manager))
2 Gagliotta è un ragazzo che sta- (.)
Gagliotta is a boy that is- (.)
3→in ventiquattresima giornata,
in his twenty-fourth day,
4→allora, (.) le novità sono:
so, (.) the news is:
5 sono tre giorni che ha delle
it’s three days now that he has
6 puntate febbrili con brivido scuotente,
fever spikes with shaking tremors,
7 l’ultimo ieri sera, (.) non è un-
the last one last night, (.) it is not a-
8→a- a mio modesto avviso non era
in- in my modest opinion it was not
9 una crisi d’astinenza perché
a withdrawal symptom because
10 le pupille erano totali,
his pupils were total,
Caronia et al. 39
The NP, Fernando G. (NP_F), starts by giving the name and the bed number of the
patient (line 1). He then provides the hospital day of this patient (lines 2–3): the patient
is in his 24th day. The duration of the hospital stay is crucial: first, long duration is posi-
tively correlated with the increase of hospital-acquired infectious diseases, and second,
it is a parameter used in this ward to evaluate the beginning of ATBT. Although patients
in ICUs usually begin ATBT on the first/second day following admission, at CEICU,
they start it on average on the sixth/seventh day. So NP’s discursive strategy here consists
in selecting and underlining information that orients toward treatability: the patient is far
beyond the CEICU average day for beginning ATBT.
In line 4, NP frames the incoming information as new. In doing so, he marks a differ-
ence with respect to what is already known about this patient and alerts the recipients to
the relevance of the incoming information: the patient has been having pyretic spikes
with tremors (lines 4–7). All participants know that ‘fever is one of the cardinal signs of
infection’ (Young and Saxena, 2014: 1), yet they also know that it can be a consequence
of other conditions.
The report of this objective status is followed by a first position assessment (lines
8–9). The assessment is designed in a negative format: this condition is not a withdrawal
symptom. Drawing on his first-hand knowledge (Heritage, 2012a; Pomerantz, 1980) –
the last spike occurred last night and last night he was there – he lists the patient’s con-
current symptoms (lines 10–13) that make him identify what this spike with tremors is
not a symptom of. In doing so, he restricts the range of possible assessments and makes
relevant a possible infection diagnosis.
However, the ways he designs his turn downgrades the assertiveness of his declara-
tion and reduces the claimed compatibility of the condition ‘with the asserted state of
affairs not being the case’ (Heritage and Raymond, 2005: 18). In delivering his claim
about what the fever is not a symptom of, he suddenly produces a self-repair (the last one
last night, it was not a-, line 7) that creates a slot to introduce an evidentially qualified
preface (in- in my modest opinion it was not a withdrawal symptom, lines 8–9; see
Heritage and Raymond, 2005) that frames the assessment as a personal opinion and
qualifies the opinion as a modest one (on indicators of evidentiality in doctor–doctor
interaction, see Atkinson, 1999; Hobbs, 2003). After this evidentially qualified assess-
ment, NP comes back to the territory of knowledge he masters better than RC: the
11 non sudava, brivido scuotente
he wasn’t sweating, shaking tremors
12 →con una temperatura che è saltata
with temperature that jumped
13 da trentotto a trentanove e mezzo.
from thirty eight to thirty nine and a half.
14 (2.0)
15 RC: bene.
right.
16 NP_F: ha fatto delle emocolture.
he did blood cultures.
40 Discourse Studies 19(1)
objective status of the patient (lines 10–13). He repeats the information about fever with
shaking tremors and further underlines its critical features: the fever jumped from 38 to
39 and a half (lines 12–13).
NP accomplishes two relevant actions that are consequential as to how his contribu-
tion will be received: he makes relevant a suspicion of infection (the patient is in his 24th
hospital day, his blood temperature is high and his shaking tremors are not a symptom of
withdrawal) and downgrades his own right to do that. Not surprisingly then, RC receives
the report and its marked information through the ‘doing nothing’ resource (see Excerpt
2, line 9): he provides a marked acknowledgment (right, line 15) that basically signals
the closing of the sequence. This is exactly what NP does in line 16: he changes the topic
and does not expand on peak fever (on ways to receive news with tokens that do not
encourage further elaboration and ‘may mark the end of an informing sequence’; see also
Maynard, 2003: 101).
Reporting test results and referring to antibiotic treatment
The next example (shown previously in Excerpt 1) illustrates two other discursive
resources used as a mean to make relevant a diagnosis of infection and therefore orient
toward the hypothesis that the patient might undergo an ATBT: ‘reporting test results’
and ‘referring to antibiotic treatment’. NP is presenting the case of Isola, a patient in the
weaning phase.
(4) And anyway he has a BAS with gram positive cocci [CEICU_Im_9]
18 NP_G e: comunque lui ha un BAS con dei cocchi gram positivi,(.)MSSA dieci
a:nd anyway he has a BAS with gram positive cocci,(.) MSSA ten to
19 →alla quinta(.) ma non è in terapia antibiotica, (.)il paziente è sveglio
the fifth (.) but he’s not on antibiotic therapy, (.) the patient is awake,
After having constructed the patient’s condition in a mitigated no-treatment implica-
tive way (see Excerpt 1), NP makes the alternative diagnostic trajectory (infection at stake)
relevant. By introducing his statement with a conjunction plus concessive adverb (‘and
anyway’, line 18), he refers to the presence of some detected bacteria (‘BAS with gram
positive cocci’, line 18) and markedly signals that the patient is not on antibiotics (line 19).
In doing so, he continues to display the partial alignment with the ‘watch and stay’ approach
already exhibited at the very beginning of the report phase (see Excerpt 1, line 3).
Discussion
Notwithstanding contemporary pressure for evidence-based medical decision-making
(Castel, 2009; Timmermans and Angell, 2001) and for practices relying on ‘objective
professional voice’ (Kovarsky et al., 2005: 119), our study on medical talk in an ICU
confirms the unavoidable constitutive role of discourse in shaping medical activities
as crucial as diagnosing and treatment recommendation (Alby et al., 2015; Atkinson,
1999; Brown, 1995; Glenn and Koshmann, 2005). We have illustrated how physicians
Caronia et al. 41
contentiously project diagnostic trajectories and treatment recommendations from the
initial phase of the morning briefing where they are supposed to report the patient’s
objective status as a foundation for the subsequent assessment and planning phases. In
particular, we have illustrated how physicians differently construct the assessable object
as ‘treatable’ or ‘not yet treatable’ and how, in doing so, they ‘talk into being’ (Heritage,
1984: 290) two markedly different policies concerning ATBT in ICUs, position them-
selves toward them, and pursue or resist the unwritten yet officially shared ‘off-label’
policy adopted in the ward: the ‘watch and stay’ approach.
Surprisingly, our study reveals that differences in orientation toward treatability and
some patterns of interaction identified in doctor–patient interaction (e.g. offering candi-
date diagnosis, projecting treatability, resisting a ‘no problem diagnosis/no treatment
decision’, pursuing different and often conflicting agendas; see Stivers, 2002a, 2006,
2007) are demonstrably at stake even among physicians of the same specialty, that is,
having the same epistemic access to relevant expert knowledge and similar rights to
claim it (see Heritage, 2012a, 2012b). Although it is reasonable to expect agreement
when the diagnostic reasoning and treatment prescription fall within a domain of ‘special
knowledge possessed and controlled’ (Heritage, 2006: 85) by all the participants, our
study reveals that their relative symmetry in epistemic status does not guarantee such a
shared consensus. On the contrary, it requires substantial discursive work to make diag-
nostic and treatment alternatives relevant.
Particularly, we analyzed six discursive resources used mainly by NPs to construct
the assessable object as ‘treatable’, thereby resisting the implied and known ‘off-label’
policy of the ward: partial assessment (Excerpt 1), mitigating no problem condition
(Excerpt 1), selecting and underlining relevant parameters (Excerpt 2), anticipating and
confuting alternative candidate explanations (Excerpt 3), referring to ATBT (Excerpt 4)
and reporting test results (Excerpt 4). We also illustrated one discursive resource used by
the RC in receiving his colleagues’ report: ‘doing nothing’ with information (Excerpts 1,
2 and 3). We showed how in receiving information with tokens that did not encourage
further elaboration, he pursued a ‘no-treatment yet’ agenda, weakened his colleagues’
assemblage and aligned to the ‘watch and stay’ clinical line of the ward.
The following summary reports the discursive resources analyzed above (see Table 1).
Table 1. Discursive resources to project and resist diagnostic trajectories in the report phase.
Who (mainly) Does what How Excerpts
Night physicians
(NP)
Projecting a treatable
condition
Making relevant a
suspicion of infection
1. Partial assessments Excerpt 1
2. Mitigating no problem conditions Excerpt 1
3. Selecting and underlining relevant
parameters
Excerpt 2
4. Anticipating and confuting
alternative candidate explanations
Excerpt 3
5. Reporting tests results Excerpt 4
6. Referring to antibiotic treatment Excerpt 4
Responsible
Clinician (RC)
Constructing the
assessable object as
not to be treated yet
7. ‘Doing nothing’ with information Excerpts 1,
2 and 3
42 Discourse Studies 19(1)
The resources here analyzed appear to be the primary ways through which physicians,
since the report phase of the morning briefing, orient to and make ‘actionable through
talk’ (Heritage, 1997: 222) the different policies concerning antibiotic prescription in
ICUs. Their assemblage of the assessable object is therefore highly theory-implicative
yet also praxis-constitutive: it channels the other participants’ contributions as well as
the team decision-making process.
The known discrepancy between the international guidelines strongly recommending
empirical therapy and the therapeutic line of the ward creates a clinical dilemma as well
as a practical problem for CEICU members: they have to decide every day, for each and
every patient and for ‘another next first time’ (Garfinkel, 2002: 182) to not follow the
evidence-based guidelines and make this understandably controversial decision highly
accountable.
We argue that physicians’ discursive oscillation (see Cooren, 2010) between two
locally available yet extremely different clinical alternatives accounts for the way deci-
sions are interactively accomplished: the interaction analysis reveals indeed that this
diagnostic path is not taken for granted nor followed in a mechanical, protocol-like way.
On the contrary, this extreme policy appears to be jointly and contentiously accomplished
one interaction at a time (Garfinkel, 2002) by participants who recurrently manage to
make relevant the alternative guideline-oriented empirical approach.
In an ICU where doctors work all the time on the border between life and death, dis-
playing what we may call a disaffiliative alignment toward a radical, guideline-divergent
policy leads team members to take a reflective stance toward their professional vision
(Goodwin, 1994) and to follow their policy as a highly accountable, non-standardized
process sensitive to the contingencies of each and any particular case.
Acknowledgements
This article has been written within the framework of the national research project Phenomenology
of Infectious Diseases in Intensive Care Units (PHENICE) financed by the Mario Negri Institute
for Pharmacological Research (Milan, Italy) and coordinated by Dr Guido Bertolini, MD. The
ethnographic study has been coordinated by Letizia Caronia (University of Bologna) and Luigina
Mortari (University of Verona). Giuseppina Mesetti and Roberta Silva (University of Verona) and
Marco Pino (Loughborough University) participated in data collection and analysis. We wish to
thank all ethnographic team members for their collaboration in data collection and analysis. We
wish to thank also the medical and nursing staffs of the intensive care units (ICUs) where we con-
ducted the fieldwork for their essential collaboration in data collection and interpretation. We are
most grateful to Kathy Metzger for revising our English text and an anonymous reviewer for
insightful comments on the earliest version of the article.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this
article.
Caronia et al. 43
Notes
1. The responsible clinician (RC) has the same specialty as his colleagues (i.e. intensive care
medicine/anesthesiology) and does not have any special training or expertise in microbiology
or infectivology.
2. Data come from the national project Phenomenology of Infectious Diseases in Intensive
Care Units (PHENICE) financed by the Mario Negri Institute for Pharmacological Research
(Milan, Italy) and coordinated by Dr Guido Bertolini (MD).
3. The study was approved by the Ethical Committee of the Mario Negri Institute for
Pharmacological Research. Permission was also obtained from the ICUs. Participants gave
written informed consent before research was conducted, and they were informed about
voluntariness, confidentiality and anonymity. For this reason, the names of the hospital, of
the ward and of each participant has been changed in order to anonymize data.
4. As an anonymous reviewer acutely notes, we ‘take at face value’ that the ward follows a
‘watch and wait’ approach. In doing so, we adopt the typical ethnographic emic approach:
Analysts are oriented to members’ perspectives (see Duranti, 1997). Central Italy ICU (CEICU)
members both declared (in recorded interviews and informal talk with the researchers) and
displayed (in their everyday situated talk and practice) their acceptance of what they labeled
the ‘watch and stay’ approach as the therapeutic line of the ward. Qualitative evidence from
interactional analysis documenting this specific use of antibiotic treatment (ATBT) consists
in practices aimed at delaying as much as possible the beginning of the ATBT. This does not
imply that physicians do not explore the alternative approach or that they have biases toward
not prescribing (or prescribing) ATBT. On the contrary, they manage to situate each assessable
token within a complex and even contradictory territory of expert knowledge (Caronia and
Chieregato, 2016). This article documents precisely how the different professional cultures of
ATBT that make this territory are evoked (Cooren, 2010) and made ‘actionable through talk’
(Heritage, 1997: 222) by clinicians in the course of their interaction.
5. As an anonymous reviewer notes, a question arises as to who finally decides what. Despite
his leading role, the RC is not the official decision-maker, even though he may be perceived
and even interactively ratified as such. The shared decisions collectively crafted in the morn-
ing briefing are staged as belonging to the team. If the RC is not present (e.g. on Sunday),
attending physicians are allowed to prescribe treatment and diverge from the therapeutic line
of the ward if they consider it necessary. They are asked to be accountable for the day after. In
any case, decision-making in CEICU does not lend itself to be analyzed from a ‘who decides
what’ view point. A preliminary analysis reveals that in CEICU, decisions are rarely punctual
and localizable phenomena and they are rarely communicated through declarative statements
clearly identifiable and attributable to someone. Decisions are – at least constructed as – dis-
tributed among morning briefing participants. They are also dislocated: at the patient’s bed
the physician provides or supervises the treatments, signs the clinical record and therefore
assumes the legal responsibility of the treatment. This does not imply by any means that
power and authority are not at play or that collaborative practices are democratic practices:
even following a therapeutic line as if it were a consensually shared one can be a (discursive)
behavior shaped by the hierarchical structure of a hospital ward. Whatever the impact of the
institutional ranking is in creating agreement and consensus, the distributed decision-making
model, staged in CEICU, is less rare than expected. As Atkinson (1999) showed, occasions
of decision-making can be relatively invisible and appear to be ‘discursively dispersed and
fragmented’ (p. 96).
6. Further analysis is needed to find out which formats of presentation are more recurrent in the
report phase of the briefing and how they are differently received by co-participants.
7. Broadly drawing on Stiver’s (2008) notion of alignment and affiliation, in this article we
adopt these categories to analyze participants’ orientation to the policy officially adopted in
44 Discourse Studies 19(1)
the ward. Their case presentation is analyzed as more or less aligned with the ‘watch and stay’
approach. As an anonymous reviewer notes, physicians’ displayed alignment can be easily
understood as stance-taking toward a particular object (i.e. the ward’s policy) as well as those
who embody this object (Dubois, 2007).
8. As an anonymous reviewer rightly remarks, ‘doing nothing’ should be considered a resource
in a far richer repertoire of activities used by the RC to receive his colleagues’ treatment-
implicative contributions and downgrade their relevance. For a preliminary analysis of the
RC’s tactics to passively and actively resist his colleagues trajectories, see Caronia (2015) and
Caronia and Chieregato (2016).
9. As an anonymous reviewer remarks, one of the issues at stake is understanding how the night
physicians affect treatment recommendations ‘through their description of the symptoms
[…], and how the RC responds to these alternative descriptions’. Although we recognize that
these are crucial points, this article focuses primarily on the night physicians’ resources (e.g.
description of symptoms) displayed in the report phase to project treatability and therefore
evoke the alternative clinical approach over the one adopted in the ward. As we illustrate in
the discussion, these resources impact the way the decision is taken (see also Caronia and
Chieregato, 2016).
References
Alby F, Zucchermaglio C and Baruzzo M (2015) Diagnostic decision making in oncology:
Creating shared knowledge and managing complexity. Mind, Culture and Activity 22(1): 4–22.
American Thoracic Society and Infectious Disease Society of America (2005) Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia. American Journal of Respiratory and Critical Care Medicine 171: 388–416.
Anspach RR (1988) Notes on the sociology of medical discourse: The language of case presenta-
tion. Journal of Health and Social Behavior 29(4): 357–375.
Antaki C, Barnes R and Leudar I (2005) Diagnostic formulations in psychotherapy. Discourse
Studies 7(6): 627–647.
Atkinson P (1995) Medical Talk and Medical Work: The Liturgy of the Clinic. London: SAGE.
Atkinson P (1999) Medical discourse, evidentiality and the construction of professional respon-
sibility. In: Sarangi S and Roberts C (eds) Talk, Work and Institutional Order: Discourse in
Medical, Mediation and Management Settings. Berlin; New York: Mouton de Gruyter, pp.
75–108.
Bolden GB (2009) Implementing incipient actions: The discourse marker ‘so’ in English conversa-
tion. Journal of Pragmatics 41(5): 974–998.
Brookes-Howell LC (2006) Living without labels: The interactional management of diagnostic
uncertainty in the genetic counselling clinic. Social Science & Medicine 63(12): 3080–3091.
Brown P (1995) Naming and framing: The social construction of diagnosis and illness. Journal of
Health and Social Behavior 36: 34–52.
Byrne PS and Long BE (1976) Doctors Talking to Patients: A Study of the Verbal Behaviours of
Doctors in the Consultation. London: HMSO.
Caronia L (2015) Totem and taboo: The embarrassing epistemic work of things in the research
setting. Qualitative Research 15(2): 141–165.
Caronia L and Chieregato A (2016) Polyphony in a ward: Tracking professional theories in mem-
bers’ dialogues. Language and Dialogue 6(3): 396–422.
Castel P (2009) What’s behind a guideline? Authority, competition and collaboration in the
French oncology sector. Social Studies of Science 39(5): 743–764.
Center for Disease Dynamics, Economics and Policy (CDDEP) (2015) State of the World’s
Antibiotics, 2015. Washington, DC: CDDEP.
Caronia et al. 45
Cicourel A (1985) Text and discourse. Annual Review of Anthropology 14: 159–185.
Cicourel A (1987) Cognitive and organizational aspects of medical diagnostic reasoning. Discourse
Processes 10: 346–367.
Cooren F (2010) Action and Agency in Dialogue: Passion, Incarnation, and Ventriloquism.
Amsterdam; Philadelphia, PA: John Benjamins.
Dubois J (2007) The stance triangle. In: Englebretson R (ed.) Stancetaking in Discourse:
Subjectivity, Evaluation, Interaction. Amsterdam: John Benjamins, pp. 139–182.
Duranti A (1997) Linguistic Anthropology. Cambridge: Cambridge University Press.
Duranti A (2015) The Anthropology of Intentions: Language in a World of Others. Cambridge:
Cambridge University Press.
Eggimann P and Pittet D (2001) Critical care reviews: Infection control in the ICU. Chest 120(6):
2059–2093.
Erickson F (1999) Local identities and presentation of self as a fellow physician: Aspects of a
discourse of apprenticeship in medicine. In: Sarangi S and Roberts C (eds) Talk, Work and
Institutional Order: Discourse in Medical, Mediation and Management Settings. Berlin; New
York: Mouton de Gruyter, pp. 109–143.
Galatolo R and Margutti P (2016) Territories of knowledge, professional identities and patients’
participation in specialized visits with a team of practitioners. Patient Education and
Counseling 99(6): 888–896.
Garfinkel H (2002) Ethnomethodology’s Program: Working Out Durkheim’s Aphorism. Lanham,
MD: Rowman & Littlefield.
Glenn P and Koshmann T (2005) Learning to diagnose: Production of diagnostic hypotheses in
problem-based learning tutorials. In: Felson Duchan J and Kovarsky D (eds) Diagnosis as
Cultural Practice. Berlin; New York: Mouton de Gruyter, pp. 153–178.
Good B (1994) Medicine, Rationality, and Experience: An Anthropological Perspective.
Cambridge: Cambridge University Press.
Goodwin C (1994) Professional vision. American Anthropologist 96(3): 606–633.
Goodwin C (2003) The body in action. In: Coupland J and Gwyn R (eds) Discourse, the Body and
Identity. New York: Macmillan, pp. 19–42.
Goodwin C and Goodwin MH (1987) Concurrent operations on talk: Notes on the interactive
organization of assessments. Papers on Pragmatics 1: 1–55.
Halvorsen K (2010) Team decision making in the workplace: A systematic review of discourse
analytic studies. Journal of Applied Linguistics and Professional Practice 7(3): 273–296.
Halvorsen K and Sarangi S (2015) Team decision-making in workplace meetings: The interplay of
activity roles and discourse roles. Journal of Pragmatics 76: 1–14.
Heath C (1992) The delivery and reception of diagnosis and assessment in general practice con-
sultation. In: Drew P and Heritage J (eds) Talk at Work: Interaction in Institutional Settings.
Cambridge: Cambridge University Press, pp. 235–267.
Heath C (2006) Body work: The collaborative production of the clinical object. In: Heritage J
and Maynard DW (eds) Communication in Medical Care: Interaction between Primary Care
Physicians and Patients. Cambridge: Cambridge University Press, pp. 185–213.
Heritage J (1984) Garfinkel and Ethnomethodology. Cambridge: Cambridge University Press.
Heritage J (1997) Conversation analysis and institutional talk: Analysing data. In: Silverman D
(ed.) Qualitative Research: Theory, Method and Practice. London: SAGE, pp. 222–245.
Heritage J (2006) Revisiting authority in physician-patient interaction. In: Maxwell M, Kovarsky D
and Duchan J (eds) Diagnosis as Cultural Practice. New York: Mouton de Gruyter, pp. 83–102.
Heritage J (2012a) Epistemics in action: Action formation and territories of knowledge. Research
on Language and Social Interaction 45(1): 1–29.
Heritage J (2012b) The epistemic engine: Sequence organization and territories of knowledge.
Research on Language and Social Interaction 45(1): 30–52.
46 Discourse Studies 19(1)
Heritage J and Maynard DW (2006) Communication in Medical Care: Interaction between
Primary Care Physicians and Patients. Cambridge: Cambridge University Press.
Heritage J and Raymond G (2005) The terms of agreement: Indexing epistemic authority and sub-
ordination in talk-in-interaction. Social Psychology Quarterly 68(1): 15–38.
Heritage J and Robinson JD (2006) Accounting for the visit: Giving reasons for seeking medical
care. In: Heritage J and Maynard DW (eds) Communication in Medical Care: Interaction
between Primary Care Physicians and Patients. Cambridge: Cambridge University Press,
pp. 48–85.
Hindmarsh J, Hyland L and Banerjee A (2014) Work to make simulation work: ‘Realism’, instruc-
tional correction and the body in training. Discourse Studies 16(2): 247–269.
Hobbs P (2003) The use of evidentiality in physicians’ progress notes. Discourse Studies 5: 451–478.
Hranjec T, Rosenberger LH, Swenson B, et al. (2012) Aggressive versus conservative initiation
of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-
acquired infection: A quasi-experimental, before and after observational cohort study. The
Lancet Infectious Diseases 12(10): 774–780.
Ikeda N and Okada M (2007) Doctors’ practical management of knowledge in the daily case con-
ference. In: Hester S and Francis D (eds) Orders of Ordinary Action: Respecifying Sociological
Knowledge. Aldershot: Ashgate, pp. 69–89.
Jefferson G (2004) Glossary of transcript symbols with an introduction. In: Lerner GH (ed.)
Conversation Analysis: Studies from the First Generation. Amsterdam: John Benjamins,
pp. 13–23.
Koschmann T, LeBaron C, Goodwin C, et al. (2011) Can you see the cystic artery yet? A simple
matter of trust. Journal of Pragmatics 43(2): 521–541.
Kovarsky D, Snelling LK and Meye E (2005) Emotion and objectivity in medical diagnosis. In:
Felson Duchan J and Kovarsky D (eds) Diagnosis as Cultural Practice. Berlin; New York:
Mouton de Gruyter, pp. 179–200.
Lindwall O and Lymer G (2011) Uses of ‘understand’ in science education. Journal of Pragmatics
43(2): 452–474.
Lymer G, Ivarsson J, Rystedt H, et al. (2014) Situated abstraction: From the particular to the
general in second-order diagnostic work. Discourse Studies 16(2): 185–215.
Måseide P (2007) Discourses of collaborative medical work. Text & Talk 27(5–6): 611–632.
Maynard DW (1992) On clinicians co-implicating recipients’ perspective in the delivery of diag-
nostic news. In: Drew P and Heritage J (eds) Talk at Work: Interaction in Institutional Settings.
Cambridge: Cambridge University Press, pp. 331–358.
Maynard DW (2003) Bad News Good News: Conversational Order in Everyday Talk and Clinical
Settings. Chicago, IL: University of Chicago Press.
Mondada L (2007) Operating together through videoconference: Members’ procedures for accom-
plishing a common space of action. In: Hester S and Francis D (eds) Orders of Ordinary
Action: Respecifying Sociological Knowledge. Aldreshot: Ashgate, pp. 51–67.
Mondada L (2014) Instructions in the operating room: How the surgeon directs their assistant’s
hands. Discourse Studies 16(2): 131–161.
O’Grady C, Dahm MR, Roger P, et al. (2014) Trust, talk and the dictaphone: Tracing the discursive
accomplishment of trust in a surgical consultation. Discourse & Society 25(1): 65–83.
Pomerantz A (1980) Telling my side: ‘Limited access’ as a ‘fishing’ device. Sociological Inquiry
50: 186–198.
Rees CE and Monrouxe LV (2008) ‘Is it alright if I-um-we unbutton your pyjama top
now?’ Pronominal use in bedside teaching encounters. Communication and Medicine 5(2):
171–182.
Stivers T (2002a) Participating in decisions about treatment: Overt parent pressure for antibiotic
medication in pediatric encounters. Social Science & Medicine 54: 1111–1130.
Caronia et al. 47
Stivers T (2002b) ‘Symptoms only’ and ‘candidate diagnoses’: Presenting the problem in pediatric
encounters. Health Communication 14(3): 299–338.
Stivers T (2005) Non-antibiotic treatment recommendations: Delivery formats and implications
for parent resistance. Social Science & Medicine 60: 946–964.
Stivers T (2006) Treatment decisions: Negotiations between doctors and patients in acute care encoun-
ters. In: Heritage J and Maynard DW (eds) Communication in Medical Care: Interaction between
Primary Care Physicians and Patients. Cambridge: Cambridge University Press, pp. 279–312.
Stivers T (2007) Prescribing under Pressure: Parent-Physician Conversations and Antibiotics.
Oxford: Oxford University Press.
Stivers T (2008) Stance, alignment and affiliation during storytelling: When nodding is a token of
affiliation. Research on Language and Social Interaction 41(1): 31–57.
Ten Have P (1995) Medical ethnomethodology: An overview. Human Studies 18(2–3): 245–261.
Timmermans S and Angell A (2001) Evidence-based medicine, clinical uncertainty, and learning
to doctor. Journal of Health and Social Behavior 42(4): 342–359.
World Health Organization (2014) Antimicrobial Resistance: Global Report on Surveillance.
Geneva: World Health Organization.
Young PJ and Saxena M (2014) Fever management in intensive care patients with infections.
Critical Care 18: 206–214.
Zemel A and Koschmann T (2014) ‘Put your fingers right in here’: Learnability and instructed
experience. Discourse Studies 16(2): 163–183.
Appendix
Transcription conventions
(1.5) pause (in seconds and tenths of seconds)
(.) micro-pause (shorter than 0.2 seconds)
↑ sudden rise in pitch
↓ sudden drop in pitch
descending intonation
? ascending intonation (not necessarily interrogative)
suspended intonation
, abrupt interruption of talk
- latching with previous utterance
= quiet volume
°text° very quiet volume
°°text°° emphasis
text faster pace of speech
>text< slower pace of speech
<text> start of overlapping talk
[ description of nonverbal activity
48 Discourse Studies 19(1)
((text)) unclear or dubious words
(text) unintelligible
::: elongation of a sound
Author biographies
Letizia Caronia, PhD, is full professor at the Department of Education (University of Bologna),
director of the Master’s program in Education, and member of the University Committee for the
Evaluation of Research. Her research focuses on language, interaction and culture in institutional
and ordinary contexts. She has published more than 30 articles in international peer-reviewed
journals and more than 15 book chapters.
Arturo Chieregato, MD, specialist in anesthesiology and critical care medicine, is the director of
the Neurocritical Care Unit of the Niguarda Hospital in Milan, Italy. His research concerns neuro-
trauma, neurological and neurosurgical syndromes needing admission to intensive care units. He
has had more than 228 publications, including 64 articles in peer-reviewed journals of intensive
care medicine.
Marzia Saglietti, PhD, social psychologist, is a Research Fellow at the Department of Education,
University of Bologna. Her research focuses on language, interaction and culture in residential
care for children.
