Elsevier

Social Science & Medicine

Volume 62, Issue 8, April 2006, Pages 1902-1916
Social Science & Medicine

“Does it mean I’m gonna die?”: On meaning assessment in the delivery of diagnostic news

https://doi.org/10.1016/j.socscimed.2005.09.011Get rights and content

Abstract

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

Introduction

In the context of deliveries of diagnostic news, clinicians and their recipients—patients or family members—may address the issue of what the diagnosis means. That is, they may raise a question of how to interpret the news. There is now a considerable interaction-based literature on the delivery of diagnostic news (Frankel, 2001; Heath, 1992; Heritage & Stivers, 1999; Leppänen, 1998; Maynard (1989), Maynard (2003); Peräkylä, 1998; Silverman, 1997; Stivers, 1998), which is consistent with Byrne and Long's (1976) suggestion that such delivery is a distinct and orderly phase of the medical interview, following introductory matters, discovering the reason for the patient's visit, and conducting a history and exam. The diagnostic phase, in turn, is regularly followed by treatment recommendations (Heath, 1992; Stivers, in press) and termination of the visit (West, in press). However, there is very little systematic consideration of whether and how participants, during or after diagnostic presentation, work at interpreting it through what I call meaning-assessment sequences. The sequences can be initiated by either physician or patient, and consist of proposals or formulations of meaning, followed by an aligning or disaligning response. In this paper, one overall argument is that meaning assessments are structured to give auspicious or benign versions of news. However, there can be considerable jockeying between participants as to how benign the news can be taken to be. In addition, whether and in what manner participants in a news delivery interpret the diagnosis has consequences for the doctor–patient, or more generally, clinician–client relationship.

My inquiry into meaning-assessment sequences began with an interactionally problematic episode of cancer diagnosis. One Friday morning, “Clint Jones,” a 37-year-old African-American male, walked into a primary care clinic affiliated with a US medical school. He had complaints about stomach pain, weight loss, and an inability to tolerate solid foods. Dr. “Edward Hoffman,” a white third-year resident in the primary care internal medicine training program, became extremely concerned and referred him to a gastroenterologist, Dr. Smith, for further evaluation later that same day. When Mr. Jones, the patient, was able to see Dr. Smith, Dr. Hoffman accompanied his patient. Dr. Smith performed an endoscopy, putting a scope down into the patient's esophagus, and finding a suspicious-looking mass. A biopsy was performed over the weekend. The growth proved to be malignant, and on the Monday after the Friday procedure and the weekend biopsy, Dr. Hoffman arranged to see Mr. Jones back in the clinic to tell him that the growth they had seen was cancer.

The delivery of this news, including the lead-up to the pronouncement of the cancer diagnosis, has been examined in detail elsewhere (Maynard & Frankel, in press). Of main concern here is the aftermath. When told of the cancer, Mr. Jones says, “What does this mean?” Dr. Hoffman replies that he is “going to need to see a lot of doctors,” and then Mr. Jones asks,”Does it mean I’m gonna die?”, and “How long do I got?” We will later examine the actual talk and conduct of Dr. Hoffman and Mr. Jones, but here it can be noted that Mr. Jones’ rather plaintive queries about what the news means obtain very circumspect or guarded replies answers from the physician, who ends up saying he does not “know” how long the patient has and that “there are a lot of questions,” while Mr. Jones remained agitated, got up from his chair, and appeared as if he were going to leave, although he finally sat down and completed the interview. Presently, I will draw upon an analysis of my entire collection of meaning assessment sequences to show the organization of practices whereby participants in the news delivery event raise and answer questions about meaning. This analysis will allow us to explore the social organization involved in the assembly of diagnostic-related meaning assessment sequences, and then to make sense of how Dr. Hoffman and Mr. Jones deal in the ways that they do with the meaning of the patient's cancer diagnosis in this particular episode.

Section snippets

Data

From a corpus of news delivery events in both ordinary conversations and clinical environments, I collected all in which, as part of the news delivery or its aftermath, the participants explicitly addressed what the news could “mean.” In this paper, I examine instances from clinical rather than ordinary settings, although the latter inform the analysis as well. All clinical data are from the USA. In approximately three-quarters of my clinical cases, participants do not raise the question of

Meaning assessment sequences

Meaning assessment sequences are positioned relative to the delivery of news, and I will examine each of four basic positions, which are exhaustive within my collection of data.1

The organization of meaning assessment in deliveries of diagnostic news

In clinics, meaning assessment sequences regularly involve one party—the physician or other professional—proposing an interpretation of news and the other party—the patient or family member as recipient—aligning or disaligning to the proposal. There are successive positions during a delivery of diagnostic news for meaning assessment to be initiated: (1) A clinician delivers the news and proposes its meaning as a clarifying upshot within an announcing utterance; (2) a clinician delivers the news

Conclusion

When physicians and other clinicians deliver diagnostic news, it may be relevant to interpret the news to recipients. Although conversation analysts and others have examined news deliveries, they have not explored those episodes in which the participants raise and address interpretive issues. In my data, if it is in only a minority of cases where such issues come up, it is nevertheless a substantial minority (approximately 25%). Given the range of clinics in my research, it can be surmised that

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