2 Generic features of a clinical consultation
Drawing on an extensive database of clinical exchanges, the conversation analyst Paul ten Have (1989, quoted in Harvey and Koteyko, 2013, p. 10) carried out research into the generic ‘moves’ (or stages) in a typical healthcare consultation. He identified the following six generic moves occurring in the majority of in person consultations:
- a.opening
- b.complaint
- c.examination or test
- d.diagnosis
- e.treatment or advice
- f.closing.
In the next activity, you’re asked to apply these moves to the earlier consultation dialogue.
Activity 4 Typical stages of a clinical consultation
Look again at the clinical exchange discussed in Activity 3 (and reproduced below). Using the highlighting tool, try to map ten Have’s stages, or as many as you can identify, onto the exchange. Make a note of any decisions that you find difficult.
Use the different colours as follows:
- a.opening = yellow
- b.complaint = green
- c.examination or test = dark green
- d.diagnosis = purple
- e.treatment or advice = blue
- f.closing = red
Discussion
Although this is a relatively short exchange, it does clearly demonstrate all six stages. However, given that this is a repeat visit and the treatment is ongoing, the diagnosis stage does not follow immediately after the examination but appears to follow as an afterthought to the proposed adjustment to the treatment. You may have also hesitated whether to treat ‘How are you?’ as part of the opening, but came down in favour of treating it as the start of the complaint, partly because the opening might have been extended further and ‘How are you?’ seemed to mark a turning point, and partly because the patient’s response is clearly the second part of a question-and-answer exchange.
These kinds of ‘moves’ or stages in a consultation, or other variants of them, are now regularly taught to medical students. However, what may be emerging from all that we have seen so far is that each of these moves may have very different linguistic realisations (meaning that different language is used to convey each move) and therefore a very different interpersonal effect. So a good doctor needs to be able to deploy a range of grammatical choices to elicit useful information from the patient, whilst continuing to maintain a relationship of trust. Similarly, as patients we have some control over how we choose to position ourselves through our grammatical choices (e.g. how much information versus how much hedging; how much assertion versus how much deference).
Frameworks for the analysis of any human process vary and ten Have’s was written from the perspective of conversation analysis, a tradition of language study that focuses less on language per se than on the acts people carry out by speaking to one another, and typically pays more attention to phenomena such as conversational turn-taking, intonation and body language than to grammar. Other frameworks, such as the Calgary-Cambridge Guide (2015) might refer to the stages in the interaction slightly differently, focus on different linguistic features, or pay more attention to the audiences and purposes