Is this what I wanted to be when I grew up?

Since Haloscan seems to be down for a while, this is probably a good time for me to talk a bit about my actual research. For whatever reason -- I need a vacation? I'm just too modest? -- I haven't talked about it a lot here, but I study physician-patient relationships and communication. I used to say that I focus on language and culture as factors in the above, but now I've decided that's like saying I focus on building techniques as a factor in construction methods. All doctor-patient communication is cross-cultural and bilingual.

It might be said that communication is the most important clinical skill. Certainly it is the skill that is used the most. A typical physician visit - or medical encounter, as some would have it - is occupied with almost continuous speech, mostly in the form of what we call a conversation -- a back and forth exchange of utterances between two people. This is not very much like the conversations we have with our friends, family members, co-workers, lovers, or anybody else, for that matter. These are highly ritualized, asymmetrical encounters that are powerfully shaped by cultural tradition, the way in which physicians are socialized and trained, our previous socialization and experience of medical encounters, the instrumental goals of the visit, time constraints, legal requirements, inequality in possession of information and social status, and other factors. As complex as they are to describe and understand, they are often as critically important. Their success or failure can mean health or illness, life or death, and even if nothing that dramatic is at stake in a particular instance, they can greatly affect how we feel -- whether we are reassured, anxious or even terrified, satisfied, frustrated, guilty, proud . . .

There is an immense literature on this subject. There are many instrumental purposes for MD/PT communication, obviously -- diagnosis, treatment decision making, emotional support, personal relationship building. The funding I have right now happens to concern the objective of motivating behavioral change, and more specifically achieving better adherence by patients to prescribed medication regimens, but the work I'm doing is much more broadly applicable. Here is a link to a review just this week of how people think about this issue, which includes some concepts similar to ones I am working with.

What I am trying to bring to the party is a new way of characterizing and analyzing conversation based on an idea in sociolinguistics called Speech Act Theory. You'll notice in the BMJ article concepts such as informing, open questioning, directing, etc. These are rudimentary representations of Speech Acts -- specific kinds of social resources that are exchanged in conversation. Representatives (statements of fact about the world), Expressives (assertions about one's inner reality), Questions of various kinds (which place a social obligation on the interlocutor to respond), Directives (intended to influence the interlocutor's behavior, whether in the form of mandates or suggestions), Commissives (promises and official acts affecting one's status), Praise and Insults, Affective exchanges, Social Ritual, Conversation Management, and others. These are properties of speech in all languages, and they are only loosely and inconsistently related to grammar and syntax.

One can define a completed speech act as a unit, called an utterance, classify it as a speech act, and then classify it according to topic -- what is being discussed. In this way, we develop a rich and revealing quantitative description of an interaction. We are developing computer software to facilitate the coding process.

Where this all leads, I hope, is to a convincing way of consistently characterizing and understanding interaction processes, and the amount and quality of information and other social resources that passes between physicians and patients. We can relate this to outcomes -- such as better medication adherence, patient satisfaction, informed decision making, etc. -- and to inputs such as physician training and other interventions.

It probably sounds rather arcane and boring. One of the great difficulties in social science is in linking levels of analysis. Critical discussion of systems such as the medical institution and public health infrastructure, policy analysis -- these macrosociological fields are usually more exciting than the minutiae of individual encounters. But they are connected. Medicine is hierarchical, unequal, embedded in the our unequal society and shaped, in the U.S., by our powerfully individualistic cultural norms. All of this manifests in the particular.

Anyhow, it's dirty work, but somebody has to do it.