Cognitive overload and communication in two healthcare settings*

AARON V. CICOUREL

Abstract
The confluence of organizational social interaction
and cognitive information processing constraints create noisy conditions in institutionalized settings.
Attentional and memory limitations always influence
the ability of participants to comprehend each others
communication. Two organizational settings (a medical specialty clinic and periodontal office) will be
used to explore a few features of healthcare delivery
that are often ignored in studies of such systems.
Scheduling appointments, for example, creates stress
for both patients and healthcare personnel but is often
an unexamined aspect of healthcare delivery that has
become both challenging and often irritating for all
concerned. For example, when patients call, someone
at a general scheduling center or the particular clinic
or office of an individual physician or dentist or a
group practice will answer the call with a menu of
options, or the caller may be asked to leave message.
When a patient leaves a clinic or surgery office after
a visit, they may be allowed to make a new appointment. The term cognitive overload is a ubiquitous
element of all healthcare systems and refers to organizationally induced and constrained limited capacity
processing inherent in the way improvised discourse
practices, and annotative devices or artifacts (such as
written notes or some related strategy) become an
integral part of everyday healthcare delivery.
Keywords: cognitive overload; expository/narrative
texts; discretionary power; interruptions; scheduling
appointments; local artifacts.

1.

Introduction

This article will focus on a few cognitive and communicative aspects of a mundane but persistent type
of organizational problem solving: the way medical
and dental appointments reflect the limitations and
necessary interdependence of cognition and cultural
practices in healthcare delivery. For example:
a. The use of expository (more formal speech or)
texts, and narrative texts (or more spontaneous and
casual speech, gestures, and prosody).

b. The different types of texts activate different memory systems (explicit or conscious and implicit or
subconscious memory) necessary for speech production and comprehension.
c. Dentists exert considerable discretionary power
over the way appointments are scheduled.
I use the term cognition to refer to individual and
distributed cognitive mechanisms inherent in collaborative activities involving perception, attention,
memory, and reasoning whose origins are inherently
cultural (Tomasello and Call 1997; Tomasello 1999).
The term discourse will refer to locally instantiated
and managed speech acts and events that are always
influenced and constrained by the collaborative use of
socially distributed knowledge (Schutz 1964), and
cognition (Hutchins 1991, 1995), that emerge in
socially organized physical and cultural settings,
appearances, and artifacts in the joint pursuit of a
practical task. A more abstract notion of cognition at
the level of a community (or organizational activities)
may or may not include face-to-face social interaction, but is always part of a larger informational system that evolved from and remains inherently
contingent on an oral culture (Roberts 1964).
Social representations are accessible to the observer
only if he or she shares elements of them with subjects and, therefore, can identify the tacitly perceived
relevance of organizational elements such as the
expertise and experience associated with a problem
solving task. Ethnographic research presumes that
observation, subsequent semistructured interviews,
and, occasionally, participation enables the research
analyst to identify relevant organizational elements
associated with a problem solving task.
A de facto routinization of tasks by employees in
the workplace is a common practice and is (often tacitly) motivated by a desire to reduce or control the
impact of a multitask environment on stress or what
here is being called cognitive overload. One source
of cognitive overload in healthcare delivery is the
mismatch between experience, expertise, temperament, the details of a task at hand, and the demands
of supervisory personnel. This article will focus on
the way organizational discourse materials and local
artifacts, constrained by cognitive mechanisms, help
to shape the creation and use of individual mental and
collective representations. Such representations are
commonplace within work settings as participants go
Communication & Medicine xx(xx) (2004), pp. xxxxxx

Walter de Gruyter

2 Aaron V. Cicourel

about clarifying and explaining practical solutions to

problem solving tasks as they work.
In the pages that follow, therefore, I pursue a seldom examined aspect of healthcare delivery: the role
of nonmedical personnel in providing the necessary
activities needed to sustain professional services
(Cicourel 2002). These activities include providing
the patient with information about medical or dental
conditions that are essential for particular medical or
dental procedures to be carried out subsequently by
healthcare professionals.
2.

Aspects of local bureaucratic lifeworlds

The research analysts observation of subjects in the

workplace identifies settings which suggest minimal
and multiple demands on a persons focus of attention
as they pursue tasks and experience interruptions. The
goal is to identify classes of activities and techniques
or mechanisms employed by healthcare personnel to
cope with and minimize disruptions and errors while
sustaining control over the task environment. For
example:
1. Interruptions in healthcare settings are ubiquitous
and even experienced personnel on occasion can
only partially recover their immediate prior activity and must reconstruct the progress made in the
task before the interruption. A similar interruption
for a novice may make it difficult to know what
to do next. For example, the worker may need to
engage in constructive planning after the interruption because he or she did not realize that the task
or subtask was virtually complete. Assessments
are socially represented by informal (often tacit)
indirect and direct remarks and official written
evaluations.
2. When one person works alone on a task (or two
persons work primarily in parallel but interact
occasionally), they can experience difficulty when
interrupted unless they extend their memories by
using markers or annotations created as the task
evolves. I will focus on the local conditions that
existed in the workplace at the time of the
interruption(s).
Perceived routine problems and interruptions can
affect personnel differentially because of different
capabilities and temperament despite being engaged
in similar or related tasks. The latter issues can be
inferred by examining discourse fragments, but such
analysis often requires direct observation of work
sites while eliciting information about interaction,
artifacts, and interpersonal and status relationships.
The focus on language use poses additional semantic problems because vocabulary and verbal expressions used by personnel unavoidably truncate and
compress what we think we are seeing and hearing

when the research analyst seeks to reproduce individual and collective representations.
In order to pinpoint variations and commonalities
within and across natural settings, our research design
called for systematic observations on different days
and times, including recordings of actual work activities, and focused, open-ended elicitation of information from subjects while they worked (cf. Altmann
1974 for details on how biologists engaged in nonhuman behavioral ecological research systematically
sample individuals, groups, settings, and activities).
Interviews with personnel while they were working
elicited information about their actions and the
actions of others that had just occurred or that had
been previously observed. We used the practical environments to help us pinpoint the conditions under
which, say, work personnel cope with multiple
demands, and the extent to which recovery devices
become evident after an interruption. The theoretical
and methodological challenges involve identifying
patterns that emerge under different local and nonevident organizational constraints.
The daily exchanges by the coordinator with others
inside and outside of the clinic can be viewed as fairly
mundane activities but they all have a family resemblance and can be observed in virtually all healthcare
settings in the U.S.A. On many occasions, we would
try to clarify the coordinators activities by sitting
across from the coordinator and ask questions as she
carried out her work. The semistructured interviews
presented below probed her daily work routine in
order to obtain details about scheduling appointments
for different procedures.
Finally, the research analyst must obtain permission
to pursue the study, engage in systematic observations
and recordings of workplace activities. Such permission means satisfying higher and lower level personnel and the normal suspicions about outsiders who
wish to invade the privacy of a work setting and existing organizational alliances and conflict.
3.

Expository and narrative texts

Literature on the analysis of discourse has identified

differences between what have been called expository
and narrative texts as a means of signaling different
communicative ends. The idea of a narrative text is
a meta-level term or an observers shorthand for the
production of a family of terms often associated with
particular settings. Narrative discourse is viewed as
more personal and spontaneous and can include various kinds of socially meaningful information to participants of discourse. For example, facial
expressions, prosody, gestures, body movements, and
above all, the use of pragmatic verbal markers like
oh, so, well, but, and, or, because, then
yaknow, I mean, and now (Schiffrin 1993).
Meetings in bureaucratically organized healthcare

Cognitive overload and communication 3

contexts often include formal, expository speech acts

(e.g., the use of polite forms of speech and gestures
despite possible islands of casual speech acts
embedded) in technical and/or formal speech events.
Narrative and expository texts are often interwoven
and such interlacing is a function of local work conditions, the relations (e.g., work or social networks)
that develop between different personnel, and the way
formal status and role expectations and constraints are
perceived and acted upon. For example, nurse-physician exchanges can include both kinds of texts, and
within the narrative genre, depending on the length of
their association and interpersonal relations, the discourse can vary, contingent on the local social ecology and the presence of other personnel.
Local work conditions and the strong and weak
social networks (Granovetter 1973) that guide the use
of expository and narrative texts activate two forms
of long-term memory organization (explicit or declarative and implicit or nondeclarative memory) that
address memory for facts and memory for skills
(Squire and Kandel 1999: 1517). Memory systems
are the life-blood of all social interaction and discourse in the workplace. Research analysts and those
they study are dependent on different memory
resources for attributing semantic and pragmatic interpretations to their observations or informational
resources. Although implicit or nondeclarative memory stems from experience, according to Squire and
Kandel (1999: 15), it is expressed as a change in
behavior, not as a recollection and is unconscious.
Squire and Kandel also note that there can be aspects
of recollective achievement in nondeclarative learning
such as a motor skill about which something can be
remembered, even though we will perform it without
consciously thinking about how to carry it out.
In the medical workplace, healthcare and administrative personnel rely on different memory systems to
construct expository and narrative texts as they interact with others or a computer or dictation machine.
For example, while taking a medical history, the physician and patient rely on their explicit and implicit
memory to link an opening line like What brings you
to the clinic this morning? to a response like My
hands are stiff when I wake up each morning. Performing an endoscopy requires the physician to make
extensive use of implicit, unconscious memory while
using motor skills and interpreting a display of the
patients duodenum and stomach on a TV monitor.
Different kinds of memory, therefore, are activated to
pose questions, comprehend patient responses, and
explain to a patient what will be happening during a
procedure.
In sections 4 and 5, we will see how the scheduling
coordinator must also employ similar memory and
communicative skills when informing patients about
preprocedural activities they must follow prior to their
arrival at the clinic or hospital. Continuous small
talk during the scheduling coordinators instructions

(and during a routine physical examination) is useful

to sustain a social relationship with the patient and
provide reassuring information about what will occur.
Locally organized task environments require personnel (such as those in the medical and dental clinics
described in sections 4 and 5) to be adept at creating
convincing verbal and nonverbal accounts to colleagues and patients with whom they interact. Stated
another way, this means anchoring the present situation in meaningful speech acts, gestures, and other
actions. Identifying such practices is necessary to create an appropriate context for observing cooperation
and conflict because relevant behavior will emerge
and evolve more readily when the other person is able
to refer to or assume a similar framework for the joint
activity at hand. For example, acquiring the knowledge and competence to comprehend and produce
narrative and expository text-like entries on the computer or on bureaucratic forms, and dictated or written
summary remarks that are sent to other bureaucratic
settings such as another clinic or to an insurance company and/or placed in a patients chart. Assessing and
describing the content and implementation of such
bureaucratic skills and interpersonal relations will be
partially addressed below.
4.

A medical specialty clinic

The present work is part of a larger study of three

healthcare settings. A recent publication (Cicourel
2002) presents initial data on scheduling appointments in a medical specialty clinic (e.g., gastroenterology, pulmonary, radiology, cardiology). The clinic
is located in a fairly new, modern university hospital.
In the specialty clinic, there are many preprocedural
details that must be attended to: assigning patients to
particular appointment times and instructing patients
about special procedures (e.g., a liquid food diet the
day before, no medications with aspirin, and the like).
The coordinator must enter and extract information
from the computer, make telephone calls to insure that
a particular specialty clinic or radiology section can
accommodate the patient while also answering
returned calls from Central Scheduling and patients
seeking a new appointment or changing an old one.
The online overload that often occurs is mitigated
in part by asking a patient or hospital personnel in
another service to wait and not to hang up the telephone. But the coordinator would immediately take a
call from Central Scheduling if she had left a previous
message for them to call her. As she spoke, the coordinator wrote brief notes on small sheets of paper, and
would acknowledge a physician, nurse or patient
standing next to her by making eye contact with them,
uttering a brief comment, and perhaps making a brief
smile as she continued with the task at hand (continuing an entry on the computer or answering the
telephone).

4 Aaron V. Cicourel

The moment to moment renewal of local organizational activities followed bureaucratic and interactional constraints noted earlier, but was also
contingent on the coordinators sense (often observable by paralinguistic and nonverbal actions) of what
she perceived as necessary for satisfying the goals and
sanctions of the local and larger organizational setting. For example, repairing misunderstandings, or
catching up with a backlog of patient appointments,
and reminding patients about pending appointments.
When speaking with Central Scheduling about an
appointment, the coordinator might simultaneously
take one or more sheets of paper from a physicians
hands as he approached, enter written information,
and give them back without saying anything. The
annotations made during telephone calls or entries
into the computer or on a hospital or clinic document
reflected aspects of the coordinators tacit interpretation of what was observed or said.
The coordinators activities required a delicate balance of adapting her relatively low organizational
status vis-a`-vis the professionals with whom she communicated while being sensitive to patients demands
for medical information she was not trained to give.
The coordinator also had to be attentive to physicians
and hospital administration concerns when she gave
patients instructions about procedures (fasting, diet,
use of an enema). The coordinators routine activities
must create bureaucratic, medical narrative and
expository texts that other bureaucratic and professional actors can understand. For example, transforming an incoming call into a computer entry and
making it part of a patients medical record or an
appointment.
The coordinator is able to make such transformations by employing appropriate expository and narrative texts that carry general and specific kinds of
communicative and descriptive semantic information
to insure she and others can access particular semantic
content. The coordinators use of paper reminders and
post-its that can be attached to smooth surfaces (as
noted below) becomes a way of enhancing her memory and own internal problem solving agenda while
simultaneously synchronizing such annotations with
other online activities. The following descriptive
remarks illustrate the claims of this paragraph.
1. The coordinator took notes when listening to the
answering machine after arriving in the morning
and after her lunch break. She placed her handwritten notes on the counter to the left of her
computer.
2. The specialty clinic tasks required mapping a telephone call or a physician or patients verbal
remarks onto a spatial domain involving handwritten or electronically written information that
subsequently enabled her to glance more easily at,
say, a slip of paper, rather than having to remember
a voice message.

3. The transfer from one medium (voice) to another

(hand or electronic print) and vice versa, therefore,
created annotations and simultaneously allowed
the coordinator inadvertently to rehearse processing aspects of her problem solving space.
4. Post-its were placed around the computer monitor
or on the bookshelves above the coordinators head
and they did not appear to have been prioritized;
for example, ordering them from left (most urgent)
to right (least urgent).
5. The coordinators annotations, however, enabled
her to represent the state of the system from when
she last knew it. These reminders enabled her to
resume her questioning of a patient or physician
or Central Scheduling where she left off rather
than going through an elaborate search on each
occasion.
6. The coordinator had to acquire and negotiate
aspects of a linguistic register or vernacular such
as diagnostic shorthand terms like endoscopy
scope, raspy throat, gag reflex, or such phrases as: OK, so then youll do or OK, so you
see the problem now, right? Elements of the register had to be shared so that participants in the
system could refer back to them later and thus both
save time and achieve some level of communicative accuracy.
Central Scheduling does not know which patients
are communicating directly with the coordinator. A
physician may only communicate with the coordinator about such matters. The coordinator can call to
make appointments for patients but then must verify
if the patients can satisfy the times scheduled. The
coordinator, other clinics, and Central Scheduling can
suggest, say, a particular day or two for a given week
and one or more time slots for those days. The patient
must think of when they can arrange or rearrange their
own schedule accordingly. Some physicians do not
allow Central Scheduling to book appointments for
them. The coordinator, therefore, is given authority to
make appointments directly.
The exchange in lines 13 in (1) is an example of
narrative discourse in the clinic studied between the
coordinator (S) and the observer (C). C asked what
happens when a patient cannot satisfy a particular
appointment. C seems to anticipate the answer by
assuming that Ss response in lines 23 implies that
S would hope the patient can make the appropriate
adjustment in their schedule.
(1) Example 1
1
C But now how do you know when the
patient can do that time?
2
S Well, most cases, uh
3
C You take a chance
Lines 13 make sense because we have previously described aspects of the healthcare systems

Cognitive overload and communication 5

activities such that the elliptical remarks shown above

can be interpreted as indirectly pertaining to a discussion about making appointments before asking the
patient if they can comply. Normally, the patient has
direct access to someone who can make a primary
care (nonspecialty) appointment. Specialties like ophthalmology and dermatology, for example, have their
own appointment procedures.
In lines 49 in example (2), S seems to be saying
that one goal of the specialty clinic personnel is to
have the patients recognize how difficult it is for the
clinic to schedule an appointment for, say, an endoscopy or colonoscopy. The clinic wants to appear burdened by too many requests for appointments rather
than saying they do not have enough professionals to
fulfill the needs of the patients within days or two or
three weeks. Patients have virtually no voice in such
matters and it is the nonmedical coordinators who
must patiently and cautiously address patient irritation. It is not uncommon for clinics to have gastroenterologists review requests for endoscopies and
colonoscopies to determine if they should be delayed
or, more likely, rejected. Patients, of course, are not
told (lines 79) directly that if we can get them in
sooner than three or four months, theyre lucky. In
more general terms, the brief fragments of data (lines
19) suggest how bureaucratic constraints affect
patients ability to access medical procedures.
(2) Example 2
4
S Yah. For endoscopies, we try to get an
idea, if, eh patients are usually
5
very aware that its hard to get an (C: I
see) appointment for a
6
colonoscopy (C: I see) or an upper
endoscopy, they know that, you
7
know, there is a long wait. In most
cases they, they know that if we
8
can get them in sooner than three or
four months, theyre lucky.
9
(laughs)
Lines 49 suggest that the clinic hoped the patient
felt lucky when they were able to obtain an appointment sooner than three or four months, but the
patients were not told why the service was so difficult
to obtain. The patients treatment is linked to an
implied larger system of activity, namely, the unstated
costs and bureaucratic constraints in achieving specialty procedure appointments. The performative
aspects of the notion of an appointment involve a set
of obligations and instructions to various parties:
patient, physician, administrative staff and others who
must become aware that particular types of collaborative behavior are expected. Negotiation is required
to create effective appointments.
In lines 1019 in (3), S again displays some of the
technical terms used (endoscopy, colonoscopy),

but the language she used retained an informal, and

sometimes an incoherent narrative style as she
explained to C that patients do not understand the
limitations of the scheduling system.
(3) Example 3
10
S Okay, so they mhm, but, however,
there are a few that
11
arent, that uh dont realize and if its
not sufficient to their needs
12
and they will cause, you know, a little
bit of complaining and wyou?x
13
know, an, an beg for something
sooner, and, you know, we try to
14
accommodate them the best we can
(C: mmh, mmh), uhm, or if it
15
doesnt fit into their schedule, we like
to, we like to originally get it
16
on the books (C: Right). We like to
get it into the computer
17
(C: uh huh). And in some cases, if it
doesnt work out from the
18
patients view, they can call Central
Scheduling and schedule
19
themselves.
The patients may be unsatisfied with an appointment schedule. The existence of an appointment the
patient cannot meet would remain in the computer
until another appointment was made because it would
indicate that an attempt was made by health system
personnel to create an appointment, and also confirm
that the patient had made a previous good faith effort
to obtain an appointment.
S notes (lines 1924, not shown) that some of
the doctors wC: OKx. For some doctors uhm such wasx
C, (slight stuttering) C, M, uhm, and B, Dr. K,
they dont have an open scheduling, Central Scheduling, so nobody will be able to call and reschedule.
These latter two physicians, therefore do not allow
Central Scheduling to make appointments for them
directly. Hence the coordinator must mediate the
appointments because he or she has been delegated
the responsibility. This means patients cannot obtain
appointments from Central Scheduling for these physicians unless Central Scheduling communicated with
the coordinator or the patient knew about the physicians particular policy for accepting patients. S stated
that this is a difficult problem for the clinic and scheduling personnel by noting (lines 2224, not shown)
that when a patient called and canceled an appointment with Central Scheduling, Central Scheduling
had to call the coordinator because it is only the coordinator who has access to the physicians open time.
When one of these physicians goes out of the city for
a few days or longer, it is the coordinator who must
call and reschedule existing appointments.

6 Aaron V. Cicourel

Within the healthcare system, special organizational conditions existed that gave the physician (and
often the coordinator) considerable discretion vis-a`vis the obligation to see patients. The physicians
ability to control which patients would be accepted
remained a significant source of power for these
healthcare professionals.
During peak periods of work, the coordinator experienced multiple demands on her time, demands that
were frustrating in the sense that she could completely
fill in a physicians appointment schedule over a period of several days, but then be notified by this physician that he or she would be out of the city on those
occasions. Additional demands occurred when physicians come to her desk with a patient asking for her
assistance. For example, scheduling or giving the
patient the appropriate forms for a radiological examination, other laboratory tests, and instructions on
what was expected from them prior to undergoing a
procedure, and what would take place during a procedure (cf. Cicourel 2002 for details).
As noted above, the coordinator in a specialty clinic
enjoyed a limited but explicit amount of discretion
(administrative power) as she made local decisions
within the task environment. When S spoke with other specialty clinic coordinators in the same or the other university hospital, the speech acts consisted of
narrative discourse and such exchanges reflected their
similar status and frustrations when dealing with higher status healthcare professionals.
5.

A periodontal clinic

The periodontal clinics lifeworld consisted of two

receptionists, an office manager, two periodontal specialists, two dental assistants, two dental hygienists,
and a postoperative dental assistant. One receptionist
explained the costs of a procedure and payment plans
to the patient and this could vary according to any
insurance the patient carried. The amount of dental
activity varied with whether one or two dentists were
present in the clinic. Dental hygienists performed
their tasks independently of the dental surgery. The
latter activity could mean operations whose duration
could be as long as three hours. The two receptionists
were observed, interviewed as they worked, and
recorded on different occasions by sampling different
days of the week and different times during a given
day. Each receptionist had their own duties, but each
had to know and at times perform some of the others
tasks.
5.1. Routine interruptions and overload at the
periodontal clinic
The periodontal clinic is private and the two dentists
exercise considerable discretion in they way they allocate their time to patients. Emergencies were dealt

with on a case by case basis and everyone was prepared to extend their hours if necessary. In the following pages, I summarize elements of two unpublished
segments of transcription based on my initial visit,
and one of my subsequent visits to the dental clinic.
The fragments of narrative text from the first day of
observation at the periodontal office illustrate the
kinds of mundane demands that impinge on the two
receptionists (D and L). I focused on clinic activities
that directly confronted the receptionists (patients
arriving for surgical procedures or dental hygiene
appointments), and artifacts that serve as reminders of
things to be accomplished such as confirming the next
days schedule of patients by calling to reconfirm the
time of their appointment and notifying them of any
presurgical medication requirements. As the telephone
calls were being made, however, an outside call could
come into a free line and one of the receptionists had
to respond and ask whomever she was talking with
to hold the line while she answered the other caller.
The new caller, in turn, could be asked to hold the
line while the receptionist completed a reminder to a
patient coming the next day.
The receptionists continually shifted their focus of
attention from routine tasks such as informing patients
about payment plans, speaking with new arrivals to
the clinic, and creating annotative reminders by writing brief notes to themselves, or asking the other
receptionist for help. They also had to attend to a
dentist or hygienist who appeared at the counter in
front of them to ask for a new appointment for a
patient who was at their side. Either receptionist,
meanwhile, could receive a phone call and could also
be glancing at her computer monitor in order to see
what days and times were available for a future
appointment while negotiating with the patient about
a time that was mutually compatible.
The periodontal clinic task environment appeared
to create multiple explicit memory demands (cognitive overload) that were both disruptive and not conducive to sustaining control over the local ecology.
There were several kinds of activity taking place:
the phone would ring and either D or L would answer
it; patients would arrive, sign in the time of arrival
on a pad of paper and take a seat. Periodically, either
a dental assistant or hygienist would come out to ask
for a patient or bring a patient to the front desk after
cleaning their teeth and leave them with D or L for
another appointment or to discuss financial arrangements. A dental assistant might come out to call for
a patient who needed or had completed a surgical procedure. The assistant might also bring a patient out
after a preliminary periodontal examination and ask
D (usually) or L for an appointment to discuss the
cost of the anticipated treatment.
Early on, during the initial visit to the clinic, D was
telling C (the observer) about the office routine. She
described (transcript not shown) different personnel
and their duties (J, who does postoperative surgical

Cognitive overload and communication 7

follow-ups, sees patients one or two weeks after their

surgery, X, a dental assistant during surgery, and two
dental hygienists). D stated the surgery could take
from one to three hours, depending what needed to
be done and on the periodontists time constraints.
She indicated other activities that could occur after
surgery.
(4) Example
clinic
1.
D
2.
3.
4.
5.
6.
7.
8.

4: Initial observation at a periodontal

Good Morning, (Barely audible)
Dr. Xs office, D speaking.
OK B, I have something available
on Thursday the ninth, at 2:30, will
that work?
(..) OK, great. Youre set. Thank you,
goodbye.
(Speaking to L) And you cant find it?
wAn unclear exchange between D and
L about the patients chart and
x-rays.x

In example (4), (lines 12) the phone rang and D

answered. Lines 15 briefly illustrate a typical call
from a patient. The receptionist identified the dental
office and herself and received a request from the
patient for an appointment. The callers request was
compatible with the existing list of open appointment
dates in the office computer. The exchange indicates
the availability of an appointment time, including the
day, date, and time of day. Notice the informal, metaphorical way D terminates the exchange: OK, great.
Youre set. The informality of the speech acts suggests that a native speaker had called. In line 6, there
was a response to a previous remark by L about the
missing chart and Ds response And you cant find
it? The phone call from a patient asking for an
appointment did not erase the problem from Ds
working memory about the missing chart despite the
interruption. Perhaps the fact that L was standing
across from D helped to remind D of the question that
had been posed about the missing chart.
In lines 916 (not shown), D then turned to C and
indicated what she and L should be doing that morning; thinking about the dental hygienists scheduling
because it takes most of the working day due to frequent interruptions. The subsequent upshot of the discussion (not shown) was that the patients chart was
misplaced and D must find it. D then wrote out
CHART on a sheet of paper and placed it behind the
keyboard of her computer monitor. Ds creation of an
annotative reminder to find the chart despite frequent
interruptions (answering the telephone, attending to a
dental hygienist who brought a patient in need of
another appointment, and the like) illustrates an
empirically relevant way to address a central concern
of a theory that seeks to integrate cognitive mechanisms and cultural practices: the interaction between

attention, overlapping memory and knowledge, and

the creation and use of artifacts.
A serious type of interruption (based on interview
material while D was working but not shown here)
stems from computer down time. The computer system used was rather old and the source of continual
problems because if the computer was down, incoming calls requesting new or the changing of existing
appointments could not be entered and hence both
receptionists and the office manager were forced to
change their mode of work. Computer down time
meant writing out many notes about which patients
needed appointments or changes in their scheduling.
A key task (lines1727, not shown) began as soon
as the receptionists arrived at work and entailed calling each patient to confirm the next days schedule,
insuring patients were aware of the appointment and,
in the case of surgery, reviewing (for the second time)
the instructions the patient was expected to follow.
Although the importance of these tasks was underscored in lines 2527 (not shown), the first order of
business was to create an artifact that motivated a
task; ... the first thing we do, like when she opens
wthe officex, or whoever opens, is print out the schedule for the next day, print out the schedule so that
the professional and technical personnel are fully
aware of what is expected of them that day.
The material in example (4) illustrates ways in
which the periodontal office personnel sought to promote group cooperation and sustain their communication about social objects during the pursuit of
different tasks. The material also illustrates some of
the distributive demands made on the receptionists
language use, reasoning, and motor activities that are
relentless each day. The demands could seldom be
routinized entirely because of the various contingencies that always emerged (the volume of patients who
called to cancel an appointment, patients who failed
to appear for their appointments and were called,
emergency procedures requested by one of their
patients, or a referral from regular dentists who send
patients with periodontal problems). The general point
is that D provided C with a verbal approximation of
what we are calling cognitive overload in a distributive cognitive system in which organizational constraints, expectations, and surprises are unavoidable
consequences of the duties associated with the
position.
The activities required of D and L depended on
each others particular and overlapping experience for
resolving specific problems and for insuring that their
daily practices also met the approval of R, the office
manager. Their positions require creating and organizing artifacts that would remind them of particular
tasks while engaging in polite interpersonal skills in
their interaction with patients about scheduling and
financial matters, as well as in their necessary
exchanges with the professional and technical personnel. According to R, the office manager, D was espe-

8 Aaron V. Cicourel

cially skilled at both organizing her work space and

tasks efficiently and also skilled in her interpersonal
relations with others. L, in contrast, appeared to this
observer to be unable to manage the cognitive overload she appeared to experience. The office manager
considered her incapable of sustaining the necessary
skills needed to insure that the office work flowed
smoothly. L was discharged from her position a few
months later.
D and L shared files and hence could access the
same computer (screen) information. But only one
person could enter information on the computer at one
time and the other had to create annotations until the
first person stopped their activity. The two keyboards
would feed into the same server, but only one keyboard could be used on a particular occasion.
6.

Discussion

Ss activities required the internalization and externalization of perceived states of affairs; storing information in working memory while trying to extend her
attentional and reasoning resources in order to access
explicit and implicit memory when entering data in
the computer. She used information already stored in
the computer to remind her about particular patients
clinical circumstances, and relied on intuitive and
explicit experiences when scheduling patients. She
simultaneously had to keep the physicians and hospital administration satisfied and give patients instructions about procedures (fasting, diet, use of an
enema). In more general terms:
1. S, D and L (and others in comparable healthcare
task environments) created and negotiated aspects
of linguistic registers or vernaculars (for example,
narrative and expository texts) in order to create a
reasonably accurate yet functional system of communication that both professionals and patients
could comprehend.
2. S, D, and L often initiated calling within each system, and interacted with only a part of the system
at any given time. They exercised discretion continuously while pursuing organizational goals
demanded by the task environments. Coordination
was time-consuming; they had to remember where
things were, cope with interruptions at the work
site, remember prior conditions after taking a rest
break or going to lunch or returning to work the
next day. Each of them had to check on a given
state of affairs to see if the coordination had
occurred (e.g., phone messages to patients, entering appointments in the computer. Informational
artifacts (Norman 1987), therefore, can display the
present state of affairs in an annotative manner.
3. S, D, and L took notes while listening to the
answering machine after they arrived in the morning and after their lunch break. As noted earlier,

the notes involve a temporal transformation or

mapping of a telephone or physician or patients
voice onto a spatial domain. For example, the use
of post-its placed around the computer monitor or
on the counter and shelves nearby created annotations that could alleviate aspects of cognitive
overload while facilitating the recreation of the
events they are presumed to represent.
A final point. Throughout the paper, have underscored the fact that the study of healthcare settings
cannot ignore the inherentinformational nature of
organizations (Roberts 1964); the individual and distributed processing constraints that inherently impinge
on the production and comprehension of speech
events. The analysis of discourse materials presupposes but cannot always address the way perception
of the local setting and its artifacts activates working,
implicit and explicit memory. Attention activates participants memories and reasoning abilities, and inevitably guides speech exchanges, thus facilitating, in
an essential way, the contingent nature of what subsequently could be described as the local context.
In the medical specialty clinic and periodontal
office, the demands on S, D and Ls attentional
resources and their interpersonal skills in managing
such demands required that the research analyst
engage in sampling observations so that he or she
could identify organizational constraints, observe
actual task performance and perceive the demands
attributed to participants. We may not always have
adequate data nor the time to engage in ethnographic
observation and recordings using different temporal
samples of individuals, groups, and a given setting,
but we cannot avoid conceptualizing such concerns
even when our data sources do not lend themselves
to addressing such issues. Avoiding such conceptual
and empirical issues would undermine our understanding of how medical healthcare (and similar) systems change and sustain themselves.
7.

Concluding remarks

In the two clinical settings described in sections 4 and

5, S, D, and L tried to create a collaborative environment using verbal and written annotative devices
while negotiating a constantly changing set of emergent conditions that were buffeted by frequent interruptions. They also sought to minimize the continual
danger of cognitive overload.
The complexity of S and Ds workstations were not
unique; they reflect the way the human mind/brain
interacts with others in local and larger organizational
settings. Interactional settings and functional task
solutions, however, cannot come into existence nor
reproduce themselves and change unless we possess
essential cultural practices, communicational and
information processing skills (e.g., memory, emotions,
attentional and reasoning processes).

Cognitive overload and communication 9

The fragments of discourse presented above reveal

aspects of how computer entries, the use of bureaucratic forms, handwritten annotations, and verbal
questions and reminders became structural extensions
of S, D, and Ls declarative or explicit memory. These
latter conditions depend on taken for granted (unconscious), nondeclarative or implicit memory activated
and needed to manipulate social objects.
Consider Ss daily world. It revolved around the
manipulation of social objects or entities we call physicians, patients, scheduling centers (Central Scheduling, Specialty Scheduling, Access Scheduling for
some pulmonary procedures, radiology scheduling for
some special tests). There were other hospital personnel with whom she communicated when seeking regular appointments and activating locations for
specialty procedures such as endoscopies or
colonoscopies.
The elicitation of information by C from S, D and
L while C observed their activities underscores the
necessity of the research analyst being able to observe
the organizational setting in order to infer how the
task environment functions on a moment to moment
basis and how it sustains its daily viability. The elicitations obtained enabled C, therefore, to ask about
the relevance of specific aspects of the workplace as
he observed the personnel carry out their respective
duties. The cognitive and cultural models accessible
to the observer, therefore, are only relevant if he or
she clarifies them for the reader and identifies the
social constructions that emerge over the course of
the research. When available, therefore, direct observation and recordings of the organizational setting can
provide subtle or unstated and explicit institutional or
organizational information that are taken for granted
by work personnel but that are not self-evident from
discourse alone.

Notes
*

The research reported in this paper was facilitated by help

from a National Science Foundation grant (IIS-9873156)
awarded to Jim Hollan, Ed Hutchins and David Kirsh. I

want to thank Robert Barrett and Angus Clarke for their

helpful remarks. The articles revision followed their useful
suggestions.

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Aaron V. Cicourel has been visiting professor or lecturer at
thirteen foreign universities, at the University of California,
Berkeley and Columbia University in New York. Fellowships:
Russell Sage Foundation, National Science Foundation, Guggenheim Foundation, and two Fulbright lectureships. He is a
fellow of the American Academy of Arts and Sciences and the
American Association for the Advancement of Science. His
books and a number of his articles have been translated into
eight languages. Recent research interests: implicit folk knowledge and judgments during medical diagnostic reasoning and
medical communication. Address for correspondence: Department of Cognitive Science, Distributed Cognition/Human
Computer Interaction Laboratory, 9500 Gilman Drive Dept.
0515, University of California, San Diego La Jolla, CA 920930515, USA.