Peter K.

Manning
Review Essay
The Trouhie with Talk

C. West, Routine Complications: Troubles with Talk Between

Doctors and Patients, Bloomington, Indiana: University of Indiana
Press 1984, $27.50, xiv H- 199 pp.

Mcxiem linguistics was revolutionised by Chomsky and modem

sociolinguistics by pragmatics, the most refined example of which is
conversation analysis (CA). Conversation analysis is the study of
the social organisation of naturally ocxurdng talk. Its philosophic
background is Germanic (Husserl and Heidegger) and phenomeno-
logic, whilst its also refiects bdlliant efforts of^iarold Garfinkel and
Erving Goffinan to free sodologic:al analysis from easy empiddsm.
Formulated in lectures by Harvey Sacks, and appreciably refined by
Emmanuel Schlegloff and Gail Jefferson, it now has considerable
intellectual stature in both Bdtain and America. Conversation
analysis is perhaps the only orginal technique produced in Amedcan
sodology in the last forty years.
This e^ay considers some genedc issues and problems encountered
in the growing CA literature, using a recent bcx)k by Candace West,
Routine Complications, as a vehicle for a brief assessment. It is
important to distinguish matters of an acknowledged general
character from those discovered in the reviewed work.
Routine Complications is descdbed as a study of '. . . actual
encounters between doctors and patients in which I seek to treat
talk between the two as a subject in its own right' (p. 7), '. . . a
preliminary exploration of a much neglected area of research . . .'
(^p. 11). It aims by means of CA, 'a systematic approach to the study
of talk in its own dght' (p. 10), to analyse some 532 pages of data
transcdbed from tapes made of 21 encounters between dcKtors and
patients in a family practice centre in the Southem United States.
The dyads are composed of men and women (but all physicians are
white and all but 4 are male), black and white, and including a range
of ages and statuses. The four identified analytic fod, tum-taking,
the organisation of questions and answers, repairs of misunder-
 Review essay 179

Standings, and social commentary in medical discourse, '. . .

represent some of the major organisational issues confrtmting
analysts of face to face interaction' (p. 11).
Models of the structure of the doctor/patient relationship (DPR)
by Freidson, Parsons and others, are charac:tedsed by West as
abstracted normative descriptions which fail to address how shared
talk is accomplished. She asserts that discourse analysis (icientified
here as the work of scx:iolinguists such as Gumperz, Labov, and
Hymes p. 30-31) seeks individual intentions and meanings and fails
to explicate the structural properties of what might be called speech
management systematics. For example, many of the data us«d by
sociologists are 'secondhand' or typifications of typifications as
Schutz calls them - biographical reports, stodes told to the person
by someone else and recorded by the interviewer or observer,
census and other official statistics. Even ethnographic description,
which seeks first hand or 'front line' knowledge of social affairs, is
uxodously dependent upon descriptions, tales, anecdotes, and jokes
told about events that neither the ethnographer nor the teller of the
tale actually witnessed. Although there are methodological techniques
to control for this, it remains a problem. CA has argued that one
should attempt to reducje the layers of interpretation surrounding
social conduct, and thus direct-as-possible-access to talk's situations
is advocated. Ethnographic description is rejected because 'studies
of socially constructed meanings have told us little about the
organization of interaction used to produce those meanings' (p. 48).
West groups together in this dismissal, unfairly in my judgement,
some very diverse sorts of analysts and approaches, and omits
serious struc:turaiist analysis like Todorov, Schoies, Ecxj, and
Barthes. It is perhaps devotion to the idea that 'observable data' are
the bedrock of analysis that does distinguish West's apprc}ach.
Discourse analysis is incorrectly equated with the study of individual
intentions and the rejection of 'observable data of conversational
activities' (p. 48). Conversation analysis is advocated. The book
contains tabular distributions of laughter, interruptions, questions
and terms of address, which are generally absent in other research
employing CA conventions and techniques. Important exceptions,
however, papers by Jefferson (1983a, 1983b, 1983c, forthcoming)
and Hedtage and Greatbach (forthcoming) should be noted.
West finds by analysis of her transcdbed texts that interruptions in
turn-taking (sequences of speech) are patterned: male doctors
interrupt more than female doctors, and male doctors also interrupt
blacks and females more than whites and males. Doctors ask more
180 Peter K. Manning

questions than patients, and patients' questions are dispreferred.

Here analysis of question-answer sequences and conditional replies,
e.g. remarks of surpdse, requests for repetition, clarification or
confirmation, is subtle, insightful, careful and, in places, quite
powerful. Whilst physidans ask questions and thus dominate, equal
numbers of conc^tional responses were initiated by patients and
doctors. On the whole, women physidans are less likely to interrupt
and generally seem to find the encounters more difficult to manage
interac:tionally.
West states her value preferences clearly. She feels people have a
dght to talk (p. 61), and should not be interrupted (p. 61) nor be
denied choice in interaction. She advocates democratic/equal
interacrtional exchanges, and participative medical encounters. She
likes humour and notes that doctors refuse to laugh more frequently
than do patients (p. 150), thus asserting their power and dominance.
The analysis contributes important data to the study of the DPR,
and to professionalism at the micro-interactional level. Two of the
basic ccMwems of pragmatics, espedally in anthropological studies,
hdw respect and deference or honodfics are communicated, and
how matters assumed or outside the verbal stream ('this', 'that' 'it'
and 'the last time we met'), deixis, are communicated are at issue in
We^'s book. What might have been better explored are the precise
links between talk and specific social structures. Schegloff has
recently identified some of the difficulties in this enterpdse
(fbrthconiing). This linkage, to be analytically construed given
doSely gathered and observed data, extencis the utility of CA to the
vadousfieldsof sodology. Clearly, the impact of scx;ial organization
on interaction in the DPR, in medical training, in medical ^ttings
hnd the delivery of health care are of keen interest to medical
sod6logists. Perhaps the idea that talk is social organization is less
familiar but.no less true.
The claim made by West is that talk, elaborated by ethnographic
description, in the form of texts rendered by an exceedingly detailed
ccMiventionalised transcdption system, is the source of and documents
the utility of a formal structural model of conversations' properties.
Her analysis employs a functional inteipretation of the aims and
work of talk and it is thus teleologic in character. At least four issues
adse from my rendition of West's claims for C A, but they are part of
an integral approach and my order and separation of topic may itself
be itiisfeading.
1. The findings of CA rest in part upon a widely used transcription
system for converting speech into written texts. A line or two of talk
 Review essay 181
is extracted and presented in minute phonetically coded bits.
'Phonetic' in this context does not refer, I should hasten to add, to
the predsion made by computedsed technology now available in
phonetic laboratories. The microsecond variations which can be
studied, slight changes in pitch, stress, and length of spoken words,
are not sought for analytic reasons. The presumption of CA is that
speech as heard is the object of study. Sound, including the
phenomenological features of long gaps, rises and falls in tone, and
even individual variations in speed, is, as much as possible, that
which any hearer might be expected to discem under normal social
conditions. Simply, additional and more precise technology may
advance some aspects of the technique, but may retard others.
Explanations are based on matters of timing, volume, endings and
beginnings inferred from the transcriptions which in turn are
produced by West from her tapes. Other modes of producing
socially recx)gnised explanation b a ^ on other data are downgraded.
This observable data, described as naturally occurring is, of
course, mediated in at least three ways prior to analysis. These
data have been mediated, or transformed from one mode to
another (verbal to written for example), a process that is not well
understood, so that descn"ibing the effects of the forms of mediation
is a cdtical aspect of data analysis. First, the data are gathered by
means of tape-recorders placed in the interview rooms from patients
who have signed a release form and from doctors who are being
evaluated as members of a residency training programme. They are
transcdbed into written texts by means of a system devised by Gail
Jefferson which provides conventions for the notation of 'laughter',
silences or 'gaps, dsing and falling voice intonation, simultaneous
utterances and prolongation of words. To take but one example,
spudous precision is used to mark gaps in talk of one-tenth of a
second. Unless the most sophisticated equipment is used, such
measures are subject to error factors far larger than the unit itself.
These in tum are imputed significance in distinguishing conceptually
between interruptions, hesitations, overlaps and replies. West
claims, in a most dubious passage, that transcripts '. . . pay strictest
attention to representing what was heard as it was heard in fine
detail' (p. 46). 'As it was heard' is inferred, according to West, from
the stmcture of the foliowing talk, not from subjective meanings or
intentions dedved from observations, interviews or reports. Thus,
a rather ambiguous line is drawn between speech behaviours
or utterances and the cx>mnionsense meaning erf 'headng' or
understanding.
182 ^ t e r K. Manning
Second, a model is used to organise data presentation. This points
one to areas of inclusion and exclusion of material given a resuit of
the analytic mode. As Cicourel has most trenchantly pointed out,
models of discourse underly such assumptions and are the basis for
analytic techniques. Both are in turn dedved from a theory of the
relationships between talk and social structure, if indeed they are
viewed as separable. For example, it is assumed that actors are
cx)gnitively tuned to the slightest pause, hesitation or gap in others'
speech. Failure to do so is remarkable, as is pausing when it is not
giyen in the expectations of tum-taking for example. All sequences
are understcxxi both prospectively and retrcKpec:tively. Kierkegaard's
remark that life can only be understood backwards, but must be
lived forwards, is accepted insofar as people will indicate misunder-
standings, confusions or muddles by queries and the timing of their
queries, by conditional replies, repairs and side sequences (inserting
questions after a question to clarify the original one). Analysis of
somewhat messy conversation and group sociable talk is eschewed
because the question of orchestration and ordedng becomes
polyaural as in the classic 'cocktail party problem' (how people
orient to multiple speakers in the room). Intention to speak and
hear is imputed; no one mishears, distorts, systematically cUsattends,
or manipulates others by devious means. Such variations could be
studied, but only against the background of assumptions of normal
talk. The actual hearings or attitudes of actors to segments of talk
e.g. the degree of sexism imputed to interruptions, if indeed they
are recalled or noticed in the first instance, is not of interest (Orcutt
and Harvey, 1985). The choices of actors within the constraints of a
tum-taking system are of less interest than the choices made and
how and why they might have been made.
Third, it is claimed that transcdptions are 'an adjunct to
tape recorded materials' (p. xiii). The problem, of course, is what
'adjunct' means in this connection. What are the connections
between talk, transcribed texts, implicit and explicit knowledge
brought to such encounters, and other sources of knowledge used to
fill in, make sense of, explain and otherwise display the coherence of
ambiguous talk? The claim that fewer levels of mediation increases
validity begs the question of what 'pure talk' could be said to be.
This analysis is done on serially transformed data, subjec^ted to
conceptual election based upon an analytic model. These forms of
mediation, taping, transcdption, and selection, are part of most
sociological analysis of a naturalistic ^ r t , and do not distinguish
CA.
 Review essay 183
Transformations from natural speech into texts, from natural
speech to medical and other formats for recording, encoding and
decoding infonnation, and from one language to another, raise
further questions about the nature of 'natural speech'.
2. A second general issue is what might be called 'ad hocery' or
imputing meanings to snippets of talk. This is inevitable perhaps
insofar as the observer (West) alone possesses observations of the
setting in which the talk occurs, conversations with doctors outside
the setting, and omitted segments of those portions of talk from
given dyads which are selectively presented. West's analysis of
pattems of interruptions using aggregated data (e.g. percent of
physician interruptions), are in contrast to observations scattered
throughout the book (e.g. pp. 54, 69, 95, 102, 113), displaying a
particular insight:
I regard such an instance of simultaneous speech as a possible error in
transition timing rather than as an indication that the physician is not
listening' (p. 54).
A second class of backward-looking items I have termed requests for
confirmation. These objectives tie declarative utterances (such as
assertions) with 'Y'know?' 'Okay?' and 'Like . . .?' in simulated
inquiries:
(Dyad 2:027-028)
Patient: Ithur:::ts, ok [ay:? "j
Physician: [Mm-hmmJ
For example, in this fragment (presented earlier), the physician's
acknowledgement token overlaps the patient's queried 'okay?'. But the
acknowledgement token cannot be seen as a legitimate 'answer' to a
'question', for what would the question be? Surely, the patient is not
asking her doctor for 'permission' to hurt, nor does it seem that she is
seeking the physician's clinical assessment of her pain (e.g. 'Is it okay if
it hurts?' or 'Is it still healing properly even if it causes pain?'). Rather,
it appears that 'okay?' offers an opportunity for the physician to confirm
or disconfirm the intelligibility of the utterance so far, before the patient
continues. As in the case of requests for repair, requests for confirmation
orient their recipients to a last item rather than a next item in a series of
events, (pp. 101-102)
An elaborate and surely inferential analysis is presented to dadfy
the meaning of another 'okay' on p. 113.
Granting that individual analyses may vary in their cogency and
persuasion, disproving alternative hypotheses or interpretations, it
would appear, is a vexing problem for any technique which
combines formai analytic procedures with a phenomenologicai
184 Peter K. Manning

interest in form, context, and meaning. It is not clear whether an

adequate test of an interpretation would be rational-logic:al,
aesthetic, an empidcal test of frequency distdbution compared
to some model, presence or absence given certain conditions,
or a pattern of reproducible results with different samples or data
sets.
3. Individual choice of states of talk (ftn. 4, p. 157) seen in replies
and queries is said to be govemed by context, but context is
undefined. A fundamental problem of pragmatics generally is: how
does one understand talk's context, things unstated but assumed in
the course of speech? Context is rather more than social and
psychological attdbutes of speakers, or even implidt meaning. As
West notes, the structure of DPR is socially conditioned, and her
findings suggest this. For example, how does one know what 'this'
refers to in 'So I fe-fee:l this coming on' (p. 89)? Because it is both
anaphoric and deixic, it cannot be understood from speech, nor
from the course of talk itself. 'Whudda say' (p. 113) is another
example which requires a one paragraph explanation about how
what is heard is not what was meant. All references to deixic and
anaphoric matters are, for example, glossed by West with ad hoc
imputations. West's focus is on a few pattems of conversation, and
many of the context particulars are omitted, coming in and out as
needed to rationalise a structural interpretation of conversational
dynamics.
West might have explored other normative patterns in the
particular institutional setting. She notes, for example, that doctors
query and interrupt more than patients, and relates this to their wish
to obtain informationally oriented 'yes' or 'no' answers. She also
notes and glosses the non-verbal aspects of the interaction (gestures,
touch, use of tools, positioning and postures of speakers). She
quotes Cicourel's work, claiming mistakenly that physicians' 0-A
sequences are deductive. (They are rather examples of abductive or
inductive reasoning, cf. Meehan, 1960). She notes the possible
effects of the social form of physicians' interviews on content as well
as the structure of such naturally oceurdng talk. The DPR is a
socially sanctioned, institutionalised encounter govemed by mini-
rituals of opening and closing, by a logic of information exchange,
by time, place, and task constraints, and by a setting-sj^cific
diagnostic aims. It is not, in short, a telephone conversation, the
locus classicus of CA's apergus. That it is nevertheless governed by
tum-taking, repair work, sodable commentary and Q-A sequentes, is
 Review essay 185
well-demonstrated here. West's argument would be strengthened by
clear delineation of the form, setting, task, logic, temporal-spatial
and vocabulary constraints which also provide background or
setting-specific effects which mediate the observed regularities.
Some of the features of tum-taking could well be modified, for
example, by the size of the group (Atkinson, in Atkinson and
Hedtage, 1985), cultural differences (Goffman, 1981), ritual con-
straints (Goffman, 1984), non-verbal matters (Heath, in Atkinson
and Hedtage, 1985), notwithstanding the multiple interpretation
problem which remains (Schlegloff, forthcoming).
4. Ambiguity in the status of questions or answers (cf. 73-80,
100-103) is related to previously devised, shared and learnt/ormate
for questioning, unlike natural conversation in which response
indicates a question is heard as such. Since West does not provide
details of formats physicians used for interviewing, prescribed
questions, diagnostic outcxtmes, nor relationships between utterance
and written text, much of what is analysed could only be seen as a
result of conversation form (cctmpare Cicourel, 1984, for example).
Hedtage and Atkinson, in their introduction to an important
collection of papers, point out:
. . . specialized interactions exhibit varying detailed and systematic
differences from what is found in ordinary conversation. The practices
involved in such settings appear to involve a clustering of particular
subsets of those found in conversation, and their use commonly involves
a reshaping of the relevances associated with their use in everyday
interaction. These characteristics may eventually be shown to contdbute
to what Garfinkel. . . has referred to as the special 'quiddities' and
'identifying details' of institutional conduct. (Atkinson and Hedtage
1985:13)
Institutional 'details' are very much a part of West's intellectual
concern. TTiey also shape her moral perspective. She views
negatively tne asymmetdcal nature of DP interaction, feels inter-
ruptions result in 'lost data', prefers conditional queries which are
mutually negotiated, and values individual choice. She argues
throughout that the DPR is 'threatened' by vadous sorts of
misunderstandings (p. 118). At other points she adopts a pheno-
menologic perspective, arguing that 'talk constitutes the relationship'
(p. 147). It is perhaps the combination of CA with a value position
implied in the basic concem, the social order of conversation, that
produces a tension in Routine Complications.
The evolution of cxtnversation analysis has been striking and its
difussion remarkable. The claims made for the body of published
186 Peter K. Manning

and unpublished research are public. The ways forward are various
and doubtless will be pursued.
Centre for Socio-Legal Studies
University of Oxford, Wolfson
College, Oxford, OX2 6UD
and Michigan State University

AcknowledgenMnt

I am grateful to Robert Dingwall, Paul Drew, and John Heritage for

comments on a previous draft.

References

Atkinson, J.M. and J. Heritage, eds. (1985) Structures of Social Action,

Cambridge: CUP
Cicourel, A. (1984) 'Commonsense reasoning and medical decision making',
unpublished paper presented to the conference on "The Impact of Scientific
Knowledge on Social Structure', Technical University of Darmstadt, West
Germany.
Goffman, E. Forms of Talk, Oxford: Basil Blackwell.
Goffman E. (1984) 'The interaction order'. American Sociological Review, AP, 1,
1-17.
Jefferson, G. (1983a), 'On a failed hypothesis: conjunctionals as overlap-
vulnerable,' in G. Jefferson, 'Two explorations of the organization of
overlapping talk in conversation', Tilburg Papers in Language and Linguistics,
No. 28, Tilburg University, Tilburg, The Netherlands.
Jefferson, G. (1983b), 'Another failed hypothesis: |»tch/loudness as relevant to
overlap resolution,' Tilburg Papers in Language and Literature, No. 38, Tilburg
Univereity, Tilburg, The Netherlands.
Jefferson, G. (1983c), 'Notes on a po^ible metric which provides for a 'Standard
Maximum' silence of af^roximately one second in conversation', Tilburg Papers
in Language and Literature, No. 42, Tilburg University, lliburg, X!B£ Nedierlan<k.
Jefferson, G. (forthcoming), 'Notes on "latency" in overlap onset,' in G. Button,
P. Drew and J. C. Heritage, eds. Language in Social Interaction, Special Double
Issue of Human Studies.
Heritage, J.C. and Greatbatch, D. (forthcoming). Generating Applause: A Study
of Rhetoric and Response at Party Political Conferences, American Joumal of
Sociology.
Meehan, B. (1960) CUnical Reasoning, Minneapolis: University of Minnesota
Press.
Orcutt, J. and L. Harvey 'Deviance, Rule-Breaking and Male Dominance in
Conversation' Symbolic Interaction 8,1,15-32.
&:hegloff, E. 'Between Macro and Micro: Contexts and Other Connections' to
appear in J. Alexander, B. Giesen, R. MumA and N. Smelser, The Mkro-
Mcu:ro Unk. Bericeley University of CaUfomia Press.