Sociology of Health & Illness Vol. 16 No. 4 1994 ISSN 0141-9889

The interactional form of professionaldominanceTony Hak

(Erasmus University, The Netherlands)

Abstract Studies of 'the interactional form of professional dominance'portray particular conversational phenomena, such as interrup-tions and specific types of questions, as effective means bywhich doctors inhibit patients from getting the floor. Suchstrategies, however, depend on the patient's cooperation and,hence, cannot assure the doctor's dominance. In this paper it isargued that the Freidsonian concept of 'professional dominance'does not in the first place refer to the asymmetrical distributionof interactional tasks but rather to the asymmetrical distributionof specialised professional knowledge. Hence an 'interactionalform of professional dominance' should not be sought in thedoctor's strategies for controlling tums but rather in theunequal distribution of the parties' access to each other'sobjectives. The question is then how this asymmetry of accesscan be 'discovered' in conversational data. It is argued that thiscan be done (only) by an analysis of how episodes of theinteraction function in the process of professional assessment asa whole.

Introduction

Since Freidson (1970) analysed the structural concept of 'professionaldominance', many studies have been published on the verbal strategiesused by doctors in order to control the medical encounter. These studiesportray particular conversational phenomena, such as interruptions andspecific types of questions, as effective means by which doctors inhibitpatients from getting the floor. Eglin and Wideman (1986) have calledthese studies 'the interactional form of professional dominance'.Criticising a British volume of several studies of this kind (Wadsworthand Robinson 1976), Sharrock (1979) argued that such strategies dependon the patient's cooperation and, hence, cannot assure the doctor's domi-nance. He concluded©Basil BlackweU Ltd/Editorial Board 1994. Published by BlackweU Publishers, 108 Cowley Road,Oxford OX4 UF, UK and 238 Main Street, Cambridge, MA 02142, USA.

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that we (as sociologists) are quite a long way from having answers tothe (simple?) question 'what does go on between doctor and patient?'and that studies which are intended to provide answers can giveexaggerated, rather perverse, interpretations of the nature of themedical consultation (Sharrock 1979: 144).

Many studies have b^n published since, which give similar 'exaggerated'and 'perverse' interpretations of the nature of the medical encoimter (e.g.Fisher 1984, Mishler 1984, West 1984). Other authors, ethnomethodolo-gists in particular, have presented opposite descriptions of the nature ofthe doctor-patient encounter. Hughes (1982), for instance, describes theabsence of patients' initiatives in the encounter rather as indicating reluc-tance on the part of the patient than as the effect of doctors' cutting offpatients' utterances. He suggests that this reluctance has to do with diffi-culties that patients have in recognising relevance and in offering organ-ised descriptions of their conditions (1982: 364). And Eglin and Wideman(1986), in developing Sharrock's and Hughes' viewpoint, picture the con-versational form of the professional encoimter as derived from the par-ties' mutual orientation to the performance of a set of tasks, whichestablish a characteristic distribution of speakers' rights to turns, tumtypes and tum sizes (1986: 355).

In this paper I argue that the Freidsonian concept of 'professionaldominance' does not in the first place refer to the asymmetrical distribu-tion of interactional tasks but rather to the asymmetrical distribution ofspecialised, professional knowledge. Hence an 'interactional form of pro-fessional dominance' should not be sought in strategies for controllingtums (whether these are conceived as being imposed by the doctors' ver-bal strategies or derived from the parties' mutual orientation) but ratherin other features of the conversation - not of the tum-distdbution type -which secure doctors' objectives.

The paper consists of three parts. First, the concept of 'professionaldominance' is discussed. Freidson (1970) described the 'structural' domi-nance of the professional perspective over the layman's perspective, i.e.doctors' authority over services requested by the patient, but he did notstudy the contents nor the interactional structure of medical encounters.Next, I will discuss examples of studies of the medical encounter whichrepresent the 'interactional form of the professional dominance thesis'.Although these studies portray the encounter as an unequal transaction,following a course determined by the doctor rather than the patient, theyfall short in explaining why and how this asymmetry could be seen as aform of professional dominanc*. Eglin and Wideman's claim, however,that the interactional shape of medical encounters should rather be seenas a joint production of the doctor and the patient, raises the question ofwhat the interactional form of professional dominance then could he. Inthe third part of the paper I will propose another operationalisation of

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this concept: as the unequal d^tribution of parties' access to each other'sobjectives. I will illustrate this proposal with some data from Dutch men-tal health care encounters.'

The stmctural form of {Httfessiimal dmninance

Although Freidson (1970) does not provide a definition of the concept ofprofessional dominance, it can !>e reconstructed from his discussion of therelationship between the client and the professional. First, he notes thatprofessionals and clients bring different perspectives to the encounter.This difference is descdbol both as a function of the professional's occu-pational experience (which leads him or her to take a more routine viewof the problem than the sufferer's) and as a fvmction of the specialisedknowledge acquired both by occupational experience and by the formaltraining that professionals provide for their members (1970: 106).

Clients, as lay people, are by definition lacking the educational or expe-riential prerequisites that would allow them to decide, on grounds sharedwith the professional, whether to accept any particular piece of profes-sional advice or not. Hence the professional's grounds for persuadingclients to obey are 'inherently problematic':

Any expert whose work characteristically requires the cooperation oflaymen is handicapped because laymen know neither the occupationalrules of evidence nor the basic content of his skil!. What distinguishesthe professional from all other consulting experts is his capacity to solvesome of these problems of authority by formal, institutional means. Hissolution minimizes the role of persuasive evidence in his interaction withhis clientele (Freidson, 1970: 1(^10; stress in the original).

According to Freidson, the profession's solution to this problem lies bothin its capture of exclusive control over the exercise of particular skills,and in its capture of the exclusive right of access to goods and servicesthe layman needs in order to manage his own problems independently ofexpert advice. In short, the profession's solution to the problem ofauthority consists of its capture of the formal position of gatekeeper.Thus, a twofold definition of 'professional dominance' can be deduced:first, that, particularly in matters of health, the opinions of laymen aresubordinatwi to tlw opinions of professional experts; second, the profes-sion's legaUy guaranteed exclusive right of access to goods and servicesthe layman needs.

As is clear in the above quotation, Freidson contends that the profes-sional's formal status as a gatekeeper will minimise the role of persuasiveevidence in the interaction. On theoretical, not empirical, grounds, he dis-tinguishes four 'practical alternatives' for the interaction, of which per-suasion is only one (1970: 119):

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(1) If the practitioner's advice or service does not correspond to thedesires of the client, clieots naay merely withdraw from the situation whenthey realise that they cannot get the practitioner to conform to theirdesires. According to Freidson, no authority of any kind is exercised inthis case.

(2) If the client desires some resource which can be obtained only by atleast temporarily aoepting what the practitioner 'suggests', the client maygive in and do what the practitioner advises. The client's conformity isobtained because of command over accessory resources by the practi-tioner. It does not mean that the client accepts the value of the practi-tioner's competence.

(3) In some cases the practitioner's advice happens to correspond towhat the client expects or d^ires, whether or not the grounds for theclient's expectations are the same as they are for the practitioner.

(4) In some cases clients will be persuaded in the course of the interac-tion that the practitioner's advi(« is in their best interest, whether or notit happens to conform with what they initially believed they needed.

Freidson emphasises the necessity of faith or trust in the practitioner,i.e. imputed competence (1970: 119). It is assumed that the doctrine of'free choice' allows the professional to put the burden of compliance onthe client. This allows the professional 'to rest on the authority of hisprofessional status without having to try to present persuasive evidence tothe client that his findings and advice are correct' (1970: 120-1). Thus, inFreidson's view, the typical form of professional dominance in medicalencounters is the exclusion of altematives for the client with the effectthat he or she has little choice but to accept the practitioner's opinion(1970:122).

Freidson's description of the client-profesaonal relationship lacks any(explicit) empirical grounding. It seems to depend completely on the pro-fession's self-image. This may be an explanation also for the fact thatFreidson does not mention the other two (logically available) altematives:

(5) The practitioner may do what the client expects, without acceptingthe client's competence.

(6) Tlie practitioner is persuaded in the course of the interaction thatthe client's request is in the client's best interest, whether or not it hap-pens to conform with what the practitioner initially believed the clientneeded.

Freidson does not pr^ent any empirical evidence from which it couldbe concluded that it is legitimate to exclude these two altemativesfrom the discussion, or for the claim that professional service-fH-ovidersavoid persuasion. It is not my claim that professionals do not avoid per-suasion, but the point is that Freidson has not provided sufficient datafor judging whether or not this is the case. He explicitly exditd^ the «)n-tent of interaction between the client and the professional from his dis-cussion:O BasU Blackweli Ud/Ediumal Board 1994

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I shall not concem myself in any significant detail with the content ofinteraction between doctor and patient, or among doctors and otherhealth workers. Instead, I s h ^ focus on the significance of the waythat interaction is organized by the formal, indeed often legal, relation-ships that establish the limits of legitimate behavior, and by the way inwhich the pattem of relationships exercises influence on the content ofinteraction independently of the individual characteristics of theparticipants. (Freidson, 1970: 32)

Freidson apparently assumes that a study of the content of interactionwould imply importing individual characteristics of the participants intothe analysis. This, however, is not necessarily the case. It is not clear whywe could not ask how doctors and patients typically accomplish theirinteraction in order to (re)produce 'professional dominance'. This ques-tion is addressed by the studies of the 'interactional form of professionaldominance'.

The interactiomil form <rf ptrfessaomd doofiiBaoce

One of the first studies addressing the problem of how professional domi-nance is (re)produc«d in the medical encounter is Bloor's study (1976) ofconsultations in ENT (ear, nose and throat) clinics. In contrast toFreidson, who emphasises that the medical encounter is organised by'structural' professional dominance (i.e. the formal or legal relationshipsthat establish the limits of legitimate behaviour), Bloor claims to havefound empirical evidence that 'routine work practices' determine thedegree of professional authority. A specialist's routines are, according toBloor, related to professional authority and dominant* in two analyti-cally distinct ways. In the first fAatx:

there is a sense in which their sum is the errdjodiment of his functionalautonomy. They serve to orchestrate consultations according tospecialists', not parents', purpose. They may have the effect of exclud-ing the parent from effective participation in the decision simplythrough their structuring of the consultation without regard for theparent's purposes. Thus, while the doctor may have a diffuse, culturallyapproved 'right' to legislate by fiat in health and illness, the totality ofhis routines are the practice embodiment of his dominance in themedical encounter. (Bloor 1976: 54)

'Embodiment' is the imm^iate translation of structural professionaldominance into interactional forms. This is, however, not the case withthe Mcond way in whkh Bloor describes Uie relation betvroen the doctors'routines and professional dominance:

Yet in addition to the above ^neral sense in which routines embodyspecialists' fuoctionsl autonomy they also, in a more |»rticular sense,

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facilitate specialists' autonomy. Routines can be s^n not as just simplyexcluding parents by structuring consultations according to specialists'purposes, but as actively denying parents any potential influence.(Bloor 1976: 54)

Thus, according to Bloor, routines 'facilitate' professional dominancewhen they are seen as actively denying patients influence on the outcomeof the encounter, whereas routines 'embody' professional dominancewhen they are seen as merely giving shape to other mechanisms of exclu-sion. As with most studies of the interactional form of professional domi-nance, Bloor claims to document routines which facilitate professionaldominance rather than embody it. The doctor is seen as being concemedwith asserting and sustaining his dominance over the patient at each andevery tum, excluding any possibility that the patient might take any partin determining the outcome of the encounter. In order to enforce hisdominance, the doctor is assumed to employ various verbal strategies forcontrolling the encounter, among which the use of interruptions andquestions are prominent. The patient, for his or her part, is seen as beingcontinuously involved in trying to challenge the doctor's control over theencounter. In other words, the 'interactional form of professional domi-nance' is conceived of as located in the observable concem of parties toassert their perspective in the encounter.

One routine, which according to Bloor has the consequence of denyingpatients influence, is framing questions 'in forms that demand specificrather than elaborated replies, and so provide little in the way of a con-versational opening for parents' (Bloor 1976: 61). The following extractexemplifies this routine:

Extract 1 (from Bloor 1976: 61){D = ENT specialist; M = mother of patient)Dl How old is he?Ml Nineteen months.D2 He's had two bad attacks?M2 Yes.D3 He's fevered?M3 Yes.D4 And he came into hospital with one of them?M4 Yes.D5 In between times he's all right?M5 Yes.D6 He eats his food?M6 Yes, fine.D7 He hasn't had ear trouble?M7 No.

According to Bloor, the doctor's questions 'demand' specific answers andhence inhibit the mother to raise a topic of her ovm ioter^t. In this waye BasU BiMdcweU Ud/Editorial Board 1994

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the doctor is said not only to secure his professional autonomy but ratherto establish it actively. However, a remarkable feature of this example,and in fact of most of the other examples in the literature, is the absenceof what is supposed to be there, namely observable concem of parties toassert their own perspective. Therefore, Sharrock has argued that Extract1 documents, rather, the absence of an interactional form of professionaldominance, at least of the 'facilitating' type. He presents the followinghypothetical variant to Bloor's fragment:

Extract 2 (from Sharrock 1979: 142)(D - ENT specialist; M = mother of patient)D2 He's had two bad attacks?M2 I'm not sure really. I mean the first time I didn't know what it was

. . . etc.

Sharrock concludes from this hypothetical example that the format of theanswer is:

in answerer's control and constrained not by the form of the question,but by answerer's sense of what the answer is and of the relevancesthat dictate the question. Similarly, with the problem of topic [. . .].There is nothing in the formal stmcture of an exchange of questionsand answers wMch prevents people introducing topics. [. . .] If themedical professional is reliant upon the way in which he stmctures histalk with the patient (in this sense) for his control, then he is indeeddependent upon the very weakest constraints which could not containor control anyone who genuinely wanted to raise the topic and waswilling to try to get answers to their questions. (1979: 142)

The interactional stmcture consisting of 'restricted' questions and 'spe-cific' replies, 'embodies' rather than 'facilitates' professional dominance.There are constraints imposed upon the patient but, apparently, these areimposed by patients upon themselves rather than by doctors (Sharrock1979: 143).

Intermption is another routine which has been aax)rded particular sig-nificance in the literature on the interactional form of professional domi-nance. By means of intermptions, the doctor is said to cut off thepatient's attempts to give a full and complete story which tells it from thepatient's point of view. Mishler (1984), for example, presents the follow-ing fragment as an example of intermption:

Extract 3 (from Mishler 1984: 129-30)^(D = physician; P = patient)Dl You had an ulcer at age ninelPI Um about - between nine - nine and eleven I had the first one.D2 The first one?P2 And then - uh the two years later I developed a second one.

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D3 (0.4) That was about thirteen or so.P3 Between - between nine - nine and thirteen. (0.8) The only thing -D4 That's when you had your s«x>nd one.P4 Yes. The only thing I can remember is that my doctor was

shocked to death because he never knew a girl my - my age thathad two ulcers.

D5 And how did -how did the ulcers present. What uh - whathappened? (0.6) Just pain or uh

P5 It's a well - yeah, pa - lot - lots and lots of pain sour stomach.

In Extract 3 a pattern of 'restrictive' questions and 'specific' answers isobservable that is similar to Extract 1. The difference is that the patientat P3 does what Sharrock (hypothetically) did in Extract 2. This exampleshows that the format of the answer is in answerer's control indeed andthat it is not completely constrained by the form of the question. Butwhat the patient starts to tell (P3-P4: 'The only thing I can remember isthat my doctor was shocked to death because he never knew a girl myage that had two ulcers') seems to be unwelcome. First it is interrupted(P3/D4), and consequently the doctor does not acknowledge it in anysense but instead changes topic (P4/D5). According to Mishler, this frag-ment documents the 'struggle' between the patient's attempts to give afull and complete story which tells it from the patient's point of view andthe doctor's attempts to dominate the encounter.

Not only Mishler, but many other researchers have also claimed thatdoctors 'may interrupt the patient ahnost at his or her liking' (Lacoste1981: 170). Whereas patient's talk typically is seen as a form of story-telling (i.e. the description of the illness or problem is wrapped up in sto-ries that refer to the everyday lifeworld of the patient), the physician issaid to attempt to stop this story-telling by various means. The frequentoccurrence of interruptions is evidence indeed that the encounter is anunequal transaction following a course determined by the doctor ratherthan the patient. But does it imply that the doctor needs interruptions inorder to 'facilitate' professional dominance? Or is it rather a mere'embodiment' of structural professional dominance? It is remarkable thatMishler himself observes that interruption (such as in Extract 3) is notseen by the patient as strange:

As members of this culture we, as observers, and the patient, are likelyto assume that the physician has 'reasons' for his questions. It issomewhat remarkable, but understandable on the basis of this sharedassumption, that the patient does not reject any of his questions asinappropriate, however disjunctive they are with previous content, butmakes an effort to answer them (Mishler, 1984: 120).

Thus, according to Mishler, the patient's assumption that the doctor hasgood reasons for his or her questions, however disjunctive they are withprevious content, explains the patient's compliance (D4 and D5) ine> Basil Blackwdl Ltd/Editorial Boan) 1994

Professional dominance 477

Extract 3. But it is precisely this compliance that makes it very difficult toread this extract as a document of a 'struggle' betwwn the patient'sattempts to give a full and complete story and the doctor's attempts todominate the encounter. It is rather the absence of 'struggle' that is docu-mented by Extract 3. The assumption that the doctors' questions are rea-sonable is something that the patient brings to the encounter. It is notproduced interactionally. As such it documents the relevance of the struc-tural - not the interactional - form of professional dominance.

Discussing other examples of interruption, such as presented byLacoste (1981) and West (1984), Eglin and Wideman also conclude thatinterruptions in medical encounters, if to be found at all, typically are'joint productions', characterised by the patient's compliance (1986: 345).It can be concluded that the interactional form of professional domi-nance, as presented by authors such as Bloor (1976), Lacoste (1981),Mishler (1984) and West (1984), in which professional dominance is seenas something which the doctor actively imposes upon the patient, cannotbe sustained. This conclusion confirms Freidson's assumption that theproblematic nature of authority in the doctor-patient relationship hasbeen resolved by structural means.

Eglin and Wideman (1986) go even further in claiming that an 'interac-tional form of professional dominance' does not exist. They view the par-ticular interactional shape of medical encounters not as an 'embodimentof professional dominance' but rather as derived from 'the parties'mutual orientation to the occasion of the encounter as one directed to theperformance of a set of technical tasks, which establish the relevance ofco-identification in terms of a particular set of identities ('doctor'/'patient') and a characteristic distribution of speakers' rights to turns,tum types and tum sizes' (1986: 355). However, although Eglin andWideman convincingly describe the interactional shape of the medicalencounter as jointly produced by the doctor and the patient (which justi-fies their rejection of the version of the interactional form of professionaldominance as found in the literature), this does not justify their rejectionof any interactional form of professional dominance. This wrong conclu-sion originates from their restricting the inquiry to the unequal distribu-tion of tum types and tum sizes, which is only one possible interactionalform of professional dominance.

Freidson (1970) described professional dominance as the phenomenonof subordination of the laymen's perspective to the professional perspec-tive. The proposal of Bloor and others to describe verbal strategies forcontrolling the encounter, such as interruptions and particular types ofquestions, explicitly addressed the problem of the control of the patients'perspective, not of the patients' tum types or tum sizes. It was assumedthat doctors deny the relevance of patient perspectives by discouragingthem from voicing their concems. The finding that interruptions and par-ticular types of questions are not effective as a means of controlling

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patient talk does not imply that there are no other means of controllingpatients' opinions. On the other hand, even if interruptions and questionswere effective in controlling patients' talk, this would not establish theoperation of the interactional form of professional dominance. Therepression of patients' talk (i.e. inhibiting patients from expressing theiropinion) does not necessarily coincide with the subordination of patients'opinions. It is quite possible that patients' opinions play a role in theencounter without being expressed, and the reverse may be true also. Itfollows that

[i]f we do want to isolate 'tactics' that doctors and patients use toassert or challenge each other's autonomy we shall only be leaping topremature conclusions if we do single out episodes of interactionwithout a clear awareness of the way in which those episodes areengaged in doing medical work. (Sharrock 1979: 144)

In the next section I will present an approach which takes this intoaccount.

Another aiqiroach to intoactionai dominance

Extract 4 is a fragment from a transcript of an encounter between asocial psychiatric nurse who is working in the Emergency PsychiatryDepartment of a Dutch Regional Institution for Ambulatory MentalHealth Care (RIAGG) and a patient. The encounter takes place in theliving room of a sheltered home, where the man now lives after havingstayed, off and on, in a psychiatric hospital for some years. The patienthas asked to be re-admitted to a psychiatric hospital.'

Extract 4(N = social psychiatric nurse; P - patient)PI Well, I find it rather unpleasant to to uh well to to to go uh to

go to sleep in my own room.Nl Why? What is wrong with that room?F2 This traffic, it is going on the whole night through.N2 Mmmm.P5 It troubles me. An uh in the morning at six o'clock the birds

start whistling and uh that troubles me terribly. Because then Iknow that I cannot uh rest in a normal way.

m Yeah, yeah.P4 It is irritating to me.N4 Yes, they deprive you of your rest.P5 Yes.N5 And in the psychiatric hospital?P6 And this is this is terribly annoying. I have nothing against birds

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[data omitted]I absolutely do not want to stay here.

N6 And the birds are anywhere. You will find them particularlyeverywhere in the coimtryside.

P7 Hihi yeah yeah that is tme. Yeah.N7 Isn't it?P8 Yes, that's right.N8 Even more than here I guess.P9 That's right yes.N9 Than in the city.PIO But uh I mean this this pain in my my my head 111 do not

know what it is.

There is no doubt structural professional dominance in the relationshipbetween this nurse and his client. The nurse is a gatekeeper. It is he whodecides on the admission into a psychiatric hospital. But how can thisdominant position be read in the transcript? To begin with, not by acharacteristic distribution of speakers' rights to tums, tum types or tumsizes. There is an asymmetrical distribution of interactional roles: thepatient providing information and the nurse evaluating this, but this dis-tribution is not in any sense 'characteristic' for this encounter. It is a dis-tribution that is characteristic for any conversation in which one party isthe teller of a story and the other party is its recipient. Furthermore, thenurse's questions are not 'disjunctive to previous content'. Rather, thesequestions, however 'restrictive' they may be (e.g. N7: 'Isn't it?'), exploreand evaluate previous content. This extract resembles the type ofexchange that has been described by Jefferson and Lee (1981) as a 'prob-lematic convergence of a "troubles telling" and a "service encounter'".Compare, for example, the next fragment:

Extract 5 (From Jefferson and Lee 1981: 405-^)'*(/ = James; V = Vic)Jl The next time you see me I'm gonna be looking like hell you know

why, (0.7) Cause every damn one of these teeth coming out,bottom and top. (0.7)

VI Doesn't matter you still be you won't you James,J2 s-uh, yeh I guess so - maybe ( ) when I see that dentist (come at

me) with that damn needle I'm ready to mn like hell. I don't mindeh pulling them but he coming at me that needle's what I can'tstand.

V2 Tell him gas.J3 hhhuh?V3 Tell him gas. (0.4)J4 Uh - No I don't (want no gas, no) I will take it. You know.V4 Let me ask you one question.J5 Yeh.

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V5 Are you getting toothaches? (0.4)J6 No\ (0.2) But I got cavities!

Extract 5 is a fragment of an everyday encounter, not a serviceencounter. In Extract 4 as well as Extract 5, one person (the 'troublesteller') is complaining about certain circumstances. In both cases, theother party introduces some thoughts ('advice') which he invites the first(complaining) party to align with. Finally, in both cases, the complainerattempts to avoid the adviser's conclusion ('But I . . .'). It can be con-cluded from this resemblance that there is no interactional form to be dis-covered in Extract 4 that could be called 'characteristic' for medical orpsychiatric diagnostic encounters. But where then could the interactionalform of professional dominance be found?

In everyday 'troubles telling' and 'advice giving', acceptance and rejec-tion of advice is in great part an interactional matter, produced by refer-ence to the current talk, and more or less independent of intention to useit or of actual subsequent use (Jefferson and Lee 1981: 408). In Extract 5,neither James' rejection nor his acceptance of Vic's advice will have reallife consequences. However, in Extract 4, for parties it is clear that oneparty (the nurse) subsequently will make a judgement on the relevance ofthe patient's complaints in order to assess the necessity of an admissioninto a psychiatric hospital. For this reason, the patient's 'But uh I meanthis this pain in my my my head' and James' 'But I got cavities!' will dif-fer in subsequent effects, although they seem to have the same propertiesinteractionally. James can reject Vic's advice, because the advice and itsrejection do not have significance outside the interaction in which theyare produced. On the other hand, the client needs the nurse's consent forgetting the service he desires, an admission into a psychiatric hospital.The structural position of the nurse as a gatekeeper 'demands' that theclient makes a new attempt to present problems which may convince thenurse. The distinctive difference between Extracts 4 and 5, thus, is not ininteractional form but rather in the parties' interests and purposes.Whereas James and Vic only have to deal with what is available to theminteractionally, the nurse and the client have to deal with much more, i.e.each other's position and perspective.

It is certainly possible that institutional encounters differ from everydayencounters in systematic, describable ways and that these differencescould be found by comparing 'genres' (Ten Have 1989, Maynard 1991).Such differences, however, cannot be considered as 'embodiments' of pro-fessional dominance in the Freidsonian sense, i.e. as strategies used forsubjecting the patient's perspective to the professional perspective. Thedifferences, for instance, that Maynard (1991: 473-83) has described inthe way 'perspective display series' occur in 'bad news' interviews in com-parison to everyday conversations' can be explained by parties' mutualorientation to the doctor's obligation to provide information irrespectiveO BasU BlackweU Ltd/Editorial Board 1994

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of its accordance with the patient's expectations. Expressing a differentviewpoint is quite a different thing from dominating the encounter. Mycontention is that dominance can occur in interactions even in caseswhere the interactional form cannot be discerned from an everydayencounter. This implies, of course, that (professional, ideological, politicalor whatever) dominance can occur in everyday encounters. And there isno reason, indeed, why this could not be the case.

It follows that the interactional form of professional dominance onlycan be described by importing knowledge of the parties' perspectives, par-ticularly knowledge of parties' unequal access to each other's perspective,into the analysis. In Extract 4, the patient knows that the nurse has the'power' to decide on an admission into a psychiatric hospital but he doesnot know how the nurse should be convinced. By trial and error heattempts to find a complaint that is convincing for the nurse. Thisexplains why the nurse does not show any inclination to 'control' the sit-uation. He can simply wait for what the client offers him. The followingfragments (Extract 6) of the report, written after the visit by the nurse,document this:

Extract 6He tries to give all kinds of reasons for an admission into a psychiatrichospital. For instance, he pretends that he is not well. The trafficbothers him, but the birds also,[data omitted]When he notices that he is not successful in his arguments about beingadmitted into a psychiatric hospital, his behaviour changes to some-what more normal conduct, it becomes less pitiful.

The nurse interprets the patient's utterances as 'giving all kind of reasonsfor an admission into a psychiatric hospital'. It cannot be said that thenurse really 'knows' what the patient was doing - there is no way oflooking into the mind of the patient - but the important point is that thenurse does not have to know more for practical purposes. In this sense,he knows everything he needs to know about the patient's objectives andstrategies. The patient, in contrast, by knowing in general terms what thenurse is doing - judging whether hospitalisation is necessary - does notknow enough, because he does not know what the professional criteriaare which the nurse uses in judging his complaints. He does not knowwhat he must say or must not say in order to avoid the judgment that he'pretends that he is not well'. Thus, professional dominance is 'embodied'in this encounter by the parties' unequal access to each other's perspec-tive.̂

This inequality can be illustrated also with the following fragment. Thesocial psychiatric nurse of this extract is working at the same EmergencyPsychiatry Department as the nurse of Extract 4. The patient is a womanbeing visited at home by the nurse, after she had been referred to the

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department by a cardiologist at a public hospital to which the womanhad presented cardiac complaints. The cardiologist could not find anyserious cardiac problem and asked the Emergency Psychiatry Departmentto assess her case. During this home visit, the patient repeatedly attemptsto convince the nurse that she needs cardiological help. The nurse repeat-edly replies that the cardiologist could not find anything, but that he per-haps can provide another kind of help.

Extract 7'(N = social psychiatric nurse; P = patient)PI Someone made me feel a little bit nervous. Yes.Nl Yes? Who made you feel nervous?P2 My father.N2 And then . . . you have got those cardiac complaints?P3 I don't know suddenly.N3 Umm? ((pause))P4 Suddenly I got a couple of stupors and I started to shiver like

mad and then suddenly it stopped. I was frightened and Ithought keep breathing. And I would like to stay alive anotherwhile for I did not live yet.

N4 Yes.[data omitted]

What is on your program yet? Do you mean something inparticular when you say I like to stay alive another while?

P5 Weil, I wanted to see everything. I have seen everything. I'vebeen used all my life.((pause, then very softly:))(what I had already ( ) the whole country)

N5 Sorry.P6 The whole country knew that.N6 What did the whole country know?P7 What I just said.N7 I don't understand. I just don't get it.P8 I've just been used all my life.N8 By whom?P9 By boys.N9 Yes. And how does the whole country know about this?PIO It was broadcast.NIO It was broadcast. On radio or something?Pll And on TV.Nil That you're being used?P12 No uh with whom I went to bed.N12 Strange.

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regard to her cardiac problems. In this respect there is stmctural profes-sional dominance here. Extract 7 also shows evidence of interactionalasymmetry. It is the nurse who is doing the questioning, whereas thepatient is giving answers. But it has to be noted that there is no sign of'restrictive' questions or questions that are 'disjunctive to previous con-tent'. On the contrary, the nurse allows the patient to tell her story, anddoes not make use of pauses to interrupt her and to change the topic. Itis the hesitations of the patient that might be atypical for an everydayconversation in which the story-teller probably would elaborate upon herstory in a more fluent way.

However, it also occurs in everyday conversations that one partymakes use of a series of questions in order to get a clearer picture ofwhat the other party is saying. Similarly, in this extract, the nurse makesuse of everyday conversational means in order to reach an understandingof the patient's account. The fact that it appears to be difficult (for thenurse but also for us) to understand the patient, is not a problem of aninteractional kind. Note that there is no sign that one of the partiesbreaches mutual 'tmst' (Garfinkel 1967). Questions and answers arechained without any apparent problem in terms of the mechanisms of the'interactional machinery'. The asymmetry of Extract 7, thus, does notdocument professional (or any other kind of) dominance, but rather thenurse's difficulty in understanding the patient.

But the nurse and the patient are not mere everyday conversationalists.For both the client and the nurse it is clear that at the end of the day thelatter will assess the patient's complaints. This implies that the patient'stalk has a different meaning for the nurse than it would have had in aneveryday conversation. However, the patient does not know exactly whatthis other meaning is. Therefore, the nurse, similarly to the nurse inExtract 4, does not n^d to 'control' the situation and can merely waitfor what the client has to offer him. Yet, the nurse apparently attemptsactively to gain a better understanding. What does he want to understandbetter? This question can be answered by inspection of the nurse's assess-ment of the patient's complaints, as reported to his colleagues.

At the end of the encounter, of which Extract 7 is a fragment, thenurse advises the patient to go to an emergency centre, to which shedecides to go. Later on the same day, the nurse visits her again at theemergency centre and uses this opportunity to inform his colleague at thiscentre about his findings. Extract 8 is a fragment from the nurse's reportto the colleague of the emergency centre. Finally the nurse writes a reporton the case. Extract 9 is a fragment from the report.

Extract 8(N = social jKychiatric nurse)Nl She clearly has delusional ideas as well.[data omitted]

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Her sexual life, things that happened in it, appears to her as if theywere broadcast on the radio, or at least that somehow happened. So inthat sense she has quite clear circumscribed delusional ideas.

Extract 9There are clear delusional ideas. She fancies her sexual past beingdisclosed on the radio.

These extracts show post hoc the psychiatric relevance of the statement 'Itwas broadcast on radio with whom I went to bed'. Note that the patienthas not said in so many words that her sexual past has been disclosed onthe radio, but that it is rather the gist of the whole sequence of (thenurse's) questions and (the patient's) answers. This information, that isjointly produced by the patient and the nurse in their talk, figures in thenurse's report as a symptom of a particular psychiatric 'reality', i.e. 'delu-sion'. This is not to say that we know for sure that the nurse was con-sciously involved in conversationally eliciting the symptom by asking theappropriate questions. But it is likely that the nurse was oriented to thepotential psychiatric relevance of this talk during its unfolding.

Note that we, as analysts, now 'know' the psychiatric relevance of thenurse's questions in Extract 7, not by means of consulting a general bodyof knowledge about what an emergency psychiatric nurse is normallyaiming at (his generally assumed tasks and competences) but rather byconsulting the nurse's own 'analysis' of what was said. This implies thatwe do not need any assumption about the parties' mutual orientation andco-identification as Eglin and Wideman do. Thus, whereas I do not wantto dispute Eglin and Wideman's claim that in a medical encounter doctorand patient mutually orient to the conversational tasks at hand, i.e. thatthey jointly and concertedly accomplish a conversation, I do dispute theclaim that parties mutually orient to tasks which are specific for the med-ical encounter. In other words, parties in medical encounters co-identify interms of conversational identities (that is as turn-takers), not in terms ofinstitutional identities. The patient and the nurse mutually orient to con-versational tasks, but they do not have the opportunity to orient mutu-ally to each other's interests. Whereas the nurse is able to recognise thepatient's relevancies, the patient is not able to recognise the nurse's rele-vancies nor how these inform the nurse's utterances.

Ctmclusion

Although patients' knowledge of professional standards and objectiveswill vary considerably with the kind of service (e.g. the public knowsmore about procedures and standards of general practice than of psychia-try) and patients' characteristics (e.g. class, gender and education), it is acharacteristic feature of medical encounters that professionals (i.e. doctorsO Basil Blackwell Ltd/Editorial Board 1994

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and nui^es) have a relatively complete understanding of what the patientattempts to achieve in the encounter. On the other hand, patients cannotunderstand doctors' objectives and, hence, strategy, completely. This dif-ference constitutes my interactional version of the professional dominancethesis. The approach in which the interactional form of professional dom-inance is confined to particular tum types or to the overall interactionalshape of the encounter are bound to fail, because professional dominancehas to be conceived of as a relationship between perspectives in the firstplace, not between tums.

Address for correspondence: Tony Hak, Sociology, M5-10, Erasmus University, POBox 1738, 3000 DR Rotterdam, The Netherlands.

AcknowledgemeBts

A draft version of this paper was presented at the Annual Conferen<x of theBritish Sociological Association, University of Manchester, March 1991. The pre-sent version has benefited from comments of Fijgje de Boer, Joke Haaflcens,David Hughes and two anonymous reviewers.

Notes

1 The discussion in this paper is restricted to encounters (or those parts ofencounters) in which the professional solicits information from the client inorder to assess the problem. I do not discuss how professionals communicatetheir diagnostic conclusions and their proposals for treatment.

2 See Appendix for details of transcription symbols. Mishler's very detailed tran-script has been reduced (particularly by eliminating indications of overlap,intake of breath, and the like) because this detail is not necessary for my pre-sent purpose).

3 See Appendix for details of transcription symbols. This data was collected inthe frame of a research project on decision-making in psychiatry (see De Boerand Hak 1986). This data has not been collected for the purpose of discussingthe interactional form of professional dominance. It can be asked to whatdegree the extant discussion in the literature has been shaped by the more orless accidental fact that certain data from a particular setting was at hand. Themost extreme case is Eglin and Wideman's (1986) who present data from tele-phone calls to the police in order to criticise interpretations other researchersniade of data from medical encounters. I consider it positive that many contri-butions to this discussion refer to data of doctor-paren/ conversation, becausethis makes it easier to make the necessary distinction between the mere applica-tion by professionals of professional procedures to an object (the patient as abody, here represented by the child) and the articulation of its practice impli-cations in a dialogue with other parties and their perspectives (the patient as apterson, here represented by the parents), of which only the latter is the field inwhich professicmal 'dcnninance' mattca^ (see Strong 1979: 132). Because in

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psychiatry the patient as a person is the object of professional assessment aswell, it is more difficult to maintain the distinction between 'pure' professionalwork and its articulation to the patient's perspective. The latter perspectiveitself can become an object of professional assessment. Professional 'domi-nance' is therefore a less distinct and more pervasive feature of mental healthencoimters.

It can be asked as well to what degree the discussion in the following part ofthis paper has been shaped by the fact that it takes as data an encounterbetween a social psychiatric nurse, not a psychiatrist, and a patient. However,the aim of this paper is not to describe how professional dominance looks likein specific settings or with different kinds of professionals but rather to discusshow it can be 'discovered' and described in conversational data.

4 See Appendix for details of transcription symbols. Jefferson and Lee's verydetailed transcript has been reduced because this detail is not necessary for mypresent purpose.

5 For the purpose of this discussion I take it for granted that differences could befound. I would like to point out, however, that differences found between 'insti-tutional' and 'everyday' encounters do not necessarily reflect the effects of the'institutional' setting. There are many other concurrent differences between thecompared settings than the mere difference between 'institutional' and 'every-day'. Most of the comparisons between doctor-patient encounters on the onehand and everyday conversations between, say, friends on the other hand, forinstance, ignore the fact that the medical encounter takes place in an environ-ment in which the doctor is 'at home' and the patient is a 'guest'. Comparingthe doctor-patient interview with, e.g., 'everyday' talk between a boy and theparents of his girlfriend at the occasion of his first visit to her parents' homewill reveal that so-called 'institutional' characteristics of talk can be found inthat kind of situation as well. The same applies, for that matter, to nonverbalcharacteristics such as that the guest does not take his coat off before beinginvited by the host to do so, that the guest does not move freely in the room,etcetera ( see for more examples: Strong 1979: 130).

6 This is a good example of Freidsonian 'dominance' because there is no dis-agreement between the nurse and the client on the client's diagnosis or therapy,i.e. on matters that could be considered as entirely within the professional'scompetence. The client's problem at hand is to convince the nurse that his com-plaints about housing be considered a part of the professionally acknowledged(psychiatric) problem. It is left entirely to the professional's discretion to decidewhether a complaint is relevant in his perspective or not. In other words, it isnot a matter of 'dominance' whether an acknowledged complaint is considered asymptom of, say, schizophrenia or another kind of psychotic disturbance. Butit u a matter of professional dominance that the professional is in the positionto judge a complaint as 'serious' or just 'pretending'. This is an additional rea-son why conversational 'asymmetries' such as described by Maynard (1991),which may be correct descriptions of how professionals make use of conversa-tional devices in a particular way, are not always relevant for a study of 'domi-nance' (in a Freidsonian sense). It is not the professional assessment of theclient's problems as such (the diagnosis), nor its telling, that is the issue for thestudy of professional dominance. The issue rather is the decision on whatcounts as a 'symptom' to be diagnosed. In other words, applying a professional

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perspective cannot be 'dominant' in itself, but deciding on what is taken as arelevant thing to be diagnosed is contestable and hence a matter of dominance.This data has been collected as part of the same research project as Extract 4.See for further analyses of this data: De Boer and Hak (1986), Hak (1989) andHak (1992).

Appendix

Symbols used in data transcription.

(0.5) pause of 0.5 seconds(word) word(s) unclear but 'retrieved' as far as possible by transcriber( ) utterance produced but its sense could not be discerned((sobbing)) transcriber's commentsnine underlining indicates emphasis on that word or part of word

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