Closing medical encounters: two physician practices and their ... · The ﬁrst part of the terminal sequence (line 1) proposes closure of the interaction, obligates a second closing

Social Science & Medicine 53 (2001) 639–656

Closing medical encounters: two physician practices and theirimplications for the expression of patients’ unstated concerns

Jeffrey D. Robinson*

Department of Speech Communication, The Pennsylvania State University, 234 Sparks Building, University Park, PA 16802-5201, USA

Abstract

When patients visit primary-care physicians, they frequently have more than one concern. Patients’ first concernsare solicited by physicians at the beginnings of encounters. A challenge to health care is how to get patients’additional concerns raised as topics of discussion. If patients’ additional concerns are addressed, it tends to occurat the end of encounters. Using the methodology of conversation analysis, this article identifies and describes theinteractional organization of two physician-initiated communication practices that are used to negotiate the closure ofthe business of encounters and a transition into the activity of closing encounters themselves. These practices havedifferent implications for the topicalization of patients’ additional concerns. # 2001 Elsevier Science Ltd. All rightsreserved.

Keywords: Physician patient encounters; Communication; Conversation analysis; Closing interactions

Introduction

An examination of the structure of physician–patientcommunication, including the norms and rules ofinteraction itself, is one path to understanding andsolving problems in health care. For example, Pomer-antz (1984) examined how physicians can managedifficulties with taking patients’ medical histories,Heritage and Stivers (1999) examined how pediatricianscan reduce parents’ expectations for antibiotics, andBeach and Dixson (2000) examined how physicians canemploy empathy to improve diagnosis. This articleexamines two different structures of interaction involvedin closing medical encounters and discusses theirimplications for a recurrent problem in health care:Patients are not always able to express their full agendaof concerns. The article begins by reviewing this problemand its relationship to closing encounters. The bulk ofthe article is devoted to describing the interactionalorganization of two, physician-initiated communication

practices that physicians and patients use to negotiatethe closure of the business of encounters and thetransition into the closing phase of encounters.The article concludes by discussing the implications ofthese practices for patients’ topicalization of unstatedconcerns.

Statement of the problem

When patients visit primary-care physicians, theyoften have more than one concern, including medicalproblems, requests for non-diagnostic services (e.g.,prescriptions), and requests for information (Barsky,1981; Stoeckle & Barsky, 1981; White, Levinson, &Roter, 1994; White, Rosson, Christensen, Hart, &Levinson, 1997). Even if patients have a single concern,it can be multifaceted, containing multiple biomedicaland psychosocial components (Lipkin, Frankel, Beck-man, Charon, & Fein, 1995). All of this is importantbecause physicians’ knowledge of the full spectrum ofpatients’ concerns is vital not only to the accuratediagnosis and treatment of medical conditions, but to

*Tel.: +1-814-863-3757; fax: +1-814-863-7986.E-mail address: [email protected] (J.D. Robinson).

0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 3 6 6 - X

the delivery of comprehensive and quality health care(Fisher, 1991; Larsson, Saljo, & Aronson,1987; Lipkinet al., 1995; McWhinney, 1981, 1989; Mishler, 1984;Sankar, 1986; Todd, 1984, 1989). Thus, an importantquestion for health care is: How do patients’ concernsget raised as topics for discussion?The primary way that patients’ concerns get topica-

lized is when they are solicited by physicians at thebeginnings of encounters, with questions such as ‘‘Whatcan I do for you today?’’ (Bates, Bickley, & Hoekelman,1995; Beckman & Frankel, 1984; Billings & Stoeckle,1989; Byrne & Long, 1976; Greenberger & Hinthorn,1993; Heath, 1981; Seidel, Ball, Dains, & Benedict, 1995;Swartz, 1998; Zoppi, 1997). However, these solicitationsare routinely understood by patients, and treated byphysicians, as solicitations of single concerns. Uponcompletion of patients’ presentations of their firstconcern, rather than continuing to solicit additionalconcerns, physicians frequently deal with the firstconcern, which includes progressing through theactivities of history taking, physical examination,diagnosis, and treatment (Beckman & Frankel, 1984;Beckman, Frankel, & Darnley, 1985; Marvel,Epstein, Flowers, & Beckman, 1999). This raises thequestion: How do patients’ additional concerns gettopicalized?There are at least two types of barriers to the goal of

topicalizing patients’ additional concerns. First, thereare psychological barriers. Patients can be anxious orembarrassed about raising and talking about additionalconcerns, either due to their serious nature (Lipkin et al.,1995) or to their relatively non-serious nature, in thesense that patients can feel that non-serious concerns aretrivial and/or that their topicalization is accountable(e.g., patients might fear being labeled a hypochon-driac).Second, there are interactional barriers } that is,

barriers built into the organization of communicationitself. Specifically, interactants do not raise topicsrandomly. Rather, there are orderly communicationpractices for introducing new topics (Button & Casey,1984, 1985, 1988/1989; Schegloff & Sacks, 1973).Important for the present article is a practice discussedby Schegloff & Sacks:

A further feature of the organization of topic talkseems to involve ‘‘fitting’’ as a preferred procedure.That is, it appears that a preferred way of getting[topics] mentioned is to employ the resources of thelocal organization of utterances in the course of theconversation. That involves holding off the mentionof a [topic] until it can ‘‘occur naturally,’’ that is,until it can be fitted to another conversationalist’sprior utterance, allowing his utterance to serve as asufficient source for the mentioning of the [topic](p. 301).

Schegloff and Sacks observed that there is ‘‘noguarantee that the course of the conversation willprovide the occasion for any particular mentionable to‘come up naturally’’’ and ‘‘[t]his is so even when theoccasion for the conversation was arranged in theinterests of that topic’’ (Schegloff & Sacks, 1973, p.302). Thus, even in the context of physician–patientencounters, there is no guarantee that the interactionwill provide a ‘‘natural’’ environment for the topicaliza-tion of patients’ additional concerns. This dilemma iscompounded by the phase organization of encounters.Encounters are routinely composed of six activities: (1)relating to patients (i.e., opening encounters), (2)discovering patients’ reasons for attendance (i.e., physi-cians soliciting, and patients presenting, medical busi-ness or chief complaints), (3) conducting verbal and/orphysical examinations (i.e., information-gathering in-vestigations), (4) considering patients’ conditions (i.e.,diagnosis), (5) detailing treatment or further investiga-tion, and (6) terminating (i.e., closing encounters) (Byrneand Long, 1976). During the course of dealing with (i.e.,diagnosing and treating) patients’ first concerns, thetopicalization of additional, new concerns may bespecifically non-relevant (Robinson, 1999). Further-more, upon completion of dealing with patients’ firstconcerns, it can be relevant to end, or close, encounters(Heath, 1986).These barriers have promoted the classic ‘‘by-the-

way’’ syndrome (Byrne & Long, 1976), where patientspresent ‘‘doorknob’’ concerns. As Zoppi (1997) elabo-rated, ‘‘When the physician’s hand is on the doorknob,ready to exit, patients may have one or more importantunresolved concerns that they want to discuss’’ (p. 51).This phenomenon appears to be quite general. Whiteet al. (1994) found that patients raised new concernsin the closing phase of 21% of encounters. Thus,it appears that if patients topicalize additionalconcerns, one primary location is during the transitionout of the business of encounters and into the activity ofclosing.In order to solicit the full spectrum of patients’

concerns, physicians are trained to ‘‘survey concerns,’’or solicit additional concerns throughout encounters(Cohen-Cole, 1991; Roter & Hall, 1992; Seidel et al.,1995; Swartz, 1998). Although physicians are encour-aged to survey concerns after patients finish presentingtheir first concern (Lipkin et al., 1995), this rarely occurs(Beckman & Frankel, 1984; Beckman et al., 1985;Marvel et al., 1999). In practice, if physicianssolicit additional concerns, they tend to do soafter dealing with patients’ first concerns (Whiteet al., 1994, 1997). Thus, analogous to patients,if physicians seek to topicalize patients’ additionalconcerns, one primary location is during the transitionout of the business of encounters and into the activity ofclosing.

J.D. Robinson / Social Science & Medicine 53 (2001) 639–656640

Despite the fact that this transition appears to be acritical locus for the negotiation of the topicalization ofpatients’ additional concerns, it has received extremelylittle analytic attention. In his groundbreaking analysisof videotapes of closings in British encounters, Heath(1986) focused primarily on the ‘‘series of movesthrough which the face-to-face orientation is dismantled,and mutually coordinated interaction is brought to anend’’ (p. 129). Although Heath was fully aware that‘‘ending the consultation entails bringing the business toa satisfactory conclusion’’ (p. 129), the rigorous detailwith which he analyzed the activity of closing itselfallowed him only a brief discussion of how physiciansand patients negotiate the transition from the businessof encounters into the activity of closing. This transitionwas studied (albeit with a different methodology andanalytic goal) by White and her colleagues (White et al.,1994, 1997). White et al., analyzed audiotapes ofAmerican encounters and focused on how physiciansand patients communicate a ‘‘transition from theeducational phase to closure.’’ White et al.’s research

has been both pioneering and productive. For example,they demonstrated that the frequency with whichpatients topicalize new concerns is negatively associatedwith certain physician communication behaviors, suchas giving patients information about the therapeuticregimen (White et al., 1994). The primary limitation ofWhite et al.’s research is its reliance on audiotape data,which hampered their ability to operationalize andlocate sentences that accomplished a transition intoclosing. Because they did not have access to physicians’and patients’ closing-relevant, embodied actions asevidence for what constituted transition-relevant sen-tences, they relied on coders’ assessments of the talk.Coders’ exact agreement was only 50% (White et al.,1994).This article identifies, and describes the interactional

organization of, two practices that physicians andpatients use to negotiate a transition from the businessof encounters to the activity of closing. In order to dothis, a brief review of the literature on closing interac-tions is necessary.

Closing interactions

The goal of closing medical encounters is verbally andnonverbally ending a spate of interaction betweenphysicians and patients. However, physicians andpatients cannot appropriately end encounters simply

by stopping talking or walking out of the office.Communication during encounters is organized by aturn-taking system (Sacks, Schegloff, & Jefferson, 1974).As long as the rules for turn taking are operative, thepossible completion of a turn of talk is a place whereturn transfer is relevant (Sacks et al., 1974). Thus, theaction of stopping talking or physically leaving theinteraction is accountable (Schegloff & Sacks, 1973).That is, without additional work, post-turn silences willbe understood as the product of one participant‘‘declining’’ to speak and thus as a silence within acontinuing encounter rather than as constituting the‘‘end’’ of the encounter. In order to appropriately endencounters, physicians and patients must collaborativelywork to suspend the transition relevance of possible turncompletion such that stopping talking or leaving isunderstood as ending the encounter. According toSchegloff & Sacks (1973), a standard solution to thisproblem is a sequence of talk specialized for thisparticular job, called the ‘‘terminal’’ sequence, as seenin Extract 1:

The first part of the terminal sequence (line 1)proposes closure of the interaction, obligates a secondclosing token from the recipient (line 2), and commu-nicates that, upon completion of such a response, theinteraction will end and the rules for turn taking will nolonger be operative.However, there are at least two reasons why a

terminal sequence is not sufficient to appropriately closean interaction. First, initiating the first part of a terminalsequence (e.g., ‘‘Bye’’) is not necessarily, by itself or inisolation, understandable as doing the action ofproposing closure. For example, a patient who says‘‘Bye’’ after a physician has completed history takingbut before the physician has performed a physicalexamination would not be heard as seriously proposingclosure but perhaps as ‘‘joking’’ and/or making somecommentary on the anticipated pain of the exam. Inorder to get ‘‘Bye’’ heard as seriously proposing closure,participants must establish a warrant for proposingclosure (Schegloff & Sacks, 1973), or an interactionalenvironment in which the proposal of closure can beunderstood as such. Second, at any point during anencounter, physicians or patients may have additionaltopics to discuss that have not yet been introduced. Theaction of proposing closure of an interaction (e.g.,‘‘Bye’’) threatens to interfere with participants’ as-of-yetunspoken agendas and thus infringe upon their rights toproduce further talk and topicalize those agendas(Schegloff & Sacks, 1973). According to Schegloff and

J.D. Robinson / Social Science & Medicine 53 (2001) 639–656 641

Sacks, a standard, simultaneous solution to both ofthese problems is the ‘‘possible preclosing’’ sequence, asseen in Extract 2.

A’s initial preclosing token (line 1) simultaneouslyproposes a warrant for closing the interaction andprovides B with the opportunity to topicalize as-of-yetunspoken agendas. B’s responsive preclosing token (line2) accepts and establishes a warrant for closing theinteraction.Important for the present article, practices for

establishing warrants for closing interactions (e.g.,producing a preclosing token, such as ‘‘Okay’’),themselves face the problem of not necessarily, bythemselves or in isolation, being understandable as such.For example, after the completion of history taking, aphysician’s ‘‘Okay’’ is not likely to communicate awarrant for closure, but rather a likely shift to a newactivity, such as physical examination (Beach, 1995b).Participants must create an interactional environment inwhich warrants for proposing closure can be understoodas such (Schegloff & Sacks, 1973). These can be called‘‘closing-relevant’’ environments. Closing-relevant en-vironments are largely determined by the organizationof topics within conversations (Schegloff & Sacks, 1973).Specifically, some topics are understandable as ‘‘possiblylast’’ topics of interactions and their completion canconstitute closing-relevant environments. In medicalencounters, due to the institutionalized ordering ofactivities (Byrne & Long, 1976; Waitzkin, 1991), thecompletion of treatment-related topics and actions }such as educating patients about treatment, writingprescriptions, and filling out insurance and laboratorytest forms } can constitute closing-relevant environ-ments (Heath, 1986; Robinson, 1999).In addition to ‘‘possibly last’’ topics, there can also be

‘‘designedly last’’ topics, which are hearable as a lasttopic of an entire interaction and thus can communicatethat the completion of the topic will constitute a closing-relevant environment. For example, it has been widelydocumented that, in both mundane and institutionalcontexts, the general action of arrangement making }especially when the arrangements invoke actions thatwill be accomplished after the current interaction isterminated } is socially understood as a last topic(Button, 1987; Hartford & Bardovi-Harlig, 1992; Heath,1986; Houtkoop-Steenstra, 1987; Schegloff & Sacks,1973; White et al., 1994).

This article analyzes two, physician-initiated commu-nication practices that physicians and patients use tonegotiate the closure of the business of encounters and

the transition into the closing phase of encounters.These practices are deployed in closing-relevant envir-onments and are organized into sequences of talk. Thus,they will be referred to as business-preclosing sequences.

Data and method

The data are drawn from a corpus of 48 audio- andvideotaped adult, primary-care encounters collectedfrom seven, community-based, Southern Californiapractices between 1995–1998. Participants included anavailability sample of one physician from each practice(four men and three women) and 48 of their patients (anaverage of seven patients per physician). All datacollection was approved by a university human-subjects’protection committee. Participants provided informedconsent to be recorded prior to the study, were aware ofbeing recorded, and gave permission to publish therecordings. All data were transcribed by the author (seeThe appendix for transcription conventions). Themethod used is conversation analysis (CA; for review,see Atkinson & Heritage, 1984), particularly as it isapplied to the study of institutional interaction (forreview, see Drew & Heritage, 1992). CA uses audio- andvideo-tapes of naturally occurring conduct to induc-tively describe the norms and rules of interaction; thisincludes a description of the procedures by which peopleproduce their own behavior and understand and dealwith the behavior of others. For example, researchershave examined how people build and coordinate turnsof talk (Sacks et al., 1974), repair problems of speaking,hearing, and understanding (Schegloff, Jefferson, &Sacks, 1977), and build actions (e.g., offers, requests,assessments) and activities (e.g., opening and closinginteractions) (Schegloff, 1968, 1995, 1996).

Analysis

The ‘‘arrangement-related ’’ business-preclosing sequence

The first practice will be referred to as the‘‘arrangement-related’’ business-preclosing sequence


(hereafter, ‘‘arrangement sequence’’). The arrangementsequence is typically composed of two sequences of talkand is schematically represented in Diagram 1.The first sequence (la and 1b) is called the future-

arrangement sequence. In the first part of this sequence(la), physicians invoke an action that will be accom-plished after the current encounter is terminated.Typically, these actions involve future arrangementsthat are particularized to the context of medicine. Forinstance, physicians can initiate instructions or propo-sals concerning when patients are to visit physiciansnext, such as ‘‘I’ll see you again in a couple of months’’or ‘‘Come and see me at the end of next week.’’Alternatively, physicians can initiate announcements ofevents that will or should occur after the encounter ends,such as ‘‘They’ll contact you with the appointment forthe dermatologist’’ or ‘‘The nurse will be in a minutewith a flu shot.’’ Similar to arrangements in mundaneinteraction, physicians’ future arrangements initiatedesignedly last topics and thus communicate that theirresolution will constitute a closing-relevant environ-ment.1

The future-arrangement sequence deals primarily withsecuring patients’ acceptances of an arrangement. Thefirst part of this sequence obligates either an acceptanceor rejection of the proposed arrangement, and this iswhat the second part of the future-arrangement se-quence (lb) is composed of. Patients routinely respondwith tokens such as ‘‘Okay’’ or ‘‘Alright.’’ Theseresponses simultaneously accept physicians’ arrange-ments, close the future-arrangement sequence, andcollaborate in the creation of a closing-relevant envir-onment.Upon patients’ acceptances of the future-arrangement

sequence, physicians frequently initiate a second, topic-

closing sequence (2a and 2b; re: topic-closing sequences,see Davidson, 1978; Schegloff & Sacks, 1973).2 In thefirst part of this sequence (2a), physicians producetokens such as ‘‘Okay?’’ and ‘‘Alright?’’, typically withrising intonation. These tokens request reconfirmationof patients’ prior acceptances of physicians’ arrange-ments. These tokens obligate a response (2b) andprovide patients with an opportunity to raise issuesdealing with the particularities of physicians’ arrange-ments and patients’ prior acceptances of them. Insofaras physicians’ requests for reconfirmation (2a) markedlypropose to close a designedly last topic (i.e., the futurearrangement), and insofar as they are produced inclosing-relevant environments, they strongly projecta contingent shift into the activity of closing } that is,contingent upon patients’ confirmations. Patientsroutinely respond by confirming their acceptance withtokens such as ‘‘Okay’’ or ‘‘Alright.’’ When patientsprovide confirmations, they collaborate in closing adesignedly last topic and establishing an environment inwhich closing the encounter is the most relevant nextactivity.Two examples are provided of the arrangement

sequence. First, see Extract 3. The patient is visitingthe physician to monitor two chronic problems (bloodsugar and blood pressure) and to deal with one newproblem (extremely dry skin). At the end of the visit, thephysician fills out a variety of forms, the last of which isfor a referral to a dermatologist for her skin problem.Note that by saying, ‘‘An’ then, (0.9) one more form’’(line 724), the physician indicates that the form for thedermatologist will be the last and thus that itscompletion will constitute a closing-relevant environ-ment (Heath, 1986).While the physician fills out the form for the

dermatologist, the patient tells a story about buyingwormy fish at a local supermarket. After the physicianfinishes filling out the form, he picks it up and confirms

Diagram 1. The Arrangement-Related Business Preclosing Sequence

1This is supported by White, Levinson, and Roter (1994),who found that two of the most frequent communicationbehaviors associated with transitions into closings were‘‘clarifying the plan of care’’ and ‘‘orienting patients to specificnext steps of the visit.’’ For example, White et al. cited sentencessuch as ‘‘Okay, let’s see you back in four or five months,’’ ‘‘Ifit’s not getting better in a week, let me know,’’ and ‘‘We’ll justsee how it goes in the future’’ (p. 25).

2Sequentially, the topic-closing sequence is a post-expansionsequence (Schegloff, 1995) to the future-arrangement sequence;it continues and finalizes the course of action of making thearrangement.


the patient’s address. Subsequently, at line 856, thephysician initiates an arrangement sequence by announ-cing } and proposing for confirmation } an event thatwill occur after the ending of the encounter: ‘‘They’llcontact you. uh: with the appointment for thedermatologist’’ (la! ). This arrangement, itself adesignedly last topic, is produced in a closing relevantenvironment (i.e., after treatment). There is visual (i.e.,videotape) evidence that the patient understands thephysician’s arrangement to be initiating a transition intothe activity of closing.3 Through the completion of thearrangement (line 857), the patient is sitting in a chair(next to the physician’s desk) and gazing at the physician(the physician is sitting at his desk). As the patientaccepts the arrangement, ‘‘Okay’’ (1b; line 859), sheshifts her gaze, and thus her current focus of attention,from the physician down to her lap, in which she has hersweater and purse (re: gaze, body orientation, andattention, see Argyle and Cook, 1976; Goffman, 1967;Goodwin, 1981; Kendon, 1990a–c; Scheflen, 1974).Insofar as patients routinely gather their personalbelongings preparatory to leaving the room, a shift inattention to them can display patients’ orientation to therelevance of closing.

The physician’s ‘‘Should hear within a couple weeks’’(la; line 860) provides an additional component to, andthus is an extension of, his initial arrangement. Thepatient accepts this with ‘‘Alright’’ (lb; line 861).Throughout this sequence (at lines 860–861), the patientcontinues to prepare to leave the room. That is, she leansforward in her chair and visually scans the floor for herbelongings.The physician’s ‘‘Okay’’ (2a! ; line 862) seeks to

reconfirm the patient’s acceptance; it also stronglyprojects a contingent shift into closing. The patientconfirms with ‘‘Uh huh’’ (2b! ; line 863), which ratifiesthe physician’s proposal to shift into closing. This issupported by the fact that, as the patient completes ‘‘Uhhuh’’ (line 863), she begins to stand up. In the ensuingtalk, which constitutes the activity of closing, thephysician and patient exit the room.4

3All claims in this article concerning visual data aresupported by frames of videotape, which were made availableto the reviewers. A version of this article with photographs canbe obtained by contacting the author.

4Although this article is primarily about how physicians andpatients close the business of encounters and transition intoclosing, Extract 3 raises issues concerning the activity of closingitself. In face-to-face contexts (compared to, for example,telephone contexts), the activity of closing interactions includesboth the termination of talk as well as the termination ofcopresence. The termination of copresence cannot be accom-plished instantaneously (compared to, for example, hanging upa phone). This complicates the activity of closing because aslong as people are copresent they are available to each other forfurther interaction. As in Extract 3, physicians and patientsfrequently leave offices together and engage in talk while


For a second example of the arrangement sequence,see Extract 4. The patient’s primary reason for visitingthe physician is to follow up on a sinus infection. Afterconcluding this business, they proceed to deal with threesecondary pieces of business: reviewing an EKG,evaluating a chest x-ray, and discussing the patient’scholesterol level. The first two are dealt with at lines 89–95. The physician initiates the third piece of business bysaying, ‘‘Then: the only thing that you’re working o:n isyour cholesterol’’ (lines 109–110). The physician’scharacterization, ‘‘only thing,’’ and shift to futurebusiness, ‘‘working on,’’ communicate that cholesterolis a possibly last topic, the completion of which canconstitute a closing-relevant environment. The physicianconcludes the topic of cholesterol by formulating anupshot of the prior discussion and summarizing a planof care: ‘‘So we’ll give this a few months and see howyou do:’’ (line 144; re: summaries and upshots as topic-closing devices, see Button, 1987). At line 146 (la! ), thephysician initiates an arrangement sequence by propos-ing a future-arrangement concerning when the patientwill next visit the physician: ‘‘an’ then we’ll see youabout Ma:rch.’’

The patient accepts the physician’s proposal concern-ing the timing of the next visit, ‘‘(Uh) Okay’’ (lb! ; line148), and thus collaborates in the closure of a designedlylast topic. Upon completion of the patient’s ‘‘(Uh)Okay,’’ the physician’s gaze and body are orientedtoward the patient. After the patient accepts theproposal, the physician seeks to reconfirm the patient’sacceptance: ‘‘O:^kay^’’ (2a! ; line 150). The physician’s‘‘O:^kay^’’ is a bid to close the topic of the arrangement,which was itself positioned in a closing-relevant envir-onment and thus projects a contingent shift into theactivity of closing (Davidson, 1978; Schegloff & Sacks,1973). This is supported by visual evidence. The patientis sitting on the edge of the bed and the physician isstanding next to the patient. As the physician initiates‘‘O:^kay^,’’ she begins to turn her body and gaze awayfrom the patient toward a counter on the opposite sideof the room, which communicates that she is removingher attention from the patient and making a transitioninto a new activity, most likely closing (Goodwin, 1981;Goodwin & Goodwin, 1987; Kendon, 1990a, 1990b,1990c; Schegloff, 1998). The patient responds byconfirming his acceptance, ‘‘N:ot a ^pro^blem’’ (2b! ;

Footnote 4 continuedleaving, thereby producing relatively extended closings. One important point is that talk is typically understood relative to the coursesof action and activity in which it is embedded (Schegloff & Sacks, 1973). For example, in Extract 3, after the patient has begun to bothreconfirm her acceptance of the physician’s arrangement (line 863) and stand up, the physician says, ‘‘I’ll see you again in a month’’(line 864). Although this is a proposal of a future arrangement to be confirmed or disconfirmed ( which the patient confirms at line 865,‘‘Okay’’), it is produced in the context of the in-progress activity of closing and does not accomplish exactly the same action as thefuture-arrangement proposal discussed earlier } that is, those produced in the context of closing-relevant environments. For example,the physicians’ proposal at line 864 is neither produced nor understood to project a contingent shift into closing; rather, it is a ‘‘lastminute’’ reminder. These observations drive home the imperative that, when coding communication, researchers be sensitive to thecourses of action and activity in which it is embedded.


line 151), which collaborates both in closing thearrangement and in the projected shift into the activityof closing. It was argued earlier that topic-closingsequences provide patients with a sequential opportunityto raise issues dealing with the particularities of physic-ians’ arrangements. This is supported by the patient’s‘‘N:ot a ^pro^blem,’’ which displays his orientation tothe physician’s ‘‘O:^kay^’’ as seeking confirmation ofthe acceptability of the arrangement. Following thepatient’s ‘‘N:ot a ^pro^blem,’’ the physician continues tomove toward the counter and produces ‘‘O:kay’’ (line153), which initiates a shift to new matters (Beach,1995a, 1995b), in this case the activity of closing . This issupported by the fact that, as the physician produces‘‘O:kay,’’ she begins to close the patient’s medicalrecords (which she has used throughout the encounter)and continues to move away from the patient.There is also evidence that the patient understands

that the physician is making a transition into closing.Precisely upon completion of the physician’s ‘‘O:kay’’(line 153), and before the physician verbally begins toclose the encounter, the patient initiates what Schegloff(1980) described as a pre-presequence } ‘‘I got (.) abouttwo- questions for >you though.5 three questions’’(lines 154–155) } which communicates the contingentpossibility that multiple courses of action will beproduced, in this case multiple questions about addi-tional, new concerns. Here, the patient solicits either a‘‘go-ahead’’ or ‘‘blocking’’ response from the physician.

The physician’s ‘‘Su:re’’ (line 156) grants the patientpermission to go ahead with his line of questioning,which he does at lines 157–161. The patient’s attempt totopicalize additional concerns is produced with referenceto, and competitively with, the physician’s transitioninto closing and functions to interdict this activity. InButton’s (1987) terms, the patient re-opens the closing.This is supported by the patient’s use of the word‘‘though’’ (line 155), which positions his proposedactivity of asking ‘‘questions’’ as competing with analternate activity, that of closing. The patient’s move tointerrupt closing is a delicate matter } after all, he andthe physician had just collaborated in paving a road toclosure. Indeed, as Schegloff (1980) found, tellingsomeone that you have a question to ask them can bea way of communicating that the projected questionconcerns a ‘‘delicate’’ matter.The patient re-opens the closing in order to topicalize

new concerns. However, if the arrangement sequence atlines 146–151 was, in fact, a practice for negotiating theclosure of the business of the encounter and a transitioninto closing, then we should expect that, after thephysician and patient finish discussing the patient’sadditional concerns, then they should proceed to, onceagain, transition into closing. Indeed, after the topic ofthe cyst is closed, they close the encounter. Thus, there isevidence that the patient’s additional concerns areproduced interruptively with, and as a ‘‘diversion’’from, the activity of closing.


The physician’s summary of the diagnosis andtreatment at lines 250–251, ‘‘Yea:h it’s just a small littlecyst that we’ll really wouldn’t do anything about it,’’proposes to close the topic of the cyst (Button, 1987),and the patient collaborates with this by producing‘‘Okay’’ (lines 253). Upon completion of the patient’s‘‘Okay’’ (line 253), the physician is again standing infront of, and gazing at, the patient. At line 254, thephysician asserts ‘‘So you’re all set,’’ which proposes toend the encounter and thus begins to negotiate a shiftinto the activity of closing. This is supported by the factthat, as she says this, she begins to shift her body andgaze away from the patient toward the door inpreparation for exiting the room. These nonvocalbehaviors are similar to those that the physician enactedduring her initial shift into closing (line 150) andagain communicate that she is removing her attentionfrom the patient and making a transition intoclosing (Goodwin, 1981; Goodwin & Goodwin,1987; Kendon, 1990a–c; Schegloff, 1998). There isevidence that the patient understands this. As he acceptsthe physician’s proposal, ‘‘Oka:y’’ (line 256), he beginsto get off of the table in preparation for exiting theroom.In sum, the arrangement sequence is typically

composed of two, ordered sequences of action: aproposal of a future-arrangement and a request forreconfirmation of patients’ acceptances. The future-arrangement sequence deals primarily with securingpatients’ in-principle acceptance of the arrangement-related action and the topic-closing sequence providespatients with a sequential opportunity to raise issuesdealing with the particularities of physicians’ arrange-ments. The arrangement sequence is one communicationpractice that physicians and patients use to negotiate theclosure of the business of encounters and a transitioninto the activity of closing.

The ‘‘final-concern’’ business-preclosing sequence

A second practice will be referred to as the ‘‘final-concern’’ business-preclosing sequence (hereafter,‘‘final-concern sequence’’). In its most basic form,the final-concern sequence consists of a single sequenceof talk, and is schematically represented in Diagram 2.In the first part of this sequence (la), physicians’ solicit

‘‘last’’ or ‘‘final’’ concerns, with questions such as ‘‘Any

other problems?’’, ‘‘Any other questions?’’, and‘‘Anything else?’’ These questions obligate either ‘‘yes’’-or ‘‘no’’-type answers (lb). ‘‘Yes’’-type answers areones that topicalize concerns (which do not have to be‘‘new’’ relative to the prior encounter) and lead totheir discussion. ‘‘No’’-type answers are ones thatdecline to topicalize concerns and acquiesce to a shiftinto closing.In principle, final-concern questions can be gramma-

tically designed, and rhetorically delivered, in manydifferent ways. For example, physicians can either ask‘‘Do you have other concerns?’’ or ‘‘Any otherconcerns?’’( Cohen-Cole, 1991). However, in practice,physicians’ final-concern questions are frequently de-signed with a bias such that they ‘‘prefer’’ ‘‘no’’-typeanswers, or answers that decline to topicalize additionalconcerns and acquiesce to a shift into closing (re: theconversation-analytic conception of ‘‘preference,’’ seeHeritage, 1984; Pomerantz, 1984; Sacks, 1987; Schegloff,1988, 1995). One of the most common ways in whichthis bias is achieved is by including the negative polarityitem ‘‘any’’ into the final-concern question (e.g., ‘‘Anyother concerns?’’; Bolinger, 1957; Cohen-Cole, 1991;Frankel, 1990; Quirk, Greenbaum, Leech, & Svartvik,1985; White et al., 1994, 1997). This bias can also beachieved by using negative question formats (e.g., ‘‘Youdon’t have other concerns, do you?’’). Another way isthat physicians can ask final-concern questions with an‘‘exasperated’’ tone of voice. Finally, physicians can askfinal-concern questions while their gaze and bodyorientation nonverbally communicate that they are not(fully) engaged in interaction with patients and/or thatthey are more dominantly engaged in another activity.For example, physicians can ask while gazing at, andwriting in, the medical records, or while they are in theprocess of standing up and preparing to leave the room.This is perhaps why one textbook encourages physiciansto ‘‘ask the patient if there are questions or unfinishedbusiness before beginning to stand up’’ (Zoppi, 1997, p.51, emphasis added).Boyd and Heritage (forthcoming) found that, during

the activity of history taking, physicians design ques-tions according to the ‘‘principle of optimization’’ }that is, with a bias toward pro-social or pro-health(i.e., no-problem) outcomes. At least regarding final-concern questions, physicians appear to ascribe to thisprinciple by designing them to prefer ‘‘no’’-type answers.

Diagram 2. Two Trajectories of the Final-Concern Business Preclosing Sequence


However, for all of the benefits that ‘‘optimized’’final-concern questions offer regarding saving patients’face (Brown & Levinson, 1978), they can have thedisadvantage of being heard as ‘‘perfunctory’’ or‘‘not genuine.’’ The result is that, when physicians‘‘optimize’’ final-concern questions, they interaction-ally manipulate patients away from topicalizing addi-tional concerns and toward closing encounters. In sum,if physicians want to maximize the potential of theirfinal-concern questions for soliciting additionalconcerns, they should halt competing activities(e.g., writing in the medical records), orient their bodiesand gaze toward patients, and grammatically designtheir questions so as not to prefer ‘‘no’’-type responses(e.g., ‘‘Do you have other questions or concerns?’’ or

‘‘Are there other things that you wanted to addresstoday?’’).What follows are two examples of the final-concern

sequence. First, see Extract 5. The patient is visiting thephysician for shoulder pain. The physician concludesthat an X-ray is necessary and, at lines 342–347,discusses when and how he will contact the patient withthe results. During the long silence at line 348, thephysician writes a prescription for an anti-inflammatorymedication. The completion of writing the prescriptionpossibly completes the activity of treatment and thusconstitutes a closing-relevant environment (Heath,1986). At line 349, as the physician finishes writing theprescription, he asks a final-concern question, ‘‘8Any-thing e:lse.8’’ (la).


If the physician’s ‘‘8Anything e:lse.8’’ (la! ; line 349)projects a contingent shift into the activity of closing }that is, contingent upon a ‘‘no’’-type answer } thenupon completion of the patient’s ‘‘no’’-type response,‘‘No::(b) I don’t think so. hhhhhhhh I’m doing prettywell otherwise’’ (lb! ; lines 351–352), we would expectthe physician to shift into closing. Initially, this isnot what happens. Rather, the physician instructsthe patient about what to do if the medicine burnsher stomach (lines 354–356). However, there is evidence,in the design of the physician’s instruction, that his final-concern question did, in fact, project a contingent shiftinto closing. Specifically, the physician prefaces hisinstruction with ‘‘>By thuh way5’’ (line 354). Accord-ing to Schegloff and Sacks (1973), this is an example of a‘‘misplacement marker,’’ which

display an orientation by their user to the propersequential-organizational character of a particularplace in a conversation, and a recognition that anutterance that is thereby prefaced may not fit, andthat the recipient should not attempt to use thisplacement in understanding their occurrence (Schegl-off & Sacks, 1973, p. 320).

With ‘‘>By thuh way5,’’ the physician communi-cates that his instruction is ‘‘misplaced,’’ or inconsistent,relative to the trajectory of the encounter established byprior talk, which was the final-concern sequence. Thephysician’s misplacement marker displays his orienta-tion to producing his instruction within an environmentwhere ‘‘proceeding to close’’ was the most relevanttrajectory, and thus to the final-concern sequence ashaving established that trajectory.If the physician’s instruction was misplaced relative to

closing, then upon completion of the instruction, weshould expect the physician to, once again, shift intoclosing, and this is what happens. The physician’sinstruction to the patient is possibly complete whenthe patient agrees to comply with ‘‘Okay’’(line 362). Thephysician’s subsequent ‘‘8‘Ka:y8’’ (line 363) communi-cates that he has completed his instruction and that he isabout to shift to a new matter (Beach, 1995a, 1995b), inthis case the activity of closing. There are two pieces ofevidence to support this. First, as the physician produces

‘‘8‘Ka:y8’’, he places a carbon copy of the prescriptionslip into the patient’s records, which is preparatory tocompleting medical business. Second, the physicianproceeds to ask a second final-concern question, ‘‘Anyother questions’’ (line 366). The fact that this question isfunctionally similar to the physician’s prior ‘‘8Anythingelse.8’’ (line 349) is some evidence that his prior action ofinstructing the patient (lines 354–363) was an excursusfrom a shift into closing. In response, the patientultimately produces a ‘‘yes’’-type response by asking aquestion about the logistics of her treatment: ‘‘>I j’st5wait to hea:r about thuh physical therapy?’’ (lines 368–369).If the physician’s ‘‘Any other questions’’ (line 366)

projected a contingent shift into closing, then we shouldexpect that, after the patient’s question is answered, thephysician and patient will shift into closing. This issupported by visual evidence. The patient is sitting onthe edge of the bed and the physician is seated in a chairin front of the patient. After the physician answers thepatient’s question (lines 370–371), and after the patientcommunicates that her question has been satisfactorilyanswered, ‘‘(Okay)’’ (line 372), the physician begins tostand up in preparation for exiting the room. In sum,upon resolution of the question–answer exchange, thephysician displays his orientation to closing the en-counter and thus to the patient’s question as being a‘‘final’’ question. In this way, the physician displays hisorientation to ‘‘Any other questions’’ as soliciting‘‘final’’ questions preliminary to shifting into the activityof closing.For a second example of the final-concern sequence,

see Extract 6. The patient’s primary concern is amole on her neck. After dealing with this concern, thephysician and patient proceed to deal with twosecondary concerns: migraines and high blood pressure.After dealing with these concerns, the physicianwrites multiple prescriptions (lines 433–436).The patient’s ‘‘‘Kay, Thank you’’ (line 452) is responsiveto the physician handing her the prescription slip.The termination of the activity of prescription writingconstitutes a closing-relevant environment (Heath,1986). In this environment, the physician asks a final-concern question, ‘‘Anything else’’ (la; line 454).


In response to the physician’s ‘‘Anything else’’ (line454), the patient produces a ‘‘yes’’-type answer bybeginning to ask a question about the future contingen-cies of her treatment: ‘‘Now shou(ld)- could you- if: thisseems to be working...’’ (1b; lines 455–456). Before thepatient finishes her question, the physician answers byoffering to perform a blood test (to monitor potentialnegative side effects of the medication he just pre-scribed). The physician and patient proceed to discussthe blood test and the effects of different drugs (data notshown). At line 512, the physician is writing in thepatient’s medical records, most likely documenting theblood test.If the physician’s initial ‘‘Anything else’’ (line 454)

communicated a contingent shift into closing} one thatwas not realized due to the patient’s question (455–456)} then we should expect that, upon completion of thediscussion prompted by the patient’s question, they willonce again move toward closing. Indeed, at line 513, thephysician re-asks, ‘‘Anything else’’ (la). At this point, thephysician is still writing in the records. Because his gazeand body orientation communicate engagement with theactivity of writing, and not with interacting with thepatient, the physician literally embodies a preference fora ‘‘no’’-type answer. The physician’s second ‘‘Anythingelse’’ (line 513) is a repeat of, and ties back to, his earlier‘‘Anything else’’ (line 454), and this is additionalevidence that the physician’s original ‘‘Anything else’’was designed to project a contingent shift into closing.Although the patient’s response, ‘‘Yeah just don’t

move- (0.8) Just don’t lea:ve here’’ (lb; lines 514–515)nominally constitutes a ‘‘yes’’-type response (i.e., it is arequest), it is designedly non-serious, as indicated by thepatient’s laughter (lines 515 and 518), and does not raise

additional concerns. There is visual evidence that thepatient understands the physician’s ‘‘Anything else’’(line 513) as communicating a contingent shift intoclosing. The patient is sitting on the edge of the bed andthe physician is sitting in a chair in front of the patient.At the completion of her answer (line 515), the patientshifts her hands from being clasped in front of her in herlap to on top of her legs (palms down) in preparation forstanding up, thereby displaying her orientation to a shiftinto closing. As the physician responds to the patient’sjoking request with an equally non-serious answer, ‘‘Iwon’t. As long as there’s surf’’ (line 517; the physician’soffice is one block away from the Pacific Ocean), bothphysician and patient begin to stand up in preparationfor exiting the room.In sum, the final-concern sequence consists of a

single sequence of talk, which is initiated by physic-ians’ solicitations of last or final concerns. Thesesolicitations allow patients the opportunity to provideeither ‘‘yes’’- or ‘‘no’’-type answers, which either raise,or decline to raise, new concerns, respectively. Like thearrangement sequence, the final-business sequence al-lows physicians and patients to negotiate the closure ofthe business of encounters and a transition into theactivity of closing.

Implications for the topicalization of patients’ additionalconcerns

The arrangement sequence and final-concern sequencehave different implications for the topicalization ofpatients’ additional concerns. First, consider the ar-rangement sequence. As seen in Diagram 3, there are


essentially four ‘‘slots’’ in which patients can opt totopicalize new concerns.The arrangement sequence does not provide patients

with a formal opportunity to topicalize additionalconcerns. That is, physicians’ proposals of futurearrangements obligate a specific type of response (inslot 1), that being an acceptance or rejection of theproposal. Thus, it is not initially relevant (in slot 1) forpatients to respond by topicalizing new concerns. Afteraccepting physicians’ proposals (i.e., at the end ofslot 1), patients have the potential to relevantlytopicalize new concerns. However, doing so at thispoint is problematized by two issues. First, the rules forturn taking (Sacks et al., 1974) stipulate that, afterpatients accept or reject physicians’ proposals, physi-cians (and not patients) have the right to speak next (inslot 2).5 Second, when patients accept physicians’proposals (as their initial response in slot 1), they closea designedly last topic and collaborate in the creation ofa closing-relevant environment. When physicians’ pro-posals of future arrangements are themselves alreadypositioned in closing-relevant environments (as were allof the cases examined), patients’ acceptances collaboratein the first part of a transition out of the business ofencounters and into the activity of closing. Thus, even ifpatients ‘‘want’’ to continue to topicalize new concerns(i.e., at the end of slot 1), they must do so in competitionwith the relevance of closing.Similar to the future-arrangement sequence, the first

parts of physicians’ topic-closing sequences (i.e., slot 2)obligate a specific type of response (in slot 3), that beingpatients’ reconfirmation or non-confirmation of theirprior acceptances of physicians’ proposals of futurearrangements. Thus, it is not initially relevant (in slot 3)

for patients to topicalize new concerns. Admittedly, itmay be relevant for patients to respond to physicians’topic-closing utterances with questions about theparticularities of the prior arrangement, but it is notrelevant to initiate wholly new concerns (Houtkoop-Steenstra, 1987). This is supported by Heath (1986). Inhis data corpus of over one thousand British encounters,he found only three cases in which patients declinedphysicians’ proposals to end the business of encountersand transition into the activity of closing. Furthermore,Heath found that when physicians’ proposals aredeclined, ‘‘subsequent talk focuses on the earlierproblem or related matters. There are no examples inthe data corpus of the third possibility occurring, theintroduction of a new topic, a different complaint, orwhatever’’ (p. 142).After confirming their acceptance (i.e., at the end of

slot 3), patients have the potential to relevantlytopicalize new concerns. However, this is again proble-matized by the two issues mentioned previously. First,the rules for turn taking (Sacks et al., 1974) allowphysicians (not patients) first rights to speak afterpatients reconfirm their acceptance. Second, whenpatients reconfirm their acceptance (in slot 3), theycollaborate in the creation of an environment in whichclosing is the most relevant next activity. Thus, morethan before, even if patients ‘‘want’’ to continue totopicalize new concerns, they must do so in competitionwith closing. Perhaps this is why White et al. (1997)found that, in 18% of encounters, patients interruptedphysicians’ attempts to close encounters by topicalizingnew concerns.In sum, the arrangement sequence does not provide

patients with a formal opportunity to topicalize new

Diagram 3. Topic-Raising Opportunities in The Arrangement-Related Business Preclosing Sequence

5In sequence-structural terms, in response to physicians’ proposals of future arrangements, patients have the right to produce oneturn-constructional unit before turn transfer is relevant (Sacks et al., 1974). Patients’ acceptances or rejections typically constitute oneturn-constructional unit. If patients want to topicalize new concerns after accepting or rejecting physicians’ proposals, they must doadditional work to secure a response that contains more than one turn-constructional unit. There are a variety of communicationpractices for doing this (see Schegloff, 1987; Just, 1996).


concerns; that is, it does not provide patients witha sequential ‘‘slot’’ dedicated to the possibility ofrelevantly topicalizing new concerns. This is not to saythat patients cannot topicalize new concerns. Forinstance, see Extract 7. The physician proposes a futurearrangement at lines 123–124, which the patient acceptsat line 125. The physician elaborates this proposal at line126, which the patient again accepts at line 127.

At line 128, when the physician says ‘‘Uh:m’’ hecommunicates that he will eventually produce a turn oftalk and thus ‘‘holds’’ his turn of talk (Schegloff, 1996).During the extended silence at line 129, the physiciangazes ahead of him and embodies a ‘‘thinking’’ position,which is another way that he holds his turn. After twoseconds of silence, and in competition with the turn thatthe physician is holding, the patient topicalizes a newconcern by asking, ‘‘Now do I have to have a vaginal t-uh examination’’ (line 130).For another example, return to Extract 4. The

physician’s proposal of a future arrangement (line 146)is accepted by the patient (line 148) and the physicians’request for reconfirmation (line 150) receives a con-firmation by the patient (line 151). At line 153, thephysician verbally and nonverbally begins to close theencounter. At just this point, the patient topicalizes newconcerns (lines 154–155). However, just as in extract 7

(above), the patient does so (and, as analyzed earlier,orients to doing so) in competition with the activity ofclosing.In sum, the arrangement sequence interactionally

constrains patients away from topicalizing newconcerns by simultaneously: (1) initiating a designedlylast topic (i.e., making a future arrangement), the

completion of which is tantamount to closing; and (2)not providing patients with a formal opportunity totopicalize additional concerns. If patients topicalize newconcerns during the arrangement sequence, they must:(1) initiate that topicalization; (2) specifically work todo so; and (3) do so in competition with other,more relevant actions and activities related to closingencounters.

The arrangement sequence differs markedly from thefinal-concern sequence. Although physicians’ final-con-cern questions, such as ‘‘Anything else?’’, may verballyand/or non-verbally embody a preference for ‘‘no’’-typeanswers, they nonetheless obligate an answer in terms ofnew concerns and provide patients with a formalopportunity to topicalize those concerns. And patientsdo capitalize on this opportunity. For example, as wesaw in Extract 6 (above), in response to the physician’s,‘‘Anything else’’ (line 454), the patient asks a questionabout the future contingencies of her treatment (lines455–456). For another example, see extract 8. Thepatient is visiting the physician to follow up on acondition of dizziness. In response to the physician’s,‘‘Alright anything else’’ (line 216), the patient ultimatelyinitiates a new telling about her interaction with apsychologist (who she saw in between the last visit andthe current visit).

This telling ultimately results in a discussion about awide variety of both psychosocial concerns of the patient(e.g., not feeling completely comfortable with thepsychologist) and biomedical concerns of the physician(e.g., the psychologist recommended that the patient seea psychiatrist in order to be prescribed anti-depressantmedication).


Discussion

Quality health care depends on physicians knowingthe full spectrum of patients’ concerns (Fisher, 1991;Larsson et al., 1987; Lipkin et al., 1995; McWhinney,1981, 1989; Mishler, 1984; Sankar, 1986; Todd, 1984,1989). Although physicians’ opening solicitations ofpatients’ concerns (e.g., ‘‘What can I do for youtoday?’’) provide patients with a formal opportunity topresent at least one of their concerns, this leaves open,and presents the problem of, how additional concernswill be topicalized. This problem is compounded bypsychological and interactional barriers to the topicali-zation of additional concerns (Lipkin et al., 1995;Schegloff & Sacks, 1973; Zoppi, 1997). Perhaps themost relevant location for either physicians or patientsto topicalize additional concerns is in closing-relevantenvironments where they begin to negotiate the closureof the business of encounters and a transition into theactivity of closing (White et al., 1994, 1997). This articleidentified, and described the interactional organizationof, two physician-initiated communication practices thatare used to accomplish such negotiations: the arrange-ment sequence and the final-concern sequence. Althoughboth of these practices project a contingent shift into theactivity of closing, they have different implications forthe topicalization of patients’ additional concerns.Specifically, the arrangement sequence does not providepatients with a formal opportunity to topicalize addi-tional concerns, whereas the final-concern sequence does.This article suggests that patients are more likely to

topicalize additional concerns when physicians use thefinal-concern sequence. However, it was noted thatphysicians frequently verbally and non-verbally designfinal-concern questions in ways that interactionallymanipulate patients toward responses that do not raiseadditional concerns. If physicians want to maximize thepotential of their final-concern questions for solicitingadditional concerns, they should halt competing activ-ities (e.g., writing in the medical records), orient their

bodies and gaze toward patients, and grammaticallydesign their questions so as to not bias patients’responses (e.g., ‘‘Do you have other questions orconcerns?’’ or ‘‘Are there other things that you wantedto address today?’’). One avenue for future research isthe examination of whether or not different wordchoices } such as ‘‘Do you have other questions’’versus ‘‘Do you have other concerns?’’ versus ‘‘Do youhave other problems?’’ } have implications for patients’responses.Admittedly, the arrangement sequence and the final-

concern sequence perform different functions, each ofwhich are important. That is, physicians may need toboth secure future arrangements with patients andsolicit additional concerns. These two practices are notmutually exclusive and physicians can and do use themin combination.Although this article examines two business-preclos-

ing practices, it is likely that there are others. Forexample, there are other communication practices formarkedly closing topics, such as: (1) producing ‘‘aproverbial or aphoristic formulation of conventionalwisdom which can be heard as the ‘moral’ or ‘lesson’ ofthe topic’’ (Schegloff & Sacks, 1973, p. 306; see alsoButton, 1987); (2) producing a ‘‘figurative expression’’(Drew & Holt, 1998); and (3) summarizing the upshot ofa topic (Button, 1987). When these practices are used inclosing-relevant environments to close possibly ordesignedly last topics, they can project a contingentshift into the activity of closing. Future research needs toinvestigate these practices and their implications forhealth care.

Acknowledgements

The author would like to thank two anonymousreviewers, Steve Clayman, Manny Schegloff, TanyaStivers, and especially John Heritage for their commentson previous drafts.

Appendix

The following transcription conventions were developed by Jefferson (1984).

DOC/PAT: Speaker identification: Physician (DOC); patient (PAT).[overlap] Brackets: Onset and offset of overlapping talk.= Equal Sign: Utterances are latched or ran together, with no gap of silence.! Hyphen: Preceding sound is cut off / self-interrupted.#word# Number sign: Words/sounds are produced with a gravel voice.£word£ British pound sign: Talk is produced while smiling."word # Up arrow/Down arrow: Increased pitch relative to surrounding talk.#word " Down arrow/Up arrow: Decreased pitch relative to surrounding talk.(0.0) Timed Pause: Silence measured in seconds and tenths of seconds.(.) Parentheses with a period: A micropause of less than 0.2 seconds.


References

Argyle, M., & Cook, M. (1976). Gaze and mutual gaze.Cambridge: Cambridge University Press.

Atkinson, J. M., & Heritage, J. (1984). Structures of Socialaction: Studies in Conversation analysis. Cambridge,England: Cambridge University Press.

Barsky, A. J. (1981). Hidden reasons some patients visitphysicians. Annals of Internal Medicine, 94, 492–498.

Bates, B., Bickley, L.S., Hoekelman, R. A. (1995). Physicalexamination and history taking (6th ed). Philadelphia, PA: J.B. Lippincott Company.

Beach, W. A. (1995a). Conversation analysis: ‘‘Okay’’as a clue for understanding consequentiality. InS. J. Sigman (Ed.), The consequentiality of communication(pp. 121–161). Hillsdale, NJ: Lawrence Erlbaum Associates,Inc.

Beach, W. A. (1995b). Preserving and constraining options:‘‘Okays’’ and ‘official’ priorities in medical interviews. In B.Morris & R. Chenail (Eds.), Talk of the clinic: Explorationsin the analysis of medical and therapeutic discourse. HillsdaleNJ: Erlbaum.

Beach, W. A., & Dixson, C. N. (2000). Revealing moments:Formulating understandings of adverse experiences in ahealth appraisal interview. Social Science and Medicine, 52,25–44.

Beckman, H. B., & Frankel, R. M. (1984). The effect ofphysician behavior on the collection of data. Annals ofInternal Medicine, 101, 692–696.

Beckman, H. B., Frankel, R. M., & Darnley, J. (1985).Soliciting the patient’s complete agenda. A relationship tothe distribution of concerns. Clinical Research, 31, 714A.

Billings, J. A., & Stoeckle, J. D. (1989). The clinical encounter: Aguide to the medical interview and case presentation. Chicago,IL: Year Book Medical Publishers.

Bolinger, D. L. (1957). Interrogative structures of AmericanEnglish. Alabama: University of Alabama Press.

Boyd, E., & Heritage, J. Analyzing history-taking in primarycare: Questioning and answering during verbal examination.In J. Heritage, & D. Maynard (Eds.), Practicing medicine:Talk and action in primary-care encounters. Cambridge,England. Cambridge University Press, in press.

Brown, P., & Levinson, S. C. (1978). Politeness: Someuniversals in language use. Cambridge, England: CambridgeUniversity Press.

Button, G. (1987). Moving out of closings. In G. Button, & J.R. E. Lee (Eds.), Talk and social organisation (pp. 101–151).Clevedon: Multilingual Matters.

Button, G., & Casey, N. (1984). Generating topic: The use oftopic initial elicitors. In J. M. Atkinson, & J. Heritage(Eds.), Structures of social action: Studies in conversationanalysis (pp. 167–190). Cambridge: Cambridge UniversityPress.

Button, G., & Casey, N. (1985). Topic nomination and topicpursuit. Human Studies, 8(3), 3–55.

Button, G., & Casey, N. (1988/87). Topic initiation: Business-at-hand. Research on Language and Social Interaction, 22,61–92.

Byrne, P. S., & Long, B. E. L. (1976). Physicians talking topatients: A study of the verbal behaviour of generalpractitioners consulting in their surgeries. London: HerMajesty’s Stationery Office.

Cohen-Cole, S. A. (1991). The medical interview: The threefunction approach. St. Louis, MO: Mosby Year Book.

Davidson, J. (1978). An instance of negotiation in a call closing.Sociology, 12, 123–133.

Drew, P., & Heritage, J. (1992). Analyzing talk at work: Anintroduction. In P. Drew, & J. Heritage (Eds.), Talk atwork: Interaction in institutional settings (pp. 3–65). Cam-bridge: Cambridge University Press.

Drew, P., & Holt, E. (1998). Figures of speech:Figurative expressions and the management of topictransition in conversation. Language in Society, 27,495–522.

Fisher, S. (1991). A discourse of the social: Medical talk/powertalk/oppositional talk?. Discourse and Society, 2(2), 157–182.

Frankel, R. M. (1990). Talking in interviews: A dispreferencefor patient-initiated questions in doctor-patient encounters.In G. Psathas (Ed.), Interactional competence (pp. 231–262).University Press of America.

Goffman, E. (1967). Interaction ritual: Essays in face to facebehavior. Garden City, NY: Doubleday.

Goodwin, C. (1981). Conversational organization: Interactionbetween speakers and hearers. New York: Academic Press.

: Colon (s): Preceding sound is extended or stretched; the more the longer.. Period: Falling or terminal intonation., Comma: Continuing or slightly rising intonation.? Question mark: Rising intonation.word_ Underline after word: No intonation shift.underline Underlining: Increased volume relative to surrounding talk.8soft8 Degree signs: Decreased volume relative to surrounding talk.>fast5 Greater-than/less-than signs: Increased pace relative to surrounding talk.5slow> Less-than/Greater-than signs: Decreased pace relative to surrounding talk..h Superscripted periods preceding h’s: Inbreaths; the more the longer.h H’s: Outbreaths (sometimes indicating laughter); the more the longer.hah/heh Laugh token: Relative open or closed position of laughter.(that/hat) Filled single parentheses: Transcriptionist doubt about talk.((Cough)) Filled double parentheses: Scenic detail/event/sound not easily transcribed.


Goodwin, C., & Goodwin, M. (1987). Concurrent operationson talk: Notes on the interactive organization of assess-ments. IPrA Papers in Pragmatics, 1(1), 1–52.

Greenberger, N. J., & Hinthom, D. R. (1993). History takingand physical examination: Essentials and clinical correlates.St. Louis, MO: Mosby Year Book.

Hartford, B. S., & Bardovi-Harlig, K. (1992). Closing theconversation: Evidence from the academic advising session.Discourse Processes, 15, 93–116.

Heath, C. (1981). The opening sequence in physician-patientinteraction. In P. Atkinson, & C. Heath (Eds.), Medicalwork: Realities and routines (pp. 71–90). Famborough:Gower.

Heath, C. (1986). Body movement and speech in medicalinteraction. Cambridge: Cambridge University Press.

Heritage, J. (1984). Garfinkel and ethnomethodology. Cam-bridge, England: Polity Press.

Heritage, J., & Stivers, T. (1999). Online commentary in acutemedical visits: A method of shaping patient expectations.Social Science and Medicine, 49(11), 1501–1517.

Houtkoop-Steenstra, H. (1987). Establishing agreement: Ananalysis of proposal-acceptance sequences. University ofAmsterdam: ICG Printing, Dordrecht.

Kendon, A. (1990a). Some functions of gaze direction in two-person conversation. In A. Kendon (Ed.), ConductingInteraction: Patterns of behavior in focused encounters (pp.51–90). Cambridge: Cambridge University Press.

Kendon, A. (1990b). Spatial organization in social encounters:The F-formation system. In A. Kendon (Ed.), ConductingInteraction: Patterns of behavior in focused encounters (pp.209–238). Cambridge: Cambridge University Press.

Kendon, A. (1990c). Behavioral foundations for the process offrame-attunement in face-to-face interaction. In A. Kendon(Ed.), Conducting Interaction: Patterns of behavior in focusedencounters (pp. 239–262). Cambridge: Cambridge Univer-sity Press.

Larsson, U. S., Saljo, R., & Aronson, K. (1987). Patient-physician communication on smoking and drinking: Life-style in medical consultations. Social Science and Medicine,25(10), 1129–1137.

Lipkin Jr., M., Frankel, R., Beckman, H., Charon, R., & Fein,O. (1995). Performing the interview. In M. Lipkin Jr., S. M.Putnam, & A. Lazare (Eds.), The medical interview: Clinicalcare, education and research (pp. 65–82). Springer: NewYork, NY.

Marvel, M. K., Epstein, R. M., Flowers, K., & Beckman, H. B.(1999). Soliciting the patient’s agenda: Have we improved?.JAMA, 281(3), 283–287.

McWhinney, I. (1981). An introduction to family medicine. NewYork, NY: Oxford University Press.

McWhinney, I. (1989). The need for a transformed clinicalmethod. In M. Stewart, & D. Roter (Eds.), Communicatingwith medical patients. Newbury Park, CA: Sage.

Mishler, E. (1984). The discourse of medicine: Dialectics ofmedical interviews. Norwood, NJ: Ablex.

Pomerantz, A. (1984). Agreeing and disagreeing with assess-ments: Some features of preferred/dispreferred turn shapes.In J. M. Atkinson, & J. Heritage (Eds.), Structures of socialaction: Studies in conversation analysis (pp. 57–101). Cam-bridge, England: Cambridge University Press.

Quirk, R., Greenbaum, S., Leech, G., & Svartvik, J. (1985). Acomprehensive grammar of the English language. New York,NY: Longman.

Robinson, J. D. (1999). The organization of action and activity inprimary-care, physician-patient consultations. Unpublisheddoctoral dissertation, UCLA, Sociology.

Roter, D. L., & Hall, J. A. (1992). Doctors talking withpatients/patients talking with doctors.Westport, CT: AuburnHouse.

Sacks, H. (1987). On the preference for agreement andcontiguity in sequences in conversation. In G. Button, &J. R. Lee (Eds.), Talk and social organization (pp. 54–69).Clevedon: Multilingual Matters.

Sacks, H., Schegloff, E. A., & Jefferson, G. (1974). A simplestsystematics for the organization of turn-taking for con-versation. Language, 50, 696–735.

Sankar, A. (1986). Out of the clinic into the home: Control andpatient-physician communication. Social Science and Med-icine, 22(9), 973–982.

Scheflen, A. E. (1974). How behavior means. Garden City, NY:Doubleday.

Schegloff, E. A. (1968). Sequencing in conversational openings.American Anthropologist, 70, 1075–1095.

Schegloff, E. A. (1980). Preliminaries to preliminaries: Can Iask you a question? Sociological Inquiry, 50, 104–152.

Schegloff, E. A. (1987). Analyzing single episodes of Interac-tion: An exercise in conversation analysis. Social PsychologyQuarterly, 50(2), 101–114.

Schegloff, E. A. (1988). On an actual virtual servo-mechanismfor guessing bad news: A single case conjecture. SocialProblems, 35(4), 442–457.

Schegloff, E. A. (1995). Sequence organization. Unpublishedmanuscript.

Schegloff, E. A. (1996). Turn organization: One intersection ofgrammar and interaction. In E. Ochs, E. Schegloff, & S.Thompson (Eds.), Interaction and grammar (pp. 52–133).Cambridge: Cambridge University Press.

Schegloff, E. A. (1998). Body torque. Social Research, 665(3),535–596.

Schegloff, E. A., Jefferson, G., & Sacks, H. (1977). Thepreference for self correction in the organization of repairin conversation. Language, 53(2), 361–382.

Schegloff, E. A., & Sacks, H. (1973). Opening up closings.Semiotica, 7, 289–327.

Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W.(1995). Mosby’s guide to physical examination (3rd ed.). St.Louis, MO: Mosby Year Book.

Stoeckle, J. D., & Barsky, A. J. (1981). Attributions: Uses ofsocial science knowledge in the ‘‘doctoring’’ of primary care.In L. Eisenberg, & A. D. Kleinman, (Eds.), The relevance ofsocial science for medicine. Amsterdam: D. Reidel.

Swartz, M. H. (1998). Textbook of physical diagnosis: Historyand examination. Philadelphia, PA: W B Saunders Com-pany.

Todd, A. D. (1984). The prescription of contraception:Negotiating between physicians and patients. DiscourseProcesses, 7, 171–200.

Todd, A. D. (1989). Intimate adversaries: Cultural conflictsbetween physicians and women patients. Philadelphia: Uni-versity of Pennsylvania Press.


Waitzkin, H. (1991). The politics of medical encounters: Howpatients and doctors deal with social problems. New Haven:Yale University Press.

White, J., Levinson, W., & Roter, D. (1994). ‘‘Oh, by theway’’. . .: The closing moments of the medical visit. Journalof General Internal Medicine, 9, 24–28.

White, J., Rosson, C., Christensen, J., Hart, R., & Levinson, W.(1997). Wrapping things up: A qualitative analysis of the

closing moments of the medical visit. Patient Education andCounselling, 30, 155–165.

Zoppi, K. A. (1997). Interviewing as clinical conversation. InM. B. Mengel, & S. A. Fields (Eds.), Introduction to clinicalskills: A patient-centered textbook (pp. 41–55). New York,NY: Plenum Medical Book Company.


Documents

Closing medical encounters: two physician practices and their ... · The ﬁrst part of the terminal sequence (line 1) proposes closure of the interaction, obligates a second closing