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The production of an ethnography : some methodological and substantive issues for analyzing social setttings Katz, Bruce Allen 1975

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THE PRODUCTION OF AN ETHNOGRAPHY: SOME METHODOLOGICAL AND SUBSTANTIVE ISSUES FOR ANALYZING SOCIAL SETTINGS  by BRUCE ALLEN KATZ .A. C a l i f o r n i a State U n i v e r s i t y , Northridge, 1968  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  i n the Department of Anthropology and Sociology  We accept t h i s thesis as conforming to the '  required standard  THE UNIVERSITY OF BRITISH COLUMBIA February, 1975  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this  thesis  for scholarly purposes may be granted by the Head of my Department or by his representatives.  It  is understood that copying or publication  of this thesis for financial gain shall not be allowed without my written permission.  Department of /2i€sJ\»fx\»y  ^  £&c\**>LtfJ**j  The University of B r i t i s h Columbia Vancouver 8, Canada  ABSTRACT This study seeks to provide an a n a l y s i s of some o f the features which underly any ethnographic d e s c r i p t i o n .  F i r s t , i t focuses on the  d a i l y r o u t i n e of a community medical c l i n i c i n a l a r g e c i t y i n Western Canada, then i t "looks back" on the methodological and theor e t i c a l issues inherent i n the production of any ethnography.  A  d a i l y r o u t i n e known as "chart rounds" (a review of p a t i e n t s ' medical h i s t o r i e s ) i s examined i  n  detail.  That d e s c r i p t i o n i t s e l f then becomes a  t o p i c of i n q u i r y i n i t s own r i g h t . The a n a l y s i s r e s t s on f i e l d observations conducted over a year and a h a l f w i t h i n the research s e t t i n g .  During t h i s p e r i o d the r e -  searcher was p r i v y to medical examinations, to chart rounds, and to much of the ongoing r o u t i n e of the C l i n i c .  I was a l s o a b l e t o tape-  record v a r i o u s aspects of i t s o r g a n i z a t i o n .  Most of the m a t e r i a l  which I have analyzed c o n s i s t s of t r a n s c r i p t i o n s taken from tape recordings of d o c t o r - p a t i e n t i n t e r v i e w s and of chart rounds. Some of the issues which w i l l be given s p e c i a l a t t e n t i o n a r e (1) the beginning of the ethnographic r e p o r t and the r e l a t i o n s h i p of t h i s s e c t i o n to the subsequent s e c t i o n s of an ethnography;  (2) how  i t i s that ethnographic d e s c r i p t i o n s are n e c e s s a r i l y based i n a s e t of common sense r e l e v a n c i e s ; (3) the use of ' t a l k ' i n i n t e r a c t i o n and as a source of data f o r " d i s c o v e r i n g " the s e l f - o r g a n i z i n g features of the s e t t i n g s and occasions from which t h i s t a l k i s c o l l e c t e d ; and (4) the r e l a t i o n s h i p between ethnographic d e s c r i p t i o n and the i  researcher i n the research s e t t i n g . The research reported here i s to be seen as exploratory and tentative.  I t i s not intended as a -manual f o r ethnographic researchers,  but as an attempt to e x p l i c a t e some of the o r g a n i z a t i o n a l features i n the c o n s t r u c t i o n of an ethnographic d e s c r i p t i o n . 3iany  No doubt i t r a i s e s  more questions than i t answers, but i t s purpose w i l l be s a t i s f i e d  i f i t i s able to generate some debate about the o r g a n i z a t i o n of ethnographies.  ii  TABLE OF CONTENTS Page Introduction Chapter One:  . .  1  Beginning an Ethnographic Report  30  The I n i t i a l D e s c r i p t i o n  30  A n a l y t i c a l Features of the I n i t i a l D e s c r i p t i o n  56  Chapter Two: Issues i n Producing an A n a l y t i c a l D e s c r i p t i o n  . .  Introduction  79  The Research S e t t i n g :  A Medical Sociology Approach  ...  The Ethnographic Approach Chart Rounds:  A H e u r i s t i c a l l y Inadequate D e s c r i p t i o n  Chart Rounds:  81 84  . .  Talk and the Organization of Chart Rounds Chapter Three:  79  92 100  An I n t e r a c t i o n a l A n a l y s i s . . . .  107  Introduction  107  A C h a r a c t e r i z a t i o n of the Data  109  The Progression Problem  112  The R e f e r e n t i a l Adequacy of the Use of F i r s t Name plus Last Name The Reason f o r a V i s i t :  120 I .  A S o c i o l o g i c a l Treatment of Referring  124 ...  127  An Organizational Treatment of an Organizational Problem .  141  The Reason f o r a V i s i t :  149  II  Conclusion Chapter Four:  157  The Researcher and the Research S e t t i n g  160  Introduction  160  The S o c i o l o g i s t as C u l t u r a l Stranger  166  iii  Page On P a r t i c i p a n t - N o n - P a r t i c i p a n t Observation . . Researcher I d e n t i f i c a t i o n :  Accepting S t a f f Accounts . . .  169 183  E t h i c a l Considerations . . .  188  Conclusion  194  Chapter F i v e :  Conclusion  . . . . . . . . .  198  Summary and Further Research  198  Concluding Remarks  213  Bibliography  219  iv  ACKNOWLEDGEMENT  I would l i k e to take t h i s opportunity to thank Roy Turner and Matthew Speier f o r introducing me to t h i s method of investigation. I am thanking Roy Turner for providing me with h e l p f u l c r i t i c i s m during the research and writing of t h i s report. I wish to thank my readers for their patience and f o r their valuable suggestions:  E l v i Whittaker, Adrian Marriage, Jay Powell,  Robert Boese. I would also l i k e to thank Peter E g l i n f o r being a colleague throughout my graduate studies. I wish to express my thanks to the physicians and patients who provided the data f o r this d i s s e r t a t i o n . their anonymity, a l l names have been changed.  v  In order to maintain  INTRODUCTION  The data and observations which constitute the ethnographic section of this d i s s e r t a t i o n represent more than one and a half years of f i e l d work i n a community medical c l i n i c (hereafter c a l l e d the C l i n i c ) located i n greater metropolitan Vancouver.  During this period,  Iobbserved the ongoing a c t i v i t i e s of the C l i n i c , made notes, conducted and tape recorded interviews, etc.  That i s , I d i d those things which  might be expected of "any" researcher who graphy.  intended to produce an ethno-  However, this was not my primary intention and the findings  which constitute the crux of this paper diverge widely from those of standard ethnographic practice f o r t h i s paper i s directed towards an examination of the problems inherent i n the production of an ethnography rather than merely an elaboration of the features of the setting Further, my findings are exploratory and tentative.  This introduction  i s provided as an e x p l i c a t i o n of some of the i n t e l l e c t u a l currents that run throughout this paper. To begin with, I would l i k e to make i t clear that, when I began my research at the C l i n i c , I had no f i n a l product i n mind. though I i n i t i a l l y intended to do an ethnography focus upon the problems involved therein.  That i s , a l  I did not intend to  Further, I had no formal  research proposal guiding my a c t i v i t i e s at the C l i n i c , and no s p e c i f i c hypothesis about the parameters that this d i s s e r t a t i o n would encompass. Instead, a f t e r spending considerable time at the C l i n i c , I found myself i n possession of a large c o l l e c t i o n of f i e l d notes and audio tapes of various medical interactions, and was faced with the problem of how I  2  could best make use of them.  These are but some of the ways i n which  my work d i f f e r s from conventional  ethnographic reports.  Before s t a r t i n g the present d i s s e r t a t i o n , I had constructed  a  detailed analysis of a d a i l y c l i n i c a l routine known as chart rounds. At t h i s time, I assumed that this analysis would occupy a section of the f i n a l research report.  (Although I did not have any  conception  of what the f i n a l ethnographic d e s c r i p t i o n would look l i k e . )  When i t  came time to address myself to the pragmatic task of writing a d i s sertation, I saw,  f o r instance, that i t was  necessary to provide  an  i n i t i a l description of the Community C l i n i c so that I would be able to place my description of the chart rounds i n i t s proper ethnographic context.  I t was  a concern with matters such as t h i s , i . e . , a concern  with the features which make for an adequate ethnography that eventually shaped this present d i s s e r t a t i o n . The point to note, however, i s that I had no i n t e r e s t i n these matters p r i o r to s t a r t i n g f i e l d work i n the Community C l i n i c .  It was  only a f t e r I began the ethnography that I  became interested i n c e r t a i n features of ethnographic description as features which were i n themselves worthy of i n v e s t i g a t i o n . I decided  to make an ethnography into a topic i n i t s own  u t i l i z e my own  To this  end,  r i g h t , and to  description of the C l i n i c as data i n order to i l l u s t r a t e  some of the pervasive features of ethnographic d e s c r i p t i o n . Thereby, while the description of the C l i n i c presented i n this report i s intended as a bona f i d e ethnographic description, that description w i l l l a t e r be treated as a resource f o r discovering (or better, "rediscovering") organizational features of an ethnography.  3  I t i s an attempt,necessarily  an exploratory and t e n t a t i v e one, to move  2 towards what Berreman  has c a l l e d a "sociology of ethnographic know-  ledge; an ethnography of ethnography." To embark upon an a n a l y s i s of my own d e s c r i p t i o n of the C l i n i c and to then turn that d e s c r i p t i o n i n t o a t o p i c f o r i n v e s t i g a t i o n i s not equivalent to saying that such an a n a l y s i s c o n s t i t u t e s a s p e c i a l or priviled.edd case because of my self-conscious awareness of the research experiences under d i s c u s s i o n .  Such an awareness plays no  s p e c i a l part i n my subsequent a n a l y s i s of the o r g a n i z a t i o n a l propert i e s of ethnographic d e s c r i p t i o n .  I t i s , however, a t o p i c which oc-  cupies a prominent p o s i t i o n i n recent work dealing w i t h ethnographies. Let us consider some of the recommendations that a t t e n t i o n to t h i s issue has generated. In t h e i r a r t i c l e "The Emergence of Self-Consciousness i n Ethnography" Dennison Nash and Ronald Wintrob conclude that: (The) r i s e i n i n t e r e s t i n the s u b j e c t i v e o r personal f a c t o r i n a n t h r o p o l o g i c a l research appears to have been accompanied by a deo b j e c t i v a t i o n of the anthropological world view. By t h i s we mean that f i e l d observations are l e s s l i k e l y t o be thought of as having the q u a l i t y of o b j e c t i v e r e a l i t y and more l i k e l y to be conceived as r e l a t i v e to the observers p e r s o n a l i t y , h i s experiences and h i s actions i n the f i e l d .3 (emphasis mine)3 4 They point out that the ethnographer i s i n h e r e n t l y biased.  Many s o c i a l  s c i e n t i s t s maintain that such inherent biases should be brought i n t o conscious awareness so that some remedy can be found f o r the errors that they cause.  There i s some dismay about the paucity of knowledge  4  concerning  the ethnographer's actual f i e l d experiences.  Consequently,  i t has been suggested that incorporating one's personal f i e l d experiences into the ethnographic report might make f o r a higher degree of c l a r i t y and o b j e c t i v i t y . ^ The r e l a t i o n s h i p between the ethnographer and the subjects of his inquiry'has also been cast into question. P a r t i c u l a r attention has been paid to the type of knowledge the ethnographer can obtain v i s - a - v i s that r e l a t i o n s h i p .  For example, Robert  Jay contends that: The main point I am t r y i n g to make i n this paper i s that the relationships we form with the subjects of our work — for whatever reasons we s e t t l e upon those relationships —- control the kind of knowledge that the material we gain w i l l y i e l d and also control how we exercise whatever r e s p o n s i b i l i t y we may f e e l to our subjects and to ourselves as persons. I have further been trying to show that there i s a c e r t a i n knowledge relevant f o r understanding one another i n our own personal l i v e s , i n which we look upon one another as autonomous, mutually responsible selves, and that there i s another kind of knowledge relevant to understanding our subjects as shaped and moved by extrapersonal forces allowing at most very l i m i t e d autonomy or r e s p o n s i b i l i t y . The knowledge involved i n each kind of understanding i s not d i r e c t l y pr even r e a d i l y translatable into that of the other. That disconformity between our d i r e c t , personal sight of the universe and the sight that an objective science gives us has been at the root of much i n t e l l e c t u a l discontent i n Western c i v i l i z a t i o n f o r some time. 7  The ethnographer, then, i s no mere reporter of s o c i a l l y observable phenomena, but an i n t e g r a l part of the description he produces. seems to be suggesting  Jay  that the ethnographer can make his report a more  v a l i d document of the s e t t i n g by considering the types of personal relationships thattlre develops with h i s informants,  and  incorporating  5  his feelings about these relationships into his report.  Jay goes on  to o u t l i n e some of the possible advantages of this approach. It i s p r e c i s e l y here that I see the difference between my p o s i t i o n i n anthropology and that of many, perhaps most, of my colleagues. I want to choose, with f u l l awareness, to r e l a t e to my subj e c t s f u l l y as persons, as I would to any other — f r i e n d , colleague, student, chance acquaintance. That choice determines the realm of knowledge I s h a l l be able to explore, and i t i s a realm f o r which the concept of culture, and for that matter of s o c i a l structure, ecology, and the l i k e (extrapersonal bases f o r explaining behavior) are of only peripheral value.® Another procedure which takes the ethnographer's bias into account and attempts to bring that bias to the l e v e l of consciousness i s the analysis of anthropologists v i a the use of psychological experiments and Rorschach tests.  Dennison Nash, for one, f e e l s that Ann Roe's  psychological studies of anthropologists are a useful method f o r assessing the i n d i v i d u a l anthropologists o v e r a l l a d a p t a b i l i t y to what he c a l l s the r o l e of  "ethnologist-stranger":  In her project involving a number of kinds of research s c i e n t i s t s , Roe interviewed and tested 8 eminent anthropologists and gave group Rorschach to 25 anthropologists on f i v e f a c u l t i e s . Her claim that "the research s c i e n t i s t s studied individually...show p r e c i s e l y the differences (on the Rorschach) between f i e l d s that the subjects studies i n groups do" appears v a l i d . In their Rorschach responses, anthropologists are most l i k e psychologists and l e a s t l i k e b i o l o g i s t s and physical s c i e n t i s t s . However, i t was not possible to specify differences between d i f ferent f i e l d s of anthropology, e.g., between archaeology, physical anthropology, and s o c i a l or c u l t u r a l anthropology....(Therefore) i f the general c h a r a c t e r i s t i c s of Roe's sample suggest some adaptive p o t e n t i a l f o r the r o l e of ethnologiststranger, we may be encouraged to undertake further  6  studies with, more refined samples to reach more f i r m conclusions. (emphasis mine) 10  From the perspective of this research report the c r i t i c i s m s I have regarding this movement of self-awareness, and the incorporation of that awareness into the body of the research report, i s that i t t e l l s us l i t t l e about the formal properties of ethnographies and i t i s i n no way  clear that such concerns t e l l s us much about the s o c i a l  background and psychological c h a r a c t e r i s t i c s of ethnographers, matters which are i n themselves of enormous complexity.  To regard the ethno-  grapher as inherently biased i s to give up the enterprise of ethnography. If the ethnographer i s unintentionally but nevertheless biased, i t follows that accounts of his f i e l d experiences and the relationships he develops with h i s subjects i n the f i e l d w i l l also be biased.  Does the mere re-  counting of one's personal feelings towards one's informants make the ethnographic description more objective? g i s t s from this claim to bias?  Further, are we to exempt psycholo-  Can i t be said that biases of any kind  are peculiar to those anthropologists whose province i s ethnography? And are the psychologists who  contrive these elaborate testing procedures  necessarily exempt from this ailment such that they occupy a p r i v i l e g e d p o s i t i o n from which they may  cast judgment upon ethnographers?  I think not.  Indeed, there are ways i n which focussing attention on ethnographic bias and on the ethnographer's self-conscious awareness i s one way  of not looking  at the formal properties of ethnography. Since this d i s s e r t a t i o n i s directed towards an examination of the o r g i n i z a t i o n a l features of an ethnographic description, I have provided the reader with l i t t l e information about my relationships with members  7  of the C l i n i c , about my musings or r e f l e c t i o n s or about "how i t i s that I f e l t " a t t h i s or that time during the course of my research. This does not mean, however, that I do not intend to address the issue of the r e l a t i o n s h i p which obtains between the ethnographer, the research s e t t i n g , and the members who a r e under study. chapter four:  Indeed,  "The Researcher and the Research S e t t i n g , " i s con-  cerned s p e c i f i c a l l y w i t h these issues.  However, the m a t e r i a l which  i s examined i n that chapter c o n s i s t s of f i e l d notes and audio tapes of i n t e r a c t i o n s between myself and members of the research s e t t i n g . Issues dealt w i t h i n that chapter are: p a r t i c i p a n t observation;  (1) p a r t i c i p a n t and non-  (2) the r e l a t i o n s h i p of the ethnographer's  s i t u a t e d e t h i c s i n the doing of f i e l d work; and (3) how the r o l e of the researcher can be taken as a resource f o r the discovery of the features of a s e t t i n g .  I n contrast, the issues dealt w i t h i n chapter  four a r e s i m i l a r to those mentioned by Nash and Wintrob,  although  the a n a l y s i s of the data presented does not i n v o l v e any attempt on my part to speculate about my f e e l i n g s a t the time of the production of the data, or about the personal r e l a t i o n s h i p s between myself and members of the research s e t t i n g . Although r e c o l l e c t i o n s and personal f e e l i n g s are o f t e n incorporated i n my d e s c r i p t i o n of the C l i n i c (since such f e e l i n g s and personal r e c o l l e c t i o n s are a constituent feature of many ethnographic d e s c r i p t i o n s ) they a r e not a part of the a n a l y s i s of that d e s c r i p t i o n . I wish to point out that I am engaged i n the study of the o r g a n i z a t i o n a l features of the construction of an ethnographic d e s c r i p t i o n and not with what any i n d i v i d u a l ethnographer w i l l  8  say about his ethnography or his f i e l d work experiences. This d i s s e r t a t i o n i s concerned with the production of ethnographies, yet, up to this point, there has been no attempt to specify what an ethnography consists of.  Then, too, while I have said that  this report i s something other than a conventional ethnographic description, to properly make this claim i s to e n t i t l e the reader to an explanation  of the difference between the two,  and t h i s under-  taking necessarily involves a d e f i n i t i o n of what i s meant by the term ethnography.  However, to provide a complete answer to t h i s basic  question i s i t s e l f a task of much more than a d i s s e r t a t i o n magaitude, for ro complete d e f i n i t i o n i s possible.  In a few b r i e f pages, then, I would  l i k e to try to explain some of the differences between t h i s research report and more conventional ethnographic descriptions.  I t i s hoped  that the following e x p l i c a t i o n w i l l s a t i s f y some of the questions about the basic c h a r a c t e r i s t i c s of an ethnography, although I r e a l i z e that i t w i l l not provide the reader with a d e f i n i t i v e or f i n a l answer. Tobbegin with, The Dictionary of Anthropology affords us with  11 the following d e f i n i t i o n of 'ethnography': Ethnography. The study of i n d i v i d u a l cultures. It i s primarily a d e s c r i p t i v e and non-interpretive study.Il Compare t h i s with Charles Frake's more elaborate  formulation:  Ethnography...is a d i s c i p l i n e which seeks to account for the behavior of a people by describing the s o c i a l l y acquired and shared knowledge, or culture, that enables members of the society to behave i n ways deemed appropriate by t h e i r fellows. The d i s c i p l i n e i s akin to l i n g u i s t i c s ; indeed, descriptive l i n g u i s t i c s i s but a s p e c i a l case of ethnography since i t s domain of study,  9  speech messages, i s an i n t e g r a l part of a larger domain of s o c i a l l y interpretable acts and a r t i f a c t s . I t i s t h i s t o t a l domain of "messages" (including speech) that i s the concern of the ethnographer. The ethnographer, l i k e the l i n g u i s t , seeks to describe an i n f i n i t e sets of v a r i a b l e messages as manifestations of a f i n i t e shared code, the code being a set of rules f o r the s o c i a l l y appropriate construction and interpretation of messages.^ Does Frake's formulation resolve our questions about the basic character of ethnographies?  Is i t i n any way  d e f i n i t i o n given by the dictionary? the other?  clearer or better than the  When would you use one and  not  I t i s apparent that f o r some persons and i n some situations  the f i r s t d e f i n i t i o n might well be more appropriate; i f , for example, someone who  had l i t t l e i n t e r e s t i n the subject were to require a  d e f i n i t i o n of the word.  On the other hand, the second d e f i n i t i o n  would be seen as more appropriate i n a discussion between fellow efibhugpologists or s o c i o l o g i s t s . While both equate ethnography with c u l t u r a l description, the difference between them i s that Frake's formulation t e l l s us something about how accomplished.  such a d e s c r i p t i o n i s to be  I t i s this feature of ethnographic description —  manner i n which that d e s c r i p t i o n i s to be produced —  the  that occupies  13 a f o c a l point of debate within anthropology. The precursors f o r modern ethnographies were the l e t t e r s , d i a r i e s t r a v e l documents, etc. by laymen who societies.  had some contact with exotic  Today bona f i d e ethnographic descriptions are confined  almost exclusively to the professional community.  Thus, our standards  for deciding what i t i s that constitute an ethnography changes over time.  10  Whereas the aim of ethnography i s the production of a recognizable c u l t u r a l d e s c r i p t i o n , the manner i n which t h i s aim i s achieved, and  the  s p e c i f i c character of the d e s c r i p t i o n produced, have been c o n t r o v e r s i a l issues f o r s o c i a l s c i e n t i s t s , and to say that an ethnography i s concerned w i t h d e s c r i b i n g a c u l t u r e and to leave i t at t h a t , t e l l s us next to nothing since i t s goals and the methods or fundamental  "how"  of i t s production are themselves problematic features of that d e s c r i p tion. While acknowledging that the scope and d e f i n i t i o n of ethnography has changed i n the past, i s undergoing f u r t h e r r e - d e f i n i t i o n i n the present (and w i l l undoubtedly change i n the f u t u r e ) , Harold Conklin has proposed the f o l l o w i n g formulation of ethnographic  concerns:  An ethnographer i s an anthropologist who attempts — at l e a s t i n part of h i s p r o f e s s i o n a l work — to record and describe the c u l t u r a l l y s i g n i f i c a n t behav i o r s of a p a r t i c u l a r s o c i e t y . I d e a l l y t h i s d e s c r i p t i o n , an ethnogaahhy, requires a long period of intimate study and residence i n a small w e l l - d e f i n e d community, knowledge of the spoken language, and the employment of a wide range of observational techniques i n c l u d i n g prolonged face-to-face contacts w i t h members of the l o c a l group, d i r e c t p a r t i c i p a t i o n i n some of that group's a c t i v i t i e s , and a greater emphasis on i n t e n s i v e work w i t h informants than on the use of documentary or survey d a t a . ^ 4  This c h a r a c t e r i z a t i o n seems to provide us w i t h a standard from which we can point out c e r t a i n s i m i l a r i t i e s and d i f f e r e n c e s between the present research report and conventional, i . e . , current or standard descriptions.  ethnographic  Therefore, l e t us take Conklin's statement as a working  definition. Since ethnography i s concerned w i t h producing c u l t u r a l d e s c r i p t i o n s , i t should be incumbent on any ethnographer to give h i s readers  11  some idea about the relationship between the data he c o l l e c t s and the character of the description that he produces with and from that data.  This i s not usually the case. However, my second chapter, "Issues i n Producing an A n a l y t i c a l  Description," takes this relationship between research data and the production of an a n a l y t i c a l ethnographic description as i t s central concern.  That i s , i t branches o f f from chapter one which contains a  standard piece of ethnographic material describing a community c l i n i c . This description would, i n standard ethnographies, stand as a preface to some subsequent, more detailed or p a r t i c u l a r analysis of some aspect or aspects of the c l i n i c ' s organization. Chapter two considers some of the issues involved i n the production of such a description. I t looks a t some of the ways i n which a s o c i a l researcher might approach the opportunities which access to the C l i n i c would afford him, and also examines the primary source of data f o r h i s analysis and the r e l a t i o n s h i p that adheres between the data and the setting from which i t i s collected.  Thus, i t begins with an analysis of how a t r a d i t i o n a l  medical s o c i o l o g i s t might approach the setting i f given the opportunity to do so. I t i s suggested that a medical s o c i o l o g i c a l perspective would not be concerned with producing a description of c l i n i c organization alone, but would also address i t s e l f to some preconceived research hypotheses concerning topics and issues within the area of medical sociology. The C l i n i c would constitute the locus from which to gather data about such things as status relationships between physicians and nurses, be-r tween niirsesiand o r d e r l i e s , or s t a f f and patients, etc.  While this  12  approach i s not to be c r i t i c i z e d as worthless, I f e e l that i t can be f a u l t e d f o r f a i l i n g to respect what I have c a l l e d "the i n t e g r i t y of the research s e t t i n g . "  That i s , medical and other branches of sociology  tend to approach s e t t i n g s w i t h a b u t t e r f l y net of a p r i o r i categories f a c t s , f i g u r e s and hypotheses i n which they w i l l catch the s e t t i n g self.  it-  On the other hand, ethnographers who have been concerned w i t h  describing the strange, and o f t e n e x o t i c f e a t u r e s , seem to be more concerned w i t h preserving the c u l t u r e ' s " i n t e g r i t y . "  Thus, as T y l e r t e l l s  us, "In a very r e a l sense, the anthropologist's problem i s to discover how other prople create order out of what appears to him to be u t t e r c h a o s , a n d the s o l u t i o n to t h i s problem can be e i t h e r "impose a p r e - e x i s t i n g order on i t , or discover the order underlying i t " . " ^ Many ethnographers b e l i e v e that ethnographic d e s c r i p t i o n s are fundament a l l y concerned w i t h the l a t t e r task and must therefore t r e a t the c u l t u r a l scenes observed as having, i n and of themselves, a s o c i a l l y organized character a v a i l a b l e to e m p i r i c a l i n v e s t i g a t i o n and d e s c r i p t i o n . c u l t u r a l world of the ethnographer i s s o c i a l l y constructed and by and f o r i t s members.  Ethnographic d e s c r i p t i o n recognizes  The  maintained  and  respects t h i s feature and attempts to e x p l i c a t e the order underlying the doings of the c u l t u r e under study. speak of ethnographies the research s e t t i n g . "  This i s what I mean when I  as something which respect the " i n t e g r i t y of That i s , u n l i k e the medical s o c i o l o g i s t , the  ethnographer i s concerned w i t h the members' explanations of the ways i n which c u l t u r a l scenes are constructed and  maintained.  The d i s c i p l i n e of ethnography has been subjected to much c r i t i c i s m  13  from concerned s o c i a l s c i e n t i s t s and chapter two addresses some of the p i t f a l l s of what may methods of a n a l y s i s .  be regarded as the e a r l i e r or more t r a d i t i o n a l  The thrust of t h i s c r i t i c i s m i s that, while pur-  porting to describe aspects of the organization of other c u l t u r e s , t r a d i t i o n a l ethnographic a n a l y s i s has approached these c u l t u r a l scenes w i t h pre-established  sets of t h e o r e t i c a l i n t e r e s t s that, as  Tyler has shown us, impose a p r e - e x i s t i n g order on them. Among anthropologists, a aew s t y l e of ethnography ( i . e . , c o g n i t i v e anthropology) has attained currency. the o l d ethnography was  B r i e f l y stated, whereas  concerned w i t h discovering  anthropological  u n i v e r s a l s and a general theory of c u l t u r e , c o g n i t i v e anthropology addresses i t s e l f to the ways i n which: ...the people of some other c u l t u r e expect me to behave i f I were a member of t h e i r c u l t u r e ; and what are the r u l e s of appropriate behavior i n t h e i r culture? Answers to these questions are provided by an adequate d e s c r i p t i o n of the r u l e s used by the people i n that c u l t u r e . Consequently, t h i s d e s c r i p t i o n i t s e l f c o n s t i t u t e s the "theory" f o r that c u l t u r e , f o r i t represents the conceptual model of organization used by i t s members. Such a theory i s v a l i d a t e d by our a b i l i t y to p r e d i c t how these people would expect us to behave i f we were members of t h e i r c u l t u r e . I 7  Basic to t h i s ethnographic model i s a change i n the t r a d i t i o n a l concept of ' c u l t u r e ' .  anthropologists'  The e a r l i e r anthropological  has been stated sucfdfactly by T y l e r : Previous t h e o r e t i c a l o r i e n t a t i o n s i n anthropology can i n a very general way be classed i n t o two types — those concerned p r i m a r i l y w i t h change and development and those concerned w i t h s t a t i c des c r i p t i o n s . Thus, the e v o l u t i o n i s t s and the d i f f u s i o n i s t s concentrated on patterns of change,  position  14  w h i l e the f u n c t i o n a l i s t s eschewed t h i s work as mere "speculative h i s t o r y , " and focussed on the i n t e r n a l organization and comparison of systems, hoping thereby to discover general laws of s o c i e t y . . . . These formulations were attempts to construct u n i v e r s a l o r g a n i z a t i o n a l types which were l i n k e d e i t h e r by s i m i l a r processes of change or by s i m i l a r i t i e s of i n t e r n a l s t r u c t u r e . I n order to achieve t h i s g o a l , only c e r t a i n kinds of information were accepted as r e l e v a n t , and concrete ethnographic data had to be elevated to more abstract forms such as index v a r i a b l e s and t y p o l o g i c a l constructs The new ethnography, on the other hand, operates on the assumption that to describe another c u l t u r e i s to describe what i t i s that one would need to know i n order to be regarded as a competent c u l t u r a l 19  member of that c u l t u r e .  The parameters of t h i s task have been  formulated by Charles Frake as f o l l o w s : F i r s t , i t i s not, I think, the ethnographers' task to p r e d i c t behavior per se, but r a t h e r to s t a t e r u l e s of c u l t u r a l l y appropriate behavior. In t h i s respect the ethnographer i s again a k i n to the l i n g u i s t who does not attempt to p r e d i c t what people w i l l say but to s t a t e r u l e s f o r constructing utterances which n a t i v e speakers w i l l judge as grammatically appropriate. The model of an ethnographic statement i s not: " i f a person i s confronted w i t h stimulus X, he w i l l do Y," but: " i f a person i s i n s i t u a t i o n X, perform= ance Y w i l l be judged appropriate by n a t i v e a c t o r s . " The second d i f f e r e n c e i s that the ethnographer seeks to d i s c o v e r , not p r e s c r i b e , the s i g n i f i c a n t s t i m u l i i n the subjects' world. He a t tempts to describe each a c t i n terms of the c u l t u r a l s i t u a t i o n s which a p p r o p r i a t e l y evoke i t and each s i t u a t i o n i n terms of the acts i t appropriately evokes. 2u  Thus, t h i s perspective conceives of a c u l t u r e as a s e t of r u l e s f p r app r o p r i a t e behaviour which bona f i d e members of that c u l t u r e u t i l i z e i n order to conduct (and to be seen as conducting) themselves i n recognizably  15  appropriate ways.  These r u l e s have a demonstrably consequential  character, f o r i t i s by attending t o them that members are able to 21  produce the organized character of t h e i r world.  I n t h i s sense,  the new notion of c u l t u r e i s r e l a t e d to G a r f i n k e l ' s concept of competence. He states t h a t : I use the term "competence" to mean the claim that a c o l l e c t i v i t y member i s e n t i t l e d to exe r c i s e that he i s capable of managing h i s everyday a f f a i r s without i n t e r f e r e n c e . 2 2  The new ethnography i s an eminently p r a c t i c a l e n t e r p r i s e .  I t attempts  to provide a d e s c r i p t i o n of a c u l t u r e that could be used by a c u l t u r a l stranger i n such a way that the stranger could, i f he so wished, conduct himself i n a manner which members of the c u l t u r e described would deem appropriate f o r that c u l t u r e . That i s , the reader would be able to act a p p r o p r i a t e l y and, through h i s a c t u a l , on-going performance, d i s p l a y and maintain what G a r f i n k e l has c a l l e d h i s c u l t u r a l competence. The m a t e r i a l discussed i n chapter two of t h i s report provides c e r t a i n c r i t i c i s m s of t h i s new approach to ethnographic d e s c r i p t i o n , p a r t i c u l a r l y to the programme that i t seeks to accomplish.  At the same  time, i n attempting to provide an a n a l y t i c a l d e s c r i p t i o n of some aspect of the s o c i a l o r g a n i z a t i o n of the C l i n i c , t h i s d i s s e r t a t i o n adopts the p o s i t i o n that such a d e s c r i p t i o n should be responsive to those s e l f organizing features of the research s e t t i n g which i t i s studying. Therefore, an ethnographer should not attempt to impose some pre-exi s t i n g framework on that which he describes. These issues are discussed i n chapter two, then, a more d e t a i l e d  16  d e s c r i p t i o n of a c l i n i c a l r o u t i n e known as chart rounds ( i . e . , a d a i l y review of p a t i e n t s medical records) i s presented.  This c o n s t i t u t e s an  appropriate topic f u l f i l l i n g the requirements that the p r e l i m i n a r y d e s c r i p t i o n of the C l i n i c i n chapter one provides f o r . I decided to describe chart rounds s i n c e i t i s a normal, r o u t i n e feature of the o r g a n i z a t i o n of the C l i n i c ; a feature which members of the s e t t i n g take f o r granted as a c o n s t i t u e n t f e a t u r e of t h e i r d a i l y r o l e s as p h y s i c i a n s , nurses, medical students, p a t i e n t s and the r e s t .  P r a g m a t i c a l l y , the  occasion of chart rounds was selected because my research a t the C l i n i c made i t p o s s i b l e f o r me to acquire an extensive corpus of notes and tapes of the i n t e r a c t i o n occurring i n these medical sessions. Thus, I was able to make transcribed records of a c t u a l chart rounds. Aside from the a v a i l a b i l i t y of audio recordings, i t was s e l e c t e d because i t i s an occasion which has as i t s underlying r a t i o n a l e , the generation of t a l k about p a r t i c u l a r p a t i e n t s and r e l a t e d medical matters. Then, i n my t h i r d chapter "Charts Rounds:  An I n t e r a c t i o n a l  A n a l y s i s , " I s h a l l attempt to describe t h i s occasion by attending to the t a l k which occurs between p a r t i c i p a n t s as data from which to d i s cover the s e l f - o r g a n i z i n g features of chart rounds.  Here, I s h a l l adopt  23 an ethnomethodological o r i e n t a t i o n .  While i t i s not my i n t e n t i o n to  examine the major tenets of ethnomethodology, I would l i k e to o f f e r some comments concerning the general c h a r a c t e r i s t i c s of the a n a l y s i s that w i l l be presented i n t h i s chapter. As I have already noted, I had no s p e c i f i c topic of i n q u i r y ,  17  research proposal or hypothesis when I f i r s t began this d i s s e r t a t i o n . Instead, the material contained i n this report, that i s , the d i r e c t i o n that i t takes and the topics that i t addresses were "discovered" or flow from the production of the paper i t s e l f . standard" format.  Hence, i t s "non-  While the accepted ways f o r doing an ethnography  may have many advantages, they may also have inherent Consider the f a c t that ethnographic  disadvantages.  researchers often provide research  proposals regarding the scope, character, and objective of their research.  I f the main purpose of ethnographic  descriptions i s to  discover how some "other" culture i s organized, i t seems odd to speak of objectives other than describing the underlying organizational rules of that culture.  I would l i k e to suggest that to have any other ob-  j e c t i v e , e.g., to have predetermined ideas about what you w i l l f i n d and how you w i l l f i n d i t i s to loose sight of what may a c t u a l l y be there awaiting d i s c o v e r y . ^ While Conklin describes an ethnographer as "an anthropologist working i n a foreign culture", as a s o c i o l o g i s t attempting  to describe  his own culture, I do not encounter some of the obstacles that are c h a r a c t e r i s t i c a l l y faced by anthropologlstss ((puch as learning a foreign language).  My problems are of a d i f f e r e n t nature.  For instance, I am  confronted with the f a c t that my research subjects often know that I am a s o c i o l o g i s t and "know" what i t i s that s o c i o l o g i s t s do. Thus, I must deal with the r e l a t i o n s h i p between my own aims and those imputed to me by members of the research s e t t i n g . throughout my stay with the C l i n i c .  (This feature was operative  I t i s given s p e c i a l attention i n  18  chapter four.) Thus, being a member of the society which I am interested i n describing i s both an asset and a l i a b i l i t y .  Turner  has stated the relationship between s o c i o l o g i c a l topics and one's own c u l t u r a l knowledge of those topics i n the following manner: It i s increasingly recognized as an issue for sociology that the equipment that enables the "ordinary" member of society to make h i s d a i l y way through the world i s the equipment a v a i l a b l e f n r for those who would wish to do a "science" of that world. This might be formulated as the sociol o g i s t s "dilemma," but only so long as a notion of science i s employed that f a i l s to recognize the s o c i a l l y organized character of any enterprise, including the enterprise of doing science.25 This d i s s e r t a t i o n , then, i s an attempt to u t i l i z e my own c u l t u r a l equipment to provide an ethnographic description of a routine within the C l i n i c .  occasion  Throughout this report I intend to demonstrate the  relationship between the production of an ethnographic description and that description's dependence on common-sense c u l t u r a l knowledge f o r i t to obtain an accredited status as an "adequate" ethnographic d e s c r i p t i o n . I f i n d i t d i f f i c u l t to state this point more s u c c i n c t l y and,  therefore,  wish to inform the reader that i t constitutes a major point of research interest i n this document. Like anthropological ethnographers, I am concerned with l i n g u i s t i c events that are a part of those c u l t u r a l scenes that I am a t tempting to describe.  Unlike such ethnographers, however, I am  neither conducting formal interviews with my subjects, nor engaged i n 26 formal e l i c i t i n g  techniques aimed at taxonomic construction.  Instead, my chief source of data i s those naturally occurring of i n t e r a c t i o n themselves.  instances  Much of the i n t e g r i t y of the i n t e r a c t i o n i s  19  preserved i n audio tapes.  The forthcoming a n a l y s i s of chart rounds  i n chapter three i s an attempt to describe them through an examination of transcribed tape recordings. By attending to t a l k as a n a t u r a l l y occurring phenomenon, I am suggesting that i t i s p o s s i b l e to attend to the s e l f - o r g a n i z i n g features of c u l t u r a l o r g a n i z a t i o n .  To quote  Turner again: A science of society that f a i l s to t r e a t speech as both t o p i c and resource i s doomed to f a i l u r e . And yet, although speech informs the d a i l y world and i s the s o c i o l o g i s t ' s b a s i c resource, i t s p r o p e r t i e s continue to go almost unexamined....If we take sociology to be, i n e f f e c t , "a n a t u r a l h i s t o r y of the s o c i a l world," then s o c i o l o g i s t s are committed to a study of the a c t i v i t i e s such a world provides f o r f o r and of the methodical achievement of those a c t i v i t i e s by s o c i a l i z e d members.27 While the f i n d i n g s o f f e r e d i n t h i s paper do not purport to describe the occasion of chart rounds i n ways that w i l l allow the reader to a c t as a competent member of the C l i n i c (and thereby d i f f e r from the d e s c r i p t i v e goal of the c o g n i t i v e a n t h r o p o l o g i s t ) , the d e s c r i p t i o n o f f e r e d does t r y to (1) respect the i n t e g r i t y of the s e t t i n g by attending to a c t u a l l i n g u i s t i c events, and (2) be r e sponsive to the s e l f - o r g a n i z a t i o n of the l i n g u i s t i c data under consideration. Admittedly, the f i n d i n g s presented i n t h i s paper r a i s e complicated issues f o r the study of s o c i a l s e t t i n g s .  These w i l l be addressed i n  forthcoming sections of t h i s r e p o r t . At t h i s time, I wish only to give the reader some i n d i c a t i o n of what I meant when I r e f e r r e d to my f i n d i n g s as exploratory and t e n t a t i v e . The a n a l y s i s of chart rounds presented i n chapter three i s an  20  analysis conducted under the auspices of an ethnomethodological tation. dology?"  orien-  It i s not my concern to address the question "What i s ethnomethoI would, however, l i k e to o f f e r some comments about what i t i s  that I mean when I refer to an "ethnomethodological o r i e n t a t i o n . "  Then,  I would l i k e to discuss c e r t a i n methodological considerations about the primary source of data f o r this analysis of chart rounds, i . e . , conversat i o n a l transcripts taken from tape recordings done during chart rounds. An ethnomethodological o r i e n t a t i o n does not mean that the researcher operates with some prefabricated theory of society. organization i s seen as members' accomplishments. tions" are directed towards discovering how possible i n the f i r s t place.  Rather, a l l s o c i a l And a l l "investiga-  i t i s that s o c i a l order i s  More p r e c i s e l y , findings about members'  methods of s o c i a l organization can be achieved only by confronting data i t s e l f , and can not be generated from any substantive body of theory, hypotheses, or research design which simply assumes this order-as-given and summarily dismisses i t .  Such procedures do not lend themselves  to  the learning of a set of technical s k i l l s such as survey or interview techniques, or experimental designs; that i s , s p e c i f i c s k i l l s wherein the researcher acquires the "how  to do i t " of the enterprise. Members'  methods are available f o r investigation, but such investigation i s not dependent on the a c q u i s i t i o n of a body of methodological techniques. 28 i t i s apparent that ethnomethodology i s not a method. To present an analysis of chart rounds under the auspices of an ethnomethodological orientation as i t i s , i s to adhere to Harold Garf i n k e l 's recommendation that: In exactly the ways that a setting i s organized, i t  Thus  21  c o n s i s t s of members' methods f o r making evident that s e t t i n g ' s ways as c l e a r , coherent, p l a n f u l , c o n s i s t e n t , chosen, knowable, uniform, reproduceable connections, i . e . , r a t i o n a l connections. In e x a c t l y the way that persons are members to organized a f f a i r s , they are engaged i n serious and p r a c t i c a l work of d e t e c t i n g , demonstrating, and persuading through d i s p l a y s i n the ordinary occasions of t h e i r i n t e r a c t i o n s the appearance of c o n s i s t e n t , coherent, c l e a r , chosen, p l a n f u l a r rangement. In e x a c t l y the ways i n which a s e t t i n g i s organized, i t c o n s i s t s of methods whereby i t s members are provided w i t h accounts of the s e t t i n g as countable, s t o r y a b l e , p r o v e r b i a l , comparable, p i c t u r a b l e , r e p r e s e n t a b l e — i . e . , accountable events?9 Any data u t i l i z e d f o r such a study must be a c o n s t i t u e n t f e a t u r e of some organization.  The data must be produced and used by the s e t t i n g ' s  members of that s e t t i n g during the course of t h e i r everyday  affairs.  Furthermore, i f we are to study members' everyday a f f a i r s and a c t i v i t i e s , then we must a l s o examine data that are produced as part of and r e f l e c t back upon these a f f a i r s and a c t i v i t i e s .  I f we are to properly study  and describe s o c i a l l i f e , we must be able to attend to the d e t a i l s of events that have a c t u a l l y happened.  We should be able to do t h i s i n  an a b s t r a c t way, but, nevertheless, such a d e s c r i p t i o n should be r e sponsive to the a c t u a l d e t a i l s of the events that they purport to describe.  Thus, some s o c i a l s c i e n t i s t s have elected to focus t h e i r  a t t e n t i o n upon members' t a l k as a decidedly n a t u r a l occurrence i n sequences of i n t e r a c t i o n , developing i n and over the course of various s e t t i n g s and occasions. an a n a l y s i s .  Chapter three i s one such instance of such  S p e c i f i c a l l y , then, I w i l l be t r e a t i n g productions of  t a l k as one of the fundamental ways i n which members achieve and  22  display i n , and through the occasion of t h e i r i n t e r a c t i o n s , the cons i s t e n t , coherent, clear, chosen, and planned arrangements, i . e . , that fundamental foundation f o r any type of s o c i a l order. That members' t a l k can be subjected to rigorous s o c i o l o g i c a l  30 analysis i s demonstrated i n the recent works of Harvey Sacks  and  31 other "conversational analysts".  A c l a r i f i c a t i o n and j u s t i f i c a t i o n  of the methodological foundations for conversational analysis goes well beyond the scope and intent of this research report. for not addressing  My reason  these issues i s not simply that to do so would  require more space and time than current concerns warrant.  Rather,  i t i s based on a feature of the present l i t e r a t u r e concerned with conversational analysis.  This l i t e r a t u r e does not provide the reader  with methodological statements about i t s foundations,  and, since such  statements have not been made, I am unable to present a summary of them. However, since I intend to present an analysis of conversational material i n chapter three, I f e e l that i t i s uncumbent on me to present an analysis of the methodological issues raised i n that  chapter.  Thereby, I could attempt to r e l a t e the work of conversational analysts to various developments i n l i n q u i s t i c s and philosophy.  linguistic  I t i s sometimes proposed, for example, that work on  theories of meaning must be absolutely fundamental to work i n conversational analysis.  This would seem to suggest that an appro-  p r i a t e procedure would be to attempt to explicate the connections  32 between the philosophical l i t e r a t u r e and theories of meaning  and  23  conversational analysis.  The point, however, i s that these con-  nections would be a r t i f i c i a l , and might have no necessary connection to the type of analysis presented i n chapter three.  Let  me give an example. In philosophy there i s debate about "meaning" and the manner i n which the concept operates i n language use. H.P.  The philosopher  Grice has proposed a formulation of "meaning" i n terms of  the subjective intentions of i n d i v i d u a l speakers,33 while John Searle has offered us an opposing view i n which meaning i s seen as dependent on speakers attending to the proper conventions of a language rather than to subjective intentions of i n d i v i d u a l speakers.  I t would be possible to engage i n a lengthy and elabo-  rate discussion of these philosophical "theories of meaning" since, commonsensically,  i t would appear that such a discussion i s relevant  to the present analysis of conversational materials. However, this i s not the case.  While I could compare and contrast these arguments,  I know of no way of tying them to the analysis of the conversat i o n a l materials presented i n my own account of chart rounds. Furthermore, my analysis of chart rounds was generated independently of these "theories of meaning".  It does not seem to be  the case that, i n d a i l y l i f e , we need to r e f e r to theories of meaning i n order to understand each other's utterances nor does i t appear useful f o r me at t h i s point to provide the reader with an explication such as Grice's theory of meaning f o r I see no way of tying that theory to the analyses i n chapter three.  What, then,  24  i s the alternative? The analysis of conversation  presented i n chapter three i s my  attempt to treat an instance of chart rounds as a source of data from which to explicate some of the organizational features of this occasion.  Thereby, I attend  casion of chart rounds.  to the t a l k that occurs during  the  oc-  In connection with t h i s , the reader i s  directed to the detailed utterance-by-utterance analysis i n chapter three and i s i n v i t e d to o f f e r a l t e r n a t i v e analyses i f those which are offered  there seem i n c o r r e c t .  While this may  seem t o t a l l y a s c i -  e n t i f i c , i t i s the nature of the data that makes the analysis take t h i s character.  Roy Turner has made t h i s point when discussing  the analysis of conversational materials  how  i s responsive only to the  materials upon which that analysis i s conducted: I stress not only that i t i s to the participants that my analysis must be t i e d , but also the f a c t that we are dealing with a possible i n t e r p r e t i v e schema. The s i g n i f i c a n c e of t h i s i s two-fold. In the f i r s t place, the analysis I am o f f e r i n g i s not intended to provide a d e f i n i t i v e , onceand-for-always reading of the utterance sequence under examination. Nevertheless, I don't mean to suggest, by o f f e r i n g t h i s observation, that the analysis i s tentative i n the sense that with the a p p l i c a t i o n of more time and energy i t might become d e f i n i t i v e . What i s intended, i s that for the participants themselves determinate readings depend upon the a p p l i c a t i o n of i n t e r pretive schemas. Such schemas warrant the i n t e l l i g i b i l i t y and propriety of the hearing of an utterance: there i s , of course, no further warrant. Thus, the conversational analyst may argue well or badly, may be r i g h t or wrong i n f i n d i n g one piece of analysis to be entailed by another; but he cannot provide a " s c i e n t i f i c " warrant f o r his claim which i s stronger than the warrant -members employ as conversationalists. And this i s not an admission of the p r i m i t i v e  state of the a r t , but a characterization of the enterp r i s e and of the c r i t e r i a of adequacy which control i t , given the materials to which i t i s ultimately responsive.3^ And now I s h a l l turn to my i n i t i a l characterization of the setting.  26  Foo tno tes:  Introduction  1.  This does not mean that I was unable to produce a formal research proposal. Indeed, during the course of my f i e l d work at the Community C l i n i c the director of the c l i n i c required that I produce such a document. The point i s , however, that that research document was i t s e l f produced f o r p r a c t i c a l purposes and should not be regarded as being i n d i c a t i v e of "guiding" the character of this work. Rather i t was produced to s a t i s f y the d i r e c t o r ' s request f o r a research proposal and thereby s a t i s f y one of the organizat i o n a l constraints placed upon me by the d i r e c t o r . A copy of this research proposal i s presented l a t e r .  2.  Gerald D. Berreman, "Anemic and Emetic Analyses i n S o c i a l Anthropology", American Anthropologist, (Vol. 68, 1966), p. 348.  3.  Dennison Nash and Ronald Wintrob, "The Emergence of Self-Consciousness i n Ethnography", Current Anthropology, (Vol. 13, No. 5, December 1972), p. 529.  4.  See, f o r example, Dennison Nash, "The Ethnologist as Stranger", Southwestern Journal of Anthropology, (Vol. 19, 1963), p. 158 as well as Bob Scholte's discussion of the ideology of value-free s o c i a l science i n h i s a r t i c l e "Toward a Reflexive and C r i t i c a l Anthropology" i n D e l l Hymes, Ed., Re-inventing Anthropology, (New York: Pantheon Books, 1972), pp. 432-438.  5.  Nash and Wintrob, op. c i t .  6.  Ibid.  7.  Robert Jay, "Personal and Extrapersonal V i s i o n i n Anthropology", i n D e l l Hymes, Ed., Re-inventing Anthropology, (New York: Pantheon Books, 1972), pp. 367-381.  8.  Ibid., p. 375.  9.  Ann Roe, "A Psychological Study of Eminent Psychologists and Anthropologists, and a Comparison with B i o l o g i c a l and Physical S c i e n t i s t s " , Psychological Monographs, (Vol. 67, 1952), pp. 1-55, and "Analysis of Group Rorschachs of Psychologists and Anthropologists", Journal of P r o j e c t i v e Techniques (Vol. 15, 1952), pp. 211-224.  10.  Nash, op. c i t . , p. 160.  11.  Charles Winick, The Dictionary of Anthropology, (New York: Philosophical Library, 1956), p. 193.  27  12.  Charles Frake, "Notes on Queries i n Ethnography" i n Stephen T y l e r , Ed., Cognitive Anthropology, (New York: Holt Rinehart and Winston, 1969), p. 123.  13.  An e x c e l l e n t reader i n t h i s regard i s Stephen T y l e r , Ed., Cognitive Anthropology, (New York: Holt Rinehart and Winston, 1969). I t addresses, i n a c r i t i c a l f a s h i o n much of the contemporary debate between new developments i n ethnographic a n a l y s i s and the more " t r a d i t i o n a l " ethnography of an e a r l i e r anthropology.  14.  For a general d i s c u s s i o n of ethnography and a comprehensive bibliography see Harold Conklin, "Ethnography" i n David S i l s , Ed., I n t e r n a t i o n a l Encyclopedia of the S o c i a l Sciences V o l . 5, (New York: Holt Rinehart and Winston, 1968), pp. 172-178.  15.  Stephen T y l e r , "Introduction", Cognitive Anthropology,(New York: Holt Rinehart and Winston, 1969), p. 6.  16.  I b i d . , p. 11.  17.  T y l e r , "Introduction", Cognitive Anthropology, p. 5.  18.  I b i d . , p. 2.  19.  The methods used i n order to obtain t h i s goal include the c o n s t r u c t i o n of taxonomies, l e x i c o g r a p h i c a l systems,formal i n t e r view and e l i c i t i n g techniques, discourse a n a l y s i s , and ethnosemantics to name but a few. See T y l e r , Cognitive Anthropology f o r a d e t a i l e d representation of these methodological p o s i t i o n s .  20.  Charles Frake, "Notes on Queries i n Ethnography" i n Stephen T y l e r , Ed., Cognitive Anthropology, p. 124.  21.  Harold G a r f i n k e l ' s "A Conception of and Experiments w i t h "Trust" as a Condition of Stable Concerted A c t i o n s " , i n O.J. Harvey, Ed., M o t i v a t i o n and S o c i a l I n t e r a c t i o n , (New York: Ronald Press, 1963), pp. 187-238, i l l u s t r a t e s how members attend to and demonstrate t h e i r a t t e n t i o n to a mass of background expectancies which order their actions.  22.  Harold G a r f i n k e l , Studies i n Ethnomethodology, N.J.: P r e n t i c e - H a l l , 1967), p. 57.  23.  Harold G a r f i n k e l ' s Studies i n Ethnomethodology, (Englewood C l i f f s , N.J.: P r e n t i c e - H a l l , Inc., 1967) can be regarded as the primary source f o r those who are doing or who wish to know about ethnomethodology. Other suggested references are Thomas P. Wilson's "Normative and I n t e r p r e t i v e Paradigms i n Sociology" i n Jack. D.  (Englewood C l i f f s ,  28  Douglas, Ed., Utidefstanding Everyday L i f e (Chicago: Aldine P u b l i s h i n g Co., 1970), pp. 80-103. These i l l u s t r a t e some of the d i f f e r e n c e s between what I have c a l l e d an "ethnomethodological o r i e n t a t i o n " and standard ways o f approaching s o c i a l phenomena. Roy Turner's, Ed., Ethnomethodology, (London: Penguin Books, 1974) furnishes us w i t h an example of the wide v a r i e t y of research that i s now being conducted under the name of ethnomethodology. I would l i k e to p o i n t out, here, that ethnomethodological studies are, a t present, viewed w i t h some d i s d a i n by many of the "standard brand" methodologists. And, whereas stigmatized d i s c i p l i n e s are o f t e n c a l l e d upon to defend t h e i r p o s i t i o n , i t may w e l l be the case that t h e i r status r e f l e c t s fashions and trends i n u n i v e r s i t i e s , i n p u b l i s h i n g companies, i n p u b l i c t a s t e , e t c . , rather than any a c t u a l q u a l i t i e s they may have. 24.  Even Berreman, f o r example, adopts such a research perspective when he states i n h i s a r t i c l e " S o c i a l Categories and S o c i a l I n t e r a c t i o n i n Urban I n d i a " , American Anthropologist, ( V o l . 74, 1972), p. 567 that: The research was undertaken from a "symbolic i n t e r a c t i o n i s t " perspective, using d e t a i l e d observation and i n q u i r y regarding what people do i n face-toface i n t e r a c t i o n , t o discover how they choose among a l t e r n a t i v e behaviours i n terms of the meanings of s p e c i f i c a t t r i b u t e s , a c t i o n s , and s o c i a l s i t u a t i o n s have f o r them and f o r those w i t h whom they i n t e r a c t .  25.  Roy Turner, "Words, Utterances and A c t i v i t i e s " i n Jack Douglas, Ed., Understanding Everyday L i f e , (Chicago: Aldine P u b l i s h i n g Co., 1970), p. 169.  26.  See footnote 19.  27.  Turner, op. c i t .  28.  Richard J . H i l l and Kathleen Stones Crittenden, Eds., Proceedings of the Purdue Symposium on Ethnomethodology, (Department of Sociology, Purdue'University: I n s t i t u t e f o r the Study of S o c i a l Change, 1968). This monograph contains a s e r i e s of edited t r a n s c r i p t s between Harold G a r f i n k e l and other s o c i o l o g i s t s i n which the i s s u e of whether ethnomethodology i s a "method" or a major topic of d i s c u s s i o n .  29.  Harold G a r f i n k e l , Studies i n Ethnomethodology, p. 34.  30.  Throughout t h i s report I have been influenced by the w r i t i n g s of Harvey Sacks and I would l i k e to take t h i s opportunity to acknowledge the i n s i g h t I have obtained through encountering h i s work.  29  31.  U n t i l recently much of the research i n the area of conversational analysis was only available through the private c i r c u l a t i o n of unpublished papers. This s i t u a t i o n i s now changing. Two excellent readers that contain a representation of the works of many conversational analysts are David Sudnow, Ed., Studies i n Social Interaction, (New York: The Tree Press, 1972), and Roy Turner, Ed., Ethnomethodology, (London: Penguin Books, 1974).  32.  The philosophical l i t e r a t u r e dealing with this issue i s vast. I can do no more here than to o f f e r s p e c i f i c references that deal d i r e c t l y with t h i s issue of "meaning" and which also supply the reader with a multitude of references. J.L. Austin, Philosophical Papers, (London: Oxford University Press, 1970), L. Jonathan Cohen, The D i v e r s i t y of Meaning, (London: Menthuen and Co.,1966), Harold Morrick, Ed., Wittgenstein and the Problem of Other Minds, (New York: McGraw-Hill, 1967), George Pitcher, Ed., Wittgenstein: The Philosophical Investigations, (London: MacMillan, 1968), John Searle, Speech Acts: An Essay i n the Philosophy of Language, (London: Cambridge University Press, 1970), Ludwig Wittgenstein, Philosophical Investigations, (Oxford: B a s i l Blackwell, 1963), and Paul Z i f f , Semantic Analysis, (New York: Cornell University Press, 1964).  33.  H.P. Grice, "Meaning", Philosophical Review, 1957.  34.  John Searle, "What i s a Speech Act", i n Max Black, Ed., Philosophy i n America, (New York: MacMillan, 1969), pp. 221-239.  35.  Roy Turner, private correspondence, 1973.  30  CHAPTER I  BEGINNING  AN ETHNOGRAPHIC REPORT  The I n i t i a l Description The Setting The i n i t i a l overtures f o r t h i s paper came from my thesis supervisor.  A colleague had informed him of an attempt to establish a  series of community medical c l i n i c s i n Vancouver.  He suggested that  i t might be possible f o r me to obtain a p o s i t i o n i n one of these c l i n i c s since many of the doctors attached to the project seemed amiable to the goals and values of sociology and might allow me to study the project. While I had had no previous training i n medical sociology, the opportunity to do an ethnography i n such a s e t t i n g seemed too good to miss.^  Before discussing the procedures I used to gain access to the  setting, I would l i k e to provide a d e s c r i p t i o n of the C l i n i c and i t s surroundings. It i s located i n a predominantly lower class area i n the eastern end of the c i t y .  The neighbourhood  i s predominantly I t a l i a n but has a  large Chinese population and a number of other, smaller, ethnic groups. The C l i n i c i s located on a busy street l i n e d with clothing shops, record shops, pool h a l l s and an array of ethnic restaurants and groceterias. The C l i n i c i t s e l f i s housed i n what was once a business o f f i c e , but has been renovated to meet the needs of medical p r a c t i t i t i o n e r s . What were i n i t i a l l y s e c r e t a r i a l o f f i c e s were converted into examination  31  rooms.  A small laboratory, a reception area and three small o f f i c e s  were constructed i n the rear of the b u i l d i n g .  During the course of  this research, however, the C l i n i c expanded i t s f a c i l i t i e s by  ac-  quiring an adjacent b u i l d i n g which has been renovated to accommodate a dental  clinic.  Yet, from the outside, i t i s an inconspicuous b u i l d i n g ; one without many of the c h a r a c t e r i s t i c s t y p i c a l l y associated with medical buildings.  Although the name of the C l i n i c appears on the door and  on the window of the waiting room as w e l l , and a closer inspection w i l l show a l i s t of those physicians who  operate the C l i n i c , i t i s  quite possible to walk or drive past the b u i l d i n g without r e a l i z i n g that i t i s a medical c l i n i c . Although i t i s a community-medical f a c i l i t y , the C l i n i c does not provide in-patients care, i . e . , i t has neither a resident patient population nor a s p e c i a l i s t f a c i l i t y such as an eye, ear, nose and throat c l i n i c .  Therefore, i t does not have r e s t r i c t i v e medical  practices but provides the type of medical care one would normally associate with a p r i v a t e medical p r a c t i c e .  However, this s i m i l a r i t y  to ordinary medical p r a c t i c e requires some e s s e n t i a l c l a r i f i c a t i o n . While the patients at the C l i n i c are, as a matter of routine, assigned  to one, and only one physician, they are also thought of  as patients of the C l i n i c s as a whole and may  thus, as a matter of  course, be treated by a physician other than their "own" physician.  (regular)  While continuity of patient care i s viewed (here, as e l s e -  where,) as desirable, contingencies  peculiar to the Centre may mean  32  that a patient's regular p h y s i c i a n can not attend to him. happens the patient i s seen by another C l i n i c p h y s i c i a n .  When t h i s Note however,  that p a t i e n t s are informed of t h i s p r a c t i c e . The o r i g i n a l s t a f f consisted of four f u l l - t i m e p h y s i c i a n s ,  one  p u b l i c health nurse, a laboratory t e c h n i c i a n , a volunteer community worker, and three s e c r e t a r i e s .  Later, r e l a t e d medical p r o f e s s i o n a l s  such as a n u t r i t i o n i s t and dental h y g i e n i s t s were added to the s t a f f . In a d d i t i o n , since the C l i n i c has some support from the Faculty of Medicine at the U n i v e r s i t y of B r i t i s h Columbia, fourth-year medical c l e r k s (students) may  e l e c t to spend two weeks t r a i n i n g at the C l i n i c  i n order to gain experience i n the " r e a l world" of the medical o f f i c e . In a d d i t i o n to a f u l l - t i m e s t a f f and medical students who work on a part-time b a s i s , the C l i n i c has a group of family physicians donate t h e i r services on a part-time b a s i s .  who  O r i g i n a l l y , physicians  who maintained t h e i r own p r a c t i c e and worked only part-time had r o s t e r of patients at the C l i n i c who  a  they saw on a scheduled b a s i s .  However, t h i s procedure was changed to allow them more time f o r d i s cussion with the medical students. While the s t a f f does not view the organization as aelilwglfare" or c h a r i t y c l i n i c , there i s a s u b s t a n t i a l proportion of i t s p a t i e n t population who  i s , f o r economic or s o c i a l reasons, unable to receive  conventional p r i v a t e medical care.  One p h y s i c i a n characterized the  patient population as "...the type of persons that a regular doctor would not want to drop i n t o h i s o f f i c e .  Theysiscare other p a t i e n t s ,  cause trouble, and require bureaucratic red tape."  Thus, the  33  c l i e n t e l e of the C l i n i c i s l a b e l l e d as somehow of "conventional'' o f f i c e p r a c t i c e .  d i f f e r e n t from that  The C l i n i c sees i t s e l f as an a l t e r -  native to the t r a d i t i o n a l mode of treatment offered i n the out-patient centres of the l o c a l h o s p i t a l s .  Those patients who could be seen by  the s t a f f as f i n a n c i a l l y and s o c i a l l y acceptable to conventional physicians, yet preferred to use the f a c i l i t i e s of the C l i n i c , were seen as expressing a "preference" for the type of care offered at the Clinic. In addition to i t s regular operations, the C l i n i c also runs a Night Drop i n C l i n i c for youths.  This Night C l i n i c i s t y p i c a l of the  pattern followed by many of the youth-oriented C l i n i c s that have recently sprung up i n many metropolitan areas.  The Youth Night  Clinic  2 advertises i n one of the l o c a l underground newspapers  and, as i s  expectable, much of the patient population on such nights consists of youths from the community regularly serviced by the C l i n i c and of transients who have come to Vancouver and are i n need of medical attention or advice.  A l l share some common and recurrent problems.  Many youths want general information on contraception or request b i r t h control p i l l s or abortions.  Other common problems include  amenorrhea (overdue menstrual periods), vaginal discharge, venereal disease, skin problems, and n u t r i t i o n a l problems a r i s i n g from a vegetarian diet or improper n u t r i t i o n a l habits. l i s t are drug-related complaints  Absent from this  for the Vancouver area has many  neighbourhood c l i n i c s that s p e c i a l i z e i n such problems, and the majority of patients s u f f e r i n g from such problems u t i l i z e  those  34  facilities  r a t h e r than the s e r v i c e s of the C l i n i c .  Indeed, the  of the C l i n i c does not want the p l a c e to be c h a r a c t e r i z e d as a clinic,  and  those who  telephone  a r e r e f e r r e d to another a p a t i e n t who  staff "drug"  the C l i n i c about d r u g - r e l a t e d problems  treatment  facility.  T h i s does not mean t h a t  comes to the Youth Night C l i n i c w i t h a drug problem w i l l  be r e f u s e d , treatment, b u t t h a t e t h e c l i n i c w i l l not go out of i t s way to a c q u i r e a drug-using p a t i e n t p o p u l a t i o n . Here i s a quote from t h e i r "Student Handbook, Community Youth N i g h t Program, September 1971".  I t f u r n i s h e s us w i t h an  interesting  self-description: I  PHILOSOPHY AND  HISTORY  An o f t e n u n r e c o g n i z e d m e d i c a l l y u n d e r - p r i v i l e g e d , n e g l e c t e d and a l i e n a t e d group i s the "youth" of our s o c i e t y . M e d i c a l groups have been o r g a n i z e d i n the p a s t to p r o v i d e temporary emergency m e d i c a l c a r e d u r i n g r o c k f e s t i v a l s and s t u d e n t demonstrat i o n s , but many of these groups were as t r a n s i e n t as t h e i r p a t i e n t s . In September of 1970 the Community C l i n i c and the I n t e r p r o f e s s i o n a l Educat i o n of developed an " a d o l e s c e n t c l i n i c " to r e a c h and p r o v i d e m e d i c a l c a r e t o the youth community o f Vancouver. The Community C l i n i c , under the d i r e c t i o n of Dr. i B o b k A l l e n l Jones, donated the p h y s i c a l , p h a r m a c e u t i c a l and l a b o r a t o r y f a c i l i t i e s and encouraged the v o l u n t e e r h e l p of p h y s i c i a n s and d e n t i s t s , w h i l e the PPE group, under Dr. L. P i t k i n ' s a u s p i c e s , arranged the v o l u n t e e r m u l t i d i s c i p l i n a r y h e l p of m e d i c a l , . n u r s i n g and s o c i a l work s t u d e n t s . The o b j e c t i v e s of the " a d o l e s c e n t c l i n i c " were to d e l i v e r h i g h q u a l i t y c a r e to a young p o p u l a t i o n between the ages of 13 to 25 y e a r s , to educate the a d o l e s c e n t i n p r e v e n t i v e ( c o n t r a c e p t i v e ) m e d i c i n e , and to p r o v i d e a l e a r n i n g s i t u a t i o n i n which s t u d e n t s c o u l d e x p e r i e n c e i n t e r professional cooperation.  35  II  INTERPROFESSIONAL EDUCATION  1.  I t i s o u r b e l i e f t h a t o n l y an i n t e r p r o f e s s i o n a l team can p r o v i d e comprehensive c a r e .  2.  The Thursday n i g h t program o f f e r s the s t u d e n t an o p p o r t u n i t y t o observe the r o l e s o f d i f f e r e n t p r o f e s s i o n a l s and u t i l i z e t h e i r s p e c i a l i z e d s k i l l s when a p p r o p r i a t e . N u r s i n g , n u t r i t i o n , r e h a b i l i t a t i o n , d e n t a l and m e d i c a l s t u d e n t s w i l l s t a f f t h e c l i n i c each week.  The Youth Night C l i n i c i s much d i f f e r e n t from day-time o f f i c e practice.  A t y p i c a l evening c l i n i c b e g i n s around 7:30, and a t o r around  t t e t time one may o f t e n f i n d a group.of  b o t h p a t i e n t s and m e d i c a l  s t u d e n t s c o n g r e g a t i n g i n f r o n t of the main e n t r a n c e — of the p h y s i c i a n s who has a key.  Indeed, I o f t e n found  d i s t i n g u i s h m e d i c a l and n u r s i n g s t u d e n t s from  a l l a w a i t i n g one i t d i f f i c u l t to  the a c t u a l p a t i e n t popu-  l a t i o n s i n c e b o t h groups were o f t h e same age.  Thus I had to r e l y  h e a v i l y on cues such as manner o f d r e s s and grooming to p r o v i d e an i n d i c a t i o n of their " r e a l " s o c i a l i d e n t i t i e s .  I t i s interesting that  some of t h e m e d i c a l s t u d e n t s were a l s o c o n f r o n t e d w i t h t h i s problem and  i t s p o s s i b l e consequences and brought  t h e i r stethoscopes  so t h a t  i t was sometimes p o s s i b l e t o l o c a t e " s t u d e n t s " by s e a r c h i n g f o r the s t e t h o s c o p e hanging  out o f t h e i r pocket.  i d e n t i f y many o f t h e s t u d e n t s on sight,.  E v e n t u a l l y , 1 was a b l e to However, s i n c e the s t u d e n t s  on duty d i f f e r e d from week t o week.„identification was always a p o t e n t i a l  /  problem. My f i r s t  encounter w i t h t h e  Youth N i g h t C l i n i c .  Research s e t t i n g was w i t h t h e  The f o l l o w i n g f i e l d note r e c a l l s my f i r s t im-  p r e s s i o n s o f t h e C l i n i c and i l l u s t r a t e s t h e problem o f s t a f f identification;3  36  October 13, 1971 — accompanied by and Dr. Turner. R e l a t i v e l y f r e e and easy a t mosphere w i t h a n o t i c e a b l e absence o f what I ' l l c a l l "recognizable apparel', that i s , doctor's uniforms. S t a f f wear name t a g s . S t a f f composed not o n l y o f d o c t o r s , b u t a l s o n u r s e s , n u t r i t i o n i s t s , rehab, m e d i c i n e , e t c . Name tags c o n s i s t o f name + medical category. One p e r s o n was wearing a tag t h a t s a i d " I s a b e l Nurse" where I take i t t h a t her l a s t name was n o t 'Nurse'. To say t h a t s t a f f r e c o g n i t i o n i s p r o b l e m a t i c p o i n t to j o k e that o c c u r r e d . Since s t a f f i s voluntary and o f t e n changes from week to week there i s / c a n always be a new s e t o f p e r s o n n e l . Consequently d e t e r m i n i n g who these new p e o p l e a r e can be i n t e r e s t i n g f o r the s t a f f a l r e a d y p r e s e n t . Dr. Turner and were asked the q u e s t i o n " I f anybody here was a d o c t o r " . They were seen as p o t e n t i a l candidates f o r that s l o t given t h e i r age and the f a c t t h a t we were on the i n s i d e ( i n the l u n c h room/lounge area) r a t h e r than i n the w a i t i n g room. I was t r e a t e d as a s t u d e n t . 3  As  I was to f i n d out l a t e r ,  the o r g a n i z a t i o n o f the s t a f f and  p r o v i s i o n s f o r the care o f p a t i e n t s i s d i f f e r e n t on y o u t h n i g h t during  day-time p r a c t i c e .  i s r e p l a c e d by v o l u n t e e r  For instance, help  the r e g u l a r s e c r e t a r i a l  from the community.  than staff  The two f o l l o w i n g  t r a n s c r i p t i o n s may g i v e the sense o f what i s meant by "a r e l a t i v e l y f r e e and easy atmosphere."  The f i r s t  i n v o l v e s a m e d i c a l s t u d e n t and the  C l i n i c ' s r e c e p t i o n i s t , and the second a p a t i e n t and the r e c e p t i o n i s t :  #1.  CLINIC RECEPTIONIST AND MEDICAL STUDENT:  1.  Receptionist:  Hi  2.  Medical  Hi,- I am a second-year m e d i c a l student thought I'd come by t o n i g h t spend some time here i f I can  3.  Receptionist:  student:  Yes  37  5.  Researcher:  Sure (Note: I was h e l p i n g a t the r e c e p t i o n desk on t h i s o c c a s i o n and my tape r e c o r d e r was p l a c e d i n view near the top of the r e c e p t i o n i s t ' s desk.)  Medical  Look around f o r a w h i l e , some of my c l a s s m a t e s have been by and s a i d i t was worth coming down  student:  Receptionist:  Good, we've been v e r y busy but we're j u s t s o r t o f ( s i t t i n g ) g e t t i n g our second wind.  Medical  Get your second wind eh - so so s h o u l d I j u s t f l o a t around or  student:  8.  Receptionist:  Yes  9.  Researcher:  Might put you  10.  Receptionist:  Yes  11.  Medical  Can't s t a y too l o n g have to go home and do some work (laughs)  12.  student:  Receptionist:  #2.  to work  might put you  to work  Good ( ) and you know I'm sure y o u ' l l f i n d youirwayay around i t i s n ' t too complicated t h a t y o u ' l l get l o s t .  CLINIC RECEPTIONIST AND  PATIENT  1.  Receptionist:  Have you beerithere b e f o r e ?  2.  Patient:  (Note: There i s much n o i s e around the r e c e p t i o n desk due to p a t i e n t s queueing to see the r e c e p t i o n i s t ) I was suppose to have an appointment on Monday but I'm g o i n g away so I c a l l e d i n today and they/.said to come i n t o n i g h t .  3.  Receptionist:  That's f i n e , ah but the d o c t o r won't see you t i l l I've made t h i s out (a p a t i e n t ' s i n t a k e f o r m ) . You've never been b e f o r e  38  4.  Patient:  Yes I've been here before, my doctor was Doctor M i l l e r but he's on holiday so they s a i d I ' l l be seeing Doctor Jones  5.  Receptionist:  I see, so what's your name?  6.  Patient:  Joan Smith  7.  Receptionist:  Smithnt (the r e c e p t i o n i s t looks at the f i l e s to f i n d the patient's name and corresponding chart number) two seven two nine (pause) You ah ah are you a vegetarian?  8.  Patient:  Umm?  9.  Receptionist:  Ah I j u s t wondered because ah we have someone here who i s i n t e r e s t e d i n ah taking s t a t i s t i c s umm  10.  Patient:  Just about though  11.  Receptionist:  Umm?  12.  Patient:  Just about though  13.  Receptionist:  Umm, j u s t about though ah are you s t i l l at two three four six Howard Avenue?  14.  Patient:  Yes  15.  Receptionist':':  and you s t i l l have the same B.C.M.P. ( B r i t i s h Columbia Medical Plan) number?  16.  Patient:  Yes  17.  Receptionist:  and ah what did you come i n to see the doctor tonight about?  18.  Patient:  ah he's going to ah I.U.D. he's going to give me one of those  39  19.  Receptionist:  Well (  20.  Patient:  O.K.  21.  Receptionist:  Fine —  )  have a seat  This relaxed, l e s s formal a t t i t u d e i s intended as something which encourages p a r t i c i p a t i o n i n the youth night program. Once the r e c e p t i o n i s t has obtained the necessary information and c o l l e c t e d the minimum (<£.00) fee, the patient i s asked to take a seat i n the w a i t i n g room.  I t i s not uncommon on youth night to see an odd  assortment of p a t i e n t s .  On one p a r t i c u l a r night the w a i t i n g room was  f i l l e d w i t h members of the Hare Krishna order accompanying a f e l l o w devotee who had broken h i s ankle while chanting on the s t r e e t .  There  were also some very nervous young women, [And, according to the s t a f f , such nervousness u s u a l l y i n d i c a t e s that they have problems r e l a t e d to b i r t h c o n t r o l or abortion.]  t r a n s i e n t youth, young t r a n s i e n t parents  with t h e i r c h i l d r e n , and some adults who, f o r various personal and s i t u a t i o n a l reasons, p r e f e r to attend the Youth Night C l i n i c . The students who c a l l the patients from the waiting room address them by f i r s t name or, sometimes, f i r s t name plus l a s t name, but terms such as Mr. or Miss are seldom used.  The p a t i e n t i s con-  ducted i n t o o f f i c e s which, during the day serve as regular p h y s i c i a n s ' o f f i c e s , but are, f o r the present purposes, made a v a i l a b l e as i n t e r viewing rooms.  Here, the students interview the p a t i e n t and note  his medical h i s t o r y .  This procedure provides them with an opportunity  to make a t e n t a t i v e diagnosis.  A f t e r the interview the p a t i e n t i s  taken to an examination room or i s asked to r e t u r n to the w a i t i n g room  40  u n t i l an examination room becomes a v a i l a b l e .  And since there are only  three examination rooms and a short supply of doctors, i t i s the norm that p a t i e n t s are often returned to the w a i t i n g room.  I t i s not at a l l  uncommon to hear students asking, " I s there a doctor a v a i l a b l e ? " or "Is there an examination room open?" When an examination room becomes a v a i l a b l e and a p h y s i c i a n i s located, the p a t i e n t i s r e c a l l e d from the w a i t i n g room. Frequently, one of the students . w i l l t r y to secure the examination room ( i . e . , to occupy i t p h y s i c a l l y ) , w h i l e the other student t e l l s the p h y s i c i a n that they are going to get the p a t i e n t .  (Furthermore, i t i s not un-  common f o r a d d i t i o n a l students to be summoned to an examination room i f , upon^examination  i t i s revealed that a patient has some ailment  that the p h y s i c i a n considers to be of p r a c t i c a l i n t e r e s t to students.) A f t e r the examination and any necessary laboratory work, the p a t i e n t ' s dealings w i t h the C l i n i c may be terminated, or he may be i n s t r u c t e d to return to the C l i n i c the next week f o r a follow-up. That the Youth Night C l i n i c deals w i t h a t r a n s i e n t p a t i e n t popul a t i o n i s , f o r some members of the medical p r o f e s s i o n , a problematic phenomenon.  Thus, one p h y s i c i a n was concerned w i t h the f a c t that  the Youth Night C l i n i c i s dealing only i n " e p i s o d i c " medical care and not able to do the necessary follow-up care and which i s standard • medical p r a c t i c e .  The C l i n i c ' s s t a f f sees t h i s f a i l u r e as one of the  major d i f f e r e n c e s between the day-time p r a c t i c e and the Youth Night Clinic. Yet, i t i s notable that the Youth Night C l i n i c a l s o d i f f e r s  41  from the day-time C l i n i c i n other e s s e n t i a l ways.  I t s p a t i e n t s are  observed as coming i n " o f f the s t r e e t " , and, w h i l e a p a r t i c u l a r patient may be r e f e r r e d to as a "regular" Youth Night C l i n i c p a t i e n t , he, l i k e a l l other patients here, i s not regarded as a regular i n the sense of having made an appointment.  I t i s a l s o a f a c t that p a t i e n t s  encounter student personnel before seeing a regular p h y s i c i a n .  And,  as alluded to above, the s t a f f views the. youth night program as something which i s e s s e n t i a l l y d i f f e r e n t from the day-time o f f i c e p r a c t i c e . As the previous d e s c r i p t i o n of the Youth NightCGblnic's "Philosophy and H i s t o r y " s t a t e s , i t s purpose i s "to provide a learning s i t u a t i o n i n which students could experience i n t e r p r o f e s s i o n a l cooperation". Yet, u n l i k e the day-time p r a c t i c e which the s t a f f sees as corresponding to everyday conceptions of standard medical p r a c t i c e , the very openness of the programme created e s s e n t i a l problems.  The d i r e c t o r  of the C l i n i c had apprehensions about youth night turning i n t o what he c a l l e d a " f i s h bowl", that i s , that the C l i n i c might become so open that anyone could come down and view what was happening.  And  t h i s would of course run contrary to the C l i n i c ' s conception of i t s e l f as a community medical p r a c t i c e rather than a neighbourhood  medical  drop-in centre. Yet, the centre seems to have avoided t h i s problem f o r , as a nurse t o l d me, "At f i r s t p a t i e n t s would j u s t drop i n but they have learned that i t i s necessary to make an  appointment."  Since the C l i n i c operates on a group rather than s t r i c t l y i n d i v i d u a l b a s i s and i t i s p o s s i b l e f o r p a t i e n t s to be treated by physicians other than the one they normally v i s i t , the C l i n i c has  42  developed a s p e c i a l routine procedure to monitor patient care. This procedure i s c a l l e d "chart rounds" and deserves s p e c i a l comment;.: I t involves a review of p a t i e n t s ' medical h i s t o r i e s ( t h e i r charts) 4 by the medical s t a f f of the c l i n i c .  O r i g i n a l l y , t h i s was done every  morning, before any p a t i e n t s were attended t o .  The s t a f f would review  the charts of those p a t i e n t s scheduled to be seen that day. This allows the s t a f f to keep a f i n g e r on the day-to-day s i t u a t i o n of the C l i n i c . Later, t h i s procedure was changed to allow £'8MD-&§ to be taken a t the end rather than the beginning of the working day. This proved to be more e f f i c i e n t f o r two reasons.  (a) P a t i e n t s discussed a t morning  chart rounds might miss t h e i r appointments, and (b) unexpected (and unreviewed) p a t i e n t s might "drop i n " to the c l i n i c . Gaining Entry The above c o n s t i t u t e s a general d e s c r i p t i o n of the C l i n i c .  In  t h i s s e c t i o n of the paper I intend to provide an e x p l i c a t i o n of the procedures which I followed i n order to gain access to the c l i n i c self.  it-  While both my supervisor and h i s colleague thought there would  be few problems involved i n doing a research project at the C l i n i c , t h i s d i d not turn out to be the case.  Instead, my entrance i n t o the  C l i n i c as a s o c i o l o g i c a l researcher proved to be immanently and d i v e r s e l y problematic. My f i r s t encounter w i t h the C l i n i c took place on October 13, 1971.  A Youth Night C l i n i c was i n progress as my thesis supervisor,  h i s aforementioned colleague and£ I entered the C l i n i c .  None of us  43  had v i s i t e d the place before but my supervisor's colleague knew the d i r e c t o r of the C l i n i c and had arranged t h i s v i s i t f o r us.  Our  first  impressions of the C l i n i c are summed up i n the f o l l o w i n g f i e l d note which I made s h o r t l y a f t e r t h i s " f i r s t contact":"' Everyone commented that the C l i n i c d i d not appear to be s i m i l a r to any other c l i n i c we had seen. Thus, the problematic question: what i s i t about "~ the place Tthat allows us to recognize i t as being a medical c l i n i c ? That i s , without amy of the external appointments of medical s e t t i n g s what allows t h i s c l i n i c to have i t s status as a c l i n i c ? Doctors do not look l i k e doctors, s t a f f do not look l i k e t y p i c a l medical s t a f f , the place does not appear to be'a c l i n i c . - * We were a l l , no doubt, somewhat surprised by the absence of the t r a d i t i o n a l "white" which i s u s u a l l y associated w i t h h o s p i t a l and c l i n i c a l settings.  This being youth n i g h t , the place had that un-  expectedly informal character described above.  r.And to add f u r t h e r  to the p i c t u r e , there was a video camera team wandering throughout the premise's, f i l m i n g doctor-patient encounters and the o v e r a l l Clinic.  We were introduced to the d i r e c t o r , Dr. Cough.  Dr. Cough  said that he was busy at the time but would be able to t a l k w i t h us l a t e r i n the evening and he suggested  that we should "look around"  u n t i l then. Dr. Turner and I saw the d i r e c t o r l a t e r that evening. companion had l e f t us to attend to some other business.)  (Our  We pointed  out that we were both i n t e r e s t e d i n studying doctor-patient communicat i o n and that i t was often d i f f i c u l t f o r s o c i o l o g i s t s to gain access to medical s e t t i n g s .  We discussed the purpose of our research and  44  t o l d how we hoped that the C l i n i c would prove an i d e a l research s e t t i n g for t h i s .  N a t u r a l l y , we a l s o expressed our appreciation f o r being a l -  lowed access to the C l i n i c .  I t soon became evident that the d i r e c t o r  viewed the C l i n i c as something q u i t e outside the t r a d i t i o n a l mode of treatment afforded by most h o s p i t a l s .  He appeared to be favorably i n -  c l i n e d towards s o c i o l o g i c a l research although he seemed to hold the view that most s o c i o l o g i c a l research i s or at l e a s t ought toiVbe something which i s s o c i a l l y relevant arid/or problem-oriented. as something akin to a remedy f o r a disease.  That i s , he saw i t  Thus he hoped that our  research might p o t e n t i a l l y contribute to the betterment of the C l i n i c . Several times, he expressed the hope that I would be able to give the C l i n i c some "feedback" on how w e l l they were communicating with p a t i e n t s . We agreed that we too were i n t e r e s t e d i n the communication obtaining between doctors and patients and suggested that the i d e a l procedure would be to tape-record physician-patients conversations.  The d i r e c t o r  understood our concern f o r d e t a i l , but suggested that tape-recording  con-  versations would be problematic because of the e t h i c a l issues involved. The f i r s t encounter ended s a t i s f a c t o r i l y and i t was  decided that I would  return at a l a t e r date i n order that we could discuss my research  plans  i n greater d e t a i l . I can r e c a l l a sense of excitement about t h i s f i r s t encounter with the C l i n i c .  At that time, an acquaintance of mine who was  also  a graduate student was engaged i n a study of the maternity ward at one of the l o c a l h o s p i t a l s .  Unfortunately, he was  considerable resistance from h o s p i t a l s t a f f .  encountering  I was e n t h u s i a s t i c  45  about the C l i n i c and i t s apparent openness, I entertained v i s i o n s of being allowed r e l a t i v e l y unhampered access to the s e t t i n g and was exc i t e d by the prospect of viewing and tape-recording a c t u a l medical encounters. My next v i s i t to the C l i n i c was on November 4, 1971. 22 days a f t e r the i n i t i a l meeting) discuss w i t h Dr.  'Cough  (i.e.,  The purpose of the v i s i t was to  what goals I would pursue i n observing the  C l i n i c and how I would conduct that observation.  P r i o r to t h i s ,  I had had discussions w i t h my supervisor about what the " l i n e " I should take when I saw the d i r e c t o r .  We decided that I should d i s -  cuss my i n t e r e s t i n communication, leaving the t o p i c broad enough so that I would be permitted access to the workings of the C l i n i c while at the same time g i v i n g Dr. 'Cough some idea of what I would a c t u a l l y be doing.  (At t h i s time, i t was my i n t e n t i o n to tape some  pieces of i n t e r a c t i o n occurring between doctors and p a t i e n t s . )  After  the second meeting at the C l i n i c I went home and made the f o l l o w i n g notes which, although lengthy, I s h a l l now present i n t h e i r e n t i r e t y as they show c l e a r l y how I f e l t about the research s e t t i n g at t h i s time. Clinic,November 4, 1971 —  1-3 p.m.  1.  A f t e r t e l l i n g Dr. Cough that I would l i k e to observe the various aspects of the C l i n i c he posed the question: "With what purpose i n mind?" My answer contained general comments concerning communication and how I would l i k e to study doctorpatient i n t e r a c t i o n s . I admit t h i s i s a gloss of the encounter but i t w i l l provide a "sense of t h i s encounter.  2.  Dr. Sough was concerned w i t h the methodology of my research. He proposed an a l t e r n a t i v e  to o b s e r v a t i o n i n t e r v i e w s and s u r v e y s . Since I do n o t r e g a r d t h i s a l t e r n a t i v e as adequate, I b e l i e v e I was c r i t i c a l o f the i n t e r v i e w method. I e x p l a i n e d t h a t I was i n t e r e s t e d i n o b s e r v i n g the workings o f t h e C l i n i c i n some l i t e r a l sense, r a t h e r than d e a l i n g w i t h d a t a removed from the d a i l y r o u t i n e s of c l i n i c l i f e by v a r i o u s coding p r o c e d u r e s . In discussing my r o l e as o b s e r v e r c e r t a i n f a c t o r s became apparent. Dr. Cough wanted t o know the i n t e n d e d l e n g t h o f my r e s e a r c h study. I t o l d him the study would take a t l e a s t a y e a r and t h a t I intended to become i n v o l v e d w i t h the C l i n i c . I o f f e r e d my s e r v i c e s as a v o l u n t e e r worker and i t appeared t h a t t h i s o f f e r was w e l l r e c e i v e d . I thought t h a t by v o l u n t e e r i n g I would n o t i n t e r f e r e w i t h the workings o f the C l i n i c and y e t be a b l e to g a i n a q u i c k u n d e r s t a n d i n g o f c l i n i c procedure. Dr. 'Cough seemed v e r y much concerned w i t h t h e u t i l i t y o f my r e s e a r c h f o r the C l i n i c . He was not r e a l l y i n t e r e s t e d i n my own s o c i o l o g i c a l position. No r e a s o n why he should be. He was v e r y much C l i n i c - o r i e n t e d . I d i d some i n t e r a c t i o n a l work s t a t i n g t h a t I am n o t engaged i n pure t h e o r e t i c a l r e s e a r c h , hoping to demonstrate t h a t I am not an " I v o r y Tower" s o c i o l o g i s t . I a l s o s a i d t h a t I thought i t was o n l y f a i r t h a t the C l i n i c should r e c e i v e "feedback" from me concerning my r e s e a r c h . I f e e l as i f I c o u l d have p r e s e n t e d any r e s e a r c h i d e a to t h e d i r e c t o r and he would have t r a n s formed i t i n t o a r e s e a r c h concern f o r the C l i n i c . Communication became the e q u i v a l e n t of problems i n communicating. I f e l t t h a t i t was b e t t e r to a l l o w the d i r e c t o r t o adopt t h i s view o f my r e s e a r c h r a t h e r than engage i n some speech conc e r n i n g "how d i f f i c u l t the concept o f communicat i o n was" and so f o r t h . I s t a t e d t h a t I d i d t h i n k t h e r e would be some " s p i n o f f " o f my r e s e a r c h t h a t would be r e l e v a n t f o r the C l i n i c . Dr. Sough s a i d t h a t he wanted feedback from me. I s a i d t h a t was a good i d e a . Put b l u n t l y , Dr. Tough has a d e f i n i t e i d e a ofwwhat he wants from me as a p e r s o n about to come to the C l i n i c and I f o r e s e e t h a t I may have t o g i v e i t t o him.  47  5.  The end of our t a l k r e s u l t e d i n h i s w i l l i n g n e s s to allow my presence at the C l i n i c . He thought that the r e s t of the s t a f f would agree but he wanted me to come back and e x p l a i n to the s t a f f my research goals. He thought that t h i s would be a mere f o r m a l i t y . ^  Note that while the C l i n i c had i n i t i a l l y held f o r t h the promise of easy and unproblematic access, these expectations were not borne out by the a c t u a l course of events.  The d i r e c t o r of the '3'Clinic demanded  convincing answers to rigorous questions before entrance was allowed. His concerns w i t h methodology, hypotheses, and the s o c i a l u t i l i t y of the research werenmuch more r i g i d and demanding than those concerns which I encountered on the part of my own d i s s e r t a t i o n committee. Another appointment was made f o r me.  I was to go to the C l i n i c i n  order to discuss my research w i t h the s t a f f .  I remember f e e l i n g  dismayed about the prospect of having to r e i t e r a t e my " s t o r y " f o r their benefit.  Concomitantly, I was becoming more and more p e s s i -  m i s t i c about the p o s s i b i l i t y of being permitted to undertake research i n the C l i n i c . My t a l k with the C l i n i c s t a f f was s i m i l a r to the interview w i t h the d i r e c t o r .  I d i d not make any f i e l d notes at t h i s time since I d i d  not know whether or not I would u l t i m a t e l y be admitted as a researcher. Indeed, I feared that I would not be. morning.  Our meeting took place e a r l y one  The d i r e c t o r introduced me to the s t a f f and 'ligaveor.  a b r i e f presentation of my research i n t e r e s t s and mentioned that I would eventually l i k e to tape-record medical i n t e r a c t i o n s . seemed upset by t h i s .  The s t a f f  They made comments about my being able to  evaluate t h e i r performance.  I t r i e d to impress upon them that I was  48  not  i n t e r e s t e d or i n v o l v e d i n such an e v a l u a t i o n .  members of s t a f f were v e r y and  concerned about the use  suggested t h a t i t s , and/or my  would r a i s e a host of e t h i c a l and C l i n i c was  a copy.  was  t h a t I would be  problematic  issue.  become e v i d e n t  During my  i n dresses  s h i r t and  and  I  g i v i n g me  permission  time and  past  to  do  the s p e c i a l  time as a r e s e a r c h  still  sociologist  I found myself a t t e n d i n g  contacts with  not  a  to  considered  the C l i n i c i t had  casual with blue jeans being  permissible  By c a s u a l I mean t h a t male p h y s i c i a n s would o f t e n  wear a s p o r t coat and attired  terminated  p h y s i c a l appearance .that I had  t h a t dress was  on youth n i g h t .  the  providing  t h a t the use o f a tape r e c o r d e r was  a somewhat d i s o r i e n t i n g e x p e r i e n c e . .  p r i o r to t h i s event.  d i r e c t o r of  informed i n a week o r so about t h e i r d e c i s i o n .  Going to the C l i n i c f o r the f i r s t  matters of d r e s s and  recorder  t h a t I might p u b l i s h any-  ( d u r i n g the r e g u l a r day  C l i n i c ) , but  was  The  the s t a f f was  Three days l a t e r I r e c e i v e d a phone c a l l  Youth Night  this,  p r e s e n c e i n the examination room  legal issues.  T h i s meeting w i t h  r e s e a r c h a t the C l i n i c  of the tape  i n a sociology j o u r n a l without f i r s t  him w i t h told  own  concerned about the p o s s i b i l i t y  t h i n g about the C l i n i c  In a d d i t i o n to  t i e and  female p h y s i c i a n s and  or pant s u i t s .  s t a f f were o f t e n  I n c o n t r a s t , I f r e q u e n t l y wore a  t i e (never b l u e j e a n s ) w h i l e  doing  research during  day-  time p r a c t i c e . I was t h a t , li had be  t o l d t h a t c h a r t rounds began a t 8:30 no  a.m.  Other than  i d e a of what to expect i n t h i s s i t u a t i o n or what would  expected of me.  However, I hoped t h a t doing  these Eoundsdwo.ulda  49  allow me to l e a r n the p h y s i c a l layout of the C l i n i c .  I soon found out  where i t was not p e r m i s s i b l e or appropriate f o r me to go. Aside from the d i r e c t o r ' s o f f i c e , a l l the other rooms became open areas and as I soon learned through experience, I was permitted to use the phone or to make notes at the desk i f i t was not occupied.  Since there was no  o r g a n i z a t i o n a l " s l o t " f o r me i n the workings of the C l i n i c , a great deal of my time i n the research s e t t i n g was spent i n purposeful wandering.  Sometimes I would j u s t s i t i n the lunch room, i n the  w a i t i n g room, or i n an empty examination room.  At t h i s time, I want  to emphasize that the s t a f f made.no o r g a n i z a t i o n a l , i . e . , f u n c t i o n a l use of my presence i n the C l i n i c .  Thus a very s u b s t a n t i a l p o r t i o n of  my research time at the C l i n i c was spent "standing around" and observing. While i t had formally .been' e s t a b l i s h e d that I would be able to observe doctor-patient encounters, i t turned out to be ©.ver a month before I was permitted to enter an examination room.  I would often  stand i n the area outside the examination rooms hoping that a p h y s i c i a n would ask i f I would l i k e to observe a medical encounter.  Some-  times I would ask to observe a medical interview and receive a r e p l y such as " I think I'd b e t t e r see him (or her) alone".  I t soon became  c l e a r that, while the C l i n i c presented a casual appearance, the ethic of privacy of the examination room was an i d e a l which was to be maintained.  During t h i s period of research, I r e g u l a r l y attended  d a i l y sessions.of morning chart rounds and would often spend e n t i r e days at the C l i n i c .  I a r r i v e d at the C l i n i c a t 8:30 a.m. and u s u a l l y l e f t  sometime a f t e r 5 p.m. when I would r e t u r n home and apply myself to  50  the task of writing up notes from that  day.  I soon learned that many of the s t a f f bought their lunch at the l o c a l cafe.  Often they would phone i n their order and walk  across the street to pick i t up when i t was  ready.  I started to  order lunch from this cafe as well and to o f f e r * to pick up lunch of other C l i n i c personnel as well as my own.  the  I ate with the  s t a f f and participated i n noontime lunch discussions. My research at the C l i n i c was  directed towards obtaining a  corpus of audio tapes of various types of interactions that take place between s t a f f and patients.  Since this was  often f e l t that the time which I spent there was  not happening I being wasted.  In  retrospect, however, I canlsee many advantages accruing from this period.  I became acquainted with the C l i n i c ^ i t s e l f and learned some-  thing about the p e r s o n a l i t i e s of the physicians and nurses.  Meanwhile,  I became more and more a normal and unquestioned features of the s e t t i n g . The s t a f f became accustomed to seeing me around, e.g., when I did not  go  to the C l i n i c , s t a f f members would sometimes comment upon my next v i s i t "where were you" or "we missed you."  In many respects I began to f e e l  obligated to go to the C l i n i c as much as possible, even though I was not securing the corpus of audio tapes that I had i n i t i a l l y desired to obtain. While the opportunity  to observe chart rounds was  with c e r t a i n d e t a i l s , i t upset me  that I was  record even this aspect of C l i n i c l i f e . was  providing  not permitted  me  to tape-  I told the d i r e c t o r that I  finding i t d i f f i c u l t to remember a l l that was  said during  the  51  conference  and  that I f e l t  t h a t t a k i n g notes d u r i n g  would be v e r y d i s r u p t i v e .  I asked him  tape r e c o r d these s e s s i o n s . and would l e t me  He  i f i t might be p o s s i b l e to  s a i d t h a t he would ask  know t h e i r d e c i s i o n .  t a p e - r e c o r d morning c h a r t rounds.  I was  I felt  and  staff  eventually allowed  of my  o n e - h a l f months i n the f i e l d ,  to b r i n g a tape r e c o r d e r i n t o the  the  t h a t t h i s was  changing p o i n t i n the conduct and p r o g r e s s spending two  c h a r t rounds  a  significant  research.  1 was  to  And  finally  after  permitted  Clinic.  O r i g i n a l l y I used a Sony TC100 p o r t a b l e tape r e c o r d e r but  was  e v e n t u a l l y a b l e to purchase a Sony TC40, a much s m a l l e r and more v e r s a t i l e machine.  C l i n i c members soon became accustomed to  p r e s e n c e of the tape r e c o r d e r . been p e r m i t t e d  While up  and p a t i e n t s , once I began to t a p e - r e c o r d  some of the p h y s i c i a n s allowed me  to observe, but not  of t h e i r i n t e r a c t i o n s w i t h p a t i e n t s . chances of b e i n g p e r m i t t e d  As  c h a r t rounds  to r e c o r d some  time p r o g r e s s e d ,  I realized  to observe d o c t o r - p a t i e n t  a c t i o n were b e t t e r on c e r t a i n days than on o t h e r s , depending upon which members were working t h a t day. never asked me  only  to observe a v e r y s m a l l number o f m e d i c a l i n t e r a c t i o n s  between d o c t o r s  t h a t my  to t h i s p o i n t I had  the  interlargely  F o r example, the d i r e c t o r  i f I would l i k e to observe him w i t h a p a t i e n t and,  obvious reasons,  I felt  t h a t i t was  b e s t not  this direction.  While many o t h e r p h y s i c i a n s were q u i t e f r i e n d l y  w i s e , they were r e l u c t a n t to a l l o w me  although  attempt i n  i n t o the e x a m i n a t i o n room.  of the younger p h y s i c i a n s s a i d t h a t he was s i d e r a t i o n s and,  to make any  he d i d a l l o w me  for  concerned w i t h e t h i c a l to observe some of h i s  otherOne con-  52  encounters with p a t i e n t s , i t was always on my own i n i t i a t i v e ; he never asked i f I would " l i k e to s i t i n on t h i s one." He would allow me to observe one type of p a t i e n t only, —  t h i s u s u a l l y was an older male  rather than one of the many female patients who frequented and who often required p h y s i c a l .examinations.  the C l i n i c  My two best informants  were a female p h y s i c i a n and an older p h y s i c i a n who had recently moved to Vancouver and secured a p o s i t i o n with the C l i n i c .  Both  informants,  while not becoming close personal f r i e n d s , expressed an i n t e r e s t i n my research and allowed me access to t h e i r encounters with p a t i e n t s . Some of the apprehension about my presence at the C l i n i c may be a t t r i b u t e d to the f a c t that the C l i n i c was p a r t i a l l y funded by the u n i v e r s i t y and was conscious of i t s status as an experimental facility.  medical  The C l i n i c was being monitored by members of the medical  profession to determine i t s effectiveness and worthwhileness.  There  was some c o n f l i c t between those members of the medical p r o f e s s i o n who f e l t that the t r a d i t i o n a l "out p a t i e n t " departments of h o s p i t a l s were s u f f i c i e n t , and those physicians who advocated the establishment of community medical c l i n i c s .  Because of t h i s , the C l i n i c was more than  o r d i n a r i l y anxious about being able to present a favourable image. Therefore, having a s o c i o l o g i s t i n t h e i r midst must have made f o r some u n c e r t a i n t i e s on the part of many s t a f f members.  I assume, too,  that many of the s t a f f did not b e l i e v e me when I t o l d them that I was not i n t e r e s t e d i n the i n t e r n a l p o l i t i c s of the C l i n i c or the personal p o l i t i c s of i n d i v i d u a l s t a f f members. When I f i r s t s t a r t e d the research I would often p a r t i c i p a t e i n the Wednesday business-lunch  meeting, but I soon r e f r a i n e d from t h i s p r a c t i c e because some of the issues discussed at these meetings were " p o l i t i c a l l y hot" and I wanted to make i t c l e a r that I was not concerned w i t h the p o l i t i c s of the C l i n i c .  Nevertheless, I b e l i e v e that many of the s t a f f  still  viewed my presence w i t h considerable caution. U n t i l May 1972 my research a c t i v i t i e s a t the C l i n i c consisted i n observing and tape-recording sessions of chart rounds, and of observ ing the general workings of the C l i n i c and some, but not many, medical encounters.  I n a d d i t i o n I t r i e d to attend the Youth Night C l i n i c on  a regular b a s i s .  Some a d d i t i o n a l s t a f f was h i r e d during t h i s period  since a d d i t i o n a l funds had been acquired through various community and governmental agencies.  Further, the C l i n i c had been able to expand  to include not only general medical services but also dental and nutritional  clinics.  As was previously the case, there was s t i l l  no defined o r g a n i z a t i o n a l place for.me i n the s t r u c t u r e of the C l i n i c , so that much of my time was spent standing and w a i t i n g f o r opportunit i e s to view medical i n t e r a c t i o n s . In May 1972 I managed to secure a research stipend from the Department of P a e d i a t r i c s at the U n i v e r s i t y . The purpose of the s t i pend was to allow me to continue my research at the C l i n i c throughout the coming summer months.  This was important because, aside from  f i n a n c i a l support alone, i t meant that f o r the f i r s t time during my research at the C l i n i c , I was l e g i t i m a t e l y e n t i t l e d was working f o r a medical department.  to say that I  I t also brought me into c l o s e r  contact with those physicians i n the Faculty of Medicine who expected  54  to see some results at the end of the summer period. research p o s i t i o n i n the C l i n i c was search s o c i o l o g i s t who  was  Hereafter my  one of a semi-credentialed r e -  employed by a medical department to do  research into doctor-patient communication.  In this way  clinic  members knew that my research was being monitored by physicians outside the s t a f f of the C l i n i c .  I remember going to a c o c k t a i l party  i n which one medical Department Head asked me while the director of the C l i n i c was within hearing distance, i f I thought that the C l i n i c was  r e a l l y worthwhile.  vative.  I replied that I thought i t was most inno-  Thus the d i r e c t o r could not only c r e d i t me with a favourable  response towards the C l i n i c but was I was  also made aware of the fact that  i n contact with other medical professionals who  the C l i n i c .  were monitoring  I confess that gaining this p o s i t i o n of a credentialed  appointment to do research at the C l i n i c made me f e e l more confident for I was  now  a bona-fide medical researcher receiving money from a  medical department to secure tape recordings of doctor-patient interaction. At this state I spoke to the d i r e c t o r and informed him that I was hoping that I could begin to record medical interactions as soon as possible.  He thought there would be no problem i n doing so but asked  that I construct a formal proposal of the type and quantity of medical interactions I wished to record.  The r a t i o n a l e given for this  that the s t a f f should have an idea of exactly what i t was interested i n recording. f e a s i b i l i t y of complaining  was  that I was  I remember going home and considering the to one of my medical contacts that Dr. Tough  55  was not c o o p e r a t i n g , proposal.  b u t i n s t e a d I d e c i d e d to produce the  I t was subsequently  The use of  d i s t r i b u t e d to the  requested  staff.  the tape r e c o r d e r posed c e r t a i n p r a c t i c a l and  problems.  The C l i n i c s t a f f  patient  i t was p e r m i s s i b l e to r e c o r d the m e d i c a l e n c o u n t e r .  if  ethical  d e c i d e d t h a t the p h y s i c i a n s h o u l d ask  his  The  e t h i c a l problems were f u r t h e r r e s o l v e d when my r e s e a r c h p r o p o s a l was approved by the F a c u l t y of' Mea'ielhe E t h i c s Committee. going of  to be allowed  At l a s t  to t a p e - r e c o r d m e d i c a l i n t e r a c t i o n s .  the data i n t h i s r e p o r t comes from t r a n s c r i p t s  I was  The m a j o r i t y  of these tape  recordings. Thus f a r ,  t h i s chapter has been o r i e n t e d towards  of an opening d e s c r i p t i o n f o r an ethnographic r e p o r t .  the p r o d u c t i o n I t s main c o n -  c e r n has been to p r o v i d e the r e a d e r w i t h a summary and d e s c r i p t i o n of the C l i n i c , like  its  to focus  itself,  setting  In c o n t r a s t ,  I would now  upon the ways i n which the p r e c e d i n g d e s c r i p t i o n i s ,  made a v a i l a b l e  remainder of t h i s initial  and'modus o p e r a n d i .  to us as a t o p i c f o r i n v e s t i g a t i o n .  chapter  "standard ethnographic format." i n i t i a l description is related  I also  component o f  i n t e n d to show how  to o t h e r and subsequent  sections  s h i p which o b t a i n s between the p r o d u c t i o n o f an ethnographic of t h a t d e s c r i p t i o n .  the  this  And i n a d d i t i o n , I want to o u t l i n e the  t i o n and the r e c i p i e n t s  the  I wish to examine the ways i n which an  d e s c r i p t i o n such as t h i s i s a c o n s t i t u e n t  ethnographic r e p o r t .  In  in  of an  relationdescrip-  56  A n a l y t i c a l F e a t u r e s -ofl the I n i t i a l  Description  L i k e any ethnographer, p r o d u c i n g a d e s c r i p t i o n of a r e s e a r c h s e t t i n g , I have p r o v i d e d my  r e a d i n g audience w i t h a g e n e r a l d e s c r i p -  t i o n of the c h a r a c t e r o f the r e s e a r c h s e t t i n g . The r e a d e r can presume t h a t the m a t e r i a l s p r e s e n t e d thus f a r c o n s t i t u t e what might be c a l l e d a "background  d e s c r i p t i o n " of the  C l i n i c and t h a t a more a n a l y t i c a l d e s c r i p t i o n of the C l i n i c i s to follow.  He might  expect f u r t h e r t h a t i n subsequent  s e c t i o n s of t h i s  r e p o r t I w i l l address i s s u e s c o n c e r n i n g v a r i o u s s o c i a l f e a t u r e s o f the C l i n i c . subsequent to  t o p i c s as:  of  I t would be r e a s o n a b l e to a n t i c i p a t e  such  the c h a r a c t e r i s t i c s o f community as compared  p r i v a t e m e d i c a l p r a c t i c e , r o l e - c o n f l i c t between v a r i o u s c l i n i c  s t a f f , drug problems the  organizational  amongst t h e young, m i d d l e c l a s s d o c t o r s and  treatment o f lower c l a s s p a t i e n t s , the o r g a n i z a t i o n a l  structure  m e d i c a l i n t e r v i e w s , the s e a r c h f o r an a b o r t i o n , d i s e a s e terms  used by non-medical personnel,'pregnancy and i l l e g i t i m a c y , m e d i c a l d i a g n o s i s as a s o c i a l achievement,  and so f o r t h .  In s h o r t ,  after  r e a d i n g these i n i t i a l m a t e r i a l s , i t would not be unreasonable f o r the reader to expect to f i n d  that the subsequent  r e p o r t was  concerned  w i t h and o r g a n i z e d around t o p i c s such as .those suggested above. to  see such e x p e c t a t i o n s as "normal" e x p e c t a t i o n s would not be  as  inappropriate. Indeed,  the i n i t i a l  d e s c r i p t i o n of the C l i n i c  must be viewed as t h e background s e c t i o n of the ethnography,  And seen  thus f a r p r e s e n t e d  t o some subsequent and more a n a l y t i c  f o r , were I to f u r n i s h o n l y the p r e v i o u s  57  d e s c r i p t i o n of the C l i n i c and claim that such a d e s c r i p t i o n was an adequate ethnography, t h i s claim would be r e j e c t e d by anyone who has had some experience i n ethnographic research.  Although we are unable  to s p e c i f y exactly what i t i s that c o n s t i t u t e s adequate ethnographic d e s c r i p t i o n we are able to see that these i n i t i a l d e s c r i p t i v e materials do not comprise an ethnography of the C l i n i c .  At best, t h i s : - i n i t i a l  d e s c r i p t i o n can be viewed as mere background m a t e r i a l prefacing a subsequent a n a l y s i s of some aspects of c l i n i c a l  organization.  In standard ethnographies, the f a c t that a d e s c r i p t i o n such as the one given at the s t a r t of t h i s chapter i s to be seen as "a preface or lead i n " to some subsequent body of m a t e r i a l , islno.tsanf eafcuf eat^.e to be examined i n those ethnographies themselves. In contrast to standard ethnographies which take such features for granted as an obvious and unquestionable part of "the scheme of things," i t i s my i n t e n t i o n to make a r a d i c a l departure here.  To w i t ,  I want to ask how i t i s that such m a t e r i a l can be seen as a resource to the reader f o r the understanding of subsequent sections of the ethnography, that i s , u s e f u l i n such a way that i f t h i s prefatory m a t e r i a l was absent the ethnography could be viewed somehow d e f i c i e n t or d e f e c t i v e . Therefore, instead of proceeding w i t h a d e s c r i p t i o n of the C l i n i c ' s a n a l y t i c features, t h i s chapter w i l l now focus on how i t i s that such prefatory or background materials contribute to the s o c i a l organization of the ethnography as a whole.  I would l i k e to add that i t i s not my  primary i n t e n t i o n to come up with a l i s t of d e f i n i t i v e answers f o r the  58  s u c c e s s f u l p r o d u c t i o n of an ethnography. forthcoming  Yet,  i f no  then, h o p e f u l l y , some thought-provoking  such l i s t s questions  are  will  have been r e a l i z e d . The  d e s c r i p t i o n of the C l i n i c g i v e n a t the s t a r t of the p r e s e n t  chapter c o u l d have been, had  I decided  c e r t i f i e d and a c c e p t a b l e way  of b e g i n n i n g an e t h n o g r a p h i c  on the s u b j e c t of  the C l i n i c .  as such by a n t h r o p o l o g i s t s and  to f o l l o w i t up as such,;.a  I t would have been* seen; and  It  accepted  s o c i o l o g i s t s doing Ethnographic  I t would not have been seen as some i d i o s y n c r a t i c format esoteric  monograph  research.  adopted f o r  reasons. i s a common p r a c t i c e f o r a n t h r o p o l o g i c a l ethnographers  to  p r o v i d e t h e i r r e a d e r s w i t h a p r e l i m i n a r y d e s c r i p t i o n of "some o t h e r c u l t u r e " as a p r e f a c e f o r a more h i g h l y d e t a i l e d and a n a l y t i c a l d e s c r i p t i o n of t h a t c u l t u r e .  Thus Raymond F i r t h i n h i s work We,  g i v e s some p r e l i m i n a r y i n f o r m a t i o n c o n c e r n i n g  The T i k o p i a  the T i k o p i a :  R a r e l y v i s i t e d by Europeans and w i t h no w h i t e r e s i d e n t s , T i k o p i a l i e s i n the extreme e a s t o f of the B r i t i s h Solomon I s l a n d P r o t e c t o r a t e , and i s i n h a b i t e d by twelve hundred h e a l t h y and v i g o r o u s n a t i v e s . Homogeneous i n speech and c u l t u r e , they a r e a u n i t of what may be termed the " P o l y n e s i a n f r i n g e " i n M e l a n e s i a , t h e i r c l o s e s t a f f i n i t i e s being not w i t h the p e o p l e of the Solomons r e g i o n but w i t h those of Samoa, Tonga and even more d i s t a n t groups to the e a s t . Almost untouched by the o u t s i d e w o r l d the p e o p l e of T i k o p i a manage t h e i r own a f f a i r s , a r e governed by the c h i e f s , and a r e proud of themselves and their culture. They a r e p r i m i t i v e i n the sense t h a t the l e v e l of t h e i r m a t e r i a l t e c h n i c a l a c h i e vement i s not h i g h and they have been a f f e c t e d i n o n l y a few e x t e r n a l s by Western c i v i l i z a t i o n ; a t the same time they have an e l a b o r a t e code of e t i quette, a c l e a r - c u t systematic s o c i a l o r g a n i z a t i o n and they have developed v e r y s t r o n g l y the c e r e m o n i a l s i d e of t h e i r l i f e . They s t i l l wear o n l y t h e i r sim  59  simple b a r k - c l o t h , they l i v e i n p l a i n s a g o - l e a f t h a t c h h u t s , they c a r r y out the t r a d i t i o n a l forms of mourning, m a r r i a g e , and i n i t i a t i o n . Mirabile d i c t u , a l a r g e s e c t i o n of them s t i l l worship t h e i r a n c i e n t gods w i t h f u l l panoply of r i t u a l , a cond i t i o n almost unique i n the P o l y n e s i a of to-day. A b r i e f r e f e r e n c e to the r e l i g i o u s c o n d i t i o n of thercpeople i s n e c e s s a r y i n o r d e r to g i v e some i d e a of the s e t t i n g i n which my work was c a r r i e d  out..  .J  In a s i m i l a r f a s h i o n E v a n s - P r i t c h a r d  makes some p r e l i m i n a r y  remarks  about the Azande i n h i s c l a s s i c ethnography W i t c h r a f t Among the Azande: The Azande ( s i n g u l a r , Zande) are a n e g r o i d p e o p l e who l i v e on the Nile-Congo d i v i d e . They a r e mesat i c e p h a l i c , of medium s t a t u r e , and of a s k i n c o l o u r v a r y i n g from c h o c o l a t e to l i g h t r e d d i s h brown. No f u r t h e r account of t h e i r p h y s i c a l c h a r a c t e r s i s g i v e n here because the photographs of a number of Azande a r e s u f f i c i e n t to show the r e a d e r what they look l i k e . L i k e w i s e no e f f o r t i s made to a s s e s s s c i e n t i f i c a l l y their psychological characters,but i t may he s a i d t h a t i n the e x p e r i e n c e of the author, as w e l l as i n the e x p e r i e n c e of o t h e r Englishmen who have l i v e d among them, the Azande a r e so used to A u t h o r i t y t h a t they are d o c i l e ; t h a t i t i s u s u a l l y easy f o r Europeans to e s t a b l i s h c o n t a c t w i t h them; t h a t they a r e h o s p i t a b l e , good n a t u r e d , and almost always c h e e r f u l and s o c i a b l e ; t h a t they adapt thems e l v e s w i t h o u t undue d i f f i c u l t y to new c o n d i t i o n s of l i f e and are always ready to copy the b e h a v i o u r of those they r e g a r d as t h e i r s u p e r i o r s . i n c u l t u r e and to borrow new modes of d r e s s , new weapons, and u t e n s i l s , new words, and even new i d e a s and h a b i t s ; and t h a t they a r e u s u a l l y i n t e l l i g e n t , s o p h i s t i c a t e d , and p r o g r e s s i v e , o f f e r i n g l i t t l e o p p o s i t i o n to f o r e i g n a d m i n i s t r a t i o n , and d i s p l a y i n g l i t t l e s c o r n f o r f o r e i g n e r s . The r e a d e r w i l l be a b l e to form h i s own judgement o f t h e i r c h a r a c t e r s from the i d e a and a c t i o n s recorded i n t h i s book. The r o y a l c l a s s a r e more proud and c o n s e r v a t i v e ; they a r e contemptuous of t h e i r s u b j e c t s and d e t e s t t h e i r European c o n q u e r o r s . They a r e o f t e n handsome, f r e q u e n t l y t a l e n t e d , and can be charming h o s t s and companions, but g e n e r a l l y they mask behind a c o l d  60  p o l i t e n e s s t h e i r d i s l i k e of the new order of things and of those who impose i t , and I found that, w i t h rare exceptions, they were useless as informants, since they f i r m l y refused to discuss t h e i r customs and b e l i e f s , always d e f l e c t i n g conversation i n t o some other channel,, and that they contrasted i n t h i s respect with t h e i r subjects, who seldom objected and were often keen, to f u r n i s h information....^ I t would appear that the accredited ethnographic constructions of an ethnographic report f o l l o w a recognizable s t r u c t u r e which may char/aeferifzed as a "standard ethnographic format".  be  When reading an eth-  nography, the f i r s t thing which a reader encounters i s a body of materials designed tct60 "set the scene", "to serve as an i n t r o d u c t i o n t o " , or "to provide background m a t e r i a l f o r " subsequent a n a l y t i c a l sections of the ethnographic report.  F i r t h ' s c h a r a c t e r i z a t i o n s of Polynesian s o c i e t y  and Evans-Pritchard's  d e s c r i p t i o n of Azandeland occur i n the i n t r o -  ductory sections of t h e i r r e p o r t s , that i s , before t h e i r d e t a i l e d main accounts of the s o c i e t y which they are studying i n much the same way  as  my i n i t i a l d e s c r i p t i o n of the C l i n i c stands as prefatory to what could w e l l have been a more d e t a i l e d and thoroughgoing report on the organiz a t i o n of the C l i n i c . To speak of a "standard ethnographic format" i s to do much more than to n o t i c e that ethnographic reports are r e c u r r e n t l y constructed 9  i n t h i s manner.  In attending to t h i s , one r a i s e s as an issue the  r e l a t i o n s h i p between these i n i t i a l , introductory sections and those subsequent a n a l y t i c a l sections of the ethnography that are presumed to be forthcoming.  In t h i s way,  the format i t s e l f becomes a v a i l a b l e  as a t o p i c i n i t s own r i g h t ; one s u i t a b l e f o r e m p i r i c a l i n v e s t i g a t i o n . It. may w e l l be the case that an i n v e s t i g a t i o n of the r e l a t i o n s h i p  61  between the beginning sections of an ethnography and the more a n a l y t i c a l sections of the ethnographic report w i l l contribute to our understanding of the s o c i a l organization of ethnographic d e s c r i p t i o n . Let us begin our present i n q u i r y by examining my own  initial  d e s c r i p t i o n of the C l i n i c and asking the f o l l o w i n g question:  How  does  such prefatory d e s c r i p t i v e m a t e r i a l .contribute to the reader's understanding of the forthcoming a n a l y t i c sections of the ethnography? One possible answer to t h i s question i s that such prefatory m a t e r i a l provides the reader with a "sense of the s e t t i n g " .  Unfor-  tunately, t h i s answer does not address the question, f o r the issue i s how does t h i s prefatory m a t e r i a l r e l a t e to the subsequent a n a l y t i c -  section of the ethnography rather than whether or not we are able to characterize i t s contents.  In what sense i s the m a t e r i a l  contained  i n the i n i t i a l d e s c r i p t i o n of the C l i n i c relevant f o r an understanding of some subsequent o r g a n i z a t i o n a l feature of the C l i n i c ?  I t remains  that while such m a t e r i a l may be used by the reader to understand the subsequent a n a l y t i c a l sections of an ethnographic r e p o r t , exactly  how  the reader i s to u t i l i z e t h i s m a t e r i a l remains something which i s not customarily s p e c i f i e d by the w r i t e r of an ethnography.  An example may  help to c l a r i f y t h i s p o i n t . Evans-Pritchard provides the reader with the f o l l o w i n g charact e r i z a t i o n of the Azande:"^ The Azande of the Anglo-Egyptian Sudan l i v e i n Savannah f o r e s t . During the r a i n y season the grasses grow so high and so densely that they present a serious obstacle to any one who wishes to leave the paths. During the dry season, which commences i n November and continues t i l l  62  A p r i l , the whole hush i s f i r e d and the country i s revealed as an undulating p l a i n , i n t e r s e c t e d by innumerable small streams, and not so l e v e l as one might suppose when t r a v e r s i n g i t while the grasses are high. I t i s sparsely wooded and the trees grow to a great height a t the sides of streams where they form f r i n g i n g f o r e s t s . Azande prefer to l i v e along, these streams rather than i n the open p l a i n , b u t are now forbidden to do so i n the Anglo-Egyptian Sudan because species of t s e t s e (Glossina) which contain trypanosomes harmful to man breed near water. Here and there are outcrops of ironstone or g r a n i t e , e i t h e r bare or covered with low g r a s s e s . ^  u  Admittedly we recognize Evans-Pritchars's commentary about the Azande as being a.recognizably standard way of beginning an ethnography and can r e s t assured that i n the forthcoming  sections of h i s work he w i l l  us w i t h d e t a i l e d accounts of ZSnde w i t c h c r a f t .  provide  This commentary, however,  gives absolutely no i n d i c a t i o n of the ways i n which  Evans-Pritchard s 1  readers are to u t i l i z e t h i s information v i s - a - v i s the subsequent materials on w i t c h c r a f t .  How i s i t that information about such things as the r a i n y  season, the savannah f o r e s t , or^the height of the trees at the side of the stream w i l l be usable by the reader when reading subsequent parts of the ethnography? The point I am making i s that ethnographic  d e s c r i p t i o n s do not, as  a routine part of t h e i r procedure, recognize a need f o r o u t l i n i n g the r e l ationship between prefatory sections of the ethnography and those sections that are t y p i c a l l y to f o l l o w .  By i n s t r u c t i o n s I mean a common sense d e f i -  n i t i o n or set of p r i n c i p l e s t e l l i n g the reader to use the m a t e r i a l s i n some s p e c i f i c way. T e l l i n g him, f o r instance, "to use the information about the r a i n y season when reading (and only when reading) chapter four of t h i s report" or "to make s p e c i a l note of the f a c t that Azande  63  t e r r i t o r y i s i n t e r s e c t e d by innumerable small streams," (or, perhaps, small  streams). My d e s c r i p t i o n of the C l i n i c included information about the  " e t h n i c i t y " of the neighbourhood, the c h a r a c t e r i s t i c s  of the p a t i e n t  population, the dress and character of the s t a f f , and so f o r t h . materials may give a "sense of the research setting ,'" — 1  These  at no point  i n t h i s d e s c r i p t i o n do I t e l l the reader why I. have included t h i s information or s t a t e how i t i s that t h i s m a t e r i a l i s part of and relevant to subsequent sections of the ethnographic  report.  Thus i t appears that, although we can speak of a "standard ethnographic  format" i n which the ethnographer provides some i n i t i a l  and prefatory m a t e r i a l i n order to provide the reader with a sense of the s e t t i n g , the reader i s l e f t on h i s own to make the necessary connections between these prefatory m a t e r i a l s and the more a n a l y t i c a l sections that f o l l o w .  Let us continue our examination of the r e l a t i o n -  ship between them. There are some d i s c i p l i n e s , f o r example, formal l o g i c or chemistry, where the reader's a b i l i t y to make sense out of what he i s reading may be d i r e c t l y dependent upon the s e r i a l placement of the materials presented  to him. That i s , some of these presentations are unavoidably  "cumulative"  i n nature so that the reader must understand  theorem A  before he can grasp theorem B, or he must appreciate chapter one before he w i l l be able to read chapter two with the necessary comprehension, e t c . This means that there w i l l be recognizably correct ways of doing a report.  Be that as i t may, there seem to be no such c o n s t r a i n t s i n the  64  ordering of the parts of an ethnographic report. While ethnographies t y p i c a l l y have beginning s e c t i o n s , and these sections c o n s t i t u t e background m a t e r i a l to the more a n a l y t i c a l sections of the report, the reader i s not required to read the beginning s e c t i o n f i r s t so that he w i l l then have the r e q u i s i t e knowledge f o r understanding the subsequent sections of the ethnography.  Indeed, the report could  w e l l be arranged i n such a way that present l e a d - i n m a t e r i a l would then appear elsewhere i n the monograph and t h i s rearrangement would not i n t e r f e r e with the reader's a b i l i t y to understand the m a t e r i a l presented to him i n the a n a l y t i c a l sections of.the report. be p o s s i b l e f o r Evans-Pritchard  For example, i t would  to have informed h i s readers about  Azande w i t c h c r a f t , poison o r a c l e s , accusations of w i t c h c r a f t , e t c . , without r e q u i r i n g . t h a t the reader f i r s t become f a m i l i a r with h i s m a t e r i a l containing information, about the geography of the Egyptian-Sudan. Our examination of the r e l a t i o n s h i p between the i n i t i a l and subsequent a n a l y t i c a l sections of the ethnographic report suggests that i t s construction follows from the d i c t a t e s of what i s seen as an accepted format f o r ethnographies rather than from any necessary or l o g i c a l ordering of m a t e r i a l .  I t i s a l s o notable that introductory  d e s c r i p t i o n s of the research s e t t i n g , l i k e my own d e s c r i p t i o n of the C l i n i c , are at the beginning of ethnographies merely to s a t i s f y s t y l i s t i c and p r e s e n t a t i o n a l concerns, strict  and not because i t i s i n some  sense necessary that the reader understands them before a t -  tempting to make good or comprehensive  sense out of subsequent m a t e r i a l .  While one.could perhaps claim that these i n i t i a l materials are intended  65  to provide the reader w i t h some sense of the s e t t i n g or to get him i n the proper mood, such claims have l i t t l e t h e o r e t i c a l import i f these beginning sections make l i t t l e c o n t r i b u t i o n towards or are p r o b l e m a t i c a l l y r e l a t e d to the a n a l y t i c a l m a t e r i a l s that f o l l o w . Another feature of ethnographic  d e s c r i p t i o n which becomes ap-  parent when we consider t h e . i n i t i a l sections of these ethnographies i s that the d e s c r i p t i o n s which they give us could e a s i l y have been supplied by an educated layman.  I t i s obvious, too, that i n order  to produce such a d e s c r i p t i o n , one does not have to acquire any s p e c i a l or previous t r a i n i n g in' the s o c i a l sciences.  Indeed, my d e s c r i p t i o n  of the C l i n i c might w e l l have been w r i t t e n had I no knowledge whatsoever about i t s p o s s i b l e or p o t e n t i a l r e l a t i o n s h i p to the subsequent sections of t h i s report.  A l l of these considerations point to the  f a c t that t h i s d e s c r i p t i o n i s a product of "common- sense" rather than 1  rigorous " s c i e n t i f i c  v  procedures."  Therefore, the dominant f a c t s about  the materials under consideration are a) that t h e i r production r e s t s l a r g e l y upon mere commonssense and i s l a r g e l y independent of any anthropological or s o c i o l o g i c a l considerations; and b) that these materials are r e l a t e d to the subsequent'sections report i n unspecified and problematic ways. ethnographic this  of the  ethnographic  This second feature of  d e s c r i p t i o n w i l l be discussed i n greater d e t a i l l a t e r i n  chapter. The preceding observations and comments are not meant as c r i t i c i s m s  of the ethnographic  e n t e r p r i s e , nor are they c r i t i c i s m s of the work of  F i r t h or Evans-Pritchard.  The observation that the i n i t i a l prefatory  66  materials of ethnographic reports are not l o g i c a l l y or t h e o r e t i c a l l y connected to the subsequent a n a l y t i c a l sections of an ethnography i s not a proposal that such materials should be so connected. I t i s observable too that the main part or body of an ethnography contains materials that are more a n a l y t i c a l than those which occur i n the introductory sections and that these more a n a l y t i c a l materials generate various  t h e o r e t i c a l problems f o r the s o c i a l s c i e n t i s t .  Such  sections t y p i c a l l y concern such things as kinship and/or family organiz a t i o n , various views of r e l i g i o n or magic, or p o l i t i c a l organization and i t s r e l a t i o n s h i p to economic organization. whereas members of the p r o f e s s i o n a l community frequently f i n d that they are able to engage i n conversations  about, to agree with or  argue about the main sections of ethnographic r e p o r t s , these main features are, as has already been pointed out, generally prefaced by some d e s c r i p t i v e body of m a t e r i a l which has been designed to give the reader a sense f o r the s e t t i n g of the major p o r t i o n of the ethnography. And such prefaces, while omnipresent parts of standard  ethnographic  presentations are, i n themselves, not seen as something which has any abiding t h e o r e t i c a l i n t e r e s t .  Thus, e.g., while there has been much  controversy about Evans-Pritchard's  r i g i d dichotomy of Azande b e l i e f s  concerning that which j u s t happens and that which i s caused by magic, no i n v e s t i g a t o r could be expected to argue with h i s statement that, "Azande prefer to l i v e along these streams rather than i n the open p l,a i.n . . . „11 Are we to regard these i n i t i a l sections to ethnographic reports  67  as being merely "scene s e t t i n g " materials?  And, since t h e i r r e l a t i o n -  ship to the more a n a l y t i c a l sections of an ethnographic report i s not grounded i n any l o g i c a l connection but i n adherence to a p r e s e n t a t i o n a l format alone, do they have no t h e o r e t i c a l i n t e r e s t ? • I would l i k e to suggest that instead of t r e a t i n g these i n i t i a l materials as mere scene s e t t i n g devices, they should be examined i n t h e i r own r i g h t , i . e . , i n terms of t h e i r o r g a n i z a t i o n a l relevance f o r the construction of ethnographic reports.  Thus, having noted some of the features which obtain  between the i n i t i a l and subsequent sections of the ethnography, l e t us focus our attention, upon the examination of these i n i t i a l materials thems e l v e s , and attempt to e x p l i c a t e t h e i r o r g a n i z a t i o n a l import f o r what may.ybe seen as the standard ethnographic format. The ethnographer enjoys a p r i v i l e g e d p o s i t i o n or perspective which the reader does not.  For one thing, he has a greater knowledge  of the c u l t u r e under study than does the reader.  Ethnographers  often  become s p e c i a l i s t s on some c u l t u r e or s o c i e t y and can be s a i d to  "own"  a c e r t a i n expertise on that c u l t u r e which, by and l a r g e , the reader 12  does not and w i l l never "own."  The ethnographer has the job of  mediating between the phenomena which comprise the research s e t t i n g and the reader of h i s report.  In many instances, a l l that the reader  w i l l come to know about the research s e t t i n g i s dependent on what i t i s that the ethnographer t e l l s him.  Ethnographic d e s c r i p t i o n s have  been characterized by A.R. Lough as somewhat s i m i l a r to " t r a v e l l e r ' s tales":  1 3  68  R e c a l l f i r s t t h a t the a n t h r o p o l o g i s t was a t the beginning a t r a v e l l e r . By v i r t u e of h i s a c q u a i n t a n c e w i t h p a r t s of the world out of r e a c h o f most of us, he c o u l d t e l l stay-at-homes i n t e r e s t i n g s t o r i e s about the d i e t and economy, the r e l i g i o u s and s e x u a l p r a c t i c e s of a l i e n and o f t e n e x o t i c p e o p l e s . His t a l k l o o k s to be of a p i e c e w i t h t h a t of one's neighbour who has j u s t come back (with s l i d e s ) from Bermuda or a t o u r of the Western P a r k s - l 3  S o - c a l l e d "arm-chair a r e unable  social scientists  (that i s , i n s o f a r as  to p a r t i c i p a t e i n the a c t u a l e x p e r i e n c e s of the  they  ethnographer  they a r e n e c e s s a r i l y f i n d i n g out what he meant from a d i s t a n c e ) must t r u s t t h a t the ethnographer  has done h i s b e s t to p r o v i d e an a c c u r a t e  and comprehensive d e s c r i p t i o n o f the c u l t u r e b e i n g s t u d i e d . must assume t h a t the ethnographer or  simply l y i n g to him.  Clinic.  The  i s not f a t t e n i n g up h i s d e s c r i p t i o n s  F o r example, c o n s i d e r my  d e s c r i p t i o n of  I t i s e v i d e n t t h a t r e a d e r s are not a b l e to i n v e s t i g a t e  p r o p o s i t i o n s about the C l i n i c , and  reader  the my  to a s c e r t a i n t h a t i t i s i n f a c t  l o c a t e d i n an I t a l i a n a r e a of Vancouver, t h a t i t s s t a f f were c a s u a l l y d r e s s e d , t h a t the C l i n i c had a f r e e and easy atmosphere, e t c .  (In  o t h e r c a s e s , of course, where, say,the r e s e a r c h e r i s t a l k i n g about some d i s t a n t o r e x t i n c t s o c i e t y , v e r i f i c a t i o n i s an almost  insurmountable  problem.) F u r t h e r , t h i s p r i v i l e g e d p o s i t i o n ' i s a g e n e r a l f e a t u r e of a:: ethnographies  and does not a p p l y to each and every type of d e s c r i p t i o n .  For example, people commonly read p o l i t i c a l documents or newspapers w i t h the i n t e n t of f i n d i n g not t r u e accounts but propaganda i n t h e s e . For they have assumed from the o u t s e t t h a t the author has a b M a s e d viewpoint.  In' c o n t r a s t , the reader of an ethnographic  r e p o r t i s not supposed  69  to hold t h i s type of a t t i t u d e towards the ethnographer.  While the  reader may i n i t i a l l y grant the ethnographer qua ethnographer, a high degree of u n q u e s t i o n a b i l i t y , t h i s i s to say that there i s no guarantee that the reader w i l l maintain t h i s a t t i t u d e throughout the reading of the ethnography.  What i s there about the character of  ethnographic d e s c r i p t i o n s that allows the ethnographer to continue to have t h i s p r i v i l e g e d p o s i t i o n ?  I suggest that those i n i t i a l and  prefatory sections of ethnographic r e p o r t s , w h i l e not being l o g i c a l l y connected to the more a n a l y t i c a l sections that f o l l o w , help provide the ethnographer w i t h t h i s credentialed s t a t u s . Because he has a reading audience composed almost e n t i r e l y of stay-at-homes, the ethnographer can r e l y on t h i s f a c t to assume that his reading audience w i l l have some c u r i o s i t y about, but no a c t u a l experience i n the research s e t t i n g .  For example, how members i n the  foreign c u l t u r e dress, what women do i n the s o c i e t y , various r e l i g i o u s aspects of the c u l t u r e , what type of p e r s o n a l i t i e s they have,and so f o r t h are a l l matters that can be assumed to be of i n t e r e s t to the reader, and the ethnographer can presume that the readers of h i s ethnographic d e s c r i p t i o n can make use of the f a c t that h i s audience w i l l have a set of common sense' c u l t u r a l relevancies concerning the c u l t u r e being studied.  The ethnographer can r e l y upon these c u l t u r a l r e l -  evancies f o r the construction of h i s i n i t i a l prefatory materials f o r he knows i n advance that they w i l l c o n s t i t u t e items which can be app r o p r i a t e l y included i n the opening s e c t i o n of h i s ethnography. While such materials may not be the c e n t r a l concern of the  70  ethnographic report, t h e i r placement i n t h i s i n i t i a l or prefatory s e c t i o n s a t i s f i e s much of the reader's c u r i o s i t y about the research s e t t i n g . These prefatory materials also serve to i n d i c a t e that the ethnographer knows much more about the c u l t u r e than he intends to put down i n h i s report.  And they f u r t h e r claim that he knows the s e t t i n g i n the ways  that are t y p i c a l l y expected of someone who has spent a considerable period of time i n some c u l t u r e .  While the ethnographic report may be  a s p e c i a l i z e d monograph on a subject such as k i n s h i p , the sum of m a t e r i a l s presented i n the opening s e c t i o n demonstrates that the ethnographer has considerably more knowledge about the c u l t u r e than he has chosen to present i n the ethnography.  Thus, i f he had wanted to he could have  t o l d the reader not only about k i n s h i p but about other aspects of s o c i a l organization.  Thereby, introductory m a t e r i a l s o f t e n suggest that the  author has much knowledge which i s not s p e l l e d out i n the main s e c t i o n of the paper.  Yet, such materials do not i n d i c a t e how i t i s that the  ethnographer has chosenato include some .things i n the preface and q u i t e d i f f e r e n t things i n the body.  Nor, of course, does the.preface t e l l us  exactly what i t i s that the ethnographer has f a i l e d to t e l l us i n the major parts of h i s presentation.  Thus, the r e l a t i o n s h i p between these  two parts remains unclear. The ethnographer does not merely occupy a p r i v i l e g e d p o s i t i o n v i s - a - y i s h i s reading audience, but rather he displays that p r i v i l e g e d position.  The ethnographer uses the opening sections of h i s report to  f u r n i s h h i s readers w i t h a d e s c r i p t i o n of some phenomena relevant to the s o c i e t y which i s being studied.  He assumes that h i s audience would  71  normally be curious about these features and that they would expect him to mention them i n h i s report. I t was pointed out e a r l i e r that these i n i t i a l or prefatory materials do not come with an e x p l i c i t set of i n s t r u c t i o n s explaining t h e i r r e l a t i o n s h i p to subsequent sections of the ethnography.  However,  these i n i t i a l materials do provide the reader w i t h a host of i m p l i c i t resources which he can use i n h i s subsequent reading of the ethnography.  Thus, while the i n i t i a l m a t e r i a l s customarily included i n such  a report do not provide the reader with an e x p l i c i t l i s t s t a t i n g how he should or must use them, they are s t i l l an important part of the ethnography and, as such, merit a t t e n t i o n .  Perhaps an example w i l l  help c l a r i f y what I mean by t h i s . Evans-Pritchard (see above) t e l l s the reader that the Azande l i v e i n the Anglo-Egyptian  Sudan (see above).  Although t h i s piece of  geographical or l o c a t i o n a l information i s not accompanied by a set of i n s t r u c t i o n s t e l l i n g the reader why i t i s relevant or important and how i t i s to be understood and used, i t i s , nevertheless, informat i o n that has consequentiality f o r the ethnography of the Azande. Had Evans-Pritchard l e f t the reader to.take a guess at the l o c a t i o n of Azande t e r r i t o r y , the reader could e a s i l y be misled.  Were he to assume,  for instance, that the Azande l i v e d i n South America or P o l y n e s i a , h i s e n t i r e understanding  of the ethnographic  report would be colored by  t h i s assumption since he would t r y to make what he read about the Azande f i t i n w i t h h i s knowledge of these c u l t u r e s .  Or, to use.an  absurd example, were he to decide that the Azande were n a t i v e to  72  Oxford rather than to Azandeland, i t would be q u i t e p o s s i b l e f o r him (the reader) to f i n d Evans-Pritchard's m a t e r i a l s on .witchcraft preposterous since he knows about Oxford and what goes on there and r e a l i z e s that p r a c t i c e s such as those described by Evans-Pritchard could not p o s s i b l y take place there.  Then, too, the author i s es-  t a b l i s h i n g the f a c t that the things described i n the ethnographic report are things common to the Anglo-Egyptian  Sudan (and, by i m p l i -  c a t i o n , to A f r i c a ) and are not n e c e s s a r i l y things bearing any resemblance to any other s o c i e t y w i t h which the reader i s himself f a m i l i a r . In t h i s way too, Evans-Pritchard i s s e t t i n g himself up as an expert, i.e.,  as one who, i n contrast to the reader, i s l e g i t i m a t e l y e n t i t l e d  to describe Azande c u l t u r e . Thus, materials that may i n i t i a l l y appear to have the chatty 14  character of a travelogue, understanding  are usable by a reader as a resource f o r  the subsequent a n a l y t i c a l sections of the ethnography.  However, these materials are a resource made a v a i l a b l e to the reader which i s to be used i n any way he so chooses.  For t h i s reason, they are  not subject to enumeration as a set of e x p l i c i t i n s t r u c t i o n s . For instance, my d e s c r i p t i o n of the C l i n i c stated that i t was located i n Vancouver.  This d e s c r i p t i o n allows the reader to use h i s own stock  of common sense knowledge about the o r g a n i z a t i o n of medical p r a c t i c e i n North America and toccome up w i t h an approximation p r o p r i a t e to Vancouver.  that i s ap-  And t h i s c h a r a c t e r i z a t i o n w i l l be important  to subsequent d e s c r i p t i o n s of the C l i n i c .  Note, however, that the  exact r e l a t i o n s h i p between t h i s geographical information and subsequent  73  a n a l y t i c a l materials  remains u n s p e c i f i a b l e .  While such i n i t i a l , m a t e r i a l s can u t i l i z e , rather  c o n s t i t u t e resources  the o r d e r i n g of these m a t e r i a l s  than a s e t of s c i e n t i f i c p r o c e d u r e s .  the m a t e r i a l s  contained  i n my  which readers  i s based on common sense Earlier,  I showed  d e s c r i p t i o n o f the C l i n i c was  that  not  the  p r o d u c t of any.-cspecial s o c i o l o g i c a l t r a i n i n g but were s e l e c t e d  with-  out  help  reference  to any  to c l a r i f y and  s c i e n t i f i c " procedure.  A few  examples may  expand upon t h i s .  L e t us assume t h a t an ethnographer i s w r i t i n g a d e s c r i p t i o n of some feature* i n h i s own  society.  I t may  i n c l u d e a d e s c r i p t i o n of the c l i m a t e ,  not be n e c e s s a r y f o r him  topography, or p h y s i o l o g i c a l  c h a r a c t e r i s t i c s of the p e o p l e he i s s t u d y i n g tion i s t y p i c a l l y included The  a l t h o u g h such i n f o r m a -  i n ethnographies of f o r e i g n c u l t u r e s .  d e c i s i o n of what to i n c l u d e and what to omit i s not,  something which he decides standard  audience and  common-  their relationship  s.etiting. Thus, i n my  d e s c r i p t i o n of the C l i n i c ,  cuss the c l i m a t e or g e o g r a p h i c a l know t h a t I can r e l y upon my couver to supply  I felt  i s considerably  no need to  r e a d e r ' s knowledge of Canada and  Van-  Thus, were I to  the number of p a t i e n t s a t t e n d i n g higher  dis-  c h a r a c t e r i s t i c s of Vancouver f o r I  the d e t a i l s f o r these f e a t u r e s .  say f o r i n s t a n c e , t h a t Clinic  Instead,  the b a s i s of what i t i s t h a t he  s e n s i c a l l y knows about h i s i n t e n d e d to the  however,  upon a f t e r r e f e r r i n g to some e m p i r i c a l  f o r the c o n s t r u c t i o n of e t h n o g r a p h i c r e p o r t s .  such d e c i s i o n s are made on  to  i n summer than i n w i n t e r ,  the Youth N i g h t I would  not  74  have to go i n t o an a n a l y s i s f o r t h i s b u t c o u l d r e l y on the r e a d e r ' s knowledge of Canada and Vancouver•-,to account f o r t h i s That i s , I would expect him to know t h a t r a i n f a l l  increase.  i s heaviest  here  d u r i n g the w i n t e r months, and t h a t d u r i n g the summer Vancouver t r a c t s a c o n s i d e r a b l e number of t r a n s i e n t s . count f o r the d i f f e r e n t r a t e s of a t t e n d a n c e . my  And  at-  these s h o u l d a c -  I f however, I expected  audience to be i g n o r a n t o f the c l i m a t e and geography  o f the  city,  then, and o n l y then s h o u l d such f e a t u r e s be d e s c r i b e d f o r t h e i r benefit.  Indeed, had I e l e c t e d , to i n c l u d e such i n f o r m a t i o n i n my  i n i t i a l d e s c r i p t i o n of the C l i n i c , the  the reader may  m a t e r i a l b o r i n g or questioned,my  w e i l r have found  competence as an  ethnographer.  F u r t h e r i t i s apparent t h a t a) d i f f e r e n t ethnographers  may  d e s c r i b e the same s o c i e t y i n v e r y d i f f e r e n t ways, and b) an e t h nographer w i l l a t t e n d to d i f f e r e n t f e a t u r e s i n d i f f e r e n t phies.  ethnogra-  That i s , he w i l l not d e s c r i b e , say, the m a g i c a l b e l i e f s of  every s o c i e t y f o r which he produces an e t h n o g r a p h i c r e p o r t . f e a t u r e s a r e a r e s u l t o f the f a c t  These  t h a t h i s d e s c r i p t i o n s a r e based  upon the d i c t a t e s of common.sense r a t h e r than some e m p i r i c a l  system.  A c h i e f c o n s t r a i n t here i s the v a r i a b l e o f the a u d i e n c e . has pragmatic i m p l i c a t i o n s f o r the p r o d u c t i o n o f the r e p o r t .  This Thus,  one can imagine, say, E v a n s - P r i t c h a r d c o n s t r u c t i n g a monograph which i s i n t e n d e d f o r t h o s e ' f a m i l i a r w i t h the doing of e t h n o g r a p h i e s , and, on a l a t e r o c c a s i o n , r e v i s i n g i t i n o r d e r to p r e s e n t i t to a l a y audience. problems  I t i s apparent here t h a t a l a y audience would have c e r t a i n a p p r e c i a t i n g a r e p o r t addressed to p r o f e s s i o n a l  ethnographers,  75  w h i l e a p r o f e s s i o n a l audience might w e l l f i n d any o t h e r p r e s e n t a t i o n unsatisfactory. Thus f a r I have shown how  the ethnographer  c o n s t r u c t s the p r e f a t o r y  m a t e r i a l s of the e t h n o g r a p h i c r e p o r t by u s i n g common-sense c r i t e r i a  to  d e c i d e what i s and what i s not proper m a t e r i a l i n terms of h i s i n t e n d e d audience.  I have a l s o shown t h a t r e a d e r s a r e a b l e to understand  make good use o f these m a t e r i a l s i n a way That i s , whereas the ethnographer  and  to  which i s r e c o g n i z a b l y s e n s i b l e .  p r o v i d e s the reader w i t h r e s o u r c e  m a t e r i a l s , he does t h i s w i t h o u t knowing how  i t i s t h a t the r e a d e r  will  be a b l e to make use of them i n h i s r e a d i n g of subsequent s e c t i o n s of the r e p o r t .  T h i s a l l o w s f o r the p o s s i b i l i t y  these i n i t i a l  r e s o u r c e s i n ways t h a t a r e c o m p l e t e l y d i f f e r e n t  i n t e n d e d by the ethnographer. to-one correspondence understanding  t h a t the r e a d e r may  utulize  than  those  T h e r e f o r e , t h e r e does not have to be a  between the ethnographers  i n t e n t i o n s and  one-  the r e a d e r ' s  i n o r d e r f o r these m a t e r i a l s to c o n t r i b u t e to the under-  s t a n d i n g of subsequent s e c t i o n s of the ethnography. Thus, i t i s to the ethnographer's  advantage to p r o v i d e the r e a d e r  w i t h as much i n f o r m a t i o n about the r e s e a r c h s e t t i n g as he t h i n k s might c o n t r i b u t e to an u n d e r s t a n d i n g graphy.  While  of the subsequent s e c t i o n s of the  these p r e f a t o r y s e c t i o n s f o l l o w no  e m p i r i c a l l y demons  s t r a b l e o r d e r , they have the advantage of b e i n g open to an wide range of i n t e r p r e t a t i o n s .  The  ethnographer  ethno-  extremely  would u s u a l l y p r e f e r  to f u r n i s h the r e a d e r w i t h too much r a t h e r than too l i t t l e i n f o r m a t i o n about the r e s e a r c h s e t t i n g i n o r d e r to be on the " s a f e s i d e " . he p r o v i d e s the r e a d e r w i t h any and a l l i n f o r m a t i o n which might t r i b u t e to h i s u n d e r s t a n d i n g  That i s , con-  of the subsequent s e c t i o n s of the ethnography.  76  Here, remember t h a t my  d e s c r i p t i o n of the C l i n i c  materials  designed to p r o v i d e  setting.  However, I am  these m a t e r i a l s paper.  Nor  am  included  the r e a d e r w i t h a sense of the  unable to s p e c i f y e x a c t l y how  i t i s that  a r e r e l e v a n t to the f o r t h c o m i n g s e c t i o n s of I able  this  to f o r m u l a t e the ways i n which the r e a d e r  u t i l i z e these m a t e r i a l s when v i s - a - v i s subsequent p a r t s of presentation chapter  (such as my  inherent  i n ethnographic r e p o r t s .  amined t h a t d e s c r i p t i o n i t s e l f  i n order  d e s c r i p t i o n as data,  (the C l i n i c ) and  grapher and  focussed  h i s intended  By  excommon  treating this  I have argued t h a t an ethnography i s  than i n terms of some s p e c i f i c  have, to t h i s end,  then  to i l l u s t r a t e f e a t u r e s  o r d e r e d i n terms of common,sense procedures and cies rather  organizational  I have p r e s e n t e d a  to the b e g i n n i n g s e c t i o n s 1P;f e t h n o g r a p h i c r e p o r t s .  consider  this  three).  d e s c r i p t i o n of a community m e d i c a l c l i n i c  initial  will  a n a l y s i s of c h a r t rounds p r e s e n t e d i n  In t h i s chapter I have examined some o f the features  research  common sense  e m p i r i c a l procedures.  on the r e l a t i o n s h i p between the  readers.  In the f o l l o w i n g c h a p t e r ,  some of the i s s u e s i n v o l v e d  t h a t i s , the a n a l y t i c s e c t i o n to an  relevan-  ethnoI  shall  i n p r o d u c i n g the next s e c t i o n ethnography.  I  77  Footnotes:  Chapter One  1.  While having no previous t r a i n i n g i n medical sociology, I d i d have an i n t e r e s t i n studying the general features of conversat i o n a l s t r u c t u r e . At the time t h i s research was i n i t i a t e d I f e l t that the C l i n i c would provide an e x c e l l e n t opportunity for me to c o l l e c t a corpus of conversational m a t e r i a l s on which i t would be p o s s i b l e to conduct a "conversational a n a l y s i s " . This goal became transformed over the course of the research.  2.  Note: Respect f o r the c o n f i d e n t i a l i t y of the _ C l i n i c d i c t a t e s that no source be quoted here: Community C l i n i c Address  Telephone Number  i s open 9-5 Monday-Friday i f you.have B.C. insurance and make an appointment; o r , i f you don't have insurance, go"to t h e i r Youth C l i n i c on Thursday 6-9 p.m. Cost i s $2. 3.  Author's f i e l d note October 13, 1971. The reader should note that I constructed t h i s note several hours a f t e r terminating my v i s i t to"the C l i n i c .  4.  During youth night i t i s r o u t i n e c l i n i c a l p r a c t i c e to open a medical chart on each new p a t i e n t . These charts are f i l l e d and are u t i l i z e d on each subsequent v i s i t to the Youth Night C l i n i c . These charts, however, are not u s u a l l y reviewed during the occasion of chart rounds as the Youth Night C l i n i c p a t i e n t populat i o n i s regarded as s t r i c t l y a t r a n s i e n t p a t i e n t population.  5. Author's f i e l d note October 13, 1971. 6.  AutaiorVs f i e l d note November 4, 1971.  7.  Raymond F i r t h , We, The T i k o p i a , (Boston: Beacon Press, 1957), pp. 3-4.  8.  E.E. Evans-Pritchard, W i t c h c r a f t , Oracles and Magic Among the Azande, (London: Oxford U n i v e r s i t y Press, 1937), pp. 13-14.  9.  EornexamplebarWerner Oswald, "The Basic Assumptions of Ethnoscience", .Semiotica, (Vol. 1, 1969), pp. 329-338.  10.  Evans-Pritchard, op. c i t . , p. 17.  11.  Ibid.  78  12.  See W.W. Sharrock, "On Owning Knowledge", i n Roy Turner, Ed., Ethnomethodology, (London: Penguin Books, 1974), pp. 45-54.  13.  A.R. Louch, Explanation and Human A c t i o n , (Berkeley: "University of C a l i f o r n i a Press, 1969), p. 159.  14.  See D.L. Wieder, The Convict Code: A Study of a Moral Order as a Persuasive A c t i v i t y , (Unpublished doctoral d i s s e r t a t i o n , U n i v e r s i t y of C a l i f o r n i a at Los Angeles, 1969), Chapter Four.  The  79  CHAPTER TWO ISSUES IN PRODUCING-AN ANALYTICAL DESCRIPTION Introduction In the preceding chapter, I looked at some of the features of the standard ethnographic format and examined some of the p r o p e r t i e s of those m a t e r i a l s that may be'said to occur r o u t i n e l y i n the i n i t i a l part of an ethnographic report.  The next s e c t i o n of t h i s report were  i t a "standard ethnography," would provide the reader w i t h a d e t a i l e d , a n a l y t i c a l d e s c r i p t i o n of some noteworthy aspect of C l i n i c o r g a n i z a t i o n . This would n e c e s s i t a t e that I s e l e c t some feature which I considered to 1  be p a r t i c u l a r l y important or i n t e r e s t i n g and describe i t i n d e t a i l and i n a way that i s responsive to the c u l t u r a l l y s i g n i f i c a n t behaviour of C l i n i c members.  Instead of presenting such a d e s c r i p t i o n , t h i s chapter  w i l l attend p r i m a r i l y to the question:  How i s i t that the ethnographer  i s able to do a d e s c r i p t i o n of a s e t t i n g i n the f i r s t place?  Thereby,  I w i l l consider my r e l a t i o n s h i p to the research s e t t i n g and how i t i s that I am able to s e l e c t some aspect of C l i n i c o r g a n i z a t i o n from which to produce a d e s c r i p t i o n . I wMia-lsoaexami-neWiflyie r e l a t i o n s h i p to the type of data that I have c o l l e c t e d and look a t some of the ways i n which I might u t i l i z e that data were i t my i n t e n t i o n to provide a "standard d e s c r i p t i o n of C l i n i c o r g a n i z a t i o n . " As i n the previous chapter, our focus w i l l be on the production of an ethnographic d e s c r i p t i o n i t s e l f . S p e c i f i c a l l y , t h i s chapter w i l l discuss some of the issues involved i n producing a d e s c r i p t i o n of "chart rounds."  The core of t h i s chapter w i l l  80  be devoted to a l o o k at the s t e p s l e a d i n g to the s e l e c t i o n of t h i s c a s i o n as a t o p i c i n an ethnographic  r e p o r t and  to an examination  ocof  the manner i n which a d e s c r i p t i o n of i t s o r g a n i z a t i o n a l f e a t u r e s i s produced. I w i l l b e g i n t h i s chapter w i t h a review which a s o c i a l s c i e n t i s t l e c t e d d u r i n g my  could u t i l i z e  of some of the ways i n  the corpus o f d a t a which I c o l -  r e s e a r c h a t the C l i n i c .  T h i s w i l l f o r c e us to c o n s i d e r  the r e l a t i o n s h i p o b t a i n i n g between the r e s e a r c h e r and setting.  I will  examine 'the way  i n which a m e d i c a l  might u t i l i z e data c o l l e c t e d a t the C l i n i c an approach f a i l s  to p r e s e r v e  the r e s e a r c h  s o c i o l o g i s t m±£'":.  and w i l l demonstrate t h a t such  the i n t e g r i t y of those a c t i v i t i e s and  c a s i o n s from which the data o r i g i n a t e s .  I will  thereby  show how  oc-  i t is  t h a t c h a r t rounds c o n s t i t u t e an a p p r o p r i a t e p o s s i b l e t o p i c f o r f u r t h e r analytical description.  However, I w i l l argue that a d e s c r i p t i o n of  o c c a s i o n s h o u l d be r e s p o n s i v e that occasion,  to how  the members of the s e t t i n g  analyses.  to  c o g n i t i v e anthropology)  (i.e.,  Next, I w i l l  c o n s i d e r how attends  s h i p between the r e s e a r c h e r and .the r e s e a r c h s e t t i n g . of  t h i s new  approach to ethnography, a l t h o u g h  as an u n a t t a i n a b l e g o a l .  of  The is  approach  relation-  research  goal  criticized  A f t e r c o n s i d e r i n g some of the v a r i o u s ways i n of the C l i n i c ,  I  the r e a d e r w i t h what I term an " i n a d e q u a t e " d e s c r i p t i o n "  c h a r t rounds.  tages  a new  to the  admirable,  which a r e s e a r c h e r c o u l d . r e l a t e to the data gathered w i l l present  organize  and p o i n t out some of the d e f i c i e n c i e s i n h e r e n t i n t r a -  d i t i o n a l ethnographic ethnography  an  In t h i s way,  I i n t e n d to demonstrate some of .tneaadvan-  i n u s i n g t a l k as a r e s o u r c e f o r d e s c r i b i n g the s e l f - o r g a n i z i n g  81  features of an occasion.  At the same time, the issues discussed i n t h i s  chapter are intended as an i n t r o d u c t i o n leading up to the i n t e r a c t i o n a l analysis of chart rounds presented i n the f o l l o w i n g chapter.  This chap-  t e r , then, could be regarded as a map of the path that I ventured i n producing the d e s c r i p t i o n of chart rounds which occurs i n the f o l l o w i n g chapter. The Research S e t t i n g :  TlAs Medical Sociology Approach  I found myself i n the possession of many hours of audio tapes and many pages of f i e l d notes taken a t t h e . C l i n i c .  L i k e any researcher, I  now faced the task of organizing t h i s data and presenting i t to the reader i n a competently organized format.  Since I d i d not have a research  hypothesis d i r e c t i n g my research, I had to consider the various ways i n which.my data, might best be u t i l i z e d i n a way that would r e f l e c t the r e search s e t t i n g from which i t was c o l l e c t e d .  Therefore, as a f i r s t step  towards a s o l u t i o n to t h i s problem, I thought about some of the ways i n which a t r a d i t i o n a l medical s o c i o l o g i s t might o r i e n t himself to research w i t h i n the C l i n i c and how he might want to make use of the data which I had c o l l e c t e d . The t r a d i t i o n a l approach would regard the p r i v i l e g e d p o s i t i o n of the researcher being " i n " the research s e t t i n g as a way of obtaining information about how physicians t r e a t lower c l a s s p a t i e n t s , how s t a f f c o n f l i c t s are resolved, p a t i e n t s ' a t t i t u d e s towards p h y s i c i a n s , the "informal" o r g a n i z a t i o n a l s t r u c t u r e of the C l i n i c , etc.  He would f e e l  f r e e to use data c o l l e c t e d from the e n t i r e range of s o c i a l i n t e r a c t i o n s that.occur w i t h i n the C l i n i c , and would not be required to attend to the  82  s o c i a l c o n t e x t from which h i s data was to show what I mean by  collected.  An example may  help  this.  L e t us assume t h a t the r e s e a r c h e r i s concerned w i t h s t u d y i n g how p h y s i c i a n s t r e a t lower c l a s s p a t i e n t s .  When I say t h a t the r e s e a r c h e r  c o u l d u t i l i z e d a t a o b t a i n e d from w i t h i n the C l i n i c and y e t f a i l tend to the s o c i a l c o n t e x t i n and by which  t h a t d a t a was  to a t -  produced, I mean *v  t h a t he c o u l d use data o b t a i n e d from such d i v e r s e p i e c e s o f i n t e r a c t i o n as m e d i c a l examinations, c o f f e e b r e a k s , l u n c h - t i m e c o n v e r s a t i o n s and so f o r t h as i n d i c a t i o n s of p h y s i c i a n s ' a c t u a l a t t i t u d e s towards patients.  lower  class  I t would be a p p r o p r i a t e f o r the r e s e a r c h e r to e x t r a c t from the  stream o f C l i n i c b e h a v i o u r those i n s t a n c e s o f i n t e r a c t i o n t h a t somehow manage to support h i s . r e s e a r c h i n t e r e s t s . t h i s presupposes  However, an approach such as  t h a t the r e s e a r c h e r knows beforehand — i n terms of  hypotheses, methodology and r e s e a r c h d e s i g n — the n a t u r e and scope of the q u e s t i o n s t h a t h i s r e s e a r c h was first  place.  d i r e c t e d towards  More .importantly, i t presupposes  answering i n the  t h a t the r e s e a r c h e r knows  what d a t a would c o n s t i t u t e s o c i o l o g i c a l l y r e l e v a n t answers to such questions.  I t i s apparent, however, t h a t an o r i e n t a t i o n such as t h i s i s  not a t t e n t i v e to o c c a s i o n s and a c t i v i t i e s as t o p i c s i n t h e i r own  right.  That i s , i t i s not concerned w i t h p r e s e r v i n g the i n t e g r i t y of the stream of C l i n i c b e h a v i o u r s but f o c u s s e s upon t h e . C l i n i c as a l o c a t i o n f o r g a i n i n g i n f o r m a t i o n about some p r e d e c i d e d r e s e a r c h i n t e r e s t .  That i s ,  an approach such as t h i s sees an event i n a second-hand  I t sees  way.  what i t sees and reaches the c o n c l u s i o n s t h a t i t does o n l y a f t e r the events a t hand through the p r i s m o f a p r e s p e c i f i e d package of  filtering  83  o r i e n t a t i o n s and  hypotheses.  n a t i v e to t h i s approach. attend  t p the o c c a s i o n s  However, as I w i l l show, t h e r e  I t i s also p o s s i b l e f o r a s o c i a l researcher and  activities  t h a t o c c u r w i t h i n the C l i n i c  i n t r i n s i c a l l y interesting topics for investigation. s i b l e to t r e a t the d a t a which one something bounded p r i m a r i l y by rather  obtains  from the r e s e a r c h  i t s a c t u a l context  upon i t .  Thus, an o c c a s i o n  p r o p e r s o c i o l o g i c a l t o p i c i n i t s own  to  as  That i s , i t i s poss e t t i n g as  (context-sensitive)  than something which w i l l . b e d e f i n e d p r i m a r i l y by  research  i s an alter.-*  the n a t u r e of  our  such as c h a r t rounds can become a right.  I t i s my  i n t e n t i o n to attempt  such an a n a l y s i s h e r e . To b e g i n w i t h ,  c h a r t rounds o c c u r on a r e g u l a r l y scheduled b a s i s .  They form a r e c u r r e n t and is,  bounded o c c a s i o n . f o r members of the C l i n i c .  they have p r e s c r i b e d b e g i n n i n g and  normal and  ending times and  n a t u r a l p a r t of the working day  they c o n s t i t u t e an i n t e r e s t i n g aspect  constitute a  for Clinic staff.  As  of C l i n i c o r g a n i z a t i o n ; an  which an ethnographer m i g h t . a n a l y z e i n d e t a i l .  That  This present  such, aspect  description  i s d i r e c t e d towards an a n a l y s i s of c h a r t rounds, however, i t i n t e n d s above a l l e l s e to r e s p e c t by d e s c r i b i n g how  the i n t e g r i t y of t h i s o c c a s i o n .  p a r t i c i p a n t s view and  n a t u r a l f e a t u r e of t h e i r everyday l i v e s .  o r i e n t to i t as a normal In t h i s r e s p e c t ,  c r i p t i o n d i f f e r s from the above mentioned m e d i c a l s o c i o l o g y s i n c e i t i s the o c c a s i o n  of c h a r t rounds i t s e l f  r a t h e r than f a c t o r s d e r i v e d from any interest.  I t w i l l do and  such a desapproach  that i s being  examined  p r e c o n c e i v e d , extraneous  research  this  84  The Ethnographic Approach S i m i l a r l y , ethnographies are d i s t i n g u i s h e d from most other r e searches b y . t h e i r abiding concern to protect the i n t e g r i t y of the s e t t i n g they study.  They t r y to produce a d e s c r i p t i o n of how members  themselves o r i e n t to a s e t t i n g r a t h e r than impose h i s own (the ethnographer's) e x t r i n s i c categories upon i t .  This means that the ethnogra-  phic researcher must have f i r s t hand knowledge of how the s o c i e t y under study i s organized.  Of course, t h i s does not mean that the ethnographer  has mojtheoretical i n t e r e s t s , but rather that those i n t e r e s t s which he does have must be subordinate to a d e s c r i p t i o n of how those c u l t u r a l members he i s studying a c t u a l l y view and organize t h e i r c u l t u r e . A l though we recognize that d e s c r i p t i o n s , such as Evans-Pritchard's present a t i o n of Azande w i t c h c r a f t , have relevance f o r broader a n t h r o p o l o g i c a l issues (issues such as magic and r e l i g i o n ) , we can presume that these d e s c r i p t i o n s are intended p r i m a r i l y as d e s c r i p t i o n s of how the Azande organize their; w i t c h c r a f t p r a c t i c e s . . That i s , they are not intended as elaborations or part of some preconceived hypothesis about how w i t c h c r a f t i s organized i n general.  (Of. course,.Evans-Pritchard' o r some  other t h e o r i s t might make use of h i s d e s c r i p t i o n s i n t h i s way i n some subsequent a n a l y s i s . ) Since I: was concerned with the production of an a n a l y t i c a l d e s c r i p t i o n of chart"rounds,.I was forced to examine the t r a d i t i o n a l ethnographic approach.  I soon found that such an approach might be l e s s responsive  to the i n t e g r i t y of the research s e t t i n g than i t f i r s t seemed to be. At t h i s p o i n t , I would l i k e to introduce some m a t e r i a l s that, at f i r s t glance,  85  might seem to bear l i t t l e r e l a t i o n to the topic of ethnographic description.  That i s , I s h a l l consider some f i n d i n g s gleaned from research  into the s o c i a l psychology of experiments.  The relevance of these  materials should become apparent over the course of the f o l l o w i n g d i s cussion. A vast amount of .'literature has r e c e n t l y been devoted to what has been termed the s o c i a l psychology of the experiment."'" attempted  Researchers have  to abstract and examine some of the o r g a n i z a t i o n a l features  that researchers and subjects attend to when conducting or p a r t i c i p a t i n g i n an experiment.  Thereby, much a t t e n t i o n has been focussed upon the  ongoing matrix of s o c i a l l i f e i n which, experiments n e c e s s a r i l y occur. For example, those doing experimental s o c i a l research o f t e n t a l k about "dependent" and "independent" v a r i a b l e s .  They t r y to inform t h e i r  readers about those v a r i a b l e s which were under t h e i r c o n t r o l and which were not.  those  The experimental researcher t e l l s how h i s subjects were  selected, what they knew or d i d not know about the experiment at hand, etc.  Yet, research i n t o the social.psychology of experiments has shown  how the e x p e r i m e n t a l - s i t u a t i o n i s eminently connected.to  the everyday  r e a l - l i f e - w o r l d of the researcher and h i s research subjects. stance, students may  For i n -  i n f a c t know beforehand or be able to make accurate  guesses about the design and i n t e n t of the research, and so on. these may occur outside of the experiment proper.  A l l of  Yet as current c r i t i c s  point out,, i t i s only because the experimental s i t u a t i o n i s a part of our ongoing r e a l l i f e that i t i s made a v a i l a b l e to us as a topic f o r emperical investigation.  Because t h i s i s so, i t i s f u t i l e to speak of  86  "independent" or "dependent" v a r i a b l e s i f we f a i l to attend to those background expectancies which allow f o r the o r g a n i z a t i o n of the experiment.  The experimental researcher u s u a l l y ignores, and f e e l s  j u s t i f i e d i n i g n o r i n g , f a c t o r s such as these.  I t i s apparent however  that, were i t not f o r features such as these, i t would be impossible f o r him to conduct an experiment.  In t h i s way, experimental research abstracts  observations about human behaviour out of the context of everyday l i f e and ignores the f a c t that actions are irremediably a part of the context i n which they occur.  Needless to say,, such an approach i s of l i m i t e d  u t i l i t y and, while i t might purport t o . t e l l us something about p a i n , pleasure, the behaviour of crowds, e t c . , i t w i l l t e l l us nothing about how these come to be recognizable phenomena i n the f i r s t place. Although ethnographers do not speak of dependent or independent v a r i a b l e s , the construction of an ethnographic report displays s i m i l a r features.  That i s , the ethnographer, assumes that he can simply and as  a matter of r o u t i n e , make observations r e l a t e d to various anthropolog i c a l topics as i f those topics were observable independent of the 2 matrix of everyday l i f e i n which he found them.  That i s , although  ethnographers have a more loosely' defined research language and speak i n terms of s o c i a l organization, r e l i g i o n , magic, p o l i t i c s and power, the f a m i l y , economic organization, and the l i k e , i t i s often the case that these subjects are abstracted from the s o c i a l context i n which they were encountered i n the course of f i e l d research.  When the ethnographer makes  a f i e l d note about, say., kinship organization, that note came from somewhere.  I t may have been generated from data which he picked up while  87  eating a meal, while walking w i t h an informant, from overhearing a conversation, or from various s i t u a t i o n s which he may have encountered.  To see each piece of data p r i m a r i l y as an instance of k i n -  ship o r g a n i z a t i o n i s to deny the i n t e g r i t y of the s o c i a l s i t u a t i o n s from which the information was c o l l e c t e d .  In some mundane sense,  members of a c u l t u r e do not j u s t happen to e x h i b i t k i n s h i p organizat i o n (or anything e l s e f o r that matter).  And to view some feature or  features of a s o c i e t y as phenomena r o u t i n e l y displayed as a part of everyday l i f e i s to ignore the s o c i a l s i t u a t i o n s from which ethnographers e x t r a c t t h e i r data.  Thus, t r a d i t i o n a l ethnographic d e s c r i p t i o n  may i n a d v e r t e n t l y impose a p r e - e x i s t i n g framework on a d e s c r i p t i o n of another c u l t u r e by going to the f i e l d "armed" and "programmed" w i t h a set of t h e o r e t i c a l issues and t o p i c s that tend to .make t h e i r ethno,-r graphic r e p o r t : l e s s responsive to the s e l f - o r g a n i z i n g features of r e current bounded occasions and a c t i v i t i e s .  Thereby, too, they ignore the  world o f : d a i l y l i f e as a primary topic f o r i n v e s t i g a t i o n . Since my concern was w i t h the production of an a n a l y t i c a l desc r i p t i o n of chart rounds, I considered t h i s t r a d i t i o n a l ethnographic approach and came to the conclusion that although such an approach was concerned with.preserving the i n t e g r i t y of the research s e t t i n g , i t f e l l f a r short of i t s aim.  Recently, however, t r a d i t i o n a l ethnographic des-  c r i p t i o n s have been reconsidered and t h e i r goals have been reformulated. The r e s u l t of t h i s r e c o n s i d e r a t i o n has been c a l l e d the "new ethnography" or c o g n i t i v e anthropology.  I soon turned to t h i s new approach to eth-  nographic d e s c r i p t i o n i n the hope that i t would help me to produce a  88  d e s c r i p t i o n which would respect the i n t e g r i t y of the Some of the prominent features of t h i s new  Clinic.  approach to ethnogra-  phic d e s c r i p t i o n have been o u t l i n e d by Tyler i n the i n t r o d u c t i o n to his work, Cognitive Anthropology.  He t e l l s us that, i n contrast to  other, older ways of doing an ethnography, ...cognitive anthropology c o n s t i t u t e s a new t h e o r e t i c a l o r i e n t a t i o n . I t focusses on discovering how d i f f e r e n t peoples organize and use t h e i r c u l t u r e s . This i s not so much a search f o r some generalized u n i t of behavioral a n a l y s i s as i t i s an attempt to understand the organizing p r i n c i p l e s underlying behavior. I t i s assumed that each people has a unique system f o r p e r c e i v i n g and organizing mat e r i a l phenomena — things, events, behavior,and emotions. The object of study i s not these mat e r i a l phenomena themselves, but the way they are organized i n the minds of men. Cultures then are not m a t e r i a l phenomena; they are c o g n i t i v e organizations of m a t e r i a l phenomena. Consequently, cultures are neither described by mere a r b i t r a r y l i s t s of anatomical t r a i t s and i n s t i t u t i o n s such as house type, family type, kinship type, economic type, and p e r s o n a l i t y type, nor are they necessar. i l y equated with some o v e r - a l l i n t e g r a t i v e pattern of these phenomena. Such d e s c r i p t i o n s may t e l l us something about the way an anthropologist thinks about a c u l t u r e , but there i s l i t t l e , i f any, reason to b e l i e v e that they t e l l us anything of how the people of some c u l t u r e think about t h e i r c u l t u r e . -  In essence, c o g n i t i v e anthropology seeks to answer two^questions: What m a t e r i a l phenomena are s i g g n i f i c a n t f o r the people of some c u l t u r e ; and, how do they organize these phenomena. 3  To u t i l i z e t h i s approach i n attempting  a d e s c r i p t i o n of chart  rounds necessitates a concern w i t h the ways i n which the members who p a r t i c i p a t e i n chart rounds c o g n i t i v e l y organize the occasion.  By t h i s  I mean not only that my d e s c r i p t i o n must respect the i n t e g r i t y of t h i s occasion, but also that i t must discover and describe the way(s) i n  89  Vhi'ch the s t a f f produces t h e o c c a s i o n as a r e g u l a r feature  o f l i f e a t the C l i n i c .  Naturally,  and r e c u r r e n t  to respond to t h e aims of  a d i s c i p l i n e such as c o g n i t i v e anthropology i s t o r a i s e i s s u e s  about  data c o l l e c t i o n and about .what i s to be.done w i t h the d a t a a f t e r i t has  been c o l l e c t e d .  moment I would l i k e of c o g n i t i v e  These i s s u e s w i l l be d i s c u s s e d tooconsider  Tyler's formulation  later.  F o r the  of the r e s e a r c h  goal  anthropology:  The " t h e o r y " here i s n o t so much a THEORY OF CULTURE as i t i s t h e o r i e s o f c u l t u r e s , o r a theory of d e s c r i p t i o n s . The aim o f such a theory i s t o p r o v i d e answers to t h e q u e s t i o n s : How would t h e p e o p l e o f some o t h e r c u l t u r e expect me to behave i f I were a member o f t h e i r c u l t u r e ; and what a r e the r u l e s o f a p p r o p r i a t e b e h a v i o r i n t h e i r c u l t u r e . Answers to these q u e s t i o n s a r e p r o v i d e d by an adequate d e s c r i p t i o n o f the r u l e s used by the p e o p l e i n that c u l t u r e . Consequently, t h i s d e s c r i p t i o n i t s e l f c o n s t i t u t e s the "theory" f o r that c u l t u r e , f o r i t r e p r e s e n t s t h e c o n c e p t u a l model of o r g a n i z a t i o n used by i t s members. Such a theory i s v a l i d a t e d by our a b i l i t y t o p r e d i c t how these p e o p l e would expect ,us t o behave i f we were members of t h e i r c u l t u r e . ^ It  i s not my i n t e n t i o n t o engage i n a c r i t i c i s m of c o g n i t i v e  anthropology.^  I would, however, l i k e t o n o t e two f e a t u r e s  from T y l e r ' s p r e c e d i n g comments;  First,  derivable  and a p o s i t i v e f e a t u r e , i s  the way t h a t t h i s approach d i r e c t s t h e ethnographer t o d i s c o v e r s o c i a l scenes and s t r u c t u r e s members who produce them.  how  a r e o r g a n i z e d from t h e s t a n d p o i n t o f t h e  To t h i s end, the v e r y f a c t t h a t some scene  can be r e c o g n i z e d as an. "X" i n the f i r s t  place  i s made a t o p i c f o r i n -  v e s t i g a t i o n and i s n o t simply i n c o r p o r a t e d  i n t o t h e ethnographer's  analysis.  i s that  Second, and a n e g a t i v e f e a t u r e ,  c o g n i t i v e anthropology i s not a t t a i n a b l e .  the research  goal of  Some o f the reasons why t h i s  90  i s so have been discussed i n the preceding chapter, however, t h i s w i l l require f u r t h e r elaboration. I t seems as i f , f o r the c o g n i t i v e anthropologist, an adequate ethnographic  d e s c r i p t i o n c o n s i s t s of an a n a l y s i s that would allow the  reader who had the opportunity and wished to do so, to behave i n ways that would be deemed c u l t u r a l l y appropriate by members of the s o c i e t y which he i s d e s c r i b i n g .  This i s an u t t e r l y , impossible goal f o r a t  l e a s t two reasons, the f i r s t reason i s not nearly as i n t e r e s t i n g as the second.  Let us consider the recommendation from the standpoint of an  ethnographer who wishes to produce an adequate ethnographic d e s c r i p t i o n of chart rounds. I t should be obvious that no matter how d e t a i l e d or responsive a d e s c r i p t i o n of members' c o g n i t i v e o r g a n i z a t i o n or doing of chart rounds i s made, i t could never allow the reader to act as a f u l l y competent p a r t i c i p a n t to a l l aspects of t h i s occasion.  For instance, a necessary  component of such competence i s a c e r t a i n degree of medical expertise and no matter how d e t a i l e d and s o p h i s t i c a t e d my d e s c r i p t i o n became, the reader would not be able to a c t as a f u l l y competent member of the C l i n i c such that he c o u l d . f u l l y p a r t i c i p a t e i n t h i s occasion unless he were w i l l i n g and able to acquire the appropriate medical t r a i n i n g . -  The  second and more i n t e r e s t i n g point i s that of common-sense r e l e v a n c i e s . That i s , the c o n s t r u c t i o n of any d e s c r i p t i o n requires that the ethnographer u t i l i z e h i s own predetermined set of common-sense relevancies with reference to which items are to be included or omitted from h i s d e s c r i p t i o n . This point was discussed i n d e t a i l i n the preceding chapter.  Further, the  ethnographer not only uses h i s own set of common-sense r e l e v a n c i e s to produce h i s d e s c r i p t i o n , but also r e l i e s upon h i s reader to employ t h e i r own common-sense knowledge to inform or to f i l l i n the ethnographic d e s c r i p t i o n .  While. Tyler's comments seem to suggest that the  ethnographer would be able to describe everything one would need to know i n order to act as a competent c u l t u r a l member.?, as I have 1  demonstrated here, to attempt any complete d e s c r i p t i o n i s an impossible task to attempt.  Tyler.and others'have, however, f a i l e d to take t h i s  i n t o account A f t e r examining t r a d i t i o n a l ethnographic d e s c r i p t i o n and the recommendations promulgated by the exponents of c o g n i t i v e anthropology, I found that T s t i l l faced.the task of producing an a n a l y t i c a l d e s c r i p t i o n of chart rounds.  I f e l t that any d e s c r i p t i o n that I produced  should respect the i n t e g r i t y of the occasion but I also r e a l i z e d that my d e s c r i p t i o n would not enable the reader, to act i n the same ways that a f u l l y competent participant..to t h i s occasion would i n f a c t a c t .  Fur-  thermore, u n l i k e t r a d i t i o n a l ethnographers or those engaged i n c o g n i t i v e anthropology, I did not have some a p r i o r i t h e o r e t i c a l or t o p i c a l i n t e r e s t .in the research s e t t i n g before commencing my research.  In many  ways t h i s proved to be an asset f o r I was t r y i n g to make the best p o s s i b l e sense of what .I was observing'at the C l i n i c .  With no research proposal,  design, or hypothesis to be e m p i r i c a l l y proved or disproved, I was often f r e e to do so.  Thus, while I propose to o f f e r a more a n a l y t i c a l d e s c r i p -  t i o n of some aspects of C l i n i c o r g a n i z a t i o n , namely chart rounds, the generation of t h i s d e s c r i p t i o n was prompted by my examination of the  92  issues involved i n the production of an ethnographic d e s c r i p t i o n ,  and  c h i e f l y my consideration of t r a d i t i o n a l and c o g n i t i v e anthropologies • The preceding d i s c u s s i o n has d e a l t with the manner i n which a researcher could r e l a t e tolthis d e s c r i p t i o n of some aspect of a s e t t i n g ' s organization.  I t has not, however, provided the reader with  any  d e f i n i t i v e recommendations f o r the construction of such a d e s c r i p t i o n . However, i t i s i n t e r e s t i n g that d e s c r i p t i o n s are something which have been doing'as a member of s o c i e t y long before gaining any f e s s i o n a l s o c i o l o g i c a l competence.  I/we  pro-  For instance, i t i s by and through  our everyday common-sense knowledge that we can see that the  occasion  of chart rounds could c o n s t i t u t e a p o s s i b l e and appropriate subject f o r further i n v e s t i g a t i o n i n a standard ethnography.  This, l i k e any of our  ongoing a f f a i r s i n the l i f e - w o r l d i s i n t i m a t e l y connected to our a b i l i t y to use a v a s t amount of common sense. chart rounds.  What f o l l o w s i s a d e s c r i p t i o n of  I t i s a d e s c r i p t i o n which I have labeled as "inadequate."  The reasons f o r t h i s w i l l be examined a f t e r the reader has had a chance to examine i t s contents. Chart Rounds:  A H e u r i s t i c a l l y Inadequate D e s c r i p t i o n  Chart rounds i s a scheduled occasion f o r reviewing p a t i e n t s ' medical h i s t o r i e s .  I t i s .a review of p a t i e n t s ' charts.  During my  research,  there were two occasions w;rhie^eino:some of i&s.ec<b£ai^c Sights, tfeirfes--were eahacmgnejdd.  At f i r s t , chart rounds consisted of a review of the charts  of those p a t i e n t s scheduled to be seen on that day. place i n the morning, around 8:30 patients.  a.m.,  This review took  that i s before seeing  any  Later, t h i s procedure was changed to a review of the charts  93  t h a t belong to those p a t i e n t s who When I q u e s t i o n e d a nurse about about  change, I r e c e i v e d  had been seen on the p r e v i o u s day.  the r e a s o n o r reasons f o r t h i s  the f o l l o w i n g  account:^  Researcher:.  And morning yeah, what was the r e a s o n f o r changing c h a r t rounds?  Nurse:  W e l l we d e c i d e d t h a t we were m i s s i n g a l o t of p e o p l e and a l o t of the p e o p l e we were d i s c u s s i n g weren't coming i n i t would be b e t t e r to d i s c u s s i t a f t e r they came i n and cover everybody.  T h i s p r o c e d u r e was  a l s o changed.  change i n procedure was  offered  The f o l l o w i n g e x p l a n a t i o n of t h i s to me  by the d i r e c t o r of the  Clinic:  Director:  ...We're j u s t m o d i f y i n g our c h a r t p r o c e d u r e a l i t t l e Bruce  Researcher:  Urnm mm  Director:  i n t h a t ah ah we're we're g o i n g to change the system so t h a t one of the p a r t - t i m e one o f the f u l l time f a m i l y d o c t o r s i s g o i n g to be r e s p o n s i b l e f o r a student each two weeks  Researcher:  I see  Director:  and p a r t o f t h e i r j o b have you met S h e r r i (Note: a t t h i s p o i n t an i n t r o d u c t i o n o c c u r s between a member of s t a f f and a new m e d i c a l s t u d e n t ) . . . Ah the family charts select  new  8  round  ah the ah i d e a w i l l be t h a t the d o c t o r w i l l go through a l l of the from the p r e c e d i n g day and t r y t o out  Researcher:  Urnm mm  Director:  ah r e p r e s e n t a t i v e group of go o v e r . . .  Urnm mm ah which w e ' l l  Note the t a k e n - f o r - g r a h t e d c h a r a c t e r o f c h a r t rounds. attested  round-  to by the l a c k of c o n c e r n which C l i n i c  sort  This i s  staff display i n orienting  94  to t h e i r occurrence. times.  Chart rounds take place every day a t prescribed  They c o n s t i t u t e one of the many demand c h a r a c t e r i s t i c s which  C l i n i c s t a f f o r i e n t to i n the course of t h e i r d a i l y occupational r o u 9  tines.  Chart rounds are a part of the schedule of the C l i n i c . There-  by, such things as medical appointments are scheduled i n a way that w i l l not c o n f l i c t with the time allb.tited f o r chart rounds.  Indeed, I  have seen physicians hurry through an examination i n order to be on time f o r chart rounds.  When s t a f f a r r i v e l a t e f o r chart rounds, how-  ever, i t i s not normally necessary to o f f e r an apology; they u s u a l l y j u s t enter the room and take a seat. A minimal number of p a r t i c i p a n t s i s required i f chart rounds are to proceed as scheduled.  I have observed that at l e a s t one p h y s i c i a n ,  and a t l e a s t one other medical person (usually a nurse or a medical student) i s required. This necessary minimum complement of personnel i s f a c i l i t a t e d by having a scheduled time and place f o r reviewing charts. Thus, on any given day,members of the C l i n i c know who they may expect to see at.chart rounds f o r they are f a m i l i a r w i t h each other's schedules. This does not mean that chart rounds do not take place i f a usual or expected p a r t i c i p a n t has not a r r i v e d , but h i s absence provides grounds f o r s t a r t i n g without him. Chart rounds are scheduled to l a s t approximately f o r t y - f i v e minutes.  That i s , they have a scheduled beginning and a  scheduled end, and are geared i n t o some notion of time which p a r t i c i p a n t s o r i e n t to i n t h e i r jobs a t the C l i n i c . While reviewing the charts requires a minimum complement of p a r t i cipants, i t i s t y p i c a l l y the case that only one s t a f f member presents  95  (that i s , has c o n t r o l of) the charts.  Physicians and nurses take turns  presenting the charts to the r e s t of the group that has assembled f o r chart rounds.  I f , f o r some reason, the.person scheduled to present the  charts i s absent, one of the other s t a f f members w i l l present the charts, and i f the person who was i n i t i a l l y supposed to present the charts should a r r i v e w h i l e a review i s i n progress, the charts are not r e l i n q u i s h e d to him.  Sometimes, the charts scheduled f o r review.were assembled by the  secretary on the previous evening; a t other times they were selected by a p h y s i c i a n j u s t p r i o r to chart rounds.  Thus, they were made ready, f o r  the person presenting the.charts during chart.rounds.  A l l the charts i n  the p i l e had to be reviewed, so..that members were able to o r i e n t to the progress of any p a r t i c u l a r occasion by noting the number of charts l e f t to be reviewed. Chart rounds are intended .primarily-as a procedure which w i l l f a c i l i t a t e and promote'better p a t i e n t care but they serve other functions as w e l l .  They provide an occasion f o r s t a f f to exchange and to pool  t h e i r knowledge about diagnoses, treatment,, and so on. That i s , they serve as a general forum where .pertinent information i s exchanged.  Some-  times, a chart w i l l generate d i s c u s s i o n s about current a r t i c l e s i n medical j o u r n a l s , about research, about new techniques i n surgery, e t c .  Organiza-  t i o n a l l y , chart rounds are an' occasion where physicians and nurses can and should take the opportunity to f a m i l i a r i z e themselves w i t h current advances i n the medical p r o f e s s i o n .  Of course, they also serve as a  t r a i n i n g session f o r medical students. A p a t i e n t ' s medical chart..is always a v a i l a b l e as a document-in-use  96  for the b e n e f i t of medical personnel..  I t constitutes a patient's  n a t u r a l h i s t o r y and i s referred- to as a matter of routine i n almost every i n t e r a c t i o n between physician and p a t i e n t .  A patient's chart  consists.of a standard 8 1/2 x 11 inch f i l e f o l d e r which i s divided i n t o two p a r t s ; a "face.sheet" of the f o l d e r .  i s attached  to .the l e f t hand p o r t i o n  A face sheet i s a medical form containing general informa-  t i o n about the p a t i e n t :  name, address, age,., occupation,  Columbia Medical Insurance number.  and B r i t i s h  This form remains i n the patient's  chart f o r a l l subsequent encounters w i t h the C l i n i c . face sheet, the patient Is chart contains, another form.  In a d d i t i o n to the This i s composed  of detachable .sections f o r , l a b o r a t o r y work, a s e c t i o n f o r the w r i t i n g of p r e s c r i p t i o n s , and a return appointment' date f o r the p a t i e n t .  The  p h y s i c i a n consults t h i s form during every encounter w i t h a p a t i e n t . I t i s constantly updated. A completed medical form .is l e f t i n the p a t i e n t ' s chart and i s l a t e r re-arranged i n the f o l l o w i n g manner. attached  to the face sheet.  A " v i s i t record" form i s  This form contains a b r i e f summary of what  occurred during a patient's v i s i t .  Each.time the p a t i e n t v i s i t s the  C l i n i c , another " v i s i t record" form i s placed above the form which represents  the preceding v i s i t .  A h i s t o r i c a l .record of the patient's  v i s i t s to the C l i n i c i s thereby e a s i l y a v a i l a b l e . p o r t i o n of a patient's chart i s attached laboratory reports. information contained  To the r i g h t hand  a l l other medical documents and  Thus when a physician opens a patient's chart the t h e r e i n i s usable f o r the purposes at hand —  medical interview or chart rounds.  a  97  Chart rounds c o n s t i t u t e f o r t h e i r p a r t i c i p a n t s an occasion c h a r a c t e r i z a b l e by the necessity to "get through" them."'"^  "Getting  through", however, i s not subject to the capriciousness of the i n dividual participants.  The s u c c e s s f u l accomplishment of a review of  the charts i s t i e d to and i n t e r r e l a t e d to u t i l i z i n g the p a t i e n t ' s chart to s a t i s f y the o r g a n i z a t i o n a l features mentioned thus f a r . Whatever t a l k that occurs during chart rounds i s oriented to these features.  I t i s t a l k by medical personnel being medical  personnel.  The above d e s c r i p t i o n of chart rounds i s decidedly more analyt i c a l than the i n i t i a l d e s c r i p t i o n which I presented i n the previous chapter.  Following the standard ethnographic .format, I provided the  reader w i t h some p r e f a t o r y , chatty comments about the C l i n i c i n general and a subsequent d e t a i l e d a n a l y s i s .  I t s a n a l y t i c a l s t a t u s , however, i s  not a feature of i t s p o s i t i o n . i n the standard ethnographic  format, but  derives ff.rom--<theu f a c t tfhati.it i s a d e t a i l e d d e s c r i p t i o n of some s p e c i f i c aspect of c l i n i c a l o r g a n i z a t i o n .  The d e s c r i p t i o n of chart  rounds presented above i s supposedly informative about the ways i n which p a r t i c i p a n t s accomplish i t s o r g a n i z a t i o n .  The word 'supposedly'  i s used d e l i b e r a t e l y f o r I regard the above d e s c r i p t i o n as ana-inadequate one. . An a l t e r n a t i v e d e s c r i p t i o n w i l l be offered i n the next chapter. At t h i s p o i n t , however, l e t us consider some of the f a c t o r s which make f o r an inadequate d e s c r i p t i o n . The above d e s c r i p t i o n of char grounds i s not an i n c o r r e c t d e s c r i p tion.  Yet, i t could be c r i t i c i z e d on the grounds that i t does not provide  enough information about the occasion.  This c r i t i c i s m could be attended  98  to  by expanding the d e s c r i p t i v e m a t e r i a l to i n c l u d e , f o r example,  notes o r t r a n s c r i p t s of t h i n g s s a i d d u r i n g the o c c a s i o n .  The  field  problem  f a c i n g the ethnographer however, i s not t h a t of p r o v i d i n g e i t h e r , _ moo  rsioe-e ojr l e s s data but d e c i d i n g what the g u i d e l i n e s are f o r the  c o n s t r u c t i o n of an ethnographic of  report.  What i s i t t h a t an a n a l y s t  some s o c i a l scene must a t t e n d to i n o r d e r to produce a d e s c r i p t i o n  t h a t i s r e s p o n s i v e to h i s o b s e r v a t i o n s and p r e s e r v e s the i n t e g r i t y of s e t t i n g under c o n s i d e r a t i o n ?  To p r o v i d e a t e n t a t i v e answer to t h i s ques-  t i o n , one must c o n s i d e r the r e l a t i o n s h i p between the r e s e a r c h e r and everyday It  w o r l d of the s o c i e t y he i s i n v e s t i g a t i n g .  L e t me  members of the w o r l d of d a i l y l i f e ,  p r o b l e m a t i c f o r them.  ment of c h a r t rounds. f e a t u r e of l i f e  t h i s way.  of  my  i s not u s u a l l y  members of the C l i n i c  o r p r o b l e m a t i c about the p r a c t i c a l  found  accomplish-  I n s t e a d , they were taken f o r granted as a r o u t i n e  around the c l i n i c .  That  b e i n g i n the w o r l d  Note, f o r i n s t a n c e , how  d a i l y r o u t i n e of the C l i n i c , in  other  see the w o r l d as a s e n s i b l e and  T h e i r everyday  n o t h i n g s t r a n g e , unusual,  the  elaborate.  i s an i n e s c a p a b l e f a c t t h a t s o c i a l s c i e n t i s t s , l i k e any  manageable phenomenon.  the  I was  Once I became a c q u a i n t e d w i t h  the  a l s o a b l e to r e l a t e to c h a r t rounds  i s , they soon became a r o u t i n e and an expected  l i f e as a r e s e a r c h e r a t the C l i n i c .  And  I found p a r t s of my  o r i e n t e d to c h a r t rounds as a matter of c o u r s e . p l a c e o r d e r o f the C l i n i c and p a r t i c u l a r l y  life  To t r e a t t h i s common-  c h a r t rounds as p r o b l e m a t i c i s ,  however, an a n a l y s t ' s d e v i c e to f a c i l i t a t e the p r o d u c t i o n of an p h i c d e s c r i p t i o n of t h i s r o u t i n e C l i n i c o c c a s i o n . the same problems as r e s e a r c h e r s do.  part  ethnogra-  Members do not  see  G a r f i n k e l e x p l i c a t e s the a n a l y s t ' s  99  p o s i t i o n when he s t a t e s : In e x a c t l y the ways that a s e t t i n g i s organized, i t c o n s i s t s of •members' methods f o r making evident that s e t t i n g ' s ways as c l e a r , coherent, p l a n f u l , consistent, chosen, knowable, uniform, reproduci b l e connections, — i . e . , r a t i o n a l connections. In e x a c t l y the ways that persons are members to organized a f f a i r s , they are engaged i n serious and p r a c t i c a l work of d e t e c t i n g , demonstrating, and persuading through d i s p l a y s i n the ordinary occasions of t h e i r i n t e r a c t i o n s the appearance of c o n s i s t e n t , coherent, c l e a r , chosen, p l a n f u l arrangements. In exactly the ways i n which a s e t t i n g i s organized, i t c o n s i s t s of methods whereby i t s members are provided w i t h accounts of the s e t t i n g as countable, s t o r y a b l e , p r o v e r b i a l , comparable, p i c t u r a b l e , representable — i . e . , accountable e v e n t s . H Thus the problem f a c i n g the ethnographer  i s to discover how the members  he i s o b s e r v i n g . u t i l i z e procedures and methods f o r producing recognizably, coherent s o c i a l scenes.  In attempting to provide an ethnographic des-  c r i p t i o n of chart rounds, I w i l l take the very f a c t that they are events as problematic, and w i l l attempt to e x p l i c a t e the procedures employed by the members of the C l i n i c i n t h e i r production of chart rounds.  In  other words, an ethnographic d e s c r i p t i o n of chart rounds should attend to the s e l f - o r g a n i z i n g features that C l i n i c members u t i l i z e i n producing t h i s occasion.  In c o n t r a s t , the d e s c r i p t i o n of chart rounds that I  presented e a r l i e r does.not c o n s t i t u t e ,a d e s c r i p t i o n of t h i s type. Instead, i t merely provides the reader, with a d e s c r i p t i o n of what t r a n s pires.  For t h i s reason I have termed the previous d e s c r i p t i o n of chart  rounds an inadequate' d e s c r i p t i o n s i n c e ' i t does n o t attend to providing a d e s c r i p t i o n of the s e l f - o r g a n i z i n g features of t h i s occasion. That the ethnographer  should attend to the s e l f - o r g a n i z i n g features  100  of some s o c i a l scene i s i t s e l f a recommendation.  However, there i s  s t i l l a problem about what the fundamental source of data f o r conducting such research w i l l be.  That i s , what w i l l c o n s t i t u t e evidence of the  s o c i a l o r g a n i z a t i o n of some observable s o c i a l scene, and how w i l l t h i s data be u t i l i z e d ? whatever the da'fcaogs.yp'&fermust a c t i v i t y under study.  be an i n t r i n s i c feature of the  That i s , i t must be produced and u t i l i z e d by  p a r t i e s to the s e t t i n g as an e s s e n t i a l part of t h e i r everyday  affairs.  I f we are to study members' everyday a f f a i r s and a c t i v i t i e s , we must u t i l i z e data that r e f l e c t these concerns.  We should be able to attend  to the actual ongoing d e t a i l s of an event when o f f e r i n g d e s c r i p t i o n s thereof.  We can do t h i s i n an a b s t r a c t way, but, nevertheless, such a  d e s c r i p t i o n should be responsive to the a c t u a l d e t a i l s of those s o c i a l scenes being described. A candidate piece of data f o r such a d e s c r i p t i o n i s members' t a l k as i t occurs i n and over the course of sequences of i n t e r a c t i o n .  Since the next chapter.presents an a n a l y s i s of con-  v e r s a t i o n a l m a t e r i a l s , ( i . e . , t r a n s c r i p t s of recorded sessions of chart rounds), I would l i k e to discuss the u t i l i t y of these m a t e r i a l s f o r study and description" of s o c i a l o r g a n i z a t i o n . Talk and the Organization of Chart Rounds In the course of my research I was able to observe and tape record various segments.of i n t e r a c t i o n ithat occurred during chart rounds.  Such  recordings c o n s t i t u t e a f a i r l y d e t a i l e d record of the occasions, f o r f i r s t , t a l k i s a pervasive feature of s o c i a l l i f e and, of course, the  101  use of a tape recorder adds s u b s t a n t i a l l y to one's memory and to the r e l i a b i l i t y of one's f i e l d notes.  But secondly, and most importantly,  these materials are an e x c e p t i o n a l l y good record of chart rounds since these rounds are designed s p e c i f i c a l l y f o r the purpose of d i s c u s s i n g p a t i e n t s ' medical h i s t o r i e s . j e c t i v e , for.example,  Talk does not f a c i l i t a t e some other ob-  g i v i n g a p a t i e n t an i n j e c t i o n or taking a blood  sample, but rather t a l k i s c e n t r a l t o . t h i s occasion, that i s , were no t a l k to take place here, chart rounds would be impossible i n the f i r s t place.  Chart rounds, then, i s an i n t e r a c t i o n a l and conversational oc-  casion such that the t a l k which, t r a n s p i r e s over theeco.urseiof dts occurrence . i s c e n t r a l to the self-organizing, character of the occasion.  A good  deal of the i n t e g r i t y of the occasion.is preservable by audio  tapes.  I propose,that  an ethnographic d e s c r i p t i o n of chart rounds should be  responsive to the.kinds of o r g a n i z a t i o n a l features that are l o c a t a b l e 12  'within isuch'a data record. . I am not proposing that t a l k c o n s t i t u t e s a l l that occurs during the occasion of chart rounds f o r i t i s e a s i l y observable that things other than.talk r o u t i n e l y occur as an i n t e g r a l part of the occasion. Thus, people r o u t i n e l y . s t a y seated,. look at each other, leave the room to answer the phone, and so f o r t h . . T h e . l i s t i s v i r t u a l l y endless and I have not attended to such occurrences aside from those instances i n corporated i n t o the subsequent a n a l y s i s . . Furthermore, w h i l e things other than t a l k occur, i t i s presumed and presumable that the reader w i l l make use of h i s common-sense knowledge i n order to incorporate these taken-for-granted .features of the world i n t o h i s a n a l y s i s of these -  102  occasions. for  As stated i n the previous chapter, i t would be impossible  the ethnographer to construct any report i n the f i r s t place i f he  were not able to r e l y on h i s audience to use t h e i r common sense, that i s , to f i l l out and inform the d e s c r i p t i o n which he o f f e r s them. S p e c i f i c a l l y , then, t r a n s c r i p t s made from tape recordings of chart rounds w i l l c o n s t i t u t e the data f o r my a n a l y s i s of t h i s r o u t i n e C l i n i c occasion.  Thereby i intend to-examine a member's t a l k as  c o n s t i t u t i n g displays i n and through which members accomplish and give to t h e i r actions the appearance of c o n s i s t e n t , coherent, c l e a r , chosen, p l a n f u l arrangement.' "^ 1  That i s , my a n a l y s i s . w i l l .treat memberss'  conversations as an index f o r determining how t a l k i s a constituent feature of the o r g a n i z a t i o n of d a i l y l i f e . As I s a i d before, the format of chart rounds was changed twice during my research a t the C l i n i c .  These changes were i n s t i t u t e d i n s  order to increase the e f f i c i e n c y of p a t i e n t care.  While such changes  occurred f o r o r g a n i z a t i o n a l reasons:, I am suggesting that there are c e r t a i n i n v a r i a n t features that C l i n i c s t a f f must n e c e s s a r i l y o r i e n t towards 5Ln order to (1) allow.changes i n procedure to be recognized as such, and (2) provide f o r these changes to be e a s i l y implemented.  Thus  i n my next chapter I w i l l attempt to describe some of the features which provide f o r the i n t e r a c t i o n a l s t r u c t u r e of chart, rounds.  I w i l l not be  concerned with p r e d i c t i n g what w i l l , as.a c e r t i f i a b l e matter of f a c t , be said at some subsequent chart rounds.  While i t i s p o s s i b l e f o r C l i n i c  s t a f f to i n s t i t u t e changes i n i t s chart round procedure, i t i s the i n v a r i a n t features of the occasion that allow f o r changes i n procedure!to  103  occur i n the f i r s t place.  These are the things that I intend to study.  Our a t t e n t i o n w i l l now be directed•towards of the routine features of chart rounds.  a d e t a i l e d examination  104  Footnotes: 1.  Chapter  Two  See A . J . Crowle, Post E x p e r i m e n t a l I n t e r v i e w s : An Experiment and a S o c i o l i n g u i s t i c A n a l y s i s . Unpublished d o c t o r a l d i s s e r t a t i o n , U n i v e r s i t y of C a l i f o r n i a , Santa B a r b a r a , 1971, N e i l Friedman, The S o c i a l Nature of P s y c h o l o g i c a l Research: The P s y c h o l o g i c a l Experiment as a S o c i a l I n t e r a c t i o n . (New York: B a s i c Books, 1967), M a r t i n T. Orne, "On the S o c i a l Psychology of the P s y c h o l o g i c a l Experiment", American P s y c h o l o g i s t , November 1962, pp. 776-783,, and Roy Turner, "The Ethnography of Experiment' , American- B e h a v i o u r a l Scientist. 1  2.  By way of i l l u s t r a t i o n c o n s i d e r the f o l l o w i n g e x c e r p t from a d o c t o r a l candidate's research proposal: , ; The main t o p i c of r e s e a r c h i s a d e t a i l e d examination on the i d e o l o g y and o p e r a t i o n of l e a d e r s h i p i n a Melanesian s o c i e t y . A c e n t r a l aim of the study w i l l be to d e p a r t from the common emphasis on p e r s o n a l c h a r a c t e r i s t i c s as determinants of l e a d e r s h i p i n Melanesia. The s t r a t e g i c f o c u s of the study w i l l be the a n a l y s i s of the r e l a t i o n s between l e a d e r s and followers QUESTIONS TO BE POSED IN THE FIELD:...!. Arenas of p o l i t i c a l c o m p e t i t i o n : What a r e the arenas of p o l i t i c a l c o m p e t i t i o n and how a r e these d e f i n e d ? . . . A r e c e r t a i n k i n d s of c o a l i t i o n s s t r u c t u r a l l y e n j o i n e d , i n h i b i t e d , o r p r o h i b i t e d ? What normative r u l e s a r e a p p r o p r i a t e i n which arenas? How does a l l the above a f f e c t s t r a t e g i e s of l e a d e r ship?... 3. P o l i t i c a l r e s o u r c e s : How a r e p o l i t i c a l resources defined? Has the d e f i n i t i o n of p o l i t i c a l r e s o u r c e s changed over time? How?...TECHNIQUES AND METHODS: 1. Formal I n t e r v i e w i n g . Formal i n t e r v i e w s w i l l be conducted a l o n g the l i n e s suggested by B l a c k , Metzger, and o t h e r s to e l i c i t the c o n c e p t u a l framework of p o l i t i c a l a c t i v i t y . . . . A n important g o a l i n t h i s phase of work w i l l be to d i s c o v e r the ways i n which people c o n c e i v e of and t a l k about p o l i t i c s and the d e t e r m i n a t i o n of meaningful q u e s t i o n s t h a t can be asked about p o l i t i c s . . . . 5. P a r t i c i p a n t o b s e r v a t i o n . P a r t i c i p a n t o b s e r v a t i o n w i l l c a r r y much of the burden of d a t a c o l l e c t i o n and w i l l be p a r t i c u l a r l y important i n the a n a l y s i s of d i s p u t i n g and p o l i t i c a l manoeuvring which may occur d u r i n g the time spent i n the f i e l d .  Thus, we  hThusf.nwenhav.ecanoinstancehofpanoanthropoibQgisttgoingetd the f i e l d programmed w i t h a s e t o f p r e c o n c e i v e d r e s e a r c h i n t e r e s t s and g o a l s . I t would appear t h a t , i n o b s e r v i n g " p o l i t i c s , " much of the m a t r i x of everyday l i f e from which such o b s e r v a t i o n s w i l l be abandoned f o r some p r i o r t h e o r e t i c a l i n t e r e s t when i t comes time to c o n s t r u c t the f i n a l monograph.  105  3.  Stephen T y l e r , Ed., C o g n i t i v e Anthropology, (New York: h a r t , and Winston, 1969), p. 3. •  4.  I b i d . , p. 5.  5.  For a d e t a i l e d d i s c u s s i o n o f the c o g n i t i v e a n t h r o p o l o g y approach see P e t e r E g l i n , A Taxonomy o f Canadian D o c t o r s : Ethnosemantics and Ethnomethodology, Unpublished d o c t o r a l d i s s e r t a t i o n , The U n i v e r s i t y o f B r i t i s h Columbia, f o r t h c o m i n g .  6.  F o r a f u r t h e r d i s c u s s i o n o f t h i s p o i n t see Harold pp. 24-31.  Garfinkel,  7.  Transcribed  rounds.  8.  Ibid.  9.  I am u s i n g the term "demand c h a r a c t e r i s t i c s " i n t h e same sense as Roy Turner uses i t i n h i s paper " O c c u p a t i o n a l R o u t i n e s : Some Demand C h a r a c t e r i s t i c s o f P o l i c e Work", p r e s e n t e d to the Canadian S o c i o l o g y and Anthropology A s s o c i a t i o n , Toronto, June 1969. He s t a t e s ! "By demand c h a r a c t e r i s t i c s I mean to r e f e r to those s i t u a t i o n a l and cont e x t u a l f e a t u r e s which persons engaged i n everyday r o u t i n e s o r i e n t to as governing and o r g a n i z i n g t h e i r ^ a c t i v i t i e s . . . "  10.  "ge  from a tape recorded  session of chart  Holt  Rine-  (Ibid.)  T h i s f o r m u l a t i o n i s borrowed from a working paper by M e l v i n P o l l n e r , Department o f S o c i o l o g y U n i v e r s i t y o f C a l i f o r n i a a t Los Angeles e n t i t l e d "Working Notes on Ad-Hocing i n a S e l f - E x p l i c a t i n g F i e l d . " P o l l n e r uses the term " g e t t i n g through" i n r e f e r r i n g t o , f o r i n s t a n c e , how t r a f f i c c o u r t i s an o c c a s i o n r e q u i r i n g courtroom p e r s o n n e l to gget through i t " .  11.  Harold  G a r f i n k e l , op. c i t . , p. 34.  12.  The use o f t r a n s c r i b e d m a t e r i a l i s o f t e n c r i t i c i s e d on t h e ground t h a t i t does n o t c o n s t i t u t e an adequate i n t e r a c t i o n a l r e c o r d s i n c e t r a n s c r i p t s do n o t a t t e n d t h e p a r a l i n g u i s t i c f e a t u r e s o f f a c e - t o f a c e i n t e r a c t i o n . W i t h i n our s o c i e t y , however, t r a n s c r i p t s a r e o f t e n used i n making s e r i o u s and c o n s e q u e n t i a l d e c i s i o n s . F o r example, a p p e l l a t e c o u r t s o f t e n c o n s u l t the t r a n s c r i p t s o f lower c o u r t p r o c e e d i n g s i n a r r i v i n g a t t h e i r v e r d i c t . Such t r a n s c r i p t s a r e n o t regarded as inadequate because they do n o t c o n t a i n p a r a l i n g u i s t i c features. That i s , they a r e n o t regarded as d e f i c i e n t , u n i n t e l l i g i b l e , open to a thousand and one i n t e r p r e t a t i o n s , and so f o r t h . I t would < ^ a b p e a r r t o s b e i a t p r e - t h e o r e t i c a l a f aetho.f. l i f e lihatotranser.dipts have-a usablegstatused'espite tffietf a c t L t h a t i t h e y j d o i n o t ^ a t t e n d t o :par-alinguis.tie-;features o f t i n t e f actofomie Whiifcewaelcn6wjkedgingtthat5t.tr.anscriptionsddoonotrattend^toucertafnifeaturesoof interaction.;! this dbesenotlmean t h a t there w i l l be any n e c e s s a r y " f a t a l f l a w " i n any a n a l y s i s t h a t may be performed upon t r a n s c r i b e d m a t e r i a l . That t  106  members o f s o c i e t y can u t i l i z e t r a n s c r i p t s and render p r a c t i c a l and c o n s e q u e n t i a l d e c i s i o n s from them i s i n d i c a t i v e t h a t they do n o t have the e s s e n t i a l weaknesses t h a t opponents t o t h e i r use c l a i m f o r them. An examination o f t r a n s c r i p t s o f C l i n i c c h a r t rounds should a l l o w us to d i s c o v e r some o f the s e l f - o r g a n i z i n g f e a t u r e s of t h i s o c c a s i o n .  107  CHAPTER THREE  CHART ROUNDS:  AN INTERACTIONAL ANALYSIS  Introduction I t i s the purpose  o f t h i s chapter to do an examination o f a  p i e c e o f d a t a o b t a i n e d from a s e s s i o n o f c h a r t rounds.  During the  course o f my r e s e a r c h I was a b l e to s e c u r e a number o f audio and,  tapes  consequently, to produce numerous t r a n s c r i p t s o f what t r a n s p i r e d  on each o c c a s i o n t h a t was r e c o r d e d .  The i n s t a n c e to be examined was  e x t r a c t e d from t h i s corpus o f m a t e r i a l s .  In the f o l l o w i n g , a nurse i s  p r e s e n t i n g the c h a r t s o f those p a t i e n t s to be seen by c l i n i c s t a f f on t h a t day. The  TheaData 1.  Doctor A.  T h i s i s ah you know the ah upper (bar) of the ah lower  (bar) o f the f e m e r a l g l a n d  2.  Doctor B.  Um  3.  Nurse  John Doe  4.  Doctor B.  Who?  5.  Nurse  John Doe (spoken l o u d e r than i n U t t e r a n c e 3)  6.  Doctor A.  He's a r o u t i n e baby who's a b i t c o n s t i p a t e d  7.  Doctor B.  That's ah the  8. 9. 9.  Nurse  The commune  Doctor B.  Oh yeah  10.  Nurse  (  11.  Doctor A.  They've put him a b i t e a r l y f o r t h i s a f t e r n o o n . I don't know whether he's coming to see me o r to see you b u t I s h a l l be s o f t o f squeezed I t h i n k t o g e t back i n time you d e a l w i t h i t  ,  QUesecci pause)  John Doe (  )  )  108  12.  Doctor B.  Well ah Mama's patient  13.  Doctor A.  Urnm?  14.  Doctor B.  Mothers a patient woman  15.  Nurse  He's probably here for  16.  Doctor A.  Oh yeah he's a month from his l a s t shot so that's (mostly what he's here for  17.  Doctor B.  He had mumps?  18.  Doctor A.  Urnm?  19.  Doctor B.  Did you say he had mumps?  20.  Docdor A.  Ho ah month  21.  Doctor B.  Oh ah month  22.  Nurse  He's here for his second shot  23.  Doctor A.  Judy was (pause) Judy.was immunizing him I guess. Have we got him on fluoride?  24.  Nurse  Yeah  25.  Doctor A. Yep ((Doctor has looked at chart)) I saw that the enlightened c i t i z e n s of North City had voted f o r . . .  Before starting our analysis, the reader should note that I did not select this instance by r e f e r r i n g to any preconceived method or methods for data selection.  While an analysis has indeed been produced, i t was  not generated by a preconceived interest TthatH'had i n mind" p r i o r to an examination of the corpus from which i t was taken.  Although i t i s true,  £hatithisrpar.Meular piece of data would not have been used were I unable to produce some analysis of i t , i t i s important that the reader r e a l i z e that i t was selected i n a r e l a t i v e l y unmotivated manner. The data was not selected v i a a "coding procedure" where I had a set of a n a l y t i c a l issues  109-  and a set of categories that would allow me to select instances of data that would be appropriately responsive tossuch categories.  The abbve  data, then, i s not to be regarded either as a sample of chart rounds or as a t y p i c a l occurrence thereof.  Rather, I selected this p a r t i c u l a r  piece of conversation because i t happened to s t r i k e my interest, and i t i s from this i n i t i a l i n t e r e s t that the subsequent analysis took form. A Characterization of the Data As a beginning we might o f f e r a single,simple characterization of of the data, e.g., there appears to be a progression from talking about one patient to talking about another.  While this observation may i n i -  t i a l l y appear to be of l i t t l e interest, i t i s nevertheless an observable feature and responsive to the data. might now be attended a more complicated  Having noticed t h i s , i t  to i n a more a n a l y t i c a l fashion and come to reveal  structure than i s f i r s t apparent.  If we are to a t -  tend to the self-organizing features of this occasion, we should to the fact that progress  attend  from one chart to another i s something which i s  oriented or attuned to by participants and thus a legitimate topic of i n vestigation despite (and some would say because of) i t s mundane appearance. The s e r i a l review of the charts i s an a r t f u l l y and i n t r i c a t e l y accomplished a c t i v i t y .  Progression from one chart to another i s problem-  a t i c a l for the participants i n many ways.  For example, they face a  problem with reference to the opening and closing of talk generated by the review of a s p e c i f i c chart or patient.  The problem of how to terminate  talk generated from a review of one chart and progressing to a review of the next i s a constraint faced by the person presenting the charts.  He  110  or she has some control over the procedings and an o b l i g a t i o n to "pace :  the charts" so as to manage the f o r t y - f i v e minute period a l l o t t e d to the task at hand.  Our concern here w i l l be with the devices employed f o r  terminating talk about one chart and opening t a l k about the next. Throughout the analysis, reference w i l l be made to the i n t e r n a l organization of conversational structure.  The reason for doing so i s that  chart rounds i s s p e c i f i c a l l y an occasion wherein t a l k i s produced by the p a r t i c i p a n t s and i s , -more importantly, a resource used by them.  As such,  i t i s a v a i l a b l e to the analyst as data from which to examine the s e l f organizing features of an occasion. Tn utterance 2 (U2) we have an instance of a doctor talk generated  from a discussion of a previous chart.  completing  U3 i s an ex-  ample of the person presenting the charts doing a progression to the next chart v i a the use of a patient's name. to recognize completions  How i s i t that we are able  and progressions i n this context?  What i s i t  that provides f o r the accomplishment of termination of talk about one chart and the progression'to the next?  Obviously, i t does not j u s t  happen, but i s somehow made to happen.  I t i s my intention to look at  some of the ways i n which this i s a planned and motivated  occurrence.  Let us begin by examining the more general phenomenon of how we recognize that a p a r t i c u l a r conversational p a r t i c i p a n t has finished talking. Harvey Sacks (1) has noted two general features of conversation (1) 1  at least no more than one party talks at a time i n a single conversation and  (2) speaker change recurs.  With reference to the co-occurrence of  these features he raises the following issues:  Ill  I want how to make a case f o r what may or may not be obvious to you on any s o r t of r e f l e c t i o n ; t h a t a c h i e v i n g the c o - o c c u r r e n c e of 1 and 2 takes work. And what we want i n i t i a l l y to do, i s to come up w i t h some d e t e r m i n a t i o n of the s o r t s of work i t takes. We have an i n i t i a l problem, how i s i t t h a t w h i l e 2_pccurs 1 i s p r e s e r v e d , and what we want to do : i s to f i n d out what the achievement of a s o l u t i o n to t h a t problem i n v o l v e s . What s o r t s of c o o r d i n a t i v e work are i n v o l v e d . F i r s t of a l l , t h e r e ' s t h a t s o r t of work as between a c u r r e n t speaker and any o t h e r s ; which i n v o l v e s how i s i t t h a t a c u r r e n t speaker i s a b l e to show o t h e r p a r t i c i p a n t s to the c o n v e r s a t i o n t h a t he i s n ' t y e t , t h a t he's about to be, t h a t he i s now c o m p l e t i n g . What does he do so as to i n d i c a t e t h a t he's s t i l l t a l k i n g , or t h a t now he's not t a l k i n g . I take i t t h a t i t ' s p l a i n to you t h a t i t i s n ' t o b v i o u s l y the case t h a t you j u s t have to keep spewing f o r t h words; i . e . , p e o p l e a r e r e c o g n i z a b l y ' s t i l l t a l k i n g ' when they are e.g., paused. A p p a r e n t l y i n any event, speakers have ways of showing t h a t they are s t i l l t a l k i n g ; and more i m p o r t a n t l y i n i t s f a s h i o n , showing t h a t they are now f i n i s h e d . I f the f e a t u r e i s t h a t e x a c t l y one should be t a l k i n g , then showing t h a t you're f i n i s h e d when you're f i n i s h e d , i s important so as to a l l o w somebody to s t a r t t a l k i n g d i r e c t l y upon your c o m p l e t i o n . One s o r t of t h i n g then i s , how i t i s t h a t a speaker goes about showing o t h e r s t h a t he's not f i n i s h e d , t h a t he's about to be f i n i s h e d , t h a t i s he i s f i n i s h e d , or whatever i t i s t h a t those s o r t s of problems l o o k like. Showing these t h i n g s to a l l o t h e r s . And i t has a c o r r e l a t e , how i s i t t h a t n o n - c u r r e n t speakers go about d e t e r m i n i n g , from whatever i t i s t h a t a speaker i s d o i n g , t h a t he i s or i s not f i n i s h i n g , i s or i s not f i n i s h e d . Another s o r t of problem concerns — i n i t i a l l y anyway • the r e l a t i o n s h i p between the v a r i o u s n o n - c u r r e n t speakers. How i s i t t h a t the v a r i o u s c u r r e n t nonspeakers c o o r d i n a t e t h e i r a c t i o n s a t the t r a n s i t i o n p o i n t so t h a t a t the t r a n s i t i o n p o i n t someone of them t a l k s and o n l y one of them talks l" ' 1  112  The P r o g r e s s i o n Problem The person p r e s e n t i n g  the c h a r t s must o r i e n t to what we may c a l l  "the p r o g r e - s i o n p r o b l e m " , i . e . , The p e r s o n p r e s e n t i n g  p r o c e e d i n g from one c h a r t  the c h a r t s must monitor the o t h e r  t a l k not o n l y f o r c o n v e r s a t i o n a l a p p r o p r i a t e n e s s as to when t a l k generated by one c h a r t i s Secondly, reasonable  when such t a l k l i m i t of  A possible called  for —  to the n e x t .  participants'  but a l s o  for  indications  "ended" o r " p o s s i b l y  ended".  i s over they p r e s e n t a next c h a r t w i t h i n some  time.  s o l u t i o n would be f o r a t e r m i n a t i o n to be e i t h e r by the person p r e s e n t i n g  the o t h e r p a r t i c i p a n t s .  Someone c o u l d s a y ,  end of d i s c u s s i o n oh t h i s c h a r t ,  let  explicitly  the c h a r t s or by one of  f o r example,  "That i s  us proceed to the n e x t . "  the  However,  t h i s c o u l d w e l l prove more d i s r u p t i v e than b e n e f i c i a l . Suppose speaker B proposes but s p e a k e r ( s ) tion.  t e r m i n a t i o n to the d i s c u s s i o n o f a c h a r t  A , C, D , . . . N w i s h to c o n t r i b u t e something  A formulated ending by B would then c o n s t i t u t e  the proposed t e r m i n a t i o n .  might have to be taken to determine i f  conversa-  a premature ending  and would r e q u i r e the o t h e r c o n v e r s a t i o n a l p a r t i c i p a n t s i n o r d e r to f o r e s t a l l  to the  to do something  Something a k i n to a v o t e  indeed t h a t was to be a l l the  c u s s i o n about a p a r t i c u l a r c h a r t . . Such a f o r m u l a t e d t e r m i n a t i o n to t a l k would a l s o  is  the  imply t h a t the person d o i n g the f o r m u l a t i o n has a degree  of c o n t r o l over speaker i n fact possess.  dis-  s e l e c t i o n and speaker a c t i v i t y  Typically,  t h a t they do not  formulated endings do not o c c u r .  the p r o g r e s s i o n from one c h a r t to the next While the person p r e s e n t i n g  How then  accomplished?  the c h a r t s must " p l a c e  the c h a r t s " ,  this  113  does not mean that he can proceed at any pace whatsoever.  Rather, the  progression of rounds i s achieved by the consent of the conversational participants.  A d i s c u s s i o n can be monitored by the p a r t i c i p a n t s f o r i t s  relatedness to the current chart.  Pacing requires that the person  presenting the chart, and other p a r t i c i p a n t s as w e l l , o r i e n t to i n t e r a c t i o n a l devices f o r terminating the d i s c u s s i o n and f o r opening t a l k about another chart.  Given the sequencing r u l e s of conversation d i s -  cussed by Sacks,ewe may venture a s o l u t i o n to the progression problem. Uss 1 and 2 deal with instances of t a l k generated from a previous chart.  U3 i s the name of the p a t i e n t tcowhom the next chart belongs.  Progression from one chart to the next has taken place.  Can we formulate  the notion of an end to the t a l k about a,previous chart such that i t warrants the Nurse i n U3 progressing to the next chart.  Our f i r s t  concern,  then, i s with the notion of an end to the previous t a l k . The four-second pause i n U l seems to i n d i c a t e the end of the speaker's turn.  That the pause comes at the end of what i s recognizable  as a complete utterance i s a rather strong i n d i c a t i o n that t h i s i s a completed utterance.  That i s , i f someone weretbospeak at t h i s p o i n t , i t  would not be seen as an i n t e r r u p t i o n .  More g e n e r a l l y , one of. the ways  speakers have of i n d i c a t i n g that they are f i n i s h e d and a next speaker may speak (take a turn at t a l k ) i s to pause at the end of t h e i r utterance (assopposed to a pause i n the middle of an utterance which might i n d i c a t e that something more i s to f o l l o w and that the present speaker has not y e t finished).  Sacks makes the f o l l o w i n g comments: How i s i t that people go about producing recogn i z a b l y complete utterances. And a b a s i c t h i n g ,  114  s  s ]  at l e a s t g e n e r a l l y , that seems to be involved i s that there's a g e n e r i c a l l y a v a i l a b l e packaging device f o r utterances; and that's the sentence, And what w e ' l l , at l e a s t f o r our purposes, be doing w i t h the sentence, i s to be considering i t as a packaging device f o r utterances i n conversation; to be examined f o r those aspects of i t s s t r u c t u r e which are relevant to sequencing i n conversation.... The sentence i s a great packaging technique f o r a s e r i e s of reasons; only a few of which I ' l l mention. I t has a s t r u c t u r e which can at a l l p o i n t s be seen as to whether i t i s p o s s i b l y complete or not p o s s i b l y complete, and people are able to deal w i t h i t i n such a way as to see that e.g., i t i s now p o s s i b l y comp l e t e ; i . e . , to see on i t s occurrence that i t ' s poss i b l y complete. And a l s o , from i t s beginning i t can be looked at to see what I t w i l l take to complete i t . If somebody begins w i t h " I f " , f o r example, then there's already strongly usable information as to what i t w i l l take to complete that sentence.... That suggests to us how people massively go about producing utterances which are recognizably complete or recognizably incomplete, and how then, i f others don't t a l k while they're t a l k i n g , you get one-at-atime u n t i l the t r a n s i t i o n p o i n t . And i t t e l l s us when i t i s that t r a n s i t i o n points w i l l occur.^ Returning to our data, the pause f o l l o w i n g the Doctor's complete  utterance provides a s l o t whereby any of the other p a r t i c i p a n t s may take a turn at t a l k i n g .  That i s , a p o s s i b l e complete utterance followed by a  s i l e n c e provides f o r a next.speaker to take a turn at t a l k i n g .  I s there  some way we can assign ownership to t h i s s i l e n c e , that i s , whose s i l e n c e is i t ? One p o s s i b i l i t y i s that the pause f o l l o w i n g the Doctor's utterance may belong to the Doctor.  That i s a pause f o l l o w i n g an adequate complete  utterance does not "condemn" a speaker to the loss of h i s turn at t a l k . I t merely creates the p o s s i b i l i t y of such a l o s s .  Given the pause i n U l ,  115  and g i v e n the f a c t t h a t no one e l s e has chosen to speak a f t e r  the  speaker has stopped, t h e r e might w e l l e x i s t some o b l i g a t i o n f o r the speaker to c o n t i n u e .  However, as the t r a n s c r i p t shows, t h i s does not  happen. The Doctor who  spoke u t t e r a n c e U l paused and p r o v i d e d a s l o t  anyone w i s h i n g to speak may  fill,  y e t no one does.  T h e r e f o r e , we  which may  r e g a r d the s i l e n c e which o c c u r s between Us 2 and 3 as a c o l l e c t i v e By c o l l e c t i v e s i l e n c e  I mean'that each 0^jtfeeepaa^c%aits.ctoGilfl24tagct-he • l a s t  speaker, a r e . s a y i n g , i n e f f e c t , " I have n o t h i n g more to say about particular chart."  silence.  this  Thus, a mere f o u r - s e c o n d pause generated out of the  t a l k about one c h a r t has s i g n a l l e d the c l o s u r e o f one c h a r t and  the  opening, of another. T h i s i n s t a n c e of a pause a t the end of an u t t e r a n c e i s one  example  of members' methods f o r p r o d u c i n g and/or r e c o g n i z i n g a completed u t t e r a n c e . The pause i s heard as a p o s s i b l e end to the speaker's t u r n and a l e g i t i m a t e p l a c e f o r another speaker to b e g i n .  Given the f a c t t h a t none of the o t h e r  c o n v e r s a t i o n a l p a r t i c i p a n t s took a t u r n a t t a l k i n g , i s t h e r e a way c o u n t i n g f o r the Nurse, p r e s e n t i n g the c h a r t s , speaking i n U3? everyone i s s i l e n t , can we perhaps  of a c -  When  f o r m u l a t e whose t u r n i t .is to speak  next g i v e n t h a t the l a s t speaker has produced a complete u t t e r a n c e and does not engage i n i a c o n t i n u a t i o n ? t h a t accounts f o r the Nurse  I suggest t h a t i t i s not mere  chance  t a k i n g a t u r n a t t a l k , but t h a t t h e r e a r e good  o r g a n i z a t i o n a l reasons f o r h e r speaking next.  These reasons t r a d e upon  the sequencing r u l e s of c o n v e r s a t i o n . While the c u r r e n t speaker can s e l e c t a next speaker, he need  not  116  do  so.  Instead,  he may, f o r example, s e l e c t a next a c t i o n .  someone may ask a q u e s t i o n ,  but n o t s p e c i f y who should  For instance,  answer i t .  If a  group of p e o p l e had seen a movie, and you hadn't, you might say " W e l l , was i t a good p i c t u r e ? " i . e . , provide The resource pants.  and then somebody w i l l  an answer to t h a t  fact  s e l e c t themselves t o speak,  question.  t h a t c h a r t s a r e p r e s e n t e d by a p a r t i c u l a r i n d i v i d u a l i s a  which e s t a b l i s h e s a s e t o f a p p r o p r i a t e  actions f o r the p a r t i c i -  I t i s p o s s i b l e to view, s e t t i n g s and o c c a s i o n s  as c o n s t r a i n i n g  4  topical talk.  With r e f e r e n c e  to the o r g a n i z a t i o n o f c h a r t rounds, the  "core a c t i v i t y " i s the review: o f p a t i e n t s ' c h a r t s .  The p e r s o n  presenting  the c h a r t s must a c c o m p l i s h a r e v i e w by managing the t a l k t h a t o c c u r s during  the o c c a s i o n .  That i s , he o r she has an o b l i g a t i o n to l i s t e n  to the t a l k which o c c u r s ,  n o t o n l y o u t o f p o l i t e n e s s , b u t to be a b l e  to see, e.g., when t a l k about a g i v e n etc.  c h a r t i s coming to an end, d r i f t i n g ,  I n a d d i t i o n , s i n c e he must " p a c e the c h a r t s " , he should  proceed  to the next c h a r t when i n d i c a t i o n s such as these c o n s t r a i n t s o f time, etc. require that a progression  be accomplished.  During the f o u r - s e c o n d pause f o l l o w i n g U2, the p e r s o n the c h a r t s by  can hear the ensuing s i l e n c e as a c o n s e n s u a l s i l e n c e  the p a r t i c i p a n t s i  being  This provides  the next speaker.  She can say something p e r t a i n i n g to the c u r r e n t T h i s does n o t mean t h a t the p r o -  to a next c h a r t p r o h i b i t s f u r t h e r t a l k about a c u r r e n t  Hence, U3 i s o n l y a c a n d i d a t e f o r c l o s u r e . of  data.  authorized  good o r g a n i z a t i o n a l reasons f o r h e r  c h a r t o r to proceed to the next c h a r t . gression  presenting  chart.  C o n s i d e r the f o l l o w i n g  piece  117  1.  Researcher What?  2.  Doctor A.  The t r i a l of labor. L e t t i n g the baby go and see i f the baby comes out. I f i t doesn't come, move down then -H t h e y ' l l ah do do ah Ceasarean s e c t i o n  3.  Researcher  Urnm mm (7 seconds)  4.  Nurse  Mrs. Smith  5.  Doctor B.  I n c i d e n t a l l y i f I can go on f o r a moment there's a very recent paper i n one of the j o u r n a l s . . .  S i m i l a r l y , t a l k generated from one chart can be extended even though the progression to a next chart has been proposed. ever, requires some remedial work.  Such an extension, how-  The ' I n c i d e n t a l l y ' i n U5 t i e s U5 back  to i t s relevant target, i . e . , the d i s c u s s i o n generated from the previous chart.  What i s of i n t e r e s t i s that U5 does not propose that U4 c o n s t i -  tutes an i n t e r r u p t i o n .  That i s , the segment which reads ' I n c i d e n t a l l y  i f I can go on f o r a moment' i s not something that would j u s t i f y our c l a s s i f y i n g Us 3 and 4 as i n t e r r u p t i o n s to Doctor B's turn at t a l k . Since U5 does not.address i t s e l f to an i n t e r r u p t i o n , the referent of the utterance becomes the previous chart, i . e . , i n the preface ' I n c i d e n t a l l y i f I can go on f o r a moment' the hearers can o r i e n t to the u t terance being t i e d back to the l a s t chart I(as opposed t o , say, any other c h a r t ) . In "unpacking" t h e . i n t e r a c t i o n a l s t r u c t u r e of U5, I have attempted to show that, while t a l k about one chart can be extended even a f t e r t a l k about the next chart has been proposed, such an extension requires work, i . e . , i s an i n t e r a c t i o n a l accomplishment.  Furthermore, by examining U5,  we may be able to formulate when, i n some temporal sense, what gets s a i d ,  118  i s shaped i n t e r a c t i o n a l l y by the s t r u c t u r a l features of the occasion. Let me elaborate. U5 extends the t a l k about a previous chart.  I t occupies second  p o s i t i o n w i t h reference to the f i r s t mention of a new chart i n U4.  If  a p a r t i c i p a n t wishes to say more about a p a r t i c u l a r chart, given the progression by the Nurse to the next chart,. then there -might be c e r t a i n i n t e r a c t i o n a l l y important reasons why U5 occurs i n second p o s i t i o n rather than say e^.g., t h i r d , f o u r t h , f i f t h , or nth p o s i t i o n .  I am suggesting that i t  becomes more problematic and requires more i n t e r a c t i o n a l work to say something about a previous chart a f t e r t a l k about a next chart has been a l lowed to develop.  With each utterance about a new chart, i t becomes  harder to return to a previous chart.  What gets s a i d , w i t h reference to  any p a r t i c u l a r chart, i s not merely an outcome of the f a c t that someone has something to say, but r e s u l t s from the ways i n which p a r t i c i p a n t s must r e l y on the o v e r a l l s t r u c t u r e of conversation to f i n d appropriate s l o t s f o r r?their comments. Thus f a r , i t has been e s t a b l i s h e d that the four-second pause f o l lowing U2 ( i n our o r i g i n a l data) provides warrantable grounds f o r the person presenting the charts to proceed to the "next" 'chart.  This i s  accomplished by using the p a t i e n t ' s name as an i n t e r a c t i o n a l device f o r opening a review of h i s chart. Having s t a r t e d w i t h a c h a r a c t e r i z a t i o n of our data, we have proceeded to examine that c h a r a c t e r i z a t i o n i n d e t a i l .  Such a procedure  tends to r a i s e f u r t h e r issues to be examined that were not part of our i n i t i a l characterization.  One such issue i s how  the o r g a n i z a t i o n of the  119  occasion warrants the use of the p a t i e n t ' s name to f a c i l i t a t e the progression of the charts. I t should be noted that the use of the p a t i e n t ' s name i s i t s e l f a methodical accomplishment.  The person presenting the charts picks  up the next chart and reads aloud from i t . For example: Doctor;.  ...Carol Bern (7 sec.) whose age (3 sec.) twenty-six (4 sec.) ((Note: Doctor looking through, chart)) She seems to have a l o t of s t u f f , abdominal p a i n , abdominal pain, urinary t r a c t i n f e c t i o n , cough arid fever,:pain i n the chest and shooting pains i n the l e g s , and a h i s t o r y of perhaps p h e b i t i s thinks t h i s might be the same, cOugh arid fever, a g i t a t e d and can't sleep, worried Ree: daughter's boyfriend won't make up h i s itiind whether to marry her, a g i t a t e d depression and i s claimirig pains i n her legs again ( 3 sec.) (Note: The underlined portions of t r a n s c r i p t i n dicate m a t e r i a l being read l i t e r a l l y from the p a t i e n t ' s chart)  Nurse  She the one that John.(another doctor) C ) see her l e g problems?  Doctor  Yeah, Urnm of course....  The p a t i e n t ' s name —  l a s t name (LN) + f i r s t name (FN), age and  date of b i r t h are w r i t t e n on h i s chart.  However, the person presenting  the charts gives a p a t i e n t ' s name and age as i t normally occurs i n ordinary conversation.  Name and age are not merely read aloud, but  rather constructed i n t o pieces of n a t u r a l t a l k .  Reading aloud i s f a r  more than j u s t saying what i s w r i t t e n . I t i s an accomplished  activity,  subject tonMie o r g a n i z a t i o n a l c o n s t r a i n t s of s e t t i n g s and occasions. The use of a p a t i e n t ' s name serves as both a proposed terminator to thePdisUussionaofa^ichart an'de aseavdeviceb.fiok op'endngsdiscussion on  120  a next chart.  The person presenting the charts can and should monitor  the t a l k to determine i f i t i s a t t e n t i v e to the c o n s t r a i n t s of the occasion, i . e . , i f i t i s c o n t r i b u t i n g to the successful completion of chart rounds.  When i t becomes apparent that the t a l k generated by a  chart i s 'wandering' or 'closing down' the person c o n t r o l l i n g the charts can terminate.the p a t i e n t ' s name. v i s u a l cues.  t a l k by introducing the next chart v i a the  This change i n t o p i c i s u s u a l l y accompanied by c e r t a i n  The person presenting the charts might put down one  and pickcup the next while reading o f f the p a t i e n t ' s name. cates the previous chart to the completed p i l e .  chart  This a l l o -  The p h y s i c a l c l o s i n g  of a chart however, does not warrant the assumption that that chart has been f u l l y reviewed.  That .is, t a l k generated by a chart may  tinue even though the person presenting the chart may  con-  e l e c t to close i t .  His doing so, however, does i n d i c a t e that he sees that chart as  one  which i s p o s s i b l y completed. The R e f e r e n t i a l Adequacy of the Use of F i r s t Name plus Last Name This s e c t i o n examines how  the use of a patient's name does not pro-  vide adequate information about the p a t i e n t . the p a t i e n t i s not present at chart rounds.  I t must be remembered that What we are dealing with  i s the use of names as adequate r e f e r e n t i a l devices, that i s , w i t h t h i r d party references i n conversation.  F i r s t , l e t us consider the i n -  t e r a c t i o n a l work accomplished by the use of the p a t i e n t ' s f i r s t name (FN) and l a s t name (LN). The s o c i a l organization of chart rounds has as i t s fundamental concern the review of a corpus of p a t i e n t ' s charts.  One of the features  121  of c h a r t rounds i s t h a t the p a t i e n t may o r may n o t be known to many o f the p h y s i c i a n s  present.  mah o r may n o t be p r e s e n t . provides  Further,  the p a t i e n t ' s  physician  The use o f the p a t i e n t ' s FN p l u s LN  s u f f i c i e n t information,  f o r those p h y s i c i a n s who know the  p a t i e n t , t o l o c a t e the p a t i e n t i n t o some c a t e g o r y v i s - a - v i s encounters w i t h t h a t p a t i e n t .  I t provides  their  f o r a c e r t a i n amount o f  memory work. The for  previous  progressing  appropriate  s e c t i o n d e a l t w i t h the use o f the p a t i e n t ' s name  to the next c h a r t .  Such p r o g r e s s i o n  speaker a c t i o n s , i . e . , t a l k about the c h a r t .  the p a t i e n t ' s name can a l s o p r o v i d e p a t i e n t ' s p h y s i c i a n i s present,  then the i n t r o d u c t i o n o f a c h a r t v i a grounds f o r t h a t p h y s i c i a n to  I f the p a t i e n t ' s p h y s i c i a n i s n o t p r e s e n t  p h y s i c i a n who knows the p a t i e n t i s p r e s e n t , make some comment a t t h i s  However,  f o r a next speaker f o r , i f the  the use o f the p a t i e n t ' s name p r o v i d e s speak next.  provided f o r  b u t another  i ti s likely  t h a t he w i l l  time.  Although the use o f t h e p a t i e n t ' s name may p r o v i d e know t h e p a t i e n t w i t h adequate r e f e r e n t i a l i n f o r m a t i o n ,  those who a name a l o n e  does n o t p r o v i d e much f o r those who a r e n o t a c q u a i n t e d w i t h the patient. to c l a r i f y  An examination o f the q u e s t i o n this  point.  "Who?" o f U 4 should  help  122 Two d i f f e r e n t h e a r i n g s and  a c t e d upon.  for  a repeat.  not hear her.  o f the q u e s t i o n "Who?" o f U 4 a r e p r o v i d e d  I n U 5 the Nurse.hears the 'Who?' as. a simple One p o s s i b l e reason  f o r a repeat  Un U 6 , however, Doctor  more than a simple r e q u e s t  i s t h a t Doctor  A. t r e a t s Doctor  f o r a repeat.  request B. d i d  B's q u e s t i o n as  I n s t e a d he o f f e r s a r e f e r e n t  o t h e r than the p a t i e n t ' s name to l o c a t e the p a t i e n t f o r him. The  question  'Who?' then becomes i n t e r e s t i n g when i n f a c t the  p a t i e n t has a l r e a d y been named, i . e . , one i s a l r e a d y supposed to know who the p a t i e n t i s .  ?The p a t i e n t ' s name as an i d e n t i f i e r i s o f t e n n o t  s u f f i c i e n t i n f o r m a t i o n to i d e n t i f y the p a t i e n t to p a r t i c i p a t i n g members. S i m i l a r l y , a problem w i t h t h i r d p a r t y r e f e r e n c e s i n the c o n v e r s a t i o n between speaker A and speaker B above i s when A makes r e f e r e n c e to person  C n o t known to speaker B.. T h i s r e q u i r e s t h a t speaker A s e l e c t  a r e f e r e n t i a l l y adequate category It  d e v i c e a p p r o p r i a t e to the o c c a s i o n  i s apparent t h a t FN + LN does n o t always p r o v i d e enough i n -  formation  to s u c c e s s f u l l y i d e n t i f y a p a t i e n t .  Doctor  a m e d i c a l l y r e l e v a n t c h a r a c t e r i z a t i o n o f the p a t i e n t . allowed  o t h e r p a r t i c i p a n t s to i d e n t i f y  p r a c t i c a l purposes.  Consider  A i n U6 produced This d e s c r i p t i o n  the p a t i e n t , a t l e a s t f o r a l l  the f o l l o w i n g d a t a :  Doctor  A.  But I t h i n k t h a t would be 'aowofethwhile one j u s t to s o r t of g e t your s i g n a l s c o o r d i n a t e d between you and Karen on it. Ah T e r r y M a r t i n  Doctor  B.  T h i s i s a g i r l w i t h abdominal p a i n s  Doctor A.  Okay, B e v e r l y Jones  Doctor B.  T h i s i s a g i r l Judy has been s e e i n g f o r anxiety  123  In a d d i t i o n to themame, some f u r t h e r c h a r a c t e r i z a t i o n i s u s u a l l y c a l l e d for.  What w i l l be used i n the construction of such a c h a r a c t e r i z a t i o n  i s i n t e r e s t i n g since the patient's h i s t o r y i s immediately a v a i l a b l e . Such a c h a r a c t e r i z a t i o n , I suggest, i s constructed to provide p a r t i c i pants with a grasp of the C l i n i c ' s current concerns with that p a t i e n t . By proposing that a p a t i e n t i s "a g i r l with abdominal pains", or i s "being seen f o r anxiety", the person i s providing a c h a r a c t e r i z a t i o n that i s medically and o r g a n i z a t i o n a l l y relevant to the C l i n i c ' s transactions with the p a t i e n t rather than j u s t any d e s c r i p t i o n which happens to come to mind. One of the i n t e r a c t i o n a l features of such medically  relevant  c h a r a c t e r i z a t i o n s i s that they can provide good o r g a n i z a t i o n a l reasons for adducing a p a t i e n t ' s reason f o r coming to the C l i n i c .  That i s , given  the f a c t that the s t a f f are reviewing the charts of those p a t i e n t s who are to be seen l a t e r that day, the c h a r a c t e r i z a t i o n s used can be monitored by the p a r t i c i p a n t s to formulate a patient's reasonCs) f o r coming to the C l i n i c on t h i s day. Thus, i n the above data, "has been seeing f o r anxiety" suggests that the p a t i e n t i s C l i n i c because she has problems with anxiety.  s t i l l coming to the  S i m i l a r l y , s t a f f can  conclude that Terry Martin has "abdominal pains" and i f he did not have, he would not be v i s i t i n g the C l i n i c . U6 c o n s t i t u t e s a medically relevant c h a r a c t e r i z a t i o n of the p a t i e n t . Whether t h i s c h a r a c t e r i z a t i o n provides adequate grounds f o r e s t a b l i s h i n g a p a t i e n t ' s reason f o r coming to the C l i n i c w i l l be examined i n the next section.  Thus f a r , however, i t should be apparent that the examination  124  of s m a l l segments o f c o n v e r s a t i o n a l m a t e r i a l s  can be u t i l i z e d  to d i s -  cover some o f the ongoing p r o p e r t i e s of s e t t i n g s and o c c a s i o n s . The  Reason f o r a V i s i t : The  I  reason f o r a v i s i t  members o f t h e s t a f f .  c o n s t i t u t e s an o r g a n i z a t i o n a l problem f o r  I t i s intended  t h a t t h e problems which a v i s i t o r  s e r i e s of v i s i t s e n t a i l w i l l be, a t l e a s t i n p a r t , r e s o l v e d d u r i n g rounds.  U6 i s a m e d i c a l l y  relevant  c h a r a c t e r i z a t i o n o f the p a t i e n t .  ways i n which t h i s c h a r a c t e r i z a t i o n p r o v i d e s p a t i e n t ' s reason f o r a v i s i t  chart  requires  The  grounds f o r adducing a  t h a t theoongoing  interactional  s t r u c t u r e which produced i t be examined i n f u r t h e r d e t a i l . The concern i s n o t simply  whether o r not U6 i s a m e d i c a l l y  relevant characterization,  but how such a c h a r a c t e r i z a t i o n i s a c h i e v e d . U6 seems to p r o v i d e p a t i e n t w i t h the d i s e a s e t i o n of the u t t e r a n c e ,  s u f f i c i e n t grounds f o r a v i s i t term " c o n s t i p a t e d " .  however, i s to i g n o r e  To f o c u s  by l a b e l l i n g the  o n l y on t h i s p o r -  the o r g a n i z a t i o n a l  of t h e f i r s t p o r t i o n , namely, "He's a r o u t i n e baby".  While  import  apparently  a non-medical c h a r a c t e r i z a t i o n , I suggest t h a t the segment "He's a r o u t i n e baby," i s the o p e r a t i v e p o r t i o n o f the u t t e r a n c e  i n terms of  providing  I shall  the s t a f f w i t h a r e l e v a n t reason f o r a v i s i t .  Post-natal  care a t the C l i n i c i n v o l v e s a package o f procedures which  are conducted over a d e f i n i t i v e p e r i o d o f time. t i n u e s f o r about s i x and o n e - h a l f babies's  growth, weight, h e i g h t ,  coordination  elaborate.  Such c a r e u s u a l l y con-  months a f t e r b i r t h .  During t h i s  time,  n e u r o l o g i c a l development and muscular  a r e checked t h o r o u g h l y .  t e s t s , and v a c c i n a t i o n s may be g i v e n .  In addition, u r i n a l y s i s ,  blood  While a l l o f these take  place  125  d u r i n g p o s t - n a t a l care,  I should  package a r e arranged..inia  s p e c i f i c way so t h a t the baby i s n o t randomly  checked each time he v i s i t s a step  emphasize t h a t the components o f the  the C l i n i c .  Instead,  each v i s i t  constitutes  i n the developmental sequence o f the programme o f p o s t - n a t a l  care.  While the f i r s t v i s i t may o n l y r e q u i r e t h a t h i s weight and h e i g h t be measured, the f o u r t h v i s i t might r e q u i r e such t h i n g s as the i n i t i a t i o n of p o l i o immunizations.  The c h a r a c t e r i z a t i o n " r o u t i n e baby", then, i s  something t h a t can p r o v i d e  members o f the C l i n i c w i t h a s e t o f o r g a n i z a -  t i o n a l parameters about why the p a t i e n t i s coming to the C l i n i c . While the c h a r a c t e r i z a t i o n "a r o u t i n e baby" p r o v i d e s w i t h some g e n e r a l  parameters that c o u l d warrant a v i s i t ,  remains to be d i s c o v e r e d .  the  defect.  e.g., a baby w i t h a c o n g e n i t a l  Any s e r i o u s c o n d i t i o n would e x p e c t a b l y  be mentioned i n  course of a review o f the p a t i e n t ' s c h a r t and thus become a v a i l a b l e  to p a r t i c i p a n t s as a p o s s i b l e reason f o r a v i s i t  t o the C l i n i c .  c h a r a c t e r i z a t i o n s i n v o l v i n g a serious medical ailment, does n o t p r o v i d e  the p a r t i c i p a n t s w i t h s u f f i c i e n t  the p a t i e n t ' s reason f o r coming to the C l i n i c .  to adduce  The f i r s t p o r t i o n o f f o r the p a t i e n t ' s  coming to the C l i n i c b u t , t h i s f a r i n t o the u t t e r a n c e , a v i s i t has been f o r m u l a t e d .  Unlike  " r o u t i n e baby"  information  U6 may narrow the parameters i n v o l v e d i n a c c o u n t i n g  for  a f u r t h e r reason  Compare t h i s c h a r a c t e r i z a t i o n to one i n v o l v i n g  a r e l a t i v e l y serious medical ailment, heart  participants  no o t h e r  reason  What i s the i n t e r a c t i o n a l import o f  the second p a r t of U6 "who's a b i t  constipated"?  G i v e n the f i r s t p a r t o f U 6 , whatever i s appended to t h i s must c o n s t i t u t e a minor complaint.  To append a s e r i o u s m e d i c a l problem would  negate the i n i t i a l c h a r a c t e r i z a t i o n o f the p a t i e n t .  One o f the two, t h a t  126  is,  e i t h e r "He's a r o u t i n e baby," o r ("who has a s e r i o u s d i s e a s e " )  not  r e s t on w a r r a n t a b l e grounds.  bit  constipated"  would  I n c o n t r a s t , the a d d i t i o n o f "who's a  t o the p a r t o f the u t t e r a n c e  r e a f f i r m s t h a t the p a t i e n t  i s a " r o u t i n e baby" f o r the most s e r i o u s problem t h a t D o c t o r A can c i t e i s t h a t he i s "a b i t c o n s t i p a t e d " . standing  Being c o n s t i p a t e d  i s proposed as a  c o n d i t i o n and presumably the worst c o n d i t i o n t h a t can be s a i d  of t h i s p a r t i c u l a r p a t i e n t .  I t should  a l s o be noted t h a t Doctor A does  not propose t h a t the p a t i e n t i s c u r r e n t l y being whereas such treatment c o u l d w e l l p r o v i d e  treated f o r constipation  grounds f o r the p a t i e n t ' s  visit  to the C l i n i c . While U6 perhaps looks for  coming t o the C l i n i c ,  l i k e a formulation  i t only provides  c o u l d warrant such a v i s i t .  The o p e r a t i v e  of a patient's  the p o s s i b l e parameters p a r t o f the u t t e r a n c e  a r o u t i n e baby" arid n o t "who's a b i t c o n s t i p a t e d " . to,say,  "He's a d i a b e t i c who's a l i t t l e  diabetes  t h a t c o n s t i t u t e s the m e d i c a l l y  "who's a l i t t l e The  reason that  i s "He's  U6 might be compared  depressed", where i t i s the relevant  c h a r a c t e r i z a t i o n and  depressed" c o n s t i t u t e s some q u a s i - m e d i c a l  characterization.  l a s t p a r t of U6, w h i l e l o o k i n g l i k e a p o s s i b l e r e a s o n f o r a v i s i t by  the p a t i e n t , g l o s s e s  over the o r g a n i z a t i o n a l l y r e l e v a n t a s p e c t s of the  c h a r a c t e r i z a t i o n " r o u t i n e baby".  The c h a r a c t e r i z a t i o n " r o u t i n e baby",  then, i s one o f a c l a s s of p a t i e n t s who a r e h e a l t h y babies,  have grounds f o r v i s i t i n g  The  but,  because they a r e  the C l i n i c .  r e a d e r w i l l n o t i c e t h a t u n t i l U16, no grounds f o r a v i s i t by  the p a t i e n t have been proposed.  Rather than c o n s i d e r U16 a t t h i s  time,  I would l i k e to make a d i g r e s s i o n i n the a n a l y s i s o f how c l i n i c members  127  account f o r a p a t i e n t ' s reason f o r a v i s i t  and c o n t i n u e w i t h the examina-  t i o n o f t h i s t r a n s c r i p t i n terms o f some o f i t s o t h e r features.  My reason f o r doing t h i s a r e t w o f o l d .  organizational  First,  i t will  fallow  me t o c o n t i n u e to work w i t h t h e d a t a i n a m e t h o d o l o g i c a l f a s h i o n by attending  to the order  i n which i t was produced.  Second, i t a l l o w s  me  to demonstrate how such dat'abeantB"eiutn!li'zedthtovun'coveBn6r.gahi>zationaT ~ features  t h a t we may n o t have been a b l e  to f o r m u l a t e ,  o r assume as  o p e r a b l e u n t i l we pay r i g o r o u s a t t e n t i o n to t h e i r a c t u a l , s i t u a t e d production. A S o c i o l o g i c a l Treatment o f R e f e r r i n g U6 i s i n h e r e n t l y connected to the o r g a n i z a t i o n a l f e a t u r e s i  occasion, manner. by  i . e . , the p a t i e n t was r e f e r r e d t o i n a m e d i c a l l y  relevant  An examination o f Us 7-9 shows an i n t e r a c t i o n a l exchange where-  the Nurse o f f e r s another c h a r a c t e r i z a t i o n o f the p a t i e n t i n order to  a l l o w D o c t o r B to i & d e n t i f y him. z a t i o n i s i t s "mundaneness". evident It  of the  -  A n o t i c e a b l e f e a t u r e of t h i s c h a r a c t e r i -  By t h i s I mean t h a t i t i s n o t immediately  t h a t i t i s o r need be r e l a t e d to a c o n c e p t i o n  of medical p r a c t i c e .  i s the purpose o f t h i s s e c t i o n t o d i s c u s s how such a c h a r a c t e r i z a t i o n  can r e f e r to the p a t i e n t i n such a way as to s u c c e s s f u l l y l o c a t e t". -: t h a t p e r s o n f o r D o c t o r B. One o f the f i r s t  things  to n o t i c e w i t h r e f e r e n c e  Doctor B's U7, "That's ah t h e , "  to Us 7-9 i s t h a t  i s n o t completed by him, and t h a t the  nurse's U8, "The commune," f o l l o w s and completes i t .  This  utterance  warrants c o n s i d e r a t i o n s i n c e i t i s o n l y by v i r t u e of the f a c t  that i t i s  a completion o f U7 t h a t i t g e t s t o be seen as a c h a r a c t e r i z a t i o n .  We a r e  128'  concerned  then w i t h the f i t t h a t t h i s u t t e r a n c e has w i t h i n the ensuing  conversation.  L e t me  elaborate this point.  F i r s t o f f j-iHis t h e r e a way  i n which we  can account f o r a  completion  of U7 such t h a t , i f t h e r e i s to be a c o m p l e t i o n by another speaker, i t w i l l be c o n s t r a i n e d by c e r t a i n s t r u c t u r a l f e a t u r e s of the t a l k preceeded  it?  that  Sacks remarks on t h i s phenomenon:^  Now i n f a c t , t h e r e i s p e r f e c t l y l o v e l y n a t u r a l d a t a which shows p r e t t y w e l l t h a t persons not o n l y a n a l y z e u t t e r a n c e s g r a m m a t i c a l l y i n the course of those u t t e r a n c e s , but, f u r t h e r m o r e , they have the r e s u l t s of t h e i r a n a l y s i s , grammatical a n a l y s i s , a v a i l a b l e to them w h i l e t h a t u t t e r a n c e i s y e t g o i n g on. And can use i t f u r t h e r m o r e , e i t h e r on the o t h e r ' s c o m p l e t i o n or even b e f o r e i t s completion. Data c o n s i s t s of t h i s s h o r t of thing...what you get i s something l i k e A produces, i s engaged i n p r o d u c i n g a sentence, a t some p o i n t i n i t he h e s i t a t e s , pauses, and B s t i c k s i n quote the word he was l o o k i n g f o r . Now i f we ask how i s i t that B c o u l d do t h a t , then s i n c e a t t h a t p o i n t , l e a v i n g a s i d e t h a t B g e t s the r i g h t word, a l l t h a t would be i n t e r e s t i n g i s t h a t B g e t s the r i g h t c l a s s of words. That i s to say t h a t he knows t h a t what's b e i n g l o o k e d f o r i s a noun, perhaps a noun of a c e r t a i n s o r t i s b e i n g looked f o r so as to be a b l e to s t i c k i t i n , what he has had to be d o i n g i s to see t h a t a t t h a t p o i n t i n an u t t e r a n c e he's a n a l y s i n g o n l y , say, such a noun i s e l i g i b l e w h i l e the sentence would y e t r e t a i n i t s g r a m m a t i c a l i t y . Now as i t haphejns, i f you l o o k a t o r d i n a r y t a l k y o u ' l l f i n d t h a t i t i s very frequent that s o - f a r hearers i n t e r j e c t completions of the sentences of o t h e r s i n a s y n t a c t i c a l l y coherent way and thereby show among o t h e r t h i n g s t h a t they understand the sentence s y n t a c t i c a l l y t h a t they have been doing t h e i r u n d e r s t a n d i n g , doing the a n a l y s i s t h a t a l l o w s them to understand w h i l e the t h i n g i s b e i n g produced, so as to have i t s r e s u l t s a v a i l a b l e to them w h i l e the sentence i s y e t being produced. What then, i f any,  are the s t r u c t u r a l c o n s t r a i n t s o f U7  that provide f o r  the type of p r o d u c t i o n which occurs i n U8? In r a t h e r broad  terms, the l i n g u i s t i c s t r u c t u r e o f U7  s u b j e c t and p r e d i c a t e ("That's" s t h a t i s ) and  the d e f i n i t e  c o n s i s t s of a article.  129  (Linguists relegate the "ah" i n U 7 to the arena of l i n g u i s t i c performance and, as such, something which i s not a v a i l a b l e f o r a n a l y s i s . ) However, we are not doing l i n g u i s t i c s here, but"* i n t e r a c t i o n a l a n a l y s i s and I suggest "ah" i n U 7 i s of importance i n describing the i n t e r ,13  a c t i o n a l s t r u c t u r e of the conversation at hand.  I w i l l return to a  consideration of i t i n a moment. Given the l i n g u i s t i c s t r u c t u r e of U 7 , p o s s i b i l i t i e s with r e f e r ence to i t s completion ( e i t h e r by the current speaker or by a "so-far hearer") are r e l a t i v e l y l i m i t e d .  The subject of the sentence i s a  demonstrative pronoun and, given that a d e f i n i t e a r t i c l e f o l l o w s , e i t h e r an a d j e c t i v e phrase or a noun phrase constitutesjpossible completions.  Thus there are good s y n t a c t i c reasons f o r the Nurse i n U 8  to complete Doctor B's U 7 w i t h a noun phrase as she d i d .  However, there  are also strong i n t e r a c t i o n a l reasons f o r t h i s . I t has been argued that, f i r s t , the use of a patient's name does not always provide enough information to i d e n t i f y the p a t i e n t .  Second,  that the use of a medically relevant c h a r a c t e r i z a t i o n may also f a i l to i d e n t i f y the patient f o r he can be "a routine baby who's a b i t constipated" regardless of who he i s . Thereby, the i d e n t i f i c a t i o n of the p a t i e n t i s , f o r Doctor B, s t i l l problematic  so that U7 may be seen as a search under-  taken to e x t r a c t the baby's i d e n t i t y .  The Nurse completes t h i s search by  providing a c h a r a c t e r i z a t i o n which resolves Doctor B's problem.  This i s  evidenced by U9. But, how i s i t that we are able to see U7 as part of a mental "search" and thereby to see U8 as a completion to t h i s search.  I suggest that the  130  answer l i e s at l e a s t i n part i n the h e s i t a t i o n implied by the use of the aforementioned  "ah".  A search has the character of a question,  and questions are t y p i c a l l y followed by answers.  Thus the doctor's  h e s i t a t i o n can be heard by the Nurse both as grounds and as the proper place or s l o t f o r providing a c h a r a c t e r i z a t i o n which might solve the problem. The formulation o f f e r e d by the Nurse i n U 8 needs to be elaborated. C l e a r l y , we hear i t as a c h a r a c t e r i z a t i o n of the p a t i e n t as something which r e f e r s back to "the baby". evident.  That U 8 i s a c h a r a c t e r i z a t i o n i s s e l f -  How i t i s constructed so.that i t r e f e r s and i d e n t i f i e s a  p a r t i c u l a r p a t i e n t i s problematic.  What we seem to be dealing w i t h i s  the type of s i t u a t i o n ?Strawson discusses:  6  The a p p l i c a t i o n of the phrase ' i d e n t i f i c a t i o n of p a r t i c u l a r s ' which I s h a l l f i r s t be concerned with i s t h i s . . Very o f t e n , when two people are t a l k i n g , one of them, the speaker, r e f e r s to or mentions some p a r t i c u l a r or other. Very o f t e n , the other, the hearer, knows what, or which, p a r t i c u l a r the speaker i s t a l k i n g about; but sometimes he does not. I s h a l l express t h i s a l t e r n a t i v e by saying that the hearer e i t h e r i s , or i s not,, able to ident i f y the p a r t i c u l a r r e f e r r e d to by the speaker. Among the kinds of expression which we, as speakers, use to make references to p a r t i c u l a r s are some of which a standard f u n c t i o n i s , i n the circumstances of t h e i r use, to enable a hearer to i d e n t i f y the p a r t i c u l a r which i s being r e f e r r e d to. Expressions of these kind include some proper names, some pronouns, some d e s c r i p t i v e phrases beginning w i t h the d e f i n i t e a r t i c l e , and expressions compounded of these. When a speaker uses such an expression to r e f e r to a p a r t i c u l a r , I s h a l l say that he makes an i d e n t i f y i n g reference to a p a r t i c u l a r . I t does not f o l l o w , of course, from the f a c t that a speaker OH a given occasion, makes an i d e n t i f y i n g reference to a p a r t i c u l a r , that h i s hearer does i n f a c t ident i f y that p a r t i c u l a r . I may mention someone to you by name, and you may not know who i t i s . But when a speaker makes an i d e n t i f y i n g reference to a  131  p a r t i c u l a r , and h i s hearer does, on the strength of i t , i d e n t i f y the p a r t i c u l a r r e f e r r e d t o , then I s h a l l say, the speaker not only makes an i d e n t i f y i n g r e ference t o , but also i d e n t i f i e s , that p a r t i c u l a r . So we have a hearer's sense, and a speaker's sense of ' i d e n t i f y ' . 6  Strawson i s c l e a r l y into s o c i o l o g i c a l t e r r i t o r y when t a l k i n g about a speaker's versus hearer's sense of " i d e n t i f y " , "expressions", "the circumstances of t h e i r use'!, and/or the negotiated character of p a r t i c u l a r s . The crux of what I take Strawson to be saying i s that, when i n d i v i d u a l s i n t e r a c t with one another, they make references and, whether or not such references succeed i n accomplishing an "identification':' must be negot i a t e d between speakers and hearers over the course of t h e i r exchange. Note that while p h i l o s o p h i c a l l i t e r a t u r e recognizes that ' r e f e r r i n g 'identification  v  and  are accomplished i n the course of various speech s i t u a -  t i o n s , i t tends to subsume d e s c r i p t i o n under some general theory rather than focus upon i t as a s i t u a t i o n a l l y constructed accomplishment. I n contrast to t h i s , our concern i s with the l a t t e r , s p e c i f i c a l l y , here, with accounting f o r how U8 i d e n t i f i e s the p a t i e n t i n a unique way. U3 uses a p a t i e n t ' s name to i d e n t i f y the p a t i e n t to the s t a f f . When t h i s f a i l s , a medical c h a r a c t e r i z a t i o n i s used:  U6. When t h i s  a l s o s f a i l s , another type of c h a r a c t e r i z a t i o n i s o f f e r e d .  This charac-  t e r i z a t i o n "The commune", could have been constructed without any medical expertise.  That i s to say, i t could have been constructed by any com-  petent c u l t u r a l member.  Let me begin to elaborate by attending to the  semantic r e f e r e n t s of the preceeding utterances. The r e l a t i o n s h i p  between names and pronouns i s a r a t h e r s t r a i g h t -  forward one that i s , a pronoun can stand f o r a name.  Interactionally,  132  however,  " H e ' s " must be r e c o g n i z e d  "John Doe" —  an o p e r a t i o n  the  i n terms of the  some o p e r a t i o n  p e r s o n and number. referent  of  that  stipated,"  " J o h n D o e " i n U 5 , "Who?" and " J o h n D o e " i n U3 a l l  " T h e Commune," " H e ' s a r o u t i n e  on  Similarly,  c a n assume  " T h e Commune"?  baby who's  We  a bit  con^  refer  to  patient. Note  patient,  that,  w h i l e d e a l i n g wthh the  we h a v e  come u p o n a m o r e  The w o r l d i s  full  that  are  persons  pendent via  of  of  noticeable  able  to  the  referring  to  Volvo  references,  zations  seem  to  for  the  Returning self,  be  that  who comes definite the  to  the the  from the  to  to,  pick-up-on,  wagon?"  This  thing is  for,  a place  do t h e  at  note  name o f  that  is  not  i n "the"  name.  Place  is just  to  are  point w i l l  Such  yet  that  names  i d e n t i f y phenomena w h i c h a r e  Thus,  can, not,  I  the  guy  of  Thus,  seems  suf-  later.  i n and by  it-  Another p o s s i b i l i t y  I  have  a b a b y who l i v e s  commune.  patient  characteri-  it  something l i k e ,  important  inde-  memories,  be d e v e l o p e d  place.  say  that  jog  " T h e Commune" c a n ,  to  these  intended f o r .  characterization,  can be expanded  it  they  appears'  common s e n s e way  identifications.  This  and i t  Identifying a  sufficient  that  particular  interaction.  and u t i l i z e  routine,  a particular  It  of  than asking,. "Is  often  job  hand.  data,  feature  expertise.  b e no d i f f e r e n t  commune".  b a b y who l i v e s  Commune" a s be u s e d  purposes  identifying a  and i d e n t i f i a b l e f e a t u r e s ,  a unique medical  utterance  article  to  of  generalizable  a n d make n e c e s s a r y  not  t a k e n as the  station  be a b l e  Commune" i s  ficient  to  issue  t r a i n i n g or  some p e r s o n o r  clarify  "The  orient  any p r o f e s s i o n a l  " T h e Commune" seems  who owns  but  is  of  the  is  What  product  we may a s k  the  question:  as  am t r e a t i n g  i n the  strict  baby  retained  in "a"  given certain  "the  the  commune "The  circumstances, sense of  the  133  term, p l a c e s .  Here a r e a few p e r t i n e n t examples from S c h e g l o f f who  t e l l s us t h a t : . . . p l a c e terms can be used to f o r m u l a t e A: B:  You uh wha ' d i j u h do, f e r a l i v i n g ? Ehm, I work i n n a d r i v i n g s c h o o l  They can be used t o f o r m u l a t e A: B:  "stage  When d i d t h i s happen? When I was i n J u n i o r High  They can used t o formulate *A: B:  occupation:  of l i f e " :  School.  activities:  What's J i m doing? Oh, he's a t the b a l l p a r k .  *Indicates invented data: here the answer c o u l d i n d i c a t e e i t h e r work o r l e i s u r e a c t i v i t i e s depending on'Jim's" o c c u p a t i o n . Where a p l a c e term i s used t o f o r m u l a t e somet h i n g o t h e r than l o c a t i o n , the f i r s t q u e s t i o n may betnot how t h a t term was s e l e c t e d out o f the s e t o f terms t h a t a r e c o r r e c t f o r t h a t p l a c e , but r a t h e r how a p l a c e term came t o be used t o do a non-place f o r m u l a t i o n . ^ I f I am r i g h t i n r e g a r d i n g  "The Commune" as a p l a c e name,  then,  f o l l o w i n g S c h e g l o f f i's recommendation, I would l i k e to c o n s i d e r how i t comes to r e f e r to a p a r t i c u l a r p e r s o n . reader w i t h The  To t h i s end, I w i l l p r o v i d e the  some background i n f o r m a t i o n about t h i s . p a t i e n t .  C l i n i c provides medical  c a r e f o r a group o f f a m i l i e s , the Smiths,  the Jones, and the Does, who l i v e i n a nearby commune. c o n s t i t u t e "The Commune".  These f a m i l i e s  I t i s n o t merely the f a c t t h a t they l i v e i n  a commune t h a t i s i n t e r e s t i n g , b u t t h a t t h e i r l i v i n g i n t h i s way has p r o v i d e d members o f the C l i n i c a s u i t a b l e term a p p l i c a b l e t o any member or members o f t h e commune.  Of c o u r s e ,  t h i s i s n o t t o say t h a t an i n d i -  v i d u a l member can p r o p e r l y be c a l l e d by the u n i t ' s name.  By t h i s I mean  134  t h a t the name "John Doe" i s n o t synonymous w i t h , i . e . , r e p l a c e a b l e by "The  Commune".  What I am s a y i n g i s t h a t whereas "John Doe" d i d n o t  a d e q u a t e l y i d e n t i f y the p a t i e n t , the term, "The Commune," was i n t e n d e d to and d i d l o c a t e him.  s i n c e membership i n the commune was b o t h  the p o i n t o f view o f the nurse  from  (speaker) and Doctor B (hearer) an ade-  qMlstni4§e-t^fy-Mgi*ef§Eefi(S6. p a t i e n t . References a r e s t r o n g l y connected speakers and h e a r e r s .  t o t h e shared b i o g r a p h i e s o f  That i s , i t i s up to the speaker t o choose an  i d e n t i f y i n g r e f e r e n c e and the n a t u r e o f t h a t r e f e r e n c e i s c o n s t r a i n e d both by the n a t u r e o f the o c c a s i o n and by what he can assume t h a t :.,he and h i s c o n v e r s a t i o n a l p a r t n e r ( s ) know i n common about referred about  the phenomenon  t o . Sacks e l a b o r a t e s upon t h i s i n the f o l l o w i n g  discussion  the c o n s t r u c t i o n o f a s t o r y : ...Now she c o u l d e a s i l y handle t h a t by h a v i n g s a i d "Ruth Henderson and I drove down to see Mary Smith who l i v e s i n V e n t u r a " b u t t h e r e a r e some problems about t h a t . I f she was going to see somebody t h a t the o t h e r person doesn't know, then i t f - c o u l d cause a c o m p l i c a t i o n to say "We went down t o see Mary Smith y e s t e r d a y " "Oh, whois she?" "She's a f r i e n d o f mine who l i v e s i n V e n t u r a . " "Oh, I s e e . " But anybody knows t h a t when somebody uses, i n s t e a d o f the name of the person they went t o see, a p l a c e , then t h e y ' r e t e l l i n g you among o t h e r t h i n g s , 'you don't know who I'm t a l k i n g about', e.g., " I went to a p a r t y a t L a Marian l a s t n i g h t " t e l l s you among o t h e r t h i n g s , 'you don't know the p e r s o n I wentttoosee'. Where i f you knew who they went to see they would t e l l you who they went to see.8  For  us, however, the problem  i s the r e v e r s e o f t h a t f a c e d by Sacks.  Doctor B has n o t been a b l e t o i d e n t i f y t h e p a t i e n t e i t h e r by name, o r a f t e r o b t a i n i n g a m e d i c a l c h a r a c t e r i z a t i o n o f him.  Rather, i t was a  c h a r a c t e r i z a t i o n o f the p a t i e n t ' s r e s i d e n c e t h a t f i n a l l y enabled an identification.  135  Us  3, 6 and  8 have been t r e a t e d as " f u r t h e r i n f o r m a t i o n , "  to enable Doctor B to i d e n t i f y the p a t i e n t .  U9,  i t has  designed  been argued, com-  p l e t e s t h i s sequence f o r i t i s here Doctor B f i n a l l y manages to the p a t i e n t .  U8  leads  to an adequate i d e n t i f i c a t i o n of the  T h i s i s evidenced by U9.  In Strawson's terms, U9  identify  patient.  i s the u t t e r a n c e  b y e t h e r s p e a k e r " i d e n t i f i e s the p a r t i c u l a r r e f e r r e d t o . "  On  the one  t h i s seems to s a t i s f y Strawson's model of a speaker i d e n t i f y i n g a c u l a r , on  the o t h e r ,  ment, i . e . , Us of  3-9,  'remembering' and  i t provides  f o r the p o s s i b i l i t y  i s not an i n s t a n c e 'recognition'.  The  How  'Oh  i s this  was  being  U9  c a s t s doubt on  yeah' of U9  The  'John Doe'  That i s , i t i s not  the name.  I suggest t h a t U9  'John Doe'  and,  i s the o p e r a b l e p o r t i o n o f  hence, net  i s not  the f i r s t  time he has  an example of r e f e r r i n g .  The  the p a t i e n t i s but had  f o r g o t t e n and  sequence under a n a l y s i s i s thus one  r a t h e r than r e f e r r i n g .  I f I am  Rather, U9  l e t us c o n s i d e r  p a r t i c i p a n t s to c h a r t rounds;  heard  has  been made to "remember."  o f remembering and  a n a l y s i s of Us the b u r e a u c r a t i c  Those p e r s o n n e l who  provides  known a l l  recognition  c o r r e c t i n the a n a l y s i s of U9,  e f f e c t does t h i s have on the p r e v i o u s To b e g i n w i t h ,  who  an i n s t a n c e of Doctor B i d e n t i f y i n g  us w i t h r a t h e r s t r o n g grounds f o r assuming t h a t Doctor B has along who  this  s i g n i f i e s r e c o g n i t i o n of s u c c e s s f u l l y a t -  i n t h a t i t s i g n i f i e s t h a t the Doctor knew a l l a l o n g  t a l k e d about.  the  so?-  t a c h i n g a p a t i e n t to a name. the u t t e r a n c e  patient's  does not know what  p a r t i c u l a r i s t h a t the speaker i s t a l k i n g about. assumption.  parti-  c o n s t i t u t e s a case  have been t r e a t i n g the  name as something mentioned to a p a r t i c i p a n t who  hand,  t h a t the e n t i r e s e g -  of r e f e r r i n g but  *We  where-  what  3-9? situation facing  r o u t i n e l y come i n t o  c o n t a c t w i t h p a t i e n t s are engaged i n a r e l a t i o n s h i p whereby, because of  136  the nature of C l i n i c business, they must or at l e a s t should remember who patients are.  Because the s i z e of the patient population t y i n g  names to patients i s an omnipresent problem f o r the s t a f f .  Medical  personnel are under a strong o b l i g a t i o n to remember whoipatients are when dealing with them.  S t a f f discussions about patients place a sim-  i l a r o b l i g a t i o n on those f a m i l i a r with a patient to be able to t i e patient names to patient problems.  S t a f f are concerned not only that  some patient has some medical problem, or that some patient has a problem, but with which patient has which problem.  Rounds i s not merely  an occasion to discuss the medical problems of various patients but an opportunity to discuss and to o r i e n t to the problems associated with each p a r t i c u l a r p a t i e n t . are not acquainted  At the same time, some of the p a r t i c i p a n t s  with the patient who i s being discussed.  One of  the o r g a n i z a t i o n a l problems of the C l i n i c i s t y i n g patient names to the problems which c o n s t i t u t e the o r g a n i z a t i o n a l business of the C l i n i c . Chart rounds i s an occasion where such business should be discussed. With these features i n mind, l e t us return to an examination of our data. U6, while a medically relevant c h a r a c t e r i z a t i o n , i s also i n h e r e n t l y connected to the business at hand.  I mean that i t i s , at l e a s t i n some  ways, adequate f o r the purposes at hand and w i l l do f o r any "routine baby who's a b i t constipated") regardless of i t s biography.  Itis a  c h a r a c t e r i z a t i o n usable,to any personnel i n general; one that does not require members know the patient's name i n order to f i n d i t usable.  As  such, i t i s t i e d to the bureaucratic concerns f o r g e t t i n g things done. Following the name references, Us 3 and 5, Doctor A proceeds to state the o r g a n i z a t i o n a l business that the C l i n i c has with t h i s p a r t i c u l a r p a t i e n t .  137  Such b u s i n e s s need n o t be concerned w i t h who the p a t i e n t i s , b u t o n l y w i t h the ways i n which he i s t i e d Clinic.  to the o r g a n i z a t i o n a l concerns o f the  Because Doctor A i s t h e p a t i e n t ' s p h y s i c i a n , t h e c h a r a c t e r i z a -  t i o n provided  by U6 need n o t be seen as a c o n s t r u c t i o n designed t o  'help' Doctor B l o c a t e the p a t i e n t . it  Instead,  i n a r a t h e r s t r o n g way,  seems to i n d i c a t e t h a t the Nurse's f o r m u l a t i o n ,  "John Doe" i s  r e f e r e n t i a l l y adequate, t h a t i s , a non-problematic matter o f r o u t i n e to t h e b u s i n e s s a t hand so t h a t p a r t i c i p a n t s can proceed w i t h a r e v i e w of the c h a r t . However, t h i s does n o t undercut the e a r l i e r a n a l y s i s o f how the use  o f a p a t i e n t ' s name a l l o w s  those f a m i l i a r w i t h him to r e c o g n i z e  him  and a f f o r d s those who a r e not f a m i l i a r w i t h an o p p o r t u n i t y to  become f a m i l i a r w i t h h i s name and problem.  In the f i r s t  c a s e , t h e name  i s used f o r the b e n e f i t o f those who know the p a t i e n t whereas, i n the second, i t s use a l l o w s and/or o r g a n i z a t i o n With r e f e r e n c e  those who a r e u n f a m i l i a r w i t h the name, problem  concerns t h e r e o f ,  to become f a m i l i a r w i t h them.  to Strawson's remark, " I may mention someone to  you by name, and you may n o t know who i t i s , " i t i s now e v i d e n t he One  i s neglecting  t h e i n t e r a c t i o n a l consequences o f such name d r o p p i n g .  does n o t mention a name to someone u n l e s s  name w i l l have some meaning f o r them. references  that  they assume t h a t  that  People u s u a l l y make t h i r d  to h e a r e r s who they assume w i l l know the mentioned  I n such a case, one i s n o t making an i d e n t i f y i n g r e f e r e n c e so t h a t the h e a r e r may, on the s t r e n g t h o f i t , be a b l e  party  party.  to a hearer  to i d e n t i f y the  p a r t i c u l a r r e f e r r e d t o , but r a t h e r , i n making such a r e f e r e n c e , the  138  speaker assumes that the hearer w i l l remember the person r e f e r r e d t o . Where a t h i r d party reference i s made and the p a r t i c i p a n t s do not know who i t i s , as i s the case i n our present a n a l y s i s , circumstances warrant that the name be connected to some category rather than to a p a r t i c u l a r p a t i e n t .  That i s , i t i s obvious that the name  i s the name of a patient and a l l that now i s required of those who are present but u n f a m i l i a r with the name i s that they associate i t with a p a r t i c u l a r p a t i e n t .  The name i s not being used  as'information  to allow anyone to i d e n t i f y someone who they do not know.  In opposi-  t i o n to Strawson, i t i s not the case that when people mention someone to you they expect you to know who that someone i s ; instead they only require that you know who that someone i s i n terms of some category or c l a s s , e.g.,  a patient.  For a l l p r a c t i c a l purposes, the category  of p a t i e n t serves to i d e n t i f y any p a r t i c u l a r p a t i e n t mentioned. For some purposes mentioning someone's name need not require that you know "who"  he i s , but merely "what" he i s i n order to i d e n t i f y him f o r the  purposes at hand. Given our reformulation of the data, the f a c t that the Nurse repeated the patient's name i n U5 can be taken to substantiate our claim that the name i s posited as adequateiinfdrmatrfcontfor. thehtask at hand. I t i s assumed ttiattDdetortB's "Who?" i s a "request f o r a repeat" rather than f o r further i d e n t i f y i n g d e t a i l s .  The name alone i s adequate f o r  anyone f a m i l i a r with the p a t i e n t , and anyone not f a m i l i a r with the patient knows at l e a s t that the name i s t i e d to a p a t i e n t .  So what  we have i n U3 i s the name, i n U6 a statement of o r g a n i z a t i o n a l business  139  with reference  U6 t r e a t s Us  to t h i s p a t i e n t .  s u f f i c i e n t information  3 and  5 as  providing  f o r Doctor B to i d e n t i f y the p a t i e n t and  proceeds to the t a s k s a t hand, namely, a review of the c h a r t , moreover, the scheduled c o m p l e t i o n o f t h i s s e s s i o n of c h a r t Thus, i n U 9 ,  i t i s not  v i a the i n f o r m a t i o n remembered who i s one  provided  t h a t Doctor B has 3,  i n Us  6 and  8 alone.  the p a t i e n t i s f o r he knew him  between a name and  of i d e n t i f y i n g i n f o r m a t i o n i d e n t i t y of the p a t i e n t . remember what he has  t h a t would a l l o w  f o r g o t t e n , and  not  they can be used as a r e s o u r c e be r e c o g n i z e d  but  i s no^t can  the  patient  The  connection  a l l o w him  a h e a r e r to to  identify  police descriptions  when a t h i r d p a r t y r e f e r e n c e  come to be remembered?  r e l a t i o n s h i p which o b t a i n s between t h i s p a r t y , t h a t the mention of "The  g n i z M g what heoshouflidshaveiknown and, Our  concern, now,  w i l l be  that  Earlier,  i t was  l e c t i v e l y as "The  In t h i s c a s e , how  the speaker and  the  himself  i n f a c t , d i d know a l l a l o n g . "The  Commune" can  serve  patient.  s t a t e d t h a t a group of p a t i e n t s were known c o l -  Commune" and  t h a t t h i s c h a r a c t e r i z a t i o n was  p l i c a b l e to each member of the commune.  I t i s not  t h i s group of p a t i e n t s are or become known as it  should  Commune" f-aeiibitafeesshiisrr-.eGO-  i n e x p l i c a t i n g how  as a rememberable item about t h i s  do.  seen as "rememberable" such t h a t  can Doctor B draw upon h i s knowledge of the mentioned p a r t y , and  i n such a way  has  a case of some amount  only allows  does not  i s i t t h a t some items can be  rounds.  someone to e s t a b l i s h the  p a r t i c u l a r i n d i v i d u a l s i n the sense t h a t , say, How  and  Rather, he  a l l along.  a known p a t i e n t and  Such i n f o r m a t i o n  identified  thereby  "The  only  also  ap-  the case t h a t  Commune," f u r t h e r  i s what they are or become remembered f o r , i . e . , b e l o n g i n g  to a  <-  140  commune.  Let us consider the r e l a t i o n s h i p between "being  known" and "being  (or becoming)  (or becoming) remembered f o r " .  Becoming known as a patient can r e s u l t from one's a s s o c i a t i o n with any part of an extensive l i s t of items which concern medical p r a c t i t i o n e r s , one can have a broken l e g , be a d i a b e t i c , "a routine baby who's a b i t constipated'," etc. g e t t i n g known, they may b e r a b i l i t y , e.g., pated.  While any of these may be a way  of  or may not be adequate i n terms of t h e i r remem-  there may be numerable routine babies who  are c o n s t i -  I t i s u n l i k e l y that the s t a f f w i l l remember an i n d i v i d u a l patient  simply because he s u f f e r s from some common ailment since there are numerous p a t i e n t s who have the same complaint and receive the same k i n d of a t t e n t i o n .  However, that t h i s p a t i e n t i s a member of "The Commune"  i s somehow a "rememberable" feature. A l a y notion of how doctors r o u t i n e l y remember t h e i r patients might assume that they remember them v i a t h e i r aches and pains.  It  turns out, however, that they remember patients i n the same way  that  any other member of s o c i e t y might remember a phenomenon, i . e . , by ass o c i a t i n g i t with some a t t r i b u t e that i s unique to them.  Thus,  "The  Commune" i s a rememberable feature, and by l i n k i n g the patient to i t , Doctor B i s able to remember what he knew a l l along. This s e c t i o n began by t r e a t i n g Us 3-9 as an instance of what Strawson c a l l e d " r e f e r r i n g to p a r t i c u l a r s . " This a n a l y s i s , however, was re-evaluated and deemed inadequate,for  a second examination of the  data suggested that i t may better c o n s t i t u t e an instance of remembering and r e c o g n i t i o n .  What could be more p r i v a t e than an i n d i v i d u a l ' s  141  memory?  As i t turns out, memory i s not the product of i n d i v i d u a l  awareness along, but i s shaped v i a the r e l a t i o n s that obtain between the item to be remembered and the ways i n which i n d i v i d u a l s can be helped to remember.  The process of remembering i s not s o l e l y a product  of the workings of one mind, but a s o c i a l l y - o r g a n i z e d phenomenon. ^O'Egar^zMlsnal Treatment of an Organizational Problem An encounter between patient and physician i s u s u a l l y arranged through an intermediary such as a secretary. coincidence between physician and p a t i e n t . time "x", he w i l l see Doctor "y".  accomplishes  I f the patient comes i n at  I f circumstances p r o h i b i t h i s seing  Doctor "y", another doctor w i l l see him. are aware of t h i s p o s s i b i l i t y .  Scheduling  Both patients and  physicians  The f a c t of scheduling allows  physicians  to consult the secretary's appointment l o g p r i o r to chart rounds so as to have some idea of who  i s scheduled to see whom that day.  This does  not mean that a physician always does t h i s , however, the' p o s s i b i l i t y always e x i s t s .  Since our data comes from a session of chart rounds  where the charts belong to those patients who  are to be seen l a t e r on  i n the day, a d i s c u s s i o n of scheduling problems seems to be i n order for they c o n s t i t u t e an area of concern f o r the personnel involved i n chart rounds. Before addressing  t h i s i s s u e , however, I would l i k e to draw the  reader's a t t e n t i o n to the manner i n which the forthcoming d i s c u s s i o n w i l l r e l y f o r sense upon those features of c l i n i c organization r e f e r r e d to i n the opening s e c t i o n of the d i s s e r t a t i o n . S p e c i f i c a l l y , i t w i l l require that the reader remember and use c e r t a i n f a c t s from t h i s s e c t i o n ,  142  e.g.,  the f a c t that the c l i n i c operates on an appointment system.  the time that these materials were presented,  At  I stated that I d i d not  know how such d e t a i l s would come to be usable f o r whatever subsequent a n a l y s i s was presented.  Despite t h i s , I r e l i e d and s h a l l r e l y upon the  reader to make use of these m a t e r i a l s i n order to inform the a n a l y s i s to be presented.  While somewhat of an aside from our present concern,  i t i s i n t e r e s t i n g how not only does th&sssubstantiate our e a r l i e r a n a l y s i s of the standard ethnographic  format, but also i l l u s t r a t e s some  of the ways un which these i n i t i a l materials come to c o n s t i t u t e the background f o r subsequent m a t e r i a l s .  Noting how such i n i t i a l materials  are used as a resource f o r our appreciation of some subsequent a n a l y s i s r e i n f o r c e s the i n i t i a l s e c t i o n and contributes as w e l l t o the a n a l y s i s 1  at hand.  Let us now r e t u r n to our t r a n s c r i p t and to an a n a l y s i s of the  scheduling problem. Continuing; with our data, U l l c o n s t i t u t e s both an o r g a n i z a t i o n a l ; problem, i . e . , which physician w i l l see the p a t i e n t given that Doctor A i s unable to do so? and a proposed s o l u t i o n to t h i s problem. cern i s with how U l l handles the problem of who  Our con-  should see the p a t i e n t .  To begin w i t h , l e t us consider the p o s s i b l e hearings members could engage i n . 1.  The beginning of a complaint.  I t i s the secretary's job to  a l l o c a t e appropriate time s l o t s f o r meetings between doctor and p a t i e n t . The secretary knows which physicians are a v a i l a b l e at what times and i t i s her job to schedule appointments accordingly.  Thus, the  beginning  section of U l l , "They've put him a b i t e a r l y f o r t h i s afternoon," could  143  w e l l c o n s t i t u t e a complaint, i . e . , given Dr. A's schedule, the p a t i e n t was scheduled f o r too e a r l y a time s l o t and, f u r t h e r , that "They," the secretary (or the c l i n i c i n general) should have known b e t t e r than to make an appointment f o r that time.  Put crudely, the beginning of U l l  provides f o r the p o s s i b i l i t y of a f f i x i n g r e s p o n s i b i l i t y or blame to some o r g a n i z a t i o n a l member who should have scheduled the p a t i e n t at a time l a t e r than that a l l o t e d .  We can assume that Doctor A had consulted  the appointment schedule p r i o r to rounds and i s , thereby, i n a p o s i t i o n to know when the p a t i e n t i s scheduled .2. ; A contingency i n Doctor A's schedule has developed.  Another  p o s s i b l e hearing f o r the beginning part of U l l i s that ' t h i s afternoon' i s d i f f e r e n t from any afternoon because something has a r i s e n i n Doctor A's schedule.  Something which the secretary could not have known about.  The ' b i t e a r l y ' seems to suggest t h i s p o s s i b i l i t y since i t undercuts . the notion of making a complaint about, e.g., the e f f i c i e n c y of secret a r i a l scheduling.  I f one i s going to make a complaint, i t i s not that  the secretary made the appointment "a b i t e a r l y " , but that she made the appointment "too e a r l y " .  ' B i t e a r l y ' implies a temporal period short  enough i n duration not to be problematic with reference to coincidence between p h y s i c i a n and p a t i e n t . Regardless of which p o s s i b l e hearing i s c o r r e c t ( f o r our business i s not one of deciding h i s t o r y ) , e i t h e r hearing provides that the beginning of U l l e s t a b l i s h e s an o r g a n i z a t i o n a l problem with reference to the speaker.  The p a t i e n t i s "a b i t e a r l y f o r t h i s afternoon" only  with reference to Doctor A's whereabouts.  Doctor A i s not making some  144  statement about scheduling procedures i n general where e.g., would not be anyone at the C l i n i c to see the p a t i e n t .  there  Given the group  character of the c l i n i c , the beginning of U l l establishes the organizat i o n a l problem of "Who should see the p a t i e n t ? " The o r g a n i z a t i o n a l problem provides those other physicians present with the p o s s i b i l i t y of seeing another and unexpected p a t i e n t . however, increases t h e i r patient load.  This,  As such, the beginning of U l l ,  while an o r g a n i z a t i o n a l problem f o r the C l i n i c , allows those candidates for another patient t o / o r i e n t to that f a c t i n terms of e i t h e r accepting another p a t i e n t or constructing a p o s s i b l e excuse f o r not accepting another p a t i e n t .  What c o n s t i t u t e s an o r g a n i z a t i o n a l problem can also  be seen by physicians as a personal problem that i s , seeing another patient i n an already busy work day.  What we are dealing with then,  i s both an o r g a n i z a t i o n a l concern, i . e . , someone has to see the p a t i e n t , and the personal  Goncems:.of  oDcctfor. A and the other physicians.  U l l pro-  vides us with an instance of how the organization of the work day i s attended to by the ongoing p r a c t i c e s employed by members of the s e t t i n g . Given that U l l i s preceeded by the Nurse's U10, how i s i t that Doctor B hears himself as the referent to the pronoun 'you' i n " I don't know whether he's coming to see me or to see you..."  Again we are  dealing with p o s s i b i l i t i e s , although i n t h i s instance my f i e l d notes w i l l serve as a piece of h i s t o r y . 1.  Eye contact.  One p o s s i b i l i t y i s that Doctor A has spoken the  utterance while looking at Doctor B providing thereby, i n a d d i t i o n to a v e r b a l d i s p l a y , a p a r a l i n g u i s t i c means f o r speaker s e l e c t i o n .  145  2.  Medical  specialty.  B i s a family physician.  Doctor A i s a p a e d i a t r i c i a n w h i l e Doctor  The d i s t i n c t i o n b e i n g  that, while a  paedia-  t r i c i a n s p e c i a l i z e s i n c h i l d r e n , a f a m i l y p h y s i c i a n t r e a t s the f a m i l y as a whole.  However, e i t h e r p h y s i c i a n c o u l d  t r e a t the p a t i e n t and  the s e c r e t a r y c o u l d have scheduled him t o see e i t h e r o f them. 3.  P a s t m e d i c a l e n c o u n t e r s.  By p r o v i d i n g a m e d i c a l c h a r a c t e r i ^  . —  z a t i o n o f the patientv(inaU:6,PDoct0)r . A g i v e s us w a r r a n t a b l e grounds f o r assuming t h a t he has seen t h e p a t i e n t p r e v i o u s l y . data to s u b s t a n t i a t e  A l t h o u g h we have no  t h i s c l a i m , f.oritteis.aequally p o s s i b l e t h a t the  p a t i e n t has been seen p r e v i o u s l y by Doctor B, Us 7-9 a t t e s t t o the f a c t t h a t Doctor B i s a t l e a s t f a m i l i a r w i t h the p a t i e n t . 4.  P a r t i c i p a n t s to the occasion.  to Doctor B can be d e r i v e d  from the f a c t t h a t o n l y Doctor A, Doctor B,  the Nurse, and myself were p r e s e n t scheduled to see p h y s i c i a n s , Doctor B.  That t h e 'you' i n U l l r e f e r s  a t t h i s time.  Since p a t i e n t s a r e  the o n l y c a n d i d a t e f o r the 'you' i s  Note how p a r t i c i p a n t s o r i e n t t o such c o n t i n g e n c i e s  or when h e a r i n g  an u t t e r a n c e .  when making  Doctor B i s now i n a p o s i t i o n t o see t h a t  he w i l l have t o d e a l w i t h t h e p a t i e n t .  A l t h o u g h t h e p o s s i b i l i t y has  not y e t been e x p l i c i t l y proposed by Doctor A, I suggest t h a t i t has been established here. Note another i n t e r e s t i n g f e a t u r e o f the segment " I don't know whether he's coming t o see me o r t o see you",  i . e . , i n some s t r i c t  sense,  the p a t i e n t i s n o t "coming to see anyone" s i n c e he i s a baby and c a p a b l e of no such independent a c t .  Rather, he i s b e i n g brought t o t h e C l i n i c .  However, f o r . t h e purposes a t hand, he i s a p a t i e n t and p a t i e n t s a r e s a i d  t  o  146  "come to the doctor" regardless of whatever else they do. The remainder of U l l reads "...but I s h a l l be sort of squeezed I think to get back i n time you deal with i t " .  This i s both an e x p l i -  c i t formulation of the problem and a possible s o l u t i o n f o r i t , i . e . , Doctor B should see the p a t i e n t should Doctor A be unable to do so. Notice that Doctor A i s not r e f u s i n g to see the patient but e s t a b l i s h i n g good grounds f o r such a p o s s i b l i t y , i . e . , he has business elsewhere. The " I think" then sets up t h i s as a p o s s i b i l i t y rather than a c e r t a i n t y , i . e . , the p o s s i b i l i t y e x i s t s that Doctor A w i l l be busy elsewhere and/ or unable to make it. back i n time to see the p a t i e n t .  Although he pro-  vides a s o l u t i o n to the problem, namely "you deal w i t h i t " , t h i s may not be s a t i s f a c t o r y to the physician so delegated. Let me elaborate t h i s point. One way of handling the present s i t u a t i o n would be to look at i t through some t r a d i t i o n a l s o c i o l o g i c a l concept such as s t a t u s .  Thereby,  Doctor A could be viewed as a senior p h y s i c i a n , e n t i t l e d to s p e c i f i c r i g h t s and duties from j u n i o r physicians such as Doctor B.  When c o n t i n -  gencies p r o h i b i t Doctor A from seeing a p a t i e n t , he can, as a matter of v-course, assign that patient to a l e s s senior p h y s i c i a n .  However, were  the s i t u a t i o n reversed, i t would be harder f o r Doctor B to assign a patient to Doctor A.  Such a view would be concerned wholly w i t h how  various medical personnel r e l a t e to each other i n terms of power and would s h i f t our a t t e n t i o n away from the a c t u a l , ongoing sequences of i n t e r a c t i o n i n and through which members produce and s u s t a i n f o r one another t h e i r d a i l y a f f a i r s .  To t r e a t U l l i n such a manner would be to  147  ignore the i n t e r a c t i o n a l s t r u c t u r e of the occasion. who  The problem of  should see the patient involves the ways i n which the problem i s ;.  something produced and attended to by p a r t i c i p a n t s , and the answers to these concerns are much more complicated  than notions such as status  and the r e s t provide f o r . A r e s o l u t i o n to the'problem can be achieved i n many d i f f e r e n t ways —  i t can be done t a c t f u l l y , rudely, g r a c e f u l l y , etc.  The  inter-  a c t i o n a l structure of the r e s o l u t i o n i s another i n t e r e s t i n g feature here.  Ulljis  not merely an instance of a senior physician passing  the buck to a j u n i o r p h y s i c i a n .  Ratherm i t i s s p e c i f i c a l l y designed  to undercut the notion that one doctor i s ordering another to see a patient.  Doctor A establishes a reasonable excuse f o r having to assign  the p a t i e n t to another p h y s i c i a n .  I t i s not merely that he does not  want to see the p a t i e n t , but rather that he provides f o r the p o s s i b i l i t y that he may not be able to do so and, therefore, warrantable grounds f o r assigning him to another physician. That a patient i s assigned to another physician does not mean that that physician need accept the p a t i e n t , nor need i t r e s u l t i n a r e f u s a l to do so.  U14 i s an example of how an attempt to re-assign the patient  can be f o r e s t a l l e d by reformulating the bases of the problem; that i s , i t i s not that there w i l l be no physician a v a i l a b l e to see the p a t i e n t at the appointed time, but rather that the patient i s not the problem here.  The patient i s a baby and, whether Doctor A or Doctor B:is  a v a i l a b l e or not i s not a matter of concern f o r him.  The problem and  p o s s i b l e s o l u t i o n l i e s i n the f a c t that the person bringing the baby to  148  the  d o c t o r i s h i s mother who  w i l l have to w a i t .  the  \'he''s" o f U l l i n t o the a p p r o p r i a t e c a t e g o r y o f p e r s o n f o r whom i t  would be a problem were Doctor A not a v a i l a b l e .  Doctor B has  transformed  At the same time, he  p r o v i d e s a c h a r a c t e r i z a t i o n of the p a t i e n t ' s mother t h a t undercuts Doctor A's concern t h a t he may p o s i n g t h a t "Mother's  not be a b l e to get back i n time by p r o -  a p a t i e n t woman".  T h i s i s not a mere c h a r a c t e r i -  z a t i o n of the p a t i e n t ' s mother, but i s t i e d to the reasons why A might not be a b l e to see the p a t i e n t on time. these grounds  Doctor  Doctor B has undercut  r a t h e r than r e f u s e to see the p a t i e n t .  Note t h a t such a  r e f u s a l c o u l d have severe consequences,  e.g., an argument might  ensue.  Thus, f o r the moment, Doctor A i s s t i l l  r e s p o n s i b l e f o r s e e i n g the  patient. What gets t r e a t e d i n the l i t e r a t u r e as s t a t u s and r o l e  relation-  s h i p s and r i g h t s and d u t i e s w i t h r e f e r e n c e to such r e l a t i o n s h i p s , t e l l us l i t t l e  about  the ways i n which members come up w i t h s o l u t i o n s to  t h e i r everyday problems of  can  (problems which I suggest, f a l l under  "the p o l i t i c s o f everyday l i f e " ) .  the heading  That p e o p l e a r e r o u t i n e l y p l a c e d i n  s i t u a t i o n s p r o v i d i n g them w i t h some degree of s a t i s f a c t i o n or d i s s a t i s f a c t i o n i s something such problems  one need not be a s o c i o l o g i s t  to a t t e n d t o .  come to be n e g o t i a t e d i n everyday i n t e r a c t i o n ,  ever, a t o p i c worthy  i s , how-  o f s o c i o l o g i c a l i n q u i r y and one t h a t w i l l not be  answered by p r o v i d i n g g l o s s e s of the v e r y phenomena i n v e s t i g a t e d . p o l i t i c s of everyday l i f e for  theoretical In  How  The  i s a t o p i c f o r r e s e a r c h i n v e s t i g a t i o n and not  speculation.  a t t e m p t i n g to handle the d a t a as i t was  produced,Iilhave made  149  two  d i v e r s i o n s from the a n a l y s i s o f a p a t i e n t ' s r e a s o n f o r a v i s i t .  First,  I have d i s c u s s e d  Us 3-9 as an i n s t a n c e  o f memory and r e c o g n i t i o n .  Second, I have attempted t o e l a b o r a t e how an o r g a n i z a t i o n a l problem i s handled by the p r a c t i c e s employed by membersrinhandoover ithetcourse o f the o c c a s i o n  i n which i t i s '.roduced.  At t h i s p o i n t , I w i l l r e t u r n to  an a n a l y s i s o f a p a t i e n t ' s r e a s o n f o r a v i s i t The  Reason f o r a V i s i t :  t o the C l i n i c .  II  U n t i l U15, no grounds f o r the p a t i e n t ' s r e a s o n f o r coming to the Clinic  had been proposed.  I t should  be remembered t h a t U 6 o n l y  us w i t h the parameters t h a t c o u l d warrant t h e p a t i e n t ' s v i s i t . the Nurse b e g i n s to f o r m u l a t e the r e a s o n .  provides I n U15,  Although, i n p r i n c i p l e , a  p a t i e n t can see a p h y s i c i a n f o r a wide v a r i e t y o f reasons,, members o f the C l i n i c  do n o t engage i n g u e s s i n g games t o account f o r a p a t i e n t ' s  reason f o r a v i s i t .  I t i s an i n h e r e n t  c e r t a i n treatments may r e q u i r e repeat f e a t u r e , members o f the C l i n i c for  a present  Clinic.  visits  are able  to a p h y s i c i a n .  as p a t i e n t s .  Given  this  to f o r m u l a t e p o s s i b l e grounds  v i s i t on t h e b a s i s o f t h e p a t i e n t ' s p a s t v i s i t s  What we a r e d e a l i n g w i t h ,  have c a r e e r s  feature of medical p r a c t i c e that  to the  then, i s t h a t p a t i e n t s can come to  I w i l l address t h i s i s s u e i n a moment.  In U15, the Nurse has a p p a r e n t l y  found some grounds, v i a r e c a l l o r  by c o n s u l t i n g the c h a r t , which a l l o w h e r to f o r m u l a t e a p o s s i b l e r e a s o n for  the p a t i e n t ' s coming to the C l i n i c  not  simply  fail  today.  t o w a i t f o r the Nurse's f o r m u l a t i o n  but r a t h e r o r i e n t s t o t h e Nurse's a c t i v i t y visit.  Doctor A, i n U16, does to be completed,  o f f i n d i n g a reason f o r a  The "Oh yeah" i n U16 does n o t c o r r o b o r a t e  the Nurse's  finding  (as o f y e t she has n o t proposed a p o s s i b l e r e a s o n f o r a v i s i t ) , b u t  150  r a t h e r by  seeing  t h a t the Nurse i s a t t e m p t i n g or about to produce some,  r e a s o n f o r the v i s i t , Doctor A'.via hisimemo.r^yof the p a t i e n t , produces t h a t r e a s o n and The  does  so.  s t r u c t u r e of U16  Nowhere i n the u t t e r a n c e  i s complex and warrants f u r t h e r comment.  i s i t e x p l i c i t l y s t a t e d t h a t the p a t i e n t i s  coming to the C l i n i c f o r a s h o t . being  proposed.  "next s h o t " .  The  The  p a t i e n t had  Yet,  I take i t t h a t t h i s i s what i s  a " l a s t s h o t " and  i s coming f o r h i s  elegance here l i e s not o n l y i n remembering t h a t  p a t i e n t r e c e i v e d a shot, but  remembering t h a t the p a t i e n t r e c e i v e d  shot as p a r t of a s e r i e s of shots i n a course of treatment, and the shot r e c e i v e d d u r i n g series.  The  use  a p r i o r v i s i t was  not  the f i n a l shot  that  in  In a d d i t i o n , I suggest, i t serves  r e a f f i r m the e a r l i e r c h a r a c t e r i z a t i o n of the p a t i e n t as a  the  i t turns out  i n Us  to  "routine  baby" where the f e a t u r e s o f such a c h a r a c t e r i z a t i o n p r o v i d e As  a  of " l a s t s h o t " invokes the n o t i o n of a " s e r i e s " of  shots i n a r a t h e r s t r o n g way.  shots.  the  f o r such  22-25, the shots are a s e r i e s of  immuni-  zations . I t has  been demonstrated t h a t members of the  f o r m u l a t e grounds a c c o u n t i n g  C l i n i c are a b l e  f o r the p a t i e n t s ' f o r t h c o m i n g  E m p i r i c a l l y , however, the adduced r e a s o n f o r a v i s i t may wrong.in the a c t u a l encounter between p a t i e n t and c o u l d have become s e r i o u s l y i l l f o r coming to the C l i n i c . in their discussion.  The  and  visit.  be  proved  physician.  t h a t i l l n e s s c o u l d be  to  the  The  baby  grounds  N e v e r t h e l e s s t h i s p o s s i b i l i t y never a r i s e s parameters of a v i s i t  members of the C l i n i c , an i s s u e d e c i d e d  and  to the C l i n i c a r e ,  decidable  by r e f e r e n c e  for to  151  t h e i r knowledge of the p a t i e n t and current o r g a n i z a t i o n a l concerns. Thus what was o r i g i n a l l y thought to be an o r g a n i z a t i o n a l problem w i t h reference to doctor-patient scheduling, Us 11-14, i s now seen as something which may only require the a t t e n t i o n of a nurse, f o r routine immunizations are given by the Nur-se and the p a t i e n t need not see a doctor i n order to receive them. The above a n a l y s i s i s but one instance of p a r t i c i p a n t s to chart rounds formulating or attempting to formulate a p a t i e n t ' s reason f o r coming to the C l i n i c . occasion.  This i s a regular and recurrent feature of the  I would l i k e to make some general comments concerning  the  accomplishment of t h i s . While a p a t i e n t ' s reason f o r a v i s i t i s generated from h i s chart and the accumulated knowledge of the p a r t i c i p a n t s , there are various ways i n which the p a t i e n t ' s r e l a t i o n s h i p to the C l i n i c i s u t i l i z e d i n t h i s accomplishment. 1.  Use of the chart f o r programmed information.  Consider  f o l l o w i n g pieces of data: ONE 68.  Doc. A  Mrs. Jones. I take i t she i s r e c e n t l y married. Condyloma podophyllin r e t u r n i n one week. (Condyloma i s a disease term f o r veneral warts, and podophyllin i s the medication used i n treatment)  69.  Doc B  Ah oh Steve Schwartz had been seeing them applying podophyllin.  70.  Doc. A  Um w e l l ah she must be back f o r more.  the  152  TWO  132.  The  131.  Doc  A  132.  Doc  B  (  133.  Doc  A  For an I.U.D. i n s e r t i o n  M i s s Joan Summer wishes I.U.D. p e r i o d f i n i s h e d to go take p i l l and r e t u r n when she's menstruating., I take i t she i s coming back now.. )  above c o n s t i t u t e i n s t a n c e s  o f how t h e s t a f f use i n f o r m a t i o n  what took p l a c e on a p a t i e n t ' s l a s t v i s i t account f o r what w i l l  take p l a c e  place previously i s placed c h a r t rounds.  today.  about  to the C l i n i c i n order t o A w r i t t e n r e c o r d o f what took  i n the p a t i e n t ' s c h a r t and a v a i l a b l e d u r i n g  The p a t i e n t ' s c h a r t may c o n t a i n i n f o r m a t i o n  such as  " r e t u r n i n one week," " r e t u r n when she's m e n s t r u a t i n g , " e t c .  Note t h a t  formulating  activity  and  a p a t i e n t ' s reason f o r a v i s i t  i s n o t merely d i s c o v e r e d  by r e a d i n g  c o n t a i n programmed i n f o r m a t i o n ,  i s an accomplished  the c h a r t .  While a c h a r t may  e.g., " r e t u r n i n one week," i t must be  e s t a b l i s h e d why the p a t i e n t was t o l d the c h a r t s a r e n o t s e l f - i n t e r p r e t i n g . p l e i n s t r u c t i o n , the s t a f f f a c e s  to " r e t u r n i n one week".  Clearly,  Even i n the case o f such a sim-  the task o f f i n d i n g some correspondence  between the i n s t r u c t i o n and the r a m i f i c a t i o n s t h a t f o l l o w from i t . The  drawing up o f c h a r t s i s a members' s accomplishment.  Those who  produced them knew t h a t they may come to be u t i l i z e d a t some l a t e r  point.  Thus, I would l i k e to examine the u n d e r l i n e d  pieces  of d a t a as produced to be a b l e point.  to be u t i l i z e d  That i s , the u n d e r l i n e d  to some n o t i o n s  portions  i n the above  successfully at a later  p o r t i o n s have an o r d e r  and t h a t i s t i e d  o f proper and improper accounts o f what t r a n s p i r e d be-  tween p h y s i c i a n and p a t i e n t .  I am t r e a t i n g these i n s t a n c e s  as r o u t i n e  153  accounts  of p r e v i o u s c o n t a c t s which p a r t i c i p a n t s to c h a r t rounds use  to d e c i d e a p a t i e n t ' s reason f o r a v i s i t . Such accounts, however, can b e p p r o b l e m a t i c a l and  commented upon.  There are r i g h t ways and wrong ways of d e s c r i b i n g what t r a n s p i r e d between p a t i e n t and p h y s i c i a n .  C o n s i d e r the  following:  36.  Doctor  And here's Mr.sr. Heather Moore who's fifty-one.  37.  M e d i c a l student  Yes and  38.  Doctor  Is her p r e s e n t i n g problem ah um Dr. Marsh hasn't l e a r n e d the t e r s e b r e v i t y of The C l i n i c yet? (Dr. Marsh i s a new p h y s i c i a n ) sometimes i t ' s a b i t ( d i f f i c u l t ) to know exactly (5.0 s e c . pause) pigmented a l l over i n c l u d i n g her ah ( )_ mucosa w i t h a normal b l o o d p r e s s u r e  39.  Medical  215. sec.  student  Doctor pause  Still  216.  Judy  217.  Doctor  I t h i n k her p r e s e n t i n g problem was amenorrhoea  r  Irene Coombs, s t i l l on m e l o r a l (11.0 sec. pause) L o t of s o c i a l s t u f f (7.0 on mesec,?.lpause) S t i l l on m e l o r a l , she's b a b y s i t t i n g a t home on m e l o r a l same dose, more m e l o r a l same dose ( ) (present m e d i c a t i o n ) A s i d e from the f a c t t h a t she's bored and does some o c c a s i o n a l b a b y s i t t i n g from time to time I haven't found out why she got on m e l o r a l . Do you know M r s i Irene Coombs, Judy?  (the Nurse) ~  I remember her ah Doctor Marsh I saw her  She's a s c h i z o p h r e n i c W e l l now  t h a t ' s the reason th2re_ we  The above instances, i l l u s t r a t e h o w , ^ d e s c r i b i n g  are-• •  what took p l a c e be-  tween p h y s i c i a n and p a t i e n t i s t i e d to c e r t a i n o r g a n i z a t i o n a l concerns  154  of what an adequate d e s c r i p t i o n would e n t a i l . we may d e c i d e t h a t such a d e s c r i p t i o n should  From these two i n s t a n c e s , be brief,- d e s c r i b e the  p a t i e n t s problem, and account f o r c e r t a i n treatment p r o c e d u r e s , e.g., the a d m i n i s t r a t i o n o f d r u g s .  How then do t h e u n d e r l i n e d  portions of  our d a t a c o n s t i t u t e adequate d e s c r i p t i o n s u s a b l e f o r d e c i d i n g a p a t i e n t ' reason f o r a v i s i t ? tion.  To g e t a t t h i s , I w i l l p r e s e n t  one f u r t h e r  illustra  I t i s an i n s t a n c e where the p h y s i c i a n makesea m i s t a k e i n r e a d i n g  the c h a r t .  From t h i s m i s t a k e , we may g a i n i n s i g h t i n t o the o r g a n i z a t i o n  of our d a t a . 346.  Doctor  Mrs. C h i l d , f e e l s much b e t t e r coughs much b e t t e r . Pardon me, f e e l s w e l l cough much b e t t e r . Her pneumonia's cured, treatment n i l  347.  Doctor-B. Mary was s e e i n g her  We may b e g i n by n o t i n g  t h a t the e r r o r made by the Doctor i n U346  i s an e r r o r i n sequencing, i . e . , the f i r s t u n d e r l i n e d provide  an adequate a c c o u n t .  f o r " f e e l s much b e t t e r " . and  provides  a correction.  The "coughs much b e t t e r " d e n i e s the ground  The d o c t o r  recognizes  He reads i t a g a i n ,  r e c t l y what was w r i t t e n i n t h e c h a r t : where "cough much b e t t e r " p r o v i d e s The  p o r t i o n does n o t  t h i s e r r o r i n sequencing t h i s time, he reads  cor-  " f e e l s w e l l cough much b e t t e r "  grounds f o r " f e e l s w e l l " .  i s s u e o f sequencing and record-making has been d i s c u s s e d by  Raffel. The g e n e r a l problem f o r members i s t o g e t some sequence t o a s e t o f s e n t e n c e s . To sequence i s one aspect o f making a r e c o r d as a f a c t u a l account of what happened. To sequence i n c e r t a i n ways would be t o c a l l i n t o q u e s t i o n t h e f a e t u a l i t y o f the account...^ Examining the sequencing o f the u n d e r l i n e d  p o r t i o n s o f our d a t a , what  155  would be the consequences of reordering, e.g., the underlined p o r t i o n of U68 to "return i n one week condyloma podophyllin".  One p o s s i b i l i t y  i s that the patient i s returning to the C l i n i c f o r determining  whether  or not she has condyloma and, i f she does, the treatment i s podophyllin. Such an account would s t i l l leave i n question what i n f a c t transpired between the patient and physician at the time the entry was made i n t o the chart.  Why couldn't she be examined and treated then?  The "return  i n one week" provides f o r the f a c t that the i l l n e s s and accompanying treatment account f o r her reason f o r a next v i s i t .  The patient i s made  out to be a medical case, r e q u i r i n g v i s i t s u n t i l the course of treatment i s over and she no longer s u f f e r s from the i l l n e s s . The f i r s t part of U131, "wishes I.U.D.", establishes that the patient did not i n f a c t receive an I.U.D. on her l a s t encounter. "Wishes" establishes that the request was not f u l f i l l e d on the l a s t encounter and c o n s t i t u t e s the grounds f o r t h i s current encounter.  Compare t h i s to, e.g.,  "wished I.U.D. period f i n i s h e d to go take p i l l and return when she's menstruating" where 'wished' would then provide the p o s s i b i l i t y that the patient had since changed her mind.  The patient wanted an I.U.D. and  s t i l l wants one. I.U.D.s are u s u a l l y inserted when the patient i s menstruating.  That the patient was i n s t r u c t e d to return "when she's  menstruating", must be read that she i s r e t u r n i n g , not because she i s menstruating, but f o r an I.U.D. to be- i n s e r t e d . portion of U131 were i t reorganized  Consider the underlined  i n the f o l l o w i n g way:  "period  f i n i s h e d to go take p i l l and return when she's menstruating wishes I.U.D."  Such a reordering provides the p o s s i b i l i t y that she i s coming,  156  not f o r an I.U.D. i n s e r t i o n , but f o r an examination to determine i f such an i n s e r t i o n i s p o s s i b l e . 2.  Consulting the o r g a n i z a t i o n a l p o l i c y of the C l i n i c .  C l i n i c ' s p o l i c y requires e.g., the c e r v i x ) be administered  The  that a Pap Test (a t e s t f o r cancer of  to women who want b i r t h c o n t r o l p i l l s .  A p a t i e n t unable to have the t e s t on a given day can schedule an appointment to r e t u r n a t a l a t e r date.  When the p a t i e n t ' s chart i s reviewed,  t h i s p o l i c y can be u t i l i z e d i n constructing the reason f o r the v i s i t . Consider the f o l l o w i n g : 187.  Doc. A  Charlen Pinch ah wants b i r t h c o n t r o l p i l l , EhliTsI was i n December, ah taking a n t i anxiety p i l l s when she cannot sleep, one p i l l every two nights approximately. She must be ah yeah she's a Youth night program  188.  Doc. B  Umm hum  189.  Doc. A  Given one month supply of b i r t h c o n t r o l p i l l s and t o l d to r e t u r n w i t h i n a month for a Pap so I guess she's i n f o r p i l l s  The p a t i e n t wants b i r t h c o n t r o l p i l l s and she has to go through a Pap Test i n order to get them. The Pap i s an o r g a n i z a t i o n a l p o l i c y of f • Test i n order to get themPapTie Eapoisaanzorganizat-i!onal p o l i c y atUthe r  C l i n i c while her own reason f o r coming to the C l i n i c , however, i s not for a Pap Test, but f o r p i l l s . That s t a f f can decide on a p a t i e n t ' s reasons f o r v i s i t i n g the C l i n i c i s an e s s e n t i a l feature of chart rounds. run contrary to layanotions of medical p r a c t i c e . be formulated  as, e.g.,  Chart rounds, I suggest, Such a notion might  "the physician should always expect the worst  when seeing a p a t i e n t ( i . e . , be f u l l y a t t e n t i v e f o r any p o s s i b l e manif e s t a t i o n s of disease.)"  Contrary to t h i s l a y conception,  physicians  157  f i n d t y p i c a l courses of a c t i o n that can account f o r the patient scheduling a v i s i t to the C l i n i c .  They do not t y p i c a l l y view the v i s i t  as an open f i e l d of contingencies.  Rather, once a reason f o r a v i s i t  :  i s found, i t i s treated o r g a n i z a t i o n a l l y u n t i l or unless f u r t h e r n o t i c e should prove i t wrong as the reason f o r the patient's v i s i t .  The medical  h i s t o r y of the patient i s held i n e q u i l i b r i u m with reference to the o r g a n i z a t i o n a l concern f o r the patient's presence at the C l i n i c . This suggests then, that physicians emerge from chart rounds with a p r o v i s i o n a l o r i e n t a t i o n to the problems of the day's incoming p a t i e n t s . Of course, t h i s i s not to say that these p r o v i s i o n a l o r i e n t a t i o n s are not f u l l y r e t r a c t a b l e or that, upon encountering p a t i e n t s , physicians do not b r i n g t h e i r f u l l medical s k i l l s and a t t e n t i o n to bear. Conclusion '  ^  Conclusion  This chapter has attempted to present a d e t a i l e d a n a l y s i s of the occ a t i o n of chart rounds.  I have proposed that t h i s occasion i s one designed  for and accomplished by t a l k by c l i n i c members. I have discussed some of the a c t i v i t i e s that are accomplished through t a l k and have discovered  some  of the s e l f - o r g a n i z i n g features of t h i s occasion v i a an a n a l y s i s of transc r i p t i o n s of a c t u a l meetings.  I have dealt with the progression  problem,  the reason f o r a patient's v i s i t , the adequacy of p a t i e n t names, and other matters r e l a t e d to the o v e r a l l organiza£t±cuva>l!. structure of conversations. Without claiming that t h i s i s a l l that there i s to f i n d or that I have produced an exhaustive a n a l y s i s of chart rounds, the f i n d i n g s presented i n t h i s chapter stand as ethnographic f i n d i n g s , responsive to our concern for maintaining  the i n t e g r i t y of the occasion while responding to i t s s e l f -  158  organizing features. Over the course of producing t h i s a n a l y s i s of chart rounds, i t has hopefully been evident that I have i n f a c t followed a "standard  ethno-  graphic format" i n s o f a r as I have made use of those i n i t i a l background materials provided i n an e a r l i e r s e c t i o n of t h i s report.  At the time  of t h e i r c o n s t r u c t i o n , however, I d i d not know that theywwould come to have t h i s kind of prospective value and i t can be assumed the reader d i d not see the s i g n i f i c a n c e of these materials e i t h e r .  This seems to be a  general feature of the construction of d e t a i l e d ethnographic d e s c r i p t i o n . We may also note that the i n t e r a c t i o n a l and conversational approach used here has allowed us to i l l u s t r a t e some of the s e l f - o r g a n i z i n g features of chart rounds.  Such a n a l y s i s , however, also works the other way round  f o r , by examining some of the data from chart rounds, we have discovered some generalizable features of i n t e r a c t i o n that operate across scenes and settings.  Thus, while engaging i n a d e s c r i p t i o n of chart rounds, the  a n a l y s i s pertains also to areas beyond the confines of the research s e t t i n g .  159  Footnotes:  Chapter  Three  1.  The u n p u b l i s h e d work o f Harvey Sacks must be mentioned as an o u t s t a n d i n g source of i n t e l l e c t u a l and r e s e a r c h s t i m u l a t i o n . Since much of h i s m a t e r i a l i s o n l y a v a i l a b l e i n a s e r i e s o f u n p u b l i s h e d , t r a n s c r i b e d l e c t u r e s g i v e n to h i s c l a s s e s a t the U n i v e r s i t y o f C a l i f o r n i a , I r v i n e , the r e a d e r s h o u l d note thatiLt o f t e n has a c h a t t y and c a s u a l c h a r a c t e r r a t h e r than t h a t o f m a t e r i a l submitted f o r publication. While the s t y l e o f these l e c t u r e m a t e r i a l s i s c a s u a l , the i d e a s put f o r t h a r e our main c o n c e r n . Rather than attempt to paraphrase or condense these r e f e r e n c e s I have chosen to p r e s e n t them as they a r e w i t h i n the l e c t u r e s . T h i s a l l o w s the r e a d e r t o see how c o n v e r s a t i o n a l m a t e r i a l s a r e u t i l i z e d i n the p r o d u c t i o n o f a conversational analysis.  2.  Harvey Sacks, u n p u b l i s h e d  3.  I b i d . , p.  4.  C e r t a i n s e t t i n g s and o c c a s i o n s p r o v i d e f o r the accomplishment o f " c o r e a c t i v i t i e s " and the t a l k t h a t o c c u r s w i t h i n these s e t t i n g s and o c c a s i o n s must be r e s p o n s i v e to t h e i r " c o r e a c t i v i t i e s " . This i s not to say t h a t the t a l k t h a t o c c u r s must o n l y be about the c o r e a c t i v i t y , but t h a t such t a l k cannot be absent w i t h o u t some r e - e v a l u a t i o n o f the c h a r a c t e r o f the o c c a s i o n . I t i s i n t h i s sense t h a t we can speak of " c o n s t r a i n t s " on t o p i c a l t a l k . For a more d e t a i l e d d i s c u s s i o n see Bruce K a t z , C o n v e r s a t i o n a l Resources o f Two-Person Psychotherapy, unpub. M.A. T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, Vancouver, 1971.  l e c t u r e no.  3, October  16,  1968,  p.  4.  20.  t f  5.  Harvey Sacks, u n p u b l i s h e d  lecture.  6.  P.F. Strawson, I n d i v i d u a l s : An Essay i n D e s c r i p t i v e M e t a p h y s i c s , (tton'donr.L aMetfiuenaand Company, 1969), > pp. 15-16.  7.  c f . Emanuel S c h e g l o f f , "Notes on a C o n v e r s a t i o n a l P r a c t i c e : Formulat i n g P l a c e " i n D a v i d Sudnow, e d i t o r , S t u d i e s i n S o c i a l I n t e r a c t i o n , (Hew York: The F r e e P r e s s , 1972),, pp. 82-83.  8.  Harvey Sacks, u n p u b l i s h e d  9.  Stan R a f f e l , "Notes on Time as a Method to Sequence Sentences'.', unp u b l i s h e d working paper, Domingez H i l l s C o l l e g e , C a l i f o r n i a , 1969, p. 2.  lecture, April  24,  1968,  p.  6.  160  CHAPTER FOUR  THE  RESEARCHER AND  THE  RESEARCH SETTING  Introduction Throughout t h i s r e p o r t we and  the procedures  was  addressed  one  have been concerned  with  c o u l d employ t o study i n t e r a c t i o n .  interaction Chapter  to some of the ways i n which a r e s e a r c h e r , h a v i n g  a c c e s s t o the C l i n i c ,  c o u l d a c t u a l l y do h i s a n a l y s i s .  be d e d i c a t e d to an examination and the r e s e a r c h s e t t i n g .  two  gained  This chapter  will  of the r e l a t i o n s h i p between the r e s e a r c h e r  S p e c i f i c a l l y , i t w i l l be concerned w i t h  those  f e a t u r e s which c o n f r o n t the r e s e a r c h e r i n the a c t u a l doing of f i e l d work. I t w i l l f o c u s upon some o f the c o n t i n g e n c i e s t h a t a f i e l d r e s e a r c h e r must d e a l w i t h i n and over the course of h i s work.  S i n c e much of these  t e r i a l s i s r e l a t e d to those i s s u e s d i s c u s s e d i n chapter two,  ma-  I would  like  to go over the major p o i n t s r a i s e d i n t h a t c h a p t e r . Chapter  two began w i t h a c o n s i d e r a t i o n of some of the ways i n which  a m e d i c a l s o c i o l o g i s t might conduc t (  I t was  suggested  r e s e a r c h i f g i v e n access to the  Clinic.  t h a t h i s approach would i n v o l v e a p r e d e c i d e d s e t of r e -  s e a r c h q u e s t i o n s and  t h a t the C l i n i c would s e r v e as the l o c u s from which  answers c o u l d be o b t a i n e d .  I argued  t h a t such an approach would n o t , i n -  deed, c o u l d not, r e s p e c t the i n t e g r i t y of the r e s e a r c h s e t t i n g .  I pointed  out t h a t the a c t u a l , ongoing b e h a v i o u r would be seen and used as d a t a sup-r p o r t i n g o r r e f u t i n g some r e s e a r c h h y p o t h e s i s .  T h i s f a c t alone would p r e -  c l u d e any r i g o r o u s m e t h o d o l o g i c a l c o n c e r n w i t h o r a t t e n t i o n to the members' p o i n t of view and/or w i t h the s e l f - o r g a n i z i n g f e a t u r e d of  the  Clinic.  :  161  Next, I c o n s i d e r e d t r a d i t i o n a l e t h n o g r a p h i c as a fundamental concern, affairs.  an a n a l y s i s of how  T h i s looked more p r o m i s i n g .  r e v e a l e d t h a t ethnographies p r o f e s s i o n a l concerns" —  d e s c r i p t i o n which  members o r g a n i z e t h e i r  However, a c l o s e r  o f t e n i n c o r p o r a t e what may  matters  daily  examination  be c a l l e d  "standard  such as k i n s h i p o r g a n i z a t i o n , r e l i g i o n  and magic, and p o l i t i c a l o r g a n i z a t i o n — cerns c o n s t r i c t ethnographers  has,  into their analyses.  i n much the same way  Such con-  as a r e s e a r c h h y p o t h e s i s  l i m i t s our m e d i c a l s o c i o l o g i s t f o r they tend to channel, observations, about daily l i f e  i n t o p r e c o n c e i v e d a b s t r a c t i o n s of s i n g u l a r l y  professional  interest. T h i s weakness was who  promulgated  new  approach,  of  n o t i c e d not o n l y by me  an a l t e r n a t i v e to s t a n d a r d ways of doing ethnography.  This  c a l l e d c o g n i t i v e anthropology, has as i t s f o c u s the p r o d u c t i o n  a d e s c r i p t i o n which "understands  behaviour."  but by those a n t h r o p o l o g i s t s  the o r g a n i z i n g p r i n c i p l e s u n d e r l y i n g  In t h i s r e s p e c t , i t i s concerned  not o n l y w i t h a s e t t i n g ' s  o r g a n i z a t i o n a l f e a t u r e s but w i t h m a i n t a i n i n g what I have c a l l e d g r i t y of the r e s e a r c h s e t t i n g as w e l l .  the  inte-  I t i s aimed a t a c u l t u r a l d e s c r i p -  t i o n which would a l l o w the r e a d e r to behave i n ways t h a t would be deemed c u l t u r a l l y a p p r o p r i a t e by members of the s t u d i e d c u l t u r e .  It criticized  t r a d i t i o n a l ethnography on the grounds t h a t the q u e s t i o n s t h a t i t asked and  thus .the answers t h a t i t o b t a i n e d were not r e s p o n s i v e to the o r g a n i -  z a t i o n of the c u l t u r e under o b s e r v a t i o n . f e r e n c e between.the two  Frake c h a r a c t e r i z e d t h i s  approaches i n the f o l l o w i n g manner:  The o n l y . e x i s t i n g f i e l d manual f o r ethnographers Notes and Queries on Anthropology p r e s e n t s a l i s t of q u e r i e s t h a t an i n v e s t i g a t o r can take to the  dif-  162  f i e l d , p r e s e n t to h i s i n f o r m a n t s , and thereby produce a set of r e s p o n s e s . His ethnographic r e c o r d , t h e n , i s a l i s t of q u e s t i o n s and answers. (The t r a d i t i o n i n modern a n t h r o p o l o g y , however, i s not to make such a r e c o r d p u b l i c but to p u b l i s h an essay about i t . ) The image of ethnography we ( c o g n i t i v e a n t h r o p o l o g i s t s ) have i n mind a l s o i n c l u d e s l i s t s o f q u e r i e s and r e s p o n s e s , but w i t h t h i s difference: both the q u e r i e s and t h e i r responses are to be d i s c o v e r e d i n the c u l t u r e o f the people being studied. The problem i s not s i m p l y to f i n d answers to q u e s t i o n s the ethnographer b r i n g s i n t o the f i e l d , but a l s o to f i n d q u e s t i o n s t h a t go w i t h the responses he observes a f t e r h i s a r r i v a l . - * While a t t e n d i n g  to the i n t e g r i t y  proach to ethnographic able  to s p e c i f y  viour,  o f s e t t i n g s and o c c a s i o n s  d e s c r i p t i o n has a l s o advocated  "the grammar of a c u l t u r e . "  the g o a l o f c o g n i t i v e  l i n g u i s t who f a c e s  anthropology  is  the task o f c o n s t r u c t i n g  t h i s new a p -  the g o a l of  Rather than p r e d i c t somewhat  l i k e that  the grammar o f a  being beha-  of  the  language:  The aims o f ethnography, t h e n , d i f f e r from those of s t i m u l u s - r e s p o n s e psychology i n at l e a s t two respects. F i r s t i t . i s n o t , I t h i n k , the e t h n o g r a p h e r ' s task to p r e d i c t behaviour per s e , but r a t h e r to s t a t e r u l e s of c u l t u r a l l y a p p r o p r i a t e b e h a v i o u r . In t h i s r e s p e c t the ethnographer i s a g a i n a k i n to the l i n g u i s t who does not attempt to p r e d i c t what people w i l l say but to s t a t e r u l e s f o r c o n s t r u c t i n g u t t e r a n c e s which n a t i v e speakers w i l l judge as grammatically a p p r o p r i a t e . The model of an e t h n o g r a p h i c statement i s n o t : " i f a person i s confronted w i t h s t i m u l u s X, he w i l l do Y , " b u t : " i f a person i s i n s i t u a t i o n X, performance Y w i l l be judged ap-p r o p r i a t e by n a t i v e a c t o r s . " The second d i f f e r e n c e i s t h a t the ethnographer seeks to d i s c o v e r , not p r e s c r i b e , the s i g n i f i c a n t s t i m u l i i n the s u b j e c t ' s world. He attempts to d e s c r i b e each a c t i n terms of the c u l t u r a l s i t u a t i o n s which a p p r o p r i a t e l y evoke i t and each s i t u a t i o n i n terms of the a c t s i t a p p r o p r i a t e l y evokes.^ The g o a l of c o g n i t i v e  anthropology  is  itself  commendable,  i t was p o i n t e d out that no d e s c r i p t i o n c o u l d p o s s i b l y to a c t  i n an ongoing c u l t u r a l l y a p p r o p r i a t e way.  a l l o w the  The b a s i s  for  however, reader this  163  c r i t i c i s m d e r i v e s from the i n e s c a p a b l e first,  t h a t the r e s e a r c h e r  r e l y upon h i s own  s o c i a l s t r u c t u r e s when producing that readers description.  use  t h e i r own  f a c t t h a t any  description requires  common sense knowledge of  a d e s c r i p t i o n of a s o c i e t y and,  common sense to i n t e r p r e t the  second,  researcher's  Thereby, a d e s c r i p t i o n t h a t would s a t i s f y the g o a l s  of  c o g n i t i v e a n t h r o p o l o g i s t s would r e q u i r e the ethnographer to g i v e more d e t a i l than would be c o n t a i n e d d e s c r i p t i o n i s generated. of producing The  An  i n any  s e t t i n g or domain from which  example may  help  to c l a r i f y t h i s  a n a l y s i s of c h a r t rounds i s not i n t e n d e d  d e s c r i p t i o n t h a t would enable anyone r e a d i n g p r o p r i a t e ways.  i t to a c t i n c u l t u r a l l y  To  transform  a n a l y s i s of c h a r t rounds i n t o an a n a l y s i s t h a t s a t i s f i e s c o g n i t i v e anthropology  the  to  ap-  the  previous  the g o a l of  would n e c e s s i t a t e t h a t 1 i n f o r m the reader  f e a t u r e s of the o c c a s i o n .  t e l l him  as a  Rather, i t i s a d e s c r i p t i o n t h a t i s r e s p o n s i v e  s e l f - o r g a n i z i n g f e a t u r e s of t h i s o c c a s i o n .  to  feature  descriptions.  previous  many o t h e r  the  about  For example, I would be o b l i g e d  t h a t the s t a f f are u s u a l l y seated d u r i n g the  occasion,  t h a t i t i s p e r m i s s i b l e to smoke, t h a t i t would be i n a p p r o p r i a t e to "make"'faces"i and  so on and  so f o r t h . .  I t i s apparent t h a t a v i r t u a l l y  i n f i n i t e number of items c o u l d be added to t h i s or indeed tion.  That i s , as G a r f i n k e l has p o i n t e d out,  to any  descrip-  the i n h e r e n t problem f o r  any  such d e s c r i p t i o n i s the problem>iof(fcKemecessary appendage of an e t c e t e r a 3 clause. to  For, as a p r a c t i c a l matter of f a c t or procedure, i t i s  c i t e a l l of those  t h i n g s t h a t any  impossible  reader would need to know i n o r d e r  be a b l e to a c t i n a c u l t u r a l l y a p p r o p r i a t e manner.  to  164  I t can be assumed t h a t no one  t r e a t s c o g n i t i v e anthropology  d i s c i p l i n e which should or even c o u l d a c h i e v e not a d v o c a t i n g arduous and  complicated  than may  t h a t a d e s c r i p t i o n be r e s p o n s i v e to a c t i n and  first  seem to be  to a c h i e v e  I  am  the case and,  such a g o a l .  finally,  To  require  to " e v e r y t h i n g one would need to know  to be seen as someone who  a p p r o p r i a t e ways" i s to ask f o r the i m p o s s i b l e describe that  goal.  a  a c o n t r a r y p o s i t i o n , but n o t i n g t h a t the g o a l i s more  that i t i s pragmatically impossible  i n order  i t s expressed  as  i s acting i n culturally  f o r i t i s impossible  to  "everything".  This synopsis  of chapter  twoiiillustrates that c o g n i t i v e  anthro-  p o l o g i s t s have proposed a c e r t a i n r e s e a r c h g o a l towards Which t h e i r c u l t u r a l d e s c r i p t i o n s are o r i e n t e d . has,  similarly,  s e t t i n g and  some c o n c e p t i o n  The  s o c i a l s c i e n t i s t i n the  of h i s r e l a t i o n s h i p to the  field  research  the ends towards which h i s d e s c r i p t i o n s a r e d i r e c t e d .  Where-  as c o g n i t i v e a n t h r o p o l o g i s t s s p e c i f y the g o a l s or i d e a l s towards which t h e i r s t u d i e s are d i r e c t e d , s o c i o l o g i c a l l i t e r a t u r e o f t e n attempts to g i v e a d v i c e and/or d e t a i l e d i n s t r u c t i o n s about c e r t a i n ways i n which r e c o g n i z a b l y good s o c i a l e t h n o g r a p h i e s are to be accomplished.  For  4  i n s t a n c e , t h e r e i s much l i t e r a t u r e researcher  can and  e x p l i c a t i n g the r o l e s t h a t  should p l a y w h i l e  In g e n e r a l , such l i t e r a t u r e a t t e n d s make h i m s e l f m i n i m a l l y  s t u d y i n g a community or an o r g a n i z a t i o n . to the i d e a t h a t the r e s e a r c h e r  d i s r u p t i v e and  thereby  terms of the a c t u a l c o l l e c t i o n of d a t a . s e l f with v  " setting.  the  An  should  be maximally p r o d u c t i v e  in  e n t i r e l i t e r a t u r e concerns i t -  the problems a f f o r d e d the r e s e a r c h e r by h i s r o l e i n the  research  I t c o u l d not be reviewed here.  part  However, a c o n s i d e r a b l e  165  attempts to p r o v i d e the a n a l y s t w i t h i n s t r u c t i o n s on how to a c t competently w h i l e i n the r e s e a r c h  setting.  I t i s somewhat i r o n i c t h a t , on the one hand, c o g n i t i v e a n t h r o p o l o g i s t s s p e c i f y a g o a l which t h e i r d e s c r i p t i o n s s h o u l d a t t a i n to but p r o v i d e no l i t e r a t u r e o u t l i n i n g be a c h i e v e d .  the way o r ways i n which t h i s g o a l i s to  While, on the o t h e r hand, we have s o c i o l o g i c a l  manuals which attempt to i n s t r u c t  field  the s o c i a l r e s e a r c h e r i n a p p r o p r i a t e  f i e l d methods but espouse no f i x e d g o a l which he s h o u l d attempt to achieve.  I n sum, w h i l e c o g n i t i v e anthropology  has i g n o r e d the p o s s i b i l i t y  (or i m p o s s i b i l i t y ) o f a c h i e v i n g i t s proposed g o a l , s o c i o l o g i s t s have no proposed g o a l but have made the a c t u a l doing o f f i e l d work i n t o a method o l o g i c a l problem. The  a d v i c e o f f e r e d i n s o c i o l o g i c a l f i e l d manuals i s by and l a r g e  of a k i n d t h a t c o u l d be r e a d i l y c h a r a c t e r i z e d as "boy s c o u t " a d v i c e . The  r e s e a r c h e r i s i n s t r u c t e d to be " t a c t f u l " ,  a r o l e " , and so f o r t h . but  I t i s n o t t h a t such a d v i c e cannot be f o l l o w e d  t h a t i t does n o t t e l l  the manner p r e s c r i b e d .  "non-disruptive","adopt  the r e s e a r c h e r i n the s e t t i n g how to a c t i n  I n s t e a d , every  i n d i v i d u a l i n every  particular  r e s e a r c h s e t t i n g i s r e q u i r e d to make p r a c t i c a l r e s e a r c h d e c i s i o n s f o r the purposes a t hand so as to f o l l o w such a d v i c e . what w i l l o r w i l l n o t c o n s t i t u t e b e i n g  By t h i s , I mean t h a t  " t a c t f u l , " "non-disruptive" or  whatever w i l l have to be d e c i d e d w i t h i n an a c t u a l i n t e r a c t i o n a l  context.  F i e l d methods t e x t s tend to i g n o r e t h e i n t e r a c t i o n a l context o f the r e s e a r c h e r and the r e s e a r c h s e t t i n g and to p r e s e n t  t h e i r readers with a  s e t of vacuous i n s t r u c t i o n s t h a t have t o be transformed  into  practical  166  accomplishments i n the f i e l d s i t u a t i o n .  While the goal of c o g n i t i v e  anthropology i s as a p r a c t i c a l matter of f a c t unobtainable, the i n s t r u c tions o f f e r e d by research manuals are of a p r o b l e m a t i c a l l y empty character.  Admittedly, the advice that they o f f e r to f i e l d researchers i s ,  i n some sense, demonstrably  good advice, however, the manner i n which  that advice i s to be implemented by the researcher i n the research s e t t i n g i s never i t s e l f a topic f o r examination; thence, the vacuous character of f i e l d research manuals. Neither the proponents of c o g n i t i v e anthropology nor those w i t h f i e l d work methodology have provided us w i t h a thoroughgoing  concerned account  of how the members of p a r t i c u l a r research s e t t i n g s manage the p r o p e r t i e s of a s e t t i n g (including the presence of the researcher). Nor have they studied the ways i n which the researcher manages h i s f i e l d i n the s e t t i n g .  experiences  In.the f o l l o w i n g pages, i t i s my i n t e n t i o n to examine  t h i s r e l a t i o n s h i p between the analyst and the research s e t t i n g by cons i d e r i n g my own research experiences at the C l i n i c .  Instead of t r e a t i n g  my presence i n the f i e l d as an e s s e n t i a l l y methodological problem, I s h a l l look at some of the ways i n which i t must be regarded as a necessary part of the d e s c r i p t i o n of the C l i n i c . The S o c i o l o g i s t as C u l t u r a l Stranger S o c i o l o g i c a l f i e l d work manuals t y p i c a l l y attempt to deny the s o c i o l o g i s t the b e n e f i t of h i s own c u l t u r a l e x p e r t i s e . By t h i s , I mean that he i s often treated as an " i n t e r a c t i o n a l buffoon" who has to be i n s t r u c t e d i n such things as the proper ways of entering a research s e t t i n g , i d e n t i t y management, r o l e , p l a y i n g , and r o l e s e l e c t i o n .  I t seems odd that  167  the adult layman going to a new setting should  require  a  manual of  instructions on how to be inoffensive, unobstrusive, and/or non-disruptive."'  Furthermore,  the very act of giving such instructions could  be seen as an implication that the author, the reader or both regard the person seeking i n s t r u c t i o n as s o c i a l l y incompetent.  Be that as i t  may, concerns about methodological p r o p r i e t i e s occupy a central focus i n the l i t e r a t u r e of f i e l d research.  These very methodological issues  have seemingly denied the s o c i o l o g i s t that which he ( i n essential contrast to the anthropologist) has i n common with the people and society he i s investigating, that i s , h i s own c u l t u r a l f i d e member of the society he i s studying.  competence as a bona-  Instead, he i s cast i n the  role of a c u l t u r a l stranger. There i s something i n t r i n s i c a l l y strange about the assumption that we should instruct a s o c i o l o g i s t i n proper procedures f o r the doing of f i e l d research.  If the s o c i o l o g i s t i s denied h i s c u l t u r a l competence  and regarded instead as a stranger to a setting, whatever instructions he may be provided with w i l l not show him to behave i n appropriate ways since, paradoxically, this very set of instructions trade upon the assumption that he i s a competent c u l t u r a l member i n order to deny that he has this competence.  Rather than treat him as a stranger, we should attempt to  explicate the relationship obtaining between s o c i o l o g i c a l topics and our resources f o r the investigation of those topics.  Thus, Turner has stated  that: It i s increasingly recognized as an issue f o r sociology that the equipment that enables the ordinary member of the society to make h i s d a i l y way through  168  the world i s the equipment a v a i l a b l e f o r those who would wish to do a "science" of that world....'' F i e l d work methodology t r e a t s everyday features of i n t e r a c t i o n — entering a new s i t u a t i o n , being i n o f f e n s i v e , being t a c t f u l , e t c . ,  —  as a s u i t a b l e t o p i c f o r i n v e s t i g a t i o n by i n c o r p o r a t i n g i n t o i t s prop o s i t i o n s our own common-sense knowledge of how these methodological problems are ;resolved on an i n t e r a c t i o n a l basis without every making the researcher's c u l t u r a l competence i t s e l f a t o p i c of s o c i o l o g i c a l inquiry.  Often a f t e r tedious discussions of r o l e s e l e c t i o n , p a r t i c i -  pant observation and research strategy the f i e l d researcher  encounters  what I c a l l the "et cetera clause of f i e l d work methodology."  An ex-  ample of t h i s et cetera clause i s found i n Junker's c l a s s i c on f i e l d work: I t i s not p o s s i b l e to s p e c i f y the combinations and conditions and thence to w r i t e p r e s c r i p t i o n s f o r r o l e choices to match s o c i a l science problems, i f only because f i e l d workers vary so g r e a t l y i n respect to i d e n t i t y and s e l f that each must l e a r n to solve these problems as they crop up. Moreover, the a b i l i t y to f i n d such s o l u t i o n s and to r e j e c t impossible f i e l d work tasks doubtless develops as each f i e l d worker learns more about s e l f and the repertory of r o l e s p o s s i b l e and g even most congenial f o r him, given who i s i s . A f t e r any d i s c u s s i o n about the methodological problems which are said to confront the f i e l d worker, h i s "ultimate s t r a t e g y " b o i l s down to the i n escapable f a c t that he can make use of h i s everyday common sense about how to act i n or react to any new strange or problematic s i t u a t i o n which he may meet w i t h i n the course of h i s work.  Therefore, while such  methodological discussions may be i n t e r e s t i n g , they seem to have l i t t l e r e l a t i v e u t i l i t y f o r persons doing s o c i a l  ethnographies.  169  Let us now turn our a t t e n t i o n to an examination of some of the everyday contingencies which are part and p a r c e l of any research. research i s regarded as a p r a c t i c a l accomplishment.  Field  In order to under-  take an adequate i n v e s t i g a t i o n of some of i t s p r o p e r t i e s , i t seems app r o p r i a t e that we examine a c t u a l instances of data from f i e l d s i t u a t i o n s . Many of my experiences at the C l i n i c have been preserved on audio tapes. I t i s my i n t e n t i o n to examine my tape recordings and f i e l d notes i n order to e x p l i c a t e some of the contingencies that may confront one i n the f i e l d . I w i l l consider three s p e c i f i c aspects of my f i e l d research at the C l i n i c : (1)  p a r t i c i p a n t or non-participant observation; (2) the manner i n which  C l i n i c s t a f f i d e n t i f i e d me to p a t i e n t s during the course of various medical encounters; and (3) some e t h i c a l considerations r e v o l v i n g around the ways i n which I was i d e n t i f i e d to p a t i e n t s . On P a r t i c i p a n t - N o n - p a r t i c i p a n t Observation There i s a p r e v a i l i n g notion i n s o c i o l o g i c a l f i e l d work that the researcher has a choice about how he w i l l conduct himself once h i s presence, as a s o c i a l researcher, i s known to the c r e d e n t i a l e d members of the s e t t i n g .  He can e l e c t to be a p a r t i c i p a n t observer or a non-  p a r t i c i p a n t observer, or various combinations  and permutations  thereof.  While methodologists acknowledge that these two c h a r a c t e r i z a t i o n s are i d e a l types so that i t i s impossible f o r the s o c i o l o g i s t to be wholly one or the other, s o c i o l o g i c a l l i t e r a t u r e continues to p o s i t the d i s t i n c t i o n between the two as an issue of consequence f o r those engaged i n f i e l d research.  However, the d i s t i n c t i o n i s neither c o n s i s t e n t l y c l e a r nor  free from contradictions. research at the C l i n i c .  The following f i e l d note comes from my I t i s apparent that i t can not be easily  c l a s s i f i e d i n terms of participant or non-participant observation! I had just finished recording a medical interview when one of the physicians (Doctor X)c.asked me i f I had ever seen a cyst removed. I replied that I had not. Doctor X then gently pushed me into another examination room and told me that I should "Have a look". I found myself i n the presence of Doctor Y, a part-time physician who came to the C l i n i c every other week. He was preparing the patient for a minor surgical operation. Doctor Y was familiar to me and with my presence at the C l i n i c and I assumed that he knew I was a sociological researcher. I was not introduced to the patient. Doctor Y proceeded to remove the cyst. He asked me to hand him certain instruments from a nearby medical stand. I often did this when observing medical examinations since i t was a\yway of doing something that I thought might be helpful. Doctor Y then showed me the cyst which was located on the patient's stomach. He then made an incision into the cyst and i n serted a hemostat (a pair of blunt s c i s o r - l i k e prongs) into the .cut i n order to spread the patient's skin. Next he asked me to hold the hemostat (which was s t i l l inserted i n the cyst) while he proceeded to wipe the wound with cotton. He asked me to spread the skin a b i t more i n order to get a l l the pussout. I did as requested. After the procedure was over and the patient had l e f t the examination room I asked Doctor Y i f he knew that I was not a medical student. He said that he thought I was a medical student and that he wanted me to have a good look at the procedure. It appeared that the director of the C l i n i c had not informed Doctor Y about my research project and that he had assumed I was a medical student. Nothing was made out of this incident and, on subsequent occasions, Doctor Y would allow me g to observe his medical encounters with patients. This experience i s not merely some "cute example" of one of  171  those unusual or unexpected contingencies t y p i c a l l y encountered arid r e l a t e d by those who have done some f i e l d work.  Rather, i t i l l u s t r a t e s  how f i e l d researchers face c e r t a i n demand c h a r a c t e r i s t i c s by v i r t u e of the f a c t that they are accountable parts of an ongoing s e t t i n g .  By  demand c h a r a c t e r i s t i c s , I am r e f e r r i n g to what Turner has described as the " s i t u a t i o n a l and contextual features which persons ( i n t h i s instance f i e l d researchers) engaged i n everyday routines o r i e n t to as governing and organizing t h e i r activities.""'"^  Thus, rather than regard t h i s f i e l d  note as an i n d i c a t i o n of an instance when a researcher who was a nonp a r t i c i p a n t observer became a p a r t i c i p a n t observer, I would l i k e to examine some of the exigencies which i t so c l e a r l y i l l u s t r a t e s .  These  are an inescapable part of any.section of d a i l y l i f e , f i e l d work of course included and, because t h i s i s so, a thorough reconsideration of the u t i l i t y of the categories of p a r t i c i p a n t and non-participant observer may be i n order. I would l i k e to begin our i n q u i r y by noting that I came to view the operation on the cyst by chance rather than by any purposeful e f f o r t on my part.  Since I had t o l d the s t a f f of the C l i n i c that my  research was concerned with doctor-patient communication, I assume that theyivknew that the observation of the removal of a cyst would not f a c i l i t a t e my research.  At t h i s p o i n t , i t i s important that the  reader understand how my research i n t e r e s t s were formulated to and f o r members of the s t a f f .  For t h i s reason I would l i k e to present  the reader w i t h the research d e s c r i p t i o n that I had constructed f o r the C l i n i c .  I know that the aforementioned "Doctor X" had read the  172.  following research proposal p r i o r to the incident with the cyst: Research Proposal As a consequence of my interest i n basic communication processes and because I must s a t i s f y my thesis requirement for the Ph.D. degree i n the Department of Anthropology and Sociology, I have decided to focus on certain basic communication processes employed i n medical situations. It i s hoped that the outcome of the analysis w i l l prove to be of interest to physicians (although this may not be evident at the outset of the research). Medical practice i s not a mechanical operation i n which patients enter the doctor's o f f i c e , are examined and treated, and then depart. Rather, the talk that occurs between a doctor and a patient constitutes an e s s e n t i a l component for the e f f e c t i v e implementation of medical care. It i s this talk, a basic communicative process, which i s the proposed area of i n v e s t i g a t i o n . The medical consultation exemplifies the s i t u a t i o n of parties who have d i f ferent knowledge and d i f f e r e n t vocabularies for talking about matters that are of serious import to both of them. How i s "adequate" communication achieved under these conditions? More importantly, what constitutes adequate communication between such parties, given that they have d i f f e r e n t stakes i n the process and i t s outcome? While many forms of communication are operative i n face-to-face interactions (for example, verbal cues, gestures, and f a c i a l movements), the focus of my research i s on the talk which occurs i n i n t e r a c t i o n . The study takes as i t s fundamental p o s i t i o n that the talk which occurs i n various i n t e r a c t i o n a l situations (between a doctor and a patient) contributes to the s o c i a l organization of such s i t u a t i o n s . Talk i s much more than the common-sense notion of exchanging "packets" of information or messages; people, when engaging i n talk, also perform a c t i v i t i e s , and i t i s these conversational a c t i v i t i e s performed by both doctor and patient i n the course of their i n t e r a c t i o n s , which are my main concern. Thus I am not using a "Telephone Company" notion of communication but rather an i n t e r a c t i o n a l one. Doctors and patients interact with one another and such i n t e r a c t i o n i s s o c i a l l y  173 o r g a n i z e d v i a the t a l k t h a t o c c u r s between the p a r t i cipants. Hence I am h o t engaged i n e v a l u a t i n g d o c t o r performance. Rather i t can s a f e l y be assumed t h a t d o c t o r s have a c q u i r e d the competence w i t h which to t r e a t p a t i e n t s and, indeed, have l e a r n e d to t a l k l o n g b e f o r e becoming p h y s i c i a n s . However, the t a l k t h a t does o c c u r between d o c t o r and p a t i e n t has n o t been subj e c t e d to a n a l y s i s . I t i s my i n t e n t i o n to do t h i s . In o r d e r to a c c o m p l i s h t h i s t a s k , i n October of 1971 I began a study o f b a s i c communication p r o c e s s e s employed i n medical s e t t i n g s . The members o f the medical c e n t r e g e n e r o u s l y allowed me to e n t e r t h e i r domain and observe the o p e r a t i o n o f a m e d i c a l p r a c t i c e . At t h a t time my r e s e a r c h s t r a t e g y p r o v i d e d f o r a p e r i o d o f time to a c q u a i n t myself w i t h a new s e t t i n g and e q u a l l y to p r o v i d e time f o r the members o f the c e n t r e to a d j u s t to h a v i n g a s o c i o l o g i s t i n t h e i r midst. While such f a m i l i a r i t y w i t h a s e t t i n g i s an a s s e t , the study o f b a s i c communication p r o c e s s e s r e q u i r e s a c e r t a i n degree of p r e c i s i o n i n d a t a acquisition. I n s t u d y i n g t a l k as a communicative p r o c e s s , i t i s e s s e n t i a l to have a corpus o f p r e c i s e data from which to perform an a n a l y s i s . When i n d i v i d u a l s engage i n convers a t i o n , i t i s p o s s i b l e to make r e f e r e n c e to "what was s a i d i n a p r e v i o u s c o n v e r s a t i o n " w i t h o u t b e i n g a b l e to produce a v e r b a t i m account o f the e n t i r e i n t e r a c t i o n . Indeed, to spontaneously produce a l i t e r a l account o f what was s a i d would seem s t r a n g e . However, w h i l e the r e l i a n c e on one's memory f o r the r e p o r t i n g o f c o n v e r s a t i o n a l exchanges i s adequate f o r everyday encounters, such a procedure as a m e t h o d o l o g i c a l technique f o r s t u d y i n g c o n v e r s a t i o n i s h a r d l y a p p r o p r i a t e . The study o f the communicative p r o c e s s e s employed i n a complex i n t e r a c t i o n — as t h a t between d o c t o r and p a t i e n t — r e q u i r e s a d e t a i l e d r e c o r d o f what was s a i d . F o r t h i s reason I use t a p e - r e c o r d i n g s as my source o f data.-'- The procedure i s l o n g and time consuming. The r e s u l t , however, i s a corpus o f data t h a t c o n s t i t u t e s a w r i t t e n r e c o r d o f a c o n v e r s a t i o n a l encounter. I t i s from such r e c o r d s t h a t a study o f b a s i c communication p r o c e s s e s can proceed. S i n c e my concern i s w i t h the d o c t o r - p a t i e n t r e l a t i o n s h i p , i t would be advantageous to s e c u r e a corpus o f data c o n s i s t i n g of t r a n s c r i p t s o f r e c o r d e d d o c t o r patient interactions. Data would t h e r e f o r e be  Due to the c o n f i d e n t i a l n a t u r e o f the data r e q u i r e d , t h i s proposed r e s e a r c h has been c l e a r e d and approved by Dr. A. o f the Department of X and the E t h i c s Committee o f the F a c u l t y o f M e d i c i n e .  o b t a i n e d from those s i t u a t i o n s i n v o l v i n g m e d i c a l p e r s o n n e l i n t e r a c t i n g w i t h p a t i e n t s . T h i s would i n c l u d e data o b t a i n e d from m e d i c a l c o n s u l t a t i o n , d o c t o r - s t u d e n t i n t e r a c t i o n s , Youth Night C l i n i c i n t e r a c t i o n s between d o c t o r s , s t u d e n t s , and p a t i e n t s , as w e l l as d o c t o r - p a t i e n t i n t e r a c t i o n s of the day-time p r a c t i c e . I t i s hoped t h a t such a broad f o c u s w i l l a l s o e l a b o r a t e the mechanisms whereby m e d i c a l d i a g n o s i s i s accomplished. I t should be made c l e a r a t t h i s time t h a t I am n o t engaged i n an e v a l u a t i v e study o f the m e d i c a l c e n t r e . The c e n t r e p r o v i d e s a s e t t i n g from which the data may be o b t a i n e d . I am extremely g r a t e f u l and express my thanks to the members o f  In o r d e r to f a c i l i t a t e the a c q u i s i t i o n o f d a t a , Dr. Tough asked t h a t I p r e s e n t an i n v e n t o r y o f the q u a n t i t y and type o f m e d i c a l i n t e r a c t i o n s t h a t I w i s h to examine. The f o l l o w i n g l i s t w i l l s e r v e as a g u i d e l i n e w i t h r e f e r e n c e to t h e a c q u i s i t i o n of d a t a : 1.  30 m e d i c a l i n t e r a c t i o n s between a m e d i c a l student and a p a t i e n t i n which a p a t i e n t ' s m e d i c a l h i s t o r y i s obtained. These m a t e r i a l s would be o b t a i n e d from the Youth Night C l i n i c , and w i l l prove u s e f u l when I compare them t o those i n t e r a c t i o n s i n which a d o c t o r e l i c i t s a p a t i e n t ' s medical h i s t o r y .  2.  25 i n t e r v i e w s between d o c t o r and p a t i e n t . These i n t e r v i e w s s h o u l d be both the p a t i e n t ' s and the p h y s i c i a n ' s i n i t i a l c o n t a c t w i t h each o t h e r . I t i s i n the i n i t i a l encounter between p a t i e n t and p h y s i c i a n t h a t one may expect to f i n d problems i n communication. F o r example, d i f ferefierentavaeabu'laries o f language use. Such interviews are of considerable t h e o r e t i c a l interest. 3.  40 i n t e r v i e w s between d o c t o r and p a t i e n t o b t a i n e d from the day-time o f f i c e p r a c t i c e . These w i l l p r o v i d e a comparison w i t h those i n t e r v i e w s conducted d u r i n g the Youth Night C l i n i c .  4.  40 i n t e r v i e w s between m e d i c a l teams i n t e r a c t i n g w i t h p a t i e n t s . These i n t e r v i e w s w i l l be o b t a i n e d  175  from the Youth Night C l i n i c and w i l l provide the comparison set of interviews to those obtained from the day-time p r a c t i c e . Admittedly my research c o n s t i t u t e s a new area of i n v e s t i g a t i o n and, from a s o c i o l o g i c a l perspective, a departure from a t r a d i t i o n a l s o c i o l o g i c a l approach. While the research i s exploratory, i t i s acceptable to my Ph.D. Committee. I am sure that my supervisor, Dr. Roy Turner of the Department of Anthropology and Sociology would be happy to attempt to answer any questions you might have concerning the proposed research. In presenting t h i s research proposal, I hope to accomplish three things:  F i r s t , i t allows the reader to see what I , as a s o c i o l o g i s t  i n the f i e l d s i t u a t i o n , t o l d C l i n i c s t a f f about my research.  (This i n -  formation i s seldom o f f e r e d to the reader of a research report.) Second, i t allows the reader to understand what I meant by the "demand c h a r a c t e r i s t i c s " faced by the f i e l d researcher i n a f i e l d s i t u a t i o n . This research proposal was produced at the request of the C l i n i c ' s director.  I t s contents are d i r e c t e d s p e c i f i c a l l y at s a t i s f y i n g h i s  request f o r a research proposal that would s p e c i f y both the character of my research and the type and quantity of tape recorded medical i n t e r a c t i o n s that I required.  As such i t represents a s i t u a t i o n a l l y  constructed account of my proposed research at the C l i n i c rather than a formal "academic" research proposal.  Thus, f o r example, the numbers  of medical interviews that I requested were not generated out of any " s c i e n t i f i c " concerns with having a representative sample of medical i n t e r a c t i o n s , but were generatedr s o l e l y out of my abiding concern with being allowed to remain i n the research s e t t i n g f o r an extended period of time.  I t was thought that, by s p e c i f y i n g a large number of  176  medical  i n t e r a c t i o n s , i t would be p o s s i b l e to o b t a i n s u s t a i n e d  access  to the C l i n i c f o r a l o n g e r p e r i o d than i f t h e q u a n t i t y o f m e d i c a l views was o f a l e s s e r number. not have a p r e c o n c e i v e d munication,  inter-  As s t a t e d e a r l i e r i n t h i s r e p o r t , I d i d  research hypothesis  about d o c t o r - p a t i e n t com-  but t h i s absence o f a s p e c i f i c r e s e a r c h h y p o t h e s i s and  r e s e a r c h methodology d i d n o t p r o h i b i t the c o n s t r u c t i o n o f a r e s e a r c h p r o p o s a l f o r the p r a c t i c a l purpose of s a t i s f y i n g members o f C l i n i c staff.  T h i r d , t h i s p r o p o s a l should a l l o w the r e a d e r  when Doctor  X ushered  to r e c o g n i z e  me i n t o an a l r e a d y ongoing m e d i c a l  he was n o t r e a l l y a s s i s t i n g me i n my r e s e a r c h .  that,  interaction,  Not o n l y was t h e r e no  time i n which to s e t up my tape r e c o r d e r , but I was a l s o e n t e r i n g an ongoing s i t u a t i o n without trance.  I n essence,  knowing what had o c c u r r e d p r i o r to my en-  I was b e i n g shown a m e d i c a l procedure r a t h e r  b e i n g a f f o r d e d w i t h an o p p o r t u n i t y to t a p e - r e c o r d a m e d i c a l  than  interaction.  O b j e c t i v e l y , watching the removal o f a c y s t d i d n o t c o n t r i b u t e to my understanding  o f d o c t o r - p a t i e n t communication.  However, I d i d not  i n d i c a t e t h a t I was not i n t e r e s t e d i n watching the removal o f a c y s t when Doctor  X i n d i c a t e d t h a t he would l i k e me to do so n o r d i d I o b j e c t  when he p l a c e d me i n an examination patient.  room w i t h another  That i s , I d i d n o t t e l l Doctor  p h y s i c i a n and a  X t h a t I was n o t p a r t i c u l a r l y  i n t e r e s t e d i n watching a c y s t removed o r t h a t I was s p e c i f i c a l l y i n t e r e s t e d i n t a p e - r e c o r d i n g i n t e r a c t i o n s r a t h e r than j u s t o b s e r v i n g My reason o r reasons not hard  to fathom.  f o r n o t r e s i s t i n g Doctor  As a r e s e a r c h e r i n the f i e l d ,  be p o l i t e towards C l i n i c s t a f f .  Regardless  them.  X's i n v i t a t i o n a r e I felt  that I should  of whether o r n o t Doctor  X  177  had a c o r r e c t u n d e r s t a n d i n g o f my r e s e a r c h p r o j e c t a f t e r having r e a d my research proposal, I f e l t  t h a t i f he thought I might be i n t e r e s t e d i n  s e e i n g a c y s t removed o r t h a t watching  t h i s m e d i c a l procedure would  b e n e f i t my r e s e a r c h i n some way, then i t was incumbent upon me to demonstrate  some i n t e r e s t i n t h i s o p e r a t i o n .  I t would n o t have been  courteous o r expedient to have thwarted any p o s s i b l e i n t e r e s t w h i c h Doctor X might  have i n me o r i n my r e s e a r c h by i n f o r m i n g him t h a t he  d i d n o t understand what i t was t h a t I was t r y i n g to do. have done t h i s might have had the r e s u l t m e d i c a l examinations.  Furthermore, to  t h a t I would n o t see any f u t u r e  While i t i s t r u e t h a t I was unable to r e c o r d t h i s  p a r t i c u l a r encounter, to g a i n l e g i t i m a t e a c c e s s to the examination room was,  i n t h i s p e r i o d o f the r e s e a r c h , a step forward f o r me.  Whatever  i t was t h a t m o t i v a t e d Doctor X to show me the " c y s t removal" i t was app a r e n t t h a t my t h e o r e t i c a l s o c i o l o g i c a l i n t e r e s t s were o f l i t t l e o r no concern to him. I t i s apparent t h a t the s u b j e c t s i n t h e s e t t i n g under i n v e s t i g a t i o n can have v a r i o u s views about project.  Instead of t r e a t i n g  the purposes  of the r e s e a r c h e r ' s  t h i s as a r e s u l t o f some f a i l u r e o r  r e l u c t a n c e on the p a r t o f the r e s e a r c h e r to p r o v i d e an adequate  portrayal  of h i s r e s e a r c h i n t e r e s t s , i t may be b e t t e r t i e d t o the f a c t t h a t members of the s e t t i n g can, and i n some sense n e c e s s a r i l y , o p e r a t e w i t h d i v e r s e and sometimes d i s c r e p a n t views o f "matters o f f a c t " i n c l u d i n g i d e a s about what the r e s e a r c h e r i s d o i n g .  Furthermore,  any attempt  to r e c t i f y  these d i s c r e p a n t c o n c e p t i o n s r e s u l t i n more i n t r i n s i c problems than tions .  solu-  178  Note t h a t n e i t h e r Doctor X nor Doctor Y f e l t in  t h a t my p r e s e n c e  the examination room was something t h a t r e q u i r e d  Further,  they saw no n e c e s s i t y  t h a t I be i n t r o d u c e d  further  explanation.  to the p a t i e n t .  Furthermore, I saw no need to o f f e r a s e l f - i n t r o d u c t i o n o r s e l f - i d e n t i fier.  I d i d not say, f o r example, " I am Bruce Katz the s o c i o l o g i s t , "  or " H i , I am Bruce Katz from U.B.C." duction f o r s e v e r a l reasons. s t a f f decided  I d i d n o t engage i n a s e l f - i n t r o -  However, i t i s important to note t h a t the  t h a t i t was the p h y s i c i a n who should  properly  introduce  me to the p a t i e n t . At  t h i s p o i n t , I would l i k e to make c l e a r t h a t I am r e p o r t i n g  n e i t h e r my p s y c h o l o g i c a l f e e l i n g s nor p s y c h o l o g i c a l m o t i v a t i o n s time of the o p e r a t i o n ;  a t the  r a t h e r I am p r o p o s i n g good o r g a n i z a t i o n a l o r  s t r u c t u r e d i n t e r a c t i o n a l reasons f o r n o t o f f e r i n g cany/ s e l f - i n t r o d u c tion.  These were my o v e r r i d i n g concerns on t h i s and o t h e r  occasions.  To have done a s e l f - i n t r o d u c t i o n on t h i s p a r t i c u l a r o c c a s i o n would not o n l y have been i n a p p r o p r i a t e ,  i t may have proved to be  d i v e r s e l y and i n t r i c a t e l y p r o b l e m a t i c ; a s w e l l . i n a s i t u a t i o n i n which a p a t i e n t was a l r e a d y and  I suddenly found myself on the examination t a b l e  about to have an i n c i s i o n made i n t o a c y s t on h i s stomach.  I did  not know whether t h e p a t i e n t would be w i l l i n g o r happy to have a s o c i o l o g i s t i n the examination room a t t h i s time.  F o r me to have c r e a t e d a  s i t u a t i o n i n which there was some p o s s i b i l i t y o f the p a t i e n t becoming upset seemed to be s t r i k i n g l y setting  inappropriate.  to f u r n i s h an i d e n t i t y f o r me.  Instead,  I a l l o w e d the  That i s , I presume t h a t t h e  p a t i e n t thought t h a t I was a m e d i c a l s t u d e n t .  The grounds t h a t I had  179  for  not engaging i n a s e l f - i n t r o d u c t i o n at t h i s time were based on my  concerns f o r (1) the p o s s i b i l i t y of a problematic s i t u a t i o n developing between p a t i e n t and p h y s i c i a n due to the f a c t that I was a s o c i o l o g i s t and not a medical student and, (2) the p o s s i b i l i t y of j e o p a r d i z i n g my own p o s i t i o n as a s o c i o l o g i c a l researcher w i t h i n the C l i n i c , and (3) my general concerns f o r the p a t i e n t . To have engaged i n a s e l f - i n t r o H l ' duction might have caused i n t e r a c t i o n a l problems f o r t h i s p a r t i c u l a r s i t u a t i o n and lead to f u r t h e r general conclusions about the problems created by the presence of a s o c i o l o g i s t .  Obviously, these must be  avoided. My r e c o g n i t i o n of the p o s s i b l e problems and repercussions that could have a r i s e n from a s e l f - i n t r o d u c t i o n d i d not o r i g i n a t e i n my having acquired any s p e c i a l s o c i o l o g i c a l competence gleaned from f i e l d research manuals.  My r a t i o n a l e f o r a c t i n g as I d i d was based on my own  common-sense notions of s i t u a t i o n a l p r o p r i e t i e s .  That i s , I was r e l y i n g  and was able to r e l y on everyday common-sense notions about "how the s o c i a l world operates" i n order to manage my r o l e i n t h i s and other situations. Although one could ask whether I was a p a r t i c i p a n t or n o n — p a r t i c i pant observer i n t h i s p a r t i c u l a r s i t u a t i o n , i t vfcss obvious that a "yes" or "no" answer to such a question would t e l l us l i t t l e which would be of use to a researcher i n a f i e l d s i t u a t i o n .  This i n c i d e n t i l l u s t r a t e s the  absurdity of the notion that we can e a s i l y define e i t h e r a p a r t i c i p a n t or a non-participant observer.  The r o l e of the f i e l d researcher, l i k e  that of any other members of the world of d a i l y l i f e , i s not something  18Q which admits  to any easy, f i x e d d e f i n i t i o n .  The range o f  interactional  c i r c u m s t a n c e s i n which he w i l l f i n d h i m s e l f d u r i n g the course o f h i s work admits  to no hard and f a s t c l a s s i f i c a t i o n .  i s o f t e n to l i m i t  the scope and n a t u r e o f h i s o p e r a t i o n s .  the r i c h c o n t e x t u a l f i e l d e r c i s e s may How,  To c a t e g o r i z e the r e s e a r c h e r  o f a l l o f our d a i l y a f f a i r s .  I t i s to i g n o r e  While  such  be i n t e r e s t i n g , , they o f t e n h i d e much more than they  f o r i n s t a n c e , c o u l d one  s e l f and Doctor Y?  Am  classify  I t h i s a t one  reveal.  the above i n t e r a c t i o n between time and  that at  or  i s so, any a b s t r a c t concern w i t h the r o l e o f the f i e l d r e s e a r c h s e t t i n g i s e m p i r i c a l l y empty.  Because  While i t i s p o s s i b l e to d i s c u s s  c o n n e c t i o n to the p r a c t i c a l and  such  discus-  common-sense s o l u -  r e s e a r c h e r must a t t e n d to when a c t u a l l y engaging  the d a i l y c o n t i n g e n c i e s of a r e s e a r c h e r i n a f i e l d S i n c e t h i s i s the case, ©he may. s t a r t  in  situation.  to view the m e t h o d o l o g i c a l  concerns w i t h the proper r o l e s e l e c t i o n as p r a g m a t i c a l l y u s e l e s s and t h e o r e t i c a l l y empty.  this  r e s e a r c h e r i n the  r o l e s e l e c t i o n proo'rjto cor a s i d e from the a c t u a l doing o f any  tions that a f i e l d  the  They cannot be p r e p a r e d f o r , accounted f o r ,  u l t i m a t e l y c o n s t r u c t e d p r i o r to t h e i r a c t u a l o c c u r r e n c e .  s i o n has v e r y l i t t l e  my-  another?  S i t u a t i o n s must be d e a l t w i t h on an ad hoc b a s i s i n and over c o u r s e o f t h e i r development.  ex-  C o n s i d e r the f o l l o w i n g f i e l d  note:  B e f o r e c h a r t rounds onetoftiMae s e c r e t a r i e s o r one of the nurses u s u a l l y makes c o f f e e . The c o f f e e machine i s one of those i n d u s t r i a l c o f f e e makers. A f t e r spending some time a t the C l i n i c , I s t a r t e d to make the morning c o f f e e i f I a r r i v e d a b i t b e f o r e rounds s t a r t e d . One day I j u s t made c o f f e e . No one o b j e c t e d to my doing so nor d i d they spec i f i c a l l y r e q u i r e t h a t I do so. I t j u s t happened. In the f u t u r e , I o f t e n made c o f f e e f o r C l i n i c s t a f f when I a r r i v e d f o r morning rounds.  181  A l t h o u g h a simple  and mundane f e a t u r e of my  t h i s p i e c e of data i l l u s t r a t e s practical,  two  field  experience,  s p e c i f i c f e a t u r e s , one  the o t h e r i s t h e o r e t i c a l .  First,  the f i e l d  of these i s  researcher i s  not g e n e r a l l y i n c o r p o r a t e d i n t o the d a i l y a c t i v i t i e s of the s o c i e t y t h a t he i s s t u d y i n g .  By  t h i s I mean t h a t , as a r e s e a r c h e r , one  not have a s p e c i f i c t a s k to p e r f o r m o t h e r at t h e i r work and  forming  However, t h i s i n i t s e l f  c e r t a i n opinions  than t h a t of o b s e r v i n g from these  others  observations.  can c r e a t e some v e r y p r a c t i c a l problems.  example, as a s o r t of t h i r d wheel a t the C l i n i c , n i z a t i o n a l space which I c o u l d c a l l my nurses,  does  own.  I d i d not have  For orga-  U n l i k e p h y s i c i a n s or  I d i d not have a desk or an o f f i c e where I c o u l d do any work  t h a t I had  to do.  I p u r p o s e f u l l y spent  a good d e a l of my  time a t  the  C l i n i c wandering around or s i t t i n g e i t h e r i n the l u n c h room or i n an empty examination room. amination fill  I tried  whenever I was  allowed  to be as h e l p f u l as p o s s i b l e .  t h i n g s t h a t L o f l a n d has  ex-  For example, I would  out l a b o r a t o r y i n f o r m a t i o n sheets, hand instruments  c i a n , take u r i n e specimens to the l a b o r a t o r y and to do  to view a m e d i c a l  to the p h y s i -  so f o r t h .  I attempted  d e s c r i b e d as an "exchange of s e r v i c e s " :  In terms of "exchange of s e r v i c e s " the pure o b s e r v e r r o l e i n v o l v e s a h i g h l y imbalanced r e l a t i o n to the p a r t i c i p a n t s . They l e t him watch, but he does n o t h i n g f o r them i n r e t u r n (except i n the most long-term and a b s t r a c t way, i n "doing s o c i a l s c i e n c e " ) . More immediate r e c i p r o c i t i e s are n e c e s s a r y . Indeed, i n a wide range of emergent c i r c u m s t a n c e s , i t w i l l seem h i g h l y p e c u l i a r i f the observer does not v o l u n t e e r h i s h e l p . . . p e o p l e need r i d e s , l o a n s , messages c a r r i e d , c o f f e e brought, a d v i c e , o p i n i o n s , defense, i l l e g a l goods h e l d , l i e s i n t h e i r b e h a l f , and so on, through the e n t i r e range of normal f r i e n d l y r e l a t i o n s  182  t y p i c a l to organized s o c i a l l i f e . The observer must n e c e s s a r i l y engage i n such things, unless he i s w i l l i n g to give o f f the impression of being a very odd, cold withdrawn f e l l o w , "indeed.H Lofland would regard performance of such a c t i v i t i e s as a feature which i s compatible with the pure observer r o l e .  He would point out  that the researcher must do such things as these to give the that he i s a r i g h t f e l l o w .  impression  In contrast to t h i s , my experience at the  C l i n i c taught me that such a c t i v i t i e s are not so much a component of the observer r o l e as a consequence of the f a c t that any party involved i n an ongoing s i t u a t i o n f o r a long period of time — any researcher i n a f i e l d s i t u a t i o n —  and t h i s includes  has to engage i n some a c t i v i t i e s  i n order to account f o r h i s continued presence i n the s e t t i n g .  The  performance of a c t i v i t i e s i s not connected s o l e l y to the observer  role,  but c o n s t i t u t e an e s s e n t i a l part of those demand c h a r a c t e r i s t i c s which are unavoidable i n a f i e l d s i t u a t i o n . Secondly, while the performance.of. these a c t i v i t i e s may  be classed  as aniexchange of s e r v i c e s , t h e i r very necessity leads us to question the v a l i d i t y of the t h e o r e t i c a l d i s t i n c t i o n between the p a r t i c i p a n t and non-participant observer.  What w i l l be taken as an instance of p a r t i -  c i p a t i o n or non-participation?  For example, i s the f a c t that I some-  times made the morning coffee going to be i n d i c a t i v e of an exchange of services ( i . e . , non-participation) or i s i t going to be viewed as a sign that I was,  i n f a c t , a p a r t i c i p a n t i n the research setting?  What  t h e o r e t i c a l status obtains between my helping during a medical exami n a t i o n as opposed to my making of the morning coffee?  When does the  researcher engage i n an a c t i v i t y that makes him a p a r t i c i p a n t as opposed  183  to a mere observer?  I f we  cannot s p e c i f y whether o r not some a c t i v i t y  i s i n d i c a t i v e o f e s s e n t i a l p a r t i c i p a t i o n , what i s the a c t u a l s t a t u s of this distinction?  Researcher  Is i t not l a c k i n g any worthwhile  Identification:  Accepting Staff  The p r e v i o u s s e c t i o n a l l u d e d cher i s someone who For example, my  substance?  Accounts  to the f a c t  t h a t the s o c i a l r e s e a r -  i s not a r e g u l a r member of the r e s e a r c h s e t t i n g .  presence as a s o c i o l o g i s t was  p l a n or r e g u l a r workings  not a p a r t of the f o r m a l  of the C l i n i c ' s a f f a i r s .  The r e s e a r c h e r ' s  presence can c r e a t e a h o s t o f problems f o r r e g u l a r members o f the r e s e a r c h s e t t i n g and the n a t u r e of and the soluticnsi f o r these problems are not n e c e s s a r i l y dependent on any c a l c u l a b l e t h i n g t h a t the r e s e a r cher does. my  T h i s was  i d e n t i t y was  illustrated  time a f t e r time i n the manner i n which  managed by the s t a f f when they i n t r o d u c e d me  .during a m e d i c a l examination.  C o n s i d e r the f o l l o w i n g  to p a t i e n t s  transcript:  1.  Doctor:  Do you mind i f Mr. w i t h us?  Katz s i t s i n  2.  Patient:  No no by a l l means  3.  Researcher:  Great  4.  Doctor:  ( ) t h i s room r i g h t Have a s e a t  5.  Patient  T i s s u e (Note: the p a t i e n t asked f o r a t i s s u e )  Doctor:  M r i Katz i s working w i t h ah the Department of M e d i c i n e F a c u l t y of M e d i c i n e f o r the next few months and he's doing ah study of communications and we wondered i f i t would be a l l r i g h t i f he taped what we s a i d to each o t h e r i t ' s j u s t f o r h i s use  Patient:  Sure..  here.  had  V  184  It  was  patients  decided that  and s e e k  interview.  their  However,  (utterance  6)  shows  he o f f e r e d  to  the  Faculty  the  consent  several  patient.  Faculty  doctor-patient  that  posal,  it  I was  Thus,  all,  me t o  i n the  Department  a n d was  tape a medical  a P h . D . student  o f my  research  characterization  That  is,  only  I was n o t  to Clinic  which the  certified student  e n a b l e me t o  staff  knew t h a t  a medical student.  i n sociology.  a  g i v e n a summer  of  not  their  I was n o t w o r k i n g w i t h  here.  communication.  seems o d d t h a t  identity.  of  implied  a m e d i c a l degree  aware  flaws  o f M e d i c i n e b u t was  study  have  notable First  is  s t i p e n d from the  not  allowing i  research of  before  i n t r o d u c e me t o  a n e x a m i n a t i o n o£:ti£Lcbcta:' s p o r t r a y a l  o f M e d i c i n e as  member o f  p h y s i c i a n s would  They  do  I  a  did  were  G i v e n my r e s e a r c h  pro-  p h y s i c i a n s c o u l d b e m i s i n f o r m e d a b o u t my  an a c c u r a t e  room m i g h t m o r e r e a s o n a b l y  account  be  o f my p r e s e n c e  expected  to  resemble  i n the the  examination  following:  Mr.  Katz i s working f o r the Department of F a c u l t y o f M e d i c i n e o v e r t h e summer. He i s d o i n g a s o c i o l o g i c a l s t u d y o f d o c t o r patient interaction for his Ph.D. dissertat i o n i n S o c i o l o g y at U . B . C . We w o n d e r e d i f i t would be a l l r i g h t w i t h y o u i f , h e t a p e d w h a t we s a i d t o e a c h o t h e r . It's just for his use. While it  such a c h a r a c t e r i z a t i o n  could also  delay or  accomplishment of number o f in  the  patients  the  be o t h e r w i s e interview.  over  the  e x a m i n a t i o n r o o m was  w e r e now r e q u i r e d t o  attend  e x a m i n a t i o n room i n s w a y s  to.  i n d e e d be more  problematic  Clinic  course for  smight  of  for  the  successful  p h y s i c i a n s had to  any w o r k i n g  day.  that would  still  see  that  manage my p r e s e n c e  a l l o w them t o  a.  large  My p r e s e n c e  them a n a d d i t i o n a l f e a t u r e They had to  accurate,  they in  accomplish  the their  185  job i n a s u c c e s s f u l and expedient f a s h i o n .  One way o f coping  w i t h my  p r e s e n c e would be to o f f e r an account o f my i d e n t i t y s i m i l a r to the above example.  However, t h i s might make t h i n g s more d i f f i c u l t  s t a f f and f o r me. might q u e s t i o n  about the purpose o f my r e s e a r c h ,  problem a t hand.  etc.  questions  They c e r t a i n l y would not make the encounter any  Indeed, the p a t i e n t might b a l k a t the i d e a o r r e f u s e  and t o r e g a r d  i n the way t h a t I  such an i n t r o d u c t i o n as i n a c c u r a t e  i s to n e g l e c t  to con-  I am p r o p o s i n g , then, t h a t t h e r e were good  o r g a n i z a t i o n a l reasons f o r my having been i n t r o d u c e d  formation  Such  He might  to the pragmatic task o f t r e a t i n g the m e d i c a l  t i n u e the m e d i c a l i n t e r v i e w .  was,  t h a t the p a t i e n t  He might f e e l easy o r uneasy about t h i s .  would c o n t r i b u t e n o t h i n g  shorter.  f o r the p o s s i b i l i t y  the p h y s i c i a n about the p r e s e n c e o f a s o c i o l o g i s t i n the  examination room. ask q u e s t i o n s  To do so a l l o w s  f o r the  or l a c k i n g i n i n -  the f a c t t h a t my p r e s e n c e i n the r e s e a r c h  set-  t i n g i s , f o r the C l i n i c s t a f f , a problem t h a t has to be r e s o l v e d by them on an ongoing b a s i s .  Thereby, w h i l e i n some t e c h n i c a l sense, the  account quoted above may be i n c o r r e c t , i t would n o t be i n c o r r e c t to say t h a t the p h y s i c i a n had, i n some way, i n t r o d u c e d Interactionally, theidoctor's c r e d e n t i a l e d reason f o r being  me to the p a t i e n t .  i n t r o d u c t i o n f u r n i s h e d me w i t h a  i n the examination room.  Interactionally,  i t would n o t be i n c o r r e c t f o r the p a t i e n t to assume t h a t I was a m e d i c a l p r o f e s s i o n a l , f o r p a t i e n t s o f t e n o r i e n t to the p r e s e n c e o f m e d i c a l s t u d e n t s i n such s i t u a t i o n s . c o u l d have c o r r e c t e d t h i s should "set  be f a i r l y  the r e c o r d  Furthermore, w h i l e i t i s p o s s i b l e t h a t I  the p h y s i c i a n ' s obvious.  p o r t r a y a l , t h e consequences o f doing  To c o r r e c t h i s account would, no doubt,  s t r a i g h t " , but i t c o u l d w e l l r e s u l t i n my b e i n g  prohibited  186  from o b s e r v i n g  or recording  any f u r t h e r e n c o u n t e r s .  My concerns w i t h  accuracy would n o t c o i n c i d e w i t h h i s pragmatic concern f o r s e e i n g a l a r g e number o f p a t i e n t s w i t h as l i t t l e wasted time as p o s s i b l e . Instead often allow Since  o f i n t r o d u c i n g me to a p a t i e n t , C l i n i c p h y s i c i a n s  the r e s e a r c h  this point  room.  s e t t i n g t o d e f i n e my i d e n t i t y f o r t h e p a t i e n t .  the m e d i c a l i n t e r v i e w s were to be r e c o r d e d , I would simply  the tape r e c o r d e r At  would  and then i n f o r m  the p h y s i c i a n t h a t I was  the p h y s i c i a n would c a l l  position  recording.  the p a t i e n t i n t o the examination  C o n s i d e r the f o l l o w i n g p i e c e o f data: 1.  Patient:  (walking  towards the examination  room) 2.  Researcher:  Hello  3.  Patient:  Hi  4.  Doctor:  W e l l ah how you doing?  5.  Patient:  Oh I t h i n k I'm j u s t about as good as I'm g o i n g t o be  6.  Doctor:  uh good, i t ' s q u i t e a b i t b e t t e r  7.  Patient:  Yeah  8.  Doctor:  Oh t h a t ' s good. A l l r i g h t , now ah you know t h a t we want to c u t down the Prenason ah t h a t the urn not the Anasec n o t the T e d r a l the other one t h a t you s t a r t e d t h r e e a day....  This interview continued  w i t h o u t my i d e n t i t y o r purpose i n t h e  examination becoming a t o p i c . o f c o n v e r s a t i o n .  I presumed t h a t the  patient' i d e n t i f i e d me as a m e d i c a l student f o r the s e t t i n g for this characterization. should  provided  While i t had been s t i p u l a t e d t h a t  i n t r o d u c e me t o t h e i r p a t i e n t and ask f o r t h e p a t i e n t ' s  physicians consent  187  before I would be allowed to do any recording, the procedure was. rrt .always adhered t o . One way i n which C l i n i c physicians managed my presence was to say nothing at a l l about my i d e n t i t y and allow the p a t i e n t to assume that I was a medical  student.  In the above s i t u a t i o n , f o r example, the doctor and the p a t i e n t were acquainted w i t h one another although I had never met the p a t i e n t . I t i s customary f o r a party who knows two other persons who do not know each other to introduce the two people. 'However, no i n t r o d u c t i o n was forthcoming, nor was the p a t i e n t informed of the presence of the tape recorder.  What was I to do i n t h i s s i t u a t i o n ?  To have introduced myself as a s o c i o l o g i s t would have been cont r a r y to the d e f i n i t i o n which the p h y s i c i a n had allowed to develop. This would be problematic i n i t s e l f but, f u r t h e r , were I to i n t e r r u p t , the p h y s i c i a n and introduce myself as a s o c i o l o g i s t i t would be p o s s i b l e f o r the p a t i e n t to conclude that the doctor had purposefully withheld t h i s information from him.  Again, although I could have i n t e r r u p t e d  the p h y s i c i a n to remind him of the presence of the tape recorder and/or the requirement that we obtain the p a t i e n t ' s consent to have the medical examination recorded, to have done t h i s could have caused some trouble f o r t h i s p a r t i c u l a r occasion and have unpleasant r a m i f i c a t i o n s f o r future encounters as w e l l .  I d i d not think that I should inform the p a t i e n t  about those things that should properly have been conveyed to him by the doctor.  Indeed, i t seemed more trouble to challenge or disagree  w i t h the developing character of the encounter than to allow the physician's unstated tutimaMiest^deMhi-tion  BgfbeisuSlai-nedv s a e - e n *  188  r e s u l t o f t h i s encounter was t h a t both myself and the p h y s i c i a n o p e r a t e d as a team i n o r d e r to m a i n t a i n a r o u t i n e i n which my was f o r a l l i n t e n t s and purposes  that of a medical student.  identity As a  r e s e a r c h e r i n t e r e s t e d i n c r e a t i n g as few t r o u b l e s as p o s s i b l e , I found i t n e c e s s a r y t h a t I o f f e r no s e l f - i n t r o d u c t i o n  o r mention of t h e  presence o f the tape r e c o r d e r .  E t h i c a l Considerations I had to s e c u r e a p p r o v a l from the F a c u l t y o f M e d i c i n e E t h i c s Committee b e f o r e doing my r e s e a r c h a t the C l i n i c .  Many o f the p r e l i m i -  nary o b s t a c l e s were the r e s u l t o f a concern which the C l i n i c s t a f f had about the e t h i c a l i m p l i c a t i o n s of my r e s e a r c h .  I n r e t r o s p e c t , i t seems  p a r a d o x i c a l t h a t many of these same p h y s i c i a n s , when c o n f r o n t e d by the situations  d e s c r i b e d i n t h i s paper d i d n o t i n f o r m t h e i r p a t i e n t s o f my  i d e n t i t y o r t h a t they were b e i n g r e c o r d e d . instances.  C o n s i d e r the f o l l o w i n g two  They a r e t y p i c a l o f the way many o f the p h y s i c i a n s handled  my presence d u r i n g the m e d i c a l i n t e r a c t i o n . I -  1.  Doctor:  I don't know i f I ' l l even  tell  her t h a t t h i s t h i n g i s on 2.  Researcher:  Umm  mm  3.  Doctor:  I t h i n k I'd b e t t e r n o t  4.  Researcher:  Umm  5.  Doctor:  I don't know how s h e ' l l take i t so l e t ' s l e a v e i t on  s 6. 7.  Researcher: Doctor:  Um mm She saw two s t u d e n t s b e f o r e so she's used t o s t u d e n t s  189  8.  Researcher:  Okay, maybe I should j u s t turn i t the other way (reference to tape recorder) I don't think i t makes any d i f f e r e n c e leave that l i k e that she's not gonna  9.  Doctor:  Yeah ah okay (patient entering o f f i c e ) Well Jane how are you. You're looking a l o t better than you d i d the other night  Patient:]  Yeah  1.  Doctor:  Mrs. Jones (pause) Mrs. Jones (the patient i s being summoned from the w a i t i n g room) Here (doctor i s r e f e r r i n g to the examination room)  2.  Patient:  Well w e l l how many doctors have I got (Note: i n a d d i t i o n to myself there was a medical student present)  3.  Doctor:  Do you mind i f Dr. Katz  4.  Patient:  Now  5.  Doctor:  Do you mind i f Dr. Katz and Dr. X (the medical student)  6.  Patient:  Not at a l l  7.  Doctor:  ah stay i n here  8.  Patient:  No I don't mind  9.  Doctor:  Fine....  10. II —  I can't hear very good you know  Note that these are a c t u a l occurrences.  They are part of the  corpus of t r a n s c r i p t i o n s which grew out of my work at the C l i n i c .  No  doubt the reader appreciates the e t h i c a l i m p l i c a t i o n s contained t h e r e i n . In the f i r s t instance, the f a c t that I was not introduced or i d e n t i f i e d to the patient was not simply an oversight, i . e . , "a f a i l u r e to give a proper i n t r o d u c t i o n , " rather i t must be i n t e r p r e t e d as part of a c a l c u l a t e d strategy to allow my i d e n t i t y to be furnished f o r the p a t i e n t by  190  the s e t t i n g .  I assume t h a t the p a t i e n t was  assume t h a t I was borne out by  a medical  student.  supposed to and  Indeed, my  did i n fact  assumption seems to be  the second i n s t a n c e i n which the p h y s i c i a n s p e c i f i c a l l y 12  i n t r o d u c e d me  to the p a t i e n t as "Dr.  were not informed  t h a t t h e r e was  researchers  While i t seems important  that  c o n s i d e r the e t h i c a l i m p l i c a t i o n s i n v o l v e d i n d t h e i r  s t u d i e s , t h e r e are few, which f i e l d  Note too t h a t p a t i e n t s  a tape r e c o r d e r on o r t h a t they were  t a k i n g p a r t i n a s o c i o l o g i c a l study. field  Katz."  i f any,  d e s c r i p t i o n s of the e t h i c a l problems  r e s e a r c h e r s encounter i n the course of t h e i r work.  g e s t t h a t by examining these two  i n s t a n c e s we  t h a t whatever a r e s e a r c h e r ' s own  e t h i c a l p o s i t i o n , t h e r e a r e everyday  c o n t i n g e n c i e s i n h e r e n t i n the f i e l d  can'ibegin to  I sug-  s i t u a t i o n t h a t p r o h i b i t him  exercising his personal i n c l i n a t i o n s i n a u n i l a t e r a l The  c h o i c e s open to the f i e l d  determined by  of  The  field  With r e f e r e n c e to my  own  s t a f f i f I was,  and  1  access  to  does not possess  c o u l d be  an  terminated.  I had proposed a p r o j e c t  i n the r e s e a r c h s e t t i n g f o r over  always s u b j e c t to t e r m i n a t i o n by  f o r example, c a u s i n g  the  Throughout one's r e s e a r c h ,  r e s e a r c h a t the C l i n i c  T h i s p r o p o s a l however was  gained  t h a t t h a t access  t h a t would r e q u i r e t h a t I be p r e s e n t  anything  to him  to be i n the r e s e a r c h s e t t i n g .  i s an omnipresent p o s s i b i l i t y  year.  r e s e a r c h e r i n ongoing!*  r e s e a r c h e r has  r e s e a r c h s e t t i n g as a p r i v i l e g e granted  it  way.  are not dependent on some " a b s t r a c t " adherence to a s e t  ethical principles.  ongoing r i g h t  from  researcher are o r g a n i z a t i o n a l l y  the f a c t t h a t he i s a f i e l d  s i t u a t i o n s and  understand  trouble.  that s t a f f considered problematic  Trouble  a  Clinic  could Constitute  f o r t h e i r everyday o c c u p a t i o n a l  191.  routines.  One o f the concerns o f C l i n i c s t a f f was w i t h t h i s  concept  of t r o u b l e , s p e c i f i c a l l y t h e e f f e c t my p r e s e n c e might have on p a t i e n t s . The one  C l i n i c was an e x p e r i m e n t a l m e d i c a l f a c i l i t y  of t h e i r outstanding  population.  and, as such,  concerns was t h a t o f a c q u i r i n g a l a r g e p a t i e n t  They were always on the a l e r t f o r a n y t h i n g  cause t h a t p a t i e n t p o p u l a t i o n of a r e s e a r c h  to d e c l i n e .  Needless to say, the presence  s o c i o l o g i s t was a p o s s i b l e s o u r c e o f t r o u b l e ,  t h a t c o u l d have an adverse e f f e c t on the a b s o l u t e population.  t h a t might  My r e s e a r c h  into doctor-patient  something  numbers of the p a t i e n t  communication, w h i l e  t h e o r e t i c a l l y i n t e r e s t i n g , c o u l d l e a d to c e r t a i n c o m p l i c a t i o n s  since I  was not a m e d i c a l p r a c t i t i o n e r and/or, i n a d d i t i o n to t h i s , I would be using  a tape r e c o r d e r .  Given t h i s i n f o r m a t i o n ,  knew t h a t from a s t r i c t l y  e t h i c a l standpoint,  the p h y s i c i a n  have informed the p a t i e n t of my t r u e i d e n t i t y , m y p r e s e n c e o f the tape r e c o r d e r .  cited  L e t me e l a b o r a t e  I  should  purposes and the  However, I found myself i n an under-  s t a n d a b l e quandary about an a p p r o p r i a t e situation.  what was I to do?  course o f a c t i o n i n t h i s  by r e f e r r i n g to the two t r a n s c r i p t s  above. I n t h e f i r s t t r a n s c r i p t the p h y s i c i a n  t h a t the tape r e c o r d e r  should  p a t i e n t t h a t the i n t e r v i e w  be l e f t  ( i n utterance  on and d e c i d e s  i s going to be r e c o r d e d .  1) i n f e r s  n o t to i n f o r m the The p h y s i c i a n  making these p r o p o s i t i o n s has o s t e n s i b l y "good m e d i c a l grounds" f o r doing so.  By t h i s ,  I mean t h a t t h e p h y s i c i a n has made a d e c i s i o n about  the use o f the tape r e c o r d e r  i n terms o f the p o s s i b l e r e p e r c u s s i o n  i t might have f o r the i n t e r v i e w .  As he s t a t e d i n u t t e r a n c e  5:  that  " I don't  192  know how  s h e ' l l take i t so l e t ' s l e a v e i t on."  p r i a t e to d i s a g r e e w i t h the p h y s i c i a n . tell  1 felt  s t a y at the r e s e a r c h  .2)  s e t t i n g or at l e a s t my  t h i s p a r t i c u l a r p h y s i c i a n would be p l a c e d not want to do anything  I f he f e l t I  d i d not  that could  and  f e e l i t was  best my  It  p o s s i b l e con-  a s i t u a t i o n i n which  my  working r e l a t i o n s h i p w i t h  i n jeopardy.  Obviously,  I  c r e a t e a s t r a i n i n the working  t h a t I would have w i t h t h i s and w i t h other  t h a t i t was  he  so would  1) immediate problems f o r the s i t u a t i o n at hand.  s t e r n a t i o n f o r the p a t i e n t as w e l l , and  relationship  inappro-  t h a t to do  would cause undoubtable embarrassment f o r the d o c t o r  did  i t was  I c o u l d have suggested t h a t  the p a t i e n t about the tape r e c o r d e r .  have c r e a t e d  I felt  physicians.  to conduct the i n t e r v i e w i n t h i s manner,  p o s i t i o n to t e l l him  t h a t he was  procedures which might be  l a b e l l e d as u n e t h i c a l .  who  i n matters of the d o c t o r - p a t i e n t r e l a t i o n s h i p .  should  Here, I was As f a c e d by  have f i n a l only  the  a researcher  say  I t was  engaging i n he,  the  doctor  researcher. I had  Clinic staff.  to o r i e n t to the demand c h a r a c t e r i s t i c s  Thus, p h y s i c i a n S s  of the c o n s t r a i n t s b e a r i n g  upon my  working c o n d i t i o n s were p a r t  actual research  procedures.  There-  by,  w h i l e I c o u l d have engaged i n a d i s c u s s i o n w i t h the p h y s i c i a n about  his  d e c i s i o n , to have done so would have i n t e r f e r e d w i t h the  concern t h a t the p h y s i c i a n should  attend  p o s s i b l e amount of time.  t h i s does not mean t h a t the  should  (Note:  r e c e i v e inadequate m e d i c a l c a r e .  ongoing  to the p a t i e n t i n the l e a s t patient  Rather, i t comes from the  that physicians  are busy w i t h a number of p a t i e n t s and  for  s p e c i f i c a l l y r e l a t e d to the examination at hand.)  m a t t e r s not  fact  do not have time  193  P h y s i c i a n s have a j o b to do and, from t h e i r p o i n t o f view, they accomplish  i t i n as s h o r t a time as i s p r a c t i c a l l y p o s s i b l e .  should  As such,  t h e i r p r i m a r y o r i e n t a t i o n was d i r e c t e d towards t h e f a c t t h a t these i n terviews  c o u l d be done w i t h o r without  the tape  recorder.  Although i t would have been p o s s i b l e f o r me to have r a i s e d  these  i s s u e s a t C l i n i c s t a f f meetings, to p o i n t out t h a t some p h y s i c i a n s had not  i n t r o d u c e d me to t h e i r p a t i e n t s , informed  c a l r e s e a r c h e r r a t h e r than a m e d i c a l  them t h a t I was a s o c i o l o g i -  student,and t h a t I wanted to tape-  r e c o r d t h e i r i n t e r v i e w s would p o r t r a y c e r t a i n p h y s i c i a n s as u n e t h i c a l and would s u r e l y have r e s u l t e d i n the t e r m i n a t i o n o f e i t h e r my  research  a t the C l i n i c o r o f the good working r e l a t i o n s h i p which h e l d between myself and the s t a f f .  I saw no reason  to do t h i s s i n c e i t was apparent  t h a t t h e staff was happy w i t h t h i n g s as they were. In the second i n s t a n c e o f data, Katz".  T h i s c h a r a c t e r i z a t i o n was both f a l s e and d e l i b e r a t e l y m i s l e a d i n g .  What was I to do i n t h i s s i t u a t i o n ? during  I was i n t r o d u c e d o v e r t l y as "Dr.  the i n t e r v i e w  To make the n e c e s s a r y  correction  ( i n f r o n t o f the p a t i e n t ) seemed g r o s s l y  inappro-  p r i a t e and t o c o r r e c t him a f t e r the i n t e r v i e w a l s o seemed to be i n a p propriate.  F u r t h e r , note t h a t the m e d i c a l  as a d o c t o r , a l t h o u g h periences  he was j u s t a s t u d e n t .  a t the C l i n i c  t y p i c a l l y introduced  student was a l s o  introduced  I t seems from o t h e r ex-  t h a t t h i s i s the way i n which students a r e  to p a t i e n t s and the p h y s i c i a n assumed t h a t , were  he t o manage my p r e s e n c e i n t h e room i n t h i s way t h e r e would be as few problems as p o s s i b l e . While the two i n s t a n c e s quoted above a r e examples o f some of the  194  e t h i c a l problems t h a t a r e s e a r c h e r might encounter i n the f i e l d ,  they a l s o  show how  To  such problems take p l a c e w i t h i n a s i t u a t i o n a l c o n t e x t .  speak of e t h i c a l c o n s i d e r a t i o n s i n the a b s t r a c t asione i s to n e g l e c t the s i t u a t i o n a l and  c o n t e x t u a l f e a t u r e s of f i e l d  e v e r y t h i n g p o s s i b l e to assure an e t h i c a l manner.  t h a t my  Indeed, t h i s was  research.  not o n l y my  concern  to C l i n i c s t a f f .  who  of the F a c u l t y of M e d i c i n e  It i s ironic  by  However, as I p o i n t e d out,  alone,  that a  i t was  researcher  E t h i c s Committee  before s t a r t i n g h i s p r o j e c t should f i n d himself v i o l a t i n g considerations.  done  r e s e a r c h would be conducted i n  a l s o of c e n t r a l concern sought the a p p r o v a l  I had  certain  t h i s v i o l a t i o n was  ethical  motivated  the i n e s c a p a b l e c o n t i n g e n c i e s f a c e d by a r e s e a r c h e r c o n f r o n t i n g an  a c t u a l ongoing s i t u a t i o n r a t h e r than by any p e r s o n a l c h o i c e a l o n e . would appear t h a t any i s indeed  d i s c u s s i o n on the t o p i c of e t h i c s and  empty i f i t f a i l s  e v o l v e over  transformed  by  research  to c o n s i d e r the p r a c t i c a l c o n t i n g e n c i e s  the course of any  t h a t the r e s e a r c h e r ' s own  field  It  field  research.  ethical position w i l l  the members of the s e t t i n g  I t may  w e l l be  the  that  case  come to be c u r t a i l e d  to which he has  and  access.  Conclusion In the p r e v i o u s  chapter we  examined some of the s e l f - o r g a n i z i n g  p r o p e r t i e s of c h a r t rounds o r i e n t e d to by p a r t i c i p a n t s . dress the r e l a t i o n s h i p between c o l l e c t i o n of data and presence i n and o f t e n regarded chapter has of  af the r e s e a r c h s e t t i n g .  the  We  d i d not  ad-  researcher's  While t h i s r e l a t i o n s h i p i s  as the "other s i d e " of e t h n o g r a p h i c  description, this  attempted to r e c o n s i d e r t h i s f o r m u l a t i o n by c o n s i d e r i n g some  the w r i t e r ' s e x p e r i e n c e  d u r i n g h i s r e s e a r c h a f the Community  Clinic.  195  Research manuals often provide the analyst with a set of i n s t r u c tions on how  to act during h i s stay i n the research s e t t i n g .  He i s  supposed to s e l e c t the r o l e which w i l l most s u c c e s s f u l l y allow him to accomplish h i s research goals.  I d e a l l y , he s«should t r y to be  r u p t i v e , unobtrusive, and so f o r t h .  non-dis-  This chapter has attempted to  point out the f a l a c i o u s character of t h i s formulation f o r the researcher -is nbtsmerely  i n but also becomes a part of the s e t t i n g and  he i s to act i s not something which he can c o n t r o l i n advance.  how Rather,  whatever the advice he may acquire about how to act i n the f i e l d , that advice has to be negotiated with the r e a l i t i e s  of every s e t t i n g .  The  e s s e n t i a l demand c h a r a c t e r i s t i c s of the f i e l d s i t u a t i o n remain unspec i f i e d i n f i e l d research t e x t s . We focused p r i m a r i l y upon three features of doing f i e l d research: p a r t i c i p a n t - n o n - p a r t i c i p a n t observation, how I wdsinideribrOf iedpfcbipa.tients of the C l i n i c ,  and c e r t a i n e t h i c a l considerations a r i s i n g out of these  identifications.  While such features are often treated by methodolo-  g i s t s as separate t o p i c s , I have attempted to demonstrate that each of these can properly be examined i n conjunction w i t h a c t u a l instances of f i e l d data, i . e . , that they become substantive topics only when they -are responsive to those i n t e r a c t i o n a l occasions i n which they occurred.  196  Footnotes:  Chapter Four  1.  C h a r l e s 0. Frake, "Notes on Queries T y l e r , Ed., C o g n i t i v e Anthropology, and Winston, 1969), p. 123.  i n Ethnography", i n Stephen (New York: H o l t , R i n e h a r t  2.  I b i d . , p. 124.  3.  H a r o l d G a r f i n k e l , S t u d i e s i n Ethnomethodology, N.J.: P r e n t i c e H a l l , 1967), p. 73.  4.  F o r example, Raymond L. Gold, "Roles i n S o c i o l o g i c a l F i e l d Observ a t i o n s " , S o c i a l F o r c e s , V o l . 36 (March 1958), Benjamin D. P a u l , " I n t e r v i e w Techniques and F i e l d R e l a t i o n s h i p s " i n A.L. Kroeber, Ed., Anthropology Today, (Chicago: U n i v e r s i t y o f Chicago P r e s s , 1969), M o r r i s S.Schwartz and C h a r l o t t e Green Schwartz, "Problems i n P a r t i c i p a n t O b s e r v a t i o n " , American J o u r n a l o f S o c i o l o g y , V o l . LX (January 1955), George S p i n d l e r , Ed., Being an A n t h r o p o l o g i s t , (New York: H o l t , R i n e h a r t and Winston, 1970), and Thomas R. W i l l i a m , F i e l d Methods i n the Study of C u l t u r e s , (New York: H o l t , R i n e h a r t and Winston, 1967). A l s o see, Aaron V. C i c o u r e l , Method,- and Measurement i n S o c i o l o g y , (New York: The Free P r e s s , 1964) e s p e c i a l l y chapter two.  5,ii  I r e c o g n i z e t h a t t h e r e a r e m a t e r i a l s such as e t i q u e t t e manuals d e a l i n g w i t h a p p r o p r i a t e ways of behaving i n v a r i o u s s e t t i n g s and o c c a s i o n s and t h a t people do ask " a d v i c e " when going to new and s t r a n g e p l a c e s . These c o n s t i t u t e l a y e x c e p t i o n s to t h i s f o r m u l a t i o n . The p o i n t however remains v a l i d f o r any " i n s t r u c t i o n s " they r e c e i v e a c q u i r e t h e i r substance when the person has to a t t e n d to the o r g a n i z a t i o n a l s t r u c t u r e o f t h a t they r e f e r him t o . The type o f a d v i c e and i n s t r u c t i o n s o f f e r e d i n such manuals i s n o t s e l f - f u l f i l l i n g , t h a t i s , i f someone says "you do x when you go t h e r e " i t s t i l l r e q u i r e s t h a t one f o l l o w t h a t a d v i c e w i t h i n some o r g a n i z a t i o n a l context and how t h a t a d v i c e should be c a r r i e d out w i t h i n such an o r g a n i z a t i o n a l context.  6.  The same p o i n t has been made u s i n g data from a d i f f e r e n t s e t t i n g , namely, grade s c h o o l t e s t i n g p r o c e d u r e s . I t was found t h a t to s u c c e s s f u l l y accomplish a s e r i e s o f t e s t s designed t o a s s e s s the competence o f grade s c h o o l c h i l d r e n , s t u d e n t s a l r e a d y need possess the v e r y competence which the t e s t i n g procedure was designed to a s sess. See, Robert MacKayi' "Conceptions o f C h i l d r e n and Models o f S o c i a l i z a t i o n " i n Hans P e t e r D r e i t z e l , Ed., Recent S o c i o l o g y No. 5: Childhood and S o c i a l i z a t i o n , (New York: M a c m i l l a n Company., 1973), pp. 27-44.  (Englewood  Cliffs,  f  7.  Roy Turner, "Words, U t t e r a n c e s and A c t i v i t i e s " , i n J a c k Douglas, Ed., Understanding Everyday L i f e , (Chicago: A l d i n e P u b l i s h i n g Co., 1970), p. 169.  197  8.  Buford Junker, F i e l d Work; An Introduction to the S o c i a l Sciences, (Chicago: U n i v e r s i t y of Chicago Press, 1960), p. 39.  9.  Author's f i e l d note.  10.  In the previous chapter reference was made to the "demand charact e r i s t i c s " required of p a r t i c i p a n t s to chart rounds. This term i s equally a p p l i c a b l e to the researcher who must t r e a t h i s stay w i t h i n the research s e t t i n g i n a s i m i l a r way, i . e . , as h i s j o b . As such, i t w i l l have c e r t a i n features that he must attend to i n consequential ways.  11.  John Lofland, Analyzing S o c i a l S e t t i n g s . worth P u b l i s h i n g Co., 1971).  12.  T e c h n i c a l l y speaking, medical students are not yet medical p h y s i cians. I t appears, however, that when r e f e r r i n g to these students physicians address them as "doctor".  (Belmont, C a l . : Wads-  198  CHAPTER FIVE CONCLUSION Summary and F u r t h e r  Research  In t h i s d i s s e r t a t i o n I have departed from a standard  model o f  e t h n o g r a p h i c a n a l y s i s i n t h a t I have chosen to f o r m u l a t e as a t o p i c matters customarily  t r e a t e d as f e a t u r e s o f an i n t e r p r e t i v e schema shared  by ethnographers and laymen, and used by them as r e s o u r c e s c o n s t r u c t i o n and i n t e r p r e t a t i o n o f e t h n o g r a p h i c r e p o r t s . have focused  i n the That i s , I  a t t e n t i o n upon some o f the m e t h o d o l o g i c a l and s u b s t a n t i v e  i s s u e s which u n d e r l i e t h e p r o d u c t i o n  of a description.  Chapter one began w i t h a d e s c r i p t i o n o f the C l i n i c .  I discussed  how I had come to s e l e c t t h i s p a r t i c u l a r s e t t i n g and how t h i s s e l e c t i o n arose from a fundamental pragmatic need f o r a s e t t i n g f o r my d i s s e r t a r  t i o n r a t h e r than from any p r e v i o u s medical sociology.  experience or s p e c i a l i n t e r e s t i n  Next, v a r i o u s d e s c r i p t i v e c h a r a c t e r i s t i c s o f the  C l i n i c were p r e s e n t e d so t h a t t h e r e a d e r might a c q u i r e the s e t t i n g . "  a "sense o f  Of p a r t i c u l a r importance here was the f a c t t h a t the  C l i n i c o p e r a t e s as a group m e d i c a l p r a c t i c e so t h a t t h e r e the p o s s i b i l i t y his  i s always  t h a t a p a t i e n t w i l l be seen by a p h y s i c i a n o t h e r  own, r e g u l a r p h y s i c i a n ; and t h e r e f o r e , i n order  to f a c i l i t a t e  p a t i e n t care, s t a f f review p a t i e n t s ' medical charts i n a r o u t i n e known as c h a r t rounds.  These i n i t i a l m a t e r i a l s  of the procedures I had to f o l l o w i n order The  a l s o contained  session  an account  t o g a i n a c c e s s t o the s e t t i n g .  r e a d e r was informed t h a t , w h i l e the C l i n i c appeared i n i t i a l l y  r e c e p t i v e to>?»sociological r e s e a r c h ,  than  t o be  g a i n i n g a c c e s s proved to i n v o l v e  199  c e r t a i n elaborate procedures.  F i n a l l y , however, I not only gained ac-  cess but was allowed to tape-record sessions of chart rounds and other instances of medical i n t e r a c t i o n s .  The t r a n s c r i p t s made from these  recordings would come to c o n s t i t u t e the m a j o r i t y of data f o r t h i s report. This i n i t i a l d e s c r i p t i o n was intended as a necessary component of an ethnography of the C l i n i c .  By t h i s , I mean that i t was expected that  I provide the reader with some general information about the problems of research access and the c h a r a c t e r i s t i c s of the C l i n i c p r i o r to a more d e t a i l e d and a n a l y t i c a l study of i t s organization. however, chapter one took a r a d i c a l departure.  At t h i s p o i n t ,  U t i l i z i n g a procedure  followed throughout most of t h i s study, t h i s i n i t i a l d e s c r i p t i v e m a t e r i a l was taken as a topic i n i t s own r i g h t .  That i s , I examined  the ways i n which i t came to be a recognized and recognizable d e s c r i p tion.  My concern was not w i t h those features p e c u l i a r to my own des-  c r i p t i o n , but was d i r e c t e d towards d i s c o v e r i n g the g e n e r a l i z a b l e features of any such ethnographic m a t e r i a l . A comparison of my i n i t i a l d e s c r i p t i o n w i t h the opening sections of other ethnographic works suggested that the c o n s t r u c t i o n of an accredited ethnography follows a recognizable s t r u c t u r e which was chara c t e r i z e d as a "standard ethnographic format".  That i s , an ethnogra-  phic report t y p i c a l l y presents the reader with a corpus of i n i t i a l materials as an i n t r o d u c t i o n to the subsequent a n a l y t i c a l sections that are to follow.  The f i r s t part of our task was to specify, the  r e l a t i o n s h i p which obtained between these sections. I t was found that although these i n i t i a l m a t e r i a l s provide the  200  r e a d e r w i t h a sense o f the r e s e a r c h s e t t i n g , the c o n n e c t i o n between them and the subsequent necessity. sequent  s e c t i o n s o f a r e p o r t was n o t one o f l o g i c a l  By t h i s I mean t h a t the r e a d e r ' s u n d e r s t a n d i n g o f sub-  s e c t i o n s o f the ethnography  i s n o t dependent on h i s  h a v i n g read these i n i t i a l m a t e r i a l s ;  first  Such m a t e r i a l s seem to occupy  the p o s i t i o n t h a t they do i n o r d e r t o s a t i s f y a p r e s e n t a t i o n a l  format  r a t h e r than to s a t i s f y any c r i t e r i o n f o r the l o g i c a l o r d e r i n g o f ethnographic materials.  Furthermore,  i t was shown t h a t the c o n s t r u c t i o n o f  these m a t e r i a l s i s n o t based on any s p e c i a l s c i e n t i f i c competence t h a t the ethnographer may o r must p o s s e s s .  Rather, he seems t o be a b l e t o  r e l y upon h i s own common sense to p r o v i d e h i s r e a d e r s w i t h a sense o f the r e s e a r c h s e t t i n g .  These.observations pointed to a rather curious  f a c t , i . e . , w h i l e the main s e c t i o n s o f e t h n o g r a p h i e s a r e o f t e n seen as s e c t i o n s c o n t a i n i n g i s s u e s o f t h e o r e t i c a l i n t e r e s t , these p r e f a t o r y s e c t i o n s , a l t h o u g h they a r e s t a n d a r d components o f e t h n o g r a p h i c r e p o r t s , a r e seldom regarded as worthy o f examination or a n a l y s i s . The next p a r t o f c h a p t e r one was d i r e c t e d towards an e x p l i c a t i o n of  the importance  o f these i n i t i a l m a t e r i a l s f o r the c o n s t r u c t i o n o f  an e t h n o g r a p h i c d e s c r i p t i o n .  T r a d i t i o n a l l y , i n v e s t i g a t i o n has been  focused upon the s u b s t a n t i v e c o n t e n t o f e t h n o g r a p h i c r e p o r t s r a t h e r than on the way i n which r e p o r t s a r e c o n s t r u c t e d .  In this respect,  the c h a p t e r focused a t t e n t i o n upon a s t r a n g e l y n e g l e c t e d a r e a . These i n i t i a l m a t e r i a l s were shown t o do c e r t a i n work f o r the reader w i t h r e f e r e n c e t o the o r g a n i z a t i o n o f e t h n o g r a p h i c d e s c r i p t i o n s . First,  they underscore the p r i v i l e g e d p o s i t i o n o f t h e ethnographer  201  v i s - a - v i s the reader of the report.  By presenting such materials the  author establishes himself as someone who possesses expert knowledge about the c u l t u r e under i n v e s t i g a t i o n . Second, while these d e s c r i p t i v e materials may c o n s t i t u t e a set of resources  that the reader may, or  should use to inform h i s reading of l a t e r parts of the r e p o r t , the reader i s not provided with a set of i n s t r u c t i o n s on how to u t i l i z e these materials when reading subsequent sections.  While there i s not S  a l o g i c a l a p r i o r i connection between these i n i t i a l materials and subsequent s e c t i o n of the r e p o r t , they seem to occupy the place that they do so that the report as a whole w i l l be seen as a competent piece of ethonographic m a t e r i a l . I t was demonstrated that t h e i r construction,although  conse-  q u e n t i a l f o r the ethnography, was i t s e l f founded i n a common-sense set of-'-relevancies.  The features that are incorporated i n t o the i n i t i a l  d e s c r i p t i o n are selected by the ethnographer a f t e r considering such things as the type of audience that the report i s intended f o r , e t c . To say that the ethnographer r e l i e s on common—sense procedures i n constructing the prefatory sections of h i s report i s to argue that such i n i t i a l materials are condemned to be common-sense rather than s c i e n t i f i c constructions.  T h i s , however, i s not a c r i t i c i s m f o r ,  rather than view i t as an inadequacy of ethnographic d e s c r i p t i o n , i t may be considered  simply an i n t e r e s t i n g , i n v a r i a n t property of an  ethnographic report. Chapter one not only provided an a n a l y s i s of the i n i t i a l d e s c r i p t i v e materials of an ethnographic r e p o r t , i t also contained an i n i t i a l  ..  202  d e s c r i p t i o n of the C l i n i c . graphy of the C l i n i c .  This was the opening section of my ethno-  The reader, here, could properly expect a more  a n a l y t i c a l d e s c r i p t i o n of C l i n i c organization.  However, chapter two took  as i t s point of departure a consideration of the r e l a t i o n s h i p between the researcher and the research s e t t i n g .  Thus, i t d i d not provide the  expected a n a l y t i c a l d e s c r i p t i o n of an aspect of C l i n i c o r g a n i z a t i o n , but rather turned to an examination of some of the methodological presuppositions that account f o r the a n a l y s i s of chart rounds presented i n chapter three. Chapter two began by considering how a medical s o c i o l o g i s t might t r e a t access to the C l i n i c .  I t was proposed that such an approach  could regard the s e t t i n g as a mere l o c a t i o n from which to gain i n f o r mation f o r some preconceived hypothesis.  This approach was shown to  be incapable of d e s c r i b i n g the o r g a n i z a t i o n of the C l i n i c since i t would n e i t h e r respect the i n t e g r i t y of those aspects of C l i n i c o r g a n i z a t i o n observed nor be responsive to the type of data c o l l e c t e d from the d a i l y o r g a n i z a t i o n a l routines of C l i n i c l i f e .  These points need f u r t h e r  clarification. As a researcher at the C l i n i c I was i n a p r i v i l e g e d p o s i t i o n to observe and record various aspects of C l i n i c organization.  To simply  present the reader w i t h the data which I c o l l e c t e d at the C l i n i c would not c o n s t i t u t e an adequate ethnography.  What then, should an a n a l y s i s  be responsive to with reference to the data and the s o c i a l o r i g i n s of that data?  To speak of the i n t e g r i t y of the research s e t t i n g was to  note that data does not e x i s t independent of a s o c i a l context from which  203  i t i s c o l l e c t e d . My own data i s not j u s t from the C l i n i c but from a medical interview, from a session of chart rounds, or a lunch conv e r s a t i o n , and so f o r t h .  To neglect t h i s contextual feature i s to  disregard a large part of the i n t e r a c t i o n a l background expectancies  that  members ( i n c l u d i n g the s o c i o l o g i s t ) use and d i s p l a y i n t h e i r routine i n t e r a c t i o n a l encounters.  To say that a medical sociology approach  would not respect the i n t e g r i t y of the research s e t t i n g i s to say that i t t r e a t s the stream of C l i n i c behaviour as something independent of the contextual s i t u a t i o n s i n which i t was produced.  Such an approach  would not be concerned with C l i n i c behaviour per se but r a t h e r , with some preconceived  research hypothesis which would allow the researcher  to see various behaviours as items that would support or r e f u t e h i s orientation.  Such an approach would disregard the context from which  the data was c o l l e c t e d as i t s e l f being a constituent feature of any a n a l y s i s of that data. To speak of one's a n a l y s i s as dependent on the context from which the data comes i s to note that i t should be responsive to that context. By t h i s I mean that the researcher should be able to handle the d e t a i l s of a c t u a l occurrences.  He should be able to do t h i s i n abstract ways,  but, u l t i m a t e l y , h i s a n a l y s i s should be responsive to a c t u a l s o c i a l interactions.  From the standpoint of an a n a l y t i c a l d e s c r i p t i o n of  C l i n i c o r g a n i z a t i o n , i t i s c l e a r that an approach, such as that used by the medical s o c i o l o g i s t , would contribute l i t t l e to such a d e s c r i p t i o n f o r i t would not be concerned with how the members of the C l i n i c organize t h e i r ongoing s o c i a l a f f a i r s .  204  An and  a l t e r n a t i v e research  occasions  such a r e s e a r c h  o f the r e s e a r c h  setting.  to r e s p e c t  the  To  itself  t o p i c s and  of everyday l i f e The  new  from r e s e a r c h  i n t o the s o c i a l p s y c h o l o g y of  cultural settings.  their  I proposed  around p r e c o n -  t h e o r e t i c a l i s s u e s which remove them from the m a t r i x from which they u l t i m a t e l y o r i g i n a t e d .  ethnography ( o r , c o g n i t i v e a n t h r o p o l o g y ) was o n l y made p e r t i n e n t c r i t i c i s m s of  e t h n o g r a p h i c d e s c r i p t i o n , but  a l s o proposed a new  then con-  traditional  research  strategy.  I t t r i e s i n s t e a d to produce a d e s c r i p t i o n t h a t would enable the to a c t i n c u l t u r a l l y a p p r o p r i a t e  ways.  The  c r i p t i o n of some aspect  of c l i n i c a c t i v i t y , but  In chapter one  i t was  ethno-  of a d e s -  i t s g o a l seemed to  demonstrated t h a t i t i s  must n e c e s s a r i l y u t i l i z e i n o r d e r next t a s k was  t h a t the  to "make-sense-of" what he  be  impossible  a d e s c r i p t i o n that w i l l completely inform a reader since  d e s c r i p t i o n r e l i e s on a s e t of u n s p e c i f i a b l e f e a t u r e s  The  reader  d i r e c t i o n of the new  graphy seemed to be a recommendation towards the p r o d u c t i o n  to p r o v i d e  A  t r a d i t i o n a l e t h n o g r a p h i e s , w h i l e somewhat b e t t e r  the i n t e g r i t y o f other  s i d e r e d s i n c e i t not  unattainable.  as  f o r t h i s r e a s o n became a t o p i c of i n q u i r y .  t h a t such e t h n o g r a p h i c r e p o r t s are o f t e n c o n s t r u c t e d ceived  fol-  integrity  than the t r a d i t i o n a l s o c i o l o g i c a l approach, c o u l d not m a i n t a i n c l a i m to r e s p e c t  activities  s e l f - o r g a n i z i n g char-  T r a d i t i o n a l ethnography p o r t r a y s  of m a t e r i a l s  experiments showed how  such  worthy o f e m p i r i c a l i n v e s t i g a t i o n .  s t r a t e g y would r e q u i r e one  having t h i s concern and consideration  to r e g a r d  as phenomena h a v i n g a s t r u c t u r e and  a c t e r which are open to and low  procedure would be  is  any  reader reading.  the s e l e c t i o n of a c l i n i c a c t i v i t y from which to  205  produce a d e t a i l e d a n a l y s i s .  Chart rounds was selected because i t  c o n s t i t u t e s a recurrent and bounded a c t i v i t y w i t h i n the C l i n i c .  I  then produced a d e s c r i p t i o n which I characterized as "an inadequate d e s c r i p t i o n " since i t did not attend to the s e l f - o r g a n i z i n g features of the occasion.  Given that chart rounds are s p e c i f i c a l l y designed  for t a l k about p a t i e n t s , I proposed t h a t , by examining transcribed m a t e r i a l from tape recorded sessions, i t would be p o s s i b l e to discover some of t h e i r o r g a n i z a t i o n a l features.  Since chart rounds are a  routine i n t e r a c t i o n a l and conversational a c t i v i t y , such t r a n s c r i p t s should d i s p l a y relevant features of the s e l f - o r g a n i z i n g character of the occasion.  Thus, instead of attempting  to do a d e s c r i p t i o n that  would enable one to act as a competent member to t h i s occasion, I would attempt to construct an a n a l y s i s responsive to the s e l f - o r g a n izingffeatures of the occasion by examining some p r o p e r t i e s displayed i n the t a l k of c l i n i c p a r t i c i p a n t s . Chapter four also examined the r e l a t i o n s h i p between the researcher and the research s e t t i n g , but t h i s time with a d i f f e r e n t perspective than that of chapter two. I t focused on some of the day-to-day d e c i sions that confront a researcher i n the f i e l d s i t u a t i o n and on how he might be expected to conduct himself i n and over the course of a v a r i e t y of s i t u a t i o n s . I t was not the purpose of t h i s chapter to provide a manual or a set of i n s t r u c t i o n s f o r f i e l d researchers.  Indeed, i t was  the hiatus which e x i s t s between the goals of ethnographic d e s c r i p t i o n and the nature of the i n s t r u c t i o n s offered i n f i e l d manuals that prompted t h i s examination of my own f i e l d experiences a t the C l i n i c . d i r e c t e d towards an e x p l i c a t i o n of my own f i e l d experiences  This was and, f u r t h e r ,  206v  towards an examination  of these e x p e r i e n c e s  problems f a c e d by a r e s e a r c h e r i n a f i e l d Throughout my of  the t a k e n - f o r - g r a n t e d As a student,  work:  engaged i n a v a r i e t y  about the v a l i d i t y of many of  assumptions I had h e l d about the n a t u r e  of  field  I a c q u i r e d an o r i e n t a t i o n towards the s u c c e s s f u l  accomplishment o f f i e l d aware o f the standard  general  situation.  r e s e a r c h at the C l i n i c I was  s i t u a t i o n s t h a t provoked q u e s t i o n s  work.  as i n d i c a t i v e of the  research.  By t h i s I mean t h a t I had  become  t o p i c s and problems a s s o c i a t e d w i t h d o i n g  field  the s e l e c t i o n of a r e s e a r c h s e t t i n g , the problem of s e c u r i n g  r e s e a r c h a c c e s s , the v a r i o u s s o c i a l r o l e s one would have to " p l a y " , the problem of b e i n g a p a r t i c i p a n t or n o n - p a r t i c i p a n t o b s e r v e r , so f o r t h . I had  I regarded  to c o n t r o l and  handle my  the doing o f f i e l d account f o r .  presence i n f i e l d  r e s e a r c h as something t h a t  I t seemed n e c e s s a r y  s i t u a t i o n s and  i t was  my  f o r me  to  responsibility  manage the problems a s s o c i a t e d w i t h the r o l e of a p a r t i c i p a n t or participant  r e s e a r c h a t the C l i n i c .  quickly shattered  Such p r i o r concerns  on the s o c i a l r e s e a r c h e r and n e g l e c t e d  concentrated  the f a c t t h a t h i s presence i s  something t h a t the members of the r e s e a r c h s e t t i n g must a l s o manage. In terms of my  daily l i f e  i n the f i e l d ,  whatever p r i o r c o n c e p t i o n s  i t soon became apparent t h a t  of f i e l d work I had were vacuous and  of  l i t t l e pragmatic use when c o n f r o n t i n g the d a i l y c o n t i n g e n c i e s of a r e s e a r c h e r at the  Clinic.  I n s t e a d of p r e s e n t i n g a d i s c u s s i o n of r o l e s e l e c t i o n o r ways of  b e i n g accepted  by C l i n i c  to  non-  observer:.  T h i s p r i o r c o n c e p t i o n of f i e l d r e s e a r c h was d u r i n g my  and  s t a f f , I examined what I r e f e r r e d to as  207  the demand c h a r a c t e r i s t i c s of a researcher i n a research s e t t i n g . That i s , instead of g i v i n g the standard f i e l d work t o p i c s a p r i v i l e g e d p o s i t i o n , I placed those t o p i c s w i t h i n the a c t u a l i n t e r a c t i o n a l context of doing f i e l d research.  The focus of the chapter was  thus  d i r e c t e d towards the examination of those s i t u a t i o n a l and contextual features i n which I found myself while a researcher at the C l i n i c . The reader w i l l remember that my own experience demonstrated that 1) the d i s t i n c t i o n between p a r t i c i p a n t and non-participant observer lacked substance, 2) the manner i n which a researcher's i d e n t i t y i s developed may be dependent on the s e t t i n g ' s members rather on the r e searcher, and 3) that t h i s i d e n t i t y s e l e c t i o n can lead to c e r t a i n e t h i c a l problems.  While i t i s p o s s i b l e to maintain the d i s t i n c t i o n  between p a r t i c i p a n t or non-participant observation or between e t h i c a l and non-ethical research p r a c t i c e s , these may have to be discarded i f one i s to focus on the doing of f i e l d work and to i n v e s t i g a t e the d a i l y demands placed upon the f i e l d researcher as they are t r a n s l a t e d into courses of a c t i o n . Chapter four suggests that f u r t h e r research i n t o the d a i l y contingencies of the f i e l d researcher and of the a c t u a l problems that r e searchers encounter i n t h e i r a c t i v i t i e s could provide the appropriate basis f o r a d i s c u s s i o n of how the research s i t u a t i o n can become a source of data f o r an i n v e s t i g a t i o n i n t o the methodology of f i e l d work. In chapter three I presented an i n t e r a c t i o n a l a n a l y s i s of chart rounds.  A segment of t r a n s c r i p t was examined and, from t h i s apparently  u n i n t e r e s t i n g , mundane m a t e r i a l , . i t was p o s s i b l e to discover the f o l lowing general features of t h i s occasion:  1) How C l i n i c s t a f f resolve  208  the termination of t a l k about one p a t i e n t ' s chart and a progression to the next, thereby accomplishing a s o l u t i o n to what was termed the "progression problem", 2) A p a t i e n t ' s name i s often not s u f f i c i e n t to r e f e r e n t i a l l y i d e n t i f y him to members of the s t a f f , 3) A p a t i e n t ' s medical chart c o n s t i t u t e s a document-in-use throughout the occasion of chart rounds, and can be consulted to determine h i s reason f o r a v i s i t to the C l i n i c , and 4) Physicians tend to view p a t i e n t s ' medical careers as s t a t i c between v i s i t s even though such a view i s subject to transformation upon an a c t u a l medical encounter with the p a t i e n t . That the C l i n i c s t a f f i s able to adduce a p a t i e n t ' s reason f o r a v i s i t during the occasion of chart rounds provides some i n s i g h t i n t o the workings of organizations.  The reader w i l l remember that the C l i n i c  i s regarded by s t a f f as a new and innovative type of medical treatment :•: facility. s i o n a l s who  I t i s s t a f f e d by a group of h i g h l y - t r a i n e d medical p r o f e s are i d e a l i s t i c about the p o t e n t i a l i t i e s f o r community  medical care.  They regard the C l i n i c as something d i s t i n c t l y d i f f e r e n t  from other, more conventional medical p r a c t i c e s . Yet, despite t h i s progressive i d e o l o g i c a l p p e r s p e c t i v e , c l o s e r examination  shows that the  C l i n i c d i s p l a y s some of the standard and i n v a r i a n t features of any o r ganization.  Thus, during chart rounds, C l i n i c s t a f f r o u t i n e l y provide  reasons f o r p a t i e n t ' s seeking medical a t t e n t i o n . Chart rounds i s not an occasion s p e c i f i c a l l y designed to adduce a p a t i e n t ' s a c t u a l reason f o r a v i s i t to the C l i n i c .  However, adducing  a p a t i e n t ' s reason f o r a v i s i t i s an o r g a n i z a t i o n a l outcome of chart rounds. ^ T h i s method of determining a p a t i e n t ' s reason f o r a v i s i t  209  runs contrary to a l a y notion of medical p r a c t i c e :  "the p h y s i c i a n  should always expect the worst when seeing a p a t i e n t , " that i s , "be f u l l y a t t e n t i v e to any possible manifestation of disease."  Contrary  to t h i s l a y notion, physicians f i n d t y p i c a l courses of a c t i o n that can account f o r the p a t i e n t scheduling a v i s i t to the C l i n i c .  They do not  t y p i c a l l y view the v i s i t as something generated by an open f i e l d of contingencies.  Rather, once a "reason f o r a v i s i t " i s found, i t i s  treated o r g a n i z a t i o n a l l y and " u n t i l f u r t h e r n o t i c e " as the reason for a v i s i t . Thus, despite the progressive ideology of the C l i n i c , the a n a l y s i s of chart rounds found that the C l i n i c e x h i b i t s standard properties of organizations.  The C l i n i c s t a f f c o n s t i t u t e s a group of experts dealing  with a c l i e n t e l e .  As such, they have standard formats for r o u t i n i z i n g  contacts with that c l i e n t e l e and ways of dealing with c l i e n t s that are economic i n terms of time and energy, etc.  To propose t h i s as a feature  of C l i n i c organization i s not to adopt a c y n i c a l a t t i t u d e towards the C l i n i c or i t s operation, but rather to demonstrate that, even i n a s e t t i n g which subscribes to an avant-garde concept of medical p r a c t i c e , one w i l l f i n d c e r t a i n standard and i n v a r i a n t occupational routines and o r ganizational structures. I have paid r e l a t i v e l y l i t t l e a t t e n t i o n r t o many of the areas of l i f e w i t h i n the Community C l i n i c ; areas such as  substantive  doctor-patient  i n t e r v i e w s , p h y s i c a l examinations, laboratory procedures, medical d i a gnosis, and so f o r t h .  This l a c k of a t t e n t i o n i s not stated a p o l o g e t i c a l l y .  As an ethnographer w i t h i n the C l i n i c I had no t h e o r e t i c a l framework that  210  provided me with a " s e r i a l " o r i e n t a t i o n toward ethnographic tion.  In many ways t h i s proved advantageous.  descrip-  Let me elaborate t h i s  point. T r a d i t i o n a l a n t h r o p o l o t i c a l ethnographers attempt to study some peoplej group, t r i b e or s o c i e t y .  The ethnographer i s regarded as havin  an e x p e r t i s e w i t h reference to such a group.  The product of such ethno  graphic research i s u s u a l l y a monograph which consists of the component i a l features of the c u l t u r e . F i r t h , f o r example, i n h i s work on the Tikopia has chapters on marriage r e l a t i o n s h i p s , f a m i l y , c i r c l e s , land tenure, and v i l l a g e l i f e .  E i t h e r the f a c t that these components o r i g i -  nate from the same s e t t i n g provide a sense of u n i t y , or e l s e the ethnographer i s forced to f i n d t h e o r e t i c a l connections between these components which give the ethnographic  report a sense of .unity.  I did not  have a research framework that would allow (or force me) to presume that a c o l l e c t i o n of topics from one substantive area would c o n s t i t u t e an adequate ethnography of the C l i n i c , nor d i d I have a t h e o r e t i c a l framework that would allow me to generate arguments f o r my ethnography to contain such a s e r i a l c o l l e c t i o n of d e s c r i p t i v e t o p i c s . Admittedly, I could have proposed f u r t h e r analyses of other aspects of c l i n i c o r g a n i z a t i o n , but f o r what reason?  From m a t e r i a l  discussed i n chapter one, i t should be apparent that to adopt such a conception of ethnographic d e s c r i p t i o n would be to adopt an u n a t t a i n able goal since no matter how much one attempted to describe, i t i s impossible to describe everything.  I am not r e f e r r i n g to the problem  that psychologists might c a l l a stimulus overload, i . e . , that there i s  211  so much impinging on the human senses t h a t i t i s i m p o s s i b l e  to d e s -  c r i b e a l l t h a t our senses r e a c t t o . Rather, I mean t h a t , as a n a l y s t s , we have no c o n c e p t i o n "everything"  o f what would be n e c e s s a r y t o d e s c r i b e t h e  o f some c u l t u r a l s e t t i n g o r o c c a s i o n ,  covered to be d e s c r i b e d  ±s_ d e s c r i b e d  whatever i s d i s -  and whatever s e t o f i n t e r e s t s o r  r e l e v a n c i e s the ethnographer has d i c t a t e s t h e c h a r a c t e r cription.  of that des-  As a n a l y s t s , we do n o t have a sense o f the d e s c r i p t i o n o f  a s e t t i n g standing  i n r e l a t i o n s h i p to t h a t s e t t i n g i n the same way t h a t  the items o f f u r n i t u r e o f a room stand  tQ t h a t room.  v e n t o r y o f the p r o p e r items t o be d e s c r i b e d  There i s no i n -  i n doing ethnographic des-  c r i p t i o n ; and i t i s argued t h a t t o adopt a c o n t r a r y n o t i o n  i s not a  v i a b l e way of l o o k i n g a t the world as an o b j e c t o f study. An  a l t e r n a t i v e to t h i s s e r i a l s t r a t e g y might be t o examine a  s i n g l e bounded a c t i v i t y , s e t t i n g , o r o c c a s i o n  and focus  on i t i n some  detail.  T h i s was the procedure f o l l o w e d  rounds.  I t i s apparent t h a t , a l t h o u g h we l i m i t e d our focus  to t h i s one a c t i v i t y w i t h i n the C l i n i c ,  i n our examination o f c h a r t of attention  t h e r e was, n e v e r t h e l e s s ,  i n f i n i t e amount o f d e t a i l to be d i s c o v e r e d  and attended t o .  an  Thus such  a procedure should  n o t be presumed t o have a minimal amount o f ethno-  graphic  Because no e x h a u s t i v e d e s c r i p t i o n i s p o s s i b l e , i t  interest.  seems a r e a s o n a b l e procedure t h a t we f i n d some d e s c r i b a b l e a s e t t i n g from which i t may be p o s s i b l e to d i s c o v e r g e n e r a l i z a b l e t o other The  feature of  features  that are  s e t t i n g s and o c c a s i o n s .  m a t e r i a l s p r e s e n t e d i n the a n a l y s i s o f c h a r t rounds a r e i d e n -  tdefv'ira&bly r e c u r r e n t p a r t i c u l a r s f o r the members o f the C l i n i c .  They  212  are features oriented to by the p a r t i c i p a n t s to chart rounds as constituent features of the members' world w i t h i n the research s e t t i n g . Where do such findings now lead us?  I t seems that the p a r t i c u l a r s d i s -  covered v i a an examination of an occasion with t h i s medical context may be the raw m a t e r i a l of s o c i a l l y - o r g a n i z e d a c t i v i t i e s that occur at any time or place.  While they are located by the p a r t i c u l a r s i n  t h i s medical s e t t i n g , they seem to be instances of " c u l t u r a l l o g i c s " that materials from other s e t t i n g s and occasions could be organized around; that i s , they seem to have the capacity to organize s e t t i n g s and occasions.  other  Thus, from a d e t a i l e d examination of one  instance of c l i n i c a c t i v i t y , i t may be possible to engage i n f u r t h e r research i n t o these c u l t u r a l l o g i c s rather than proceeding by examining f u r t h e r materials from other medical s e t t i n g s . An i l l u s t r a t i v e example of t h i s l a t t e r point i s found i n Sudnow's a n a l y s i s of "unit news" i n h i s ethnography Passing On:  The S o c i a l Or-  1  ganization of Dying.  He found that once a death occurred w i t h i n a  f a m i l y , n o t i f i c a t i o n of that death to other family members was a soc i a l l y - o r g a n i z e d phenomenon.  However, the t o p i c of " u n i t news" i s not  r e s t r i c t e d to the announcement of a family death nor to h o s p i t a l s e t tings but becomes a feature of everyday l i f e , a v a i l a b l e f o r other ethnographers to i n v e s t i g a t e v i s - a - v i s other s e t t i n g s .  S i m i l a r l y , I am sug-  gesting that the a n a l y s i s of chart rounds has provided us with materials that have the capacity to organize other s e t t i n g s and occasions. not proposing,that  I am  one should compare t h i s a n a l y s i s of chart rounds with  other analyses of s i m i l a r medical a c t i v i t i e s , but that f u r t h e r research  213  s h o u l d be d i r e c t e d  towards how f e a t u r e s d i s c o v e r e d from an examination  of t h i s c l i n i c c o u l d be found o p e r a t i v e i n o t h e r s e t t i n g s and o c c a s i o n s . C o n c l u d i n g Remarks A d i s s e r t a t i o n t y p i c a l l y ends by p r e s e n t i n g the r e a d e r w i t h a concluding chapter.  The format  f o r such a chapter u s u a l l y c o n t a i n s n o t  o n l y a summary o f the main p o i n t s o f the d i s s e r t a t i o n , but a l s o an assessment o f t h e i r s i g n i f i c a n c e f o r the t o p i c ( s ) under  examination.  I t i s n o t uncommon to end w i t h a d i s c u s s i o n o f p o s s i b i l i t i e s f o r f u r ther research.  The p r e c e d i n g m a t e r i a l s o f t h i s c h a p t e r conform to such  e x p e c t a n c i e s f o r the ending of a d i s s e r t a t i o n .  I have p r e s e n t e d a sum-  mary o f the h i g h l i g h t s and f i n d i n g s o f each o f t h e c h a p t e r s and some suggestions f o r f u r t h e r research.  I f e e l , however, t h a t t h i s does n o t  c o n s t i t u t e an a p p r o p r i a t e way i n which to end t h i s r e p o r t .  L e t me  elaborate. While  i t i i s p o s s i b l e to r e g a r d the p r e v i o u s s e c t i o n o f t h i s  chapter  as e x p l i c a t i n g the c o n n e c t i o n s between each o f the p r e c e d i n g c h a p t e r s and as o f f e r i n g p r o p o s a l s f o r f u r t h e r r e s e a r c h , to do so would h e t n o t to d i s r e g a r d f u r t h e r p o s s i b l e d i s c o v e r i e s about the s t a n d a r d format, b u t a l s o t o m i s r e p r e s e n t  ethnographic  the f i n d i n g s o f t h i s r e p o r t as w e l l .  T h i s r e p o r t has looked back upon c e r t a i n o f i t s s e c t i o n s as d a t a which to generate  an a n a l y s i s .  only  from  I would t h e r e f o r e l i k e t o end t h i s  r e p o r t by a d o p t i n g t h i s procedure  and c o n s i d e r i n g the p r e v i o u s s e c t i o n s  of t h i s chapter as d a t a from which t o d e r i v e f u r t h e r f e a t u r e s o f the s t a n d a r d ethnographic  format.  T h i s procedure w i l l a l s o a l l o w me to ex-  e m p l i f y the d i f f e r e n c e s between t h i s r e p o r t and a s t a n d a r d description.  ethnographic  214  I t appears to be a standard  f e a t u r e o f an ethnography t h a t one's  r e p o r t ends w i t h what may be d e s c r i b e d as a " s a t i s f y i n g " c o n c l u s i o n . By t h i s I mean t h a t t h e ethnographer does n o t f i n d t h a t h i s ethnography has,  f o r example, no t e r m i n a t i o n p o i n t , n o r i s i t the case t h a t i t  l e a v e s the ethnographer without  any r e s o l u t i o n t o h i s o r i g i n a l  task  or t h a t he f i n d s t h a t t h e r e a r e more problems a t the end o f h i s r e p o r t then when he s t a r t e d h i s r e s e a r c h .  I i n t e n d ho c y n i c i s m  to t h i s c o n c l u s i o n as s a t i s f y i n g , but merely wish t o note p o s s i b i l i t i e s noted of an e t h n o g r a p h i c  in.referring t h a t a l l o f the  above a r e p e r f e c t l y p l a u s i b l e and p r o b a b l e report.  Y e t , the ethnographer i s somehow  outcomes  expected  to end h i s work w i t h a t i g h t - k n i t c o n c l u s i o n t h a t a l l o w s ' t h e  reader  to "see" the major f i n d i n g s and h i g h l i g h t s o f the r e s e a r c h .  In pro-  v i d i n g such a c o n c l u s i o n , the reader can view the e t h n o g r a p h i c  des-  c r i p t i o n n o t o n l y as a d e s c r i p t i o n o f some c u l t u r a l s e t t i n g , but a l s o as a p i e c e o f r e s e a r c h h a v i n g some o v e r a l l t h e o r e t i c a l r e l e v a n c e . When I l o o k back upon the p r e c e d i n g c h a p t e r s o f t h i s r e p o r t , I f i n d t h a t they do n o t c o n t a i n any r e a l t e r m i n a t i o n p o i n t s n o r do they p r o v i d e any r e s o l u t i o n s t o major i s s u e s .  Rather,  the c h a p t e r s  a s e r i e s o f t o p i c s t h a t I have c o n s i d e r e d as a r e s u l t o f my i n the r e s e a r c h s e t t i n g .  represent  experience  A l l t h a t these c h a p t e r s have i n common i s t h a t  they were t o p i c s I ' c o n s i d e r e d .  Thus, the c o n n e c t i o n s  c l a i m e d i n the p r e -  c e d i n g s e c t i o n o f t h i s c h a p t e r c o n s t i t u t e what I r e g a r d as " a n a l y s t s ' c o n n e c t i o n s " r a t h e r than any n e c e s s a r y research report i s d i f f e r e n t  connection.  from a standard  I n t h i s r e s p e c t , my  ethnography and an examina-  t i o n o f t h i s d i f f e r e n c e r e v e a l s 1) what those f e a t u r e s o f t h e standard  215  standard ethnographic format are, and 2) how my report d i f f e r s from these features. The standard ethnographic format seems to make two claims that t h i s research report i s not making.  F i r s t , ethnographies e i t h e r i m p l i -  c i t l y or e x p l i c i t l y claim that they have covered at l e a s t some feature of t h e i r s e t t i n g with a reasonable degree of comprehensiveness haustiveness.  and ex-  That i s , the ethnographer has done enough research on  some aspect of the s e t t i n g to be i n a p o s i t i o n to o f f e r a coherent c l e a r , and a u t h o r i t a t i v e report of the t o p i c he i n v e s t i g a t e d . With reference to t h i s f i r s t p o i n t , my own research at the C l i n i c does not f o l l o w such a format.  While my research report contains some  items that I have discovered i n the research s e t t i n g , my report does not purport to be an exhaustive d e s c r i p t i o n of some feature of the Clinic.  Rather, i t i s a discussion of two or three topics that were  touched o f f by my being i n the s e t t i n g -— topics that I f e l t I was able to w r i t e about i n an i n t e r e s t i n g way. preceding pages.  These topics are c o l l e c t e d i n the  They do not have the r e l a t i o n s h i p to one another that  the standard ethnographic format would seem to require.  That i s , that  chapters are sequential and s e r i a l and b u i l t upon each other, or that one chapter concefns one aspect of the research s e t t i n g and another chapter deals with some other aspect such that, when the reader has covered a l l of the m a t e r i a l , he w i l l have a complete d e s c r i p t i o n of the s e t t i n g . have attempted to do n e i t h e r .  I  Instead I have talked about a few topics  that were made a v a i l a b l e to me by v i r t u e of having been a researcher at the C l i n i c .  I make no apologies f o r these topics not having the  216  relatedness required by the standard ethnographic format. The second claim of the standard ethnographic format i s that i t contributes to the cumulative knowledge about some c u l t u r e or p a r t i cular feature thereof. That i s , an ethnographic report i s not viewed as j u s t a d e s c r i p t i o n of some c u l t u r e or features of a c u l t u r e , but also as an i n t e g r a l part of the knowledge now a v a i l a b l e on a c u l t u r e or culturalfeature.  Hence, other researchers wishing to study that c u l t u r e should  read the ethnographic report since i t c o n s t i t u t e s a component of the corpus of relevant l i t e r a t u r e on that which i s to be examined.  Just as  c e r t a i n m a t e r i a l s help the nuclear p h y s i c i s t to keep abreast of recent developments i n h i s f i e l d , so the ethnographer's report i s seen as cont r i b u t i n g to a cumulative body of knowledge on some aspect of a culture's organization and should be read by other ethnographers embarking on r e search i n the same area. My research, however, does not have t h i s cumulative character and thus departs from the standard ethnographic format. discussed are not n e c e s s a r i l y s e t t i n g - r e l a t e d t o p i c s .  F i r s t , the topics By t h i s I mean  that anyone else doing an ethnography of a medical c l i n i c or s e t t i n g need not read t h i s report since i t w i l l not n e c e s s a r i l y t e l l them anything they should know i n order to conduct t h e i r own research.  Secondly, I  am proposing that what I have done, a l b e i t an a n a l y t i c a l account,is through and through a common-sense one which does not propose to have used a s c i e n t i f i c method whereby there i s some p o s s i b i l i t y of "cumul a t i v e " findings.  Rather, t h i s report c o n s i s t s of a s e r i e s of a n a l y t i c a l ,  accounts of various topics the usefulness of which remains to be  217  discovered. of v a r i o u s readers;  By  t h i s I mean t h a t a l t h o u g h they are a n a l y t i c a l accounts  t o p i c s , I cannot f o r e t e l l t h e i r u t i l i t y  and  f o r me  to propose t h a t they w i l l be u s e f u l would be  propose an incompleteness t h a t c o u l d be to spend some time and report. ceding  energy p u r s u i n g  I r e j e c t t h i s contention  and  remedied were some the t o p i c s d i s c u s s e d  regard  c h a p t e r s as i n h e r e n t l y i n c o m p l e t e .  to  researcher in this  the m a t e r i a l s  of the  pre-  In t h i s r e s p e c t  I'find  my-  s e l f i n agreement w i t h Blum and McHugh's c o n c e p t i o n They s t a t e  f o r subsequent  of u n f i n i s h e d work.  that:  Another important matter i s the s t a t u s o f the phrase " u n f i n i s h e d work." That our papers are not f i n i s h e d does not d i s t i n g u i s h them from o t h e r p i e c e s of s o c i o l o g y . Rather, the d i f f e r e n c e i s t h a t our incompleteness i s grounded whereas t h e i r s i s t r e a t e d as happenstance. C o n s i d e r , f o r example, one n o t i o n of the f u t u r e of f u n c t i o n a l a n a l y s i s . Committed f u n c t i o n a l i s t s w i l l o f t e n acknowledge, t h a t f u n c t i o n a l i s m has f l a w s . However, these flaws (a k i n d of incompleteness) are t r e a t e d as t h i n g s to be r e p a i r e d i f o n l y . . . . I f o n l y f u n c t i o n a l i s t s had the w i t , the e x p e r i e n c e , the f o r e s i g h t , or e s p e c i a l l y the money. The f u t u r e f o r these p e o p l e becomes the time — sooner or l a t e r -r~ when the money w i l l accumulate and temp o r a r y f a i l u r e s become permanent s u c c e s s e s . F a i l u r e s are n o t h i n g to worry about because, by the n a t u r e of the case, they are temporary. A theory has d e f e c t s o n l y because the t h e o r i s t happens to be s i t u a t e d i n time, space, i n an economic s t r u c t u r e . T h i s r e l a t i v i z a t i o n to the c o n d i t i o n s o f f a i l u r e i s a p e r f e c t method f o r managing i n a Goffmanesque sense, but i t h a r d l y comes to g r i p s w i t h the t r o u b l e . By a n t i c i p a t i n g t e r m i n a t i o n , they t h i n k t h e i r work w i l l come to have the f i n a l c h a r a c t e r . They are o r i e n t e d to the p o s s i b i l i t y o f c l o s u r e and i t i s i n terms o f t h i s t h a t they measure success and f a i l u r e . We say, on the c o n t r a r y , t h a t our work, because of the the n a t u r e of a n a l y s i s , w i l l always be i n need of repair.^  218  Throughout t h i s r e p o r t I have proposed procedures used  a c r i t i q u e o f the s t a n d a r d  i n the c o n s t r u c t i o n o f e t h n o g r a p h i c r e p o r t s .  f e r e d some a l t e r n a t i v e s t o u t i l i z i n g  1  I have o f -  m a t e r i a l s from r e s e a r c h s e t t i n g s .  I have been f o r c e d to r e c o n s i d e r many o f the i s s u e s i n v o l v e d i n ethnog r a p h i c d e s c r i p t i o n s i n c e , over the course o f my ethnography, e v i d e n t t h a t i t was n o t a d h e r i n g to a standard e t h n o g r a p h i c  i t was format.  Thus I r e g a r d t h i s r e p o r t n e i t h e r as a " p e r v e r s e " a l t e r n a t i v e t o the s t a n d a r d e t h n o g r a p h i c format, n o r as a c r i t i c i s m o f eitfaawography• Rather,  I have taken the t a s k o f p r o d u c i n g an e t h n o g r a p h i c  s e r i o u s l y and have produced  some r e f l e c t i o n s about  description  the p r o d u c t i o n o f  such d e s c r i p t i o n s t h a t may be worth c o n s i d e r a t i o n n o t o n l y by e t h n o g r a p h e r s , b u t b y ' o t h e r s o c i a l s c i e n t i s t s as w e l l . Ihisum, w h i l e i t might be p o s s i b l e f o r the r e a d e r t o assume t h a t t h i s d i s s e r t a t i o n has been concerned  w i t h improving e t h n o g r a p h i c  methods and p r a c t i c e s , t h i s i s n o t t h e c a s e .  Nor i s t h i s  field  dissertation  intended as a c o n t r i b u t i o n t o the s u b s t a n t i v e l i t e r a t u r e on m e d i c a l s o c i o l o g y even though i t has examined m a t e r i a l s from a m e d i c a l  setting.  A l t h o u g h i t has d i s c u s s e d e t h n o g r a p h i c f i e l d work i n some d e t a i l ,  this  d i s s e r t a t i o n i s i n t e n d e d to be a c o n t r i b u t i o n t o a s m a l l but growing l i t e r a t u r e i n a n t h r o p o l o g y and s o c i o l o g y which t r e a t s t h e d o i n g o f . f i e l d work as the o c c a s i o n f o r r e f l e c t i n g upon t h e o r e t i c a l  issues.  These i s s u e s have to do w i t h the w a r r a n t i n g o f knowledge and the possibilities  o f t r a n s c e n d i n g everyday  experience.  219  Footnotes:  Chapter F i v e  1.  David Sudnow, P a s s i n g On: The S o c i a l O r g a n i z a t i o n o f D y i n g , (Englewood C l i f f s , New J e r s e y : P r e n t i c e H a l l , 1967. (j^.u.5_Lfci <jijod C l i r f s , New .$  2.  P e t e r McHugh and A l l a n Blum e t a l , On the Beginning o f S o c i a l I n q u i r y , (London: Routledge and Kegan P a u l , 1974), p. 3.  <  220  BIBLIOGRAPHY  A u s t i n , J.L., P h i l o s o p h i c a l Papers, Second E d i t i o n . U n i v e r s i t y P r e s s , 1970.  Oxford:  Berreman, G e r a l d D., "Anemic and Emetic A n a l y s i s i n S o c i a l American A n t h r o p o l o g i s t , V o l . 68, 1966, pp. 346-354.  Oxford  Anthropology",  Berreman, G e r a l d D., " S o c i a l C a t e g o r i e s and S o c i a l I n t e r a c t i o n i n Urban India", American A n t h r o p o l o g i s t , V o l . 74, 1972, pp. 567-586. Chomsky, Noam, Aspects of the Theory of Syntax, Cambridge: M.I.T. 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