“Let's Speak in Order”: Diagnostic Interview in a Psychiatric Ward as a Performance

Abstract

Medical doctors arrive at a diagnosis after considering various types of evidence, including the patient's complaints, their outer appearance, talk, and non-verbal behavior. In psychiatry, the role of conversation is more important than in somatic medicine, because it is in the patient's talk that the disease can express itself. Some elements of the conversational machinery have been studied in diagnostic interviews in a psychiatric ward. In the interviews, a recurrent pattern of the doctor’s questions and the patient’s answers was found. Schegloff (2007) showed that “known answer” questions form a distinctive three-part sequence type: question-response-evaluation. In diagnostic interviews in psychiatry, the questions don't address knowledge but the capacity to perform the task. Not all the test questions have a correct answer, and the result of the evaluation is not always announced by the doctor. The doctor consistently repeats the patient’s answer without evaluating it and then adds a follow-up question. At least parts of the repeated cycles in the sequence of doctor-patient interaction exhibit the following pattern: Doctor’s question > Patient’s answer > Doctor’s echo > (optional Doctor's follow-up question). When the doctor's questions seek real information—and do not just test capacity—they sometimes resort to a reformulation of the patient’s answers instead of just repeating it; this reformulation works as a prompt. The questions in the clinical interview appear to follow two lines of accountability: the ordinary conversational order and that which is provided by the professional reasoning aimed at checking diagnostic hypotheses. The second line is not usually accessible to the patient.