Cosmetic surgery can be seen as a quintessential example of medicalization (Conrad, 2007; Dull & West, 1991; Sullivan, 2000), a process in which human conditions that were once merely considered problems with living are treated as medical conditions (Szasz, 2007), from baldness (Conrad, 2007) to the transformation of childbirth (Ehrenreich & English, 1978; Riessman, 1983; Wertz & Wertz, 1977). However, little has been studied on how doctors and patients take lifeworld issues such as cosmetic appearance and transform them into conditions worthy of surgical intervention.With the exception of Julien Mirivel (2002, 2005, 2007, 2008, 2010), there has been little work done using face-to-face, real time interactions between cosmetic surgeons and patients, as opposed to post hoc perceptions (Dull & West, 1991; Davis, 1994, Gimlin, 2007; Brooks, 2004). In doctor-patient interactions, most identity work and presentations of self occur early in the problem-presentations phase when patients disclose their concerns (Heritage & Robinson, 2006).Videos of initial cosmetic consultations between 19 patients and one cosmetic surgeon in a Beverly Hills practice were examined through conversation analysis and ethnomethodological principles. Of particular focus were patients’ language practices in performing the role of cosmetic surgery patient. Findings were supported with ethnographic observations. The process of becoming a cosmetic patient, what Harvey Sacks calls “doing being a patient” (1984), is performative and involves an identity that is mutually co-constructed in the course of interaction. Interactional norms of medicine are actively being enacted and expanded to fit the commercial contingencies of cosmetic medicine. In this study, patients received medically relevant responses only when their concerns invited medical evaluation, delineating a clear boundary between patient and consumer. Through interaction with the surgeon, patients legitimized seeking intervention by transforming aesthetic desires into medical concerns. Patients were also socialized into the role of cosmetic surgery patient by acquiring the ability to discuss their appearance in a medically appropriate fashion through interaction with the surgeon. In order to be seen as viable surgical candidates, patients managed tensions between conflicting sets of interactive norms to perform “being a patient” in an environment in which issues of health were virtually absent.

When patients visit their primary care physician with some new health concern, they bring along their own ideas or worries about what might be wrong and expectations for how the visit might go. Patients are more engaged in their healthcare than ever before, and patient-centered care advocates have long emphasized the importance of pursuing and addressing the patient perspective. Yet in clinical encounters, both patients and physicians maintain an orientation to the physician’s medical authority and the primacy of the biomedical perspective. Patients often feel unheard, and their concerns remain unmet. This may at least partially be due to the interactional structure of primary care encounters, which is shaped by a legacy of medical paternalism. When patients have lingering concerns after a physician has assessed their condition, they have limited interactional opportunities for raising those concerns. In this dissertation, I use conversation analysis and recordings of primary care visits to examine diagnosis resistance, one resource patients use to raise concerns about the fit between a physician’s assessment of their condition and their own experience or expectations. I find that patients resist more often than previously thought, especially when the physician’s assessment of their problem diverges from their own. But patients resist carefully, relying primarily on actions that present the least overt threat to the physician’s medical authority. In turn, physicians tend to respond in ways that prioritize their own agenda over attending to or pursuing patient concerns. This is made easier by the fact that patients resist in the least overt ways to begin with. These findings suggest a tension between patient engagement and a legacy of medical paternalism. Patients are working to get their concerns addressed, but are undermining their own efforts by strongly deferring to the physician’s authority to assess their problem in the first place. In order for healthcare to more adequately attend to, respect, and treat as central the patient’s perspective, more work is needed to find ways for practices like pursuing and attending to the patient’s perspective to become a clinical reality, rather than the aspiration they currently are.

By examining different features of turn design, this conversation-analytic dissertation investigates a range of “account-able” “members’ resources” (Garfinkel 1967) that are mobilized by participants in the service of intersubjectivity, progressivity, and the interactional negotiation thereof.

First I describe the structure and interactional use of what I term the ‘do-construction’ in English-language conversation (e.g., The kids do eat cake; cf. The kids eat cake). It is illustrated that, across a variety of sequential positions and in conjunction with a range of social actions, this construction is used consistently to index a contrast. After establishing the contrastive work that this resource accomplishes as a general feature of turn design, I consider how the use of the do-construction can be seen to be relevant to particular sequences of action, and conclude with a discussion of the relationship between this grammatical construction and ‘embedded other-correction’ (Jefferson 1987).

Chapter 3 reports on a subset of do-construction cases in which the contrast indexed through use of the do-construction is not with the content proper of a prior utterance or sequence of utterances, but rather with a potential implication thereof. That is, this grammatical resource is routinely mobilized to index contrasts not only with explicit or otherwise demonstrated understandings (as in the majority of the cases in Chapter 2), but also with possible ambiguities and potential misapprehensions that might be gleaned from prior talk. Through the use of the do-construction in such contexts, speakers can be seen to be actively holding themselves and one another accountable for the commonsense inferences (Garfinkel 1967; Sch?tz 1962) that prior talk may have generated, while simultaneously working to refine and shore up the shared understanding being developed with their hearers.

Chapter 4 takes as its point of departure the distinction between “unmarked” and “marked” progressivity across turns within a sequence (Heritage 2013, 2015, frth.), examining two turn-initial particles in Spanish: bueno and pues. The chapter argues that both bueno and pues preface some “unexpectedness” to come in the responsive turn, but a different sort of “unexpectedness” is foreshadowed by each particle. I demonstrate that bueno-prefaced turns do not overtly problematize the prior utterance, but rather accept its terms before departing from them, and thereby acquiesce to the prior turn’s design (albeit a marked form of acquiescence compared to a turn that is not qualified with a turn-initial particle). Pues-prefaced responses, on the other hand, are directly addressed to the prior turn, but they cast that prior turn’s action or design as problematic in some way. That is, rather than acquiescing to the terms of the first-position utterance (as with bueno), pues-prefaced responses target and problematize some aspect of the prior turn, thereby noticeably ‘pushing back’ on, for example, its presuppositions or epistemic stance. In this way, pues-prefacing is also a harbinger of “unexpectedness”, but, contrary to the case of bueno, the unexpectedness of pues derives from the second speaker’s comparatively on-record registration of difficulty with the terms set for response by the prior turn, as opposed to his/her tacit acceptance thereof.

The final substantive chapter of this dissertation aims to unpack Schegloff’s (2007a: 15) reference to “the measure of progressivity” by arguing that progressivity must be conceptualized as a scalar phenomenon. That is, rather than yes-progressivity vs. no-progressivity (i.e., as a binary or dichotomous variable), participants in interaction can be seen to orient to the existence of a continuum from more-progressivity to less-progressivity. Moreover, in addition to being better aligned with participants’ own understanding of this feature of interaction, it is demonstrated that such an analytic reconceptualization provides an important new dimension on which to examine various practices deployed in naturally occurring talk, as we equip ourselves with a means to ask not only whether a turn is moving forward vs. backward, but also how much.

The dissertation concludes with a discussion of the inextricable links between intersubjectivity and progressivity as accountably scalar phenomena.

Taken together, the chapters of this dissertation argue that intersubjectivity, progressivity, and accountability must be conceptualized as collaboratively constructed features of interaction that are achieved on a moment-by-moment basis, in and through the details of quotidian conduct. Exploration of such practices therefore sheds important light on the ground-level means through which we negotiate and maintain social life with one another.

Objective

Methods

Results

Conclusions

Practice implications

This dissertation analyzes video-recordings of general surgery office visits in order to investigate when and how patients initiate additional concerns, and investigates why some patient-initiated additional concerns are more likely to receive the surgeon’s help than others. This dissertation also examines how surgeons themselves initiate additional concerns during the office visit, and the interactional dilemmas they face when telling the patient about this new area of concern. In other words, how do patients and doctors try to introduce extras into the interactions, how do they formulate them as legitimate, and how are they recognizable?

Additional concerns are medical problems (e.g., pain, skin lesions, hernias) that are seemingly unrelated to the main reason for the visit. This analysis utilized a mixed-methodology approach combining Conversation Analysis, ethnography, interviews, and statistics. Data are video recordings of pre- and post-operative office visits for hernia repairs, colonoscopies, and cholecystectomies, with a longitudinal focus of following patients across consecutive visits.� This community-based study, set in rural Texas, serves as an example of the importance of incorporating the setting and context into analysis, and shows that rural patients raise additional concerns frequently and early in their visits.

Patient-initiations of additional concerns were analyzed by looking at their turn design and position in order to assess what characteristics contributed to them receiving "help" by their general surgeon. This analysis identified where in the visit’s phase-structure these concerns arose and three methods patients used to launch them: fitted to method, fitted to topic, or disjunctive. Each concern was coded and analyzed for a variety of design features (e.g., lexical choice, social action, first or subsequent mentions) and contextual factors (e.g., concern falls inside or outside the surgeon’s domain of expertise, patient mentions another doctor in relation to this concern, the degree of the relationship between the surgeon and patient). In total, 62 patients spanning 175 visits were coded with 377 patient-initiated concerns found. 188 of them ultimately received help.

Next, surgeon-initiations of additional concerns were analyzed for their turn-design, position, and function, with a focus on when surgeons perceptually notice a physical abnormality on the patient’s body and how they discussed this with their patient. Only 22 surgeon-initiated additional concerns were found in the data collection, and this analysis argues that this is because surgeons orient to raising additional concerns as first-position dispreferred actions. As the analysis reveals, surgeons must cope with several interactional dilemmas when presenting them, including patient awareness, rights to assess, health optimization, and other contextual factors. By investigating how rural patients and surgeons initiate and discuss additional concerns, this dissertation shows how the surgeon’s domain of practice consists of permeable boundaries that are negotiated, constituted, and enacted during visits.

In the last twenty-five years the media has undergone major changes, moving fully from a broadcast model to cable and beyond. One effect of this change has been shifts in how politicians reach voters, particularly when campaigning. This has lead to politicians seeking out voters in venues that would have previously been considered beneath the dignity of their office. This, along with other shifts, has lead some critics to suggest that news is becoming corrupted, but others have suggested that news in merely evolving along with technology and culture. This project seeks to understand some of these shifts by investigating both entertainment talk shows, which have become a locus of political interviews, as well as interviews on cable news. Using qualitative and quantitative methods this project seeks to chart the norms of the talk show interview, how these norms shift in the face of a political interviewee, and how cable news norms differ from or not broadcast news norms. Using conversation analysis, chapter three of this dissertation finds two norms drive the talk show: personalization and congeniality. These contrast with the norms that drive news interviewing: neutralism and adversarialness. In the chapter four interviews are coded and compared statistically, showing that when a political guest appears on a talk show a mix of norms are used. The norm most closely associated with the genre, personalization, remains strong, while the norm more associated with the treatment of the guest, congeniality, is more likely to be dropped in favor of its news counterpart, adversarialness. In the fifth chapter, the same measures are used to compare broadcast and cable news, finding that there are few significant differences between the two.