Annual Review of Applied Linguistics (2003) 23, 134B154. Printed in the USA.

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8. HEALTH CARE COMMUNICATION: A PROBLEMATIC SITE FOR

APPLIED LINGUISTICS RESEARCH

Christopher N. Candlin and Sally Candlin

In this chapter, we address, selectively, how applied linguists and those concerned
with discourse analysis in particular, have recently approached the study of health
care communication, especially in intercultural contexts, and relate these approaches
to studies undertaken by researchers in other academic disciplines such as the
sociology of medicine and by health care practitioners in the course of their own
work. At issue will be questions concerning selected sites and themes, the degree of
distinctiveness of research methodologies and different understandings of what
counts as data, and questions concerning reflexivity and practical relevance in terms
of the use to which findings can be put. Appreciating areas of difference and
similarity is a necessary basis for establishing the desirable, but potentially
problematic, partnerships among academic disciplines and between such disciplines
and the work of professional practitioners, both in research and in professional
development. As a sample site in the delivery of health care in the framework of
cultural and linguistic diversity, we identify nursing, and use this site and its
practices to advocate the collaboration of applied linguists, professional
practitioners, and researchers from other areas of social science in the exploration of
health care communication in multilingual/multicultural contexts and elsewhere.

Applied linguists, and in particular those concerned with the analysis of

discourse in professional contexts, would do well in our view to look outside their
own professional literature for studies that direct themselves at health care
communication, especially where this involves issues of intercultural
communication.1 Until relatively recently, mainstream applied linguistics journals
have to an extent ignored this field, although among journals in the field of discourse
analysis (broadly understood) there is now something of a tradition, and an
increasing interest, in exploring health care sites in journals like TEXT and Research
on Language and Social Interaction in particular, and in Discourse and Society and
Discourse Processes (although it has to be said, not all necessarily take an
intercultural focus). Of interest in this context is the planned Journal of Medical
Communication scheduled to appear in 2004, to be published by Mouton de Gruyter.
In other more core applied linguistics journals, for example, Applied Linguistics,
International Journal of Applied Linguistics, English for Specific Purposes Journal,

134
 HEALTH CARE COMMUNICATION 135

and in journals on the periphery of applied linguistics with their own constituencies,
such as the Journal of Sociolinguistics and the Journal of Pragmatics, one finds the
occasional paper, but no real sense of ongoing commitment to the health care
communication field. Given the broad scope of applied linguistics and these other
disciplines, this is understandable; but it suggests that applied linguists wanting to
explore health care communication would do better, at present at least, to address
journals in the fields of the sociology of medicine, of health care and illness, of
culture and psychiatry, of medical humanities, and of health and social behavior,
such as the Journal of Medical Education; Sociology of Health and Illness; Culture,
Medicine and Psychiatry; the Journal of Medical Humanities; the Journal of Health
and Social Behavior; Health Communication; and, in particular, Social Science and
Medicine. It is notable, in the latter case, that the editorial inaugurating the new
millennium for the journal explicitly promotes submissions drawing on qualitative
paradigms, including those involving discourse data (Blaxter, 2000).

Moreover, given the very strong and consistent commitment to issues of

health care communication, and, particularly, in the intercultural context, in the field
of nursing, applied linguistic readers would do even better to access journals such as
the Journal of Advanced Nursing, the Canadian Journal of Nursing Research, the
Journal of Transcultural Nursing, and Nursing Research, to discover resources of
clear interest to applied linguists interested in communication research in the
professions. We address this nursing focus in a brief section later in this chapter.
Another site where concern with intercultural professional communication in
language contact contexts is increasingly an issue is that of speech pathology and
communication disorder. Collections of papers such as that of Battle (1993) focus on
communication disorders in multicultural populations, as does Roger’s recent work
on exploring social and cultural factors in clinically oriented research (Roger, 1998)
or Cheng’s study on the effect of cultural diversity on assessment (Cheng, 1997).
Other collections in this field, such as Kovarsky, Duchan, and Maxwell (1999) while
not specifically so focused, have clear relevance for intercultural communication
contexts. Seminal studies such as that of Wadensjø of interpreter-mediated
interaction (Wadensjø, 1998) have broadened the audience for current research in
this health care field, as has that of Isaac and Hand (1996), although working with
interpreters has long been an issue for speech pathologists as books by Duncan
(1989), and Battle (1993) and papers in the journal Topics in Language Disorders
amply attest. Notable among such studies is the implication they carry for
professional development in intercultural awareness, based on interactional data, as
quite specifically drawn upon in Isaac’s pioneering book (Isaac, 2002a) with its focus
on training speech pathologists to accommodate to cultural and linguistic diversity.

Exploring other fields, even neighboring ones, runs the risk, however, of
assuming greater overlaps and synergies than is warranted. In what follows we
briefly explore the themes and sites, the methodologies and typical data sets that have
been the focus in what one might broadly call the sociology of health care and the
practices of health care, on the one hand, and applied linguistic approaches to health
care communication on the other. We also address issues of relevancy, in particular
the extent to which such research is a collaborative and co-constructed enterprise
136 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

(Sarangi & Candlin, 2001; Sarangi, 2002), and the extent to which the research is
directed at outcomes of practical relevance to those engaged as participants (Sarangi
& Roberts, 1999) rather than merely at the enhancement of disciplinary knowledge.

Themes and Sites

Taking a particular intercultural and language contact perspective, themes

concerning the breaking of bad news at critical moments (Dosanj, Barnes, &
Bhandari, 2001; Gillotti, Thompson, & McNeulis, 2002) highlight how contributions
from researchers in communication studies and medical education can concur. Such
studies, in turn, connect with those without necessarily a specifically intercultural
focus, such as the relaying of news about illness to lay participants outside the clinic
(Beach, 2001a, b; Frankel, 2001) with their discussions of the potential for
misalignments between lay diagnoses and professional ones. In its own way, of
course, this is an intercultural issue, albeit not an ethnolinguistic one. Medical
education has a tradition of engagement with the intercultural, with special issues of,
for example, Medical Education in 2001 being devoted to this theme; see in
particular Prideaux and Edmondson’s (2001) discussion of the relationships between
cultural identity and issues of the interaction of patients with health care systems, and
that of other papers in that special issue, especially Dogra (2001); Hardoff and
Schonmann (2001); and Spencer and Silverman (2001), which address the issue of
designing specific training and professional development for medical students and
practitioners in treating culturally and linguistically diverse patients.

The need for such training itself arises from a number of sources. Examples
include the reported problems of ethnic minority patients interacting with their
general practitioners with consequent implications for patient compliance with
treatment routines—see van Wieringen, Harmsen, and Bruijnzeels (2002); the
potential for negative impact on health care quality resulting from the need to use
interpreters—see Visandjée and Dupère’s (2000) study of interpreter-mediated
nursing interactions; to a more generally felt need for greater awareness of how
illness and health are constructed diversely in different societies—see Dowell,
Crampton, and Parkin (2001) with respect to MƗori patients in New Zealand; or, not
necessarily interculturally, as a consequence of the obstacles to understanding and
cooperation arising from gender differences between practitioners and patients in
professional encounters—see the articles by Parks (1998) and Williams (2000). It
should be noted in this context that there is a view taken by some studies in the
medical education literature that research into medical and health care
communication is seen as having a predominantly Western orientation (e.g., Kai,
Spencer, & Woodward, 2001; Skelton, Kai, & Loudun, 2001).

The Use of Interpreters

We have already alluded to this in our reference earlier to the speech

pathology field, but the use of interpreters in health care delivery contexts is a theme
of note in medical education and the sociology of medicine, and one centrally
engaging with the intercultural, as Putsch discusses in the United States health care
 HEALTH CARE COMMUNICATION 137

context (Putsch, 1985). As we note later, it is particularly so in relation to nursing.

Pöchhacker’s study of the language barriers arising in Viennese hospitals between
practitioners and patients mediated by interpreters is a case in point (Pöchhacker,
2000), as is Elderkin-Thompson, Silver, and Waitzkin’s (2001) study of Spanish-
speaking nurses doubling as interpreters for Spanish-speaking patients in U.S.
primary care contexts and Poss and Rangel’s (1995) study of nurses working with
interpreters in the primary health care setting. Lau, Stewart, and Fielding’s (2001)
report of interpreter role-play training for Cantonese-speaking first year medical
students points up the need for medical practitioner training in the use of interpreters,
but, equally, there is a severe lack of available trained and specialist interpreters—a
situation which is almost endemic in health care worldwide—such that pragmatic,
ethical, clinical, and ideological issues inevitably arise.

This is particularly so in the employment of untrained persons, as Cohen,

Moran-Ellis, and Smaje (1999) report in the context of a study of the use of children
as informal interpreters in GP consultations in the United Kingdom, or more
generally, Kaufert and Putsch’s (1997) analysis of ethical dilemmas which arise in
any interpreter-mediated context in health care as a consequence of issues of
differences in class, culture, language and power (Kaufert & Putsch, 1997). The use
of interpreters in health care is a theme which is also taken up in valuable doctoral
research in the United States (see, for example, Carol’s 1991 dissertation for the
University of California, and, more recently, Davis’s 2000 dissertation for Teachers’
College), and in Australia (in the speech pathology context, see Isaac’s 2002b
dissertation for the University of Newcastle, and Roger’s dissertation for the
University of Sydney, 2003). Emerson’s (1995) dissertation for George Mason
University addresses underlying issues of the cognitive knowledge, affective
attitudes and behavioral skills seen as vital for effective inter-cultural communication
in primary health care; Hand’s (2003) dissertation for Macquarie University
addresses issues of intercultural communication in speech pathology interview
practices.

Narratives

Undoubtedly, however, the theme most addressed in the sociology of health

care literature is that of illness as narrative, or narratives about illness. Such a theme
has obvious resonances with applied linguistic interests and in part overlaps with our
discussion of issues of data and methodology. Hydén’s (1997) review article in
Sociology of Health and Illness usefully discusses four aspects of illness narratives: a
proposed typology giving three different kinds of illness narratives—what he terms
“illness as narrative, narrative about illness, and narrative as illness,” considerations
of what is accomplished with the help of illness narratives; problems with the
organization of illness narratives; and, finally, the social context of the narrating and
how this influences the form and structure of the narrative and its themes.

Apart from some interesting anthropologically oriented studies, such as

Mogensen’s 1997 report of narratives of AIDS among the Tonga in Zambia, it seems
that less attention has been directed in non-psychiatric health care at intercultural
138 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

aspects of health care narrative. This is something of a gap since there are many
studies which take up Hydén’s four aspects of narrative, but not in a language contact
situation. As examples we can identify Little’s work and that of his colleagues in
Sydney in the field of the assignment of meanings in epidemiology, in particular in
respect of expressions of outcomes from health care treatment (Little, 1998), or in
relation to patients’ experiences of cancer and cancer treatment (Little, Jordens, Paul,
Montgomery, & Philipson, 1998). Both these studies suggest the potential for a
valuable extension to the intercultural context, as among many other studies, does
Kugelmann’s 1999 report of patients’ experiences of chronic pain. Studies that
direct themselves at gendered constructions of illness narrative, for example, that of
Johansson, Hamberg, Westman and Lindgren (1999) dealing with women’s
descriptions of symptoms of biomedically undefined musculoskeletal pain, or
Gjerberg and Kjølsrød’s (2001) study on difficulties in professional cooperation
experienced in gendered interactions between doctors and also suggest ways in
which the intercultural could be addressed within a narrative framework.

In the field of psychiatric medicine and health care, however, the existence
of journals such as Culture, Medicine and Psychiatry; Transcultural Psychiatric
Research Review; and the Journal of Transcultural Psychiatry suggests a very rich
resource of studies of great interest to applied linguists concerned with the
intercultural (as all in a sense are!). Exchanges between Barrett (1998) and Sass
(1998) into the interpretive construction and construal of schizophrenia, raising as
they do issues of culture and the problematic surrounding the socially relative
positioning of patients as socially liminal, reminds one forcibly of Rampton’s work
in applied linguistics and sociolinguistics (Rampton, 1995, 2001), while Ladson
Hinton and Levkoff’s (1999) study of the “lost” identities of Alzheimer’s patients
explicitly addresses the intercultural in its discussion of how African American,
Chinese American, Irish American, and Latino caregivers differentially draw on their
cultural and personal resources to create stories about the meaning of illness and in
its exploration of how ethnic identity affects the kinds of stories family caregivers
tell.

Risk

Interestingly, where one does find something of a priority given to the

intercultural is in the theme of health care risk, at least in the field of health care
policy. Studies stimulated by the concern of the World Health Organization (WHO)
to construct a quality of life questionnaire sensitive to cultural difference are cases in
point; see, for example, the broad international comparative study of attitudes to and
feelings about quality of life among HIV patients reported in Skevington, Bradshaw,
and Saxena (1999). Interestingly, such studies point up an issue to which we return
below, namely, whether researchers with a concern for discourse do better to derive
their data from more quantitatively designed questionnaires, as with Skevington,
Bradshaw, and Saxena (1999), or rely more on qualitative narrative data, as in the
study, again in the WHO quality of life context, of HIV patients and their
professional and nonprofessional caregivers in Hong Kong reported in Jones,
Candlin, and Yu (2000). Applied linguists certainly have something useful to
 HEALTH CARE COMMUNICATION 139

contribute in the systematically grounded analyses of narrative, as the latter authors

point out. Moreover, such studies can reveal personal constructions of cultural
relevancies that more quantitative, questionnaire-based studies do not. An example of
this is the study of Hamadeh and Adib (1998), which explored Lebanese doctors’
variable willingness to disclose truths about cancer to their patients. A more
ethnographic, narrative-based account might have augmented their useful results
considerably. Overall, however, themes such as risk still remain insufficiently
reflective of cultural differences and variations in understanding, notwithstanding
their potential for applied linguistic engagement on this and other grounds. Some
examples are Rhodes’s (1997) study on the social organization of “risk behavior”
with its data drawn from interviews and focus groups; Lauritzen and Sachs’s (2001)
study of the meanings of terms such as ‘risk’, ‘normalcy,’ and ‘deviance’; and
Plumridge and Chetwynd’s (1999) parallel study into issues of identity and the social
construction of risk among injecting drug users (on a similar theme, see McIntosh
and McKeganey, 2000).

Applied Linguistic Studies

When one examines the applied linguistic and discourse analytical literature
in terms of preferred themes and sites, what strikes the reader, surprisingly, is a
similar comparative lack of attention to the intercultural to that we have noted above
in the sociology of health care, allied health disciplines, and medical education
(although in the latter case now less so, as noted earlier). Of course, there are notable
exceptions in the applied linguistic and discourse analytical literature, such as
Cameron and Williams’s (1997) study of communicative “success” in nonnative–
native interactions in hospitals, where the authors identify the triggers for “success”
in such interactions in terms of a combination of informed inferencing and enabling
communication strategies on the part of the practitioner. This analysis resonates
strongly with the calls noted earlier in this chapter in the medical education literature
for improved health care practitioner awareness training and suggests a connection to
more recent applied linguistic and discourse analytical work on the links to be made
between discursive ability and professional expertise; see Candlin and Candlin
(2002a). Oddly, the English for Specific Purposes Journal devotes little space, in the
recent past at least, to the health care theme, although Frank’s (2000) study of (non)
understanding in native–nonnative interactions is something of an exception, as is
Ibrahim’s (2000) study of doctor-centeredness and its discursive realizations in
hospitals in the United Arab Emirates.

Patient–Practitioner Interaction

Of interest to applied linguists and discourse analysts is the highlighting of

the practitioner–patient interaction as a major theme, predominantly it must be said
in the doctor–patient clinical setting. Ten Have’s valuable commentary in a special
issue of the journal TEXT in 2001 devoted to lay diagnosis, (Ten Have, 2001),
identifies two trends in medical interaction research: on the one hand, a focus on
doctors’ behaviors in the course of performing particular professional
communication strategies, for example, inviting, allowing, or indeed, discouraging
140 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

patients from expressing their ideas or feelings; and, on the other, a focus on the
medical encounter as an activity type or genre, with a focus on delineating its phases
or moves. This contrast is one that resonates with a wider and current applied
linguistic and discourse analytical debate on models, well captured and discussed in a
recent chapter by Sarangi in relation to data drawn from genetic counseling, where he
offers the construct of discourse types and their attendant strategies as an alternative
to the Levinsonian focus on generic structure (Levinson, 1979; Sarangi, 2000). At a
risk of a bet, however, the interactional focus is now heavily foregrounded, see, for
example, the special issue of TEXT referred to above, and in particular, the papers in
that issue by Frankel (2001); Gill, Halkowski, and Roberts (2001); and Stivers and
Heritage (2001). Indeed, Drew’s commentary in the same issue (Drew, 2001)
explicitly identifies co-construction of the interaction as a key theme.

This interactional focus is taken up elsewhere, for example, in the study by

Dijkstra, Bourgeois, Petrie, Burgio, and Allen-Burge (2002) of nursing-home
residents with dementia; in Moore, Candlin, and Plum’s (2001) study of doctor–
patient interaction in the negotiation of the meanings of viral load in consultations
with HIV patients; and in a series of papers over the recent past in Research on
Language and Social Interaction, whose focus as a journal naturally prefers this
orientation. As examples we can cite Leppänen’s study on advice-giving among
Swedish district nurses and their patients (Leppänen, 1998); and Buttny’s work on
the joint construction of clients’ problems in client–therapist encounters (Buttny,
1996). At a remove, perhaps, but nonetheless interactional in character, is Coupland,
Robinson, and Coupland’s 1994 work on frame negotiation in doctor–elderly-patient
consultations arising out of a major sociolinguistic study of older persons in
interaction with health care practitioners. This particular paper, indeed, serves as a
classic contribution to anyone interested in the field of institutional discourse studies
in health care.

Critical Accounts

Current interest in critical discourse analysis suggests the possibility of

engagement by applied linguists and discourse analysts in this theme in the health
care context, although so far not one taken up generally from an intercultural
perspective. An exception to this would be Davidson’s (2000) study of contrasting
interpreter roles in Spanish–English medical encounters that speaks of setting the
interpreter as ‘institutional gatekeeper’ against the interpreter as ‘active partner’ in
the diagnostic process. The study initiated by the UK Royal College of General
Practitioners (RCGP) into issues of equity in the oral examination of nonnative
doctors seeking entry to Memberships of the RCGP, reported in Roberts, Sarangi,
Southgate, Wakeford, and Vass (2000), is notable not only for its critical focus on
issues of fairness in relation to ethnicity but that its results were reported in the
British Medical Journal. This critical orientation is not limited to applied linguistics
and discourse analysis, but also resonates strongly among writers in the sociology of
health care, as, for example, in Nijhoff’s (1998) study of naming as a naturalizing
process whereby practitioners exercise dominance over patients. Indeed, taken more
broadly, themes of autonomy, challenges to authority, and subjectification occur in
 HEALTH CARE COMMUNICATION 141

both literatures, as, for example, in Warren, Weitz, and Kulis’s (1998) work on the
relationship between patients’ challenges to practitioner authority and their effect on
patient satisfaction; Fahy and Smith’s (1999) feminist study of patients as subjects;
or Parks’s (1998) critical analysis questioning whether the ‘therapeutic relationship’
embodies some equally entered-into “contract” by practitioner and patient. As a
further example, the collection of invited papers by Kovarsky, Duchan and Maxwell
(1999) takes a critical perspective on the ways in which patients’ displays of
communicative ability can be systematically inhibited—or constructed as
incompetent—by the interactional management strategies of the professional
caregiver or health worker.

Perhaps surprisingly from this critical perspective, the classic call by

Cicourel (1992) for “ecological validity” in discourse analytical research, especially
the need to site the explanation of health care interactions in both their local micro-
interactional contexts and in the macrocontext of the historical-social-structural
seems to have been taken up less in the recent literature either by applied linguists
concerned with interaction (although see Candlin & Candlin 2002a, b), or by health
care practitioners and medical sociologists with a similar focus. Once again,
however, there exists a classic text which argues against too sweeping a judgment in
Atkinson’s seminal study of medical talk and medical work (Atkinson, 1995).

Methodologies and Data Sets

Although one might expect that given the reasonably circumscribed array of
methodologies available to the human and social sciences there will clearly be
considerable overlap among disciplines in terms of methodological choice, this need
not imply unanimity or coincidence in terms of current directions in research. This is
so in the field of health care. In the field of medical education; the key
methodological paradigm is that of qualitative, grounded theory (Glaser & Strauss
1967; Strauss & Corbin, 1990) involving careful and iterative analysis of
taperecorded (usually audio-recorded) and transcribed narrative, experiential data
drawn from focus groups, workshops, and individual semistructured interviews. We
have already referred to this focus on narrative as a key theme in medical education
and the sociology of health care more generally. Studies such as that of Kai,
Spencer, and Woodward (2001) and Nochi (1998) are typical in this sense.
However, not all so-called grounded theory is as grounded as Miles and Huberman’s
work (1994) would stipulate. It is important therefore to distinguish between studies
that perform perhaps rather superficial content analysis from those, such as that of
Armstrong, Michie, and Marteau (1998) in the field of genetic counseling or
Johansson, Hamberg, Westman, and Lindgren (1999) in the field of women’s
experiences of pain, who subject their carefully selected data to exhaustive coding.
The quality of the data thus collected is clearly as important as the methodologies
employed in its processing; even more so, one might argue. Therefore, it is worth
noting exceptional instances, such as that reported in Katz, Conant, Inui, Baron, and
Bor (2000) where, in a study of communication in elderly care settings, the
researchers set up what they called a “council of elders” in which community elders
served as a sounding board to whom medical residents could present their dilemmas
142 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

in caring for older patients in that community. From this emerged a truly
collaborative and cooperative research process, with a range of crossing, interwoven,
and compared data, creating what the authors call “a community of resources,” which
led to the institutionalizing of the referencing process in the primary care residency
education program. We will return to this key issue of collaborative research,
reflexivity, and practical relevance in the final section of this chapter.

Of course, grounded theory does not preclude the association of more

quantitative, questionnaire-driven approaches, or the use of quasi-experimental
designs involving Likert-scale evaluations of attitude and beliefs; see Lau, Stewart,
and Fielding (2001). Narratives obtained from semistructured interviews can
themselves be deliberately focused on the retrospective account, as in Kaufmann’s
1997 study of reconstructed health dilemmas and voices of different participants can
be artfully contrasted, and at times opposed, within a structured design, like that
employed by Crossley and Crossley (2001), in their comparison of patient
anthologies of psychiatric illness collected in the 1950s and the 1990s.

What may be of interest to applied linguists and discourse analysts is to

estimate how much in recent years research in the sociology of medicine and health
care has taken a discursive turn, and what opportunities now exist (although not as
yet fully taken up) for a synergistic combination of methodologies involving textual
analysis, analyses of interaction, ethnographic narratives, and social-historical and
structural accounts of the institutions and their associated ideologies that give rise to
the data in question. Studies such as that of Barry, Stevenson, Britten, Barber, and
Bradley (2001) exploring doctors’ differential communication strategies in general
practice drawing on Mishler’s (Habermas’s) distinction between the voice of
medicine and the voice of the lifeworld (Habermas, 1984; Mishler, 1984) rest firmly
on discourse data, but also make reference to a social theoretical framework.
However, while Stivers’s (2002) conversational analytical study on participation in
treatment decisions involving children in the context of pressures for antibiotic
medication in pediatric encounters is firmly based on discourse data, it might readily
have included an ethnographic as well as a critical discourse analytical dimension.
Notable in both these cases is that they derive from medical school departments of
general practice, pediatrics, and pharmacy, not from departments of applied
linguistics or discourse analysis, although they clearly acknowledge the discourse
analysis dimension.

Bridges do of course exist, increasingly so where the institutional conditions

are favorable, and where there is an agreed and mutually valued methodological
agenda. The work of Little in the Centre for Values, Ethics and Law in Medicine at
the University of Sydney with linguistics colleagues in a systemic–functional
linguistic framework is a case in point (see Jordens, Little, Paul, & Sayers, 2001), as
is the collaboration of Sarangi and colleagues at the Centre for Health
Communication Research at Cardiff University in the United Kingdom with
colleagues in the Department of Medical Genetics at the University of Wales College
of Medicine (see Sarangi & Clarke, 2002) drawing on discourse analysis,
conversational analysis, and interactional sociolinguistics, or that involving shared
 HEALTH CARE COMMUNICATION 143

analytical resources where the Department of Communication Studies in Linköping,

Sweden and the Clinical Epidemiology Unit in the Department of Family Medicine
at Uppsala (see Johanson, Larsson, Säljö, & Svärdsudd, 1998) collaborate in
researching discussions on lifestyles in relation to health care provision.

Among all such research one can detect a gradual shift from the analysis of
the one-on-one interaction between professional and patient, or between researcher
and patient, perhaps classically represented by Hamilton’s (1994) study of an
Alzheimer’s patient, toward analyses that locate such encounters within a complex
institutionally governed framework of social interactions, relationships, and
situations, whether or not studies overtly make appeal to relevant social theory. For
some discussion of this issue of the linkage between sociolinguistics and social
theory, readers are referred to Coupland, Sarangi, and Candlin (2001), and in
particular in that collection, to Sarangi and Candlin (2001). Nonetheless, it is
important not to be too sanguine about this shift, since as Atkinson makes very clear
(Atkinson, 1995) whatever the methodology, there has been (and still is) a
considerable bias in social-scientific studies of medical work towards the individual
doctor interacting with (usually) his patients. He offers some considered reasons for
this, not least those of accessibility to data and the privileging of talk (in this context,
see Hak’s 1999 cautionary chapter on talk bias in health care work and the potential
such encounters offer for exploration of collaborative action).

If this is the bias in the microsociology of health care, it has also certainly
been the case in applied linguistics and discourse analysis. Work in the 1980s
typically had such an interactional, dyadic, clinic-focused orientation; see Fisher and
Todd (1983); Silverman (1987); and West (1984) as key examples. We note now a
move to promote a careful mix of methodologies, each offering particular
perspectives on the data, grounded in an analysis of the institutional context.
Marriages between qualitative and quantitative methodologies are proving productive
and explanatory. In the study by Dijkstra, Bourgeois, Petrie, Burgio, and Allen-
Burge (2002), drawing on conversational transcripts, utterance-and discourse-level
data identified by a range of previous studies into language and dementia, researchers
have related these features to stages in the development of dementia, coded and
checked their analyses for inter-coder reliability, and processed the data statistically
with the aim of assessing the facilitative effects on patient interaction of different
discursive types of nursing interventions with different classes of patient. A further
example of this combined qualitative (discourse analytical) and quantitative
methodology is the series of studies currently being conducted by a research team
from Cardiff University, United Kingdom, and the University of Wales College of
Medicine also in Cardiff, into decision-making by general practitioners; see Atwell,
Coupland, Edwards, Elwyn, and Smith (2002). Here, an emphasis on the co-
construction of the discursive expertise of general practitioners in interaction with
their patients has involved researchers not only in exploring the interactions between
researchers and ‘researched,’ but also interactions between the ‘researched
participants’ themselves, for which discourse analytical and conversational analytical
methodologies, together with the use of patient narratives of experience, have proved
insightful.
144 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

Nursing: A Key Research Site

As a way of bringing together what we have explored so far, and to highlight

the value of interdisciplinary collaboration, we select nursing as a key site of
engagement. This also reflects the position of nurses as the group with the greatest
representation in health service delivery. Given this, what is surprising is that few
studies of nursing interaction have been conducted by, or in association with, applied
linguists and discourse analysts. The focus, as Atkinson (1995) and S. Candlin
(1997) point out, has largely been on the doctor–patient relationship. Whether this is
related to the prestige and power which doctors hold, or the autonomy they are
thought to enjoy, are moot points. What is clear is that other health professionals in
nursing and allied health do not always all enjoy the same degree of autonomy as
medical practitioners, and their interactions are neither of limited duration nor
discrete events (S. Candlin, 1997, 2000). Nursing, especially, is an ongoing 24/7
activity, with interactions often requiring long periods of time and occurring in
stretches which may occur over many days and weeks. This makes the task of data
collection formidable. Nonetheless, numerous studies with a communication focus
have been conducted at nursing sites by nursing professionals (see S. Candlin, 1997;
Gibb, 1990; Macleod-Clarke, 1984; Tan, Fleming, & Ledwidge, 2001) and published
in professional nursing journals, but these are typically not referenced in applied
linguistic and discourse analytic studies.

A number of such studies address the complexities of communication in

contexts of cultural and linguistic diversity—an increasingly common situation in
societies with high rates of immigration—in particular focusing on the crucial nature
of the nurse–patient relationship with its need to accurately identify patient needs,
determine goals, and achieve desired outcomes. The achievement of any of these
areas is jeopardized if the communication between interlocutors is not clear and
unambiguous, hence the potential value of an applied linguistic and discourse
analytical contribution to such research. As one example, in a study of Aboriginal
patients and their health care providers, Cass et al. (2002) found that not only was a
shared understanding of key concepts rarely achieved, but instances of
miscommunication often went unrecognized. Sources of such miscommunication
included not only a lack of patient control over the language, timing, content, and
circumstances of the interactions, but differing modes of discourse, cultural and
linguistic distance, and a lack of professional training in intercultural communication.

This is an issue we have highlighted earlier, and the value of appropriate

professional development programs in nursing is similarly recognized; see Davis
(2000), with a focus on communication made central. As Ulrey and Amason (2001)
argue, such programs have the potential not only to benefit patients but also to
benefit health care providers in terms of reducing their levels of stress. This need for
professional education, grounded in understanding of professional interaction in
intercultural contexts lies at the heart of studies involving nurses and interpreters, as
is clear from the research by Pöchhaker (2000) and Visandjée and Dupère (2000)
referred to earlier. The point of concern is that barriers of language and associated
lack of knowledge of patients’ cultures can inhibit the delivery of safe and effective
 HEALTH CARE COMMUNICATION 145

care by nurses, as Boi (2000) found in her study. Unless post-registration courses
address cultural differences, health beliefs, and practices, and ground these in the
study of interaction, it will be almost impossible for nurses to deliver, and for
patients to receive, holistic care. The potential for a contribution from applied
linguists and discourse analysts familiar with issues of language contact and
intercultural communication to existing emphases within nursing education on the
crucial nature of intercultural understanding (see Leininger, 1978, 1983, 1990)—
whether in terms of ethnicity or social group membership—is evident.

Reflexivity and Relevance

One issue that runs through this chapter is that of the stance taken by
researchers in the health care professions (whether from a sociological or a linguistic
orientation) vis-à-vis practitioners working in such professions. Associated with this
is the issue of the practical relevance of such research.

The formulation of the former issue has received general critical inquiry in
the applied linguistics field through the arguments of Cameron, Frazer, Harvey,
Rampton, and Richardson (1992) into the question of researching on, by and with,
and as Sarangi and Candlin point out in a recent chapter, the need is to strike a
relationship between participants’ and analysts perspectives on social data (Sarangi
& Candlin, 2001). Either the perspectives are distinct, with the likely outcome that
researchers impose or transform the data into a form of order aligned with their
disciplinary interests, as in some objectivist mode of inquiry; or participants and
researchers seek to bring their perspectives into alignment by hermeneutically
exploring and co-constructing common interpretive accounts. To achieve the latter
requires some considerable mutuality, of experience, of knowledge, of modes of
accounting, of modes of saying and reporting. This is so whether one is discussing
alliances between health care professionals, researchers from a sociological
perspective, and applied linguists or discourse analysts. As we have seen, the studies
identified here offer a variable response to this issue. In the main, such
interprofessional collaboration has been the exception rather than the rule, although
in the disciplines surrounding the sociology of medicine, and among some health
care professionals, this collaboration is becoming more common. Applied linguistics
has some way to catch up, although there are notable exceptions, as we indicate, and
they display the advantages of such a collaborative stance.

The issue of practical relevance is more contentious. At one level, it is a

matter of first achieving at least candidate or adjunct membership in the communities
of practice where practitioners are engaged. In general, applied linguists and
discourse analysts are condemned to outsider status in such practitioner communities,
unless (rarely so far) they are co-members of both. As Sarangi and Candlin (2001)
point out, considerable time and effort, and considerable negotiation, are needed to
access and achieve even the modest mutuality needed to make sense of the contexts
of interaction. Where the issue is the potential research gains for the ultimate
participants (as it ought to be in applied linguistics, namely, for those seeking health
care), then achieving practical relevance becomes much more problematic.
146 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

We can, however, make a beginning; we can adopt a more open

methodological stance; we can avoid using health care data merely to serve
refinements to our theories; we can learn to code our results conceptually and in
terms of language understandable to our professional colleagues and to the end-users;
we can begin from the problematic as defined by our collaborators and address not
just questions of how but also questions of why and to what purpose. Applied
linguists might aspire to become discourse practitioners, in Sarangi’s happy phrase
(Sarangi, 2002). In the circumstances of this chapter, this should have been easier to
guarantee than it has been. If applied linguistics is truly problem driven, then it
needs to be equally outcome focused, and collaboratively undertaken with
professional practitioners. This is no more important than in the area of intercultural
communication in health care, working from within at understanding the nature of
the relationships among interaction, diagnosis, treatment, and care, and conscious
also of the implications of such analyses for institutional and organizational change.
As S. Candlin (2000) emphasizes, any discourse analytical work in applied
linguistics presupposes understanding professional practice. At the same time, of
course, it has to be true to its own scholarly practices, as Sarangi and Roberts (1999)
in turn emphasize, acknowledging how its own academy defines and values research.
The centrality of communication in health care provision justifies efforts to meet the
simultaneous challenges of achieving both disciplinary reflexivity and practical
relevance.

Note

1. The authors would like to thank Andi Bhatia of Cardiff University and Nanette
Reynolds and Frances Wilson of the National Centre for English Language Teaching
and Research (NCELTR) Resources Centre, Department of Linguistics, Macquarie
University, for their assistance in preparing this chapter, and wish also to
acknowledge the research support received from the Department of English and
Communication of The City University of Hong Kong.

ANNOTATED BIBLIOGRAPHY

Cameron, R., & Williams, J. (1997). Sentence to ten cents: A case study of relevance
and communicative success innon-native speaker interactions in a medical
setting. Applied Linguistics, 18(4), 415–445.

One of the very few studies in the applied linguistics literature that seeks to
marry awareness of second language acquisition with an exploration of what
counts as communicative success in health care contexts, this article has
implications for professional development.
 HEALTH CARE COMMUNICATION 147

Candlin, C. N., & Candlin, S. (2002a). Expert talk and risk in health care [Special
issue]. Research on Language & Social Interaction, 35(2).
This specially edited collection of papers focuses on the relationship
between discursive competence and professional expertise. As such, it
offers clear models for research involving interactional data into a range of
health care and other sites, in first language, or in language contact
situations.

Cass, A., Lowell, A., Christie, M., Snelling, P. L., Flack, M., Marrnganyin, B., &
Brown, B. (2002). Sharing the true stories: Improving communication
between Aboriginal patients and health care workers. Medical Journal of
Australia, 176(10), 446–470.

This study offers a prime example of how qualitative research can lead to the
identification of key factors that limit the effectiveness of communication
between Aboriginal patients with end-stage renal disease and health care
workers, and shows how such research can also identify strategies for
improving communication. Trained interpreters can only provide a partial
solution; rather, what is needed are greater educational resources to facilitate
a shared understanding of the cultural, social, and economic dimensions of
the illness experience of Aboriginal people.

Hydén, L-C. (1997). Illness and narrative. Sociology of Health and Illness, 19(1), 48–
69.

An extremely valuable article for applied linguists, setting out as it does

different perspectives on illness narrative from which it is possible to
construct a range of interconnected methodologies designed to explore the
theme from different perspectives. A classic case study for bringing
together research traditions in applied linguistics and discourse analysis.

Isaac, K. (2002a). Speech pathology in cultural and linguistic diversity. London:

Whurr Publishers.

This book provides a valuable study of the relationship between culture and
communication in speech pathology practice in contexts of cultural and
linguistic diversity, addressing in particular issues of assessment and
management of patients. A great strength of the book is its comprehensive
account of ways in which professional development for practitioners
engaged in intercultural health care can be designed, especially in the
context of interpreter-mediated interaction.
148 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

OTHER REFERENCES

Armstrong, D., Michie, S., & Marteau, T. (1998). Revealed identity: A study of the
process of genetic counseling. Social Sciences & Medicine, 47(11), 1653–
1658.
Atkinson, P. (1995. Medical talk and medical work: The liturgy of the clinic.
London: Sage Publications.
Atwell, C., Coupland, J., Edwards, A., Elwyn, G., & Smith, C. (2002, April). Co-
construction of GP’s discursive expertise: Patients, GPs and patterns of
information exchange and decision-making implications for training.
University of Wales College of Medicine, Cardiff and Centre for Language
& Communication, Cardiff University, UK. Paper presented at the
Sociolinguistics Symposium 14, Gent.
Barrett, R. (1998). The schizophrenic and the liminal persona in modern society.
Review Essay. Culture, Medicine & Psychiatry, 22, 465–494.
Barry, C., Stevenson, F., Britten, N., Barber, N., & Bradley, C. (2001). Giving voice
to the lifeworld. More humane, more effective medical care? A qualitative
study of doctor–patient communication in general practice. Social Science &
Medicine, 53(4), 487–505.
Battle, D. E. (Ed.). (1993). Communication disorders in multicultural populations.
Boston: Andover Medical Publishers.
Beach, W. A. (2001a). Introduction: Diagnosing ‘lay diagnosis’. TEXT, 21(1–2), 13–
18.
Beach, W. A. (2001b). Stability and ambiguity: Managing uncertain moments when
updating news about mom’s cancer. TEXT, 21(1–2), 221–250.
Blaxter, M. (2000). Medical sociology at the start of the new millennium [Editorial].
Science & Medicine, 51(8), 1139–1142.
Boi, S. (2000). Nurses’ experiences in caring for patients from different cultural
backgrounds. NT Research, 5(5), 382–390.
Buttny, R. (1996). Client’s and therapist’s joint construction of clients’ problems.
Research on Language and Social Interaction, 29(2), 125–153.
Cameron, D., Frazer, E., Harvey, P., Rampton, M. B. H., & Richardson, K. (1992).
Researching language: Issues of power and method. London: Routledge.
Candlin, C. N., & Candlin, S. (2002b). Discourse, expertise and the management of
risk in health care settings. Research on Language and Social Interaction,
35(2), 115–137.
Candlin, S. (1997). Towards excellence in nursing. An analysis of the discourse of
nurses and patients in assessment situations. Unpublished Ph.D.
dissertation. University of Lancaster, Department of Linguistics and Modern
English Language.
Candlin, S. (2000). New dynamics in the nurse-patient relationship? In S. Sarangi, &
M. Coulthard (Eds.), Discourse and social life (pp. 230–245). London:
Longman.
Carol, E. M. (1991). Interpreting information: Health care communication among
family nurse practitioners, interpreters, and Cambodian refugee patients.
Unpublished Ph.D. dissertation, University of California, San Francisco.
 HEALTH CARE COMMUNICATION 149

Cheng, L. L. (1997). Diversity: Challenges and implications for assessment. Journal

of Children’s Communication Development, 19(1), 53–61.
Cicourel;, A. (1992). The interpenetration of communicative contexts: Examples
from medical encounters. In A. Duranti & C. Goodwin (Eds.), Rethinking
context: Language as an interactive phenomenon (pp. 291–310). Cambridge
University Press.
Cohen, S., Moran-Ellis, J., & Smaje, C. (1999). Children as informal interpreters in
GP consultations: Pragmatics and ideology. Sociology of Health & Illness,
21(2), 163–186.
Coupland, J., Robinson, J. D., & Coupland, N. (1994). Frame negotiation in doctor-
elderly patient consultations. Discourse & Society, 5(1), 89–124.
Coupland, N., Sarangi, S., & Candlin, C. N. (Eds.). (2001). Sociolinguistics and
social theory. London: Longman.
Crossley, M. L., & Crossley, N. (2001). ‘Patient’ voices, social movements and the
habitus: How psychiatric survivors ‘peak out.’ Social Science & Medicine,
52(10), 1477–1489.
Davis, M. (2000). Communicating nonverbally with non-English speaking
multicultural emergency room patients: An educational model for nurses.
Unpublished Ph.D. dissertation, Teachers College, Columbia University,
New York.
Davidson, B. (2000). The interpreter as institutional gatekeeper: The social-linguistic
role of interpreters in Spanish-English medical discourse. Journal of
Sociolinguistics, 4(3), 379–405.
Dijkstra, K., Bourgeois, M., Petrie, G., Burgio, L., & Allen-Burge, R. (2002). My
recaller is on vacation: Discourse analysis of nursing-home residents with
dementia. Discourse Processes, 33(1), 53–76.
Dogra, N. (2001). The development and evaluation of a programme to teach cultural
diversity to medical undergraduate students. Medical Education, 35(3), 232–
241.
Dosanj, S., Barnes, J., & Bhandari, M. (2001). Barriers to breaking bad news among
medical and surgical residents. Medical Education, 35(3), 197–205.
Dowell, A., Crampton, P., & Parkin, C. (2001). The first sunrise: An experience of
cultural immersion and community health needs assessement by
undergraduate medical students in New Zealand. Medical Education, 35(3),
242–249.
Drew, P. (2001). Spotlight on the patient. TEXT, 21(1–2), 261–268.
Duncan, D. M. (Ed.). (1989). Working with bilingual language disability. London:
Chapman & Hall.
Elderkin-Thompson, V., Silver, R. C., & Waitzkin, H. (2001). When nurses double
as interpreters: A study of Spanish-speaking patients in a U. S. primary care
setting. Social Science & Medicine, 52(9), 1342–1358.
Emerson, J. (1995). Intercultural communication between community health nurses
and ethnic minority clients. Unpublished Ph.D. dissertation, George Mason
University, Fairfax, Virginia, USA.
Fahy, K., & Smith, P. (1999). From the sick role to subject positions: A new
approach to the medical encounter. Health, 3(1), 71–93.
150 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

Fisher, S., & Todd, A. D. (Eds.). (1983). The social organization of doctor–patient
communication. Washington, DC: Center for Applied Linguistics.
Frank, R. A. (2000). Medical communication: Non-native English speaking patients
and native English speaking professionals. English for Specific Purposes,
19, 31–62.
Frankel, R. M. (2001). Clinical care and conversational contingencies: The role of
patients’ self-diagnosis in medical encounters. TEXT, 21(1–2), 83–111.
Gibb, H. (1990). “This is what we have to do—are you OK?” Nurses’ speech with
elderly nursing home residents. Geelong, Victoria: Deakin Institute of
Nursing Research Monograph Series #1.
Gill, V. T., Halkowski, T., & Roberts, F. (2001). Accomplishing a request without
making one: A single case study of a primary care visit. TEXT, 21(1–2), 55–
81.
Gillotti, C., Thompson, T., & McNeulis, K. (2002). Communicative competence in
the delivery of bad news. Social Science & Medicine, 54(7) 1011–1023.
Gjerberg, E., & Kjølsrød, L. (2001). The doctor-nurse relationship: How easy is it to
be a female doctor co-operating with a female nurse? Social Science &
Medicine, 52(2), 189–202.
Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine.
Habermas, J. (1984). The theory of communicative action: Reason and the
rationalization of society, Vol. 1. London: Heinemann.
Hak, T. (1999). “Text” and “con-text”: Talk bias in studies of health care work. In S.
Sarangi & C. Roberts (Eds.), Talk, work, and institutional order: Discourse
in medical, mediation and management settings (pp. 427–452). Berlin:
Mouton de Gruyter.
Hamadeh, G. N., & Adib, S. M. (1998). Cancer truth disclosure by Lebanese doctors.
Social Science and Medicine, 47(9), 1289–1294.
Hamilton, H. (1994). Conversations with an Alzheimer’s patient: An interactional
sociolinguistic study. Cambridge: Cambridge University Press.
Hand, L. (2003). Discourses in the professional practices of speech pathology
interviews. Unpublished Ph.D. dissertation, Macquarie University, Sydney,
Australia.
Hardoff, D., & Schonmann, S. (2001). Training physicians in communication skills
with adolescents using teenager actors as simulated patients. Medical
Education, 35(3), 206–210.
Ibrahim, Y. (000). Doctor and patient questions as a measure of doctor-centeredness
in UAE hospitals. English for Specific Purposes, 20, 331–344.
Isaac, K. (2002b). Breaking barriers, building bridges: Clinician-interpreter
interaction in speech pathology practice. Unpublished Ph.D. dissertation,
University of Newcastle, Newcastle, Australia.
Isaac, K., & Hand, L. (1996). Interpreter-mediated interactions in speech pathology:
Poblems and solutins. Australian Communication Quarterly, Summer, 32–
36.
Johansson, E. E., Hamberg, K., Westman, G., & Lindgren, G. (1999). The meanings
of pain: An exploration of women’s descriptions of symptoms. Social
Science & Medicine, 48(12), 1791–1802.
 HEALTH CARE COMMUNICATION 151

Johanson, M., Larsson, U. S., Säljö, R., & Svärdsudd, K. (1998). Lifestyle discussion
in the provision of health care: An empirical study of patient-physician
interaction. Social Science & Medicine, 47(1), 103–112.
Jones, R. H., Candlin, C. N., & Yu, K. K. (2000). Culture, communication and
quality of life of people living with HIV/AIDS in Hong Kong. Hong Kong:
The AIDS Trust Fund and the Centre for English Language Education &
Communication Research, City University of Hong Kong.
Jordens, C., Little, M., Paul, K., & Sayers, E-J. (2001). Life disruption and generic
complexity: A social linguistic analysis of narratives of cancer illness. Social
Science & Medicine, 53(9), 1222–1236.
Kai, J., Spencer, J., & Woodward, N. (2001). Wrestling with ethnic diversity:
Toward empowering health educators. Medical Education, 35(3), 262–271.
Katz, A. M., Conant, L., Inui, T. S., Baron, D., & Bor, D. (2000). A council of elders:
Creating a multi-voiced dialogue in a community of care. Social Science &
Medicine, 50(6), 851–860.
Kaufert, J. M., & Putsch, R. W. (1997). Communication through interpreters in
health care: Ethical dilemmas arising from differences in class, culture,
language and power. The Journal of Clinical Ethics, 8, 71–87.
Kaufmann, S. R. (1997). Construction and practice of medical responsibility:
Dilemmas and narratives from geriatrics. Culture, Medicine and Psychiatry,
21, 1–26.
Kovarsky, D., Duchan, J., & Maxwell, M. (Eds.). (1999). Constructing
(in)competence: Disabling evaluations in clinical and social interaction.
Mahwah, NJ: Lawrence Erlbaum Associates.
Kugelmann, R. (1999). Complaining about chronic pain. Social Science & Medicine,
49, 1663–1676.
Ladson Hinton, W., & Levkoff, S. (1999). Constructing Alzheimer’s: Narratives of
lost identities, confusion and loneliness in old age. Culture, Medicine &
Psychiatry, 23, 453–475.
Lau, K., Stewart, S., & Fielding, R. (2001). Preliminary evaluation of ‘interpreter’
roleplays in teaching communication skills to medical undergraduates.
Medical Education, 35(3), 217–221.
Lauritzen, S. O., & Sachs, L. (2001). Normality, risk and the future: Implicit
communication of threat in health surveillance. Sociology of Health &
Illness, 23(4), 497–516.
Leininger, M. (1978). Transcultural nursing. Concepts, theories and practices. New
York: John Wiley and Sons.
Leininger, M. (1983). An essential goal for nursing and health care. American
Association of Nephrology Nurses and Technicians Journal, 10(5), 11–13.
Leininger, M. (1990). Ethical and moral dimensions of care. Detroit, MI: Wayne
State Press.
Leppänen, V. (1998). The straightforwardness of advice: Advice-giving in
interactions between Swedish district nurses and patients. Research on
Language and Social Interaction, 31(2), 209–239.
Levinson, S. (1979). Activity types and language. Linguistics, 17, 356–399.
Little, M. (1998). Assignments of meaning in epidemiology. Social Science &
Medicine, 47(9), 1135–1145.
152 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

Little, M., Jordens, C., Paul, K., Montgomery, K., & Philipson, B. (1998).
Liminality: A major category of the experience of cancer illness. Social
Science & Medicine, 45(10), 1484–1494.
Macleod-Clark, J. 1984). Verbal communication in nursing. In A. Faulkner (Ed.),
Recent advances in nursing 7: Communication (pp. 35–69). Edinburgh:
Churchill Livingstone.
McIntosh, J., & McKeganey, N. (2000). Addicts’ narratives of recovery from drug
use: Constructing a non-addict identity. Social Science & Medicine, 50(10),
1501–1510.
Miles, N., & Huberman, A. (1994). Qualitative data analysis. Beverley Hillsc CA:
Sage.
Mishler, E. G. 1984). The discourse of medicine: The dialectics of medical
interviews. Norwood, NJ: Ablex.
Mogensen, H. O. (1997). The narrative of AIDS among the Tonga of Zambia. Social
Science & Medicine, 44(4), 431–439.
Moore, A., Candlin, C. N., & Plum, G. 2001). Making sense of viral load: One expert
or two? Journal of Culture, Health & Sexuality, 3(4), 429–450.
Nijhoff, G. 1998. Naming as naturalization in the medical encounter. Journal of
Pragmatics, 30(6), 735–753.
Nochi, M. (1998). Loss of self in the narratives of people with traumatic brain
injuries: A qualitative analysis. Social Science & Medicine, 46(7), 869–878.
Parks, J. A. (1998). A contextualized approach to patient autonomy within the
therapeutic relationship. Journal of Medical Humanities, 19(4), 299–314.
Plumridge, E., & Chetwynd, J. (1999). Identity and the social consstruction of risk:
Injecting drug use. Sociology of Health & Illness, 21(3), 329–343.
Pöchhacker, F. (2000). Language barriers in Vienna hospitals. Ethnicity & Health,
5(2), 113–119.
Poss, J. E., & Rangel, R. (1995). Working effectively with interpreters in the primary
health care setting. Nurse Practitioner, 20, 43–47.
Prideaux, D., & Edmondson, W. (2001). Cultural identity and representing culture in
medical education: Who does it? [Editorial]. Medical Education, 35(3), 186–
187.
Putsch, R. W. (1985). Cross-cultural communication: The special case of interpreters
in health care. Journal of the American Medical Association, 254, 3344–
3348.
Rampton, B. (1995). Crossing: Language and ethnicity among adolescents. London:
Longman.
Rampton, B. (2001). Language crossing, cross-talk, and cross-disciplinarity in
sociolinguistics. In N. Coupland, S. Sarangi, & C. N. Candlin (Eds.),
Sociolinguistics and social theory (pp. 261–296). London: Longman.
Rhodes, T. (1997). Risk theory in epidemic times: Sex, drugs and the social
organization of ‘risk behaviour.’ Sociology of Health & Illness, 19(2), 208–
227.
Roberts, C., Sarangi, S., Southgate, L., Wakeford, R., & Vass, V. (2000). Oral
Examination—equal opportunities, ethnicity and fairness in the MRCGP.
British Medical Journal, 320, 370–375.
 HEALTH CARE COMMUNICATION 153

Roger, P. (1998). Bilingual aphasia: The central importance of social and cultural
factors in clinically-oriented research. Aphasiology, 12(12), 127–134.
Roger, P. (2003). Linguistic diversity and the assessment of aphasia. Unpublished
Ph.D. dissertation, University of Sydney, Australia.
Sarangi, S. (2000). Activity types, discourse types and interactional hybridity: The
case of genetic counseling. In S. Sarangi & M. Coulthard (Eds.), Discourse
and social life (pp. 1–27). London: Longman.
Sarangi, S. (2002). Discourse practitioners as a community of interprofessional
practice: Some insights from health communication research. In C. N.
Candlin (Ed.), Research and practice in professional discourse (pp. 95–
135). Hong Kong: City University of Hong Kong Press.
Sarangi, S., & Candlin, C. N. (2001). ‘Motivational relevancies:’ Some
methodological reflections on sociolinguistic practice. In N. Coupland, S.
Sarangi, & C. N. Candlin (Eds.), Sociolinguistics and social theory (pp.
350–388). London: Pearson.
Sarangi, S., & Clarke, A. (2002). Constructing an account of contrast in counseling
for childhood genetic testing. Social Science & Medicine, 54(2), 295–308.
Sarangi, S., & Roberts, C. (1999). The dynamics of interactional and institutional
orders in work-related settings. In S. Sarangi & C. Roberts (Eds.), Talk,
work and institutional orders: Discourse in medical, mediation and
management settings (pp. 1–57). Berlin: Mouton de Gruyter.
Sass, L. A. (1998). Interpreting schizophrenia: Construal or construction? A reply to
Robert J. Barrett. Culture, Medicine & Psychiatry, 22, 495–503.
Silverman, D. (1987). Communication and medical practice: Social relations in the
clinic. London: Sage.
Skevington, S. M., Bradshaw, J., & Saxena, S. (1999). Selecting national items for
the WHOQOL: Conceptual and psychometric considerations. Social Science
& Medicine, 48(4), 473–487.
Skelton, J. R., Kai, J., & Loudun, R. F. (2001). Cross-cultural communication in
medicine: Questions for educators. Medical Education, 35(3), 257–261.
Spencer, J., & Silverman, J. (2001). Education for communication: Much already
known, so much more to understand [Editorial]. Medical Education, 35(3),
188–190.
Stivers, T. (2002). Participating in decisions about treatment: Overt pressure for
antibiotic medication in pediatric encounters. Social Science & Medicine,
54(7), 1111–1130.
Stivers, T., & Heritage, J. (2001). Breaking the sequential mold: Answering ‘more
than the question’ during comprehensive history taking. TEXT, 21(1–2),
151–185.
Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory,
procedures and techniques. Newbury Park, CA: Sage.
Tan, L., Fleming, A., & Ledwidge, H. (2001). The caregiving burden of relatives
with dementia. Geriaction, 19(1), 10–16.
Ten Have, P. (2001). Lay diagnosis in interaction. TEXT, 21(1–2), 251–260.
154 CHRISTOPHER N. CANDLIN AND SALLY CANDLIN

Ulrey, K. L., & Amason, P. (2001). Intercultural communication between patients

and health care providers. An exploration of intercultural communication
effectiveness, cultural sensitivity, stress, and anxiety. Health
Communication, 13(4), 449–463.
van Wieringen, J., Harmsen, J., & Bruijnzeels, M. (2002). Intercultural
communication in general practice. European Journal of Public Health,
12(12), 63–68.
Visandjée, B., & Dupére, S. (2000). La communication interculturelle en contexte
clinique: Une question de partenariat [Cross-cultural communication in a
clinical setting: A question of partnership]. Canadian Journal of Nursing
Research, 32(1), 99–113.
Wadensjø, C. (1998). Interpreting as interaction. London: Longman.
Warren, M. G., Weitz, R., & Kulis, S. (1998, December). Physician satisfaction in a
changing health care environment: The impact of challenges to professional
autonomy, authority and dominance. Journal of Health and Social Behavior,
39, 356–367.
West, C. (1984). Routine complications. Bloomington: Indiana University Press.
Williams, C. (2000). Doing health, doing gender: Teenagers, diabetes and asthma.
Social Science & Medicine, 50(3), 387–396.