Self-Initiated Problem Presentation in Prenatal Checkups: Its Placement and Construction

Abstract

Unlike primary care acute visits, which are occasioned by a matter of concern to the patient, regular prenatal checkups provide no structural positions for presenting problems that they wish to discuss. I find that there does nevertheless seem to be a systematic sequential position (namely, where an incipient activity is in progress) at which pregnant women can and do raise their concerns. I examine the defensive and evidence-sensitive nature of the construction of the problem presentations initiated at this position. I thereby demonstrate the mutual dependence between the position and construction of problem presentations. The position and construction of presentations are consequential to the way in which health-care professionals respond to them; they may engender a cycle where the pregnant woman (re)attempts to legitimize her original problem presentation and the health-care professional (re)attempts to confirm her or his no-problem response. In conclusion, I discuss some implications of the present study for the study of medical interaction in particular and the study of human interaction in general.

I owe a great deal of gratitude to Paul Drew for his very detailed comments and suggestions on earlier versions of this article, along with great encouragement. This work was supported by the Japanese Society for the Promotion of Science (Grant # 20530443).

Notes

¹Midwives are entitled to practice independently in Japan. I call the places for their practices “midwife houses.” Midwife houses are different from clinics and hospitals in regard to both institutional structure and appearance.

²In what follows, I also examine two segments of interaction from another set of data, i.e., audio and video recordings of about 30 acute and routine visits by nonpregnant women to a gynecological clinic, which were collected as part of the same research project in 2002 through 2004.

³All the extracts cited in this article are composed of three tiers: At each numbered line, there is first a romanized version of the original Japanese. Below this is a phrase-by-phrase gloss, and finally, on the third tier, a rough English translation. The first tier of transcript utilizes a transcription system developed by Gail Jefferson (see Jefferson, 2004b, for the most recent version). Furthermore, the following abbreviations are used in the phrase-by-phrase glosses in the second tier: IR for Interrogative, JD for Judgmental, MIM for Mimetic, P for Particle, PL for Polite, and PN for Proper name.

⁴Incidentally, the woman's expression of a concern in Extract 15 is also formatted as a report—the report of what she was told by the same doctor.

⁵Because later on the same visit, the midwife appears to take up the concern the woman raises here, she may have recognized the woman's problem presentation. However, the force of the utterance as a sequence-initiating action type is still defeated. Incidentally, Gill observes that the doctors' responses to patients' self-diagnoses presented during history taking in the primary care context also tend to be delayed (Gill, 1998; Gill & Maynard, 2006).

⁶Incidentally, the problem presentations in Extracts 15 and 17 also have a strong construction; the woman in Extract 15 cites what the doctor told her on the previous visit, and the woman in Extract 17 mentions what is directly observable on her abdomen (i.e., “cracks”). Thus, they propose that their problem presentations are independently grounded.

⁷The pregnant woman in Extract 2 also employs other practices for mitigating the seriousness of the possible problem, such as using nanka (“or something”) at the beginning of line 01 and laughing during line 02 indicated by (h)'s (see Jefferson, 1984, 2004a, among others, for what she calls “trouble-resistance” laughter).

⁸ Heritage (2002) and Boyd and Heritage (2006) provide a more technical discussion of the “optimization of preferences” in the construction of doctors' questions.

⁹There is a procedural ground for this ordering of explanation and demonstration. The explanation for the appearance is directly related, and therefore placed contiguously, to the pregnant woman's problem presentation, i.e., her mention of the noticeablity of the smallness of her abdomen (see Sacks, 1987).

¹⁰Interestingly, the doctor also uses an extreme case formulation mina san (“everybody”) in her explanation (in line 08).

¹¹During the utterance in line 21 and the 0.4-second-long silence in line 22, the midwife keeps palpating the pregnant woman's abdomen. In particular, given the format “Certainly X but Y,” the midwife's continuation of the palpation during the small silence following the concessive utterance in line 21 foreshadows her mentioning of a fetal condition, which further negates the problematicity of the presented problem. The pregnant woman's utterance in line 23 also appears to preempt this foreshadowed negation.