Epistemic Trust as an Interactional Accomplishment in Pediatric Well-Child Visits: Parents’ Resistance to Solicited Advice as Performing Epistemic Vigilance

ABSTRACT

Epistemic trust – i.e. the belief in knowledge claims we do not understand or cannot validate – is pivotal in healthcare interactions where trust in the source of knowledge is the foundation for adherence to therapy as well as general compliance with the physician’s suggestions. However, in the contemporary knowledge society professionals can no longer count on unconditional epistemic trust: boundaries of the legitimacy and extension criteria of expertise have become increasingly fuzzier and professionals must take into account laypersons’ expertise. Drawing on a conversation analysis-informed study of 23 videorecorded pediatrician-led well-child visits, the article deals with the communicative constitution of healthcare-relevant phenomena such as: epistemic and deontic struggles between parents and pediatricians, the local accomplishment of (responsible) epistemic trust, and the possible outcomes of blurred boundaries between the layperson’s and the professional’s “expertise.” In particular, we illustrate how epistemic trust is communicatively built in sequences where parents request the pediatrician’s advice and resist it. The analysis shows how parents perform epistemic vigilance by suspending the immediate acceptance of the pediatrician’s advice in favor of inserting expansions that make it relevant for the pediatrician to account for her advice. Once the pediatrician has addressed parents’ concerns, parents perform (delayed) acceptance, which we assume indexes what we call responsible epistemic trust. While acknowledging the advantages of what seems to be a cultural change in parent-healthcare provider encounters, in the conclusion we advance that possible risks are implied in contemporary fuzziness of the legitimacy and extension criteria of expertise in doctor-patient interaction.

Acknowledgements

We would like to warmly thank the pediatricians and families who accepted to participate in this study. We also wish to thank the anonymous reviewers for their extremely insightful comments and suggestions that improved the overall quality of the article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. We use a formula proposed by John Heritage (Rome, 2022, personal communication) as a label for studies that do rely on CA methodological techniques and constructs to show how meso or macro phenomena (like an intersubjective status of reasonable epistemic trust) are not pre-conditions of local interaction but rather participants’ local accomplishment built one interaction at a time through communicative details. Without being aimed at describing conversational structures or practices as such, CA-informed studies use them as analytical tools.

2. Well-child visits (term used by the American Academy of Pediatrics) are regular checkups where the healthcare provider assesses the baby’s growth and development according to the expected standard. In Italy, these visits are carried out by pediatricians at pediatric primary care clinics.

3. For a detailed overview of the different methodological approaches to health communication studies see Thompson et al. (2011, section VI).

4. Since in well-child visits no disease-related symptoms are commonly at stake, an out-and-out diagnosis does not occur. However, after the physical examination, the pediatrician typically provides assessments about the child’s growth and development based on both direct observation of the child and on the parents’ reported information. Despite not constituting a diagnosis in the strict sense of the term, we consider the assessment of the infant’s growth and development as constituting the diagnostic-like phase of the visit for two reasons. First, because of its position within the visit: with respect to the overall structural organization, it immediately follows the physical examination, like diagnosing (see Heritage & Maynard, 2006; Heritage & McArthur, 2019). Second, because of its similarities with the task-focused activities identified as typical of the diagnostic phase, i.e., delivering and receiving evaluations.

5. Although we are aware that advice-giving design can impact advice receiving, for the purposes of this article we mainly consider advice position and focus on parents’ resistance to solicited advice, i.e., cases where resistance is less expectable (see Heritage & Sefi, 1992; Kinnell & Maynard, 1996; Riccioni et al., 2014; Silverman, 1997).

6. The unsuitable consequences of using a pacifier as well as its benefits are part of contemporary parents’ semi-expert knowledge as an outcome of increasing caregiving socialization. Indeed, this territory of knowledge is precisely where struggles between parents’ and physicians’ epistemic and deontic rights can occur. Although still asking for advice, parents have their own ideas on caregiving and some semi-expert knowledge that they use to channel or resist even the advice they have requested. For recent data on the ways parents resist and even challenge medical authority, see Stivers and Timmermans (2020).

7. Laughter has been carefully investigated as a relevant multifunctional component of talk, which plays a crucial role in establishing meaning (not necessarily nor always humor, see Potter & Hepburn, 2010) and shapes the social organization of the interaction (see Glenn, 2003). It may be used as a resource by participants to cope with delicate aspects of the interaction (Haakana, 2001), as a marker signaling or masking troubles in talk (e.g., obscenity, see Jefferson, 1984) or to manage affiliation between co-participants (Glenn, 2003). It is commonly assumed that the laugh is highly indexical and “locally responsive” (Sacks, 1974, p. 348): it refers to and defines the element immediately preceding the laugh as laughable (see Jefferson et al., 1987; Schenkein, 1972).

8. As an anonymous reviewer rightly remarks, reporting that the teller has already talked about the matter with someone else does some interactional job. It contributes to forming the action accomplished by the mother – i.e., soliciting advice – by “merely” reporting a fact. It is indeed reasonable to assume that it is precisely this preface – which depicts the teller “talking about” the matter with someone else – that makes it relevant for the pediatrician treating the mother’s report as doing “soliciting advice.” This is a typical case of “next turn proof procedure,” i.e., the analyst aligns with what is ostensibly the case for participants: it is the pediatrician who treats the report as a request for advice, which she provides in line 6. This is why we call the parent’s action a “report-formatted advice request.”

9. The “Next-to-me” is a bedside sleeping crib merchandized by an Italian children’s brand.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.