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PRACTICE: Brian David Hodges, Ayelet Kuper, and Scott Reeves Discourse analysis BMJ 2008; 337: a879 [Full text]

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What counts as discourse analysis and what use is it?

Celia Roberts, Julia V Bailey   (20 August 2008)

What counts as discourse analysis and what use is it? 20 August 2008
Celia Roberts, Professor Department of Education and Professional Studies, King's College London, SE1 9NN, Julia V Bailey Send response to journal: Re: What counts as discourse analysis and what use is it?	Hodges et al’s article on Discourse Analysis is to be welcomed since, as the authors say, Discourse Analysis (DA) is still an underused methodology in medical research. Their conclusion is an important statement about the future of DA as a central qualitative research approach, in particular the idea that language also has meta-level meanings. However, it must be stressed that their take on what counts as discourse analysis is only one way of looking at the subject and omits some of the central players in the field. It also tends to treat DA as a set of techniques rather than as a process which acknowledges that discourse is constitutive of everyday and institutional activities, where talk is work. The three different categories of DA that Hodges et al present (formal, empirical and critical) are somewhat misleading. ‘Formal’ suggests an asocial approach, but all discourse analysis is concerned with language use in social contexts. ‘Empirical’ suggests that the other categories are non-empirical. However, all discourse analysis has an empirical base, including critical discourse analysis which has a long tradition of micro-analysis (1). DA is a hybrid and contested field, however, Gee’s notion that there are big D and little d discourses is useful (2). The former relates to the larger discourses which, drawing on social and post-structuralist (e.g. Foucauldian) theory, are the ways of acting, thinking and valuing to enact identities and practices which privilege certain groups and ways of knowing over others. The little d discourses are examples of language in use from the most micro which we subconsciously process to the larger genres of doctor-patient consultations, oral examinations, case presentations etc. Increasingly DA draws on both D/d discourses. There is a long tradition within sociolinguistics of DA in healthcare (3,4,5,6). More recently Conversation Analysis (7,8), and discursive psychology have turned their methodological gaze to health communication (9,10). While Hodges et al‘s hypothetical examples of practical relevance of DA are useful, there are already examples of how DA can contribute to problem solving: how patients’ agendas become inadvertently overlooked (11), why ethnic minority candidates receive poorer marks in medical examinations (12), developing assessment skills in genetic counselling (13), communicating with patients with limited English (14), and unpicking factors influencing ‘irrational’ prescribing (15). Finally, it is important to stress that DA is not another system for capturing and coding functions of language. Although the formal features of language have to be understood, and contribute to our understanding of any event or genre, they only have meanings as they connect to particular contexts. And while micro analysis ties down these meanings, discourse analysis also opens up these meanings to a wider appreciation of the role of language in constructing medical realities. 1. Wodak R. Disorders of Discourse. London: Longman, 1996 2. Gee J. An Introduction to Discourse Analysis. London: Routledge, 1999 p.13. 3. Fisher S and Todd A D (eds). The Social Organisation of Doctor- Patient Communication. Washington DC: Centre for Applied Linguistics, 1983. 4. West C. Routine Complications: Troubles in Talk between Doctors and Patients. Bloomington: Indiana University Press, 1984. 5. Freeman S and Heller M (eds). Medical Discourse. Special issue of Text 1987;7(1). 6. Ainsworth-Vaughn N. Claiming Power in Doctor-Patient Talk. New York: Oxford University Press; 1998. 7. Heritage J and Maynard D (eds.) Communication in Medical Care: interaction between primary care physicians and patients. Cambridge: Cambridge University, 2006 8. Stivers T. Prescribing under pressure. Parent-physician conversations about antibiotics. Oxford University Press, New York, 2007 9. Wilkinson S. & Kitzinger C. Thinking differently about thinking positive: a discursive approach to cancer patients' talk, Soc Sci Med, 2000;50(6):797-811 10. Potter J. & Hepburn A., Discursive psychology as a qualitative approach for analysing interaction in medical settings. Med Educ 2005;39(3):338-44 11. Mitcheson J. & Cowley S., Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool. Int J Nurs Studies 2003; 40(4): 413-26. 12. Wass V, Roberts C, Hoogenboom R, Jones R., & Van der Vleuten C., 'Effect of ethnicity on performance in a final objective structured clinical examination: qualitative and quantitative study', BMJ 2003;326(7393):800-3. 13. Sarangi S, Bennert K, Howell L, Clarke A, Harper P, and Gray J. Initiation of reflective frames in counselling for Huntington’s Disease predictive testing. J Genet Counsel 2004; 13(2):135-55. 14. Roberts C, Moss B, Wass V, Sarangi S, and Jones R. Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications. Med Educ 2005;39(5):465-75. 15. Ferner R E &. Scott D K. Whatalotwegot--the messages in drug advertisements. BMJ 1994;309(6970):1734-1736. Competing interests: None declared