Multiple interfaces:
Language, context and cognition in medical discourse
Malcolm N. MacDonald
Centre for Applied Linguistics
University of Warwick
1
Multiple interfaces?
• Theoretical framework
• Analysis#1: Text and social context (after Halliday 1985,
Matheisson & Halliday, 2002).
• Analysis#2: Text and cognitive context (after Van Dijk,
2002).
2
Theoretical framework
•
Archeological approach (Foucault 1972, 1973)
•
Pedagogic Device (Bernstein 1990, 1996, 2000)
3
Game of truth
Medicine organized as a field of knowledge requiring an
account of medical discourse uncovered by an
archaeological enquiry.
Three axes of enquiry
• An area of problematization: knowledge, power, ethics.
• A locus of concern: discourse, institution, subject.
• An analytic approach: archaeological approach.
4
The Archaeological Method
Three loci of medical discourse:
• primary, conceptual spatialization of disease: an ensemble
of empirico-scientific texts
• the secondary spatialization: the identity of the subject
becomes constructed as patient
• the third spatialization in extra-discursive areas:
juridico-scientific institutions.
5
The Archaeological Method
the enunciative function of the statement
• The statement establishes a set of rules and conditions by
which it defines and delimits the concept which it contains.
• The positioning of the subject within the statement is a
non-personal set of institutional, social or epistemological
relations.
• The statement is related to a supporting field of statements
- the enunciative field.
• The statement has a material existence, which arises from
its capacity to be repeated in a recognizable form repeatable materiality.
6
The Archaeological Method
discursive formations
Statements combine to make up discursive formations.
Discursive formations constitute:
• concepts within particular forms of knowledge & social practices
• subjects
• objects
• strategies
A discursive formation will be individualized if one can define the
System of formation of the different strategies that are displayed in
it; in other words, if one can show how they all derive....from the
same set of relations (Foucault, 1972, p. 68).
7
New Politics of Health
Emergence of a new politics of health
• Separation of the sick from the poor and indigent.
• Emergence of the health and well-being of the population.
An essential objective of political power
• Preservation, upkeep and conservation of the labour force.
• The body as the focus of new technologies of power.
The birth of modern medical practice
• Privilege of children and medicalisation of the family
• The privilege of hygiene and the function of medicine as an
instance of social control.
8
The Archaeological Method
The archaeological method challenges three fundamental
notions in liberal, humanistic philosophy:
• It challenges the continuity of the history of ideas
• It challenges the centrality of the notion of Man
• It challenges the transparency of empirical knowledge
9
Language and symbolic control
Bourdieu (1991)
The relations of communication par excellence - linguistic
exchanges - are also relations of symbolic power in which the
power relations between speakers or their respective groups are
actualized (1991, p.37).
Bernstein (1990, 1996, 2000)
Symbolic control is the means whereby consciousness is given a
specialized form and distributed through forms of communication
which relay a given distribution of power and dominant cultural
categories. Symbolic control translates power relations into
discourse and discourse into power relations (1996, p. 134).
10
Pedagogic Device
• The pedagogic device is the condition for the production,
reproduction, and transformation of culture.
• This device provides the intrinsic grammar of pedagogic
discourse through a hierarchical relationship between:
– distributive rules , which regulate
– recontextualizing rules , which regulate
– evaluative rules.
11
Distributive rules
Distributive rules govern the relationship between power, social groups, and
forms of consciousness.
Distributive rules maintain a differentiation between the specialization of two
fundamental orders of meanings (after Durkheim):
– the thinkable and the unthinkable
– the material and the transcendent
– the esoteric and the mundane.
Distributive rules govern the distribution of these two different orders of
meaning to different social groups. In this way there is a specialization and
distribution of forms of consciousness and practice within an
epistemological field, and within society.
– prophet
producers
– priest
reproducers
– laity
acquirers
12
Recontextualizing rules
Two different discourses which operate within a discursive field.
Discourse of competence
• transmits and interrelates specialized competences
• instructional discourse
Regulative discourse
• creates specialized order, relations and identity.
(Bernstein, 1990, p.183).
13
Pedagogic discourse
Pedagogic discourse is the rule which governs the embedding of an
instructional discourse, a discourse of competence, into a regulative
discourse. This regulative discourse operates so that the discourse of social
order always dominates the discourse of competence.
Pedagogic discourse is a principle for appropriating other discourses and
bringing them into a special relation with each other for the purposes of
their selective transmission and acquisition.
(Bernstein, 1990, pp.183-4).
14
Recontextualization: carpentry vs. woodwork
When I was at school I spent three years in a large room with wooden
benches and with side benches with saws and hammers and chisels. After
three years, I had a pile of wood chippings as high as the bench itself. But
what was I doing? Well, what I was doing was this: outside pedagogy there
was carpentry, but inside pedagogy there was woodwork. In other words,
here was a transformation of a real discourse called carpentry into an
imaginary discourse called woodwork.
(Bernstein, 1996, p. 47) .
15
Recontextualizing Rules
Contexts and fields
Field of Production
Primary contextualization is the process whereby new ideas are
selectively created, modified, or changed.
Field of Reproduction
Secondary contextualisation is the context of the selective reproduction of
discourse.
Field of Recontextualisation
Tertiary recontextualisation is concerned with the movement of texts from
the primary context of discursive production to the secondary context of
discursive reproduction.
16
Pedagogic Device
(Bernstein, 1996)
Field
Site
Text type
Production
Research laboratory
Computer terminal
Research paper
Reproduction
GP's surgery
Clinic
Health centre
Outpatients department
Interview
Recontextualisation
Medical school
Textbook
17
Analysis#2
18
Analysis #1
Text and social context
• after Halliday (1985)
• Matheisson & Halliday (2002)
19
Diagram
Page 1
DPI 2006 # 2
20
Diagram
Page 2
DPI 2006 # 2
21
Corpus 1
Four RAs from the British Medical Journal:
Two epidemiological surveys:
• Text A (Verity et al., 1992)
• Text B (European Study group on Heterosexual Transmission of HIV, 1992)
Two clinical trials:
• Text C (Greer et al., 1992)
• Text D (Muijen et al., 1992)
Four extracts from medical textbooks:
• Text I: pharmacology (Rang and Dale, 1995);
• Text J: biochemistry (Stryer, 1995);
• Text K: physiology (Guyton and Hall, 1996);
• Text L: anatomy (Guyton and Hall, 1996).
Four interviews between consultant, child and carer in a epilepsy clinic:
• Text E, F, G, H
Recontextualisation:
context of (social) situation
Context
Meanings
realised by
realised by
Tenor
Interpersonal
Speaker’s
Comment
modality
reporting verbs
reporting nouns
evaluative
adjectives
Field
Ideational
Grammar
tense
process type
transitivity
Mode
Textual
Genre
move structure
IRF structure
23
Speaker’s Comment
Speaker's comment can be expressed by:
• verbal and non-verbal modality
• a number of different types of adverb, e.g. frankly, generally, wisely,
fortunately, officially, reasonably, personally, incidentally, doubtfully,
etc.
• reporting verbs (e.g. suggest instead of shown), relating to the
intensity of support given to the thesis, as has been illustrated in the
analysis above (Swales, 1990).
• reporting nouns (e.g. speculation instead of evidence)
• evaluative adjectives (e.g. major instead of slight).
24
Table 1
Incidence and ratio per line of speaker's comment
by section of medical research article
Lines
Ratio
Abstract
Speaker‘s
Comment
26
153
1: 5.88
Intro
57
113
1: 1.98
Methods
23
366
1:15.91
Results
129
598
1: 4.64
Discussion
259
514
1: 1.98
Overall
494
1744
1: 3.53
25
Table 2
Incidence and ratio per line of speaker's comment
by textbook type
Speaker‘s
Comment
Lines
Ratio
Pharmacology
173
530
1: 3.0
Biochemistry
93
406
1: 4.37
Physiology
71
556
1: 7.83
Anatomy
42
398
1: 9.48
Total
379
1890
1: 4.98
26
Table 3
Incidence and ratio per clause of speaker's comment:
numbers of occurrences in medical interviews
Clauses
Ratio
Text A
Speaker’s
Comment
55
131
1:2.38
Text B
40
134
1:3.35
Text C
50
106
1:2.12
Text D
41
114
1:2.78
Total
186
485
1:2.66
27
Tense
• The Present Perfect tense is used to claim generality about past literature. The
Past Tense is used to claim non-generality about past litera-ture.
• The Present Perfect tense is used to indicate the continued discussion of some
of the information in the sentence in which the Present Perfect tense occurs.
• The Past tense is used when it refers to quantitative results of past literature
that are non-supportive of some aspects of the work described in the technical
article.
• The Present tense is used when it refers to the quantitative results of past
literature that are supportive or non-relevant. The Present tense is also used to
refer to past literature, rather than to discuss it.
28
Table 4
Percentage distribution of 4 major tense types
in medical discourse by context and genre
Field
Pres
Past
Perf
Fut
Genre
Production
22.5
73.4
3.6
0.5
Recontextualizing
Reproduction
94.1
4.1
1.7
0.2
Research
Article
Textbook
54.0
31.3
8.0
6.7
Interview
29
Examples of process types
(doctor
(doctor--patient interviews)
Material
I can’t find the drug sheet
Relational
Dr. Barman is not here today
Mental
I think so
Verbal
You were saying about someone else in the family
Behavioural
One day he completely fainted
Existential
There’s no urgency about it
30
Table 5
Percentage distribution of process types
in 4 types of medical text
RA
Textbook
Interview
Material
27.2
40.8
20.6
Relational
43.3
45.7
44.5
Mental
12.4
7.1
20.2
Verbal
12.7
5.6
2.9
Behavioural
1.2
0.1
5.5
Existential
3.2
0.8
6.3
31
Table 6
Percentage distribution of modes of transitivity
across 3 genres of medical discourse
RA
Textbook
Interview
Active
19.0
29.2
19.7
Passive
14.7
14.7
1.5
Middle
53.2
48.8
78.2
Medio-passive
13.1
7.4
0.6
32
Conclusion
• The symbolic function of pedagogic discourse resides in the meaning potential
of certain coding values of rhetoric and grammar.
• These features of text realise a symbolic surplus of meaning which enables
access to certain texts to authorize the utterances of their producers or users in
particular social contexts.
• Pedagogic texts operate as a symbol-system which has the ideological effect of
the creation and maintenance of the interests of certain hegemonic groups,a nd
of certain texts as ‘doxic’ texts.
33
Analysis#3
34
3. Analysis
Text and cognitive context
• after Van Dijk (2002)
35
Socio--cognitive approach
Socio
Socio-cognitive discourse analysis:
• attempts to account for the various forms of social cognition that are shared by
groups, organisations and institutions;
• describes collective mental models and the ways in which these are produced
and reproduced through discourse;
• the ‘cognitive’ part of socio-cognitive discourse analysis comprises:
–
–
–
–
knowledge
opinions
values
attitudes
36
Socio--cognitive approach
Socio
Individual as well as social cognition
Collective
• Knowledge
• Attitudes
• Ideologies
Individual
• Beliefs and goals
• Evaluations and emotions
• Other 'mental' or 'memory' structures, presentations or processes involved in
discourse and interaction
37
Corpus 2
Four (RAs) which report research into childhood epilepsy were extracted from
specialist and non-specialist journals:
• Journal of Neurology, Neurosurgery and Psychiatry (Stroink, Arts, Geerts,
Peters, & Van Donselaar, 1998);
• Journal of Epilepsy (Lancman, Asconape, Brotherton, & Penry, (1995);
• British Medical Journal (Kurtz, Tookey, & Ross, 1998);
• British Medical Journal (Smith, Bartolo, Pickles, & Tedman, 2001).
Four textbook samples were selected which were indicative of a potential range of
sub-genres on epilepsy:
• Monograph on childhood epilepsy (Appleton & Gibbs, 1998);
• Chapter from an edited collection on childhood epilepsy (Brett, 1995);
• Chapter from neurology primers (Donaghy, 2005, pp. 127-133; Drury & Gelb,
2000).
• Chapter from neurology primers (Drury & Gelb, 2000).
Four interviews between consultant, child and carer in epilepsy clinic:
• 2 initial consultations.
• 2 follow-up consultations.
Global and local meanings
GLOBAL
Topics: semantic macrostructures
Local meanings
Implicit formal structures
LOCAL
39
Global meanings:
semantic macrostructures
Topics or semantic macrostructures:
• represent what discourse is 'about' globally speaking
• embody the most important information of the discourse
• explain overall coherence of text and talk
40
Research paper (Stroink et al 1998)
Abstract
• objectives
• methods
• results
• conclusion
Introduction
Methods
• patients
• classification
• additional investigation
• follow up
• analysis
Results
• diagnostic accuracy
• risk of recurrence
• long term outcome after
recurrence
• age specific incidence,
cumulative
• incidence and prevalence
Discussion
• case ascertainment
• comparisons with other studies
• defining prevalence and
classifying seizure types
Medical Textbook (Donaghy, 1997)
Diagnosing an epileptic seizure
• witnessed convulsion
• postictal confusion
• incontinence
• tongue biting
• inability to remember
• onset
• absence attacks
• stereotyped aura
Types of epilepsy
• primary generalized epilepsy
• focal epilepsy
• grand mal
• the single seizure
• status epilepticus
Treatment of epilepsy
• anticonvulsant drugs
• phenytoin
• carbamazephine
• sodium valproate
• monitoring drug blood levels
• anticonvulsant drugs for women
• driving regulations
Vasovagal attacks (simple faints)
Cardiogenic blackouts
Hyperventilation attacks
Hypoglycaemic attacks
Medical interview
Greeting
Signs and symptoms
• birth
• illness
• convulsions
• continence
• school
•family
Physical examination
• school
• check
Signs and symptoms
• family history
Disposal
• diagnosis
• treatment
• follow up (test)
Signs and symptoms
Salutation
41
Three phase patterning of medical discourse
Research paper
Textbook
Interview
Phase 1
Abstract
Introduction
Diagnosing an
epileptic seizure
Greeting
Phase 2
Methods
Results
Types of epilepsy
Signs & symptoms
Physical examination
Phase 3
Discussion
Treatment of
epilepsy
Disposal
Salutation
Problem –
solution?
Classification?
Narrative
42
Mental models
Context defined in terms of a mental model of a communicative situation.
Mental models form the interface between:
• discourse and society
• personal and social
Two types of mental model:
• context model
• event model
On this argument, context models and event models may be the cognitive
phenomena involved in the process of recontextualisation
43
Mental models
Event models are mental models of:
• a specific situation which in which participants interact
• events or situations they speak or write about.
Context models are the interface between:
• mental information about a communicative event
• actual meanings being constructed in discourse.
44
The field of production: RA
The committee classified seizures according to the revised classification of the
International League Against Epilepsy …According to the recent guidelines on
epidemiological research of the ILAE, patients with a genetically determined type
of epilepsy manifesting through a single seizure were called idiopathic. All other
children were considered cryptogenic (Stroink et al., 1998, p. 596).
…the term “epilepsy” is beginning to be replaced by increasingly well defined
epileptic syndromes (Kurtz et al., 1998 , p. 339).
Despite a large amount of published literature from many countries on the
incidence of epilepsy in childhood, comparatively little is known about the long
term prospects for those who have epilepsy in childhood (Kurtz et al., 1998 , p.
339).
45
Recontextualizing field: textbook
Seizures are classified into either generalised or partial seizures… Partial seizures are
further classified as ‘simple’, in which consciousness is retained, or ‘complex’, in which
consciousness is impaired or lost…Partial seizures may become secondarily
generalised, resulting in a tonic-clonic convulsion. (Appleton and Gibbs, 1998, p. 10).
Generalised tonic-clonic seizures (grand mal seizures) are the commonest epileptic
manifestation of childhood (Brett, 1995, p. 444).
Tonic-clonic seizures. This is probably the category about which there is the least
consensus…(Drury and Gelb, 2005, p. 143).)
International classifications of epilepsy are unlikely to ever be entirely satisfactory…
(Appleton and Gibbs, 1998, p. 11).
46
Field of reproduction: interview
Elicitation cycle
Dr:
was she twitching at all...
Dr:
were they regular movements...
Dr:
and how long did they last...
Cr:
..she just stared and then she started - kicking her legs…
Dr:
how - together or alternately...
47
The field of production: RA
The discursive procedures to be deployed in the clinic are described in only one
of the four RAs sampled.- at the beginning of the Discussion section .
When the clinician is confronted with the problem of a child who has experienced
a single episode that seems to be of epileptic origin, some questions have to be
considered. Was the event really epileptic? If so, what is the risk of more seizures
occurring? Should anticonvulsant treatment be offered and with what goal? What
is the long term outcome with or without treatment? As the diagnosis of a first
epileptic seizure may have a great impact on the child and its parents, a correct
diagnosis is of the utmost importance (Stroink et al., 1998 , p. 598).
48
Recontextualizing field: textbook
The discursive procedures to be deployed in the clinic are asserted repeatedly in
the medical textbook.
Patients often have little or no recollection of the spell, so witnesses’ accounts are
especially important. (Drury and Gelb, 2005, p. 137).
The accurate account of any eyewitness is essential … (Appleton and Gibbs, 1998,
p. 8).
If a blackout has not been witnessed, one or more of the following features point
strongly to a diagnosis of epilepsy (p. 127).
49
Recontextualizing field: textbook
The recognition and diagnosis of epileptic seizures is almost entirely dependent on
the history…the results of any investigations can only be interpreted with
reference to the history (Appleton and Gibbs, 1998, p. 8).
…accurate diagnosis depends on obtaining as detailed a history as possible
(Drury & Gelb, 2005, p. 137).
…it is helpful to know the exact sequence of events and how long each stage
lasted.. It is best to have patients and witnesses describe in an open-ended fashion
everything they observed before, during, and after the spell in question …if
adequate detail cannot be obtained by asking several open-ended questions…
directed questions may be necessary… (Drury & Gelb, 2005, pp. 137-138).
50
Field of reproduction: interview
Open
Open--ended questions
Now, X has had some fits has he – tell me about them... (IC#1)
Now, when did she have problems with convulsions... (IC#2)
What do you notice...( IC#1)
51
Field of reproduction: interview
Elicitation cycle revisited
... and this was 2 months ago was it...
ahat was the interval between them…
and he was actually asleep...
and how long did it actually last...
and afterwards, how was he...
did he wet the bed...
and how many times has it happened since...
and all occurred at the same time did they... (elicitation cycle # 1)
…and when was the one after that… (elicitation cycle # 2)
…and tell me about the last time… (elicitation cycle # 3)
52
Treatment statement:
recontextualisation of across three fields
Research paper (field of production)
At this time, it seems to be advisable to delay long term anticonvulsant treatment
until recurrent seizures are adversely affecting the child's life without any signs of
spontaneous remission. In so doing many children will never have to start
treatment (Stroink et al, 1998 p. 599).
Textbook (recontextualizing field)
Patients with a single seizure are not usually treated with anticonvulsant drugs
unless an underlying abnormality predisposing to further seizures is detected,
such as a brain tumour (Donaghy, 1997, p. 145).
Interview (field of production)
Well I'd like her not to have any………………..… there's no urgency about it.
53
Knowledge type and text type
across three fields of medical discourse
Field
Discourse type
Knowledge type
Production
Research paper
Declarative
Social group (prof)
Recontextualisation
Textbook
Declarative
Procedural
Social: group (prof)
Reproduction
Interview
Procedural
Social: interpersonal
Personal/private
54
Multiple interfaces
Medical Discourse
[MacDonald, 2002]
[MacDonald, 2009]
Discursive practices
(Foucault, 1972)
Context
Pedagogic discourse
(Bernstein, 1996)
Language
Social semiotic
(Halliday, 1979/85)
Cognition
Social representations
(Moscovici, 2000)
OR
Field of production
research laboratory
computer terminal
Research paper
Genre analysis
(Swales, 1990)
Discursive psychology
(Potter & Wetherell, 1997)
(Billig, passim)
OR
Field of reproduction
GP's surgery
clinic
health centre
hospital
Interview
(Coulthard & Ashby, 1975)
Field of recontextualisation
medical school
Textbook
Sites
Texts
Cognitive schema
(Van Dijk, 2000)
- macrostructure
- topic
- implication
- presupposition
- coherence
- connotation
Knowledge & semantics