‘And how long have you been sick?’: The discursive construction of symptom duration during acute general practice visits and its implications for ‘doctorability’

Abstract

This study uses Conversation Analysis to investigate how doctors and patients talk about the duration of patients’ symptoms during acute general practice consultations in Denmark. Both parties treat it important to address and reach shared understanding about this issue, and it is the subject of much clarification and negotiation. Mentioning the duration of symptoms may be patient-initiated from the very outset of the consultation, as part of the problem presentation, or doctor-solicited in the subsequent interaction. Analysis reveals that in both cases, patients use concepts that stress relative duration as part of efforts to legitimise their visits. Legitimisation by such means is most evident in connection with doctor-solicited mention of duration of symptoms. Patients treat doctors’ questions as preferring an answer, which confirms that they have been sick for a long time. Overall, the study provides insight about the huge impact that discussions about time have for conversational organisation during consultations. It also shows how a shared understanding of the duration of symptoms is treated as a precondition for medical decisions and entitlements.

Keywords

Conversation analysis discourse medical encounters temporal concepts doctorability

The duration of a given symptom can be a very important medical factor. Some symptoms require urgent attention if they are not to develop rapidly into life-threatening diseases. Luckily, however, most symptoms are harmless and will vanish by themselves in time, and the best way to treat them is to leave them alone. Time can thus present medical practitioners with considerable dilemmas, not least in general practise: When should physicians commence medical treatment, and when should they send patients back home with a ‘wait and see how it develops’ message? A watchful waiting strategy may, for instance, reduce inappropriate prescriptions of antibiotics (McCormick et al., 2005). Development over time may also provide diagnostic possibilities, for instance the so-called test of time by which progression or its absence is used to ‘discriminate the minority of patients with serious disease, who require urgent attention, from the majority with self limiting or less serious problems’ (Almond and Summerton, 2009: 43; Irving and Holden, 2013). This paper uses the Conversation Analysis (CA) method to investigate how general practitioners and patients in Denmark talk about and negotiate the meaning of the duration of patients’ symptoms during acute care visits (cf. Heritage and Clayman, 2010: 104).

As the paper will show, discussions about how long a patient has experienced a given symptom seem to be integral and dominant features of most acute visits in general practice. Numerous conversation analytic studies of doctor–patient interaction, notably during general practise consultations, have been published within the past decades investigating the structural organisation of such encounters and how actors seek to achieve shared understanding during their courses of interaction (e.g. Heritage and Maynard, 2006). This includes a focus on temporal limitations: for instance, do patients have time to talk about more than one concern during a tightly scheduled consultation (Beck Nielsen, 2012)? The present study contributes to this line of research with an enhanced understanding of the impact of overt talk about symptoms’ temporal perspectives.

Talking world time into being in the doctor’s office

We learn from philosophers such as William James, Henri Bergson, and Alfred Schutz (all of whom sought to conceptualise our experience of time) that there is an analysable difference between ‘living in time’ and ‘reflecting upon living in time’. As Schutz (1967: 45) puts it, ‘The structure of our experience will vary according to whether we surrender ourselves to the flow of duration or stop to reflect upon it, trying to classify it into spatiotemporal concepts.’

In the former case, we experience time as a continuous flow of overlapping actions and events: ‘We encounter only undifferentiated experiences that melt into one another on a flowing continuum’ (Schutz, 1967: 51, see also James, 1950: 606). In the latter case, we ‘stop and think’ (Schutz and Luckmann, 1974: 53). This mode radically alters our perspective, so that ‘the flow of lived experiences’ is ‘broken down into discrete moments and subsequently recomposed through multiple connections’ (Muzzetto, 2006: 7). Schutz refers to the former type as subjective time and the latter as world time (Schutz and Luckmann, 1974). Discussion of the duration of particular symptoms by doctors and patients reflects upon duration and is an attempt to classify duration into temporal concepts, that is, world time. Which discursive and interactional features as well as institutional constraints define such classification attempts?

One of the core objects of CA research is to investigate how people coordinate their communicative actions in ever-changing real time, thus illuminating the temporal organisation of shared conversational experience (cf. Suchman, 2007, see also Rawls, 2005). Some CA scholars’ work is accordingly dedicated to the precise time of conversational contributions (e.g. Nevile, 2006, 2007a, 2007b). However, relatively few CA studies have dealt with time as an overt conversational topic, let alone negotiated phenomenon (some exceptions are Halkowski, 2006; Jefferson 2004a; and Pomerantz, 1986). There is no reason not to do this since another core object of CA is to investigate how various phenomena, including inner experiences and social affairs, are ‘talked into being’ (Heritage, 1984a). The type of world time that doctors and patients talk into being is indeed pervasively situated. That is, the discursive construction of duration of symptoms is demonstrably conditioned by the fact that they are conveyed during acute consultations, when during such consultations, which symptoms they refer to, and what the actors seek to accomplish by providing such explanations.

An important concept for the study is doctorability, which refers to the finding that patients regularly orient towards legitimising their visit to the doctor (Heritage and Robinson, 2006). When patients claim doctorability, they convey that their symptoms are worthy of the doctor’s time and attention, for instance by invoking third parties (‘I was referred/advised to come’) or by displaying troubles resistance (‘I lived with the symptoms a long time before coming’). Indeed, all of the examples of patients’ troubles resistance in medical problems discussed by Heritage and Robinson (2006) contain what I will term ‘patient-initiated mention of duration of symptoms’ (see below). However, this temporal aspect, its discursive facets, and its implications for doctorability are not the principal focus of Heritage and Robinson’s study, as opposed to the present study.

Data

Video recordings of 52 general practice consultations (a total of approximately 11 hours) at a larger health centre in Denmark have been used for the study. Four different doctors participated (two males; two females). Each patient was filmed only once. I conducted all of the recordings in 2009–2010 with the informed consent of every participant.

CA research implies that the researcher should pay close attention not only to which actions participants communicate to one another through turns-at-talk and embodied behaviour, but also to how these actions are packaged, for instance, by linguistic resources such as wording, grammar, and prosody/intonation. CA researchers thus transcribe their data rigorously using Jeffersonian principles of notation (Jefferson, 2004b). A list of symbols used for this study is found at the end of the paper (see appendix 1). I have abbreviated doctors as DO and patients as PA in the transcripts that follow, and I have placed English translations immediately below the original Danish transcriptions. Each example is given a heading, which corresponds with the patient’s main reason for seeking medical attention.

The interactional relevancy of the temporal perspective

An initial observation, which will serve as a point of departure for the rest of the study, is that mention of the duration of symptoms occurs in most of the corpus’ acute consultations and that this mention is either patient-initiated as part of the patient’s problem presentation or doctor-solicited as part of a later activity during the consultation (see Byrne and Long, 1976). Excerpt 1.1 provides an illustration of the former. It begins as the participants commence the consultation:

(1.1): Sore throat

01. DO: hva ka jeg hjælpe dig med? how can I help you?

02. PA: ja:: øh (.3) >jeg har ondt i halsen.< ye::s erh (.3) >I have a sore throat.

03. (.)

04. PA: [og jeg tror j- ] je::g har øh haft det i lang tid ret lang [and I think I- ] I::’ve had it a long time fairly long

05. DO: [du har ondt i halsen. ] [you have a sore throat]

06. PA: tid efterhånden. time by now.

This doctor’s opening offer to serve prompts the patient to state his current sore throat as the reason for visiting the clinic (Line 02). It is worth noting the next piece of information that the patient chooses as relevant to mention. In Line 04, the patient begins a turn-at-talk, which appears to project an explanation behind the circumstances of his sore throat. However, the patient cuts off this turn-at-talk and inserts the information that he has suffered from this condition for ‘a fairly long time by now’ (Lines 04–06). The use of present perfect continuous tense (‘I have had it’) establishes continuity between the past and the present condition and conveys that the patient still suffers from that condition, that is, underscores its current relevance.

Compare with Excerpt 2, where a patient states her cold symptoms as the reason for her visit but with no added mention of their temporal aspects. Similar to Excerpt 1, this example represents the first words that are uttered during a consultation, that is, the opening phase, which here quickly transgresses into the problem presentation phase followed by the doctor’s history-taking.

(2): Cold

01. DO: ↓ja hva siger du? ↓yes what do you say?

02. PA: ↓ja (.) jeg ø:h døjer med noget- et eller andet forkølelse-=>jeg ved ↓yes (.) I’m erh troubled by some- some sort of cold -=>I

03. ikke om det er< forkølelsessår. [.hh [blæner eller et eller don’t know if it’s< cold sore. [.hh [blisters or something

04. DO: [↑nej °o[kay° [↑no °o[kay°

05. PA: andet (.) mærkeligt. (.) odd.

06. DO: hvor længe har du haft det? how long have you had it?

07. PA: ø:hm det kommer og går. e:rhm it comes and goes.

This patient’s problem presentation is characterised by uncertainty about the condition’s nature. It prompts the doctor to commence an inquiry. And the first thing he asks the patient in Line 06 is how long she has suffered from the condition instead of, say, asking what it feels like. In terms of phases, this type of question has been observed to initiate the history-taking phase where doctors interview patients rather than listen somewhat more passively to patients’ own problem presentations (Heritage and Clayman, 2010; Robinson and Heritage, 2005).

These two brief excerpts reveal that doctors and patients may share a consequential understanding of the diagnostic relevance of bringing up the issue of duration of symptoms even at the earliest stages of acute consultations. They also illustrate the intrinsically situated nature of the invoked temporal concepts. In neither example do the patients define their duration of symptoms in absolute terms, such as a certain number of days. In the first example, the patient claims to have had the condition for ‘a fairly long time by now’. In the second example, the patient simply answers that her condition ‘comes and goes’, which strictly speaking does not answer the doctor’s question (although it does provide a clue that the condition has lasted for a considerable length of time). Such ways of mentioning duration of symptoms may require that doctors pursue further inquiries about the specifics, which they indeed regularly do. However, from the patients’ point of view, there may be good reason for expressing duration of symptoms in these particular ways. For instance, patients may want to claim troubles-resistant doctorability by stressing that they have lived with their symptoms for some time (see analysis of Excerpt 8 below). Conversely, if patients are asked about the duration of the symptoms, and if this duration does not qualify for ‘a fairly long time’, patients may wish to stress that it is a recurrent problem in order to achieve doctorability (see analysis of Excerpt 7 below).

In the rest of the paper, I shall explore the impact of these features in acute consultations by observing the manifestations of patient-initiated and doctor-solicited mentioning of duration of symptoms respectively: What kinds of (tacit) reasoning do these manifestations uncover regarding negotiations of the legitimacy of the visit to the doctor and appropriate treatment?

Patient-initiated mention of duration of symptoms

As Excerpt 1 illustrated, it seems to be a common strategy for patients to mention the duration of their symptoms – and to emphasise their relative length – on their own initiative as part of the problem presentation activity. This particular patient stresses that he has had the symptoms for ‘a fairly long time’. The formulation assesses the duration as ‘long’, albeit only ‘fairly’ long (the inserted ‘fairly’ resonates with the finding that patients often try hard not to exaggerate their problems in order to appear trustworthy, cf. Heritage and Robinson, 2006). We find a related example in Excerpt 3, where a patient visits his doctor because of back pain. It is an acute visit, but the patient orients towards the condition as well known. Again, the example shows the opening and initial problem presentation of the consultation.

(3): Back pain

01. DO: ja hvad siger du? yes what do you say?

02. PA: .hh ø::h jeg har nogle problemer med min ryg. .hh e:rhm I have some problems with my back.

03. DO: okay:. okay:.

04. PA: øhm det er noget jeg sådan set har døjet med erhm it’s basically something I’ve been troubled by

05. i ↑længere tid jeg tror det er fordi (…) for a ↑long time I think it’s because (…)

This problem presentation commencement is organised in much the same way as in Excerpt 1. The patient initially states that he is currently suffering from a particular condition (i.e. back pain). Its status as currently relevant is conveyed via the verb ‘have’ in present tense. The patient then proceeds, in Lines 04 and 05, to establish that he has suffered from the condition for a relatively long period. This turn-at-talk is worth careful inspection.

His present condition is re-invoked with the pronoun ‘it’, which here serves as a tying device (cf. Sacks, 1992: Lecture 5–6). The condition’s status as currently relevant is initially confirmed via the present tense verb ‘is’, and the following grammatical units in the turn-at-talk underscore the relative length of his duration of symptoms.

The patient uses the verb phrase ‘have been troubled’ in a present perfect continuous tense (Line 04), similar to the patient in Excerpt 1. This form projects more information to come, that is, a longer narrative (cf. Heritage and Clayman, 2010). But it also ties the present state to the past – whilst communicating that the condition remains unchanged. His particular choice of main verb, ‘trouble’ (Danish: ‘døje’), makes it a clear example of a troubles-resistant claim: The patient’s doctorability is strengthened by the claims that he has already endured the condition for some time. This claim is, in fact, anticipated by the preceding adverbial ‘sådan set’ (‘basically’), which marks the information to come as somewhat unexpected, similar to ‘actually’ (cf. Clift, 2001). Here, ‘basically’ conveys that back pain is a condition warranting urgent attention and, perhaps, that it is therefore somewhat unusual that he has endured the pain until now. The subsequent prepositional phrase ‘for a long time’ assesses this period as long – but without specifying exactly how long.

Excerpts 1 and 3 show how patients mention on their own initiative that they have had their symptoms for a relatively long period. A related variant of patient-initiated mention of duration of symptoms is the specifying of this duration. For example, the patients in Excerpts 1 and 3 could have stated ‘I’ve felt like this for ten days’ or ‘I’ve felt like this since last Friday’. To borrow Schutz’ distinctions, both ‘for a long time’ and ‘for ten days’ qualify as spatiotemporal concepts. The difference is that the former is an overt assessment, whereas the latter is a specification.

Consider Excerpt 4 in which a patient sees his doctor because of skin problems and initiates the problem presentation phase in this way:

(4): Acne

01. PA: for at gøre en lang historie ko:rt.= to cut a long story sho:rt.=

02. DO: =ja. =yes.

03. PA: jeg var inde for to måneder siden fordi jeg har en bums *her (…) I was in here about two months ago because I have this pimple *here (…)

*PA points to his face.

In Line 01, the patient prefaces his problem presentation with an overt intent to ‘cut a long story short’ and immediately afterwards adds the information that he visited the doctor’s colleague two months earlier concerning a pimple on his face. The verb’s past tense (i.e. ‘was’) denotes a completed act. Note, however, how the patient subtly communicates that he still suffers from this condition using deictic markers such as the verb in present tense (‘I have’) and visible identification (‘this pimple here’), accompanied by a pointing gesture. The patient’s turn-at-talk in Line 03 makes it understand that he has had his symptoms for two months: In fact, it leaves open the possibility that he has had them even longer, that is, if he initially tolerated the symptoms for some time before attending the previous doctor. The patient, however, avoids an overt assessment of the timespan.

The same is the case in Excerpt 5, in which a patient begins her problem presentation concerning a cough in this manner:

(5): Cough

01. PA: jeg har ø::hm (.) været syg i sådan en fjorten dages tid og på ø:h I’ve e:rhm (.) been sick for about fourteen days and on e:rh

02. utallige opfordringer fra folk der er rigtig trætte af at høre på mig countless requests from people who are fed up with listening to me

03. hoste er jeg blevet bedt om at gå til lægen nu. .h[h cough I’ve been asked to go to the doctor now. .h[h

04. DO: [okay. [okay.

05. PA: [ø::hm jeg [har- [e::rhm I [have-

06. DO: [XX [så det er hosten? [XX [so it’s the cough?

07. PA: jeg hoster meget højt ja. I cough very loudly yes.

In this patient’s problem presentation, the two doctorability strategies, invoking third parties and displaying troubles resistance, which Heritage and Robinson (2006) document, are intertwined. The report that she has received ‘countless requests’ to attend the doctor from people ‘who are fed up with listening’ to her clearly displays troubles resistance because it conveys her cough as more of a nuisance to her surroundings than to herself, and the very act of consulting the doctor is conveyed as the choice of these people.

This patient does not explicitly assess her duration of symptoms as long. However, the mentions of ‘countless requests’ and that people are ‘fed up’ with listening to her cough implicitly communicate that she has been ill for some time. She finishes her initial account for seeking medical attention with the deictic ‘now’ in Line 03, which marks a contrast to her preceding period of illness and underscores its relative length. Similar to Excerpt 1, arguably even to a greater extent, this patient treats the temporal aspect as a highly relevant issue. She does this by inserting it as the very first element in her problem presentation. In fact, it seems that this way of presenting the problem, which forefronts the doctorability effort at the expense of a concise explanation of the problem’s nature, prompts the doctor to ask the clarifying question as to whether it is the cough that is troubling the patient (line 06).

In summary, patients regularly mention the duration of symptoms on their own initiative and thereby treat this as a highly relevant piece of information. Furthermore, they may either overtly assess this duration as long or may specify its duration in more objective terms while embedding this specification in narratives that similarly assess the duration as long.

Doctor-solicited mention of duration of symptoms

In this section, I analyse what happens when patients do not mention the duration of symptoms on their own. In most cases, doctors will ask them instead. I will briefly consider an answer to a doctor’s yes/no question, and then in more details explore patients’ answers to doctors’ specifying ‘how long’ questions.

Confirmation-seeking yes/no questions

Yes/no questions are extremely common in talk-in-interaction. Empirical studies have documented that speakers often display difficulty in answering them in a type-confirming way, that is, with a ‘yes’ or a ‘no’ (Raymond, 2003). This certainly also goes for patients.

Occasionally, contextual factors provide doctors with reasons to assume that the patients have had their symptoms for a certain amount of time. In Excerpt 6, a patient has just presented his problem as rectal bleeding. Line 01 of Excerpt 6 represents the first question that the doctor poses in response to the patient’s problem presentation. However, the question is explicitly informed by what the doctor has just read in the calendar on her desktop computer, that is, what the secretary has noted as the reason for the visit. The doctor’s question here thus seeks confirmation that the information about his duration of symptoms is correct:

(6): Rectal bleeding

01. DO: og det kom (.) fra i går? and it came (.) from yesterday?

02. PA: nja:: det e:r et=et døgn eller sådan noget. we:ll it has been a=a day and a night or something like that.

The patient prefaces his answer with a prolonged ‘nja::’, which is a conjunction of ‘no’ (Danish: ‘nej’) and ‘yes’ (Danish: ‘ja’) that is regularly invoked when speakers depart from type-confirming answers to yes/no questions (Thøgersen and Beck Nielsen, 2009). In this case, the departure may be explained with the concept of the maximal property of a description, that is, the general expectance that a speaker’s invoked term expresses most that there is to say about some state-of-affairs (Drew, 1992). The doctor’s proposed term ‘yesterday’ may imply a shorter timespan than the patient’s ‘a day and a night’. By prefacing his turn-at-talk with ‘nja::’, the patient discretely adjusts the doctor’s proposal in favour of a description that expresses the most there is to say about his duration of symptoms without overtly correcting the doctor. As this little analysis illustrated, doctors’ confirmation-seeking yes/no questions entail assumptions about duration, and these assumptions may lead patients to negotiate their illness histories. As the analyses have revealed, duration of symptoms has implications for patients’ doctorability: longer duration means enhanced doctorability. What happens, then, when doctors have less contextually conditioned information about the duration of symptoms and/or avoid overt assumptions of such in their questions, that is, when they ask specifying but formally more open ‘how long’ questions?

Doctors’ specifying ‘how long’ questions

The answer to the question above is that patients may still respond in similar ways. Let us first consider excerpt 7 where a doctor turns a yes/no question into a specifying ‘how long’ question. Unlike in the previous examples, the exchange takes place relatively late in a consultation, 7 min after it started, in the phase where the parties settle upon the proper treatment. The patient has been examined for her stiff neck, and the doctor has consented to provide her with a referral to a physiotherapist. This act will considerably reduce her subsequent treatment costs. The parties, however, never got around to talking about exactly how long the patient has suffered from a stiff neck, and here the doctor asks her with a yes/no question design that proposes three weeks as the most likely answer, but quickly revises its design, so that it is packaged as a formally open ‘how long’ question:

(7): Stiff neck

01. DO: er det ↑tre uger siden eller hvor længe har du cirka haft det? was it ↑three weeks ago or how long have you had it approximately?

02. PA: .h det her har jeg haft en:::::: uges- (.3) °hva er det° nogle .h this here I’ve had fo:::::r a week- (.3) °what is it° some

03. dage=↑fire dage. days=↑four days.

04. DO: nå okay. oh okay.

05. (.8)

06. DO: den [XX it [XX

07. PA: [det hv- (.6) på en dødirriterende måde når man kører bil [it wh- (.6) in an extremely annoying way when you drive

08. og man kan ikk sådan and you sort of can’t

09. DO: man kan ikk dreje hovedet? you can’t turn your head?

The doctor’s initial yes/no question (i.e. ‘was it three weeks ago?’) proposes three weeks as the most likely answer (Pomerantz, 1988). However, the doctor asks in yet another way before the patient answers – now with a formally more open ‘how long’ question. The second question design is tied to the first one with an ‘or’-conjunction, which marks it as an alternative to the first one (Stivers and Enfield, 2010: 2622). The patient overtly answers the second question, that is, without a type-conforming initial ‘yes’ or ‘no’. However, at the same time she orients towards her answer as a disprefered act: She displays hesitance towards answering the question, as accomplished in breathing, prolonged vowel length, pause, and restarts (cf. Sacks, 1987). In other words: She treats ‘four days’ as a slightly inappropriate answer. Other elements in the talk confirm this orientation. For example, the prominent turn-initial placement and emphasis on ‘this here’ hints to the doctor that the patient may have suffered from the same condition before, that is, that it is a recurrent, well-known phenomenon. In addition, it prompts the patient to elaborate as to why the condition is a nuisance in Lines 07 and 08. The elaboration accounts for the act of seeking medical help after such a short interval. That is, the patient orients towards doctorability although she has already had her reason for the visit accommodated. The elaboration is probably also responsive to the doctor’s (rare) display of surprise in Line 04 and the relatively long pause that follows in Line 05. The doctor communicates surprise with the Danish ‘nå’ token that conveys change-of-state similar to the English ‘oh’ (Femø Nielsen, 2001; Heritage, 1984b). During the pause, it becomes clear that the doctor is not going to straightforwardly display support for the ‘four days’ answer – unlike at the end of this excerpt, where the doctor appears to ratify the patient’s account by completing it.

Doctors’ ‘how long have you been sick’ inquires are ‘specifying questions’. Fox and Thompson (2010) make interesting observations concerning answers to specifying questions. For example, in American English, specifying questions seem to ‘prefer’ brief, to-the-point phrasal responses instead of more elaborated full-clause responses: When speakers respond with a full-clause response, they often orient towards difficulties in answering the question. Earlier, in Excerpt 2, we witnessed a patient who was asked how long she had suffered from her cold sore:

(From Excerpt 2)

06. DO: hvor længe har du haft det? how long have you had it?

07. PA: ø:hm det kommer og går. e:rhm it comes and goes.

In a strict sense, this patient does not answer the doctor’s specifying question: The doctor is not told how long the patient has had the cold sore. She answers in a full-clause response format. Possible orientation towards difficulty in answering the question might be seen in the initial prolonged ‘erhm’. Instead of specifying how long she has had her current cold sore, she communicates that it is a recurrent phenomenon, which ‘comes and goes’. She thereby invokes another doctorability strategy, which is to orient towards a current illness as a well-known condition (Heritage and Robinson, 2006: 76–78).

Consider Excerpt 8, where a patient, as in Excerpt 6, invokes a concept that conveys the most there is to express about his duration of symptoms. He suffers recurrently and acutely from insomnia and asks the doctor for a prescription for a rather strong medication against the condition. The following exchange is part of the history-taking activity. The patient explains that getting just a single good night’s sleep usually helps. This is a claim that supports his prescription request:

(8): Insomnia

01. PA: så skal jeg bare have en nats søvn ikke? then I just need a night’s sleep right?

02. DO: okay hvor længe har det stået på i de[nne her omgang? okay how long has it been th[is time?

03. PA: [fle:re år. [se:veral years.

04. DO: men jeg tænkte bare sådan i denne her omgang her.= but I was thinking more about just this time here.=

05. PA: =arh det har været hele denne her uge. =arh it’s been all of this week.

The patient’s initial answer in Line 03 is produced before the completion of the question, which seems to be why the patient understands it as an inquiry about his insomnia as a general condition. He answers with a simple phrasal response: ‘Several years’. Upon the doctor’s repair in Line 04, the patient revises his answer in Line 05 to a full-clause response, which emphasises that he has experienced troubles sleeping ‘all of this week’. Both answers are designed to convey the maximal possible property: He has had the insomnia for ‘several’ years, and he has had the current version ‘all of this week’ (with stress on the word ‘all’). This revised response is furthermore an extreme case formulation, making explicit that ‘the amount of time was all of it, the whole unit, the maximum possible’ (Pomerantz, 1986: 221).

The final excerpt illustrates another orientation towards an experienced need for justification if the answer is too weak, that is, if patients have not had their symptoms for long enough. In other words, there are also ‘good’ and ‘bad’ answers to open-ended ‘how long’ questions, which confirms patients’ displayed assumptions about the implications of duration of symptoms for their doctorability. Let us revisit the first patient from Excerpt 1.1. Recall that he commenced his problem presentation with a claim to have had his sore throat for ‘a fairly long time by now’. In the talk that follows (not in transcript), he substantiates this claim with an explanation that his sore throat disappeared, only to come back a week prior to his visit to the doctor. The doctor in turn poses a series of questions about his condition, among others, if he has fever. Note how he responds to the doctor’s specifying ‘how long’ question (Line 42):

(1.2): Sore throat; continued from (1.1)

((30 lines omitted))

36. DO: har du feber? are you feverish?

37. (0.7)

38. PA: ikke hvad jeg (.2) hvad jeg ved af=altså jeg har taget temperatur not that I (.2) that I know of=I mean I've taken my temperature

39. sådn enGANG imellem ikk?= ocCASionally right?=

40. DO: =ja: =ye:s

41. PA: og der har jeg ikke haft [det. and then, I haven't had [it.

42. DO: [og hvor længe har du været syg? [and how long have you been sick?

43. (0.9)

44. PA: ø:hm e:rhm

45. (0.6)

46. PA: en uges tid ↑nu. about a week ↑now.

47. DO: *en uge. *a week. *DO makes a note on a piece of paper in front of her

48. PA: men altså (.) jeg har sådn skrantet siden- øh ↑nærmest siden but you know (.) I've sort of felt under the weather since- erh ↑almost since

49. nytårsaften altså. New Year’s Eve.

50. (0.7)

51. PA: sådn [hvor jeg sådn øh like [where I sort of erh

52. DO: [det var en hård nytårsaften du havde der så. [that was a rough New Year’s Eve you had there then.

53. PA: heh [ja ja å(h.)benba(h.)rt ne(h.)j-] men altså sådn ↑gået sådn heh [yes yes I(h.) gue(h.)ss so(h)I-] but you know sort of

54. DO: [hah hah hah hah hah hah ] [hah hah hah hah hah hah ]

55. PA: o:g (.) været sådn lidt s:- småsyg hele [tiden [ikke? felt (.) a little i:- ill the [whole [time right.

56. DO: [ja [ja [yes [yes

57. DO: og det e:r (.) om vinteren jo. and it i:s (.) wintertime of course.

The doctor’s first question, ‘are you feverish’ (Line 36), is a yes/no question with an obvious preference for a confirming ‘yes’ response. This preference is best observed in the fact that the patient in Lines 38–39 puts considerable effort into avoiding a flat out ‘no’ response (Sacks, 1987). The doctor’s second question, ‘and how long have you been sick’ (Line 42), is formally an open question, which should not prefer a certain answer. Yet the patient treats it as if it does: His answer is heavily delayed (Lines 43–45), and it underscores that he has been sick for about a week ‘now’, which projects an elaboration to the answer and thus difficulty answering it with a preferred brief phrasal response (cf. Fox and Thompson, 2010).

One interactionally grounded reason why he treats the question this way may be that the doctor prefaces the question with an ‘and’, thereby tying it to the previous question–answer sequence, which revealed that the patient’s condition probably is not that serious (an infection, for instance, usually leads to fever). It is well documented that ‘and’-prefaced questions accomplish such ties to prior questions or assertions (Heritage and Sorjonen, 1994; Nevile, 2006). In this light, the doctor’s second question can be heard as another means of seeking confirmation that the patient is not seriously sick (even though she uses the term ‘sick’ in her question).

As mentioned above, the patient’s elaboration of the temporal aspect in Lines 48–51 is projected by his introduction of ‘now’ in Line 46. But it may also be responsive to what the doctor in Line 47 demonstrably infers from the patient’s answers and notes on the paper, which might be added to the patient’s medical records. She leaves out ‘now’ and also avoids other ways of expressing that she notes the patient’s claim to have has the symptoms for much longer. This omission undermines his claim. The patient then attempts to reclaim the length of his symptoms in a modified way. He mentions having felt ‘under the weather’ since New Year’s Eve (the recording was conducted in late January), a much vaguer category than ‘sick’. But the doctor nonetheless contests this claim twice in the following dialogue. First, she jokingly suggests that his (drunk?) behaviour on New Year’s Eve caused this condition (Line 52). The patient’s laughing confirmation in Line 53 acknowledges the doctor’s joking dismissal, but it is followed by a defensive repetition of the assertion that he has been ‘a little ill the whole time’ (Lines 53–55). However, the doctor contests his claim for a second time. In Line 57, she produces an account on his behalf, that is an account explaining his previous contribution (Beck Nielsen, 2009). But it is not a supportive one. This account explains his ‘problem’ as a general seasonal condition. It is stated as an obvious matter-of-fact via the Danish adverb ‘jo’ (Heinemann et al., 2011). And the account undermines the patient’s problem, leaving his doctorability questioned.

Conclusion

To paraphrase Schutz and Luckmann, a consultation is a societal context in which participants are especially prone not only to ‘stop and think’ about the flow of duration – especially the duration of the patient’s symptoms – but also to talk about that reflection and organise much of their talk around this endeavour. Manifestations of this are found in patients’ tendency to mention at the outset of the consultation how long they have had their symptoms and to treat it as important to do so. The interactional relevance of such mentioning is co-constructed by the doctors: If patients do not self-initiate discussion of the duration of symptoms, doctors regularly ask them about it.

Furthermore, exactly how long the symptoms may be said to have lasted is a significant communicative factor in these exchanges. Patients strive to stress the relative length of their duration of symptoms in support of their doctorability, and doctors may acknowledge or challenge these claims. The conversation analytic method makes it possible to describe the conversational environments in which these exchanges, which sometimes lead to negotiations, take place. The analysis of patients’ self-initiated mention of duration of symptoms reveals the tendency for patients to show that they have had their symptoms for a considerable amount of time, using troubles resistance to strengthen their doctorability.

The analysis of doctor-solicited mention of duration of symptoms reveals that patients respond with terms that convey their duration of symptoms as long as possible and/or account for why it is ‘short’. This is interesting because they thereby understand doctors’ question, even formally open ‘how long’ questions, as preferring answers that confirm that they have been ill for a long time. This provides further evidence that patients orient towards doctorability as an implication of their symptoms’ relative length.

In spite of their mundanity, general practice consultations do indeed often concern relatively big decisions (e.g. diagnoses) as well as issues and entitlements that are felt to be important (e.g. doctorability). This paper has shown that shared understanding of duration of symptoms and its consequences is treated as a precondition for reaching these two goals. A question such as ‘And how long have you been sick?’ is thus anything but trivial.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Appendix 1. Transcription symbols

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