# Changing treatments: Patient responses to doctors downgrading their medical authority

Moa Hagafors

► To cite this version:

Moa Hagafors. Changing treatments: Patient responses to doctors downgrading their medical authority. Språk i praktiken - i en föränderlig värld [Language in practice - in a changing world], ASLA, The Swedish Association of Applied Linguistics, Apr 2022, Stockholm, Sweden. 10.17045/sthlmuni.24321526.v1. hal-04422620

HAL Id: hal-04422620

https://hal.science/hal-04422620

Submitted on 26 Mar 2024

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# Changing treatments: Patient responses to doctors downgrading their medical authority

Moa Hagafors

► To cite this version:

Moa Hagafors. Changing treatments: Patient responses to doctors downgrading their medical authority. Språk i praktiken - i en föränderlig värld [Language in practice - in a changing world], ASLA, The Swedish Association of Applied Linguistics, Apr 2022, Stockholm, Sweden. 10.17045/sthlmuni.24321526.v1. hal-04422620

HAL Id: hal-04422620

https://hal.science/hal-04422620v1

Submitted on 26 Mar 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
# Changing treatments: Patient responses to doctors downgrading their medical authority

Moa Hagafors¹,²

¹ICAR Laboratory (UMR 5191), ²Université Lumière Lyon 2

## Abstract

In conversation analytical research, doctors have been shown to formulate the different parts of the medical consultations, such as the treatment recommendation, in a way that more or less includes the patients in the process. Doctors' medical authority and patient agency are thus key notions to consider in the sequential unfolding of the decisions taken throughout the consultation. Aiming to study the patients' reception of doctors downgrading their authority in addressing possible treatment changes in Swedish and English medical interactions, the article shows that patients either align with the shared responsibility by accepting or resisting a treatment proposition, or disalign with it by orienting to the doctor's medical authority and refusing to claim patient agency. It is proposed that this difference is connected to the way doctors address the topic and the amount of authority they attribute to the patient. Propositions giving patients a moderate amount of responsibility seem preferable over open questions entailing a greater commitment, if one wishes to promote patient agency.

## Introduction¹

Formulations of different parts of medical consultations have received considerable attention in conversation analysis. Peräkylä (1998) has shown how previous research (Byrne & Long [1976] 1984; Freidson 1970; Heath, 1992, cited in Peräkylä) suggests that doctors fully rely on their own authority and therefore do not need to “sell” or motivate their diagnosis to the patients. However, Peräkylä himself demonstrates how on the contrary doctors in more recent days do not always simply *state* their diagnosis, but tend to display the way in which they have acquired their knowledge by referring to for example their observations. In doing so, they present themselves as accountable and thus
# Changing treatments: Patient responses to doctors downgrading their medical authority

Moa Hagafors¹,²

¹ICAR Laboratory (UMR 5191), ²Université Lumière Lyon 2

## Abstract

In conversation analytical research, doctors have been shown to formulate the different parts of the medical consultations, such as the treatment recommendation, in a way that more or less includes the patients in the process. Doctors' medical authority and patient agency are thus key notions to consider in the sequential unfolding of the decisions taken throughout the consultation. Aiming to study the patients' reception of doctors downgrading their authority in addressing possible treatment changes in Swedish and English medical interactions, the article shows that patients either align with the shared responsibility by accepting or resisting a treatment proposition, or disalign with it by orienting to the doctor's medical authority and refusing to claim patient agency. It is proposed that this difference is connected to the way doctors address the topic and the amount of authority they attribute to the patient. Propositions giving patients a moderate amount of responsibility seem preferable over open questions entailing a greater commitment, if one wishes to promote patient agency.

## Introduction¹

Formulations of different parts of medical consultations have received considerable attention in conversation analysis. Peräkylä (1998) has shown how previous research (Byrne & Long [1976] 1984; Freidson 1970; Heath, 1992, cited in Peräkylä) suggests that doctors fully rely on their own authority and therefore do not need to “sell” or motivate their diagnosis to the patients. However, Peräkylä himself demonstrates how on the contrary doctors in more recent days do not always simply *state* their diagnosis, but tend to display the way in which they have acquired their knowledge by referring to for example their observations. In doing so, they present themselves as accountable and thus
The question of authority is thus a complex matter that is sequentially negotiated
in the medical visit. Participants may claim authority, for example by referring to
their knowledge or clearly asserting what needs to be done, but they may also
downgrade their authority in different ways. One strategy is to hedge, that is, to
“reduce the force or truth of an utterance” (Kaltenböck et al., 2010), with, for
example, approximators such as “sort of” and “a little bit”, or epistemic
downgraders like “I think” and “possibly”. A participant may also use other
techniques to attenuate what Heritage (2012, 2013) refers to as their *epistemic
status*, defined as a speaker’s positioning on an epistemic gradient between more
knowledgeable (K+) and less knowledgeable (K-). As Heritage shows, different
formulations may result in different positionings of the speakers on this epistemic
gradient. Saying “You are married” to someone creates a fairly levelled gradient,
where, while the interlocutor has the first-hand information on the topic and
therefore is more knowledgeable, both speakers apparently are informed on the
subject. On the other hand, asking “Are you married?” creates a steeper gradient
between the two speakers, where the interlocutor seemingly is significantly more
knowledgeable than the person asking the question. Another form of question
such as “You are married, aren’t you?” would create a gradient whose steepness
would be somewhere in between that of the two other formulations. Not only
hedges but also the structure of the turn may thus come into play in the claim or
downgrading of a participant’s authority.

What is of interest in this article is patients’ reception of doctors downgrading
their authority in these different ways when addressing a possible treatment
change. Two key notions when looking at a participant’s reception of a turn are
those of *alignment* and *affiliation*, which, according to Stivers et al.’s (2011)
definition, respectively concern the participant’s cooperation on a structural and
on an affective level. While an aligning response “match[es] the formal design
preference of the [prior speaker’s] turn”, an affiliative response “match[es] the
prior speaker’s evaluative stance”. Moreover, according to the same definition,
an aligning response also “accept[s] the presuppositions and terms of the
proposed action or activity” (p. 21), such as the distribution of authority between
the participants. The aim of this paper is to study whether the patients align with
the doctors’ reduced authority and claim authority of their own, or if they react
in other ways. By analysing three examples with three different forms of patient
responses, the hope is to contribute to a better understanding of how reduced
medical authority relates to patient agency.
The question of authority is thus a complex matter that is sequentially negotiated
in the medical visit. Participants may claim authority, for example by referring to
their knowledge or clearly asserting what needs to be done, but they may also
downgrade their authority in different ways. One strategy is to hedge, that is, to
"reduce the force or truth of an utterance" (Kaltenböck et al., 2010), with, for
example, approximators such as "sort of" and "a little bit", or epistemic
downgraders like "I think" and "possibly". A participant may also use other
techniques to attenuate what Heritage (2012, 2013) refers to as their *epistemic
status*, defined as a speaker's positioning on an epistemic gradient between more
knowledgeable (K+) and less knowledgeable (K-). As Heritage shows, different
formulations may result in different positionings of the speakers on this epistemic
gradient. Saying "You are married" to someone creates a fairly levelled gradient,
where, while the interlocutor has the first-hand information on the topic and
therefore is more knowledgeable, both speakers apparently are informed on the
subject. On the other hand, asking "Are you married?" creates a steeper gradient
between the two speakers, where the interlocutor seemingly is significantly more
knowledgeable than the person asking the question. Another form of question
such as "You are married, aren't you?" would create a gradient whose steepness
would be somewhere in between that of the two other formulations. Not only
hedges but also the structure of the turn may thus come into play in the claim or
downgrading of a participant's authority.

What is of interest in this article is patients’ reception of doctors downgrading
their authority in these different ways when addressing a possible treatment
change. Two key notions when looking at a participant’s reception of a turn are
those of *alignment* and *affiliation*, which, according to Stivers et al.’s (2011)
definition, respectively concern the participant’s cooperation on a structural and
on an affective level. While an aligning response “match[es] the formal design
preference of the [prior speaker’s] turn”, an affiliative response “match[es] the
prior speaker’s evaluative stance”. Moreover, according to the same definition,
an aligning response also “accept[s] the presuppositions and terms of the
proposed action or activity” (p. 21), such as the distribution of authority between
the participants. The aim of this paper is to study whether the patients align with
the doctors’ reduced authority and claim authority of their own, or if they react
in other ways. By analysing three examples with three different forms of patient
responses, the hope is to contribute to a better understanding of how reduced
medical authority relates to patient agency.
Data and methodology

The data consist of two corpora of medical interactions recorded in Sweden, in the first case, and England, in the second case. The Swedish one consists of nine video-recorded consultations, of a total of five hours, with patients who have or are suspected to have a rheumatic disease. The recordings were collected by Melander Marttala (1995) in three different contexts: registration visits at a rehabilitation clinic, referred first visits and follow-up visits. The doctors are in all cases either specialised in rheumatological diseases or under further training. The English corpus contains thirteen audio-recordings of a total of about 90 minutes, collected for the Audio British National Corpus (Audio BNC; Coleman et al., 2012), which all consist of consultations with a general practitioner. The conditions of the patients are of different natures (both physical and mental), and for several patients the doctor is their attending physician. Both the Swedish and the English recordings were transcribed within their respective projects, but in an attempt to homogenise the transcriptions of the extracts presented here and add more precision (especially in terms of overlaps, pauses and multimodality), I have re-transcribed them based on the transcription systems developed by Jefferson (2004) and Mondada (2018)³.

The Swedish consultations were recorded between 1989 and 1992, and the English ones in 1993, thus during the transition period towards the more patient-centred approach which has since then more generally been put into place. This surely means that there has been an evolution in medical practice since the time of the recordings, and that the results of this paper therefore are not completely generalisable to contemporary medical interactions. However, the choice of these fairly dated corpora is motivated by a wish to make use of already existing data, something which is at the core of the notion of open science. Also, the fact that the two corpora were constituted in approximately the same period of time increases the comparability between them, and I hope that these results can be used as a basis for future diachronic comparisons.

From the above-mentioned data, I built a collection of nine extracts fulfilling the following criteria: (1) the doctor (and not the patient) addresses the topic of a treatment change, and (2) they downgrade their authority in some way in addressing this treatment change. The notion of *treatment change* is understood in a broad sense and includes any action undertaken in the goal of improving or controlling the patient's condition. It may thus be a question of changing the type or dosage of a medication, or else referring the patient to another expert or
Data and methodology

The data consist of two corpora of medical interactions recorded in Sweden, in the first case, and England, in the second case. The Swedish one consists of nine video-recorded consultations, of a total of five hours, with patients who have or are suspected to have a rheumatic disease. The recordings were collected by Melander Marttala (1995) in three different contexts: registration visits at a rehabilitation clinic, referred first visits and follow-up visits. The doctors are in all cases either specialised in rheumatological diseases or under further training. The English corpus contains thirteen audio-recordings of a total of about 90 minutes, collected for the Audio British National Corpus (Audio BNC; Coleman et al., 2012), which all consist of consultations with a general practitioner. The conditions of the patients are of different natures (both physical and mental), and for several patients the doctor is their attending physician. Both the Swedish and the English recordings were transcribed within their respective projects, but in an attempt to homogenise the transcriptions of the extracts presented here and add more precision (especially in terms of overlaps, pauses and multimodality), I have re-transcribed them based on the transcription systems developed by Jefferson (2004) and Mondada (2018)³.

The Swedish consultations were recorded between 1989 and 1992, and the English ones in 1993, thus during the transition period towards the more patient-centred approach which has since then more generally been put into place. This surely means that there has been an evolution in medical practice since the time of the recordings, and that the results of this paper therefore are not completely generalisable to contemporary medical interactions. However, the choice of these fairly dated corpora is motivated by a wish to make use of already existing data, something which is at the core of the notion of open science. Also, the fact that the two corpora were constituted in approximately the same period of time increases the comparability between them, and I hope that these results can be used as a basis for future diachronic comparisons.

From the above-mentioned data, I built a collection of nine extracts fulfilling the following criteria: (1) the doctor (and not the patient) addresses the topic of a treatment change, and (2) they downgrade their authority in some way in addressing this treatment change. The notion of *treatment change* is understood in a broad sense and includes any action undertaken in the goal of improving or controlling the patient's condition. It may thus be a question of changing the type or dosage of a medication, or else referring the patient to another expert or
putting in place a lifestyle modification. The term *change* in itself is also used in a
general sense according to the different patient profiles, and may include both
the introduction of a new treatment for a first-time visitor, and a shift from one
type of treatment to another for a more “experienced” patient. In most of the
extracts, the topic of a treatment change is addressed in the form of a
recommendation, but it can also appear as a more open question directed to the
patient. Through conversation analysis of the different addresses and patient
responses, it is possible to discern two main sequential patterns in the patients’
reception: an aligning one and a disaligning one, which will be developed in the
analysis below.

Analysis

Downgrading one's own authority in a conversation typically entails leaving room for the other(s) to take a more active part in the interaction. When this is done by a physician bringing up the topic of a treatment change, it opens up for the patient to have their say on the matter and express any possible preferences. Even though the simple fact of the patient aligning with this relative evening-out of authorities thus constitutes the preferred action, we will see that this does not necessarily correspond to an affiliation with the doctor's suggestion, but that they can claim agency both in accepting and in resisting the proposition. The patient may also disalign with the doctor opening up for an agency claim and refuse to share authority in the treatment decision.

Alignment with the attributed authority

Aligning with the authority attributed by the doctor means accepting to, at least in part, share the responsibility of the treatment decision. In the following two examples, we will see how this responsibility is assumed to different extents and with different goals: to either accept a recommended treatment or resist its execution.

***Accepting the treatment***

In our first example (Extract 1), the patient chooses to agree with the doctor and accept the treatment. The consultation, taken from the Swedish corpus, is a first-time visit with a specialist by a patient suspected by her general practitioner to have rheumatism, but who is preliminarily diagnosed with arthrosis during her visit. After discussing different blood tests that need to be carried out, the doctor
putting in place a lifestyle modification. The term *change* in itself is also used in a
general sense according to the different patient profiles, and may include both
the introduction of a new treatment for a first-time visitor, and a shift from one
type of treatment to another for a more “experienced” patient. In most of the
extracts, the topic of a treatment change is addressed in the form of a
recommendation, but it can also appear as a more open question directed to the
patient. Through conversation analysis of the different addresses and patient
responses, it is possible to discern two main sequential patterns in the patients’
reception: an aligning one and a disaligning one, which will be developed in the
analysis below.

Analysis

Downgrading one's own authority in a conversation typically entails leaving room for the other(s) to take a more active part in the interaction. When this is done by a physician bringing up the topic of a treatment change, it opens up for the patient to have their say on the matter and express any possible preferences. Even though the simple fact of the patient aligning with this relative evening-out of authorities thus constitutes the preferred action, we will see that this does not necessarily correspond to an affiliation with the doctor's suggestion, but that they can claim agency both in accepting and in resisting the proposition. The patient may also disalign with the doctor opening up for an agency claim and refuse to share authority in the treatment decision.

Alignment with the attributed authority

Aligning with the authority attributed by the doctor means accepting to, at least in part, share the responsibility of the treatment decision. In the following two examples, we will see how this responsibility is assumed to different extents and with different goals: to either accept a recommended treatment or resist its execution.

***Accepting the treatment***

In our first example (Extract 1), the patient chooses to agree with the doctor and accept the treatment. The consultation, taken from the Swedish corpus, is a first-time visit with a specialist by a patient suspected by her general practitioner to have rheumatism, but who is preliminarily diagnosed with arthrosis during her visit. After discussing different blood tests that need to be carried out, the doctor
introduces the question of a possible treatment with a bandage relieving the
pressure on the patient's wrists:

**Extract 1. LOP14 “artros” (22.45)**

1 DOC o:ch eh sen kan vi väl, (0.4) höra med arbetsterapeuten om det and er then we can PTCL “RIGHT” (0.4) see with the occupational therapist if there

2 inte e nåt: eh bandage eller nånting du kan få .h att använda isn't some er bandage or something that you can get .h to use

3 som *avlastar. när du* har mera besvär which relieves the pressure when you have more difficulties

pat *slight nod *

4 *(1.5)*

pat *deeper nod*

In suggesting that they check with the occupational therapist if the patient can
get a bandage or something, the doctor opens up with several hesitation markers
in line 1: an elongated *o:ch* ('and') and the filler *eh*, before suspending the actual
proposal with a (0.4) pause. This is accompanied by the particle *väl* which both
expresses an uncertainty about the entire verb phrase in which it is inserted and,
in a way similar to the English tag question *right*, projects a confirmation from
the patient. Not only is the patient included in the action that is to be proposed
with the inclusive pronoun *vi* ('we') preceding the particle, but *väl* thus also
establishes her as being a part of the decision-making and of the judgment of the
do-ability of the action that is to be suggested. To relate back to Stivers et al.'s
(2017) five social actions, it can be concluded that the doctor "specifically invites
the endorsement or the collaboration of the patient" (p. 14), implying that this
recommendation corresponds to a *proposal*, that is, a recommendation instigated
by the physician where the decision-making is treated as being shared between
the patient and the doctor. In pronouncing the actual proposal, to check with the
occupational therapist if the patient can get a bandage or something similar (*höra
med arbetsterapeuten om det inte e nåt: eh bandage eller nånting du kan få*, lines 1-2), the
doctor once again shares her responsibility and expresses uncertainty. The
accountability of the final decision is this time shifted to (and not as much shared
with) the occupational therapist, to whom she attributes a certain epistemic and
deontic authority in depicting her as being the one both capable of judging what
would be the right aid to use (thus referring to her colleague's expertise), and of
taking the final decision about the treatment choice. The expression of
uncertainty here takes place on two different levels: neither is it sure whether
there is an appropriate aid available for the patient (there is a need to 'check',
*höra*), nor is it certain that a bandage is what the occupational therapist will
introduces the question of a possible treatment with a bandage relieving the
pressure on the patient's wrists:

**Extract 1. LOP14 “artros” (22.45)**

1 DOC o:ch eh sen kan vi väl, (0.4) höra med arbetsterapeuten om det and er then we can PTCL “RIGHT” (0.4) see with the occupational therapist if there

2 inte e nåt: eh bandage eller nånting du kan få .h att använda isn't some er bandage or something that you can get .h to use

3 som *avlastar. när du* har mera besvär which relieves the pressure when you have more difficulties

pat *slight nod *

4 *(1.5)*

pat *deeper nod*

In suggesting that they check with the occupational therapist if the patient can
get a bandage or something, the doctor opens up with several hesitation markers
in line 1: an elongated *o:ch* ('and') and the filler *eh*, before suspending the actual
proposal with a (0.4) pause. This is accompanied by the particle *väl* which both
expresses an uncertainty about the entire verb phrase in which it is inserted and,
in a way similar to the English tag question *right*, projects a confirmation from
the patient. Not only is the patient included in the action that is to be proposed
with the inclusive pronoun *vi* ('we') preceding the particle, but *väl* thus also
establishes her as being a part of the decision-making and of the judgment of the
do-ability of the action that is to be suggested. To relate back to Stivers et al.'s
(2017) five social actions, it can be concluded that the doctor "specifically invites
the endorsement or the collaboration of the patient" (p. 14), implying that this
recommendation corresponds to a *proposal*, that is, a recommendation instigated
by the physician where the decision-making is treated as being shared between
the patient and the doctor. In pronouncing the actual proposal, to check with the
occupational therapist if the patient can get a bandage or something similar (*höra
med arbetsterapeuten om det inte e nåt: eh bandage eller nånting du kan få*, lines 1-2), the
doctor once again shares her responsibility and expresses uncertainty. The
accountability of the final decision is this time shifted to (and not as much shared
with) the occupational therapist, to whom she attributes a certain epistemic and
deontic authority in depicting her as being the one both capable of judging what
would be the right aid to use (thus referring to her colleague's expertise), and of
taking the final decision about the treatment choice. The expression of
uncertainty here takes place on two different levels: neither is it sure whether
there is an appropriate aid available for the patient (there is a need to 'check',
*höra*), nor is it certain that a bandage is what the occupational therapist will
propose, which is signalled by the approximators modifying *bandage* (**nåt** *eh bandage* **eller nånting**; ‘*some* *eh bandage* **or something**’). Furthermore, this kind of alternative (*eller nånting*) also hedges the doctor’s proposal in a way that raises the odds of a confirmation on the behalf of the patient: an acceptance would not necessarily imply a commitment to use a bandage, but the patient can confirm and still choose to go with a different kind of support without “breaking her promise” or going against what was decided. Per se, a confirmation of the proposal does not even mean a commitment to use a support, but only an acceptance to consult the occupational therapist. Thanks to the vague formulation of the treatment proposal, the patient would thus not bind herself too much by confirming. It can also be noted that incrementally to this proposition, the doctor adds justifications of why and when such a bandage is useful (*att använda som avlastar. när du har mera besvär*; ‘to use which relieves the pressure when you have more difficulties’, lines 2-3), which is a way to share her professional vision with the patient and which is in line with Peräkylä’s (1998) findings of a tendency amongst doctors to include the patient in the thought process of the diagnostic procedure, even though it is in this case a question of a treatment decision.

Towards the end of the justification, the patient affiliates with the doctor by nodding slightly as the doctor pronounces *avlastar när du* (‘relieves the pressure when you’) in line 3. After the latter’s turn-constructional unit, the patient aligns with the demand for confirmation and accepts the doctor’s treatment proposal by a more pronounced nodding. In doing so, she also accepts the shared responsibility and authority attributed to her by the professional. Although the alignment is done in a fairly weak manner (being non-verbalised), the nodding constitutes the only response to the demand for confirmation having introduced the proposal (notably by *väl*) and acts as the second part of this adjacency pair.

***Resisting the treatment***

The second extract comes from another Swedish consultation, more precisely at
the registration unit of a rehabilitation centre for rheumatic patients. The patient
in question has suffered from rheumatic issues, mainly in the knees and in the
wrists, for 17 years, and enrols the centre for the third summer in a row. The
doctor asks if she has already taken part in group treatments for the wrists and
the patient answers that she has. However, she questions the need to work on
the flexibility of these joints since she was in pain for months after doing so
during her previous years at the clinic, and she thus presents a negative stance
propose, which is signalled by the approximators modifying *bandage* (*nåt* *eh bandage* eller nånting; ‘some *eh* bandage or something’). Furthermore, this kind of alternative (*eller nånting*) also hedges the doctor’s proposal in a way that raises the odds of a confirmation on the behalf of the patient: an acceptance would not necessarily imply a commitment to use a bandage, but the patient can confirm and still choose to go with a different kind of support without “breaking her promise” or going against what was decided. Per se, a confirmation of the proposal does not even mean a commitment to use a support, but only an acceptance to consult the occupational therapist. Thanks to the vague formulation of the treatment proposal, the patient would thus not bind herself too much by confirming. It can also be noted that incrementally to this proposition, the doctor adds justifications of why and when such a bandage is useful (*att använda som avlastar. när du har mera besvär*; ‘to use which relieves the pressure when you have more difficulties’, lines 2-3), which is a way to share her professional vision with the patient and which is in line with Peräkylä’s (1998) findings of a tendency amongst doctors to include the patient in the thought process of the diagnostic procedure, even though it is in this case a question of a treatment decision.

Towards the end of the justification, the patient affiliates with the doctor by nodding slightly as the doctor pronounces *avlastar när du* (‘relieves the pressure when you’) in line 3. After the latter’s turn-constructional unit, the patient aligns with the demand for confirmation and accepts the doctor’s treatment proposal by a more pronounced nodding. In doing so, she also accepts the shared responsibility and authority attributed to her by the professional. Although the alignment is done in a fairly weak manner (being non-verbalised), the nodding constitutes the only response to the demand for confirmation having introduced the proposal (notably by *väl*) and acts as the second part of this adjacency pair.

*Resisting the treatment*

The second extract comes from another Swedish consultation, more precisely at the registration unit of a rehabilitation centre for rheumatic patients. The patient in question has suffered from rheumatic issues, mainly in the knees and in the wrists, for 17 years, and enrols the centre for the third summer in a row. The doctor asks if she has already taken part in group treatments for the wrists and the patient answers that she has. However, she questions the need to work on the flexibility of these joints since she was in pain for months after doing so during her previous years at the clinic, and she thus presents a negative stance
towards the wrist treatments mentioned by the physician. After a question from
the latter about whether she has already used supporting bandages, to which she
answers no, the doctor disaffiliates with the patient's negative stance towards the
wrist treatments in initiating her recommendation in Extract 2:

Extract 2. LOP10 “till vilket pris” (10.24)

1 DOC pt #eh::# då kansk:#e# vi i alla fall skulle b- (0.3) bestämma
pt er then maybe we would still d- (0.3) decide

2 att du får prata igenom de här lite grann med nån
that you get to talk through this a little bit with some

3 arbetsterapeut (0.2) å titta [på för att]
occupational therapist (0.2) and look at because

4 PAT [ja ]
yeah

5 DOC de e många som har stöd å #använda ibland när man gör
there are many who have support to use sometimes when one does

6 ansträngande saker# (0.7) de de e ju så att- de e bra att ha en
strenuous things (0.7) it- it is PTCL “AS IS WELL KNOWN” like that
that it is good to have

7 rörlighet (0.4) i handleden
flexibility (0.4) in the wrist

8 PAT ja jo jo visst jag är [fullt med- fullt medveten] om de men de&
yes yeah yeah sure I am fully aw- fully aware of that but it

9 DOC [men men (0.2) men inte ]
but but (0.2) but not

10 PAT &e t- *till vilket pris *
is a- at what cost

pat *shakes index finger towards doc*

The doctor proposes that the patient talk through the question of treating the
wrists with an occupational therapist (lines 1-3). Like in Extract 1, there are a
number of visible hesitation markers in the opening of this proposal in line 1,
and there are hedges of both epistemic nature (*kansk:e*, ‘maybe’, and the
conditional auxiliary *skulle*) and approximative nature (*lite grann*, ‘a little bit’, *nån*,
‘some’). These downgrade the proposal which, as already mentioned, disaffiliates
with the patient’s expressed negative opinions towards the treatments that she
has previously been assigned: even though she has had this negative experience
and has never used supporting bandages, the doctor proposes a meeting that
would possibly lead to her having to go with one or both of these options. The
disaffiliative nature of this proposition is notably displayed by the concessive
adverb *i alla fall* (‘still’). Besides downgrading this proposition with hedges, the
doctor also, like in Extract 1, includes the patient in the decision making with the
pronoun *vi* (‘we’), and shares the responsibility with the occupational therapist
who would be the one to take the final decision about the treatment. However,
towards the wrist treatments mentioned by the physician. After a question from
the latter about whether she has already used supporting bandages, to which she
answers no, the doctor disaffiliates with the patient's negative stance towards the
wrist treatments in initiating her recommendation in Extract 2:

**Extract 2.** LOP10 "till vilket pris" (10.24)

1 DOC pt #eh::# då kansk:#e# vi i alla fall skulle b- (0.3) bestämma
pt er then maybe we would still d- (0.3) decide

2 att du får prata igenom de här lite grann med nån
that you get to talk through this a little bit with some

3 arbetsterapeut (0.2) å titta [på för att]
occupational therapist (0.2) and look at because

4 PAT [ja ]
yeah

5 DOC de e många som har stöd å #använda ibland när man gör
there are many who have support to use sometimes when one does

6 ansträngande saker# (0.7) de de e ju så att- de e bra att ha en
strenuous things (0.7) it- it is PTCL "AS IS WELL KNOWN" like that
that it is good to have

7 rörlighet (0.4) i handleden
flexibility (0.4) in the wrist

8 PAT ja jo jo visst jag är [fullt med- fullt medveten] om de men de&
yes yeah yeah sure I am fully aw- fully aware of that but it

9 DOC [men men (0.2) men inte ]
but but (0.2) but not

10 PAT &e t- *till vilket pris *
is a- at what cost

pat *shakes index finger towards doc*

The doctor proposes that the patient talk through the question of treating the
wrists with an occupational therapist (lines 1-3). Like in Extract 1, there are a
number of visible hesitation markers in the opening of this proposal in line 1,
and there are hedges of both epistemic nature (*kansk:e*, ‘maybe’, and the
conditional auxiliary *skulle*) and approximative nature (*lite grann*, ‘a little bit’, *nån*,
‘some’). These downgrade the proposal which, as already mentioned, disaffiliates
with the patient’s expressed negative opinions towards the treatments that she
has previously been assigned: even though she has had this negative experience
and has never used supporting bandages, the doctor proposes a meeting that
would possibly lead to her having to go with one or both of these options. The
disaffiliative nature of this proposition is notably displayed by the concessive
adverb *i alla fall* (‘still’). Besides downgrading this proposition with hedges, the
doctor also, like in Extract 1, includes the patient in the decision making with the
pronoun *vi* (‘we’), and shares the responsibility with the occupational therapist
who would be the one to take the final decision about the treatment. However,
this sharing is not done in the same manner or with the same implication in the
two extracts. When it comes to the inclusion of the patient, it can be noted that
in Extract 1, the proposition is that ‘we’ check with the occupational therapist,
whereas in Extract 2, it is that ‘we’ decide that the *patient* gets to talk with the
occupational therapist. Consulting the expert colleague is thus a common action
in the first case, and something which would ultimately be the patient’s
responsibility in the second case. Also, given that the recommendation in Extract
2 is part of an argumentative sequence where the patient and the doctor express
different opinions on the use of wrist treatments, the recourse to the judgement
of a colleague can also be a way for the doctor to increase her authority.

The syntactic structure of the proposal reaches a possible completion at this point (line 3), but is expanded with a cut off å titta på ('and look at'), which is left incomplete in favour of an explicative subordinator (för att, 'because'). Just like in Extract 1, the speculative nature put in place by the epistemic hedges, as well as the inclusion of the patient in the decision making, signify that the recommendation corresponds to a *proposal* in the words of Stivers et al. (2017) and Stivers and Barnes (2018). As already noted, this recommendation form explicitly calls for an acceptance by the patient, and therefore the non-response at the first possible completion point in line 3 is treated as an absence of an acceptance. The expansion thus constitutes a continued pursuit for answer (Pomerantz, 1984). Part of its beginning (*på för att*, ‘at because’) is overlapped by a hesitant sounding *ja* (‘yeah’) on the behalf of the patient. The hesitancy of this affirmative answer is confirmed by the doctor not treating it as an acceptance but continuing to pursue an answer in explaining the use of supporting bandages in line 5. She starts off with an evidential claim that a lot of people use supporting bandages, which turns into a generality with the generic pronoun *man* ('one'): *när man gör ansträngande saker* ('when one does strenuous things', lines 5-6). The doctor thus shares her professional vision and knowledge acquired from other patients with the current patient and includes her in her reasoning, while deploying the argument of patients frequently using these bandages as support for her argumentation. There is another possible completion point after this (line 6), and the lack of reaction by the patient is once again treated as an absence of an acceptance, or at least an absence of a comprehension of the utility of the treatment, which provokes another pursuit for an answer. The doctor presents general knowledge, that is, another form of an argument, about the utility of the mentioned treatments, saying that it is good to have a certain mobility in the wrist. In doing so, she explicitly appeals to common ground with the modal particle *ju*.
this sharing is not done in the same manner or with the same implication in the
two extracts. When it comes to the inclusion of the patient, it can be noted that
in Extract 1, the proposition is that ‘we’ check with the occupational therapist,
whereas in Extract 2, it is that ‘we’ decide that the *patient* gets to talk with the
occupational therapist. Consulting the expert colleague is thus a common action
in the first case, and something which would ultimately be the patient’s
responsibility in the second case. Also, given that the recommendation in Extract
2 is part of an argumentative sequence where the patient and the doctor express
different opinions on the use of wrist treatments, the recourse to the judgement
of a colleague can also be a way for the doctor to increase her authority.

The syntactic structure of the proposal reaches a possible completion at this point (line 3), but is expanded with a cut off å titta på ('and look at'), which is left incomplete in favour of an explicative subordinator (för att, 'because'). Just like in Extract 1, the speculative nature put in place by the epistemic hedges, as well as the inclusion of the patient in the decision making, signify that the recommendation corresponds to a *proposal* in the words of Stivers et al. (2017) and Stivers and Barnes (2018). As already noted, this recommendation form explicitly calls for an acceptance by the patient, and therefore the non-response at the first possible completion point in line 3 is treated as an absence of an acceptance. The expansion thus constitutes a continued pursuit for answer (Pomerantz, 1984). Part of its beginning (på för att, 'at because') is overlapped by a hesitant sounding ja ('yeah') on the behalf of the patient. The hesitancy of this affirmative answer is confirmed by the doctor not treating it as an acceptance but continuing to pursue an answer in explaining the use of supporting bandages in line 5. She starts off with an evidential claim that a lot of people use supporting bandages, which turns into a generality with the generic pronoun *man* ('one'): när *man* gör ansträngande saker ('when one does strenuous things', lines 5-6). The doctor thus shares her professional vision and knowledge acquired from other patients with the current patient and includes her in her reasoning, while deploying the argument of patients frequently using these bandages as support for her argumentation. There is another possible completion point after this (line 6), and the lack of reaction by the patient is once again treated as an absence of an acceptance, or at least an absence of a comprehension of the utility of the treatment, which provokes another pursuit for an answer. The doctor presents general knowledge, that is, another form of an argument, about the utility of the mentioned treatments, saying that it is good to have a certain mobility in the wrist. In doing so, she explicitly appeals to common ground with the modal particle ju.
In one way, this particle presents the patient as knowing, affirming that she does
have this information already, and, at the same time, it challenges the patient and
expresses that she has “failed to take into account shared knowledge”, as has
been demonstrated to be the case when ju is used in answers to questions in
Swedish and Danish (Heinemann et al., 2011, p. 107). The possession of this
knowledge is backed up by the patient herself (ja jo jo visst jag är fullt med- fullt
medveten om det, ‘yes yeah yeah sure I am fully aw- fully aware of that’, line 8), and
is incorporated into a ‘yes but’ construction resisting the proposition through a
questioning of its well-foundedness: men de e t- till vilket pris (‘but it is a- at what
cost’, line 10). This turn corresponds to one of the ‘yes but’ constructions put
forward by Steensig and Asmuß (2015) in that it constitutes a disagreeing action
after a suggestion with a clear preference for acceptance. The authors
differentiate between what they call simple ‘yes but’ constructions which
“innocently” update the previous speaker with new information and accordingly
typically display no dispreference markers, and complex ‘yes but’ constructions
which are more socially problematic and focus on a difference in points of view
in addressing “a potentially morally problematic lack of knowledge, something
which prior speaker ought to have known” (p. 358). The ‘yes but’ construction
in Extract 2 clearly corresponds to the latter, and its conflictive nature is further
underlined by the patient’s gesture: while pronouncing till vilket pris (‘at what
cost’), she raises her index finger and agitates it toward the doctor in a correcting
manner. Verbally and non-verbally, she challenges the rationality of the doctor’s
thinking in reminding her of something that she has failed to keep in mind:
although the patient’s wrists became more flexible after taking part in previous
group treatments, they hurt for months afterwards. The patient thus orients to
her expertise of experience, and there is an explicit clash between her point of
view and the point of view of the doctor which is based on a professional vision
and expertise.

We thus have another example of when the doctor downgrades her authority by
presenting the recommendation as speculative, shifting the final decision to her
expert colleague and inviting the patient to have her say in the matter. Although
Extract 2 differs from Extract 1 in that the patient here clearly resists the
proposal, they have in common the fact that the patients assume the shared
responsibility put in place by the doctor by responding to her demand for
confirmation and thus taking an active part in the treatment decision. This is, as
we have seen, done at different strengths in the two extracts: whereas the patient
in Extract 1 merely nods to express her acceptance, the patient in Extract 2 clearly
In one way, this particle presents the patient as knowing, affirming that she does
have this information already, and, at the same time, it challenges the patient and
expresses that she has “failed to take into account shared knowledge”, as has
been demonstrated to be the case when ju is used in answers to questions in
Swedish and Danish (Heinemann et al., 2011, p. 107). The possession of this
knowledge is backed up by the patient herself (*ja jo jo visst jag är fullt med- fullt
medveten om det*, ‘yes yeah yeah sure I am fully aw- fully aware of that’, line 8), and
is incorporated into a ‘yes but’ construction resisting the proposition through a
questioning of its well-foundedness: *men de e t- till vilket pris* (‘but it is a- at what
cost’, line 10). This turn corresponds to one of the ‘yes but’ constructions put
forward by Steensig and Asmuß (2015) in that it constitutes a disagreeing action
after a suggestion with a clear preference for acceptance. The authors
differentiate between what they call simple ‘yes but’ constructions which
“innocently” update the previous speaker with new information and accordingly
typically display no dispreference markers, and complex ‘yes but’ constructions
which are more socially problematic and focus on a difference in points of view
in addressing “a potentially morally problematic lack of knowledge, something
which prior speaker ought to have known” (p. 358). The ‘yes but’ construction
in Extract 2 clearly corresponds to the latter, and its conflictive nature is further
underlined by the patient’s gesture: while pronouncing *till vilket pris* (‘at what
cost’), she raises her index finger and agitates it toward the doctor in a correcting
manner. Verbally and non-verbally, she challenges the rationality of the doctor’s
thinking in reminding her of something that she has failed to keep in mind:
although the patient’s wrists became more flexible after taking part in previous
group treatments, they hurt for months afterwards. The patient thus orients to
her expertise of experience, and there is an explicit clash between her point of
view and the point of view of the doctor which is based on a professional vision
and expertise.

We thus have another example of when the doctor downgrades her authority by
presenting the recommendation as speculative, shifting the final decision to her
expert colleague and inviting the patient to have her say in the matter. Although
Extract 2 differs from Extract 1 in that the patient here clearly resists the
proposal, they have in common the fact that the patients assume the shared
responsibility put in place by the doctor by responding to her demand for
confirmation and thus taking an active part in the treatment decision. This is, as
we have seen, done at different strengths in the two extracts: whereas the patient
in Extract 1 merely nods to express her acceptance, the patient in Extract 2 clearly
positions herself in the question both verbally and multimodally. This could
possibly be explained by the difference in experience between the two patients.
Patient 1 is a first-time visitor and has not yet received an official diagnosis.
Patient 2, on the other hand, is an experienced patient who has not only suffered
from rheumatism for 17 years, but is also situated in another context: she
participates in the consultation as a part of a registration process at the
rehabilitation centre where she has already tried several different treatments. It
can thus be assumed that she knows more not only about what works for her
and what is at stake, but also about how to behave in a medical consultation to
get what she desires. The sequential context is also of great importance since
Extract 2 follows an already started disagreement between the doctor and the
patient, with which the resisting response is thus in line.

Disaligning with the attributed authority

Even though the majority of the examples from our collection constitutes
recommendations where the patient accepts to share the responsibility of the
treatment decision in the two ways we have seen above, there are also some cases
where the doctor does not address the topic of a treatment change in the form
of a recommendation but by pronouncing an open-ended question about the
patient's preferences, and where the patient disaligns with the shared
responsibility, as we shall see in the following example. In Extract 3, taken from
the British corpus, the patient consults her general practitioner about the panic
attacks for which she has been taking medication prescribed by the doctor in
question for a certain period of time. She explains that she only takes them when
she needs to, and not on a regular basis. After having recounted her recent
experience, the doctor asks what she wants to do about the medication she is
currently taking in Extract 3:

**Extract 3. Eng-med-4 “panicky” (01.43)**

1 DOC what do you want to do about <u>the:se.</u> be[cause, ]
2 PAT [↑WELL, ] (.)
3 [well what do <u>you thi-</u>]
4 DOC [do you ] <u>find they wo:rk</u>
5 PAT w- well do <u>you think they're al:right I mean [er: ]</u>
6 DOC [are they he-]
7 are they <u>helping you.</u> °when you <u>take them</u>°.
8 PAT ↑WELL they er they <u>helping me</u>
9 DOC yeah
10 PAT but they're apt to make me feel a bit (0.2) ↓I suppose that's
11 what they're fo:r a bit <u>docile like you know what I m(hh)ean</u>
positions herself in the question both verbally and multimodally. This could
possibly be explained by the difference in experience between the two patients.
Patient 1 is a first-time visitor and has not yet received an official diagnosis.
Patient 2, on the other hand, is an experienced patient who has not only suffered
from rheumatism for 17 years, but is also situated in another context: she
participates in the consultation as a part of a registration process at the
rehabilitation centre where she has already tried several different treatments. It
can thus be assumed that she knows more not only about what works for her
and what is at stake, but also about how to behave in a medical consultation to
get what she desires. The sequential context is also of great importance since
Extract 2 follows an already started disagreement between the doctor and the
patient, with which the resisting response is thus in line.

Disaligning with the attributed authority

Even though the majority of the examples from our collection constitutes
recommendations where the patient accepts to share the responsibility of the
treatment decision in the two ways we have seen above, there are also some cases
where the doctor does not address the topic of a treatment change in the form
of a recommendation but by pronouncing an open-ended question about the
patient's preferences, and where the patient disaligns with the shared
responsibility, as we shall see in the following example. In Extract 3, taken from
the British corpus, the patient consults her general practitioner about the panic
attacks for which she has been taking medication prescribed by the doctor in
question for a certain period of time. She explains that she only takes them when
she needs to, and not on a regular basis. After having recounted her recent
experience, the doctor asks what she wants to do about the medication she is
currently taking in Extract 3:

**Extract 3. Eng-med-4 “panicky” (01.43)**

1 DOC what do you want to do about <u>the:se</u>. be[cause, ]
2 PAT                                          [↑WELL, ] (.)
3          [well what do <u>you</u> thi-]
4 DOC [do you              ] <u>find they wo:rk</u>
5 PAT w- well do <u>you</u> think they're <u>al:right</u> I mean [er:      ]
6 DOC                                          [are they he-]
7 are they <u>helping</u> you. °when you <u>take them</u>°.
8 PAT ↑WELL they er they they're <u>helping</u> me
9 DOC yeah
10 PAT but they're apt to make me feel a bit (0.2) ↓I suppose that's
11 what they're fo:r a bit docile like you know what I m(hh)ean
The doctor implicitly brings up the matter of a possible treatment change by the means of a question about what the patient wants to do about her medication in line 1. This manner of bringing up a treatment change is rare in this corpus and differs from the first two extracts, which are much more representative for the collected data. The exceptional nature primarily concerns the openness of the inquiry: there is a lack of a recommendation in relation to which the patient can position herself and the open-endedness of the question calls for an answer that is more elaborate than a *yes* or *no*. The doctor here gives more agency to the patient than the ones in the other extracts, and opens up for a proposition on her behalf. The preferred responsive action would be an answer to the question, but ↑WELL, in line 2 identifies a trouble source in the doctor's prior turn and signals an upcoming dispreferred action, which is indeed what follows in line 3 where the patient returns the question by asking what the doctor thinks. The trouble seems to lie in her capability to judge the efficiency of the medication based on her experience with it, and thus in the authority attributed to her, since her question asks for the doctor's opinion and orients to his professional authority.

Following the identification of the trouble source in line 2, the doctor continues his pursuit for an answer by performing a repair in line 4 in the form of a new more specific and closed-ended question orienting to the patient's experience: *do you find they work*. He thus guides the patient and specifies what needs to be known (whether the medication works) in order to reply to the first question (if they work, there is possibly no need for change; if they do not work, an alternative needs to be found). We then find the same pattern repeating itself, with the patient following up with an identification of the doctor's new question as a trouble source and a dispreferred action in the form of a returning question (*w-well do you think they're al:right I mean*).

Again, in lines 6-7, the doctor repairs by asking a new question, which this time is a reformulation of the last question (*are they helping you when you take them*). The patient aligns by providing an answer to this last question and sharing her experience of the medication. The ↑WELL in this turn signals a trouble source on another level: the trouble no longer lies in her authority in answering the question, but in the fact that the question of whether or not the pills are helping her fails to seize the entirety of her experience with them. This is expressed by the *but*-construction following her response, which, similarly to the *yes but*-construction found in Extract 2, presents information that the doctor has failed to take into account: even though they are helping her, they do make her feel
The doctor implicitly brings up the matter of a possible treatment change by the means of a question about what the patient wants to do about her medication in line 1. This manner of bringing up a treatment change is rare in this corpus and differs from the first two extracts, which are much more representative for the collected data. The exceptional nature primarily concerns the openness of the inquiry: there is a lack of a recommendation in relation to which the patient can position herself and the open-endedness of the question calls for an answer that is more elaborate than a *yes* or *no*. The doctor here gives more agency to the patient than the ones in the other extracts, and opens up for a proposition on her behalf. The preferred responsive action would be an answer to the question, but ↑WELL, in line 2 identifies a trouble source in the doctor's prior turn and signals an upcoming dispreferred action, which is indeed what follows in line 3 where the patient returns the question by asking what the doctor thinks. The trouble seems to lie in her capability to judge the efficiency of the medication based on her experience with it, and thus in the authority attributed to her, since her question asks for the doctor's opinion and orients to his professional authority.

Following the identification of the trouble source in line 2, the doctor continues his pursuit for an answer by performing a repair in line 4 in the form of a new more specific and closed-ended question orienting to the patient's experience: *do you find they work*. He thus guides the patient and specifies what needs to be known (whether the medication works) in order to reply to the first question (if they work, there is possibly no need for change; if they do not work, an alternative needs to be found). We then find the same pattern repeating itself, with the patient following up with an identification of the doctor's new question as a trouble source and a dispreferred action in the form of a returning question (*w-well do you think they're al:right I mean*).

Again, in lines 6-7, the doctor repairs by asking a new question, which this time is a reformulation of the last question (*are they helping you when you take them*). The patient aligns by providing an answer to this last question and sharing her experience of the medication. The ↑WELL in this turn signals a trouble source on another level: the trouble no longer lies in her authority in answering the question, but in the fact that the question of whether or not the pills are helping her fails to seize the entirety of her experience with them. This is expressed by the *but*-construction following her response, which, similarly to the *yes but*-construction found in Extract 2, presents information that the doctor has failed to take into account: even though they are helping her, they do make her feel
docile like (line 11). In answering, the patient orients to her epistemics of experience and performs the preferred action following the doctor's last turn. However, this does not answer the initial question in line 1, and despite orienting to her own epistemic authority (although in a downgraded fashion, by epistemic hedges such as I *suppose* and *you know what I m(hh)ean*) as well as to her authority to answer questions, she manages to avoid the deontic authority to decide or propose what needs to be done with her treatment. Instead, she presents all possibly relevant information to the doctor so that *he* can decide based on this.

In contrast with the first two examples, the patient does not accept the doctor's inclusion of her in the decision-making process but avoids all agency and gives back the authority to the practitioner, perpetrating a power asymmetry between the two. There is thus a conflict between the doctor's orientation to patient agency and epistemics of experience, and the patient's orientation to the doctor's professional vision and authority. This conflict is not present in the first two extracts where the patients both align with the shared responsibility put in place by the doctor and accept enough agency to partake in the establishment of the treatment change.

## Concluding remarks

We have thus seen two response scenarios to doctors reducing their authority and inviting the patients to participate in the decision about a possible treatment change. In the first scenario, the patients accept the agency attributed to them and participate as active members, either by accepting or resisting the treatment proposition. In the second scenario, the patient refuses the responsibility attributed to her by the doctor and disaligns with the given authority.

As we have seen, the way in which the doctors diminish their authority in the two cases varies. In the two examples of the first scenario, the doctors present a possible treatment in relation to which the patients are invited to position themselves. Just like in Peräkylä's (1998) findings concerning the diagnostic phase, the physicians let the patients in on their reasoning and make at least part of the medical knowledge accessible to them. The treatment option is furthermore introduced in a more or less hesitative and hedged manner, allowing the patients to have a say in the matter and endorse or question the proposition. In both cases, it is also formulated in a way that diminishes the commitment of a potential acceptance by presenting it as being subject to exterior factors that
*docile like* (line 11). In answering, the patient orients to her epistemics of experience and performs the preferred action following the doctor's last turn. However, this does not answer the initial question in line 1, and despite orienting to her own epistemic authority (although in a downgraded fashion, by epistemic hedges such as *I suppose* and *you know what I m(hh)ean*) as well as to her authority to answer questions, she manages to avoid the deontic authority to decide or propose what needs to be done with her treatment. Instead, she presents all possibly relevant information to the doctor so that *he* can decide based on this.

In contrast with the first two examples, the patient does not accept the doctor's inclusion of her in the decision-making process but avoids all agency and gives back the authority to the practitioner, perpetrating a power asymmetry between the two. There is thus a conflict between the doctor's orientation to patient agency and epistemics of experience, and the patient's orientation to the doctor's professional vision and authority. This conflict is not present in the first two extracts where the patients both align with the shared responsibility put in place by the doctor and accept enough agency to partake in the establishment of the treatment change.

## Concluding remarks

We have thus seen two response scenarios to doctors reducing their authority and inviting the patients to participate in the decision about a possible treatment change. In the first scenario, the patients accept the agency attributed to them and participate as active members, either by accepting or resisting the treatment proposition. In the second scenario, the patient refuses the responsibility attributed to her by the doctor and disaligns with the given authority.

As we have seen, the way in which the doctors diminish their authority in the two cases varies. In the two examples of the first scenario, the doctors present a possible treatment in relation to which the patients are invited to position themselves. Just like in Peräkylä's (1998) findings concerning the diagnostic phase, the physicians let the patients in on their reasoning and make at least part of the medical knowledge accessible to them. The treatment option is furthermore introduced in a more or less hesitative and hedged manner, allowing the patients to have a say in the matter and endorse or question the proposition. In both cases, it is also formulated in a way that diminishes the commitment of a potential acceptance by presenting it as being subject to exterior factors that
may possibly change the final outcome (such as the availability of the treatment and the opinion of an occupational therapist). Despite the downgrading of the recommendations, their content is, however, clear to the patients, whereas, in the example of the second scenario, the proposition to change treatments is more implicit and the doctor presents the patient with the possibility to openly express her wish. Indeed, there is no actual formulation of a recommendation but the implied proposition to reconsider the current treatment is situated outside of the scope of the treatment recommendation and thus the five social actions associated with it (pronouncement, suggestion, proposal, offer, assertion) (Stivers et al., 2017; Stivers & Barnes, 2018). By asking the patient to give him her opinion without offering her any option to position herself against, the doctor thus gives her the authority to take an active and independent part in the consultation and to make a treatment proposition of her own.

The extent to which the doctors orient to the patients' agency in the two scenarios consequently differs: the patients in the first two examples receive a medically endorsed proposal to take into consideration while the third one has no explicit point of reference to depart from. Being asked to judge oneself what may be a plausible option thus entails a more important attribution of authority by the doctor and corresponds to a higher risk in the interaction. This may explain why patients being addressed a proposal align more with this attribution than the patient being asked an open question. If the goal is to increase patient agency in treatment decisions, it then seems plausible to assume that a proposition form such as a proposal (Stivers et al., 2017; Stivers & Barnes, 2018), showing what is possible from a professional point of view while giving the patient a chance to engage, is preferable over open questions where the patient has no medical expertise to fall back on.

It is also important to note that the outcome of the different treatment discussions may be influenced by factors such as the identity of the patient, the type and purpose of the consultation, and the condition for which medical care has been sought. One can expect a patient's experience of their condition to be of high importance in the agency they display: someone who has suffered from their condition for a long time is probably more knowledgeable about their disease and what treatments work than someone who goes to the doctor for their symptoms for the first time. The former may hence be more prone to rely on their epistemics of experience and express their preferences. However, this would suggest that there would be a resemblance in the agency of the patients in
may possibly change the final outcome (such as the availability of the treatment and the opinion of an occupational therapist). Despite the downgrading of the recommendations, their content is, however, clear to the patients, whereas, in the example of the second scenario, the proposition to change treatments is more implicit and the doctor presents the patient with the possibility to openly express her wish. Indeed, there is no actual formulation of a recommendation but the implied proposition to reconsider the current treatment is situated outside of the scope of the treatment recommendation and thus the five social actions associated with it (pronouncement, suggestion, proposal, offer, assertion) (Stivers et al., 2017; Stivers & Barnes, 2018). By asking the patient to give him her opinion without offering her any option to position herself against, the doctor thus gives her the authority to take an active and independent part in the consultation and to make a treatment proposition of her own.

The extent to which the doctors orient to the patients' agency in the two scenarios consequently differs: the patients in the first two examples receive a medically endorsed proposal to take into consideration while the third one has no explicit point of reference to depart from. Being asked to judge oneself what may be a plausible option thus entails a more important attribution of authority by the doctor and corresponds to a higher risk in the interaction. This may explain why patients being addressed a proposal align more with this attribution than the patient being asked an open question. If the goal is to increase patient agency in treatment decisions, it then seems plausible to assume that a proposition form such as a proposal (Stivers et al., 2017; Stivers & Barnes, 2018), showing what is possible from a professional point of view while giving the patient a chance to engage, is preferable over open questions where the patient has no medical expertise to fall back on.

It is also important to note that the outcome of the different treatment discussions may be influenced by factors such as the identity of the patient, the type and purpose of the consultation, and the condition for which medical care has been sought. One can expect a patient's experience of their condition to be of high importance in the agency they display: someone who has suffered from their condition for a long time is probably more knowledgeable about their disease and what treatments work than someone who goes to the doctor for their symptoms for the first time. The former may hence be more prone to rely on their epistemics of experience and express their preferences. However, this would suggest that there would be a resemblance in the agency of the patients in
Extracts 2 and 3, who both have a long history with their conditions and have tried different treatments, which is not the case. This might on the other hand be explained by the sensitivity of their respective conditions. The patient in Extract 3 consults for a mental issue, namely panic attacks, which is of a more taboo and stigmatised nature than physical conditions such as rheumatism. The fact that there is less general knowledge available on mental issues (especially at the time of the recordings, in the early 1990s) and that it may be harder to evaluate and distinguish one's symptoms in this domain may thus come into play. Something that may also affect the alignment with the authority attributed by the doctor is the reason for the visit, and it would be interesting to examine the significance of the fact that the main objective of the patients in Extracts 1, 2 and 3 is to get a diagnosis (where the patient presumably discovers a new set of practices related to her condition), register at a rehabilitation centre specifically to get new treatments (where there are certain expectations on behalf of the patient) and to get a new prescription (where a treatment change may not be expected), respectively.

## Notes

1. The author is grateful to the ASLAN project (ANR-10-LABX-0081) of the Université de Lyon, for its financial support within the French program "Investments for the Future" operated by the National Research Agency (ANR).

2. The following examples and definitions of each of the social actions are borrowed from Stivers and Barnes (2018, p. 1333). In *pronouncements*, the physician presents the recommendation as already determined (as in “I’ll start you on X”). When it comes to *suggestions* and *proposals*, the physician is the instigator of the recommendation, but whereas with the *suggestion* the doctor “treats patient as decision maker and medication as optional” (as with “You could try X”), the decision-making is “treated as shared by doctor and patient” in the *proposal* and the recommendation is highlighted as speculative (“Let’s try X and see how that goes”). In the *offer*, the “physician treats patient as having instigated recommendation and as the decision maker, thus treating medication as having been occasioned” (as in “Would you like me to give you X”), and, finally, with an *assertion*, “physician asserts a generalization about a treatment’s benefit implying a recommendation but not proffering an overt directive” (as is the case in “X is good for this”).
Extracts 2 and 3, who both have a long history with their conditions and have tried different treatments, which is not the case. This might on the other hand be explained by the sensitivity of their respective conditions. The patient in Extract 3 consults for a mental issue, namely panic attacks, which is of a more taboo and stigmatised nature than physical conditions such as rheumatism. The fact that there is less general knowledge available on mental issues (especially at the time of the recordings, in the early 1990s) and that it may be harder to evaluate and distinguish one's symptoms in this domain may thus come into play. Something that may also affect the alignment with the authority attributed by the doctor is the reason for the visit, and it would be interesting to examine the significance of the fact that the main objective of the patients in Extracts 1, 2 and 3 is to get a diagnosis (where the patient presumably discovers a new set of practices related to her condition), register at a rehabilitation centre specifically to get new treatments (where there are certain expectations on behalf of the patient) and to get a new prescription (where a treatment change may not be expected), respectively.

## Notes

1. The author is grateful to the ASLAN project (ANR-10-LABX-0081) of the Université de Lyon, for its financial support within the French program "Investments for the Future" operated by the National Research Agency (ANR).

2. The following examples and definitions of each of the social actions are borrowed from Stivers and Barnes (2018, p. 1333). In *pronouncements*, the physician presents the recommendation as already determined (as in “I’ll start you on X”). When it comes to *suggestions* and *proposals*, the physician is the instigator of the recommendation, but whereas with the *suggestion* the doctor “treats patient as decision maker and medication as optional” (as with “You could try X”), the decision-making is “treated as shared by doctor and patient” in the *proposal* and the recommendation is highlighted as speculative (“Let’s try X and see how that goes”). In the *offer*, the “physician treats patient as having instigated recommendation and as the decision maker, thus treating medication as having been occasioned” (as in “Would you like me to give you X”), and, finally, with an *assertion*, “physician asserts a generalization about a treatment’s benefit implying a recommendation but not proffering an overt directive” (as is the case in “X is good for this”).
3. The transcriptions of the three extracts are inspired by the transcription conventions developed by Jefferson (2004) and Mondada (2018). Table 1 below shows an overview of the transcription key.

<table><caption>**Table 1. Transcription key**</caption><tr><td>[word]</td><td>Overlapping turns of talk</td><td>.</td><td>Final falling intonation</td></tr><tr><td>(.)</td><td>Pause of &lt;0.2 seconds</td><td>,</td><td>Slight rising intonation</td></tr><tr><td>(0.3)</td><td>Pause longer than 0.2 seconds in seconds</td><td>?</td><td>Sharp rising intonation</td></tr><tr><td>.h, h</td><td>Inbreath, outbreath</td><td>↑,↓</td><td>High pitch, low pitch</td></tr><tr><td>Wor-</td><td>Cut-off</td><td>°word°</td><td>Pronounced quietly</td></tr><tr><td>:</td><td>Prolonged vowel or consonant</td><td>#word#</td><td>Creaky voice</td></tr><tr><td>word</td><td>Stress</td><td>pat</td><td>Participant doing embodied action</td></tr><tr><td>&amp;</td><td>Multi-line turn cut off by overlap (marked at the end of the line where the turn is cut off and at the beginning of the line where the turn resumes)</td><td>*word*<br/>*nod*</td><td>Delimitation of embodied action synchronised with corresponding stretches of talk or pause</td></tr></table>

References

Bergen, C., Stivers, T., Barnes, R. K., Heritage, J., McCabe, R., Thompson, L., & Toerien, M. (2018). Closing the deal: A cross-cultural comparison of treatment resistance. *Health Communication*, 33(11), 1377–1388. https://doi.org/10.1080/10410236.2017.1350917

Coleman, J., Baghai-Ravary, L., Pybus, J., & Grau, S. (2012). *Audio BNC: The audio edition of the Spoken British National Corpus*. Phonetics Laboratory, University of Oxford. http://www.phon.ox.ac.uk/AudioBNC

Costello, B. A., & Roberts, F. (2009). Medical recommendations as joint social practice. *Health Communication*, 13(3), 241–160. https://doi.org/10.1207/S15327027HC1303_2

Drew, P., & Heritage, J. (1992). *Talk at work: Interaction in institutional settings*. Cambridge University Press. https://doi.org/10.1017/S0047404500020844

Goodwin, C. (2018). *Co-operative action*. Cambridge University Press. https://doi.org/10.1017/9781139016735

Heinemann, T., Lindström, A., & Steensig, J. (2011). Addressing epistemic incongruence in question-answer sequences through the use of epistemic adverbs. In T. Stivers, L. Mondada & J. Steensig (Eds.), *The morality of*
3. The transcriptions of the three extracts are inspired by the transcription conventions developed by Jefferson (2004) and Mondada (2018). Table 1 below shows an overview of the transcription key.

<table><caption>**Table 1. Transcription key**</caption><tr><td>[word]</td><td>Overlapping turns of talk</td><td>.</td><td>Final falling intonation</td></tr><tr><td>(.)</td><td>Pause of &lt;0.2 seconds</td><td>,</td><td>Slight rising intonation</td></tr><tr><td>(0.3)</td><td>Pause longer than 0.2 seconds in seconds</td><td>?</td><td>Sharp rising intonation</td></tr><tr><td>.h, h</td><td>Inbreath, outbreath</td><td>↑,↓</td><td>High pitch, low pitch</td></tr><tr><td>Wor-</td><td>Cut-off</td><td>°word°</td><td>Pronounced quietly</td></tr><tr><td>:</td><td>Prolonged vowel or consonant</td><td>#word#</td><td>Creaky voice</td></tr><tr><td>word</td><td>Stress</td><td>pat</td><td>Participant doing embodied action</td></tr><tr><td>&amp;</td><td>Multi-line turn cut off by overlap (marked at the end of the line where the turn is cut off and at the beginning of the line where the turn resumes)</td><td>*word*<br/>*nod*</td><td>Delimitation of embodied action synchronised with corresponding stretches of talk or pause</td></tr></table>

References

Bergen, C., Stivers, T., Barnes, R. K., Heritage, J., McCabe, R., Thompson, L., & Toerien, M. (2018). Closing the deal: A cross-cultural comparison of treatment resistance. *Health Communication*, 33(11), 1377–1388. https://doi.org/10.1080/10410236.2017.1350917

Coleman, J., Baghai-Ravary, L., Pybus, J., & Grau, S. (2012). *Audio BNC: The audio edition of the Spoken British National Corpus*. Phonetics Laboratory, University of Oxford. http://www.phon.ox.ac.uk/AudioBNC

Costello, B. A., & Roberts, F. (2009). Medical recommendations as joint social practice. *Health Communication*, 13(3), 241–160. https://doi.org/10.1207/S15327027HC1303_2

Drew, P., & Heritage, J. (1992). *Talk at work: Interaction in institutional settings*. Cambridge University Press. https://doi.org/10.1017/S0047404500020844

Goodwin, C. (2018). *Co-operative action*. Cambridge University Press. https://doi.org/10.1017/9781139016735

Heinemann, T., Lindström, A., & Steensig, J. (2011). Addressing epistemic incongruence in question-answer sequences through the use of epistemic adverbs. In T. Stivers, L. Mondada & J. Steensig (Eds.), *The morality of*
*knowledge in conversation* (pp. 107–130). Cambridge University Press.
[doi:10.1017/CBO9780511921674.006](https://doi.org/10.1017/CBO9780511921674.006)

Heritage, J. (2012). Epistemics in action: Action formation and territories of knowledge. *Research on Language & Social Interaction, 45*(1), 1–29.
[https://doi.org/10.1080/08351813.2012.646684](https://doi.org/10.1080/08351813.2012.646684)

Heritage, J. (2013). Epistemics in conversation. In J. Sidnell & T. Stivers (Eds.), *The handbook of conversation analysis* (pp. 370–394). Wiley-Blackwell.
[https://doi.org/10.1002/9781118325001.ch18](https://doi.org/10.1002/9781118325001.ch18)

Jefferson, G. (2004). Glossary transcript symbols with an introduction. In G. H. Lerner (Ed.), *Conversation analysis: Studies from the first generation*. (pp. 13–31).
John Benjamins. [https://doi.org/10.1075/pbns.125.02jef](https://doi.org/10.1075/pbns.125.02jef)

Kaltenböck, G., Mihatsch, W., & Schneider, S. (2010). Introduction. In G. Kaltenböck, W. Mihatsch & S. Schneider (Eds.), *New approaches to hedging* (1st ed). Emerald.

Koenig, C. J. (2011). Patient resistance as agency in treatment decisions. *Social Science & Medicine*, 72(7), 1105–1114. [https://doi.org/10.1016/j.socscimed.2011.02.010](https://doi.org/10.1016/j.socscimed.2011.02.010)

Lindström, A., & Weatherall, A. (2015). Orientations to epistemics and deontics in treatment discussions. *Journal of Pragmatics*, 78, 39–53.
[https://doi.org/10.1016/j.pragma.2015.01.005](https://doi.org/10.1016/j.pragma.2015.01.005)

Melander Marttala, U. (1995). *Innehåll och perspektiv i samtal mellan läkare och patient: En språklig och samtalsanalytisk undersökning* [PhD Dissertation]. Institutionen för nordiska språk, Uppsala universitet. [http://uu.diva-portal.org/smash/get/diva2:545708/FULLTEXT01.pdf](http://uu.diva-portal.org/smash/get/diva2:545708/FULLTEXT01.pdf)

Mondada, L. (2018). Multiple temporalities of language and body in interaction: Challenges for transcribing multimodality. *Research on Language and Social Interaction, 51*(1), 85–106. [https://doi.org/10.1080/08351813.2018.1413878](https://doi.org/10.1080/08351813.2018.1413878)

Mondada, L., & Keel, S. (2017). Participation et asymétries dans l'interaction institutionnelle. In L. Mondada & S. Keel (Eds.), *Participation et asymétries dans l'interaction institutionnelle* (pp. 9–47). L'Harmattan.

Peräkylä, A. (1998). Authority and accountability: The delivery of diagnosis in primary health care. *Social Psychology Quarterly, 61*(4), 301–320.
[https://doi.org/10.2307/2787032](https://doi.org/10.2307/2787032)

Pomerantz, A. (1985). Pursuing a response. In J. M. Atkinson & J. Heritage (Eds.), *Structures of social action* (pp. 152–164). Cambridge University Press.
[https://doi.org/10.1017/CBO9780511665868.011](https://doi.org/10.1017/CBO9780511665868.011)
*knowledge in conversation* (pp. 107–130). Cambridge University Press.
[doi:10.1017/CBO9780511921674.006](https://doi.org/10.1017/CBO9780511921674.006)

Heritage, J. (2012). Epistemics in action: Action formation and territories of knowledge. *Research on Language & Social Interaction, 45*(1), 1–29.
[https://doi.org/10.1080/08351813.2012.646684](https://doi.org/10.1080/08351813.2012.646684)

Heritage, J. (2013). Epistemics in conversation. In J. Sidnell & T. Stivers (Eds.), *The handbook of conversation analysis* (pp. 370–394). Wiley-Blackwell.
[https://doi.org/10.1002/9781118325001.ch18](https://doi.org/10.1002/9781118325001.ch18)

Jefferson, G. (2004). Glossary transcript symbols with an introduction. In G. H. Lerner (Ed.), *Conversation analysis: Studies from the first generation*. (pp. 13–31).
John Benjamins. [https://doi.org/10.1075/pbns.125.02jef](https://doi.org/10.1075/pbns.125.02jef)

Kaltenböck, G., Mihatsch, W., & Schneider, S. (2010). Introduction. In G. Kaltenböck, W. Mihatsch & S. Schneider (Eds.), *New approaches to hedging* (1st ed). Emerald.

Koenig, C. J. (2011). Patient resistance as agency in treatment decisions. *Social Science & Medicine*, 72(7), 1105–1114. [https://doi.org/10.1016/j.socscimed.2011.02.010](https://doi.org/10.1016/j.socscimed.2011.02.010)

Lindström, A., & Weatherall, A. (2015). Orientations to epistemics and deontics in treatment discussions. *Journal of Pragmatics*, 78, 39–53.
[https://doi.org/10.1016/j.pragma.2015.01.005](https://doi.org/10.1016/j.pragma.2015.01.005)

Melander Marttala, U. (1995). *Innehåll och perspektiv i samtal mellan läkare och patient: En språklig och samtalsanalytisk undersökning* [PhD Dissertation]. Institutionen för nordiska språk, Uppsala universitet. [http://uu.diva-portal.org/smash/get/diva2:545708/FULLTEXT01.pdf](http://uu.diva-portal.org/smash/get/diva2:545708/FULLTEXT01.pdf)

Mondada, L. (2018). Multiple temporalities of language and body in interaction: Challenges for transcribing multimodality. *Research on Language and Social Interaction, 51*(1), 85–106. [https://doi.org/10.1080/08351813.2018.1413878](https://doi.org/10.1080/08351813.2018.1413878)

Mondada, L., & Keel, S. (2017). Participation et asymétries dans l'interaction institutionnelle. In L. Mondada & S. Keel (Eds.), *Participation et asymétries dans l'interaction institutionnelle* (pp. 9–47). L'Harmattan.

Peräkylä, A. (1998). Authority and accountability: The delivery of diagnosis in primary health care. *Social Psychology Quarterly, 61*(4), 301–320.
[https://doi.org/10.2307/2787032](https://doi.org/10.2307/2787032)

Pomerantz, A. (1985). Pursuing a response. In J. M. Atkinson & J. Heritage (Eds.), *Structures of social action* (pp. 152–164). Cambridge University Press.
[https://doi.org/10.1017/CBO9780511665868.011](https://doi.org/10.1017/CBO9780511665868.011)
Steensig, J., & Asmuß, B. (2005). Notes on disaligning ‘yes but’ initiated utterances in Danish and German conversations: Two construction types for dispreferred responses. In A. Hakulinen & M. Selting (Eds.), *Syntax and lexis in conversation: Studies on the use of linguistic resources in talk-in-interaction* (pp. 349–373). John Benjamins. https://doi.org/10.1075/sidag.17.17ste

Stevanovic, M., & Peräkylä, A. (2012). Deontic authority in interaction: The right to announce, propose, and decide. *Research on Language & Social Interaction*, 45(3), 297–321. https://doi.org/10.1080/08351813.2012.699260

Stivers, T. (2002). Participating in decisions about treatment: Overt parent pressure for antibiotic medication in pediatric encounters. *Social Science & Medicine*, *54*(7), 1111–1130. https://doi.org/10.1016/S0277-9536(01)00085-5

Stivers, T. (2005). Parent resistance to physicians’ treatment recommendations: one resource for initiating a negotiation of the treatment decision. *Health Communication*, *18*(1), 41–74.
https://doi.org/10.1207/s15327027hc1801_3

Stivers, T. (2006). Treatment decisions: Negotiations between doctors and patients in acute care encounters. In J. Heritage & D. W. Maynard (Eds.), *Communication in medical care* (pp. 279–312). Cambridge University Press.
https://doi.org/10.1017/CBO9780511607172.012

Stivers, T., & Barnes, R. K. (2018). Treatment recommendation actions, contingencies, and responses: An introduction. *Health Communication*, *33*(11), 1331–1334. https://doi.org/10.1080/10410236.2017.1350914

Stivers, T., Heritage, J., Barnes, R. K., McCabe, R., Thompson, L., & Toerien, M. (2017). Treatment recommendations as actions. *Health Communication*, *33*(11), 1335–1344. https://doi.org/10.1080/10410236.2017.1350913

Stivers, T., Mondada, L., & Steensig, J. (2011). Knowledge, morality and affiliation in social interaction. In T. Stivers, L. Mondada & J. Steensig (Eds.), *The morality of knowledge in conversation* (pp. 3–24). Cambridge University Press.
https://doi.org/10.1017/CBO9780511921674.002

Stokoe, E., Humă, B., Sikveland, R. O., & Kevoe-Feldman, H. (2020). When delayed responses are productive: Being persuaded following resistance in conversation. *Journal of Pragmatics*, *155*, 70–82.
https://doi.org/10.1016/j.pragma.2019.10.001
Steensig, J., & Asmuß, B. (2005). Notes on disaligning ‘yes but’ initiated utterances in Danish and German conversations: Two construction types for dispreferred responses. In A. Hakulinen & M. Selting (Eds.), *Syntax and lexis in conversation: Studies on the use of linguistic resources in talk-in-interaction* (pp. 349–373). John Benjamins. https://doi.org/10.1075/sidag.17.17ste

Stevanovic, M., & Peräkylä, A. (2012). Deontic authority in interaction: The right to announce, propose, and decide. *Research on Language & Social Interaction*, 45(3), 297–321. https://doi.org/10.1080/08351813.2012.699260

Stivers, T. (2002). Participating in decisions about treatment: Overt parent pressure for antibiotic medication in pediatric encounters. *Social Science & Medicine*, *54*(7), 1111–1130. https://doi.org/10.1016/S0277-9536(01)00085-5

Stivers, T. (2005). Parent resistance to physicians’ treatment recommendations: one resource for initiating a negotiation of the treatment decision. *Health Communication*, *18*(1), 41–74.
https://doi.org/10.1207/s15327027hc1801_3

Stivers, T. (2006). Treatment decisions: Negotiations between doctors and patients in acute care encounters. In J. Heritage & D. W. Maynard (Eds.), *Communication in medical care* (pp. 279–312). Cambridge University Press.
https://doi.org/10.1017/CBO9780511607172.012

Stivers, T., & Barnes, R. K. (2018). Treatment recommendation actions, contingencies, and responses: An introduction. *Health Communication*, *33*(11), 1331–1334. https://doi.org/10.1080/10410236.2017.1350914

Stivers, T., Heritage, J., Barnes, R. K., McCabe, R., Thompson, L., & Toerien, M. (2017). Treatment recommendations as actions. *Health Communication*, *33*(11), 1335–1344. https://doi.org/10.1080/10410236.2017.1350913

Stivers, T., Mondada, L., & Steensig, J. (2011). Knowledge, morality and affiliation in social interaction. In T. Stivers, L. Mondada & J. Steensig (Eds.), *The morality of knowledge in conversation* (pp. 3–24). Cambridge University Press.
https://doi.org/10.1017/CBO9780511921674.002

Stokoe, E., Humă, B., Sikveland, R. O., & Kevoe-Feldman, H. (2020). When delayed responses are productive: Being persuaded following resistance in conversation. *Journal of Pragmatics*, *155*, 70–82.
https://doi.org/10.1016/j.pragma.2019.10.001
## Contact

Moa Hagafors
moa.hagafors@ens-lyon.fr

## Please cite as:

Hagafors, M. (2023). Changing treatments: Patient responses to doctors downgrading their medical authority. In Nelson, M., Michanek, M., Rydell, M., Sayehli, S., Skogmyr Marian, K., & Sundberg, G. (Eds.). *Språk i praktiken – i en föränderlig värld*. Rapport från ASLA-symposiet. Stockholms universitet, 7–8, april 2022. [Language in practice – in a changing world. Papers from the ASLA symposium. Stockholm University, 7–8 April, 2022] (pp. 183–201). ASLA, The Swedish Association of Applied Linguistics. Stockholm. https://doi.org/10.17045/sthlmuni.24321526
## Contact

Moa Hagafors
moa.hagafors@ens-lyon.fr

## Please cite as:

Hagafors, M. (2023). Changing treatments: Patient responses to doctors downgrading their medical authority. In Nelson, M., Michanek, M., Rydell, M., Sayehli, S., Skogmyr Marian, K., & Sundberg, G. (Eds.). *Språk i praktiken – i en föränderlig värld*. Rapport från ASLA-symposiet. Stockholms universitet, 7–8, april 2022. [Language in practice – in a changing world. Papers from the ASLA symposium. Stockholm University, 7–8 April, 2022] (pp. 183–201). ASLA, The Swedish Association of Applied Linguistics. Stockholm. https://doi.org/10.17045/sthlmuni.24321526