Reviewed by Paul Atkinson
Mishler's is an elegant and persuasive book, which will undoubtedly be regarded as an important contribution to the field. It will be read with profit by all those who are concerned with the nature of medical interaction --from linguists and discourse analysts to medical practitioners and educators. It combines a detailed analysis of medical encounters with a broader commitment to the humanistic critique of contemporary medical discourse. It is one of the particular strengths of this relatively brief monograph that the themes are skillfully interwoven, so that Mishler's general perspectives and moral preoccupations are never lost to view in the complexities of fine-grained analysis of spoken interaction. Mishler is one of a clutch of authors who have very recently produced monographs on doctor-patient interaction: West, Frankel, Heath and Silverman have all made significant contributions to the genre, based on discourse analysis and conversation analysis. In the context of those, and a substantial number of other studies in the same vein, it is not surprising that Mishler's particular empirical findings are unremarkable in themselves. He does, however, bring to bear a distinctive interpretative stance.
Mishler outlines a cluster of related strands in his approach: he combines substantive, methodological and moral considerations. In common with other analysts of discourse he poses the deceptively simple question as to whether there is a characteristic structure to doctor-patient encounters and --if so --whether there are identifiable variations on that elementary type. The question is less simple than even Mishler allows, since it opens up the vexed question of the identification of 'institutional' contexts, 'activity types' and discourse formats. Mishler rather glosses over such niceties. In common with many other commentators,, he assumes that what he finds in medical interviews may be distinctive to them --and hence manifestations of contemporary 'biomedicine.' There is a clear danger of committing a very basic ecological fallacy: Mishler and discourse analysts of a similar persuasion risk claiming that what is found in medical encounters must be especially characteristic of them.
Mishler makes clear that this empirical question is closely related to the Culture, Medicine and Psychiatry 12 (1988) 249--256.