THE CONVERSATIONAL ART OF DIAGNOSIS: THE SOCIAL CONSTRUCTION OF MEDICAL FACTS

In this dissertation I present a method for understanding clinical medicine which focuses on its central feature: the process and product of diagnosis. I begin with an observation: clinical interaction is a conversation; it turns on the social construction of a shared understanding of the patient's condition as conversations turn on the construction of intersubjective understandings. In these chapters I develop the methodological implications of this observation.;From these bases I derive two principal aspects of method: "normal medicine" and "reconstructive method." Normal medicine refers to the extensive context of membership and knowledge which structures and informs clinical diagnosis. Normal medicine links the micro-analysis of conversation with the macro-analysis of social structure. Moreover, the macro-structure of normal medicine is itself conversational. Reconstructive method describes a conversational analysis which interpretively reconstructs the local meanings of clinical utterances and the context of extra-clinical membership and knowledge in which the physician's and the patient's actions are situated.;These two aspects are presented in discussions of the historical development of normal medicine in nineteenth century American society, and the micro-history of a single clinical conversation establishing the meaning of a patient's palpably enlarged liver. They are then developed in the presentation of a prospectus for the study of chronic pain syndrome. The diagnosis of chronic pain syndrome is described as a local production of a clinical conversation embedded in an evolving institutional context of medical discourse.;I advance four basic ideas. One, diagnosis is the principal social fact of clinical interaction. Doing diagnosis constitutes clinical interaction. A diagnosis is a socially constructed artifact. Two, diagnosis takes place in the interpretive, artful exchange of conversation. Three, clinical conversations involve local social relationships and shared understandings, which are embedded in extensive contexts of social membership and shared medical knowledge. Four, diagnosis is an historical undertaking, emerging through successive interpretive exchanges and taking place in evolving social contexts.