Culture-in-Action: A Membership Categorization Analysis of Doctor-Patient Interactions in New Zealand General Practice

In the late 1980’s an enormous field of literature and professional mandates was developed, based on the premise that different cultural groups have different health values. This field has colloquially come to be known as Cultural Competence. However, problematically, the terms, outcomes and empirical standards of the field have never been sufficiently defined in a manner that does not “preimpose” categories of culture nor do most of the terms of the field address structural or historic inequalities. Essentially what is set forth in this dissertation is the idea that culture cannot be professionally mandated by “preimposed” categories or competencies but rather that culture is part of an identity practice that occurs in a bidirectional contextual manner for doctors and patients each time they come together to get the task of healthcare done. This is a study of talk-in-interaction, specifically, Membership Categorization Analysis (MCA). MCA refers to the range of practices a speech community deploys to accomplish their everyday social interactions. At the heart of these interactions is the idea of membership and its relationships to the categories used to co-ordinate social life, make sense of experience and create real life empirical understandings of social behaviors and problems. MCA was the pioneering development of Harvey Sacks (1967). In the present work I sought to explore the ways in which doctors and patients in New Zealand General Practice used their everyday identities to get the work of healthcare done. The expected Standardized Relational Pairs of doctor and patient were demonstrated and the moral rights and obligations of being a patient and being a doctor were demonstrated by each part of this pair. Findings that were new and unique to the present study were the use of an Omnirelevant Device, healthcare, to both constrain and direct doctor/patient talk and the use of Interculturality by doctors and patients. That is, identities that co-exist and are displayed iiialongside doctor and patients during the healthcare interaction and are displayed despite the presence of the Omnirelevant Device, healthcare. Another key finding was that patients in these data invoked their moral rights and obligations through the use of defensive detailing and alternative membership categories to defend their position as “good patient” (or not). What the use of the MCA method suggests is that the underlying moral dilemmas implied by the cultural competence field, are essentially made explicit when we are able to carefully explore the identity categories doctors and patients use in getting the work of healthcare done. In addition what this work has demonstrated is that doctors may need to be particularly aware of when patients are invoking their rights to reject medical advice and why this might be the case. Patients in these data clearly spoke for themselves, and they did not reject medical advice merely because they rejected the advice or the doctor, but because, they prioritized another aspect of their own identity, such as being a mother or single man. It seems important that doctors be able to hear these moral rights and obligations. In order to create culturally coherent healthcare, doctors and patients may have to buy into healthcare agendas or conversations that are not evidence based or are not necessarily “competency” based. In essence doctors in particular, but patients also may need to fully explore the alternative identity categorization behind why patients reject or accept medical advice