Doctor-patient communication: a social and micro-political performance.

In the United States the medical relationship is asymmetrical. Doctors not only control medical knowledge, they also have an institutionally based authority which allows them to act as gatekeepers, providing options to some while denying them to others. This study, conducted in a model family practice clinic of a teaching hospital, examines how decisions to do, or not to do, Pap smears are negotiated as residents and a potentially high-risk group of patients communicate. Decision-making occurs in layered phases--opening, medical history, physical examination, and closing. Each phase expresses the doctor's control and the patient's trust. Doctors initiate phases, develop topics and make key choices. They decide when patients undress--a choice which shapes the later Pap smear decision. Decisions to undress patients and to perform Pap smears or decisions not to undress patients and not to perform Pap smears produce no conflict. When there is a conflict, avoidance strategies--bowing to higher-level specialists, selling and unselling, and letting silence speak--are used negotiating devices. The doctor's choice and the patient's agreement produce a specific and a more general outcome--managing the presenting complaint and providing medically adequate health care, respectively. Although interactionally accomplished, these outcomes are institutionally constrained, and, thus are both a social and a micro-political performance.