Getting pain on the table in primary care physical exams.

Using conversation analysis and a dataset of 171 video recordings of US primary care encounters (2003-2005), this paper examines patients' unsolicited pain informings - e.g. "that hurts" - during the physical examination phase of acute care visits. I argue that when patients experience pain in a physical exam but have not been asked a question like "does that hurt?", they face an interactional dilemma. Having presented their health problem to a doctor, they have tacitly set in motion epistemic and interactional asymmetries through which the doctor investigates the problem on their behalf. In this context, volunteering unsolicited pain information could facilitate progress towards an accurate diagnosis, but it could also be heard as independently asserting the relevance of pain to what the doctor is doing, thereby departing from the previously established asymmetries. I show that patients manage this dilemma by using turn design practices to implicitly account for unsolicited pain informings as motivated by a virtual solicitation and/or a sudden pain sensation. With these practices, patients manage to share potentially relevant pain information without accountably being heard to assert its relevance to the doctor's diagnostic inquiry. This achievement demonstrates how asymmetries in doctor-patient communication are a joint accomplishment of both doctors and patients, and are incarnate in the details of everyday clinical interactions.