in description

Journal of Pragmatics 42 (2010) 3384–3399

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Journal of Pragmatics

journal homepage: www.elsevier.com/locate/pragma

‘‘I should be lucky ha ha ha ha’’: The construction of power, identity and gender through laughter within medical workplace learning encounters

Charlotte E. Rees a,*, Lynn V. Monrouxe b

a Centre for Medical Education, College of Medicine, Dentistry & Nursing, University of Dundee, Dundee, UK b Division of Medical Education, School of Medicine, Cardiff University, UK

A R T I C L E I N F O

Article history:

Received 5 June 2008

Received in revised form 2 October 2009

Accepted 9 May 2010

Keywords:

Laughter

Power

Identity

Gender

Student–doctor–patient relationship

Medical workplace learning

A B S T R A C T

Laughter is employed in social interaction to construct meaning, identities, and

relationships. Although studies have begun to examine humour within the medical

workplace, none have employed observational methods to study laughables/laughter

within the learning triad of the bedside teaching encounter (BTE). This paper focuses on

this gap by exploring the novel question: How do students, patients, and doctors construct

and co-construct power, identity and gender through laughter within BTEs? In this paper,

we focus on the disaffiliative function of laughables/laughter across BTEs. Most of the

laughables presented can be construed as teases: fallibility, frustration, cynicism and/or

sexual teasing; and this teasing was accompanied by a competitive rather than

collaborative play frame. Teasing and laughter was employed by participants to maintain

or subvert existing power asymmetries, to construct identities, for example, as individuals

who are intelligent, witty and powerful, and to construct gender by performing masculinity

or femininity. Further research with a larger and more diverse sample of participants

(including more female doctors, male students and female patients) is now essential to

explore more fully the co-construction of power, identities and gender through laughter

within medical workplace learning encounters.

� 2010 Elsevier B.V. All rights reserved.

1. Introduction

‘‘Laughing contributes to the ongoing creation of meaning, self, relationship, society and culture’’ (Glenn, 2003, p. 2).

Laughter has a vital communicative role within social interaction. Rather than being a simple behavioural response to humour, laughter is rhetorical; it can be employed to communicate meaning to others, to construct identities, and to make argumentative points (Billig, 2005, pp. 175–199; Glenn, 2003, pp. 1–6; Partington, 2006, pp. 1–24). Laughter is strongly influenced by the presence of others and who those others are, and different types of laughter are thought to communicate different meanings (Billig, 2005, p. 189; Glenn, 2003, p. 27). For example, laughter that is prompt, loud and rapid and includes many laughter particles will communicate a different meaning to laughter that is delayed, soft and slow and contains few laughter particles (Billig, 2005, p. 189).

Although researchers (e.g. Holmes, 2000; Holmes and Marra, 2002a,b) have examined laughter within workplace interactions, much of the focus has been on the operation of workplace humour rather than laughter per se; with humour often

* Corresponding author. Tel.: +44 (0)1382 381971; fax: +44 (0)1382 645748.

E-mail address: [email protected] (C.E. Rees).

0378-2166/$ – see front matter � 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.pragma.2010.05.004

C.E. Rees, L.V. Monrouxe / Journal of Pragmatics 42 (2010) 3384–3399 3385

being conflated with laughter. However, a relationship between laughter and humour cannot be assumed; humour does not necessarily make people laugh, and people laugh for many reasons other than finding something comical (Attardo, 2003).

In this paper, we therefore focus on what Glenn (2003, p. 48) calls ‘laughables’ (i.e. referents of laughter) rather than humour, and laughter itself, within the under-explored workplace context of medicine: specifically, the bedside teaching encounter (BTE). Bedside teaching can be considered a particular type of institutional talk (Drew and Heritage, 1992). It includes any teaching done in the company of the patient and therefore involves the ‘learning triad’ of student, patient and physician tutor (Janicik and Fletcher, 2003). It is considered vital in the development of students’ physical examination, procedural and communication skills, clinical knowledge and reasoning, and professionalism and typically involves students demonstrating their skills to the physician tutor and receiving feedback (Dent, 2001; Gale and Gale, 2006; Janicik and Fletcher, 2003). Furthermore, BTEs provide a forum for identity work, not only for the students who develop their own professional identities as they interact with doctors and patients in the healthcare setting, but also for doctors and patients themselves (Monrouxe et al., 2009; Rees and Monrouxe, 2008). This particular type of medical workplace interaction therefore regulates how interactants communicate with each other and contributes to the construction of workplace culture (Holmes and Marra, 2002a; Partington, 2006, pp. 57–81).

While studies have begun to examine humour within the medical workplace, these tend to employ surveys or interviews to explore students’, doctors’ and patients’ perceptions of humour use in clinical settings (e.g. Granek-Catarivas et al., 2005; Wear et al., 2006, 2009). Instead, the current study employs observational methods to study actual laughter within the learning triad of the BTE. It seeks to explore the original research question: How do students, patients, and doctors construct and co-construct power, identity and gender through laughter within BTEs?

1.1. Theoretical perspectives

The social constructionist approach we adopt for our analysis of laughter is broadly underpinned by symbolic interactionism; a perspective focusing on how individuals construct and negotiate meaning, social order and identity through social interaction (Charon, 2007; Sandstrom et al., 2006). Inspired by the work of Janet Holmes (e.g. Holmes, 2000; Holmes and Marra, 2002a,b; Holmes et al., 1999), our study draws on several complementary theoretical frameworks. While our focus is on laughter within student–patient–tutor interactions, our analysis extends beyond that talk, to explore sociolinguistic variables not specifically evident in the talk but are nevertheless relevant to the broader institutional context of the medical workplace—power, identity and gender. Drawing on the work of key scholars such as Goffman (1959, 1967, 1981) and Fairclough (2001), this study combines insights from interactional sociolinguistics and critical discourse analysis (Sarangi and Roberts, 1999, p. 30–33).

1.2. Laughter in institutional talk: interactional language and the play frame

We have already argued that bedside teaching can be seen as a form of institutional talk, regulating how interactants communicate with each other and contributing to the construction of medical workplace culture. Partington (2006, pp. 59–60) explainsthatalthoughinstitutionaltalkiscommonlyassociatedwithtransactionallanguage,italsotendstobecomposedofthe interactional discourse mode. He differentiates between transactional and interactional language, explaining that the former is employed to express content and the latter used to communicate and construct social relationships. So, politeness signals such as ‘‘please’’ (interactional language) are commonly employed to achieve transactional work. Two features are thought to commonly precede laughter in institutional talk: a shift from the transactional to interactional mode and entering into what Bateson (2000, pp. 177–193) calls ‘‘the play frame’’. Interactants convey the message that they are entering into the play frame through metacommunicative signals like sarcastic or exaggerated intonation, grimaces and/or laughter, thereby signalling to others that their talk is not serious (Lampert and Ervin-Tripp, 2006).

Coates (2007) recently argued that conversational play is essentially collaborative. However, her data focused on conversational humour within friendship groups rather than a formal and hierarchical context like medical workplace learning. Therefore, the face needs of her participants are likely to differ from ours, with an emphasis on the maintenance of affective face in friendship groups (i.e. self-image as non-threatening, congenial and good humoured) compared to the maintenance of competence face in work-related groups (i.e. self-image as capable, authoritative and in control; Partington, 2006, pp. 97–98). Furthermore, her excerpts demonstrate that although interlocutors construct a play frame collaboratively to joke with one another, their jokes are directed at absent others, demonstrating that while their laughter creates intimacy amongst those present, it simultaneously disaffiliates with absent others. Contrasting with Coates’ (2007) paper, the current study focuses on an alternative feature of the play frame by examining how students, doctors and patients construct a play frame competitively rather than collaboratively. Coates (2007, p. 47) stated that ‘‘laughter makes us feel good’’ and while this may be true for some (e.g. the teaser and audience members who are not the butt of the tease); we argue that laughter can make people feel bad (e.g. the butt of the tease).

1.3. The student–patient–doctor interaction, power and teasing

Social interaction permeates medical workplace learning encounters, ranging from dyadic interactions such as patient– doctor, patient–student, and doctor–student, to more complex triadic interactions, for example, between student, patient

C.E. Rees, L.V. Monrouxe / Journal of Pragmatics 42 (2010) 3384–33993386

and doctor. Irrespective of the number of interactants, these learning encounters are imbued with complex struggles over power (Sarangi and Roberts, 1999, pp. 1–57). Although patient–doctor interaction has been researched heavily in recent years, the triadic relationship between patients, medical students and physician tutors within workplace learning encounters has received little attention.

Power asymmetry is typical within BTEs (Monrouxe et al., 2009; Rees and Monrouxe, 2008). In terms of the dyadic student–doctor and patient–doctor relationships, the doctor tends to possess the rank of superordinate, while the student and patient typically hold subordinate positions. However, the dyadic relationship of student–patient is less predictable. Sometimes students feel disempowered within this student–patient interaction and at other times the patient feels disempowered. Within the context of the triadic student–patient–doctor relationship, students and patients sometimes feel like equals and at other times students perceive themselves to be superior to patients as they broker power between the patient and doctor (Rees et al., 2007a,b).

Although focusing on humour rather than laughables/laughter, Holmes (2000) and Holmes and Marra (2002a,b) explored the construction of power through humour in their language in the workplace project. They distinguished between repressive and contestive humour, with the former being employed by superiors to maintain their power and the latter being used by subordinates to challenge authority. They also contrast reinforcing and subversive humour: the former reinforcing existing power relations whereas the latter challenges these relations. Holmes (2000) suggested that in relationships typified by power asymmetry, humour was often employed by the powerful to maintain control while appearing collegiate, and was sometimes used by the powerless to subvert that control in a way that would be hard to challenge by the superordinate.

Holmes and Marra (2002b) outlined four strategies commonly employed in subversive humour, one of which is particularly relevant to the current study: jocular abuse, defined as negative remarks to a co-present, which others have described as teasing. Boxer and Cortés-Conde (1997) define teasing as ‘‘conversational joking. . . directed at someone present’’ (p. 279), which contrasts from joking about absent others. Indeed, they define conversational joking, as ‘‘any type of verbal activity that creates a play frame, but does not make any of the participants in the conversation the centre of the playing’’ (p. 280). Partington (2006, pp. 153–162) distinguishes between four different types of teases: teasing by withholding information (frustration); teasing by accusing the butt of some shortcoming (fallibility); teasing by mimicking the butt (mimicry); and teasing by suggesting that the butts’s motives are not as honourable as he or she implies (cynicism). In this paper, we also consider sexual teasing. Although sexual teasing has been defined in quite specific ways, e.g. as ‘‘a form of provocation characterized by the promise of sexual contact followed by withdrawal’’ (Mester and O’Sullivan, 2007, p. 531), we define the term more broadly in this paper; as conversational joking of a ‘sexual’ or ‘sexist’ nature directed at someone present. In terms of Partington’s (2006) classification of teasing, sexual teasing may combine an element of fallibility ‘sex as weakness of the flesh’ (as in sexism) and cynicism ‘sex as ulterior motive’ (as in sexual).

Although teasing and shared laughter can contribute to conversational play and intimacy, teases that are overly aggressive, highly distressing and unmarked (i.e. those not accompanied by a play frame) can be heard as insulting (Boxer and Cortés-Conde, 1997; Lampert and Ervin-Tripp, 2006). Indeed, teasing relates to laughing at rather than laughing with and can therefore be disaffiliative: promoting division, derision and feelings of superiority (Glenn, 2003, pp. 112–121). The current study illustrates participants’ use of four types of teases (fallibility, frustration, cynicism and sexual) when constructing power, identity and gender.

1.4. Identity and gender

One of the most important functions of teasing is the construction of relational identities. By teasing others we can construct our identity as someone who is intelligent and witty, and by teasing ourselves (as in self-deprecation) we can display our identity as someone who is approachable and human, bolstering our affective face (Partington, 2006, pp. 97–98). Used to perform social identity, teasing is thought to be strongly influenced by gender (Boxer and Cortés-Conde, 1997).

Laughter is a mechanism through which individuals can construct their gender identity. Through laughables and laughter, men and women can construct their identities as masculine men and feminine women, respectively. Furthermore, due to the cultural assumptions about gender and laughter (e.g. men producing more laughables and women doing more laughing), men and women can perform gender in ways that maintain and subvert the gendered order of work (Crawford, 2003; Glenn, 2003, pp. 122–161; Martin, 2004).

In this study, we primarily focus on the construction of masculinity, commonly defined as having power (Collinson, 2002; Crawford, 2003; Kotthoff, 2006). Linked with power, we illustrate how male patients (and one male doctor) engage in sexual teasing of female students (and a male student) within medical workplace learning encounters to perform masculinity and enact control.

2. Methods

The data presented in this paper were collected as part of a larger research project exploring the teaching and learning of patient-centred issues in clinical feedback sessions during years three and four of a five-year undergraduate medical curriculum in the United Kingdom. Following approval from this medical school’s research ethics committee, the second author observed and audiotaped 27 clinical feedback sessions. The students attended these 2-h sessions at the end of the

C.E. Rees, L.V. Monrouxe / Journal of Pragmatics 42 (2010) 3384–3399 3387

week and in them, they presented patient ‘cases’ to a physician tutor (commonly a hospital consultant) who then encouraged further discussion on aspects of the ‘case’, including patient-centred issues.

In five of these feedback sessions, the physician tutors took pairs of students to the bedside of six different patients in order to conduct bedside teaching. Although informed consent for tutor and student participation in this study was secured prior to the feedback sessions, due to the serendipitous nature of the BTEs, patients’ verbal consent for the examination (and study) was secured by the tutor or student immediately prior to the bedside teaching. Following each BTE, the second author re-visited the patient to explain the research in greater depth, to emphasise their right to withdraw from the study by withdrawing their data, and to gain their full written consent.

Five tutors (1 female, 4 males), 10 students (6 females, 4 males) and 6 patients (2 females, 4 males) participated across the 6 BTEs in a ward-based environment at one of two teaching hospitals. These encounters lasted between 9 and 22 min with an average of 17 min (112 min in total). The second author observed these encounters by standing at the foot of the bed and making brief notes, including aspects of non-verbal communication such as the positioning of patients around the bed and gross body movements like the removal of clothing. She did not speak during the encounters other than to greet the patient and say goodbye. She audiotaped the encounters, which were later transcribed anonymously and her field notes added to the start of each transcript. Following each clinical feedback session, she met with the student pairs (together) and separately with the clinical tutor for a ‘debrief’ of the event. Using her field notes from the session she began by asking participants their perspective on the session and followed up with specific questions about the session itself.

Our participants did not know that their laughter would be studied because laughter was not the initial focus of the research. Instead, it emerged as an important issue from our primary level analysis. Inspired by Goffman (1959), the first- order analysis involved us listening to the audiotapes while reading the transcripts for BTE1 and 2 (CR and LM together), paying attention to the roles that participants played and the extent to which they performed as teams. Working alone CR then analysed BTE3 and 6 and LM analysed BTE4 and 5, and we then swapped analyses with each other to check one another’s interpretations of the data (see Monrouxe et al., 2009 for the results of this primary analysis).

Through this process, we became aware of participants’ laughter and how their laughter seemed to serve multiple functions, most notably disaffiliation. Therefore, we decided to go back to our transcripts and transcribe all examples of laughter with seemingly disaffiliative functions in greater detail. While CA researchers advocate the full transcription and analysis of laughter particles and their sequential placement, we do not provide that level of detail here (e.g. ‘‘heh huh�hh PLAYN(h)W(h)IZ O(h)R’N ya:h’’, Jefferson, 1985, p. 29) because we want to avoid the structure of the talk over-shadowing its content and minimise the difficulties reading and interpreting the talk (Partington, 2006, pp. 14–15).

Although we transcribed laughter particles between words and we differentiated between open-mouthed (ha) and closed-mouthed laughter (huh, heh) (Glenn, 2003, p. 35–52), we do not transcribe laughter particles within words for the reason of clarity and balance between the structure and content of talk. In the event that interactants place laughter within words, called ‘‘laughspeak, a form of blended, laughing speech that communicates emotional tone’’ (Provine, 2000, p. 37, cited in Partington, 2006, p. 16), we use transcription notes such as ((says laughingly)). We feel that this gives the reader sufficient structure whilst at the same time preserving the content of the talk.

While affiliative and disaffiliative functions of laughables and laughter go hand-in-hand, we focus on the disaffiliative functions in this paper because we are interested in the construction and contestation of power within BTEs. We prepared a series of questions about laughables and laughter on the basis of our reading (e.g. Billig, 2005, pp. 175–199; Glenn, 2003, pp. 7–34) and asked these questions of our excerpts to enable a comprehensive and critical analysis: Who produces the laughable and who laughs? What is the laughable? Is a play frame constructed around the laughable and if so, how? What does the laughter sound like? How is the laughter maintained? Is it shared? How is the laughter closed? What do the laughable and the laughter accomplish in the social interaction?

3. Results and discussion

Although we identified 13 disaffiliative excerpts across our 6 BTEs (see Table 1 for an overview), for brevity, we focus in- depth on 6 excerpts in this paper. We selected these six excerpts because they illustrate clearly the multiple functions of laughables and laughter across a range of BTEs with different foci, such as cardiovascular, respiratory and abdominal examinations. The six excerpts come from different stages of the encounters (e.g. start, middle and end), and during different activities within the encounters (e.g. as the doctor gains consent from the patient for the examination, during the student’s examination of the patient, as the doctor questions the student about his/her examination, during the doctor’s feedback to the student, and during the doctor’s examination of the patient). Together, these six excerpts demonstrate how participants construct and co-construct power, identity and gender in dyadic relationships (e.g. student–doctor, patient–doctor) and the more complex triadic relationship of student–patient–doctor.

3.1. Power and identity in the student–doctor relationship

In this section, we discuss two excerpts that demonstrate how power and identities are co-constructed through laughter in the student–doctor relationship. Excerpt 5 (from BTE2) is one of many examples across the BTEs illustrating how typical power asymmetries between students and consultants are constructed and maintained through laughter. By contrast, excerpt 3 (from BTE1) demonstrates how students can momentarily subvert this power asymmetry through laughables.

Table 1 Overview of laughables/laughter in thirteen disaffiliative excerpts across the BTEs.

Excerpt BTE Who

produces

laughable?a

Who

laughs?

What is the laughable? Does a play

frame accompany

the laughable

and if so, how?

What does the laughter

sound like?

Is the

laughter

maintained

and if so, how?

Is the

laughter

shared?

How is the

laughter

closed?

What is the primary

purpose of the

laughter?

1b 1 MD1,

then MP1

MP1, then

MP1 and

MD1

together

Cynicism teasing of FS1

and FS2 and fantasy

compliment of MP1 by

MD1

Sexual teasing of FS1

and FS2 by MP1 and

self-deprecatory

laughter by MP1

Yes, exaggerated

tone

4 soft laughter particles

(MP1), then 4 louder

overlapping laughter

particles (MP1 and MD1

together)

By MP1’s sexual

tease of FS1 and

FS2

Yes, between MD1

and MP1, FS1 and

FS2 respond with

un-laughter

By MD1’s

resumption

of serious

talk

Construction of masculine

identity and power by

MD1 and MP1 and

subjugation of FS1 and FS2

2 1 MD1 MD1,

then FS1

Fallibility teasing of

FS2

Yes, sarcastic tone 7 soft laughter particles

overlapping with FS2’s

explanation for speaking

Comment by

and 2 louder

laughter

particles from

FS1

Although MD1 and

FS1 laugh, their

laughter is not

shared

By FS1’s

resumption

of serious

talk

Construction of power by

MD1 and subjugation of

FS2

3b 1 FS1 MD1 Cynicism teasing of

MD1

Yes, through MD1’s

laughter

4 soft laughter particles,

then a further 7 soft

laughter particles

Through FS1’s

rhetorical

questions

No By MD1’s

resumption

of serious

talk

Construction of power by

MD1 and subversion of

power by FS1 and

construction of identity

4 1 MP1,

then MD1

MD1 Frustration teasing of

FS1 and FS2 created by

MD1

No Prolonged loud laughter

particles, a burst of 10 ‘ha’,

followed by another burst

of 5 ‘ha’

Through MD1

asking MP1 to

reveal further

information

No By MD1’s

resumption

of serious

talk

Construction of power by

MD1 and subjugation of

FS1 and FS2

5b 2 FD1 FD1

and MS2

Fallibility teasing of

MS2

Yes, through FD1’s

laughter-talk

Comment said laughingly

(FD1), then 4 soft laughter

particles (MS2)

No Although FD1 and

MS2 laugh, their

laughter is not

shared

By FD1’s

resumption

of serious

talk

Construction of power by

FD1 and subjugation of

MS2 and construction of

identity

6 2 MS2,

then FD1

MS2 Self-deprecatory

laughter of MS2 and

then fallibility teasing

of MS2

Yes, exaggerated

tone

3 soft laughter particles

and then okay said

laughingly

Through FD1’s

tease

No By MS2’s

resumption

of serious

talk

Construction of power by

FD1 and subjugation of

MS2 and construction of

identity

7 2 FD1 FD1,

then FP1

Fallibility teasing of

FP1

Yes, through

FD1’s laughter

Hmmph (FD1), then 3 soft

laughter particles after

apology (FP1)

No Although FD1 and

FP1 laugh, their

laughter is not

shared

By FD1’s

resumption

of serious

talk

Construction of power by

FD1 and subjugation of

FP1

8 3 MP2 MS3

and MD2

Joking about absent

others ‘‘they’’

Yes, exaggerated

tone

5 soft laughter particles

(MS3), then 1 soft laughter

particle (MD2)

No Yes, between MS3

and MD2

By MP2’s

resumption

of serious

talk

Construction of masculine

identity and power by

MP2

9 3 MP2 MP2 Joking about absent

others ‘‘they’’

Yes, through

MP2’s laughter

‘they didn’t warn’ said

laughingly

No No By MP2’s

resumption

of serious

talk

Construction of masculine

identity and power by

MP2

C .E . R e e s, L .V . M o n ro u x e / Jo u rn a l o f P ra g m a tics

4 2 (2 0 1 0 ) 3 3 8 4 – 3 3 9 9

3 3 8 8

10 3 MD2,

then MP2

MS3 Fallibility teasing of

MS3

Yes, exaggerated

tone

7 louder laughter particles

with a pause after the

fourth, then 4 louder

laughter particles

Through MP2’s

construction of

the play frame

No By MP2’s

resumption

of serious

talk

Construction of masculine

identity by MD2 and MP2,

construction of power by

MD2 and subjugation of

MS3

11b 3 MP2 FS7 Sexual teasing of MS3

and FS7

Yes, exaggerated

tone

3 soft laughter particles No No By MS3’s

resumption

of serious

talk

Construction of masculine

and feminine identities,

construction of power by

MP2

12b 3 MD2 MD2 Self-deprecatory

laughter of MD2

Yes, exaggerated

tone

4 soft laughter particles,

then a further 3 soft

laughter particles

Through the

construction of

play frame by

MP2

No By MD2’s

resumption

of serious

talk

Construction of identity by

MD2

13 (a)b 6 MP4 MD4

and FS5

Fallibility teasing of

FS5

Yes, exaggerated

tone

4 soft laughter particles

(MD4) overlapping with

FS5 apology and then two

soft laughter particles

No Yes, between MD4

and FS5

By MD4’s

resumption

of serious

talk

Construction of masculine

identity and power by

MP4

13 (b)b 6 MP4 MD4

and FS5

Fallibility teasing of

MD4

Yes, exaggerated

tone

Okay said laughingly

(MD4) and two

overlapping soft laughter

particles (FS5)

No Yes, between MD4

and FS5

By MD4’s

resumption

of serious

talk

Construction of masculine

identity and power by

MP4

a MD1 = male doctor 1; MP1 = male patient 1; FS1 = female student 1; MS2 = male student 2, etc. b Excerpts discussed in-depth in the paper.

C .E . R e e s, L .V . M o n ro u x e / Jo u rn a l o f P ra g m a tics

4 2 (2 0 1 0 ) 3 3 8 4 – 3 3 9 9

3 3 8 9

C.E. Rees, L.V. Monrouxe / Journal of Pragmatics 42 (2010) 3384–33993390

However, it is important to stress that excerpt 3 is unusual, being the only example across our six BTEs where a student attempts to subvert the typical power relationship with a consultant by teasing them. We start this section by discussing the excerpt from BTE2.

BTE2 took place at the end of a clinical feedback session focusing on respiratory presentations. The feedback session was facilitated by a female consultant and the two students were males in their fourth year. These students had worked with this consultant before so had some familiarity with her teaching style. The consultant took the students to the bedside of a female patient that the student (MS2) had examined before; a patient the consultant was also familiar with. The focus of the encounter was for MS2 to conduct a respiratory examination and receive feedback from the consultant. In order to check the student’s findings, the consultant also examined the patient.

Excerpt 5 is near the start of the encounter and before the student has really had a chance to begin his examination. All he has done by this point is explain to the patient what he is going to do, and position her at a 458 angle. Immediately prior to this excerpt the consultant interrupts the student to ask him why he wants the patient at this angle. The excerpt begins with her asking him another question, this time about what chest diseases cause a raised jugular venous pressure. He fumbles over the right medical terminology, which leads to the consultant making a laughable (turn 45) and MS2 laughing (turn 46). Although the other student (MS1) participates briefly in this interaction, the patient and her husband and the researcher observe in silence:

1 Transc on speech

= pause to

Excerpt 51

38

FD1:

ript notation ; [words in sq

nearest half s

What other chest diseases can give you (a raised JVP)

39

MS2:

Uhm (4.0) cardiac pain

40

FD1:

Well we’ve had cardiac pain

41

MS1:

Oh you’ve said that

42

MS2:

Corpo-corpo

43

MS1:

pulmonale

44

MS2:

pulmonale

45

FD1:

She could be a corporal in the army (. . .) ((said in laughing manner))

46

MS2:

huh huh huh huh

47

FD1:

Yeah that’s sort of coming onto right heart failure again isn’t it?

Even though MS2 eventually articulates the word he was initially searching for (i.e. cor pulmonale; a presentation of chronic lung disease leading to right heart failure) with the help of MS1, the consultant makes a laughable directed at his earlier linguistic error (turn 42). Through the metacommunicative signal of laughter-talk in turn 45, the consultant invites laughter through the construction of a play frame, signalling to the students that her comment is not to be taken seriously. Her laughable can be construed as a playful tease of MS2 with the use of word-play, emphasising to him (and others present) his linguistic fallibility (Partington, 2006, pp. 155–159) and MS2 responds to this tease promptly with four soft laughter particles. Although his laughter shares her laughter within the tease, the laughter is not shared by the other student, despite him being actively involved in this part of the interaction. MS2’s laughter is brought to an abrupt close as the consultant shifts out of the play frame and into more serious talk about right heart failure (turn 47).

The consultant’s laughable and the students’ laughter/un-laughter help to construct power and identities in a number of ways. By teasing the student and creating the laughable, the consultant controls the encounter and constructs her identity as the powerful authority figure. Furthermore, through her clever teasing using word-play she outperforms the student through verbal competition (Tholander and Aronsson, 2002, cited in Partington, 2006, p. 145), thereby constructing her identity as intelligent, witty and humorous. Interestingly, we see her employing a softer form of control humour typical amongst women, i.e. using play and fun rather than ridicule (Kotthoff, 2006; Martin, 2004). Finally, she terminates the laughter through the resumption of non-laughing talk, shifting abruptly from an interactional to transactional mode characteristic of institutional talk, illustrating her control over the encounter and emphasising her identity as powerful authority figure.

Her tease also emphasises the student’s learner status and his identity as proto-professional. However, by playing along with her tease through laughter, MS2 constructs a positive identity for himself, one which communicates his good humour. Although his laughter contributes to the ongoing maintenance of the power asymmetry, the un-laughter of his peer reflects MS1’s reluctance to further subjugate MS2 and can be seen as an act of subversion. Although we are unsure whether MS1 smiled, his un-laughter suggests that he is keen to avoid division, derision and superiority over MS2, instead constructing a collegiate peer relationship with MS2. So, this excerpt demonstrates how typical student–consultant power asymmetries are constructed and maintained through laughter, but also how students can subvert the typical power hierarchy through

s: CAPITALS = spoken loudly; >words in sharp brackets< = spoken faster than typical speech for individual; Dash- at- end- = running uare brackets] = overtalking speech; (single brackets) = probably word spoken; (. . .) = inaudible speech; (.) = micropause; (1.5)

econd; ((double brackets)) = further information.

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un-laughter. In the next example (from BTE1), we see how a student subverts this power asymmetry in a more deliberate and obvious way through asking the physician tutor challenging questions and teasing him.

BTE1 took place at the end of a feedback session focusing on cardiovascular presentations. The session was facilitated by a male consultant and the two students were females in their third year. These two students had presented patient ‘cases’ to this consultant the previous week so had some familiarity with his teaching style. The consultant took the students to the bedside of a male patient not discussed by the students in the feedback session, but a patient he was familiar with. Although the consultant explained to the patient at the start of the encounter that the students would only listen to his heart (see excerpt 1 later), the focus of the encounter was for FS1 to conduct a full examination of his cardiovascular system and receive feedback from the consultant. However, both students got to listen to the patient’s heart during the encounter, as did the consultant.

Excerpt 3 comes about a third of the way into the BTE. The student started her examination by checking the patient’s hands, in particular his nails for clubbing and the colour of his skin. After repeated questioning by the consultant about the patient’s skin colour, FS1 tells the consultant that she thinks the patient’s skin is yellow and concludes that he may be jaundiced. The consultant challenges this observation by asking the student: ‘‘If I told you he was bilirubin level was normal what would you think?’’ implying that the patient is not jaundiced (and suggesting that his skin is not yellow). This short excerpt illustrates a fairly emotional exchange between the male consultant and female student, while the male patient, other student and researcher observe in silence. The excerpt is composed of rapid questions and answers between MD1 and FS1, signs of exasperation from both and laughter from the consultant (turns 71 and 73):

Excerpt 3:

65

MD1:

Okay so what’s the colour- what’s the- what’s the discolouration of his skin then?

66

FS1:

Don’t know of any other causes that makes the skin look yellow that aren’t jaundice

67

MD1:

Well do you think it’s yellow?

68

FS1:

YES I DO (.) I think IT’S YELLOW ((says in insistent/defensive tone))

69

MD1:

Alright okay alright alright okay it’s yellow ((sharp intake of breath))

70

FS1:

What colour do you think it is?

71

MD1:

He he he he

72

FS1:

[Orange? Blue?

73

MD1:

Well (.) he he he he he he he] Okay I’ll tell you what (.) all might be revealed

74

FS1:

Right

After insisting that she thinks the patient’s skin colour is yellow and the consultant’s remark ‘‘okay it’s yellow’’, FS1 asks the consultant what colour he thinks the patient’s skin is (turn 70). Rather than answering her question, he responds promptly with a few soft laughter particles, thereby constructing her question as a laughable. Although her laughable does not construct a play frame through metacommunicative signals like a sarcastic or exaggerated tone, the consultant’s laughter (turns 71 and 73) seems to create the play frame, communicating that he takes no offence at her direct question and suggesting that he is almost enjoying her annoyance.

In turn 72, she produces another laughable in the form of two rhetorical questions, which elicits overlapping soft laughter particles from the consultant (turn 73). The student may be motivated to ask these questions because the consultant is making contradictory inferences about the patient’s skin colour: his repeated challenges of her conclusion that the patient’s skin is yellow (both here and earlier in the BTE) suggests that the patient’s skin is not yellow and yet in turn 69, he states duplicitously: ‘‘okay it’s yellow’’. Moreover, he says this flippantly, almost as if he’s just agreeing to shut the student up. These rhetorical questions can be seen as the student teasing the consultant by suggesting that his motives are not as honourable as he implies (cynicism) (Partington, 2006, pp. 160–162). She later reveals in the debrief interview that by the consultant’s withholding of information and his line of questioning regarding the colour of the patient’s skin that she knew she was being ‘‘set-up’’ (Monrouxe et al., 2009, p. 923). Indeed, this appears to be the case because later in the encounter the doctor tells the patient to reveal their ‘strategic secret’ (they both know that the patient’s skin is sun-tanned because he lives mostly in Spain), causing the consultant to respond with loud, prolonged and open-mouthed laughter (see Monrouxe et al., 2009 for further details). Furthermore, the consultant’s laughter in turn 73 can also be construed as frustration teasing, i.e. teasing by withholding information from the student (Partington, 2006, pp. 153–155).

Interestingly, the student fails to share the consultant’s laughter and the consultant closes his laughter abruptly, and with the utterance of ‘‘okay’’ (turn 73) he resumes non-laughing talk. Notably, he has still not answered her question; instead maintaining the play frame by suggesting that the answer might be revealed later. Although play commonly combines features of collaboration and competition, the maintenance of the play frame here seems to be competitive.

Both the student’s laughables and the consultant’s laughter accomplish the construction of relational power and identities in various ways. Although this excerpt begins with the consultant asking her questions, FS1 reverses this question– answer sequence by firing three questions at the consultant in turns 70 and 72. Question-asking is largely the domain of powerful actors within social interaction (Wang, 2006), so by asking the consultant questions she not only communicates her identity as a bold and rebellious student, but she also constructs herself momentarily as a powerful figure.

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His initial laughter in response to this question sounds slightly defensive but conveys that he does not take her question (and therefore her challenge of his authority) seriously. Interestingly, through his construction of the play frame here, he seems to encourage her oppositional teasing, thereby constructing his identity as an authority figure liberal enough to tolerate challenges from subordinates. As suggested by Holmes (2000) it is difficult for a superordinate to challenge a contestive laughable without losing face.

The student’s co-construction as powerful figure in this excerpt is further illustrated by her being the producer of the laughable rather than the person laughing. Research within the medical setting, for example, has shown that subordinates tend to laugh at the comical utterances of superordinates rather than vice versa (Coser, 1960, cited in Glenn, 2003, p. 27).

Finally, the student and consultant both employ teasing as a mechanism through which they can control and compete with each other, a classic example here being their desire to outperform one another through verbal competition (Tholander and Aronsson, 2002, cited in Partington, 2006, p. 145). Despite the risks that such cynicism and frustration teasing will be interpreted as insults, teasing seems to contribute to the ongoing conversational play within the excerpt. Interestingly, the teases made by this female student vary from the softer forms of control humour thought to be typical of women (e.g. Kotthoff, 2006). It is possible that she felt brave enough to challenge this male consultant because two other females were co-present, including the female researcher who was recording the encounter.

The student’s laughables (turns 70 and 72) can be described as examples of contestive or subversive humour (Holmes, 2000; Holmes and Marra, 2002a). However, despite this resistance of the consultant’s authority through teasing, it is perhaps the consultant who has the last metaphorical laugh in this excerpt: through his teasing of the student by withholding information, his laughter maintains the existing power asymmetry.

3.2. Power and identity in the patient–doctor–student relationship

In this section, we discuss two excerpts that demonstrate how power and identities are co-constructed through laughter in the dyadic patient–doctor relationship and triadic patient–doctor–student relationship. Interestingly, despite the common construction of patients as passive objects across our six BTEs (see Monrouxe et al., 2009), we found numerous examples of patients challenging the typical power asymmetry within the patient–doctor relationship. Although the following excerpts demonstrate how patients can invert the existing power asymmetry momentarily, they also illustrate how typical power asymmetries are constructed and maintained through laughter. We start this section by discussing excerpt 12 (from BTE3), which includes the relatively rare example of the doctor teasing the patient.

BTE3 took place at the end of a feedback session focusing on abdominal pain presentations. The feedback session was facilitated by a male consultant and although it was composed of four students, only one couple (one male and one female student in their fourth year) were taken to the bedside of a patient. These two students had not met this consultant before so were unfamiliar with his teaching style. The male student (MS3) took the consultant and his peer to the bedside of the male patient (MP2) already discussed in the feedback session. The consultant had not met this patient before. The focus of the encounter was for MS3 to receive a history from MP2 and conduct an abdominal examination. In order to check the student’s findings, the consultant also examined the patient.

Excerpt 12 is near the end of the encounter. The student has already conducted his examination of the patient’s abdomen and discussed his findings with the consultant. Immediately prior to this excerpt the consultant asks the patient whether it is okay that he also examine his tummy. This excerpt illustrates an exchange between the patient and consultant about the location of the patient’s abdominal pain, while both students and the researcher observe. The patient asks the consultant a couple of questions about how he knows the location of his pain, to which the consultant responds and then laughs (turns 140 and 142):

Excerpt 12:

136

MD2:

I’m just going to have a little feel of your tummy over here

137

MP2:

Now you’ve touched it

138

MD2:

Yeah

139

MP2:

How did you know that was there? ((says playfully))

140

MD2:

They told me- that’s why (.) huh huh huh huh

141

MP2:

What’ve you got- Morse Code or something? ((says playfully))

142

MD2:

No they told me beforehand ahu huh huh (.) we’ve been discussing you in secret you see ((says playfully)) (.) are you tender on this side at all?

The consultant begins this excerpt by telling the patient he is going to feel a particular area of his abdomen. The patient’s response informs the consultant that he has successfully located his pain immediately. The patient then communicates surprise at the consultant locating his pain so quickly by asking him a question (turn 139). Question-asking is largely the domain of powerful actors within social interaction (Wang, 2006), so his question could be seen as a challenge to the consultant’s authority. However, the question is accompanied by an exaggerated tone, constructing a play frame, which signals to the consultant that his question is not a serious challenge. The consultant responds firstly with the direct answer:

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‘‘they told me- that’s why’’ (meaning the students) and then four delayed soft laughter particles after a pause (turn 140), suggesting that he is laughing at his own answer rather than the patient’s playful question; this probably being an example of self-deprecatory laughter (Glenn, 2003, pp. 105–106).

However, the patient does not share the consultant’s laughter, either indicating his disapproval of the consultant’s comment that he and the students have been talking about him prior to the examination or perhaps because he interprets the clinician’s laughter-talk as an admission of guilt/incompetence and therefore troubles-telling (Jefferson, 1984, cited in Glenn, 2003, p. 61). Nevertheless, despite his un-laughter, the patient extends the conversational play by asking a ludicrous question in a mildly sarcastic tone: ‘‘what’ve you got- Morse code or something?’’ (turn 141), which could again be construed as a challenge to the consultant’s authority. As with the patient’s first question, the consultant responds with a direct answer: ‘‘no they told me beforehand’’ (again meaning the students), and then three delayed soft laughter particles, which again suggests that he is engaging in self-deprecatory laughter.

In the next breath he says in an exaggerated tone: ‘‘we’ve been discussing you in secret you see’’, which elongates the conversational play frame and can be construed as a tease directed towards the patient. Although play has collaborative and competitive aspects, the maintenance of the play frame here seems competitive. The patient does not share the consultant’s laughter in turn 142 and after a brief pause the consultant terminates the laughter-talk (and play frame) by resuming serious talk, marked by the raising of his voice as he asks the patient about his abdominal tenderness.

Both the patient’s playful questions and the consultant’s laughter accomplish the construction of relational power and identities in numerous ways. By asking questions playfully, the patient can be seen to subvert the existing power asymmetry momentarily. Moreover, through his playful question-asking and construction and maintenance of the play frame, the patient constructs his identity as a bold, rebellious, witty and intelligent person (Boxer and Cortés-Conde, 1997). Furthermore, researchers have found that teasing is a frequent resource employed to re-rank, i.e. reduce the social distance between healthcare professional staff and patients (Grainger, 2002). So, this patient’s playful questions could be employed to construct intimacy with this consultant who he has never met before. This intimacy might also be co-constructed through the consultant’s laughing at his own responses to the patient’s playful questions, thereby engaging in self-deprecatory laughter (Glenn, 2003, pp. 105–106). Furthermore, his laughter may serve to repair his competence face; given that he admits to the patient that he only knows where his pain is because his subordinates have told him. Therefore, he may be attempting to boost his affective face instead by laughing (Partington, 2006, pp. 97–98). Indeed, such self-laughables followed by self-laughter can be employed by speakers to resolve interactional difficulties (Glenn, 2003, pp. 105–106).

However, despite constructing himself as relatively egalitarian and approachable in this excerpt, the consultant directs a tease at the patient in turn 142 and then abruptly terminates his laughter (and the play frame) by resuming non-laughing talk. This tease, coupled with a quick shift to the transactional mode emphasises his control and identity as the powerful authority figure. This suggests that the patient’s playful questions do little to change the existing power relations in the BTE other than in a short-lived way.

While this excerpt demonstrates how typical power asymmetries between patients and doctors are constructed and maintained, it does show how patients can subvert the power asymmetry momentarily through asking playful questions. This subversion of power is perhaps even clearer in excerpt 13 (from BTE6), which is particularly notable in that it includes two separate teases by the patient; the first directed at the medical student (which is fairly low-risk given the relatively subordinate status of the student), and the second directed at the consultant (which is relatively high-risk given the consultant’s superordinate status).

BTE6 took place at the end of a clinical feedback session focusing on respiratory presentations. The feedback session was facilitated by a male consultant and the two students were females in their fourth year. These two students had met this consultant previously so were familiar with his teaching style. The consultant took the students to the bedside of a male patient discussed by one of the students in the feedback session. This patient was also known to the consultant and had been examined by one of the female students previously. The focus of the encounter was for one of the students to do a respiratory examination of the patient and receive feedback from the consultant, although both females got the opportunity to conduct parts of the examination, as did the consultant.

Excerpt 13 comes about half way through the BTE. The student (FS5) has already examined the patient by checking his hands, eyes and tongue, his jugular venous pressure and assessing his lungs. Immediately prior to this excerpt she explains her findings to the consultant. The excerpt illustrates a multi-party exchange between the consultant (MD4), patient (MP4) and student (FS5), while the other student and researcher observe in silence. It starts with the consultant (and patient) giving the student feedback on her examination, and shifts to the consultant beginning his examination of the patient. Both sections include laughables from the patient (turns 50 and 58) and laughter from the student and consultant (turns 51, 52, 59 and 60):

Excerpt 13:

47

MD4:

So that’s pretty good FS5. When you’re doing examinations, although it’s quite difficult and (.) MP4 wasn’t happy sitting out of bed, that would be fine but if it’s more comfortable with their, their legs sitting out due (do you see how he struggled) and it’s often more comfortable just swinging the legs out and then (. . .) And often it’s far better for you because you can get to see- are you okay? Alright

48

MP4:

Mmm

49

MD4:

Alright

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50

MP4:

And warm your hands up (.)

51

MD4:

[Heh heh heh heh

52

FS5:

Oh yeah sorry about that] hee hee

53

MD4:

Okay, THEY’RE FUNNY BEDS THESE SO LET US KNOW IF THEY’RE NOT UNCOMFORTABLE, IF THEY ARE UNCOMFORTABLE OKAY?I’M GONNA ASK YOUIFI CAN-IFWECAN JUSTREMOVETHATPYJAMA TOP, I’LL GIVE YOU A HAND (2.0) Okay (3.0) and >DO YOU MIND IF WE TAKE OFF THE T-SHIRT AS WELL?<

54

MP4:

No

55

MD4:

TELL- TELL US- TELL US IF IT’S NOT (.) OKAY ALRIGHT? (2.0)

56

MP4:

Don’t say I’ve got surplus fat now

57

MD4:

Sorry?

58

MP4:

Don’t say I’ve got surplus fat

59

MD4:

[Okay ((says laughingly))

60

FS5:

Huh huh]

61

MD4:

Okay so when you’re examining um somebody it’s much better obviously if they can, to get them exposed. . .

The consultant begins this excerpt by giving advice to the student on the appropriate positioning of patients during respiratory examinations, after which he invites the patient to speak by asking him whether he is okay. This active inclusion possibly empowers the patient to offer some advice to the student; a laughable in turn 50, saying that she warm up her hands before examining. Although his speech is fairly laboured and muffled (being seriously ill and elderly), his comment is accompanied by an exaggerated tone and can therefore be construed as a playful fallibility tease of the student (Partington, 2006, pp. 155–159). The consultant responds promptly with four soft laughter particles, which overlap with an apology and two stronger laughter particles from the student. While this laughter is shared between the consultant and the student, the patient does not laugh, possibly because he wants to avoid engaging in self-praise (Glenn, 2003, p. 91).

Interestingly, it is the consultant who terminates this first bout of laughter by resuming non-laughing talk, which includes a request that the patient take off his pyjama top and t-shirt. The consultant’s repeated checking of the patient’s comfort, coupled with the favourable response from the consultant and student to the patient’s first tease, possibly empowers the patient to offer his second laughable, this time directed at the consultant. The face-threatening demand: ‘‘don’t say I’ve got surplus fat (now)’’ (turns 56 and 58) is accompanied by an exaggerated tone, and can be interpreted as a fallibility tease (Partington, 2006, pp. 155–159); with the patient communicating his anxiety that the consultant may make a judgemental/ rude comment about his physical appearance. Although the consultant does not hear the first tease, he does register the second, responding with an ‘‘okay’’ said laughingly, which overlaps with two soft laughter particles from the student. As before, the laughter is shared between the consultant and the student but not the patient, and it is again terminated by the consultant, who resumes the serious business of feeding back advice to the student.

The patient’s laughables and the consultant and student’s laughter accomplish the construction of relational power and identities in numerous ways. The patient’s multiple teases can be seen to contest the existing power relationships within the encounter, by constructing himself as a powerful figure momentarily. This construction is further emphasised by his teaching of the student (and the physician tutor) about the importance of warming their hands and respecting and maintaining patient dignity. Furthermore, through his teasing of the student and consultant, the patient constructs his identity as someone who is bold, rebellious, intelligent and witty. Finally, this patient’s teasing could be employed to construct intimacy with the consultant and student, particularly given the intimate (and potentially embarrassing) nature of this excerpt with his undressing, as has been found in previous research relating to nurse–patient relationships (Grainger, 2002).

By laughing along with the patient’s teases, the consultant and student also demonstrate their good humour and construct their identities as open-minded protagonists, tolerant of challenges. Their shared laughter also demonstrates collegiality between the student and doctor. However, despite constructing himself as relatively egalitarian in this excerpt, the consultant repeatedly terminates the laughter through the resumption of non-laughing talk (as found in previous examples). This shifting to the transactional mode communicates his control over the flow of the encounter, thereby maintaining his identity as the powerful authority figure. As seen in the previous excerpt, the patient’s laughables do little to change the existing power relations within the BTE, other than in a purely transitory way.

3.3. Power, identity and gender in the student–patient–doctor relationship

As mentioned in Section 1, gender is deeply intertwined with (and relevant to) the power and identity issues already discussed in the previous sections. Through laughables and laughter in excerpts 3, 5, 12 and 13, it is quite possible that participants constructed their identities as masculine men or feminine women. Although we mention gender in our interpretation of these previous excerpts and in Table 1, we purposely avoid in-depth discussion about the construction of gender in these excerpts in order to focus more on gender in this section, with specific reference to sexual humour in the form

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of male teasing of female students (and a male student). In this section, we talk about the construction of gender through laughter in the dyadic patient–student and triadic patient–student–doctor relationship by discussing two excerpts containing sexual teasing, beginning with excerpt 1 (from BTE1).

As mentioned previously, BTE1 was composed of a male consultant, male patient, two female students and the female researcher. This excerpt is taken from the beginning of the encounter, during which the consultant explains to the patient what he wants and secures consent for the female students to listen to his heart. At the end of this excerpt, we see the construction of sexual teasing by the male patient and shared laughter between the patient and consultant, directed at the female students (turns 11–13):

Excerpt 1:

1

MD1:

How are you?

2

MP1:

(. . .)

3

MD1:

Now, I’ve got some STUDENTS who (. . .) do you mind if they come and have a listen to your heart? Well the other thing is that we’re just- it’s part of an assessment, we’re tape recording the conversation

4

MP1:

uhu

5

MD1:

Do you mind if we use the tape recorder?

6

MP1:

No you can do whatever you like ((says playfully))

7

MD1:

Good for you. Now (.) what they’re going to do- ALL they’re going to do is listen to your heart

8

MP1:

Right

9

MD1:

That’s all they’re going to do

10

MP1:

No problem

11

MD1:

If they do anything else, you let me know ((says playfully))

12

MP1:

Huh huh huh huh (.) I should be lucky [ha ha ha ha

13

MD1:

Ha ha ha ha] (3.0) Now (.) er (.) right er who’s in the front- you are?

In turns 7 and 9, the consultant repeatedly assures the patient that all the female students are going to do is listen to his heart, to which he responds: ‘‘no problem’’ (turn 10). Such repetition is often a striking feature of the play frame (Coates, 2007) and the consultant further constructs this play frame saying: ‘‘If they do anything else, you let me know’’ (turn 11) in an exaggerated tone, which signals to the patient (and the students) that his comment is not to be taken seriously. This laughable can be construed as both a fantasy compliment directed at the patient in order to bolster his masculinity, and a cynicism tease of the female students because he implies that their motives are not honourable. This laughable is met with four prompt soft laughter particles from the male patient (turn 12) and he then extends the ongoing conversational play with the consultant (and the tease of the female students) by making the sexual remark: ‘‘I should be lucky’’. He follows this self- laughable with self-laughter (four stronger laughter particles), indicating that his laughter is self-deprecatory (Glenn, 2003, pp. 105–106). These four laughter particles overlap with four similar laughter particles from the consultant (turn 13), signalling intimacy between the two males (Coates, 2007). Although these two males share their laughter, the laughables and laughter is met with un-laughter by the female students. The laughter seems to terminate abruptly but is followed by a fairly lengthy pause and then the resumption of non-laughing talk by the consultant, who seems to stumble over his words to the female students (turn 13).

The consultant and patient’s laughter-talk and the students’ un-laughter do much to construct power, identities and gender in this excerpt. Through the consultant’s original tease of the female students, and the patient’s extension of that tease, the male protagonists construct themselves as powerful figures, thereby subjugating the female students from the outset of the encounter. In his original tease of the students, the consultant not only constructs his identity as an intelligent and witty authority figure, but he also constructs his masculine identity by aligning himself with the male patient against the female students. The intimacy between these two males is further emphasised by the consultant’s fantasy compliment directed at the patient. This compliment also aims to bolster the patient’s self-esteem regarding his masculinity, a re-ranking process that has been found during intimate procedures such as bathing between nurses and elderly patients (Grainger, 2002).

The construction of the patient’s masculinity in this excerpt is further emphasised by his sexual tease of the female students (turn 12). Interestingly, such sexual humour is thought to be more than just about masculinity but is believed to be: ‘‘a sustained performance of masculinity’’ (Cameron, 1997, p. 590, cited in Crawford, 2003, p. 1424). This is perhaps highly relevant for this patient whose current status (as seriously ill and elderly) challenges his masculine identity. Furthermore, Kotthoff (2006, p. 17) suggested that: ‘‘sexual joking often seems to play a role when desires cannot be satisfied’’ and this may also be relevant to our male patient whose tease takes the form of: ‘‘I should be lucky’’ (turn 12). The self-deprecatory laughter following this self-laughable also helps to construct intimacy between himself and the consultant, helps to construct his identity as someone who is approachable, and also to extract himself from the interactional difficulty at that point—his face-threatening sexual teasing of the female students (Boxer and Cortés-Conde, 1997; Glenn, 2003, pp. 105–106).

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The consultant’s laughter in response to the patient’s sexual teasing serves to co-construct the sexual humour in this encounter, thereby degrading the female students and excluding them from their ‘male’ world. Ultimately, the talk of these two males serves to sexualise this encounter; sexualising the male patient and particularly emphasising the students’ sexual rather than their proto-professional identities, and is therefore discriminatory against the two women.

The fairly lengthy pause after the men’s laughter is not filled with laughter from the females, despite research suggesting that females join the laughter of males even when they do not find the laughable funny (Jefferson, 2004). Coupled with the fact that neither student adopts a politeness tactic known as the ‘‘laughing along-while-resisting strategy’’, a strategy commonly adopted by women as the courteous response to sexual overtures by males (Glenn, 2003, p. 123), their un- laughter suggests their disapproval of the sexual teasing. By resisting laughter, the two females not only attempt to subvert their subjugation by the men’s power, but they also resist constructing their identities as feminine women, and indeed, as sexual objects. The resumption of non-laughing talk by the consultant in turn 13, coupled with his fumbling over his words to the students, suggests that their disapproval of the teasing has not gone unnoticed.

While this excerpt offers a clear demonstration of females’ un-laughter in response to sexual teasing by males, the next excerpt illustrates the: ‘‘laughing along-while-resisting strategy’’ talked about by Glenn (2003, p. 123). This final excerpt comes from BTE3, which was composed of a male doctor, male patient, and male and female student. This excerpt comes about half way through BTE3 as the male student is examining the patient’s abdomen and being observed by the consultant, female student and researcher. Although the excerpt begins with the patient making two playful fallibility teases of the male, his teasing soon switches to a sexual tease, directed primarily at the male student, but also including the co-present female student (turns 61 and 63), to which she responds with laughter (turn 64):

Excerpt 11:

57

MP2:

Well then there’s the (2.0) Yeah you’ve still got chilly fingers ((says playfully))

58

MS3:

Yeah I’ve always got chilly fingers me (.) ((says light-heartedly))

59

MP2:

What’s that- cold hands and warm heart? ((says playfully))

60

MS3:

Well

61

MP2:

You’ll have to [watch it ((says playfully))

62

MS3:

that’s what] that’s what some people think ((says light-heartedly))

63

MP2:

You’ll have to watch him (. . .) ((says playfully))

64

FS7:

Uh huh huh

65

MS3:

Right any- any PAIN AT THE MOMENT?

This excerpt begins with the patient admonishing the student for his: ‘‘chilly fingers’’ (turn 57). His talk here is accompanied by an exaggerated tone, which constructs a play frame and communicates to the student that his criticism should be taken as a playful tease rather than seriously. Although the student does not laugh, he plays along with the tease by agreeing with the patient using a light-hearted tone and employing the colloquial: ‘‘me’’ at the end of his response (turn 58). The patient replies with yet another playful tease, thereby extending the conversational banter between him and the male student (turn 59). The student only has the chance to say: ‘‘well’’ (turn 60) before he is interrupted by the patient, this time with talk directed at the female student observing the encounter: ‘‘you’ll have to watch it’’ (turn 61). This talk is again accompanied by an exaggerated tone, commensurate with the play frame and signalling to both students that he is just teasing. There is some overlapping talk between the patient and the male student here, with the student addressing the patient’s earlier question from turn 59 in turn 62. The student’s exaggerated tone extends the conversational play, and the patient responds by repeating his original tease, saying: ‘‘you’ll have to watch him’’ (turn 63). The sexual undertone of this tease is clearer here than in turn 61 because of his replacement of the words: ‘‘watch it’’ (turn 61) with: ‘‘watch him’’ (turn 63). The female student employs the ‘‘laughing along-while-resisting strategy’’ by responding promptly with three soft laughter particles. Rather than sharing her laughter, the male student, who can be considered the primary butt of this cynicism/sexual tease, terminates the laughter by resuming serious talk.

The patient’s laughables and the students’ laughter and un-laughter in this excerpt do much to construct power, identities and gender. Firstly, through the repeated teasing of the male student, the patient not only constructs his identity as a bold and witty authority figure, but he also constructs his masculine identity by co-constructing a competitive play frame (Frosh et al., 2002). Furthermore, through his introduction of sexual teasing, the patient further constructs his masculinity. As in excerpt 1, this is highly relevant for this elderly male patient whose illness status is likely to threaten his masculinity. We already talk about how this patient constructs his masculinity throughout this encounter elsewhere (see Rees and Monrouxe, 2008), but it is perhaps worth emphasising this with an additional gendered comment made by the patient later in turn 81: ‘‘I never had hands like that when I was working- They’ve gone soft like a lady’’. Although the male student is the primary butt in this excerpt, by using such sexual humour, it is possible that the female student feels unfairly singled out on the basis of her gender.

However, she responds to the sexual teasing with soft and prompt rather than loud and prolonged laughter, demonstrating the ‘‘laughing along-while-resisting strategy’’, which communicates her good humour and constructs her femininity. Indeed, not only might she be laughing to be polite (despite potentially finding the laughable unfunny), but she

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might also be laughing to construct her identity as the ‘‘girl next door’’ (Kotthoff, 2006, p. 6). In contrast to excerpt 1, in which the female students both respond to sexual humour with un-laughter, FS7’s laughter here maintains the patient’s subjugation of her male peer (and herself). Interestingly, her male peer and the other male co-participant (the consultant) respond to the patient’s sexual teasing with un-laughter, demonstrating their reluctance to subjugate the female student or be subjected (in the case of the male student). Indeed, the male student terminates the female student’s laughter, and the play frame created by the patient by abruptly shifting the frame with his utterance of ‘‘Right’’ and through his resumption of serious talk about the patient’s pain in a notably louder voice. This shifting to the transactional mode perhaps reflects the student’s attempt to regain control over the encounter, lost through the patient’s teasing. In doing so, he constructs his identity as the powerful authority figure.

4. Conclusions

In this paper, we discuss critically examples of laughables/laughter across a range of BTEs with different foci, from different stages of the encounter, and during different activities within the encounters. The laughables across the encounters are typically accompanied by metacommunicative signals such as exaggerated tone, which constructs a play frame and signals to interactants that the talk is not to be taken seriously (Lampert and Ervin-Tripp, 2006). However, unlike the collaborative play frame constructed through laughter in friendship groups (Coates, 2007), the play frame across these excerpts seems to be competitive (Partington, 2006, pp. 65–69).

The laughables can be construed as teases of various kinds: fallibility, frustration, cynicism and/or sexual teasing (Partington, 2006, pp. 153–162). Although some of the teases may have been attempts by participants to construct intimacy (Grainger, 2002), we believe that the teases functioned primarily to construct power, identity and gender. As can be seen from Table 1, three patterns relating to power seem to emerge across our excerpts that were particularly striking and warrant further discussion: (1) teasing tended to be directed at students, and was infrequently directed at patients; (2) as the butts of teases, students and consultants typically laughed along but students sometimes responded with un-laughter; and (3) laughter (and the play frame) was generally terminated by consultants.

That students were more commonly the butts of teases seems to indicate their construction as the most subordinate person within the BTE. They may be the most frequent butts because they are the youngest participants (Billig, 2005, pp. 194–199) and/or because they are the most central players within the encounter; what with the BTE being conducted specifically to help them learn (Holmes, 2000). As for the infrequent teasing of patients, it is possible that consultants and students avoided teasing them to avert the typical power asymmetry, thereby avoiding a ‘repressive discourse’ (Holmes, 2000). Interestingly, this finding contrasts with others suggesting that patients hold the most disempowered position within the learning triad (Monrouxe et al., 2009; Rees and Monrouxe, 2008; Rees et al., 2007a,b). This finding was unexpected and is therefore an important feature of our study requiring further investigation. Despite patients typically being disempowered in hospital bedside teaching encounters, they are keen to be more involved in these encounters and commonly strive for a ‘voice’: to be allowed to speak and to be heard. They have few ways ‘into’ the encounter such as being invited by others to speak and their creation of laughables and laughter seems to offer them a powerful way of taking the floor, thereby resisting their co-construction as a teaching ‘prop’.

As the butts of teases, students and consultants typically laughed along by responding with prompt, soft and brief laughter particles, suggesting that they were good humoured (Boxer and Cortés-Conde, 1997; Collinson, 2002). However, we also have obvious examples of un-laughter from students; where they fail to laugh along with teases directed at themselves or their peers (Billig, 2005, pp. 175–199). Although we are unsure whether they responded with milder alternatives to laughter such as smiles (Glenn, 2003, p. 4) this un-laughter signals their disapproval of such teases (the most notable example being the sexual tease in excerpt 1) and also their attempts to resist the power asymmetry constructed by consultants and patients (Holmes, 2000; Holmes and Marra, 2002b). Such non-laughing responses to teases by the students might signal their over-arching desire to maintain their competence face, albeit at the expense of risking their affective face (Partington, 2008).

Despite attempts by students and patients to subvert typical power asymmetries within BTEs (for example, by students responding to teases with un-laughter, and patients teasing consultants), laughter (and the play frame) was largely terminated by consultants through their resumption of non-laughing talk. That consultants shifted abruptly from interactional to transactional discourse modes characteristic of institutional talk (Partington, 2006, pp. 59–65), emphasises their desire to boost their competence face, maintain control over the encounters and their superordinate positions. Ultimately, this tends to suggest that patients and students do little to change the existing power asymmetry other than in fleeting ways during the encounters (Billig, 2005, pp. 200–235; Martin, 2004).

In terms of identity and gender, three prominent patterns seemed to emerge across the excerpts and merit further discussion. First, through creating laughables (and teasing others), participants appeared to construct their identities as people who were intelligent, witty and powerful (Boxer and Cortés-Conde, 1997). In the particular case of subordinates teasing superordinates, the teases also seemed to construct their identities as individuals who were bold and rebellious. Second, by playing along with teases, participants constructed their identities as good humoured and in the case of superordinates being teased by subordinates; they constructed their identities as people tolerant of challenges from inferiors (Boxer and Cortés-Conde, 1997; Collinson, 2002). Altogether, playing along with teases served to boost affective face within the encounters, albeit at the expense of risking competence face (Partington, 2008). Furthermore, three examples of males

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(patient—excerpt 1; student—excerpt 6; and consultant—excerpt 12) engaging in self-deprecatory laughter exist in our data. Self-deprecatory laughter not only helps our participants to construct their positives identities in the face of threats to their competence face (through the maintenance of their affective face) but it may also be employed to construct intimacy (Grainger, 2002; Partington, 2006, pp. 97–98). Third, by engaging in sexual teasing of female students (and a male student), male patients in particular seemed to construct their power and their masculinity within the BTEs (Crawford, 2003). By their response (laughing along-while-resisting versus un-laughter), female students either constructed or contested their femininity and sexual objectification (Crawford, 2003; Glenn, 2003, pp. 122–161; Kotthoff, 2006). Flirtatious or sexual remarks directed at female medical students by male patients are commonplace in cultures requiring men to ‘prove’ their masculinity (Rademakers et al., 2008). It is likely that the two male patients in our study engaged in this sexual teasing in order to perform masculinity within a context where their masculinity was particularly challenged; through serious illness and old age (Rees and Monrouxe, 2008).

This study has a number of methodological issues, which must be taken into consideration when interpreting our results. First, our analysis is based primarily on listening to audiotapes of the encounters and reading transcripts based on those audiotapes. While field notes captured some non-verbal aspects of the encounters such as participants’ gross body movements, we failed to capture more subtle gestures relevant to laughter such as smiles because laughter was not the focus of our study prior to data collection. Second, our sample size was small and although the participant composition of the BTEs varied from encounter to encounter, our participants were relatively homogeneous: (1) all of the patients were seriously ill and elderly, and mostly male; (2) all of the students were third- or fourth-year medical students at the same medical school, and mostly female; and (3) all of the physician tutors were hospital-based consultants, and mostly male. It is likely that participants’ laughables/laughter reflect this sample (particularly the gender composition of the groups). Finally, although a male colleague (see acknowledgements) listened to the audiotapes and read the transcripts to help us elucidate clinical aspects of the encounters, we, as analysts, are both female and as such, are probably sensitive to the sexual teasing of the students in excerpts 1 and 11.

Given these methodological challenges, this study has implications for further research. Additional observational research is now needed with a larger and more diverse sample of medical students, patients and physician tutors, including more male students, more female consultants, and more female (and younger) patients. Furthermore, the use of video will be essential in determining the visual cues of laughter such as eye gazes, smiling and so on. In particular, video will be fundamental in determining whether un-laughter is accompanied by smiling (thought to constitute a middle ground between laughter and un-laughter; Haakana, 1999, cited in Glenn, 2003, p. 67) or a po-faced i.e. serious response (Drew, 1987, cited in Glenn, 2003, p. 123). In terms of educational implications, we agree with Glenn (2003, p. 171) that the pedagogical recommendations arising from laughter research: ‘‘derive, not from telling people what to do, but from inviting people to examine what they do and let them decide what they might like to change’’. We therefore encourage physician tutors and medical students to reflect critically on their laughables and laughter in BTEs, both amongst themselves and with patients, and how those laughables/laughter might co-construct power, identity and gender. Without such critical reflection, it will be impossible for tutors and students to decide whether they should make a change and if so, what those changes might be.

Acknowledgements

We would like to thank the patients, students and consultants who allowed us to observe and audiotape their BTEs. We would also like to thank our medical colleague Professor Paul Bradley (Director of Clinical Skills, Peninsula Medical School, Universities of Exeter and Plymouth, UK) for listening to our audiotapes and reading our transcripts, and helping us understand the clinical aspects of the encounters.

References

Attardo, Salvatore, 2003. Introduction: the pragmatics of humor. Journal of Pragmatics 35, 1287–1294. Bateson, Gregory, 2000. Steps to An Ecology of Mind. University of Chicago Press, Chicago, IL. Billig, Michael, 2005. Laughter and Ridicule: Towards a Social Critique of Humour. Sage, London. Boxer, Diana, Cortés-Conde, Florencia, 1997. From bonding to biting: conversational joking and identity display. Journal of Pragmatics 27, 275–294. Cameron, Deborah, 1997. Performing gender identity: young men’s talk and the construction of heterosexual masculinity. In: Johnson, Sally A., Meinhof,

Ulrike H. (Eds.), Language and Masculinity. Blackwell, Oxford, pp. 47–64. Charon, Joel M., 2007. Symbolic Interactionism. An Introduction, An Interpretation, An Integration, 9th edition. Pearson Prentice Hall, Upper Saddle River,

NJ. Coates, Jennifer, 2007. Talk in a play frame: more on laughter and intimacy. Journal of Pragmatics 39, 29–49. Collinson, David L., 2002. Managing humour. Journal of Management Studies 39, 269–288. Coser, Rose L., 1960. Laughter among colleagues: a study of the social functions of humor among the staff of a mental hospital. Psychiatry 23, 81–95. Crawford, Mary, 2003. Gender and humor in social context. Journal of Pragmatics 35, 1413–1430. Dent, John A., 2001. Hospital wards. In: Dent, John A., Harden, Ronald M. (Eds.), A Practical Guide for Medical Teachers. Churchill Livingstone, Edinburgh,

pp. 98–108. Drew, Paul, 1987. Po-faced receipts of teases. Linguistics 25, 219–253. Drew, Paul, Heritage, John (Eds.), 1992. Talk at Work. Cambridge University Press, Cambridge. Fairclough, Norman, 2001. Language and Power. Pearson Education Limited, Essex. Frosh, Stephen, Phoenix, Ann, Pattman, Rob, 2002. Young Masculinities. Palgrave, London. Gale, Christopher P., Gale, Richard P., 2006. Is bedside teaching in cardiology necessary for the undergraduate education of medical students? Medical

Education 40, 11–13.

C.E. Rees, L.V. Monrouxe / Journal of Pragmatics 42 (2010) 3384–3399 3399

Glenn, Phillip, 2003. Laughter in Interaction. Cambridge University Press, Cambridge. Goffman, Erving, 1959. The Presentation of Self in Everyday Life. Doubleday, New York. Goffman, Erving, 1967. Interaction Ritual: Essays on Face-to-Face Behaviour. Doubleday, New York. Goffman, Erving, 1981. Forms of Talk. University of Pennsylvania Press, Philadelphia. Grainger, Karen (2002). Politeness or impoliteness: verbal play on the hospital ward. Working Papers on the Web, Sheffield Hallam University, UK.

http://extra.shu.ac.uk/wpw/politeness/grainger.htm (accessed 24.09.09). Granek-Catarivas, M., Goldstein-Ferber, S., Azuri, Y., Vinker, S., Kahan, E., 2005. Use of humour in primary care: different perceptions among patients and

physicians. Postgraduate Medical Journal 81, 126–130. Haakana, Markku (1999). Laughing matters: a conversation analytical study of laughter in doctor–patient interaction. Unpublished doctoral dissertation.

University of Helsinki, Finland. Holmes, Janet, 2000. Politeness, power and provocation: how humour functions in the workplace. Discourse Studies 2, 159–185. Holmes, Janet, Marra, Meredith, 2002a. Having a laugh at work: how humor contributes to workplace culture. Journal of Pragmatics 34, 1683–1710. Holmes, Janet, Marra, Meredith, 2002b. Over the edge? Subversive humor between colleagues and friends. Humor 15, 65–87. Holmes, Janet, Stubbe, Maria, Vine, Bernadette, 1999. Constructing professional identity: ‘‘doing power’’ in policy units. In: Sarangi, Srikant, Roberts, Celia

(Eds.), Talk, Work and Institutional Order. Mouton de Gruyter, Berlin, pp. 351–385. Janicik, Regina W., Fletcher, Kathlyn E., 2003. Teaching at the bedside: a new model. Medical Teacher 25 (2), 127–130. Jefferson, Gail, 1984. On the organization of laughter in talk about troubles. In: Atkinson, John M., Heritage, John (Eds.), Structures of Social Action: Studies

in Conversation Analysis. Cambridge University Press, Cambridge, pp. 346–369. Jefferson, Gail, 1985. An exercise in the transcription and analysis of laughter. In: van Dijk, Teun A. (Ed.), Handbook of Discourse Analysis; Volume 3:

Discourse and Dialogue. Academic Press, London, pp. 25–34. Jefferson, Gail, 2004. A note on laughter in ‘male–female’ interaction. Discourse Studies 6, 117–133. Kotthoff, Helga, 2006. Gender and humor: the state of the art. Journal of Pragmatics 38, 4–25. Lampert, Martin D., Ervin-Tripp, Susan M., 2006. Risky laughter: teasing and self-directed joking among male and female friends. Journal of Pragmatics 38,

51–72. Martin, Diane M., 2004. Humor in middle management: women negotiating the paradoxes of organisational life. Journal of Applied Communication

Research 32, 147–170. Mester, Cindy M., O’Sullivan, Lucia F., 2007. Such a tease: intentional sexual provocation within heterosexual interactions. Archives of Sex and Behavior 36,

531–542. Monrouxe, Lynn V., Rees, Charlotte E., Bradley, Paul A., 2009. ‘The construction of patients’ involvement in hospital bedside teaching encounters. Qualitative

Health Research 19 (7), 918–930. Partington, Alan, 2006. The Linguistics of Laughter. A Corpus-assisted Study of Laughter-talk. Routledge, London/New York. Partington, Alan, 2008. Teasing at the White House: a corpus-linguistics study of face work in performing and responding to teases. Text & Talk 28 (6),

729–771. Provine, Robert R., 2000. Laughter: A Scientific Investigation. Viking, New York. Rademakers, Jany J.D.J.M., van den Muijsenbergh, Maria E.T.C., Slappendel, Geerte, Lagro-Janssen, Antoine L.M., Borleffs, Jan C.C., 2008. Sexual harassment

during clinical clerkships in Dutch medical schools. Medical Education 42, 452–458. Rees, Charlotte E., Monrouxe, Lynn V., 2008. ‘‘Is it alright if I-um-we unbutton your pyjama top now?’’ Pronominal use in bedside teaching encounters.

Communication & Medicine 5 (2), 171–182. Rees, Charlotte E., Knight, Lynn V., Wilkinson, Clare E., 2007a. ‘‘Doctors being up there and we being down here’’: a metaphorical analysis of talk about

student/doctor-patient relationships. Social Science & Medicine 65, 725–737. Rees, Charlotte E., Knight, Lynn V., Wilkinson, Clare E., 2007b. ‘‘User involvement is a sine qua non, almost, in medical education’’: learning with rather than

just about health and social care service users. Advances in Health Sciences Education 12 (3), 359–390. Sandstrom, Kent L., Martin, Daniel D., Fine, Gary A., 2006. Symbols, Selves and Social Reality. A Symbolic Interactionist Approach to Social Psychology and

Sociology. Roxbury Publishing Company, California, LA. Sarangi, Srikant, Roberts, Celia (Eds.), 1999. Talk, Work and Institutional Order. Discourse in Medical, Mediation and Management Settings. Mouton de

Gruyter, Berlin. Tholander, Michael, Aronsson, Karin, 2002. Teasing as serious business: collaborative staging and response work. Text 22, 59–595. Wang, Jinjun, 2006. Questions and the exercise of power. Discourse & Society 17, 529–548. Wear, Delese, Aultman, Julie M., Varley, Joseph D., Zarconi, Joseph, 2006. Making fun of patients: medical students’ perceptions and use of derogatory and

cynical humor in clinical settings. Academic Medicine 81, 454–462. Wear, Delese, Aultman, Julie M., Zarconi, Joseph, Varley, Joseph D., 2009. Derogatory and cynical humour directed towards patients: views of residents and

attending doctors. Medical Education 43, 34–41.

Charlotte Rees is professor of education research & director of The centre for Medical Education, College of Medicine, Dentistry & Nursing, University of Dundee, UK. Her research interests include medical students’ professional identity formation, patient involvement in medical education, and student–doctor–patient interaction. She has published widely in a broad range of journals including Social Science & Medicine, and Communication & Medicine.

Lynn Monrouxe is senior lecturer and director of Medical Education Research in the Division of Medical Education at the School of Medicine, Cardiff University, UK. Her current research focuses on professional identity formation, which includes epistemological talk and student–doctor–patient interaction. She has published widely in a broad range of journals including Social Science & Medicine, and Communication & Medicine.