1.Patient makes a procedural appeal to deontic rights and institutional flexibility as a cue for a therapy proposal

After Doctor at line 75 proposes a therapy plan designed from Patient’s narrative account, Patient makes an emergent appeal to institutional flexibility. In other words, Patient’s request for an injection at Line 76 which is opposed to Doctor’s proposal of drugs, given her level of literacy, is a deliberate act, which is consistent with a patient’s right to explore possible options, typically affordable for medical practice, and which Patient seems to be aware of.

The sequence, “Can’t I take injection?” (Line 76) tacitly rejects Doctor’s proposal and seeks his view on her preference, implicating Patient’s desire for a personally convenient recommendation. Doctor’s next interrogative turn at line 77, “You prefer injection (.) why?”, a demonstration of emergent shared sense (Kecskes 2014Kecskes, Istvan 2014 Intercultural Pragmatics. Oxford: Oxford University Press.), gives the impression of a democratic rather than a prescriptive and pontificating style which seems to accommodate Patient’s request and, as a consequence, draw out Patient on her choice of therapy. At Line 79, Patient’s “I don’t – I DON’T LIKE USING DRUGS33. Sef: A polysemous, context-influenced Pidgin English word literally means “even”. sef ” makes her point directly and emphatically. However, she immediately inserts the contribution, “And I used to have ulcer too” (Line 79), which shifts the footing of the conversation to ulcer talk, perhaps as an emergent ploy to appeal to Doctor’s approval of her proposal.

2.Doctor interprets the utterances of patient as indexes of personal goals44.Personal goals are agendas not declared to other participants (see Clark 1996Clark, Herbert 1996 Using Language. Cambridge: Cambridge University Press. )

Between Lines 76 and 79, Doctor interprets Patient’s utterances as indexes of personal goals. The first utterance by Patient: “Can’t I take injection↓”, which presupposes an alternative treatment proposal, is interpreted by Doctor as a venture in deontic disaffiliation: “You prefer injection↓(.) WHY↑” (Line 77). The falling pitch, indicating new information, voices Patient’s strategic request. The rising one with the attendant loudness signifies given information and seeks a justification for Patient’s expression of deontic right. It consequently expresses indirect disaffiliation with Patient’s proposal

Doctor’s response with “Okay↑” (Line 81) to Patient’s second utterance, “I don’t – I DON’T LIKE USING DRUGS sef” (Line 79) (which openly disaffiliates with Doctor’s therapy proposal), followed by his preference for contiguity (see Landmark et al. 2015Landmark, Anne Marie D., Pal Gulbrandsen and Jan Svennevig 2015 “Whose Decision? Negotiating Epistemic and Deontic Rights in Medical Treatment Decisions”. Journal of Pragmatics. 78: 54–69. ), i.e. responding only to the ulcer issue, trivialises Patient’s deontic stance as inconsequential and implicates his preference for the somatic element rather than the patient. The third utterance, “And I used to have ulcer too” (Line 79), is an increment, which makes it an afterthought or an appendage and thus an emergent attention seeker. Doctor’s “Okay↑” (Line 81) interprets the utterance as a doubtful account with Doctor’s strategic repetition at Line 83: “You used to have ulcer”. The response is complemented by Doctor’s sequence “° Okay°. When was the last time you had the [symptom]?” at Line 85 which presents Patient’s utterance as an emergent effort for Doctor to find the true reason for Patient’s dispreference of his recommendation, Patient’s sudden deflection to ulcer talk being suspicious.

3.Both parties co-jointly construct patient’s dispreference of Doctor’s therapy proposal as an index of irresponsibility

Between Lines 89–97, Doctor asks questions which check-list earlier therapy plans with Patient: things such as peppery and hot foods which previous doctors told her to avoid. At Line 98, by Patient’s disaffiliative response, she confirms her non-compliance with the recommendations

Doctor’s sequence terminating “No” at Line 97 is a power-imbued, pre-emptive insertion which seems to sequentially inform Patient’s disaffiliation, but her disagreement-indicative insertion : “… initially but”, in which she seeks to interactively enrich her position, is interrupted by Doctor at Line 99. Although the disaffiliative turn confirms non-compliance and consequently works to co-construct her action as an index of irresponsibility, Doctor’s power-laden, interruptive and subsequent face separation (see Arundale 2010Arundale, Robert 2010 “Constituting Face in Conversation: Face, Facework, and Interactional Achievement”. Journal of Pragmatics, 42, 2078–2105. ; Don and Izadi 2011) sequences suppress her intended lifeworld interventions as shown in 3.3 below. The irresponsibility thesis is sustained in Doctor’s negative and positive face separationist perspectives between Lines 99–101. His sequences at Lines 99–100, which respectively imply that Patient is stubborn and that she flouts medical instructions at will, threaten her negative face. Her positive face is affected by Doctor’s turn at Lines 100 b-101 which implies being disobedient and a hater of self-wellness.

4.Patient sequentially appeals to spiritual healing as a preferred alternative to medical plan

The barrage of threats directed at Patient’s face up to Line 101 causes her to identify religion as the actual motivation for her non-compliance, a point which is not in the parties’ a priori common ground. At Line 105, in a discourse coherent relationship with Doctor’s turn at Line 104, Patient utters ‘faith’, which constitutes a difficult attention processing sequence to Doctor, who, as a consequence, has to initiate an understanding check at Line 105. At Line 106, Patient’s repair with a louder mention of ‘FAITH’ gives clearer force to her expression of religious convenience as a preferred alternative to the therapy plans she had received at previous consultative meetings. This preference is fairly consistent with the practice among some Christian sect members in Nigeria who rely on spiritual healing, also known as ‘faith healing’, as an alternative to biomedical therapies.

1.Face separation in the clash of cultural and institutional interpretations

Between Lines 99 and 123, both Doctor and Patient get engaged in facework which reveals a clash between their cultural and institutional interpretations. Essentially, Doctor steps out of his institutional boundary and takes up a cultural role as a reaction to Patient’s religious production of spiritually-tied healing preference (as shown in Sub-Section 4 above). Doctor’s cultural interpretations manifest as threats which separate from Patient’s face. In reacting to this situation, Patient abandons her earlier cultural (religious) production and opts for institutional interpretations as a way of claiming her discursive rights and recontextualising the clinical encounter to both recover her positive face and achieve her original goal of expressing a preference for an injection.

In more specific terms, the productions of both parties construct criticism, resistance, suppression and compromise which are co-jointly co-constructed as threats by them. Reacting to Patient’s rationale for non-adherence to treatment regimens, (Line 107), Doctor drops his physician role and takes up the Yoruba paternalistic and disciplinarian role. First, he increments Patient’s single-word sequence (“FAITH’ Line 106)): “You ‘re using faith” (Line 107). This, by implication, denigrates Patient’s preference of spiritual healing when considered alongside the subsequent co-text. His next sequence “Faith doesn’t mean you should be stubborn” (same line) is an unmitigated threat which condemns Patient’s preference as unreasonable and impractical. These are followed by a series of judgemental productions (up to Line 110), which criticise Patient’s abandonment of prescribed therapy plans for the embrace of religious convenience as an unintelligent act.

Doctor’s interpretations obviously miscontextualise the encounter as a socio-cultural, rather than an institutional meeting, where insults can be freely hauled at a younger interactant with no consideration for their face orientation. Patient, however, defines the encounter strictly as an institutional one, co-constructing Doctor’s productions as threats, and resists the patriarchal impositions placed by him. Her first attempt at Line 111 which is designed as a direct counter-argument against Doctor’s self-generated, generalising information, ” … the doctor I saw then” is suppressed by Doctor’s interruption in a blatant expression of power, given its high face separation potential (see also de Belder 2012, 112). To further entrench physician power and keep up his paternalistic role, Doctor initiates another face separation sequence with cultural implications at Line 112: “They did not tell you to stop things like Aspirin, Ibuprofen”. The negative statement structure is a reprimand format popular among the Yoruba to accuse a younger or junior co-interactant of a wrong done. While ‘they’ makes an exophoric reference to physicians who earlier prescribed Aspirin and Ibuprofen to Patient, the whole structure sustains the charge of disobedience which Doctor had earlier levelled against Patient. Disorienting to this accusation, Patient at Lines 113–114 negates Doctor’s sequence as an emergent misrepresentation of her medical account. By this sequence, she separates from Doctor’s face with her noisy contribution, which is a clear threat to Doctor’s paternalistic face.

Doctor, having suffered face loss from Patient’s resistance to his paternalistic style, evokes the Yoruba collectivist culture as a redressive action. At Line 115, he abandons his earlier premise and position on Patient’s dispreference by inserting an intonation-based interrogative sequence “Abi” in “And you have been doing that abi?” which is a pragmatic choice rooted in the Yoruba diplomatic culture. In its emergent use, abi, a Yoruba word often found inserted into Nigerian English discourses means: “Is that not so?” In its declarative sense, it is sometimes selected by the older/elder/superior co-interactant to express a personal, unilateral conclusion about an issue, usually following a positive, deceptively affiliative statement as in Line 115.

In the strict Yoruba cultural context, abi is selected pragmatically, as seen in this conversational context, on some occasions, as a power-imbued silencing strategy to save the face of older or superior co-interactants when they are sometimes already suffering guilt in an encounter with a younger folk. When that situation obtains, the younger addressee is expected to keep quiet in admittance of guilt for the moment, but this expectation fails in this interaction for three possible reasons. First, Patient herself has suffered heavy face loss and might not want to incur more as doing so may lead to taking unjustifiable responsibility for her health. Second, the interaction has developed into a sort of altercation, therefore, orienting to such cultural expectations as admittance of an uncommitted wrong, given the conflictual context in which the dyad relate, would not be the best pragmatic option. Third, both interactants seem not to be on the same cultural level. While Doctor orients to the Yoruba cultural concept, which he seems to intentionally mix up with the culture of the West he picked up while in training in the medical school, Patient seems to be largely influenced by the culture of her education, which to some extent, is Western, and, which therefore predisposes her to providing answers to all questions without collectivist cultural sensitivity. At Line 116, Patient’s ‘yes’, which overlaps with Doctor’s “been doing” at Line 115 provides a bold answer to what Doctor had designed as a rhetorical question to gain positive face. This spurs a complete footing change in Doctor’s next turn. At Lines 117–118, Doctor, having failed to receive a face boost (Ruhi 2006Ruhi, Sukriye 2006 “Politeness in Compliment Responses: a Perspective from Naturally Occurring Exchanges in Turkish”. Pragmatics 16(1): 43–101. ) from Patient, abandons logic and accuses Patient of complete non-compliance with all therapy plans. This interactive action by Doctor fails again as he suffers further face loss with Patient’s resistance framed disaffiliatively: “No: not at all” (Line 119).

Doctor, at Line 120, reverts to the earlier sequentially concluded religious proposal made by Patient (Lines 104/106) as an emergent mechanism to tackle his face loss. His action has a root in the Yoruba cultural ideological concept of wrong-free elderhood, expressed in the maxim, àgbà kii jebi (the elder is never wrong). His goal, considered from this cultural perspective, is to ensure Patient admits wrongness, at the least, to be able to reclaim his lost cultural face and assert his professional authority. After Patient has provided a response to his turn at Lines 117–118, which he has designed as a strategic overgeneralisation for the construction of Patient’s religious proposal as a wrong alternative, Patient disaffiliates with his interpretation with the negative response at Line 119. Doctor’s “You said you are using faith” (Line 120), though connects with the concluded issue of faith raised between Lines 103–110, serves here both as a response to Patient’s disaligning response and as a strategic choice to make Patient answerable to a charge for which she is apparently guilty for the restoration of Doctor’s face to save “the elder” from “being wrong” before the younger folk. Doctor achieves his face redressive design by Patient’s “No” at Line 121 which affiliates with Doctor’s position, and which simply jointly co-constructs her preference for religious therapy as a wrong alternative. One of the doctors interviewed considered the cause of the interactive friction in the interaction as the consulting doctor’s non-deployment of key principles of general medical and patient-centred communication which would have enabled Doctor to ask far reaching questions and offer several possible options to Patient, and consequently get most of the grey areas that constituted the friction clarified.

2.Strategic face connection as an institutional pressure

After Doctor has regained his face, he reverts to institutional power from Line 123. At this point, he stays within the scope of his institutional roles and affordances, and strategically connects with Patient’s face apparently to avoid new interactive clashes.

After addressing the face orientation questions on the religious proposal, Doctor reverts to Patient’s personal convenience proposal hitherto abandoned for the ulcer issue. He announces his disapproval of Patient’s proposal of injection. “Ok” (Line 123) is a marker of footing change from negotiation to the full voice of medicine. ”I a::m so:: sorry to inform you…” (Line 123) breaks the bad news (cf Maynard 1996Maynard, Douglas 1996 “On ‘Realisation’ in Everyday Life: the Forecasting of Bad News as a Social Relation”. American Sociological Review. 16 (1): 109–131. ) to Patient in an extremely formal manner, indicating Doctor’s complete disapproval of Patient’s preference for injection at line 76. The production, “…that we cannot give you” (Line 124), represents the voice of medicine, implying that prescribing an injection for the ailment is not affordable for medicine, which is not necessarily so, considering Patient’s clinical antecedent. This notwithstanding, the mitigated manner in which the news has been announced demonstrates a strategic face support, informed by a suppressed ego resulting most probably from Patient’s earlier resistance to Doctor’s heavy face separation acts. However, Patient’s pre-emptive completion of Doctor’s turn with “injection” at Line 124, a context-shaped sequence, is a strategic insertion to subtly point Doctor’s attention to her rights as a patient to suggest her preferred therapy type. Doctor’s quick modification of his recommendation at Lines 125–134 seems a consequence of this strategic insertion, in spite of his paternalistic position earlier displayed in the encounter, and a strategic face connection to Patient’s interactive preference.

1.Patient strategically appeals to religious proposal as a cue of positive face orientation

Prior to checking Patient’s BP, Doctor has made a broad request (Odebunmi 2013Odebunmi, Akin 2013 “Multiple Codes, Multiple Impressions: An Analysis of Doctor-client Encounters in Nigeria”. Multilingua 32 (3): 373–403. ) about Patient’s condition at Lines 7/8. Her response aligns with the no-complaint format commonly adopted by patients in most South-western Nigerian clinics (Odebunmi 2016Odebunmi, Akin 2016 “ ‘You didn’t give me to go and buy’: Negotiating Accountability for Poor Health in Post-recommendation Medical Consultations”. Journal of Pragmatics 93: 1–15. ). At Line 9, Doctor makes a specific request (Odebunmi 2013Odebunmi, Akin 2013 “Multiple Codes, Multiple Impressions: An Analysis of Doctor-client Encounters in Nigeria”. Multilingua 32 (3): 373–403. ) on therapy compliance to which he receives no response. This spurs Doctor’s next generalising turn that charges Patient with possible non-adherence to therapy plans (Line 10). Caught in non-adherence, and knowing, as an elderly patient, the possibility of having to face criticism from the doctor, Patient appeals to religious common ground as a defence, the doctor being an adherent of a cognate Christian religious sect (as confirmed by one of the members of the university community interviewed – a registered patient in the same clinic). First, at Line 11, she opts for ideological inclusivity “Ee ri naa pe”, which is designed to co-opt (Mey 2001Mey, Jacob 2001 Pragmatics: an Introduction. Oxford: Blackwell Publishers.) Doctor into her context to justify her non-compliance. This bid fails initially as Doctor partially disaffiliates with the inclusive agenda due to Patient’s low voice which Doctor could not perceive. His requestive turn at Line 12: “Ki lo sele” which calls Patient’s attention to her unheard utterance prompts her to deploy perceptual salience by which she is able to loudly and emphatically communicate her commitment to a fasting and prayer programme in her church. By this act, she is inviting Doctor’s connection with her ideological evocation, with an expectation of his interactive cooperation, working on their shared culture sense (Kecskes 2014Kecskes, Istvan 2014 Intercultural Pragmatics. Oxford: Oxford University Press.). In other words, she implies that Doctor is expected to understand the significance of fasting declared in a church and the compulsion for compliance against medical recommendations.

2.Doctor constructs Patient’s religious proposal as a positive act

Patient’s expectation of cooperation is met in Doctor’s next turn in which he constructs Patient’s religious proposal as a positive act through the expression of apriori knowledge. His use of a given token “Oka::ay↑=” at Line 14 approves of Patient’s action as she has expected. The elongation of the sequence, completed with a fall-rise tune in the actual rendition, demonstrates Doctor’s slow recognition of the religious event lexicalised in Patient’s turn at Line 13. This is confirmed by Patient in her quick next turn “Uhn” (Line 15), establishing an ideological connection with Doctor. The scenario here is a complete contrast to the event in the DCA case discussed in 3.1 where the religious proposal is treated as an unreasonable option. The acceptability or correctness of the attitudes to this proposal in the clinics is argued and determined in 3.3 below.

3.Doctor and patient co-construct religion-informed non-compliance to doctor’s therapy plan as an inconsequential action

Following Doctor’s inclusive acceptance of Patient’s non-compliance, both parties jointly construct the non-compliance as an inconsequential action. This takes several sequential stages, reflecting different degrees of professional compromises on the part of Doctor. The first is Doctor’s uncritical quick swing into redressive action:

13. Pat: A WA NI FASTING AND PRAYER NI CHURCH=
         We are in fasting and prayer in church
         We are observing a period of fasting and prayer in our church
14. Dr:  Ok:::ay↑=
15. Pat: Unh=
16. Dr:  Okay::↑ Enh, @ E MA LO LAALE E, ABI SE MARATHON IN FASTING YEN
         Yes, you will use in night night, or is it Marathon is fasting that
         Yes, use it every night, or is the fasting absolute?
17.      NI↑= ((enthusiastically)
         It

After Patient has provided a religious explanation for her non-compliance to therapy, Doctor quickly jumps to the next action without any moment of reflection over the implications of Patient’s case as shown between Lines 14 and 16. With Oka::↑, at Line 16, he further confirms his ideological association with Patient and initiates a therapy process. These are followed immediately by the pre-decision sequence “Enh” (Line 16) and laughter on the same line. “Enh”, as a pragmatic particle, works in conjunction with the preceding “okay” to provide the inference, “If that is the case” (i.e. if Patient is fasting). It suggests Doctor’s privileging of religion over medicine, an act worsened by his laughter which trivialises the action.

Next is Doctor’s spirited reconstitution of the therapy plan, carried out without relevant professional interrogations which should guide him on the actual therapeutic procedure Patient has currently designed for herself. This interpretation was confirmed by one of the doctors interviewed who believed that asking questions which query Patient’s intent and modification of the dosage of the BP drugs is the expected standard practice. The re-constitution of the plan occurs first at Line 16 where Doctor hastily announces a new therapy plan of a nocte dosage of the prescribed medicine: “E MA LO LAALE E” . He re-modifies the earlier re-constituted therapy plan (Line 19: Enh::, EN BOYA FOR THIS PERIOD KE SI GET ONI 30 MILLIGRAM YEN=), by recommending a different dosage which is co-constructed as an acceptable act with Patient’s salient turn at Line 20: OKA::Y↓. At Lines 34–35, he reverts, with Patient’s affiliation, to his first reconstitution of the therapy (Line 16) at Patient’s emergent intervention (the provision of information about the duration of the fast – Line 31) expected to have been determined earlier by him.

Acting strictly in line with the principles of PCA, Doctor offers several options to Patient contrary to the style of the doctor in Conversation 1, including his readiness to further negotiate dosage and timing to permit more leverage for religious observance (Line 16). However, as pointed out in 3.3 below, while this is a democratic clinical action, its emergent unprofessionalism is salient. For example, when Doctor seeks to find out at lines 16–17 if the fasting is absolute: “ABI SE MARATHON NI FASTING YEN NI↑= . it is wondering if he would order the complete stoppage of the medication for the period if it is so. While the doctors interviewed agreed that the doctor acted properly by modifying the dosage of the drugs (particularly his offer of 30 milligrams of Nifedipine labelled “retard”) to ensure compliance and respect Patient’s religious beliefs, they contended that doing this in absolute lack of engagement of Patient on her self-decided treatment modifications and actions was an unprofessional act.

Doctor allows quite a number of turns for Patient, but he is insensitive to her contradictory sequences, which constitute further trivialisations of her actions. For example, when Doctor first asked if she has complaints (Line 7), her pat response is none, but at Line 39, she owns up to seeing symptoms of BP while she was on her way to the clinic. Also, Patient’s refusal to provide an answer to Doctor’s question regarding compliance with regimens (Line 9) informs Doctor’s conclusion that she is not adhering to therapy plans. However, at Line 18, she contradicts herself by claiming that she is taking her drugs every night. It is curious that Doctor neither reacts to nor suspects Patient’s seemingly fraudulent action in these contributions.

4.Doctor and patient co-construct religious option as a serious health hazard

The consultative event takes a different turn towards the end of the meeting. After jointly negotiating the religious option as an acceptable act, both parties, jointly re-construct it as a serious health hazard, which negates their collective decision on religious convenience.

In retrospect, Doctor re-constructs religious convenience as a negative alternative by foregrounding its effect on Patient’s health. A telling interactive action taken by Doctor to construct religious convenience in this light is his cancellation of his earlier interactional move which licensed the religious option (Lines 36–39). At Line 36, Doctor’s re-enactment of the dyad’s joint decision on Patient’s religious proposal implicates the compromising sacrifice of medical procedure for religious observance. At Line 37, his turn overlaps with Patient’s, evoking the same object: reverting to the original therapy plan after the exhaustion of the religious option i.e. when the fast ends. However, right from Line 38, Doctor shifts his frame from the democratic, humanistic voice to the voice of medicine. This is consistent with the medical framework in PCA as reported by de Belder (2012), although unexpected in this conversation which is somewhat tainted with religious emotion.

When at Line 38 Doctor says, “E maa loo bee, tori o n reflect lara BP yin bayi tori=”, he evokes medical evidence and simultaneously implicitly drops his license for the religious option. “Ee maa loo be” implicates continuous compliance without disruption. The scope of the compliance by implication includes religious situations which form the risk factor in the current interactive circumstance. Doctor, therefore, by this reference, picks out the health hazard triggered by Patient’s religious decision co-jointly approved by the consultative parties. In the clause, “…tori o n reflect lara BP yin bayi tori” , Doctor links Patient’s religious position with her poor health (high BP) through the adverbial subordinator “tori” in the first use of the word. In this case, he practs (see Mey 2001Mey, Jacob 2001 Pragmatics: an Introduction. Oxford: Blackwell Publishers.) a warning, itself strengthened by his earlier reference to the risk factor and advice on uninterrupted compliance. “Bayi” selected, following the honorific pronoun “yin”, is a temporality marker with a pragmatic implication. While it semantically points to the current consultative session, it strategically signifies the construction of Patient’s self-approved dosage modification as a health-crisis index. This inference is rooted in the Yoruba socio-cultural orientations to “bayi” as a lexical constructor of complications. In this light, the second use of “tori” works alongside the implicatures of “bayi” to serve as a pragmatic disclaimer from Patient’s self-constructed health issues. This turns the whole sequence to a discourse marker of responsibility exoneration in the possible negative prognosis of Patient’s condition.

The shift in Doctor’s role frame and his newly assumed institutional power stirs a change in Patient’s interactive disposition. She takes up responsibility for her health by co-constructing her religious option as a health hazard with Doctor. Contrary to her typical complaint-free position, at line 39, she affiliates with Doctor’s medical opinion on the negative implication of the religious option through the expression of apriori knowledge. “O n reflect, emi gan n ri igba ti mo nbo=” presents Patient’s epistemic stance on her health which she has not expressed until this point in the interaction. In a way, the position implicates Patient’s possible compliance with a stern and strict religious obligation-free therapy plan if Doctor perhaps had proposed it. This confirms that PCA calls for wider medical knowledge (Robert di Sarsina and Iseppato 2010Robert di Sarsina, Paolo and Ilara Iseppato 2010 “Person-centred Medicine: Towards a Definition”. Forschende Komplementärmedizin 17: 277–278. ), which Doctor does not sufficiently demonstrate in this interaction.

Sustaining the voice of medicine which eventually shrinks Patient’s lifeworld voice as from Line 40, Doctor cites medical evidence to support his claim. He announces the BP reading of Patient which he has withheld since the beginning of the consultation: “Tori 156/94 ni mo get bayi…=. The interviewed doctors saw the delay in the announcement of Patient’s BP status as an unprofessional act. For them, that announcement should precede the interchanges on Patient’s current health state and compliance with therapy plans. However, contrary to this standard practice, Doctor announces the BP reading at the tail end of the encounter seemingly as a strategic insertion to press home the effect of Patient’s religion-motivated non-compliance. His deployment of repetition as a pragmatic act of emphasis and warning is equally strategic. “Tori” (Lines 38 and 40) and “o n reflect” (Lines 38, 40 and 41) are repeated in quick succession