Textual passage ➜
Noteworthy properties of the text, such as phonology, grammar, vocabulary, figures of speech, and organization, are enumerated to identify explicit and implicit meanings.
Features of discourse practice identified and interpreted in an interpersonal context.
Textual properties and discourse practice explained in relation to larger sociocultural practice, such as the VA or nephrology care.
I still haven’t been given any instructions, no treatment, or recommendations whatsoever. I am supposed to come back in 2 weeks and they are going to run some more lab tests again. You know basically I’ve been giving blood, five vials of blood, a urine sample every 3 months for the last, I don’t know, 5 or 6 years. And now they still said well no treatment. They said well we’ll know, I’ll see you in 2 weeks. I said now wait a minute, you gonna wait till I die to tell me? But anyway I’m sitting in a state now I have no medication. I haven’t been told to do anything in particular.
Statements about expected and actual patient actions in monitoring appointments are bracketed by statements about provider inaction in same
The Veteran speaker describes ongoing CKD monitoring visits to his nephrologist to fellow Veterans and the moderator/recorder.
Weighing actions of the patient against actions of the provider with the verb “give” conveys an expectation that the patient-provider encounter is an exchange governed by norms of reciprocity, with patient showing up to appointments and giving blood and urine and the providers giving meaningful information in return. Instead, here the exchange is presented as one-sided, with patient giving routinely and waiting for something but receiving nothing in return.
Repeated use of word “still” and phrases “again” and “five or 6 years” emphasize duration of situation
Speaker’s juxtaposition of “I still haven’t been given” with “I’ve been giving” characterizes monitoring as an unequal exchange
Term “whatsoever” after statement about “instructions,” “treatment,” and “recommendations” from provider emphasizes totality of the lack
Addition of provider expectations (“I am supposed to”) suggests perceived double standard (expectations for patient but not for provider)
Phrase “I am supposed to” conveys perceived expectations placed on patient
Patient suggests that he is being strung along with the promise of information in the future
Verb “to give” used to describe both patient action (“I’ve been giving” blood and urine) and provider inaction (“I still haven’t been given”) brings patient and provider into direct comparison
Colloquial shift dramatizes confrontation in which patient rhetorically questions if information will come too late to help him
Provider talk summarized as “well, we’ll know, I’ll see you in 2 weeks” implies delayed but promised delivery of information
Phrase “Now wait a minute” indicates colloquial shift to directly addressing provider: “you gonna wait til I die to tell me?”
End phrase “sitting in a state now” suggests helpless passivity
Affective content is frustration
Linear decline (n=10)
Age, mean (SD)
African-American race, n (%)
Male, n (%)
Income less than $20,000/year, n (%)
Inadequate health literacya, n (%)
Confidenceb, n (%)
Married, n (%)
Social supportc, mean (SD)
Hypertension, n (%)
Diabetes, n (%)
Number of medications, mean (SD)
eGFR, ml/min/1.73 m2
45 – 59
30 – 44
Years of monitoring in renal clinic, median (range)
2.6 (0.7 – 8.3)
2.4 (0.3 – 7.5)
4.5 (0.9 – 12.9)
Negatively viewed communication – Discourse of unequal exchange
The engaged patient waiting for information
They of course checked the creatinine and found out that was 1.7 I think it was and went to see the – I don’t even know how the hell you pronounce it – went to see the kidney doctor and he changed some of the medicines I was on. Never told me anything about why I’ve got this high creatinine. To this day I don’t know, so I kept going back to see him every 6 months for 4 years. Finally he said, you don’t need to come back to see me anymore unless something changes, he said if you were to go to 2.5, I’d be concerned. Well I went up just over 2 a few months ago and that was the first time that I have ever been over 2 that I know of and it has come back down a little since then. I never had any ill effect whatsoever. I have no idea what it is.
…nothing. The last time I was in Renal Clinic, I went in, I sat down with my doctor, I had to go back to the time thing, well I’m like all service men, you’re taught to hurry up and wait, but it still gets on your nerves, I went in and waited for quite some time. ‘Ok, I’ll talk to your primary care doctor’; he didn’t tell me anything else.
The disengaged provider stonewalling
When I go to the nephrologists, you know, they don’t really tell you very much the only thing that they usually do, is they test your, they take blood from you to find out what your creagnine (sic) is. Then they say “keep doing what you’re doing.” I’m at a 2.6, I think, it is a little high, but it is stable, “just keep doing what you’re doing,” And I only have 1 kidney. They, the nephrologists, don’t tell you that much. They have a nurse and they go in there and take your blood. Then they come in and say “things seem to be alright,” but things seem to be about the same. But I have a friend of mine and we were discussing his creagnine (sic), and it was maybe a point lower than me, and they put him on dialysis.
You know a lot of times if you see the doctor they say “Well, keep on doing what you doing, cause you seem to be doing better,” but you know… what is it that I am doing? Tell me something. But you know so you don’t know. Unless you get on the computer and do some research, or you have somebody around who can research things, to tell you well naw you don’t need to have that, you don’t need to have that, you just aren’t told anything.
Participant A: She [primary care physician] started this kidney thing, she sent me because of my numbers moving to the renal doctor because of my numbers and she sent me to the cardiologist because of my heart failure. They put me on a certain medication, I’m on that medication for let’s say 4–5 months, because she doesn’t see me but every 6 months and she will say – she’ll sit there and look at the medication – ‘I see that they put you on so and so, I don’t like that,’ and she takes you off of it. Now how does that make you feel? You’re going to her specialist doctors. He’s taking you through all of the blood tests and puts you on a medication for 6 months, and then she says I don’t like that one and takes you off of it.Participant B: Ping-pong. That’s what it is. It’s ping-pong.Participant A: One of the things in your questionnaire was, do you get frustrated. That shoots your sugar up, shoots your blood pressure up.
Positive communication – Discourse of protection
The veteran protecting his own kidney
The most dangerous thing is blood pressure for kidneys, that’s the most dangerous. If you keep your blood pressure under control that is better for your kidneys...That’s why you got to keep that blood pressure as level as you can.
They said your creatinine has been pretty much stable and we’re just going to keep an eye on it…. They said 50%. I said how much does age contribute to it? And they said it might be something. I have been going to renal for about a year and a half. But ill effects, I really haven’t had any. 5, 6, 7 years, somewhere around there, and I had a physical and creatinine was elevated. So they started sending me to nephrology and I would go to nephrology first every 2 months, then finally every 6 months, the last time I went to VA nephrology, they said to come back in a year. They prohibit me from taking NSAIDs, anti-inflammatories and dietary restrictions. And again, I think it was started by high blood pressure.
The physician protecting the Veteran’s kidney
I trust my primary care physician that he has my best interest at heart, he knows what I’m taking, he’s getting the blood tests, he’s get the urine sample, he should know what I want, if I got a problem...he’s willing to send me to a specialist and find out if I need anything or not.