Teston, C. B. (2009). A grounded investigation of genred guidelines in cancer care deliberations. Written Communication, 26(3), 320-348.

This is an original research article in Written Communication. In it, Teston's goal is to show that the standard of care document is rhetorical. That's way to simplistic but I'm leaving it for now. 

The research is in the context of cancer--oncological deliberations. Deliberation being the key word there. She's interested in how different doctors from different specialization make decisions about patient care. She never uses the word consensus. She also says that the patient is involved and that the standard of care document (SOCD) is a bridge between the patient and the experts (p. 33), kind of like the VIS for P & S. 

That the Standard of Care document is referenced, more often than not, in between references to the patient’s background information and either relevant statistics and studies or typical practice again suggests that the document provides a conceptual bridge for medical professionals—a bridge between the patient’s experi- ences and the expectations of the medical profession as a whole. This is a necessary bridge, since attempting to provide a patient with the best care according only to the expectations of the profession and not the experiences of the patient may not yield favorable results. and the same holds true in the reverse—attempting to care for the patient based only on their signs and symptoms without also consulting the recommendations of the profes- sion at large may also fail to yield favorable results. (33) 

Sounds like she had her hands tied when conducting this research. She couldn't tape deliberations and she couldn't study the documents? Or no, they don't use any documents in the sessions... Maybe she could study the SOCD itself, but could she understand it? She's not a doctor... But anyways, they don't use any documents. They don't take notes. And she can't record the conversations. So what did she do? 

In the first analysis, which was kind of reminiscent of when I was trying to do the pitch deck analysis in the spring of 2020, it looks like she was in the deliberative meetings, and she flagged when the SOCD was discussed, by whom, to what end, and how. She tip toes around the content of the document. But then again, we're looking at meso-level phenomenon...

Her goal in the second analysis is 

to better understand how this document, through linguistic and nonlinguistic rhetorical strategies, does or does not

a. establish authoritative ethos, thereby organizing and authorizing work, and 

b. facilitate decision making based on the experiences not only of the medical professional’s scientific understanding of the disease but also

the patient’s experiences (as evidenced by their signs and symptoms). (334)<---this sounds like the bridge again

But now that I come to think of it, where was the gap? how did she situate herself in the literature? I don't remember that part...

Yea, there is no literature review, so weird... I'm not seeing a literature review or a gap. Maybe because it's 2009 and the rhetoric of health and medicine wasn't even there yet??

Ok, in this second analysis, she actually analyzes a document. There's a lot of different kinds of analysis in here. Textual. Qualitative. Observational.

In this second analysis, she uses Toulmin in order to analyze a CCSC, but she doesn't get into the content at all again but rather spreads out the document on her office walls, with the aim of showing how the document functions rhetorically. She attends to the algorithms embedded in the document, or webpage. I think it's a webpage. So I think she attends to how the arrangement of the CCSC echos the form of Toulmin's argument. 

So there's only two analyses in this. She doesn't have my OCD apparently. 

It looks like this was a purely observational study. There was a personal communication, but it doesn't say anything about interviews. Actually the word interview comes up a few times. There were a few interviews. But I don't think they were systematically collected.

You need to figure out what "freehanding" is. Isn't it just like notes?

And why is this a grounded investigation? what is grounded about it? like what is grounded about the two analyses?

Couldn't be audio OR video recorded. 

It looks like she made a kind of spreadsheet? But I don't know if she went from observational notes TO the spreadsheet... I'm talking about the observational heuristics right now. I'm unsure about whether she took the observational heuristic INTO the field or if she took notes and then those notes became the observational heuristic ... 

Oh... that's where the grounded comes in. She doesn't use a theoretical framework. There is no activity theory. There is no ANT. It's grounded, which is why she has to make her own heuristics. OK. I bet you it's iterative then.  Notes -> heuristics -> using the heuristics in the field. 

Which also explains the lack of literature review. I don't get it though. Wouldn't you still need to situate the argument in the field even if you weren't going to ground your argument with a theoretical framework? 

This was reminding me of Boltanski:

I have made the case that hyperlinks, footnotes, and explicit linguistic features afford conceptual links between medical professionals’ scientific understanding of, or experience with, the patients’ disease and the profes- sion’s expectations as a whole. and yet, with any rhetorical analysis, one has to ask the following: What is not here? The answer to that question in this case is any reference whatsoever—linguistically or nonlinguistically—to the patient’s understanding of or experiences with their disease. In fact, a word search for symptom in the PDF of the CCSC document yields only three results in all 67 screens—all located on one of the later pages in the manuscript section (a section Dr. Thomas acknowledged he never reads). Symptoms and feelings are obviously some of the few ways in which patients can express to their caregivers their experiences with an illness. The fact that the pathways section has as its primary step an assessment of the clinical presentation and not the patient’s signs and symptoms indicates the NCCN’s preference for scientific generalities as opposed to individual experiences. Herein lies the paradox of standards and guidelines: In their attempt at generalization, they run the risk of losing their generalizability.

Teston / grounded Investigation of genred guidelines 345

In other words, there exists a rhetorical tension between the assumptions implicit in generalizable guidelines and actual users’ unique, individual experiences. Beverly Sauer (2003), in her volume The Rhetoric of Risk, similarly seeks to understand how large regulatory industries manage the creation of generalizable policies and procedures amid individual experi- ences and expertise invoked when working in hazardous environments. She asked, “How can we reconcile the radical differences in individual accounts of experiences with the need to create generalizable policies and procedures that can be applied across diverse situations?” (p. 323). The research presented here suggests that the medical profession wrestles with a similar conundrum: How can a genred set of generalized, standardized guidelines bridge the gap between personal experiences and professional expectations? 

This just sounded like grammar in Boltanski, i.e., how is it the case that we can have hierarchy and equality?

When in its generalizable state, the CCSC attempts to streamline and standardize, but when specifically applied [engaged? I'm thinking now of Thevenot...like how the burner doesn't turn on and you have to giggle it], it is adopted and adapted by and for particular audiences and purposes. Schryer (1993) reminded readers that

a genre coordinates work from the simplest action of constructing a shopping list (Witte, 1992) to the complex activity involved in conducting scientific research (Bazerman, 1988). Thus a genre is a frequently traveled path or way of getting symbolic action done either by an individual social actor or group of actors. (p. 207)

This research suggests that even when material action (not just symbolic action) is required, genred, textual guidelines are still only as useful as the audience invoking them and the rhetorical situation deems necessary. Spinuzzi (2003), by engaging in what he called “genre tracing,” asked some similar questions in his investigation of the ways that work is mediated by information technologies. One of his key arguments is that workers find innovative and creative ways to do work within genred systems that can be overly rule bound and systematic. He noted that in some cases genred sys- tems can become “too officialized” or “inflexible and rule-bound” (p. 21). On the other hand, Spinuzzi noted, systems can also become “too unofficial” or “too flexible and chaotic” (p. 21). Spinuzzi argued, however, that most organizations “avoid these extremes” and “maintain a dynamic tension between centripetal and centrifugal impulses” (p. 21). Like Spinuzzi’s (2003) organizations, Tumor Board participants employ “unofficial . . . unarticulated work practices and genres” (p. 23) when making decisions about their patient’s care. In other words, while Standard of Care documents have a charter function, Tumor Board participants implicitly understand

346 Written Communication

their limited applicability and are careful to augment them with additional evidence from specific patient and personal experiences.

The CCSC document as a genred set of guidelines for medical practice cannot, on its own, strike a balance between what Spinuzzi called rule- boundness and flexibility—even with its use of hyperlinks and a Toulminian- like argumentative structure. Users have a choice to follow a linear or nonlinear series of steps, but those steps are based, in large part, upon the profession’s construction of the patient’s disease through a variety of tests, procedures, and results—not the patient’s interpretation, understanding, or sense of their disease. While medical scans, tests, and clinical presentations are certainly necessary information for determining treatment plans and prognoses, so too is the patient’s position on the status of their health and wellbeing. This may be why Dr. Thomas reported that Standard of Care documents are “vague” and not “earth shattering” (L. J. Thomas, MD, per- sonal communication, February 16, 2009). They simply are not prescriptive or patient-specific enough to be anything more than vague.

How, then, is a balance struck between what Spinuzzi (2003) called “rule-boundness” and “chaos” (p. 21) in the care of cancer patients like Lori? The above analyses indicate that during deliberations medical profes- sionals make plain what could not be made plain in the Standard of Care document. That is, medical professionals make explicit, linguistic links between the patient’s experiences, the Standard of Care, and the medical profession’s expectations (evidenced by the illustration of the ways in which references to the Standard of Care document are flanked by refer- ences to the patient’s background information and the overall medical pro- fession in Table 4). On its own, the CCSC document is successful in that it establishes its authority and legitimacy through its scientifically sound, hierarchical, Toulminian-like organizational structure; it accomplishes its charter-like purpose. However, outside the context of Tumor Board delib- erations, the CCSC document simply does not, and perhaps cannot, link the patient’s experiences and understanding of his or her cancer with the pro- fession’s guidelines for how to act. When yoked to patient-specific refer- ences made during multidisciplinary deliberations, Standard of Care documents can function as symbolic guideposts for “frequently traveled paths” (Schryer, 1993, p. 207) on the way toward material action. 

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