f staff training in inter-cultural communication, and failure to call on trained interpreters (see Box 2 and Box 3).
In each interaction, it was the staff who controlled the time, place, participants, purpose, structure, topics and language, as well as the form and style of discourse. There were few opportunities for the patients to initiate or influence the agenda. The staff decided whether or not interpreters would be required, even when unaware of the patient's fluency in English.
Western modes of discourse dominated, with Yolngu modes being marginalised or excluded. Question-and-answer routines, central to Western discourse, do not feature commonly in Yolngu discourse, particularly in relation to personal topics. In Yolngu discourse, the question-and-answer approach is complicated by factors such as cultural restrictions on who may ask for, or give, specific information. It is generally considered impolite to directly contradict or to respond negatively, particularly in encounters of unequal power or when the participants lack a close relationship. The patients in our study repeatedly gave responses that they believed the staff wanted to hear, a practice known in linguistics as "gratuitous concurrence".19 Triangulation showed that these responses did not represent the patient's true feelings or experience, but were attempts to give "required" or "correct" responses, as in the following example:
Physician: How much are you drinking? How much water?
Patient: Little bit water tea, little bit ga bilin ["that's it"].
Physician: How much each day? Water, tea?
Patient: Three cup, two cup, little bit [said very confidently].
The physician believed that the patient had a clear understanding of the question and was describing the amount of fluid drunk daily. However, it later became clear that the patient responded this way because she knew what was expected. Her understanding of fluid restriction was that she should drink only two cups of "fizzy drink" per day, but that drinking tea or water whenever she felt like it was acceptable. Questions requiring a "yes"/"no" response were particularly susceptible to gratuitous concurrence. A nurse made the following comment:
The discourse in the interactions focused on renal function, renal failure, monitoring of and adherence to dialysis, and dietary and medication regimens. Non-medical aspects were excluded or marginalised. Yolngu priorities, which emerged in subsequent interviews and informal discussions, were social, cultural and economic, relating primarily to (currently) unavoidable relocation to Darwin if patients wished to access necessary treatment. One patient illustrated her problems with living in Darwin:
I told her [the staff member] the truth . . . that I wasn't getting enough [food]. When I get my allowance, they take all the money for accommodation and leave only $30 for food — that's not enough.
Yolngu priorities, which directly affect clinical management, were rarely raised, and, when raised, were either not pursued or were brushed aside. Patients had no explicit opportunities to discuss their own approaches to managing their health. For example, in two interactions, they attempted to talk about Yolngu knowledge and management practices (related to traditional foods), but their contributions were either not understood or not acknowledged.
Extensive prerequisite knowledge is essential for making sense of information about the management of end-stage renal disease. A shared understanding of kidney and heart function, and of the nature of the circulatory system (including, for example, the components and function of blood), is necessary for meaningful discussion about medication, fluid restriction and dialysis. As shared understanding of many of these concepts does not exist, effective communication is seldom achieved.
The vast cultural and linguistic distance between staff and patients in these interactions impeded communication. Staff use of culturally specific terminology was one difficulty. For instance, quantification was a constant problem. Key biomedical issues we