CHAPTER 2. LITERATURE REVIEW
2.1 D OCTOR - PATIENT C OMMUNICATION
Medical consultation is one of the institutional talks that is ritualized and can be
studied by its fundamental organization – sequential phases (Helman, 1984). The
consultation is suggested to be composed of six phases: (1) relating to the patient, (2)
discovering the reason for attendance, (3) conducting a verbal and/or physical
examination, (4) considering the patient’s condition, (5) detailing treatment or further
investigation, and (6) termination (Byrne and Long, 1976; Waitzkin, 1991, Heath, 1992).
Ten Have (1989) generates a general ‘ideal sequence’ for the consultation which brings
together the three dimensions of medical consultations: sequential phase, its discourse
genre, and major speech activities. The sequence contains 6 phases: (1) opening, (2)
complaint, (3) examination or test, (4) diagnosis, (5) treatment or advice, and (6)
closing.
The cases of the study in the NTUH ophthalmology department mostly follow the
6 phases. The time period from (1) opening to (3) examination phase is relatively short.
The doctor and the patients spend more time discussing about (4) diagnosis and (5)
medical treatments. Sometimes, when the patient is still being examined (facing an
ocular slit lamp), the doctor gives the diagnosis and they start to discuss about the
causes of the disease or further treatments.
Doctor-patient communication can be regarded as the process of mutual persuasion.
The study of persuasion could be traced back to ancient Greece, where the term
“rhetoric” was used (Brake, 1969; McKeon, 2009). It is the process of adopting a series
of symbols to induce cooperation (Brock, Scott, & Chesebro, 1989). Rhetoric is also
defined as people persuading each other to make free choices (Hunt, 1955), and the
process of persuasion through rhetoric view is conveyed by discourse. One’s utterances
carry the information that would influence the other’s decision. In doctor-patient
communication, the persuasion is mutual. Doctors provide information to influence
patients’ decision-making. At the same time, patients also try to influence doctors’
medical choices for them, because they may want to have certain prescription or
medical treatment. In other words, medical communication is a persuasive process that
both doctors and patients are involved in and take the roles of persuader and persuadee
(Smith and Pettegrew, 1986). The mutual persuasion between doctors and patients
demonstrates the shared and negotiated decision-making.
Though decision-making is negotiated by doctors and patients, doctor-patient
communication is mainly doctor-initiated. During consultation, doctors actively ask
patients’ symptoms and prescribe medications for them. And because of their unequal
medical knowledge, patients could only understand their disease through doctors’
judgment and explanation. Doctors are regarded as the one with authority and power. In
fact, the study of power and domination and effective communication in medical
encounters has been emphasized greatly since the 1960s (Lupton, 1995). The power
doctors have during consultation was regarded as the aid to assist patients to make
better medical choices and gain compliance. Doctors were expected to not only listen to
patients but also to avoid the communicative gaps or obstacles during communication.
But the doctor-patient communication is in fact a process of mutual persuasion; though
with less medical knowledge, patients strive to “equalize the balance of power or gain
and maintain control over aspects of their healthcare” (Beisecker, 1990). When in
patients’ expertise (symptoms, preferences, concerns), they should take responsibility of
their health condition, and be encouraged to ask questions or be able to choose or refuse
different medical treatments. Hence, the patient is “empowered” during consultation
(Lupton, 1995).
2.2 Politeness
Brown and Levinson (1978) proposed a general model of politeness and showed
how discourse is shaped by politeness in different cultures and societies. The idea of
“face” from Goffman (1967) claims that people’s interaction is the cooperation of
maintaining each other’s face. From their point of view, everyday discourse contains
many face-threatening acts (FTAs) like critiques and requests. From Brown and
Levinson’s (1978) definition, the face is separated into (1) negative face: the want to be
unimpeded by others, and (2) positive face: the want to be desirable and close to others.
There are two distinctions of FTAs. The first one distinguishes acts that threaten the
hearer’s negative or positive face. Acts that threaten the hearer’s negative face are those
in which the speaker impedes the hearer’s action, such as: requests, suggestions,
promises (e.g. the speaker commits a future action that benefits the hearer, and the
hearer is under pressure to accept or reject it) and compliments (e.g. the speaker shows
desire in the hearer’s possession, so the hearer might feel like he has to give it to the
speaker), etc. Conversely, acts that threaten the hearer’s positive face are those in which
the speaker disregards the hearer’s wants, like: criticism, complaints, and disagreements.
However, there may also be an overlap in the distinctions of FTAs because some of
them threaten both the negative and the positive face, such as complaints and
interruptions. The second distinction focuses on acts that threaten the speaker’s negative
or positive faces. Because the speaker and the hearer work together to maintain each
other’s faces, the acts in the second distinction may threaten the hearer’s face as well.
Acts which threaten the speaker’s negative face include: expressing thanks (make
humble the speaker’s own face), acceptance of offers (the speaker is indebted and
threatens the hearer’s negative face), and making unwilling promises and offers (the
speaker is against his own will to commit to future actions, and it threatens the hearer’s
positive face if the speaker’s unwillingness is perceived). Other acts that threaten the
speaker’s positive face are: apologies (the speaker regrets doing an FTA), acceptance of
a compliment (the speaker may have to be humble or compliment the hearer in return),
and confession of guilt or responsibility.
In Brown and Levinson’s (1978) model, the possible strategies for doing FTAs are
proposed (See Figure 1). If a speaker goes on record, his action and communicative
intention are clear to the participants. For example, if a speaker says, “I promise to
come tomorrow” and all the participants have the idea that the speaker clearly commits
himself to be here tomorrow, this unambiguous intention is considered as “on-record”.
On the other hand, off record is when the speaker’s communicative act has more than
one intention. An example provided by Brown and Levinson (1987) is “Damn, I’m out
of cash, I forgot to go to the bank today” (Brown & Levinson, 1987:316). The speaker’s
intention is not clear here; He may want to borrow some money from the hearer or is
just plainly stating that he has run out of money. Off-record strategies contain metaphor,
irony, and rhetorical questions, etc. which causes the speaker’s intention to be
ambiguous.
Figure 1. Possible strategies for doing FTAs
When a speaker does a communicative act baldly without redress, it is direct and
unambiguous. For example, a request is bald if the speaker says, “Turn on the light!” In
Brown and Levinson’s (1978) analysis, an FTA done by a speaker without redress is
categorized into one of the following three conditions; the first condition is that both the
speaker and the hearer agree that the need to maintain face can be postponed due to
urgency. The second condition is when the degree of threat to the hearer’s face is very
small and the speaker does not need to sacrifice much, such as “Do sit down.” The final
condition is when the speaker has great power over the hearer, or can get support from
the audience to damage the hearer’s face but not his own.
Brown and Levinson (1978) define actions that “give face” to the hearer as
redressive actions in which an FTA is not intended or wanted. When the speaker
performs a redressive action, the hearer’s face is acknowledged and the speaker will try
to maintain the hearer’s face wants. There are two kinds of redressive actions – positive
redressive action and negative redressive action. A positive redressive action focuses on
the hearer’s positive face, and to a certain degree, the speaker is concerned with the
hearer’s wants. So the speaker may treat the hearer as his friend or an in-group. An FTA
is minimized because the speaker sympathizes with the hearer and tries to appeal to the
hearer’s positive face. On the contrary, negative redressive actions satisfy the hearer’s
negative face or his desire to maintain self-determination. Negative politeness strategies
are applied when the speaker acknowledges and respects the hearer’s negative face and
avoids to impede the hearer’s action.
Brown and Levinson considered the sociological variables which determine the
seriousness of a face-threatening act (FTA). There are three factors: (1) the ‘social
distance’ (D) (familiarity between S and H, a symmetric relation), (2) the relative
‘power (P) of S and H (an asymmetric relation), and (3) the absolute ranking (R) of
impositions in a particular culture (Brown and Levinson, 1978). (Brown and Levinson
even propose a formula for calculating the weightiness of an FTA, using “D,” “P,” and
“R” as variables. However, the weightiness is not our focus so we do not put emphasis
on it.) According to their definition, the seriousness of an FTA contains both risk to a
speaker’s face and risk to a hearer’s face depending on the type of the FTA. For
example, requests and offers tend to threaten both parties’ faces, while apologies
threaten a speaker’s face, and advice and orders typically threaten a hearer’s face. While
Brown and Levinson’s politeness model is not specific for doctor-patient
communication, the model can help provide an explanation for the facework between
doctors and patients under politeness constraints. According to the politeness model,
language is regarded as social practice and the means to negotiate. Though in Brown
and Levinson’s (1978) examples, the utterances they analyzed were collected from
different dialogues that were difficult to present the diversity of certain social
interactions.
Though the politeness model is not specialized for doctor-patient communication,
it provides the possibility to examine their communication under the politeness domain.
In fact, during consultation, doctors would raise questions and come up with
recommendations which may threaten patients’ face. On the other hand, when facing
doctors who have authority and power in an institutional structure, any active acts from
patients could be regarded as face threats (Aronsson and Sätterlund-Larsson, 1987).
During consultation, doctors sometimes raise questions that might threaten patients’
faces or give recommendations with implied criticisms. Aronsson and
Satterlund-Larsson (1987) investigated the dialogue between doctors, adult patients and
their family. They discovered that politeness and clarity may not always be satisfied at
the same time because doctors’ most face-threatening acts were softened by indirectness.
For instance, when a patient needs to get undressed for examination, the doctor might
say, “You could perhaps undress a little and then we’ll examine your thighs…” In this
request, the doctor softens the request through negative politeness by being
conventionally indirect, using hedges, and minimizing the level of imposition. On the
other hand, the request can also be applied through positive strategies like using the
plural form to imply collaboration. These strategies softened the face-threatening degree
of the doctor’s request but may be less clear. So in Aronsson and Satterlund-Larsson’s
study, after the doctor’s request, some of the patients were not certain with regards to
how much clothing they should take off or if they needed to get undressed at all.
2.3 Power
Doctor-patient relationship involves power relationship. Tannen (1987) suggests
that power is always metaphoric when related to interaction and discourse. That is
because there are different kinds of power and people take different roles. Between
doctors and patients, power determines their asymmetrical relationship; doctors take the
dominant role while patient the subordinate, which leads to an imbalanced status
(Tannen, 1994). Thus, under doctor-patient relationships, doctors could exercise power
to inform patients according to their medical knowledge and even persuade them to
accept their advice (Burgoon et al., 1990; Ryn, 1997). According to Kettunen and
Gerlander (2002), from the view of doctor-centered paternalistic, power is shown during
the health care process “by using jargon, dictating the topics, disregarding the patient’s
initiative, interrupting, questioning, and controlling the time” (Fisher and Groce, 1990;
Jarrett and Payne, 1995; Cegala, 1997; Chapple and May, 1997; Binbin, 1999; von
Friederichs-Fitzwater and Gilgun, 2001). However, in interpersonal communication,
power and solidarity at the same time, depending on the context (Tannen, 1994).
From the traditional paternalistic view, patients are regarded as the passive ones to
receive information with few questions or requests. They are not actively involved in
communication, and do not express the need for more information or show and clarify
their confusion (DiMatteo, 1991; Binbin, 1999; Lambert et al., 1997). On the other hand,
according to a study by Ainsworth-Vaughn (1995), though with different power statuses,
doctors and patients use the same power strategies but in different ways. For example,
doctors tend to ask direct questions while patients ask questions in a more indirect or
polite way. Moreover, patients are gentle while asking questions in order not to threaten
doctors’ domain. Thus, their questions would contain short pauses. During consultation,
patients would keep bringing up the questions or problems to continue the topic actively
or propose treatment options by themselves. (Ainsworth-Vaughn, 1995). Thus, power is
performed through individual action and interaction within the sequential organization,
not rooted in the characteristic or role of doctor and patient. During negotiation, doctors
and patients work together to build authority and power.
The medical consultations we collected are examined under the doctor and
patient’s asymmetry power status and different politeness strategies while they strike to
achieve their communicative goals. In Chapter 3, the methodology of conducting the
study is presented.
Chapter 3. Methodology
In this study, the talk exchange between doctor and patient parties in 45 medical
encounters in an ophthalmology clinic in National Taiwan University Hospital (NTUH)
were observed and analyzed. The age of the recruited patients ranged from 45 to 85
years. There were in total 45 patients (16 male, 29 female) and 6 family companions
included in our study. The family members who accompanied the patients were 2 wives,
1 husband, 2 daughters, and 1 son. The study was approved by the Institutional Review
Board (IRB) of National Taiwan University Hospital (NTUH) with the number:
201612117RINB. Our study was conducted according to the rules of IRB and the
participants’ right was fully protected by the researcher. If the patients or their family
companions were under 20 years old, they were excluded from the study because
according to the rules of IRB, they are vulnerable subjects who need extra-protection if
they are included in the study.
Because these patients’ eye conditions were chronic (the process of the disease is
over a period of time, such as cataract, glaucoma, age-related macular degeneration
AMD, etc.) but not urgent in nature, most of the patients visited the ophthalmologist on
a regular basis for three months, six months, to one year or so depending on the
condition of their eyes. Therefore most of the patients and their companions in the study
were well-acquainted with the doctor. Only 4 consultations were first-time visits and
most of them were referred by other specialists from other hospitals. The
ophthalmologist in our study is an expert in the retina-related field. The average number
of patients in each clinic session is around 90. There are many patients who live outside
the metropolitan areas of Taipei and would spend hours traveling just to see this doctor
at the National Taiwan University Hospital. Operating hours are in the morning or in the
afternoon. In the morning, the clinic begins at 9AM and ends around 2PM; in the
afternoon, it begins at 1:30PM and ends around 6PM. The average time for each
consultation is around 4 minutes. The Ophthalmology Department belongs to the
Surgical Department and ophthalmologists can diagnose the disease directly from the
patient’s eyes when their pupils are dilated (unlike interns who can only diagnose from
the patient’s description of symptoms or conduct basic examinations, and are unable to
perform any surgical treatment.)
3.1 Data Collection
In order to have a better view on the doctor-patient communication in Taiwan, the
face-to-face consultation between doctors and patients were investigated. The patients
and their families were invited to participate in this study by 1 doctor in the eye clinic
prior to their consultation. The goal and method of the study were explained by the
doctor. If the patient and their companion agreed to join this study, the entire
consultation would be recorded and later transcribed. The patients’ identities would be
delinked and their identities would not be revealed. The data collected could only be
used for academic purposes.
With regards to the setup of the clinic, patients were asked to sit on a chair near the
doctor for the examination while an ocular slit lamp was on the other chair. Usually,
there were two nurses in the clinic. One would face the table with a computer while
working on patients’ appointments and scheduling upcoming examinations. The other
would stand next to the door to help with the flow of patients going in and out of the
clinic, instructing the patients to sit on the right seats (facing the doctor or in front of the
ocular slit lamp) and give them the prescription sheet.
During the consultations, as a researcher, I sat on the chair farthest from the door
and behind the doctor, observing the entire sessions without interfering. When the
doctor invited the patients and their families to join the study and have them sign the
informed consent, I would start to record the consultation and later transcribe the
conversation.
3.2 Theoretical Background
The data in our study is transcribed and examined qualitatively under concepts of
Discourse Analysis (DA). “The main strength of the DA approach is that it promises to
integrate linguistic findings about intra-sentential organization with discourse structure.”
(Levinson, 1983:287). Discourse analysis is the study of language in context that
develops from linguistic studies and semiotics (Potter & Wetherell, 1987; Edwards &
Potter, 1992; Starks & Brown Trinidad, 2007). It focuses on language-in-use and
examines how participants achieve personal, social, and political communicative goals
through language (Tannen et al., 2015). From the viewpoint of discourse analysis,
language and words are basically meaningless but are a system of signs and meaning
that is generated through the shared and mutually agreed-on use of language (Starks &
Brown Trinidad, 2007). Human beings’ understanding and perception of reality is
constructed by language. In addition, language defines people’s social roles and they
means of our communication, discourse analysis examines how language shape and
reflect cultural, social, and political activities (Crowe, 1998; Gee, 2014).
Health communication provides a chance to study the relation between discourse
and healthcare. “Discourse” here is defined as “‘contextually sensitive written and
spoken language produced as part of the interaction between speakers and hearers and
writers and readers” (Candlin et al., 1999:321). For many linguists, language is
perceived not simply a reflection of relations in social life, but it actively contribute to
the construction and constitution (Kress, 1988; Fairclough, 1992; Candlin et al., 1999).
In healthcare and health communication, language plays a very important role in the
medical settings and discourse is the core of healthcare that reflects the communication
and patient satisfaction (Harvey & Adolphs, 2012).
3.3 Analytical Framework
The purpose of our study is to understand how linguistic strategies are used by the
participants in the decision-making process while saving each other’s faces during the
medical encounters. The linguistics cues are then compared with the politeness model
and show how the communication is negotiated and co-constructed by the participants
in institutional context. Because medical discourse is complex and influenced by the
participants’ social roles, the use of politeness strategies to save the participants’ faces
participants’ social roles, the use of politeness strategies to save the participants’ faces