醫病溝通中之協商：以北台灣之眼科醫師為例

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Graduate Institute of Linguistics College of Liberal Arts

National Taiwan University Master Thesis

醫病溝通中之協商：以北台灣之眼科醫師為例 Politeness in Medical Communication:

A Study Based on an Ophthalmology Clinic in Northern Taiwan

許學旻

Vian Hsueh-Min Hsu

指導教授：蘇以文博士 Advisor: Lily I-Wen Su, Ph.D.

中華民國 106 年 7 月

July 2017

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Acknowledgements

非常感謝我的指導教授，蘇以文教授，願意支持我做這麼具有挑戰的題目，

在醫療現場採集實際醫病溝通的語料並不容易，蘇老師全然的支持是我這個研究最大的動力，蘇老師的鼓勵印證了“Do the right thing even if it's hard.”在研究過程中蘇老師樂於提供各種協助，當我遇到困難時，總是能藉由討論，激盪出更多想法與解決的方式，為我指點迷津，並給予強大的支持與鼓勵，因為有老師的引導，

這個研究才能更加完整的呈現，能有這個研究，蘇老師無疑是最大的推手。

同時，也非常感謝我的口試委員，蔡美慧教授與蔡宜妮教授，他們寶貴的建議對於研究有極大的助益，蔡美慧教授是臺灣從語言學角度研究醫病關係的先驅與巨擘，能有機會請蔡美慧教授提點我的研究真是莫大的榮幸，蔡教授對於研究的建議深入而透澈，當初決定研究的主題便是受到蔡美慧教授研究的啟發，很感謝能有機會對台灣的醫病溝通研究做一些貢獻。蔡宜妮教授曾指導我篇章分析的課程，課堂上精闢的解析與實作為我打下做言談分析深厚的基礎，蔡教授提供的建議對於這個研究的精進貢獻良多、功不可沒，更幫助我解決很多在研究中所遇到的問題。

很感謝語言所老師們的指導，謝舒凱教授、李佳霖教授、呂佳蓉教授、江文瑜教授紮實的訓練培養出我在語言學的專業，多元化的課程使我擁有跨領域的能力。也很感謝師大英語系老師們的專業教學與全方位的訓練，讓我保有熱忱繼續求知，為我打下良好的基石並擁有不同的視野，特別感謝梁孫傑教授、劉宇挺教

授、蘇席瑤教授、詹曉蕙教授、李宜倩教授與Professor Mary A. Goodwin 的啟發與

鼓勵，讓我可以在朝著目標邁進時昂首闊步，擁有智慧與執著的勇氣。

非常感謝臺大醫院眼科部的醫師，在極度繁忙的門診中願意協助研究的進行與收案，使臺灣的醫病溝通現況能以語言學的角度呈現。從研究主題發想開始，

我有機會能與蘇以文教授團隊夥伴相互討論，幫助我建立研究的主軸與方向，感

謝Chester, Hsin-Yen, Val 與 Veasna 的意見及在研究過程中所有的提攜與協助。感

謝摯友Anita, Bill, John, Ying 的各種支持、幫助與陪伴，這個研究才得以順利完成。

也很感謝所有曾經不吝給予幫助、建議、支持、鼓勵、包容與關懷的老師與朋友，

你們是我堅持下去的動力。

最後很謝謝我的家人，一路上無條件的支持、包容與愛，讓我得以追求夢想與心之所向，很感激你們總是相信我、理解我、深愛我，今天能有任何一點小成就都要歸功於我的家人。

謝謝所有在人生旅途中相助相知相惜的人們，讓我成為更好的自己，打從心底愛你們！

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Abstract

This study investigates face-to-face doctor-patient communication and aims to provide a linguistic viewpoint of doctor-patient relationships. It illustrates doctor-patient communication as a negotiated and co-constructed process between the doctor, patients, and patients’ companions. Due to their power asymmetry, the participants use different politeness strategies to achieve their communicative goals. When the patients’

companions are present, the consultation is more complex.

Researches related to doctor-patient communication have increased in the past few decades in the West. Medical education and system in Taiwan have also adapted accordingly. Studies have shown that communication between doctors and patients is influenced by their institutional power asymmetry. From a doctor's point of view, the purpose is to provide the best medical treatment for the patients. On the other hand, patients want to choose their preferred treatments. The doctor and patient parties exchange information and reach their decisions through communication.

In this study, we analyze qualitatively how the doctor, the patients, and their companions co-construct communication during their negotiations. This research is conducted in an eye clinic in a medical center in Northern Taiwan. There are in total 45 patients (16 males and 29 females), and 5 companions (2 wives, 1 husband, 2 daughters, and 1 son) in this study. We explore the data by referring to Brown and Levinson’s (1978) politeness model, specifically bald recommendations, collaborative plural, and hedges under Taiwanese social and cultural factors. During the consultations, when the participants give advice or make requests, they try to protect each other’s positive or negative faces. If the family companions join the consultation, they may raise questions or make requests for the patients. The consultation is different depending on the participants involved.

This research shows how the power asymmetry between the doctor and patients affects the way they use politeness strategies to achieve their communicative goals.

Finally it also allows us to understand the importance of doctor-patient negotiation to create more equal and harmonious doctor-patient relationships in Taiwan.

Keywords: medical discourse, doctor-patient communication, doctor-patient-companion communication, triadic medical communication, politeness

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Chinese Abstract

本研究主要關注於醫病溝通間醫師、病人與陪同者相互協商與共同建構的溝通過程。由於權力的不同導致在看診時，參與者為了達到各自的溝通目的而使用不同的禮貌策略，當有陪同者在現場時，會使問診過程更加複雜。本論文希望藉由臨床上實際醫病溝通的語料，提供一個增進醫病關係的切入點，從語言學觀點探討增進醫病溝通的可能。

醫病溝通相關研究在西方已蓬勃發展數十年，台灣的醫學教育與體系也是承襲西方醫學，然而，醫病問診中因為醫師與病人地位不平等或是權力的拉鋸，是影響醫病溝通的因素。在醫師的角度，希望能給予病患最好的治療，並增加病人遵醫囑的接受度，對於患者而言，他們想要選擇偏好的治療，或是對於病況有疑問能得到解答，雙方透過溝通來達到交換資訊與達到共同決策的目的。

本研究採用質化的方式分析語料，藉由醫病與陪同者間一步步共同構築而成的協商來探究參與者實際的溝通目的，本研究在北部一間醫學中心的眼科門診執

行，總共有45 位患者參與本研究，16 位男性，29 位女性，陪同者共有 5 位，2 位

妻子、1 位先生、2 位女兒與 1 位兒子。在台灣的社會與文化背景中，從 Brown 及 Levinson (1978)的禮貌模型出發，著重在三個禮貌策略：直接提出要求、使用第一人稱複數來涵蓋所有參與者、避免正面回答，因為在問診過程中，參與者在給予意見與提出要求時，會為了要保護對方或自己的正反面子而會有所調整。若陪同者加入，他們會替病人問問題或是提出要求，整個問診過程會因為角色與溝通目的的不同而有所改變及調整。

本研究的目標是希望能呈現醫師與病人因為權力不平等，進而影響他們為了達到溝通目的時所使用的不同禮貌策略，透過實際語料的分析，加上台灣特殊的文化背景，提供醫療服務人員與患者一個不同的視角，從語言學的角度剖析醫病協商的現況與重要性，以期在未來達到更平等更和諧的醫病溝通與醫病關係。

關鍵字：醫病言談、醫病溝通、醫師病人陪同者溝通、醫病三方溝通、禮貌

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List of Figures

Figure 1. Possible strategies for doing FTAs ………16

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Transcription Conventions

[ ] Beginning and ending of overlap in speakers’ utterances

? Upward intonation

CAPITALS Relatively high amplitude (in Mandarin transcription: bold)

/ / Encloses description of how talk is delivered

_____ Code-switching (e.g. Taiwanese)

= Latching

.. Short pause

… Long pause

[…] Text omission

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Chapter 1. Introduction

This study examines doctor-patient communication as a negotiated and

co-constructed process between health providers, patients, and patients’ family

members. Studies from Western countries have revealed that an open communication

can improve the quality of health care, the patients’ compliance, and both the doctors’

and patients’ mental health (Ong et al., 1995; Maguire and Pitceathly, 2002). It also

allows patients to express their concerns and medical preferences (Charles et al., 1999;

Makoul and Clayman, 2006). Many doctors in Southeast Asia receive their medical

education through a Western system (Claramita et al., 2011), following the curriculum

of Western medicine schools. Studies have shown that in Southeast Asian settings both

doctors and patients favor the egalitarian communication style (Haviland et al., 2005).

When under a specific clinical context, doctor-patient communication is influenced

by the power asymmetry between the participants. Because of the asymmetry between

doctors and patients, patients tend to respect doctors and not challenge their authority in

order to maintain harmony during medical consultation. Their communication is

examined as a tool for rapport and solidarity (Kuipers, 1989; Tannen, 1990).

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In Medical communication, some topics are commonly addressed:(1) different

purposes of medical communication; (2) analysis of doctor-patient communication; (3)

specific communicative behaviors; (4) the influence of communicative behaviors on

patient outcomes; and (5) concluding remarks (Ong, 1995). Most studies focus on

doctor-patient relationships only. However, patient’s companion (e.g. spouses, family

members, friends) as a third party influence the doctor-patient relationship (Keady and

Nolan, 2003; Ishikawa et al., 2005; Karnieli-Miller et al., 2012). Besides, the different

visits, companion roles, and the companion involvement are the factors to change the

dynamic of the consultations. The companion may limit the patient’s involvement or

even exclude the patient from the decision-making (Coe and Prendergast, 1985;

Beisecker , 1989; Greene et al., 1994) or can benefit the doctor-patient communication

and increase patient’s comprehension and involvement compared with the

unaccompanied patients (Clayman, 2005; Labrecque et al., 1991; Prohaska and Glasser,

1996; Schilling et al., 2002).

The growing studies examine the involvement of patient’s family companions to

the medical consultations (Wolff and Roter, 2011; Laidsaar-Powell et al., 2013; Wolff

et al., 2017). But the focuses are mostly on the specific doctor-patient-companion

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communication on the elderly or cognitively impaired patients (Smith and Beattie, 2001;

Werner and Kitai, 2004; Zaleta and Carpenter, 2010; Sakai and Carpenter, 2011;

Karnieli-Miller et al., 2012), or on doctor-parent-child communication (Tannen and

Wallat, 1983; Aronsson and Rundström, 1988; Van Dulmen, 1998; Tates and

Meeuwesen, 2001). In the United States, over one-third of elderly patients have a

companion when seeing the doctors (Wolff and Roter, 2008). In Taiwan, there are

already some researches related to the triadic doctor-patient-companion communication.

For example, the companion’s participation can influence the patient parties’

information providing sequences (Tsai, 2007b). And the opening stage in medical

encounters in Taiwan is very different from the western style because of the time limits

and replaced by situational greeting instead (Tsai, 2005). Another study focuses on the

verbal and nonverbal triadic interaction in Taiwan, the spatial arrangement of patient

companions in geriatric triadic medical consultations can reflect the patient’s role in the

medical consultations and the relationships with their family companions (Tsai, 2007a).

The present framework for analyzing the third party’s participant may not be suitable

for Mandarin and Southern Min, Tsai (2003) identifies the problems when identifying

the participant structure in medical triadic consultations in Taiwan and provides some

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solutions when examining the companion’s participation.

Tsai (2000) proposed a systematic framework to analyze the companion’s

participation. One of the results shows that the companion’s interruption does influence

the communication between the doctor and the patient. Even though most of the patients

are the main information providers, it is hard for them to complete their responses when

both the patient and the companion are talking.

Instead of studying the patterns, participants’ involvement, or patient’s satisfaction

in medical discourse, we try to analyze medical communication in a different domain,

the idea of politeness. Previous study applies politeness strategies to doctor-patient

communication to study the collaborative thinking of the doctor and patients (Aronsson

& Sätterlund-Larsson, 1987). The other study focuses on the politeness and coherence

in pediatric discourse to see how discourse is continuous negotiated between

participants (Aronsson & Rundström, 1989). The politeness model proposed by Brown

and Levinson’s (1978) is universal and with examples from different societies and

cultures. But when under the specific cultural and social context, will participant’s

politeness strategies be affected? Especially when the participants in medical context

are with great power asymmetry, their communication is more complex because of the

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social factors. Thus, we conduct our study in one medical center to understand the

communication the discourse between doctor, patient, and patient’s family companion

in order to understand the politeness strategies they used when making requests or

demand or showing medical preferences in the medical decision-making. Three

politeness strategies are mainly discussed in our study: (1) bald recommendations, (2)

collaborative plural, and (3) hedges. The process of how communication between doctor

and patient parties is negotiated and co-constructed is studied under politeness within

the social and cultural background in Taiwan.

1.1 Motivation

A growing interest in doctor-patient communication has arisen during the past few

decades. Many studies have investigated the communication of medical consultations.

However, the results from those studies have not yet shown the whole picture of

medical communication, probably due to the fact that among interpersonal relationships,

doctor-patient relationship is one of the most complicated ones. The interaction between

doctors and patients involves various power status, and is usually related to vital or

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health issues, influenced by emotions and needed cooperation and negotiation (Ong,

1995; Chaitchik, 1992).

The doctor-patient relationship can be categorized into four models: (1) informative

model; (2) interpretive model; (3) deliberative model, and (4) paternalistic model

(Emanuel and Emanuel, 1992). Among these four models, the paternalistic model, also

known as parental or priestly model, is the most prominent one. (Emanuel and Emanuel,

1992; Levine et al., 1992; Beisecker and Beisecker, 1993; Deber, 1994; Coulter, 1997).

The paternalistic model assumes that patients could receive the best medical advice and

treatment decision from doctors to improve their health. This model is based on the

assumption that both doctors and patients have mutual objective criteria for defining the

best outcome. However, the fact is that most patients lack equal medical knowledge to

discuss their health problems with doctors under medical circumstances. (Waitzkin and

Waterman, 1974; Fisher and Groce, 1985).

According to Waitzkin and Waterman (1974), and Henley and Henley (1977),

doctor-patient interactions are social and micro political. Interactions are shaped and

constrained in cultural, structural and institutional features. Furthermore, the two parties

are not equal partners during their interaction since doctors have more medical

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knowledge while patients usually do not. During the consultation, doctors are regarded

as the gatekeepers to control the process. This asymmetry leads doctors to take superior

roles while patients are perceived as subordinates.

Due to the disadvantages of the paternalistic model, that is the unequal status

between doctors and patients, patient-centered communication has been emphasized

greatly for decades. Patient-centered communication provides an environment for

patients to fully express their symptoms, feelings, concerns, and expectations during

consultation (Henbest and Stewart, 1989; Smith and Hoppe, 1991; Roter et al., 1988).

The main idea of the patient-centered method is “to follow patient’s leads, to understand

patient’s experiences from their point of view” (Weston et al, 1989), allowing the

doctor-patient relationship to become more equal and egalitarian. In addition, their

relationship would be empathic. This means that doctors would elicit patients’ feelings

and respond accordingly, remain silent to show support, listen carefully and try to

understand what they are unable to express, and provide support orally as well as

nonverbally (Lovett and Abou-Saleh, 1990; DiMatteo et al., 1980). In fact,

patient-centered communication is shown to have improved patients’ health (both

physically and mentally) and have increased the efficacy of health care and compliance

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(Oates et al., 2000; Stewart, 2001; Epstein et al, 2005). The health care providers

nowadays try to follow the principles of patient-centered care in order to create a better

relationship with patients.

1.2 Research Questions

Previous studies in medical discourse mainly examine through turn-allocation

constraints to analyze doctors’ and patients’ participation (talking frequently or raising

questions) or through conversational constraints to study institutional authority. The

present study aims to examine the communication in medical consultations through

politeness constraints. In order to understand how communication is negotiated and

co-constructed under the asymmetry between doctors and patients in an institutional

authority structure, the research questions are:

1. What linguistic strategies are used in the negotiation of doctor-patient medical

decision-making to save each other’s faces?

2. In the triadic medical consultations, what linguistic strategies do the three parties

apply in medical decision-making process while saving each other’s faces?

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1.3 Organization of the Thesis

The rest of the paper is structured as follows: Chapter 2 provides a quick review of

the related studies and basic ideas of medical communication, politeness, and power.

Chapter 3 contains the methodology used in this study, how the data is collected and

transcribed, the theoretical background and the analytical framework. In Chapter 4,

there are data and analyses of the politeness strategies used between two parties and

three parties during the medical consultation. The idea of politeness drawn from

Brown and Levinson’s (1987) politeness model. The main focuses are three politeness

strategies: (1) bald recommendations, (2) collaborative plural, and (3) hedges. Some of

the politeness strategies used by the participants are also discussed in the excerpts of the

consultations. Finally, Chapter 5 summarizes the major findings in the study and

provides suggestions for future studies.

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Chapter 2. Literature Review

The study of language and doctor-patient relationship has drawn wide attention and

interests from cross-disciplinary researchers. Medical discourse provides insightful data

for us to understand the role of language in doctor-patient communication. It offers

first-hand data for analyzing the functional meaning of the utterances in medical

encounters since language is regarded as the vehicle of meaning. Medical encounters

are ideal for understanding institutional talk by investigating the imbalance of power

between doctors and patients and the outcome of their talk. In this chapter, we will

discuss previous studies related to sequential phases of medical consultation, medical

decision-making (mutual persuasion process), the power asymmetry between doctors

and patients, and how medical discourse is shaped by politeness.

2.1 Doctor-patient Communication

Medical consultation is one of the institutional talks that is ritualized and can be

studied by its fundamental organization – sequential phases (Helman, 1984). The

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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

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“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

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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

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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.

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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

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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

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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

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‘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.

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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

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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,

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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

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achieve their communicative goals. In Chapter 3, the methodology of conducting the

study is presented.

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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

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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

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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

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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

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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

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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

is marked. The cases of this study contain medical discourse between two parties

(doctor and patient) and three parties (doctor, patient, and companion).

First, we go through the transcription and pay attention to the decision-making

process between the doctor and patients. The linguistic strategies corresponding to the

distinction of Brown and Levinson’s (1978) politeness model are marked. Later, we

select three politeness strategies that used by the participants in both two parties and

three parties communication: (1) bald recommendations, (2) collaborative plural, and (3)

hedges. The three strategies are the main focuses of the analysis but because the

communication is dynamic, the excerpts are studied sequentially. The context of the

discourse plays a very important role in medical encounters. Though Brown and

Levinson (1978) proposed clear divisions of politeness strategies, the real application of

politeness by the participants in our study is influenced by specific social and cultural

factors. Some more detailed analysis of the three strategies is in Chapter 4.

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3.4 Data Transcription

The dialogues between doctor, patients, and companions were tape-recorded and

transcribed in extenso. We listened to the conversation for each consultation and

checked the transcript many times to make sure the transcription can reveal the details

of the verbal communication between the participants. We focus on the politeness

strategies that the doctor and patient party use during the medical consultations and

draw the concepts from Discourse Analysis. The transcription contains the features

related to the possible politeness strategies appear in their consultations, so the

speaker’s emphasis, overlaps, and code-switching are marked but not other minor

linguistic features. (The transcription convention is in page iv.)¹ In the transcription, the

participants’ names or addresses are fictionalized to protect their anonymity.

1[ ] Beginning and ending of overlap in speakers’ utterances

? Upward intonation

CAPITALS Relatively high amplitude (in Mandarin transcription: bold)

/ / Encloses description of how talk is delivered

_____ Code-switching (e.g. Taiwanese)

= Latching

.. Short pause

… Long pause

[…] Text omission

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Chapter 4. Politeness Strategies in Medical Communication

This chapter presents the data and analyses of the politeness strategies used by two

role combinations during the medical consultations – two parties (doctor and patients)

and three parties (doctor, patient, and companion). The linguistic strategies they use

may threaten or save the hearer or the speaker’s faces depending on their

communicative goals. Most of the studies related to medical communication only focus

on two parties. When three parties are involved, the medical encounters are much more

complex and difficult to analyze not only because the dialogue is more complicated but

because the participants are constrained and influenced by others’ social power and

status. We select three politeness strategies that appear in both the consultations of two

parties and three parties in their medical decision-making to see how linguistic

strategies are applied when they seek to achieve their communicative goals while saving

each other’s faces. The results support that doctor-patient communication is a complex

process that is negotiated and co-constructed by the participants while they are under

power asymmetry in an institutional authority structure.

Nowadays, medical decision-making is often negotiated by both doctors and

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negotiation is a process of mutual persuasion. In medical consultations, doctors give

recommendations and advices while patients make requests or express their preferences

for medical treatments. These communicative acts are regarded as face-threatening acts

in medical communication. Examples in this chapter are excerpts from the dialogues

between doctor, patients, and family companions to demonstrate how the two parties

and three parties save each other’s faces while achieving their respective

communicative goals with a power imbalance.

4.1 Strategies in Dyadic Interaction

In Brown and Levinson’s (1978) politeness model, the possible strategies for

performing FTAs are categorized and explained. When the speaker is performing an

on-record FTA with positive politeness strategies, he tries to maintain the hearer’s

positive face and considers himself to be in the same group with the hearer and thus the

face-threatening degree decreases. Some positive politeness strategies are: seeking

agreement, avoiding disagreement, and giving reasons, etc. In addition, if the speaker

includes both the hearer and himself in the activity equally, it is a positive politeness

strategy. For example, the requests may contain in-group identity markers, such as “we”

or “Let’s do something together.” On the other hand, when performing on-record FTAs

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with negative politeness, the speaker shows respect or deference to the hearer and

maintains the hearer’s negative face by caring about his need to be unimpeded. Some

possible negative politeness strategies are: using questions or hedges, apologizing,

avoiding using pronouns, etc. In our study, we focus on three particular strategies used

in dyadic and triadic communication: bald recommendations, collaborative plural, and

hedges. These strategies are mainly used when the doctor and patients are discussing

about the diagnosis and medical treatments. The doctor provides medical advice while

the patients request their preferred treatment and asks questions. Taking into account the

circumstances during medical consultation, such as building rapport under limited time

and the asymmetry of power and medical authority, the politeness strategies applied by

the participants is able to reveal the interest of medical communication.

4.1.1 Bald Recommendations

The bald on-record strategy is most direct and unambiguous politeness strategy;

for example, the demand “Wash your hands” is a bald act (Brown & Levinson, 1978). A

bald act can be done when the speaker is not afraid of the hearer, the speaker has greater

power over the hearer, or when their social distance is close. These conditions are also

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seen in the medical consultations.

In our study, the doctor has good communication skills and can usually create and

maintain a harmonious atmosphere in the clinic. Most of the patients visit on a regular

basis so to some degree they are familiar with the doctor. When the doctor gives

medical advice or requests, he usually tries to maintain the patient’s positive or negative

face. However, there are circumstances when the doctor or patients perform an act

baldly and without redress.

In Excerpt 1a, the doctor was surprised when he realized that the patient had the

nutrition supplements that were not scientifically tested. Therefore, he gave the

recommendation that the patient stop taking the supplements and spending money on

them.

Excerpt 1a

The doctor examines the test results on the screen.

1 DOC: 還是有一點點水誒還是有一點點水

There is still some fluid inside the retina…. There is still some fluid inside your eye.

2 PAT: 又又有水了.. 右右眼？

There is still some fluid a..again… In the right right eye?

3 DOC: 恩..

Mmm..

4 PAT: 右邊有水

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5 DOC: 對..

Yes..

6 PAT: 嗯.. 又有水我之前吃那個幹細胞

Mmm.. there is fluid [in my eye] again. I had stem cells.

7 DOC: 你吃幹細胞？

YOU HAD STEM CELLS?

8 PAT: 恩我吃人人家介紹的

Yes. I did. Someone recommended them.

9 DOC: 阿呀不要浪費那個錢啦

Come on! Don’t waste your money on that!

10 PAT: 那個什麼胎盤鹿胎盤

That so-called placenta, deer placenta.

11 DOC: 你絕對不要去亂吃 haa 拜託 haa

You should definitely not take any unproven remedies. Please!

12 PAT: 他說可以修復什麼

It is said that it can repair the…

13 DOC: 我絕對不相信那些不要浪費錢

I absolutely do not believe in them at all. Don’t waste your money.

14 吃了一大堆雜七雜八的東西在身體好看正前方

Having those things in your body [may not be good]. OK. Look at the front.

Examination

In this excerpt, we see that there was some fluid in the patient’s right eye and the

problem could not be solved by the medicine or the eye drops. Usually such a problem

wouldn’t be solved until the eye starts absorbing the fluid by itself. The absorption

process might take weeks, months, or even years. The patient visits the doctor regularly

every four or six months and in this particular visit the doctor told him that there was

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still some fluid in his right eye. The patient told the doctor that he had been taking stem

cells (Line 6). Hearing that the patient had stem cells which were not scientifically

tested, the doctor was very surprised and raised his voice in Line 7. The patient admitted

and said the practice was recommended by someone else. Starting from Line 9, the

doctor tried to persuade the patient not to take stem cells extracted from deer placenta.

Instead of using other politeness strategies in his recommendation, the doctor gave the

advice baldly to show his disproval. For instance, the doctor said “阿呀不要浪費那個

錢啦Come on! Don’t waste your money on that!” (Line 9) directly to show how much

he disagreed with the patient. This clear and unambiguous request that the patient was

just wasting money on buying unverified supplements was a bald act that threatened the

patient’s face. Usually, the doctor would try to save patient’s faces when he was giving

recommendations so the form of his request was rarely imperative. This time, however,

the doctor was really surprised and he hoped the patient could undergo proper

treatments.

As discussed here, the doctor took a clear stance that he disagreed with the

supplements whose medical effects were without scientific evidence. In Line 11, the

doctor even used “絕對 must not” and “拜託 Please!” to keep the patient from taking the

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supplements. “拜託 Please!” in the request form is not commonly used by the doctor in

medical consultation. Sometimes, when one party used “Please!” as a request for the

other party, usually it is from the one with less power or between intimates. In this

example, “Please!” from the doctor was similar in tone to “Please do me a favor! Don’t

take those supplements which may not be good for your health!” The doctor treated his

conversation partner not only as a patient but like a friend. The use of “阿呀 Come on”

and “拜託 Please” shows the doctor and the patient have close social distance. And the

doctor can frankly express his genuine opinions. Otherwise, the doctor could just say

“Oh, if I were you I would think twice before I took stem cells.” Or “I do not consider

taking stem cells good for your eyes.”

However, the patient was not convinced by the doctor and he believed that the

supplements may have special curing effects. In Line 12, the patient tried to persuade

the doctor that the supplements were said to have curing effects, like repairing the cells

or the human body. The doctor immediately replied “我絕對不相信那些不要浪費錢 I

absolutely do not believe in them at all. Don’t waste your money.” (Line 13) The doctor

strongly disagreed with the patient taking stem cells by using negation (don’t) and

intensifier (at all) and repeating “don’t waste the money” one more time. (The first time

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the doctor told the patient not to waste money on the supplements is in Line 9.) Because

the stem cell extracts were not the supplements on prescription and not covered by

health insurance, the doctor kept saying “don’t waste the money” and that he personally

didn’t believe in the curing effect of the stem cells extracts. The idea of not wasting the

money is something beneficial to the patient. And the doctor did not want the patient to

waste his money on the extracts showing that the doctor cared for the patient.

In fact, during the consultation, the doctor’s recommendations were rarely bald

according to the politeness model. In most cases, the doctor tried to maintain the

patient’s faces when giving advice or making requests. This example of bald

recommendation here and the use of “阿呀 Come on” and “拜託 Please” showed the

intimacy between the doctor and the patient. Only when the doctor and the patient were

close enough, would their consultation contain these expressions. However, even

though the doctor showed his strong disapproval of the extraction, the patient still

seemed to believe in its curing effect near the end of their consultation.

Excerpt 1b

1 PAT: 沒有那這邊要開眼藥水嗎藥還沒用完

No. Then will [you] prescribe eye drops? There are still some left.

2 DOC: 好吧那我看多久再幫你追蹤半年再看好了厚

Alright. Then I’ll see when your next appointment should be. Let’s meet

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3 PAT: 好 OK.

4 DOC: 厚半年讓自己放輕鬆來生活正常不要熬夜厚

OK. Half a year. Relax yourself. Have a regular lifestyle. Don’t stay up late. OK.

5 PAT: 鹿胎盤他說什麼可以吃修復身體

About the deer placenta. They said that it can repair the body.

6 DOC: 我從來都不相信這些你就能吃能睡頂多就吃一些什麼什麼葉黃素這樣

I never believe in those kinds of things at all. You just eat well and sleep well. Or at most try something like lutein.

7 PAT: 他說可以修復身體一下

They said I could try to repair my body.

8 DOC: 嘻嘻嘻

Hehehe /laughing/

9 PAT: 癌症都可以修復

That even cancer can be cured.

10 DOC: 世界上有這種藥的話那就就天下太平了不用不用有這些醫生了厚

If such kind of medicine exists, everything will be fine and all at peace.

No need to go to the doctors. Ok.

11 好那就半年再追蹤好不好厚好自己那個厚=

Alright. Then the follow-up will be in half a year. Is that ok? Ok. Ok you take care ok=

12 PAT: =半年 =half a year

13 DOC: 對可以嗎？還是還是要四個月？

Yes. Ok? Or or four months?

14 PAT: 好半年可以

Ok half a year is fine.

15 DOC: 好半年 Ok half a year.

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In Line 4, after the doctor and the patient agreed for next follow-up, the doctor

gave the advice about having a regular lifestyle. But the patient mentioned the deer

placenta extract again and insisted that it can repair the body (Line 5). The doctor

restated his disagreement to oppose the patient directly in Line 6. (In excerpt 1a, the

doctor said “我絕對不相信那些不要浪費錢 I absolutely do not believe in them at all.

Don’t waste your money.”) Here, he asserted that as a doctor he didn’t believe in the

curing effects of the placenta extract and emphasized by “從來 never”, which implied

that the patient should not believe in it either. In addition, the doctor gave some advice

about living a regular lifestyle. The doctor believed that the nutrition supplement that

the patient could take was lutein, which is already proven scientifically to improve

vision and eye health. But the patient was not convinced; besides Line 5, he mentioned

in Line 7 and 9 that the stem cells extracts can repair cells and even cure those with

cancer. The doctor found that the patient was not convinced due to his lack of medical

knowledge and couldn’t help but laugh (Line 8). However, instead of criticizing the

patient directly and threatening his positive face, the doctor replied indirectly and wisely

by saying “世界上有這種藥的話那就就天下太平了不用不用有這些醫生了厚

If such kind of medicine exists, everything will be fine and all at peace. No need to go

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to the doctors. Ok.” (Line 9). The doctor was trying to tell the patient that there was no

such miracle elixir otherwise there would be no need for doctors. If that kind of

medicine really existed, people would only need to take the miracle elixir to cure all

diseases, since the patient claimed that even cancer could be cured by the extract. The

doctor used “厚 Ok” at the end of the sentence to seek the patient’s consent to end the

conversation. Without waiting for the patient’s response, the doctor shifted the topic

back to the follow-up appointment discussed earlier in Line 2 and 3. What is interesting

here is that when the patient repeated “半年 half a year” after the doctor in Line 12, the

doctor asked a yes/no question “可以嗎？Ok?” to seek for the patient’s agreement and

even provided an option. Usually, the follow-up is decided by the doctor because only

he knew the condition of the patient’s eyes and when the patient needed to come back

for the next examination. Most of the patients would simply agree or mention the date

which they would be available. But here the doctor provided the options of the next

follow-up for either 4 or 6 months later for the patient to make the final decision. In

Line 14, the patient made his choice and replied that half a year is fine. At the end, the

doctor confirmed by saying “yes” by repeating “half a year”.

The doctor involved the patient in the decision-making by using positive politeness

醫病溝通中之協商：以北台灣之眼科醫師為例

National Taiwan University Master Thesis