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Discourse in Medical Settings Hauptseminar: Talk at Work Dozent: Prof. Dr. Jürgen Beneke Referentinnen: Anna Dopatka & Antje Göldner. Introduction. “Disease may be a medical entity, but illness is a social phenomenon.” (Suchman, 1970). Part I: Doctor - Patient.
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Discourse in Medical SettingsHauptseminar: Talk at WorkDozent: Prof. Dr. Jürgen BenekeReferentinnen: Anna Dopatka & Antje Göldner
Introduction “Disease may be a medical entity, but illness is a social phenomenon.” (Suchman, 1970)
1.1 Social skills and social competence • doctor‘s work consists of dealing with people • as important as technical knowledge and skills are the social skills → understanding of the components of the social skills is necessary in order to anticipate and understand the possible sources of success and failure
how to measure the success of a doctor? → The average level of health of his patients? → The recovery rate of his patients? → Judging by professional colleagues? • what are the goals of a doctor?
Doctor’s social skills: • practitioner must be able to communicate, to persuade and to generally deal with the patients • social skills have to vary with the situation and the patient → different age, sex, class and personality have to be handled differently
1.2 Verbal and non-verbal communication: • Kinds of verbal utterance for a doctor: • information • talk in the doctor’s round or consultation • patient’s medical history • talk with relatives • psychiatric / psychotherapeutic talk • ...... → all have different goals and priorities
Problems in a verbal communication (doctor- patient): • technical language of medicine →dacryocystorhinostomy “surgical fistulization of the lacrimal sac for external drainage of an obstructed nasolacrimal duct” • patient’s lack of knowledge
Non- verbal signal accompanying speech: • three main roles: • completing and elaborating on verbal utterance • managing synchronising • sending feedback signals → the role of reinforcement → the role of gaze
Main attitudes towards others who are present fall along two dimensions: superior/ dominant like/ warm dislike/ cold inferior/ submissive
1.3 Sequences of social interaction • two- step sequences: → joke- laugh, complain- sympathise, request- comply or refuse → failure to make a pro- active move can stop a conversation: A: Where do you come from? B: Swindon.
four- step sequences: A (2) A (1) B (1) B (2) A: asks question B: gives inadequate answer or does not answer A: clarifies or repeats question B: gives adequate answer
episode sequence → six distinct phases of patients consultation (Byrne and Long, 1976) 1. relating to the patient 2. discussing the reason for the patients attendance 3. conducting a physical or verbal examination (or both) 4. considering of patient’s condition 5. Detailing treatment or further investigation 6. terminating
1.4 Main features of situations • goals → social acceptance → food, drinks or other bodily needs → task goals specific to the situation • rules → everyday rules → specific rules to situations
special skills → many situations require special skills • repertoire of elements → certain relevant moves defined by a situation • roles → every situation has a limited number of roles. These roles carry a different degree of power
cognitive structure → performers of professional social skills classify their clients in ways related to the task • environmental setting and pieces → situations involve special environmental settings, although there is quite a lot of variation
2.1 Reasons for adopting a style • style is an amalgam of behaviours derived from personal beliefs, knowledge, experience and skilfulness • Byrne and Long (1976) invented a scale ranging from doctor- centred to patient- centred behaviour
traditional authoritarian approach based on the assumption that the doctor is responsible for his patient’s health and will go through his agenda for the patient • opposite: doctor is seen as much less authoritarian, the responsibility for the health is shared, the patient is encouraged to go through his own agenda
“ Doctor’s experience is mostly based on skills, that makes it unsurprising that the pattern of behaviour tend to be disease- orientated and self- protectively authoritarian.” (Peter Tate, 1983)
2.2 Flexibility of style • studies of Byrne and Long (1976) and Bloor (1978) proved that if doctors have developed a set of behaviours, they use these stock pattern again and again → many of these behaviours are not significantly influenced by the patients presenting problems • doctor- centred doctors remain in their categories for a wide variety of patients with only limited movements across the spectrum → patient- centred show more flexibility
2.3 Style related to authority • throughout history doctors have a “natural authority” • Osmond (1980) divides medical authorities in three parts: → sapiental authority: doctor must have a greater technical knowledge → moral authority: the right to control - based on the doctor’s concern with the good of the patient → charismatic authority: medicine deals with powerful and mysterious forces (comes close to magic)
the majority of doctors adopted the traditional style → also most expected style by patients (Fitten and Acheson, 1979) • if patient- or doctor- centred, medical practice rests on an asymmetrical- relationship → doctor disposes of knowledge and technical skills → patient is unable to help himself, he is ignorant of the treatment of the disease
Two examples that influence doctor’s appearance and authority 1. seating position the position in which the doctor sits in relation to the patient profoundly influences the mutual exchange A D C B Three seating positions at a desk (Pietroni, 1976)
Results: • A - C six times more interaction than A - B • A - C three times more interaction than A - D • the absence of a desk reduces the perceived authority of the doctor • 2. Dress • clothes convey authority → casually dressed doctors are likely to be seen as a much less authoritarian figure than the one wearing a white coat
2.4 Information gathering and giving • information gathering →normallyfirst phase of any consultation opening statements often dictate the path that the remainder of the consultation follows → different ways of opening → doctor has to “get” the patient to talk problem: clinical check-lists, organisation of vague symptoms into categories
information giving → giving information includes explaining, sharing, advising, clarifying and dealing with questions and ideas → problems: technical language (cryptic information), patients dissatisfaction, doctor’s under- estimation of patient’s knowledge of illness, time
Part III: Patient’s understanding and compliance/ non- compliance with advice
Enduring problems in the field of health care: • presenting information about patient’s illness in a satisfying way • patients’ non- compliance with advice from health professionals • dissatisfaction with doctor- patient communications is common
patients wish for: → clear information on the effectiveness and risks of various possible treatments → decision by the patient to try one or none of the treatments → if the patient decides to pursue a given treatment, there should be regular opportunities to withdraw from the treatment
4.1 A subsuming overview (http://nyumacy.med.nyu.edu/curriculum/model/m07.html)
4.2 Difficulties reported by doctors • difficulties experienced by doctors in communicating to the patient • difficulties in the communication from the patient → more problems
• problems 1st category → mostly in the field of persuasive communication → e.g. doctor is unable to influence the patient, explaining that there is (or is not) any problem • reasons → patient has no confidence → “ did not seem to understand the doctor → “ and doctor are at cross purposes
• problems 2nd category • → mostly about the “channel” and the “noise” that • occurs in the information transmission • • reasons • → patient communicates very little or not at all • → patient withholds information, sometimes deliberately • → patient uses a different “code”
Conclusion • • three types of basic problems • → cognitive • → emotional • → social • “Emotional interference with the information transformation • by the patient to the doctor and the social class of the patient • discriminate best between consultations with and without • communication problems.” (Jaspars, King, Pendleton. 1983)
4.3 The patients’ view on good and bad consultations • 6 major categories → attention paid by the doctor → the doctor’s interpretation of the information → acceptance of the information → remarks about medical examination → observation related to the diagnosis → comments about medical treatment
• good consultation → treatment is effective / reassuring → patient is accepted as a person → prompt attention to the complaint → doctor shows understanding → quick and efficient examination → explanation of the diagnosis
• bad consultation → no attention → doctor did not treat patient as a person → prescription of wrong treatment → no understanding → wrong diagnosis → no explanation
4.4 The psychological effect of medical treatment • psychological effect of communication from doctor to patient → outcome of specific social influence process → doctor (“the source”) tries to affect a patient’s (“the receiver’s”) concern about his illness
