Frames and heuristics in doctor-patient discourse

Moments of 'touch' as a way for mental support in Traditional Chinese Medicine consultations: Analysis of the interactional process of co-constructing understanding of the patient's body conditions in Hong Kong

Traditional Chinese Medicine (TCM) is a growing phenomenon around the world. However, despite its historical role in Chinese society, there has been limited research on exploring the nature of TCM practitioner-patient interactions in the Chinese context. This study used 10 hours audio recordings of consultations to elucidate how a TCM practitioner used moments of 'touch' (where the term is used to represent the nature of holistic TCM interactions) for co-constructing understanding of the patients' body conditions. In these moments, the practitioner interacted with patients in order to explore their 'Zheng', the outcome of an in-depth analysis of all symptoms such as an imbalance in the pulse, lack of energy. This study illustrates how TCM practitioner strategically used discourse features in shaping the patient' understanding of their current body's conditions, and thus opened up space to elaborate their concerns or seek clarifications, leading to a holistic understanding and compliance with the recommended treatments. Specifically, the data show how the TCM practitioner through using the moments of 'touch' to shape the ongoing discourse so that the patients can have a better understanding of their illnesses. The results suggest that the long-term relationships between TCM practitioners and their patients can be developed through recognising the specific communication strategies used by the TCM practitioners in shaping the patient's understanding. If TCM practitioners can learn better communication skills, it will lead to better quality of interactions and reach better clinical outcomes such as high patient satisfaction and compliance with treatments.

Understanding Provider/Patient Expectations of Care in Clinical Encounters

Patients and providers bring completely different expectations to clinical encounters. When these expectations differ due to cultural reasons, beliefs, or values, communication is necessary to ensure each participant is satisfied with the result of the encounter. Using the traditional notion of “cura” can illuminate how these encounters occur, and what providers and patients can do to have a successful interaction. Patients and providers’ agendas must be understood by each party, patients must feel they are seen as individuals, and each must be aware of cultural differences that bring separate lenses to the encounter. Trust lies at the heart of the encounter, which provides a chance for each to understand the other’s culture. Each party must communicate their expectations of care to improve the nature of their interactions in the clinical setting.

Language and connectedness in the medical and psychiatric interview

OBJECTIVE

To present and develop "connectedness" as a linguistically based concept for research and teaching of the medical and psychiatric interview; and to illustrate how this concept may be operationalized for systematic study and use.

METHODS

We describe the concept and its theoretical background, illustrate it with examples, and describe a basic rating scale for connectedness that can be used for research and teaching purposes.

RESULTS

Connectedness is grounded in established concepts from the linguistic field of discourse analysis and is applicable to the study and teaching of medical and psychiatric interviews.

CONCLUSIONS

Connectedness is worthy of further study to enhance our understanding and our teaching of the interview.

PRACTICE IMPLICATIONS

Connectedness is a concept directly applicable to teaching and practice.

The role of narrative in discussing end-of-life care: eliciting values and goals from text, context, and subtext

This article reports a qualitative study of elderly veterans' perceptions of and preferences for end-of-life care. At a large urban Veterans Affairs (VA) hospital, we asked 30 veterans and 30 health care providers to define 4 terms in the VA form of the advance directive: life-sustaining treatment, terminal condition, state of permanent unconsciousness, and decision-making capacity. The veterans commonly used narratives to construct meaning, and analysis showed that the resulting texts had both a subtext (the values and goals driving the narrative) and a context (life experiences that filter and shape the current interpretation). We found that all 3 components--text, subtext, and context--are crucial to understanding the central theme of an individual's narrative and the decision-making processes associated with it. In this article we examine 1 lengthy narrative using Chafe's (1994) notion of intonation units. We then present a series of short narratives to demonstrate 3 subthemes that emerged from the data: quality of life versus quantity of life, benefit of treatment versus cost of treatment, and, most common, control versus lack of control. Our goal was to demonstrate the centrality and usefulness of storytelling in the patient-provider interaction when listeners are willing to consider the subtext and context of the story and its role in the decision-making process. As demonstrated in this study, deciphering people's stories gives us insight into their values, the mental constructs that drive their decision making, and the goals that they have for their own health care.

Meaning and agency in discussing end-of-life care: a study of elderly veterans' values and interpretations

The authors of this exploratory study used textual analysis of transcribed interviews to examine the mental constructs that individuals form around advance care terminology and to learn how elderly veterans conceptualize the language used in the Veterans Administration advance directive. They found that respondents often negotiated meaning by drawing on rigid schemas, specific mental constructs already in place: The Lord's Will, Machine Talk, Being a Burden, and Being Productive. The authors also examined the transcripts for agency. In addition to assigning external agency for end-of-life care decisions, respondents often expressed a complex interaction of "self" and "other" agency. These results challenge us to develop communication methods that allow patients to claim agency and participate fully in decisions regarding their health care, especially at the end of life.

Patients as partners, patients as problem-solvers

This article reports our ongoing work in developing a model of health care communication called collaborative interpretation, which we define as a rhetorical practice that generates building blocks for a more complete and coherent diagnostic story and for a collaborative treatment plan. It does this by situating patients as problem-solvers. Our study begins with an analysis of provider-patient interactions in a specific setting-the emergency department (ED) of an urban trauma-level hospital- where we observed patients and providers miscommunicating in at least 3 distinct areas: over the meaning of key terms, in the framing of the immediate problem, and over the perceived role of the ED in serving the individual and the community. From our observations, we argue that all of these miscommunications and missed opportunities are rooted in mismatched expectations on the part of both provider and patient and the lack of explicit comparison and negotiation of expectations-in other words, a failure to see the patient-provider interaction as a rhetorical, knowledge-building event. In the process of observing interactions, conversing with patients and providers, and working with a team of providers and patients, we have developed an operational model of communication that could narrow the gap between the lay public and the medical profession-a gap that is especially critical in intercultural settings like the one we have studied. This model of collaborative interpretation (CI) provides strategies to help patients to represent their medical problems in the context of their life experiences and to share the logic behind their health care decisions. In addition, CI helps both patient and provider identify their goals and expectations in treatment, the obstacles that each party perceives, and the available options. It is adaptableto various settings, including short, structured conversations in the emergency room, extended dialogue between a health educator and a patient in a clinical setting, and group discussions in support groups, community groups, or health education classrooms.

Health promotion talk in family practice encounters

The model of family medicine advocates a view of the patient as a psychosocially grounded person, and stresses the value of a preventive approach in maintaining health. Given such principles, it is expected that in the expression of this model--in actual family practice encounters--physicians will regularly introduce topics about health promoting behaviors in their interactions with patients. Examination of a sample of typical and unrehearsed encounters between family physicians and patients, however, reveals a striking absence of such topics. Where they do occur, there is conversational evidence that both parties find the topics troublesome, and employ conversational strategies which tend to distance these topics from the rest of the interview. The conversational features of these distancing strategies, as well as their possible sources and implications, are discussed. Physician participants in the research express no reluctance to introduce topics related to health promotion behavior, and in fact report that they do so regularly: the latter is contradicted by empirical conversational data. Difficulties that physicians evidence in managing these topics--in the absence of any conscious dispreference--suggest that shared interpretive frames operating for the remainder of the medical encounter do not work well for these topics. Physicians desiring to communicate effectively in this area may need to rethink health promotion talk as a special conversational task, which differs in key ways from more conventional topics introduced in medical encounters.