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医患门诊会话结构研究
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摘要
本篇文章以医患门诊会话的宏观整体结构和微观局部结构为研究对象,尤以前者为重,以会话分析为主要方法,在建立小型医患话语语料库基础上,通过实证法、归纳法、对比法等方法对医患门诊会话结构进行全面探究,以期发现医患互动的真实过程和交际细节,最终尝试通过对整体与局部结构的深入分析,从宏观微观上更加清晰地认识医患互动实践的过程、本质、特征与规律,并提供相应建议性措施,以缓解紧张的医患关系,改善医疗服务质量。论文主要内容有:
     第一章是引言部分,主要介绍了医患会话的国内外研究现状、本文研究的意义、运用的理论及方法、本文拟解决的问题和语料的搜集与转写等。
     第二章是医患会话整体结构中的开头及病情陈述阶段,首先分析了医患会话整体结构构成阶段的划分问题,确定该整体结构应如何划分。然后,探讨了医患会话开头的方式,是询问式,还是无话语的肢体动作式。接着探究了病情陈述的阶段定位、特点以及患者陈述病情的方式等问题。最后就患者在医疗实践中病情陈述的完成情况,建议患者如何在本阶段掌握话语技巧,扩展自己的病情陈述。
     第三章是医患会话整体结构中的病史询问阶段,该阶段的一个突出特征就是医生设计不同类型的问句,通过这些问句医生获取患者疾病信息、搜集数据和验证推断。因此本章首先分析了医生问题设计的特点,如设定议程、体现预设、传达认知立场和融入优选。然后探究医生问题设计的三原则,乐观原则、问题关注原则和接受者设计原则。最后对本阶段医生设计的问句进行分类,探讨了互动实践中不同类型的问句对患者反应的影响或限制问题,并建议医生如何选择问句类型,从而减少对患者的限制,以提高来访满意度。
     第四章是医患会话整体结构的诊断、治疗建议与结束阶段。重点考察了诊断阶段的医患互动方式,即医生给出诊断陈述的方式和患者对医生诊断陈述的反应方式。然后探讨了我国医生的诊断风格,仍然是缺少解释的、商讨与合作的、以医生为中心的风格。接着分析了治疗建议阶段医患双方的互动方式,然后探究了医生的权威与责任在这两个阶段中不同的体现。最后考察了医患会话结束阶段所采用的方式。
     第五章是医患会话微观结构中的相邻对和话轮转换。首先探讨了医患会话中相邻对的主要类型,接着分析了整体结构中不同阶段的相邻对特征。然后探究了医患会话的话轮转换机制,即话轮的构建成分和话轮的转换方式,最后总结了医患会话话轮转换的特征。
     第六章是本文的结语部分,主要对全文内容进行总结:
     第一,就医疗机构话语而言,医患会话属于十分典型的机构性会话,它有着区别于庭审会话、师生课堂会话、警察讯问话语、120急救电话等其他机构性会话的话语特征和结构模式。该机构性话语的结构模式具有潜在的约束性、规则性和可重复性。医患双方在实践中的互动就是按照这样的规则和模式实施自己的行为和理解对方的行为。医患会话以医生的打招呼询问为起点,以治疗建议结束后的告别为终点,这中间的医患互动过程不是杂乱无章的,而是存在一定顺序的互动秩序。医患会话的机构性任务就是通过互动秩序完成的,而且互动秩序是真实医患交际过程的再现。医患会话结构可以反映互动秩序和社会结构,体现双方在互动中的地位和身份。
     第二,就结构特征而言,医患会话有一个潜在的完整整体结构,它能体现医疗机构性话语的独有特征。在整体结构中,每个阶段各有自己突出的特征,它们在互动过程中出现的顺序不同,所起的作用不同,重要性与地位不同,可缺失的可能性不同,在整体结构中占有的时间比例不同,医生权威的体现程度不同,患者的权力自主性不同,参与的积极程度也不同。另外,阶段之间的界线并非截然明了,常有过渡现象的出现。整体结构的构成与该机构的目的性和任务性息息相关。医生开头问题是给患者机会,让其初步提供病症状况,使医生能锁定病症范围,并做深入调查。病史询问是搜集数据,诊断是对疾病给出肯定或否定结论,治疗建议更是直接指向交际目标。
     第三,就医患关系与互动特点而言,医患关系是机构化的角色关系。虽然医患交际的目的一致,但是两者既有合作,又有冲突,双方关系并不是理想的和谐状态,依然是以医生为中心,体现出明显不对称的现象。例如,医生开启的话轮较多,患者的较少;医生的话轮构建成分比较复杂,患者的比较简单;医生大量使用的是非类问句严重限制了患者的回答;医生经常使用打断方式强制夺取话轮;医生的诊断陈述往往采用简单断言式,很少给予解释和说明。医患互动的过程都由医生进行操控,其决定交际的进程。患者在互动交际中的表现多呈现被动特征,医患双方明显没有达成平等的对话与协商。
     第四,就相关建议而言,患者应该积极参与互动过程,掌握不同阶段的交际技巧,变被动为主动,突破医生的限制,尽多可能地陈述自己的观点。同时,我们建议医生在坐诊的过程中不能过分追求自己的技术和效率,而应多关注患者的体验和感受,在语言上少使用限制性较强的问句,多给患者表达机会,以提高其来访的满意度。
     文章只着重对宏观结构作了初步前期工作,还有很多问题亟待进一步解决。同时,对医患会话结构的分析,描写多于解释,归纳多于演绎,文章写作的理论深度还不够高,有待下一步继续挖掘。
This article uses the macro overall structure and micro local structure of doctor-patient conversation as the object of study, particularly the former as the most important,The conversation analysis as the main research method, based on the establishment of a small corpus of doctor-patient discourse, through the empirical method,inductive method, comparative method and other methods to comprehensively study the structure of doctor-patient conversation. Finally we try to find the real process of different stages of doctor-patient communication and interaction in details, and through the analysis of the global and local structure try to understand the process, nature, characteristics and the rules of the doctor-patient conversations.And we would like to provide recommended measures to ease tensions in the doctor-patient relationship, and improve the quality of medical services. The main contents are:
     The first chapter is the introduction part, mainly introduced the doctor-patient's conversation research status at home and abroad, the significance of this study, the theory and method applied, and the problems to be solved in this paper and the data collection and transcription.
     The second chapter is the begins and disease presentations stage of the overall structure of doctor-patient conversation. Firstly we analyzes the partitioning problem of overall structure of doctor-patient sessions, determine how to divide the overall structure. Then we discuss the way of the beginning conversation, it is the inquiry, body movements or no discourse. Then we explore the positioning and the characteristics of problem presentation stage, and the way of the patients' presentation. Finally according to the completion condition of patients' presentation, we advise that patients should master the discourse skills to expand their illness representations at this stage.
     The third chapter is the history-taking stage of overall structure of the doctor-patient conversation. A prominent characteristic of this phase is that there is much different types of questions designed by doctors. Through this questions doctors obtain informations of illness and collect data of patients and validate their deductions.This chapter first analyzes the characteristics of doctors question design, such as set agendas, embody presuppositions, convey epistemic stance and incorporate preferences. Then we explore the three principle of doctors' problem design:principle of optimization, problem attentiveness and principle of recipient design. Finally we classify different types of doctor's questions, and discusses the effect or restrictions on patient response it act in interactive practice, and advise doctors how to choose the question type, thus reduce the patients limits, and improve visitor satisfaction.
     The fourth chapter is the stage of diagnosis, treatment recommendations and end stage of the overall structure of the doctor-patient conversation. Emphasis on the interactive way of diagnosis stage, namely the doctors' diagnostic statement way and patients' responded way to the doctors' diagnostic statement. And then we discusses the diagnosis style of Chinese doctors, and it is still doctor-centered style which is lack of explanation, discussion and cooperation. Then we analysis the interactive mode of the stage of treatment recommendations between patients and doctors, and then we explore the different performance of doctors' authority and responsibility in the two stages. Finally we analysis the way of the over stage of doctor-patient conversation.
     The fifth chapter is the study of adjacent pairs and turn-taking of the microstructure of doctor-patient conversations. Firstly we discuss the main types of adjacent pairs of doctor-patient conversations, and then analysis the adjacent feature in different stages of the whole structure. And then we explore the turn-taking system of doctor-patient conversation, namely turn-construction component and the turn-taking way, finally we summarize the features of turn-taking of doctor-patient conversation.
     The sixth chapter is the conclusion part of this paper, mainly summarize the whole content:
     First, on the mode of communication, conversation between doctors and patients belongs to typical institutional talk. It has significant discourse characteristics and structure mode which is totally different from Courtroom Conversation, classroom sessions, police interrogation discourse,120emergency calls and other institutional session. This structure model has potential constraints, rules and repeatability. Both doctors and patients in the interactive practice perform their behaviors and according to the rules and patterns understand each other's behaviors. The doctor-patient start with doctors' questions, and end with the farewell after recommendation. The doctor-patient interactional process is not disorder, but there is a order. The doctor-patient conversation structure can reflect the interaction order and social structure, reflect their status and identity in the interaction.
     Second, the doctor-patient conversation has a potential whole structure, it can reflect the medical discourse unique features. In the whole structure, each stage has its characteristics, they appeared in different order in the process of interaction, the role of different, different of importance and status, different of deletion possibility, different proportion of time occupancy in the whole structure, different of the doctor authority of power, different of patient autonomy and actively participate degree are also different. In addition, the line between stages is not completely clear, there is often a transition phenomenon. The constitution of the overall structure are closely related the organization's objectives and tasks. The doctor began to question is to give patients opportunity, and doctors can lock range, and do in-depth investigation. History is a collection of data, diagnosis of disease is to give a positive or negative conclusion, treatment recommendations are directed to the communicative goal.
     Third, about the medical patient relationship and interactive features, although the doctor-patient have common purpose, but both of them have cooperation,and also conflict and the two sides state is not ideal harmonious, is still in the doctor as the center, and appear asymmetry phenomenon. The doctor opened turn more often, with which patients is less; Turn-construction component of the doctors' turn are more complex, with relatively patients are simple; The use of plenty of yes-no questions severely restrict patients agendas, and doctors often use interruption mode to grasp the turn; The diagnostic statements which doctors often uses simple are assertions, and they rarely explain and describe to it. In short, in doctor-patient interaction, doctors often control the communication process, and the act of patients are often passive response, the two sides did not reach an equal dialogue and consultation.
     Fourth, about advice, patients should be actively involved in the interaction process, master the communication skills of different stages, and change from passive to active, break the doctor restrictions, as much as possible to express their opinions. At the same time, we suggest that doctors cannot excessive pursuit of their own technology and efficiency in the diagnosis process, and should pay more attention to patients' experiences and feelings, in the language of less using restrictive questions, and give patients more expression opportunities, and improve the visitors' satisfaction.
     This paper just focuses on the overall structure and made a preliminary preparatory work, there are still many problems to be solved. At the same time, the analysis of doctor-patient's conversation, and description is more description than explanation, induction than deduction, the depth of the theory of writing is not high enough, to be next to continue mining.
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