医患交际中治疗建议序列的会话分析研究
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摘要
在我国,紧张的医患关系已成为突出的社会问题,医疗纠纷时有发生。资料显示,这一现象主要归因于医患之间缺乏沟通。因此,寻求有效的沟通方式迫在眉睫。在医疗门诊中,医生和患者之间的交流主要是为了发现病情和寻求治疗方案,最终达到治疗疾病的目的。由此类推,在医患交际的各个阶段中,给出治疗建议阶段的交流尤为重要,这关系着医患交际成功与否。因此,研究医患在治疗建议阶段的交谈对于促进医患交际、改善医患关系具有十分重要的意义。国外对治疗建议的研究主要从医学和会话分析的角度进行研究的。前者侧重医生提出治疗建议和患者反应的主客观影响因素;后者则是在医生和第三方的交际中展开的,语料也仅限于英语。国内对医患交际的研究很少,从会话分析角度对治疗建议阶段医患交际的研究更是凤毛麟角。基于此,本文着重研究治疗建议阶段的医患交际,旨在促进医患有效沟通,进而改善医患关系。
为了客观的研究治疗建议阶段医患交际模式,本文基于240个医患交际的录音及转写采用会话分析的研究方法对医患交际中治疗建议序列以及构成其的话轮设计进行研究。治疗建议阶段的主要任务是建议的给予。基于语料,我们发现治疗建议或由患者发起,或由医生发起。两者的不同之处在于患者的参与度。(1)在患者发起的治疗建议中,医生会根据发起的位置和发起方式做出相应的反馈。(2)语料显示,大多数治疗建议都是由医生发起。在医生发起的治疗建议中,一般会出现至少一个“建议-接受/反对”的根相邻对。医生会在给出建议前进行前扩展,以确保患者接受随后提出的治疗建议。医生在给出建议时,也会采用不同的方式进行话轮设计。在医生给出治疗建议后,患者要么接受要么保留意见。当患者接受时,他们通常会运用优先结构设计话轮。医生的最小后扩张有时紧随其后用来结束该序列。当患者保留意见时,他们通常会在反馈位置保持沉默或者在给出反馈前运用非优先结构进行中扩展。当患者接受的不是医生最初的治疗建议时,医生通常会在患者做出反馈后进行非最小后扩展。对上述出现的治疗建议序列的构建方式和医、患的具体话轮设计方式本文还进行了进一步的解释。
总之,在医患交际中,提出治疗建议阶段是一个非常重要的环节。本文运用会话分析的方法对其序列结构进行分析,通过更客观的了解这一序列结构的序列模式、结构特征和语言特点,从而为医学实践和教学提供指导,为理解医患交际、改善医患关系开辟道路。
In recent years, doctor-patient relationship is quite tense in the burgeoning reform of medical care sector in China, about 70%-80% of which are attributed to poor communication between doctors and patients. And how to achieve a successful communication and improve their relationship is imminent. As is known to all, in the medical encounter, the aim of doctor-patient communication is to identify the disease and seek for treatment plans, with solving the problem as its ultimate goal. Therefore, the phase of treatment recommendations is the most important one, and how doctors and patients communicate in this phase determines whether the doctor-patient communication is successful or not.
As literature review has shown, the existing literature abroad on treatment recommendation can be categorized into the medical and conversation analytic approaches. The former has explored both clinical and non-clinical factors influencing doctors' treatment recommendations and patients' response. However, their methods are limited and all factors are designed in a hypothetical way, which need to be tested in practice. The latter is based on the medical interaction between doctors and third parties rather than doctor-patient interaction and the studies are confined to English data. Compared with the relevant studies overseas, researches on treatment recommendations in China are fewer, let alone systematic analysis. To promote more effective communication and improve doctor-patient relationship, the study on treatment recommendations from conversation analytic approach is of necessity.
Based on 240 audio-recorded cases of medical encounters and adopting the conversational research method, this thesis will analyze the sequential organization of treatment recommendations and explore how turns are designed by doctors and patients to perform particular actions, ultimately forming a treatment-recommending sequence and serving to accomplish one medical task, that is, to recommend treatments. The research has shown the treatment recommendations can be initiated by patients or doctors, and the difference lies in patients' different degree of participation. (1) Patients usually initiate the recommendations in three ways. Accordingly, doctors will react differently, combing with consideration of their sequence positioning. (2) The vast majority of treatment recommendations in our data are initiated by doctors. And there usually exists a "proposal-acceptance/resistance" base pair. Before the treatment delivery, to avoid rejection, doctors will construct "pre-proposals". When doctors propose the treatment, they will design their recommending turns in different ways. After doctors' treatment delivery, patients will accept the treatments directly or withhold the acceptance. (a) If patients accept them, their turns will be designed in a preferred shape, sometimes followed by doctors' minimal post-expansions to close the sequence; (b) If patients withhold acceptance, they will keep silent in the response turn or do insert expansions to design their turn in a dispreferred shape before they give the response. If doctors' treatments are modified, changed or reversed, they usually will do non-minimal post-expansions after patients' response. Besides, the possible motivations for the occurrence of the above mentioned sequential organization and designed turn are also discussed accordingly.
On the whole, the phase of treatment recommendations is an important one in medical encounters. Utilizing CA to analyze its sequential organization can not only help us have a better understanding of sequence patterns, structure and language features but also provide instructions for clinical practice and education and shed light for further investigation of Chinese doctor-patient interaction.
为了客观的研究治疗建议阶段医患交际模式,本文基于240个医患交际的录音及转写采用会话分析的研究方法对医患交际中治疗建议序列以及构成其的话轮设计进行研究。治疗建议阶段的主要任务是建议的给予。基于语料,我们发现治疗建议或由患者发起,或由医生发起。两者的不同之处在于患者的参与度。(1)在患者发起的治疗建议中,医生会根据发起的位置和发起方式做出相应的反馈。(2)语料显示,大多数治疗建议都是由医生发起。在医生发起的治疗建议中,一般会出现至少一个“建议-接受/反对”的根相邻对。医生会在给出建议前进行前扩展,以确保患者接受随后提出的治疗建议。医生在给出建议时,也会采用不同的方式进行话轮设计。在医生给出治疗建议后,患者要么接受要么保留意见。当患者接受时,他们通常会运用优先结构设计话轮。医生的最小后扩张有时紧随其后用来结束该序列。当患者保留意见时,他们通常会在反馈位置保持沉默或者在给出反馈前运用非优先结构进行中扩展。当患者接受的不是医生最初的治疗建议时,医生通常会在患者做出反馈后进行非最小后扩展。对上述出现的治疗建议序列的构建方式和医、患的具体话轮设计方式本文还进行了进一步的解释。
总之,在医患交际中,提出治疗建议阶段是一个非常重要的环节。本文运用会话分析的方法对其序列结构进行分析,通过更客观的了解这一序列结构的序列模式、结构特征和语言特点,从而为医学实践和教学提供指导,为理解医患交际、改善医患关系开辟道路。
In recent years, doctor-patient relationship is quite tense in the burgeoning reform of medical care sector in China, about 70%-80% of which are attributed to poor communication between doctors and patients. And how to achieve a successful communication and improve their relationship is imminent. As is known to all, in the medical encounter, the aim of doctor-patient communication is to identify the disease and seek for treatment plans, with solving the problem as its ultimate goal. Therefore, the phase of treatment recommendations is the most important one, and how doctors and patients communicate in this phase determines whether the doctor-patient communication is successful or not.
As literature review has shown, the existing literature abroad on treatment recommendation can be categorized into the medical and conversation analytic approaches. The former has explored both clinical and non-clinical factors influencing doctors' treatment recommendations and patients' response. However, their methods are limited and all factors are designed in a hypothetical way, which need to be tested in practice. The latter is based on the medical interaction between doctors and third parties rather than doctor-patient interaction and the studies are confined to English data. Compared with the relevant studies overseas, researches on treatment recommendations in China are fewer, let alone systematic analysis. To promote more effective communication and improve doctor-patient relationship, the study on treatment recommendations from conversation analytic approach is of necessity.
Based on 240 audio-recorded cases of medical encounters and adopting the conversational research method, this thesis will analyze the sequential organization of treatment recommendations and explore how turns are designed by doctors and patients to perform particular actions, ultimately forming a treatment-recommending sequence and serving to accomplish one medical task, that is, to recommend treatments. The research has shown the treatment recommendations can be initiated by patients or doctors, and the difference lies in patients' different degree of participation. (1) Patients usually initiate the recommendations in three ways. Accordingly, doctors will react differently, combing with consideration of their sequence positioning. (2) The vast majority of treatment recommendations in our data are initiated by doctors. And there usually exists a "proposal-acceptance/resistance" base pair. Before the treatment delivery, to avoid rejection, doctors will construct "pre-proposals". When doctors propose the treatment, they will design their recommending turns in different ways. After doctors' treatment delivery, patients will accept the treatments directly or withhold the acceptance. (a) If patients accept them, their turns will be designed in a preferred shape, sometimes followed by doctors' minimal post-expansions to close the sequence; (b) If patients withhold acceptance, they will keep silent in the response turn or do insert expansions to design their turn in a dispreferred shape before they give the response. If doctors' treatments are modified, changed or reversed, they usually will do non-minimal post-expansions after patients' response. Besides, the possible motivations for the occurrence of the above mentioned sequential organization and designed turn are also discussed accordingly.
On the whole, the phase of treatment recommendations is an important one in medical encounters. Utilizing CA to analyze its sequential organization can not only help us have a better understanding of sequence patterns, structure and language features but also provide instructions for clinical practice and education and shed light for further investigation of Chinese doctor-patient interaction.
引文
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