Review of The Dynamic Consultation
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Review:
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Date: Mon, 20 Jun 2005 09:44:58 +1000
From: Helen de Silva Joyce <jgaudin@bigpond.net.au>
Subject: The Dynamic Consultation: A Discourse Analytical Study of Doctor-
Patient Communication
AUTHOR: Cordella, Marisa
TITLE: The Dynamic Consultation
SUBTITLE: A Discourse Analytical Study of Doctor-Patient Communication
PUBLISHER: John Benjamins Publishing Company
YEAR: 2004
Helen de Silva Joyce, Director of Community and Migrant Education, NSW
Department of Education and Training
Cordella states in the introduction to this volume that her central tenet
in investigating doctor-patient communication is that 'good communication
in health care contexts is of vital importance for effective treatment,
compliance -- and (hopefully) return to health' (p. 1). The book presents
analyses of doctor-patient interactions in an outpatient public teaching
hospital in Santiago, Chile. The author claims that the analysis presented
in the book identifies 'forms of talk (Goffman 1981) that may occur, with
linguistic, ethnic and cultural variation, elsewhere' (p. 2) and that the
discourse analysed in her research 'can be representative of a more
general medical discourse' (p. 2).
In Chapter 2 Cordella broadly explores the contexts of medical
interactions and the theoretical frameworks which underpinned her
research. The historical basis for the asymmetrical nature of the doctor-
patient consultation was established in the Hippocratic Oath and supported
when the Renaissance framed the body as a machine and 'de-emphasised the
role of communication in the work of healing' (p. 6). The tendency of the
current biomedical framework of Western medicine is to view health
primarily as a biological phenomenon (Mishler, 1984). This is in contrast
to the patient-centred, socio-relational approach where concern with a
patient's overall life experiences is used to build the dialogue between
practitioner and patient. Cordella explores medical and linguistic
approaches to the analysis of doctor-patient communication and concludes
that, without the insights from discourse analysis, medical
analyses 'limit their chances of detecting, understanding and solving any
overall failure in communication' (p. 39).
In the theoretical framework of interactional, socio-linguistics which
Cordella uses, as the basis of her analysis, she combines Gumperz's (1982)
socio-cultural background knowledge and Goffman's (1981) interactional
framework with the concept of power developed in areas of social theory
(e.g. Foucault, Giddens) and discourse analysis (e.g. Fairclough, Wodak,
Tannen) and the concept of 'simpatia'. Simpatia refers to individual
personal qualities which lead a person to avoid interpersonal conflict by
emphasizing positive behaviours and de-emphasising negative behaviours, an
element of Hispanic communication described by Triandis et al (1984).
Chapter 3 outlines the research design which Cordella used to investigate,
through interactional socio-linguistics and ethnography, the discourse of
the outpatient department. This included observation, questionnaires, semi-
structured interviews and tape-recordings of the medical consultations.
The Chilean health system and the outpatient context are briefly
described, as are the participants in the research, the researcher, the
doctors and the patients. Cordella focused on history taking and
management and treatment routines in her research and through analysis
identified three distinct medical practitioner voices: 'Doctor Voice,
Educator Voice and Fellow Human Voice' (p. 58), which she aligns with the
three functional medical goals identified by Cohen-Cole (1991: 4)). These
goals are to gather information about the patient's health, educate the
patient to adhere to a medical recommendation and to provide support and
show empathy. On the other hand she identifies four patient voices within
the outpatient interactions: 'Health related story telling, Competence,
Social Communicator' and 'Initiator' (p. 60). She sees the Initiator voice
as challenging the common view of patients as passive. She analysed the
frequency of these voices in combination with categorizations of
structural similarities of grammar and communicative function.
In Chapter 4 to Chapter 6 Cordella presents excerpts from her recorded
data, in Spanish and English, and discusses what these instances of
discourse reveal about the doctor voices and the implications for doctor-
patient communication. In Chapter 7 the same format is used to explore the
dimensions of the patient voices. Chapter 8 returns to Goffman's (1981)
concept of 'footing', introduced in Chapter 2 as 'any shift from one form
of talk to another' (p. 11), which affects the subsequent discourse.
Cordella explores the patterns of footing that emerged in the data and
how 'a shift from one voice to another corresponds to a re-balancing of
the interaction between doctor and patient' (p. 186), establishing the
dynamic nature of the consultation which the author then elaborates in
Chapter 9.
Through her analyses Cordella concludes that, while doctors have
institutional and expertise power in the discourse, their discourse is
limited by a need to adhere to orthodox bio-medical views and by a lack of
liberty to express personal opinions that conflict with these. It is with
the Fellow Human Voice that doctors can communicate more equally with
patients and relate more directly to patient concerns. In this voice
female nurses often fill the gaps left by doctors (Haberland and Mey,
1981). It is this voice that is crucial in reducing or increasing the
asymmetry of doctor-patient communication. Cordella also concludes that
the Educator voice appears to be fundamental to make patients more aware
of their health condition and to give them more control over their
treatment.
Overall this is a very interesting investigation of medical discourse
which I agree with the author has wider implications in other cultural and
social contexts of health practice. This is particularly important in
multicultural contexts where patients bring to medical interactions wider
cultural expectations. I think the analyses could have been more
insightful had they been supported by a social theory of language which
directly connects the grammatical choices made by speakers to their
experiential and interpersonal intentions. However this does not negate
the contribution which Cordella has made to the growing understanding of
medical discourse. It is hoped that those who educate health practitioners
will begin to take more notice of how linguistics is able to describe the
failures and the successes of communication in medical contexts, and begin
to train health practitioners to be more aware of their role in ensuring
successful communication. In this way perhaps a patient's 'return to
health' (p. 1) may be more assured.
REFERENCES
Cohen- Cole, S. A. (1991). The Medical Interview: The Three-Function
Approach. St.Louis, Baltimore: Mosby Year Book
Goffman, E. (1981). Forms of Talk. Philadelphia: University of
Pennsylvania Press.
Gumperz, J. (1982). Discourse Strategies. Cambridge: Cambridge University
Press.
Haberland. H. & J. L. Mey (1981). "Wording and warding: The pragmatics of
therapeutical conversation". Journal of Pragmatics, 5, 103-111.
Mishler, E. G. (1984). The Discourse of Medicine, Dialectics in Medical
Interviews. Norwood, NJ: Ablex.
Triandis, H. C., G. Martin, J. Lisanky & H. Betancourt. (1984). "Simpatia
as a cultural script of Hispanics". Journal of Personality and Social
Psychology, 47 (6), 1363-1375.
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ABOUT THE REVIEWER:
ABOUT THE REVIEWER
Helen de Silva Joyce is Director of Community and Migrant Education in the
NSW Department of Education and Training. She has been involved in
language and literacy education for over 20 years. Within this field she
has specialised in workplace language, spoken language, literacy teaching
and curriculum development. She has written many publications for teachers
and for students in secondary and adult education and has been involved in
action research in ESL classrooms and linguistic research in workplace
contexts. She teaches at the University of Technology, Sydney and the
University of Western Sydney. She is currently co-authoring a book on
spoken discourse and is a co-researcher in a project which is
investigating spoken discourse in hospital emergency departments.
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