к.ф.н. Шингарева М.Ю., магистрант Тазабекова С.М.

Региональный социально-инновационный университет

Medical interviews as a part of medical discourse

Medical interviews constitute a significant part of the day-to- day practice of clinical medicine. Patients describe their symptoms and complaints, occasionally surprising physicians by their particular concerns. Physicians ask a variety of detailed questions, evaluate patients' accounts, comment on their general state of health, and suggest reasons for their problem and possible courses of action. Such transcripts, and the tape recorded interviews from which they are derived, are documents that reveal the forms and qualities of clinical work. The study reported in this article focuses on the analysis of these documents. The central aim of the research is to arrive at an understanding of how clinical work is done.

This preliminary statement of direction and intention must serve for the moment as a general orientation to the study. The particular meaning and significance of the guiding idea, that the analysis of talk between patients and physicians is a primary source for understanding clinical work, will be developed and specified in the reporting of methods, findings, and interpretations of data.

Several related questions varying in depth and generality will be explored in the study. There is, for example, a first-order or descriptive question as to whether medical interviews have a characteristic or typical structure. Do they exhibit a pattern that is sufficiently strong and consistent to mark them as distinctive social events, meriting and demanding further analysis? Can useful, systematic, and appropriate methods be developed and applied to the study of interviews that would serve to isolate this structure and determine its essential features? What variations may be found within the basic type?

There are, additionally, a number of second-order or interpretive questions that refer to the significance of this structure for understanding the nature of clinical practice. What function does it serve, that is, how does it shape and organize the medical interview as a particular type of discourse? What type of relationship between patient and physician does it express and affirm? In what ways does the verbal exchange reveal differences in the meanings of problems and their respective understandings? How are these understandings related to differences in general perspectives, on the one hand, of physicians framing questions and making recommendations within the technical-scientific standpoint of the biomedical model, and on the other hand, of patients with orientations grounded in the concerns of daily life? How are such differences resolved?

Finally, a broader question motivates this study, namely, what constitutes a humane practice. This might seem to lie outside the boundary defined by the usual research questions directed to the deception, analysis, and interpretation of empirical data. Clearly, the latter are essential questions and will be addressed in detail. Nonetheless, observations of clinical practice are of more than neutral import; they both reflect and bear directly on issues of value. A central and pervasive concern of this study is whether current forms of clinical practice are consistent with and affirm criteria of humane care, that is, respect for the dignity of patients as persons and recognition of their problems within the context of their life worlds of meaning. An effort will be made to define these criteria empirically by specifying features of medical interviews that display a responsiveness to patients’ attempts to construct meaningful accounts of their problems and, further, encourage the development of non-coercive discourse based on norms of reciprocity rather than of dominance-subordination.

From this brief statement of questions that will be addressed and the general approach to be followed, it may be evident that this work is directed both to clinical practitioners and to researchers, particularly social scientists in a variety of disciplines who are engaged in the study of talk. The practical implications of research findings cannot be adequately understood, nor effectively implemented, unless there is understanding of the methods that produce the findings. This article, therefore, is both highly attentive to methodological issues and detailed in its report of methods and procedures. At the same time, significant and meaningful research requires more than methodological rigor. It depends on a reflective understanding of clinical practice that does not naively incorporate the perspectives and assumptions of practitioners. Researchers, therefore, must approach the study of clinical work within the framework of a more general theory of society and its institutions. Further, as noted earlier, the study of practice is not neutral so this investigation reflects an explicit concern with and commitment to the criteria of a humane clinical practice.

These considerations suggest the scope and complexity of the work. In weaving together these different strands—observations of clinical practice as well as the methods for studying them, and interpretations of the interactional and discourse functions of interview structures as well as their implications for humane care— the goal is to achieve an empirically-grounded and theoretically meaningful understanding of clinical practice.

To answer the questions posed in ways consistent with and directed towards the objectives stated above, an innovative research strategy is developed. It includes nontraditional methods for the analysis of discourse, a somewhat unorthodox form of reporting findings from successive stages of the study, and a reconceptualization of the features and functions of clinical practice. Using this approach, the grounds for interpretation shift in the course of the work from assumptions based on the biomedical model of physicians to the perspective of patients and the lifeworld contexts of their problems.

This assumption, that the talk between patients and physicians is serious and has clinical significance, informs the intensive investigation of medical interviews . However, it merits brief comment in this introduction, since the empirical study of clinical interviews has received little attention in the most prominent traditions of social science research on health care and medical practice. Thus, although problems of physician-patient relationships receive a good deal of discussion, it often takes the form of rhetoric, exhortation, and policy pronouncements rather than of analysis based on direct observation of doctor-patient encounters. Alternatively, characteristics of the relationship may be inferred from studies of the economics of health care or of the social organization of health care delivery systems. Until relatively recently, there were few studies that systematically examined medical interviews as loci of realization of these relationships.

A fairly typical example of the combination of general interest in the topic with a lack of attention to its particulars is found in a recent volume reporting the proceedings of an international conference. It is entitled The Doctor-Patient Relationship in the Changing Health Scene (Gallagher, 1978). Gallagher, the conference organizer and editor of the proceedings, begins the volume by asserting that “the relationship between the patient and the doctor is a basic element in health care,” and suggests that an aim of the conference is to answer the question, “What is the current state of the doctor-patient relationship” (ibid, p. 1). In his Epilogue to the conference. Parsons recognizes this emphasis: “From the social science point of view it is conspicuous that the main preoccupation of the conference was with what we call macrosocial problems” (ibid, p. 445). He goes on to point out that ‘‘...the more intimate aspect of the doctor-patient relationship seems not to have figured very prominently in the conference” (ibid, p. 446). Although Parsons does not pursue this point by suggesting studies of clinical practice, it seems evident that an understanding of the more “intimate” aspects of this relationship would require direct investigation of the interaction between patients and physicians.

The conferees represented are leading figures in their fields— researchers, educators, theorists, and policy makers. It is evident from the text that the conduct of patients and physicians, that is. the actual “stuff" of clinical practice, is peripheral to how they frame the central issues of a conference focused on the doctor-patient relationship. Perhaps it is nearer the mark to say that assumptions about clinical practice underlie their analyses and recommendations, but these assumptions are implicit and unexamined.

This emphasis on what Parsons refers to as “macrosocial" problems is not unusual among both investigators and policy makers. It reflects a well-developed approach to the analysis of health-care systems that focuses on economic, structural, and organizational issues. Although this approach need not preclude attention to the features of clinical practice as they are expressed in the interaction between patients and physicians, these topics are notably absent from serious and critical discussions of macrosocial problems in health care. This pattern of relative neglect of clinical practice among commentators on the health scene has its counterpart in medical education and training, although the reason is quite different and reflects the dominance of the biomedical model. The impact of this model on clinical training is profound. Hospitals and emergency rooms are the primary settings within which medical students, interns, and residents see patients and they have little opportunity for work with patients in the context of general medical practice. Training in situations of inpatient care and treatment tends to emphasize technical- scientific skills and the diagnosis of specific diseases; rather than the patient being viewed as a person, the person is viewed as a patient. Diagnosis, care, and treatment are short-term and they focus on singie episodes of illness in patients whom students are unlikely to see again. Thus, training differs in significant ways from general practice, where physicians enter into long-term relationships with patients whose life circumstances they become familiar with as they attend to a variety of episodes and illnesses over an extended period of time.

Although language is a topic with a long history of investigation and analysis, the systematic study of discourse between speakers is of relatively recent origin. Within this general area of inquiry, analyses of medical interviews as a specific type of discourse represent a small and specialized field of investigation. Given the newness of the work, we would expect to find that studies are based on different models and assumptions about language and use different methodological approaches.

Literature:

1.Gallagher, Eugene B. The doctor-patient relationship in the changing health scene : proceedings of an international conference / editor: Eugene B. Gallagher. U.S. Dept. of Health, Education, and Welfare, Public Health Service, National Institutes of Health ; 1978.