Medical Discourse: Communication Skills and Terminally Ill Patients

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Medical Discourse: Communication Skills and Terminally Ill Patients I G Finlay and S Sarangi, Cardiff University, Cardiff, UK ß 2006 Elsevier Ltd. All rights reserved.

Introduction Recent years have seen a strong drive for the teaching of communication skills at undergraduate and postgraduate levels of medicine in the United Kingdom. Many studies, particularly of doctor–patient interactions, have objectively supported the need for skills training, especially as health professionals’ attitudes have been changing toward patients’ psychosocial needs (Fallowfield et al., 1998; Royal Society of Medicine, 2000). The National Health Service, in seeking to better inform and understand patients’ needs, has sought to develop a paradigm of interaction that assumes of, or imposes upon, doctors and nurses the necessary ‘communication’ skills (SUPPORT, 1995). Problems with communication are recognized as being not only a major source of anxiety for patients and their relatives but also a common source of complaints and litigation; about 90% of the complaints that reach the NHS Ombudsman are attributed to poor communication between the health care professional and the patient and/or his family. Within a culture of blame and litigation, and with many patients having unrealistic expectations of clinical care, the doctor can also fear accusations of culpability, even if the patient’s disease has progressed beyond the bounds of clinical science. The training and assessment of communication skills in the medical curricula has been consolidated since the General Medical Council produced its document ‘Tomorrow’s doctors,’ which specifically outlines the core requirements of any undergraduate curriculum. At the undergraduate level, the curriculum has become increasingly crowded as medical science advances and medical students need to be familiar with a bewildering amount of rapidly advancing knowledge. Some have claimed that medical training is being compromised as a result (Williams and Lau, 2004) and that communication skills are inherent in the student upon entry to medical school, with very little cost-effective change from teaching. This recognition of the importance of effective communication has also driven the formal assessment of consultation skills in professional examinations, often using trained actors to simulate patients in an attempt to achieve a uniform assessment standard. The drive to teach communication skills at the postgraduate level has gathered momentum in the

secondary and tertiary care sectors in recent years. General practice training in the United Kingdom has incorporated communication skills training and assessment for over 20 years, yet only half of general practitioners report having had training to prepare them to communicate with the terminally ill (Barclay et al., 2003). The importance of the quality of information giving that is required to ensure that patients can make informed, competent, voluntary decisions free of coercion is now being recognized in law. In the United Kingdom, the forthcoming Mental Capacity bill focuses on the wishes of the patient, with an assumption of capacity for decision making and a rigorous requirement for objective evidence to support the view that a person is not competent to be involved in making decision about his care. The importance of effective communication and assessment of true need is nowhere more stark than when the patient requests death to be hastened or refuses consent to treatment. In the terminally ill, the desire to shield patients from the reality of their situation and avoid causing heightened anxiety often leads to poor truth telling and nondisclosure; importantly, this has been shown to usually create even greater difficulties for patients and their relatives, as it denies them the opportunity to reorganize and adapt their lives toward realistic goals (Fallowfield, 2002). Having better understanding of the nature of this important area of communication should not only improve the quality of the patients’ experience and clinical care but also improve the decision-making process, and hopefully might lead to a reduction in complaints (and possibly litigation). An additional benefit of good communication skills training may be a decrease in work-related stress, as staff often report feeling inadequately prepared to deal with patients who are dying and their families.

The Ethos of the Terminally Ill Terminally ill patients are particularly vulnerable, often having a heightened awareness and sensitivity to those around them. They are vulnerable by dint of facing death, and they are also vulnerable precisely because of their disease (Christakis, 1999; Seale, 2000). Infection, metabolic disturbances, cerebral disturbance by metastases or ischemia, and the effect of medication can make patients confused and less able to cope with new information, thus impairing their competence. Their families are also distressed and keen to minimize the distress experienced by the person they love

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– the patient. Clinicians are in a difficult position as well. They may have spent months or years advising and taking a patient through grueling investigations, treatments, and interventions in the hope of achieving a cure or disease control. When these efforts fail, the clinician can feel a sense of personal failure, making it difficult to remain strong and supportive of the patient. Attempts to keep up a strong front are then interpreted as indifference by the patient and/or his family. Distress in terminal illness is multifactorial, with overlap and interaction between the domains of concerns: physical, emotional, social, and spiritual. Problems intermingle, amplifying each other and enhancing the overall distress felt by the patient, to the point that the concept of Total Pain, coined by Cicely Saunders (Saunders, 2000), is experienced by those whose needs are not addressed. The physical assessment of symptoms will depend on taking a history, often in a semistructured way, examining the patient physically, and investigating further as appropriate with blood tests and so on. However, assessment of the concerns, fears, beliefs, and wishes of the patient requires a much more subtle interactional approach that depends on detecting cues, demonstrating empathy by reflecting comments in the language the patient uses, and presenting an overall nonverbal demeanor of active, engaged, and nonjudgmental listening. In the terminally ill, patients’ needs fall into the broad categories of: a decrease in functional status or activity; role change; symptoms, particularly pain; loss of control; financial burden; and conflict between wanting to know what is going on and fearing bad news. There have been studies of information giving in those with a poor prognosis, usually relating to the imparting of bad news (Kutner, 1999). These needs are broad in scope, not particularly associated with any specific patient characteristic, and therefore underline the need for careful individual assessment. For patients with a terminal illness, the diagnostic or prognostic news received in an outpatients’ clinic can be devastatingly traumatic; they are suddenly aware of what lies ahead of them, including the unavailability of cure, the uncertainties about how the illness will develop over time, the long-term and short-term side effects that any treatment regime might inflict, the impact of their situation on those they love, and the extent to which family relations might become affected, to name a few issues. Much research about the terminally ill has focused on the perceptions of relatives, their judgments and evaluations of the care given. Remarkably little has concentrated on the needs of children and teenagers as relatives. Children have different adapting styles

closely related to emotional development. Although beyond the scope of this article, the topic is in urgent need of good and sensitive research to guide clinical services. A cancer patient’s deficit in his quality of life has been defined as the relationship, in terms of a gap, between his expectations and the current reality experienced (Calman, 1985). Yet no health care professional can narrow this gap without really understanding a person’s hopes, expectations, and the complex nature of their current distress. Hence, the quality of interactions of the patient with various health professionals will inevitably become a key influence on his quality of life. Many of the communication issues explored in these studies, especially the tensions between the ‘medical’ and the ‘social’ in the delivery of bad news, communicating risk, decision making, and so forth, are important areas for future inquiry in hospice and palliative care patients.

Communication Issues Specific to the Terminally Ill Although the quality of clinical interaction is seen as important in training professionals, the quality of interaction has not been a topic of inquiry in its own right. From a discourse/communication perspective, there is a large body of doctor–patient communication studies, but these have been mainly limited to general practice. Most health care studies in the sociolinguistic communication tradition have mainly engaged with the general practice setting, with their analyses being doctor-oriented and focusing on the structural organization of the consultation process. Very few studies deal with cancer clinics and care centers or focus on the life history of patients or their cumulative interactional experiences. There is now widespread recognition that ‘‘the quality of clinical communication is related to positive health outcomes’’ (Simpson et al., 1991) and that the same holds true for cancer care: ‘‘inadequate communication may cause distress for patients and their families’’ (Fallowfield and Jenkins, 1999; Fallowfield et al., 1998). Specific difficulties encountered in discussion with the terminally ill relate to prognosis. Before information is given, the clinician must assess how much the patient already knows, and what he expects will be the likely course of the disease and its accompanying problems. Some patients may have witnessed poor care or distressing death in others. Others may have guilt about issues in their own life, blaming themselves for the illness or viewing it as some type of retribution for past deeds. Family conflicts, varying

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expectations from health care, and emotions such as anger, denial, or guilt are powerful influences on communication. Although to the dispassionate pragmatist the situation may feel hopeless, the vast majority of patients can cope better with reality if they have something to hope for. However, such hope must be realistic – it must be the patient’s own wish and arise from his aspirations rather than from the imposed values of others. An example is the patient who knows he is dying but hopes to be alive for his son’s wedding. Knowing that every effort will be made to achieve that goal will instill realistic hope, which is preferable to reiterating the obvious but more pessimistic view that in reality a sudden catastrophic event such as an embolism may occur at any time, and so he should not hold out too much hope!

Quality of Information Many studies have been concerned with information giving (Davison et al., 2004; Friedrichsen and Strang, 2003; Walsh and Nelson, 2003), attempting to evaluate the patients’ understanding of their situation as a proxy measure of the quality of the communication, rather than assessing the interactional data within a consultation. Such studies fail to recognize the varied competencies of those who are frail and ill, the differing individual contexts of their lives and their diseases, and that emotional factors can act as a powerful block to the patient being able to retain information, even if the clinician is normally skilled at giving information. The studies also fail to assess the information needs of the patient, often omitting assessment of the patients’ perception of the issues they feel rightly concern clinicians and those they feel would be viewed as trivial by their doctor. Patients’ past experiences, beliefs, and background knowledge are powerful influences that must be recognized in order for information giving to be effective and sensitive. Accurate information is crucial to decision making. The powerful influence of the doctor cannot be underestimated – hope, concern, and realistic optimism are powerful feelings that suffuse a consultation and are absorbed by patients. By contrast, a pessimistic outlook is rapidly detected and can lead to hopelessness, despair, loss of a sense of dignity, and demoralization of the patient (Chochinov et al., 2002; Kissane et al., 2001). There are two groups of studies: (1) those dealing with information the patients need/want; and (2) those addressing the quality of interaction between patients/their families and health professionals, seen as information exchange. The studies have used

questionnaire and interview methods and have suggested that patients prefer interview, particularly in the home setting (Montazeri et al., 1996a; Montazeri et al., 1996b). Studies of information needs of cancer patients in general (Christakis and Lamont, 2000; The et al., 2000; Montazeri, 1998; Billings, 2000) confirm that most need clear information about diagnosis and treatment. According to Sell et al. (1993), 92% of patients required a truthful disclosure of diagnosis, but 26% of patients indicated a lack of information about prognosis. A recent large-scale questionnaire study (Jenkins et al., 2001) also showed that 87% of the 2331 patients wanted all possible information concerning their illness and treatment. Gamble (1998) elicited patients’ experiences and reported variations in individual patients’ need for information and their perceptions of ‘‘insufficient information about the side effects of treatment.’’ More information per se is not the solution. Information must be contextualized, and its understanding depends on the prior knowledge base of the recipients, who are usually the patients and their family members. There is some evidence for variable communication with cancer patients and for their dissatisfaction (Royal Society of Medicine, 2000). Quirt et al. (1997) used a combination of interview and questionnaire to elicit both cancer patients’ and professionals’ views about the extent of the cancer, the intent of treatment, and the risks and benefits of treatment. Despite some agreement, the researchers found significant discordance between the understanding of doctors and patients of the extent of disease and intent of treatment. There was an indication that patients’ lack of understanding of their condition could impair treatment decisions. Only a few studies have engaged explicitly with prognosis and quality of life issues. Leydon et al. (2000) used interviews to investigate informationseeking behavior in a small study of 17 patients with a variety of cancers. They found that, as part of the coping strategy, patients may choose not to obtain further information about their condition based on ‘faith,’ ‘hope,’ and ‘charity.’ ‘Hope,’ or ‘false optimism about recovery’ may be seen as an overriding principle that guides patients’ reluctance to talk about prognosis and its impact on their quality of life (Christakis and Lamont, 2000). Montazeri et al. (1998), in an interview study of 82 patients with newly diagnosed lung cancer, commented that ‘‘proper communication remains limited.’’ A case study by The and colleagues (2000) has looked at the whole trajectory of illness; this concentrated on patients with small cell lung cancer and the issues of collusion about prognosis and

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of false optimism. However, the findings of Sell et al. (1993) and Jenkins et al. (2001) differed; these researchers found that patients and their family members may even interpret the term ‘treatment’ in a curative rather than palliative sense. In a follow-up study, The et al. (2003) explore the reasons underlying ‘false optimism’ and suggest how radiographic images as clinical evidence are given priority over interpretation of subjective bodily sensations as a way of coming to terms with the illness trajectory. This supports the change in clinical awareness that quality of life assessments should prioritize palliation of symptoms, psychosocial interventions, and understanding of patients’ feelings more than duration of survival (Billings, 2000; Girling et al., 1994). Most of these studies overlook the interactional dimensions of what actually happens in a given clinical setting.

Quality of Interaction For thematic analysis, we will regard Quality of Interaction as constituted in psychosocial/relational and biomedical/procedural dimensions. The longstanding distinction between doctors inhabiting ‘‘the voice of medicine’’ and patients inhabiting ‘‘the voice of the lifeworld’’ may be a useful starting point (Mishler, 1984). With older patients, social and relational issues often assume greater significance. Nurses are more likely to embrace a social/relational style when dealing with patients (Fisher, 1991). The decision on the part of doctors to focus on the biomedical dimension (e.g., treatment options such as chemotherapy and the treatment schedule) at the expense of the psychosocial/relational implications of a diagnosis is very much embedded in Western medical practice, but it is driven by the need to ensure that patients’ consent to treatment is realistically informed by the choices available and the probable outcomes of each course of action. Barton et al. (2005), in their study of end-of-life discussions in surgical intensive care units in the United States, identify four phases: opening, description of current status, holistic decision making, and logistics of dying. Of particular significance is the second phase, description of current status, where a shift from therapeutic to palliative care has to be accomplished discoursally. This also happens to be the phase where delivery of bad news (Buckman, 1992) has to be strategically managed (not in the diagnostic sense, though). Barton et al. (2005) thus complement Curtis et al. (2002), which is geared toward a content-based analysis of physician contributions in these end-of-life discussions.

Iedema et al. (2004), drawing upon data from Australian multiprofessional team meetings, focus on professional self-presentation and pay attention to the tension between the medical worldview and that of the dying patient. Studies in the UK context include the geriatric clinic (e.g., Coupland and Coupland, 1998), where the framing of familyrelational issues become significant in the care of the elderly. Styles of Involvement in Patient-Centered Palliative Care under Examination Conditions

In this section we outline a pilot study under examination conditions (Cardiff University Diploma in Palliative Medicine). We shift attention from labeling of itemized skills such as ‘open questioning’ or ‘active listening’ to an understanding of how consultations are interactionally achieved by using a discourse analytic perspective. In broad terms, discourse analysis focuses on the jointly constructed process of interaction as it pays attention to the multifunctional, context-specific nature of language use. Styles of involvement at the communicative level are manifest at various levels of linguistic choices and interactional trajectories. At the linguistic level, degrees of involvement can be signaled through selection of pronouns, preference for active or passive agents, choice of modalization and lexicalization, and so forth. At the interactional level, features such as overlapping talk, ellipsis, other-initiated turncompletions, and perspective display sequences are indicative of conversational involvement. Our analytic focus will be on how doctor–candidates interactionally orient to their actor–patients, with particular reference to history taking and care/treatment management. We offer a distinction between ‘recycling of patients’ words’ and ‘reformulation of patients’ words’ and suggest that these styles elicit different accounts of patients’ experiences and expectations. The data consists of transcripts of audio-recorded sessions of simulated consultations within the Cardiff Diploma in Palliative Medicine. The analysis is carried out in two phases using the discourse analytic methodology of interactional mapping and thematic staging. In conclusion, we discuss the implications of such microanalytic analysis for validating assessment and for raising professional awareness. We adopt a discourse/communication perspective, focusing on information exchange structures, use of rhetorical strategies, management of interactional role-relationships, and so on (Sarangi and Roberts, 1999). For current purposes, we draw upon what may be called theme-oriented discourse analysis (Roberts and Sarangi, 2005) based on interactional

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mapping (Roberts and Sarangi, 2002). Of particular interest in the palliative care context is the notion of topic, i.e., how topics are navigated following a schema in patterned ways (Chafe, 2001). Thematic Maps in Palliative Care Consultation

Theme-oriented discourse analysis draws upon a number of concepts from linguistics and social sciences. The following list, suggested by Roberts and Sarangi (2005), can be applied to the palliative care setting. . Interactive framing: Framing is a filtering process whereby issues of concern to each communicant are either brought into their ‘frame’ or are discarded from the focus of the interaction (Goffman, 1974; Goffman, 1981). The priorities of each party will determine the frame and its content – for example, the doctor may be focused on physical symptoms, so that descriptors of pain and other physical changes will remain in the frame, but expressions of concern for the distress that this illness is causing to the patient’s child may be discarded. By contrast, the main concern of the patient may be the child, with the awareness of physical symptoms acting as a reminder and marker of impending death and the herald to bereavement for the child. Within their shared frames there is little true overlap. When the problems are listed together, understood by both, and shared, the quality of the interaction is perceived to have improved (Roberts and Sarangi, 2003). . Contextualization cues and inferences: These are the linguistic and prosodic features that invoke the context of each utterance to give it meaning. They channel the inferences in a particular direction by calling up the frames and affecting the footing of each moment of interaction (Gumperz, 1982; Gumperz, 1992). These features include intonation, stress, pausing, and rhythm, which tend to be used unconsciously and usually are unnoticed in their role of establishing or reinforcing social relationships. For example, the clinician encourages disclosure of a previously unsatisfactory consultation by use of ‘mmm’ in a nonjudgmental tone, and then follows with ‘that seems to have angered you.’ . Face and face-work: In an attempt to ‘save face’ in an interaction, the person perceived as weaker or more vulnerable – the patient – will use politeness as a strategy to establish closeness and engage the empathy of the more powerful person – the doctor (Brown and Levinson, 1987). Thus, the patient will be hesitant to disagree with the doctor, even when in fact the doctor has failed to grasp the patient’s

priorities in the situation. This, is starkly seen when the doctor uses closed or rhetorical questions: ‘is your pain better?’ ‘your pain seems better, doesn’t it?’; to which the patient agrees before hesitantly adding a qualifier such as ‘yes – a bit – but it still gets bad as the day goes on.’ . Social identity: Gender, social status, regional and ethnic background, and many other influences affect a person’s social identity. These preexisting factors are brought to the consultation, but the way one person behaves to another will influence the social identity – the performed social identity (Erickson and Schultz, 1982) – of each during the course of the consultation. Thus, the patient who finds he comes from the same village as the doctor will feel closer and assume greater empathy than the patient who is racially different from the physician and who speaks with a very different accent. In both cases, such assumptions are reinforced or dispelled by the nature of the interaction itself, thereby increasing or decreasing the patient’s sense of comfort with and confidence in the doctor. An important factor is the time that each is allowed by the other to speak – as a general rule of thumb, the doctor does well to spend about 80% of the consultation time listening and only 20% speaking, thereby affording the patient a sense of respect and encouraging the patient to disclose anxieties. . Rhetorical devices: Rhetoric is the language used to influence or persuade, usually in a political context. However, in the consultation, such devices can be parallel syntax, repetition of lexical items, metaphor, analogy, reported speech, and lists. For example, the patient may describe various symptoms, including pain that is ‘terribly sharp out the blue, makes me bend double . . . gets me down,’ to which the doctor may reply ‘sharp . . . like a knife’ or may summarize with a list of the symptoms just reported and then check back to ensure that nothing has been omitted. This makes the patient aware that the doctor has understood the patient’s agenda of problems to be attended to. . Analysis of the consultations showed that those deemed effective by validated scoring, when used for assessment, also had specific features in discourse analysis. High scoring (effective communicator) consultations demonstrated that the doctor verbally dominated for a much shorter time (about 20% of the time); used lexical reflective statements early to encourage disclosure of problems; summarized issues demonstrating coinciding frames from the patient’s concerns and the items afforded attention by the doctor; and used contextualization cues that encouraged the patient to disclose concerns.

670 Medical Discourse: Communication Skills and Terminally Ill Patients

Extract A [D ¼ female doctor; P ¼ female patient] 1 D: [. . .] your oncologist thought it would be good to come and see me and I just wondered what you why you were coming to see me 2 P: uhm (.) well basically it’s because my hip’s still giving me pain I’m getting problems with my breathlessness it seems it seems to be almost getting worse and uh walking is becoming difficult and oh I mean it’s just (.) I don’t know where to start really but .hh I ju – I need stronger painkillers the tylex isn’t doing particularly much you know taking away the pain (it’s almost making me worse) but then I get constipation and nothing else even gets rid of that (^^^^^^) even though I tried prune juice and you know the normal kind of remedy 3 D: can you tell me who started you on tylex 4 P: my GP I think yea 5 D: I see 6 P: yea it does take some of the pain away but I’m not taking them I (take probably) eight a day but it’s sti:ll it’s still becoming quite a strain to almost sort of get through the day and I don’t know what’s happening and there seems to be so much going on and I really had – when I went to Birmingham I was like so full of hope and everything else and then suddenly it’s like no and it’s just all come as a bit of a shock as well to me 7 D: so thinking about what you’ve just said you said it’s all come as a bit of shock you wanna just tell me a bit more about that 8 P: ((crying voice)) well I thought I was gonna get treated I thought I was gonna to be okay and now just from what I can gather I’m just not going to be okay and I don’t know how long I’ve got and what I’m doing or where I’m-I mean where I’m even going you know I just ((crying voice)) I even had hopes of going to university so ((crying voice)) (^^^^^) be realistic so we even uhm ((crying)) my my family and I were (^^^^^^) and I mean they know that I do have this pain and I know and dampen it down for them and I think they know that so they think it’s probably even worse than it is ¼ 9 D: mhm 10 P: ¼ and (.) oh it’s just ((crying voice)) I don’t even like talking about it with them because they just get worried and they (can do nothing either) then there’s no one to talk to and I don’t know what’s going on and it’s just becoming really really (.) ((crying)) just stressful 11 D: (^^^^^^^^^^^) 12 P: (^^^crying voice renders words inaudible^^^)) and now my painkiller is not even doing very much for me so now I’m at a point where I’m rapidly going downhill 13 D: (^^^^^^^^^^^) 14 P: yes so it’s mainly about about the painkillers really [uhm if I can have any stronger ones

15 D: [is it about the breathing as well 16 P: yea I am quite breathless just in everyday life uhm walking becomes more and more difficult uhm because of the breathlessness and I I find it very difficult to exercise you know and I’ve got the pain in my hip as well so to be honest 17 D:hm 18 P: I never exercise 19 D:okay (1.0) (^^) when (.) when did this when did they say there was no treatment 20 P: ((crying voice)) it was about a month ago a month and a half ago when I went up to Birmingham 21 D:(and then you went) 22 P: ((angry voice)) well I had two days of tests up there and then they suddenly went well no actually we don’t – no we can’t do anything for you because you’ve got problems with your lung (2.0) and up until that point I really thought ((emotional voice)) I really thought that I was going to be okay 23 D:so it was a complete shock (2.0) 24 P: yea 25 D:what about your family 26 P: uhm (1.0) oh uhm (2.0) they know they know that I am not going to get treated they don’t know how long I’ve got and neither do I ((emotional)) you know there’s something inside me you know it’s just so: frightening to think it’s taking over my my life and my body and that its it’s gonna end [it’s just it’s just so 27 D:[it’s hard isn’t it to be (^^^^^^) isn’t it (1.0) 28 P: ((crying voice)) I don’t even know when I’ve got no idea and (^^^^^^^^^^) and uhm yeah my family do know you know they love me and they are very supportive and helpful but they are just so worried that I don’t wanna worry them more 29 D:mhm 30 P: and you know they’ve problems of their own to deal with not major ones but you know they’ve gotta go through life and it’s just 31 D:is there (^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^) 32 P: no I think it’s I think it’s my fault I know it’s a big strain on (my) marriage ((cries)) (^^^^^^^^^^^^^^^^^^^^^^) (and for me) 33 D: have you got anybody to talk to 34 P: ((crying voice)) not really 35 D:any support? 36 P: ((crying voice)) not really no well my family are supportive they are I just don’t like 37 D:you don’t like 38 P: talking to talk to them it’s not their fault it’s more it’s more me not wanting to say anything 39 D:mhm

Key analytic points: D seems to be following the flow of topic as P wishes to develop it; P is given adequate interactional space to cover her major concerns, ranging from coping with painkillers to frustration with the medical personnel to family

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support. At crucial points D summarizes the key issues (turn 7, turn 15, turn 23). Most of the doctor’s questions are derived from what the patient has said (e.g., turn 19, turn 25, turn 27, turn 33). The minimal responses throughout help the patient to reveal all her concerns, unhindered. In a sense, this flexible approach allows the doctor to get a sense of P’s priorities and major concerns before responding in any definitive sense. Let us consider a second extract from the same setting, but with rather different thematic/interactional development. Extract B [D ¼ female doctor; P = male patient] 1 D: I’m Dr (first name last name) and I work with the (symptom) control team that work here at the hospital and Dr Bloggs has dropped me a short note just to ask me to (^^^) see you and give us an opportunity to look at how you are at present 2 P: yeah 3 D: what would really help me if you could give me a little more background about what’s been happening how you’ve come to where you are now 4 P: yea (^^^^^^^) yea about a year ago I uhm I was diagnosed with a cancer in the hip and uhm I get a lot of pain from that 5 D: hm 6 P: and uhm I was I had chemotherapy for six weeks a:nd I was all geared up to go for surgery (^^^^^^^^^^) a:::nd uhm I went up to Birmingham for that ¼ 7 D: mhm 8 P: ¼ and (.) and then on the day of the operation they went and canceled it ¼ 9 D: right 10 P: ¼ and uh said that I wasn’t that the problem was it was probably my lungs 11 D: it must have been a big shock for you to have got all geared up for your surgery 12 P: yes that’s right˚it was˚ 13 D: and what problem were they explaining you had with your lungs? 14 P: well uhm they were sort of saying that the cancer had spread into the lung uhm (.) that was it 15 D: you’d been expecting that to be a possibility? were you warned that that might happen? 16 P: well no 17 D: hmm okay how long ago was that that you should have had your surgery? that was actually very [recent was it? 18 P: [that was about a month ago 19 D: ri:ght (0.5) okay how have things been in the month since then 20 P: uhm well not too brilliant uhm (0.3) a lot of pain uhm (1.0) and I just—I don’t know what to (have) (0.5) what if (^^^^^) from that (0.5) 21 D: will you just (.) just hold on to that and let me find out just a little bit more about you that would just

help me ¼ 22 P: yea 23 D: ¼ to to understand and how old are you now? 24 P: twenty 25 D: right and whereabouts are you living (^^^^)? 26 P: well I I live at home in XXX 27 D: right 28 P: uhm with my parents I am a student in uh in YYY uhm but I haven’t been there for the last (0.3) eight months or so 29 D: hm the last year has been very much taken up with being ill (I would think 30 P: yea 31 D: yes do you have any brothers and sisters? 32 P: yea I’ve got one sister 33 D: and she is at home as well is she? (^^^^^^^^^^^^) and how are your family been finding situation (.) have they been supportive to you or (^^^^^^^^^^^) 34 P: well they’re worried sick 35 D: hm 36 P: uhm (1.0) my mother is uhm (.) supportive (^^^^) taken it in (^^^^^^) 37 D: right 38 P: and my father is (.) he does not really talk about it much (^^^^^^^^^^) 39 D: mhmm that is his way (^^^^^) 40 P: yeah I think so he doesn’t really talk about it much [Ten turns omitted] 51 D: yeah (2.0) and before you had the problem with your hip did you (^^^^^^^^^^^) or (^^^^^^^) 52 P: it was a shock [5 min] 53 D: yes (2.0) oh (.) that’s helpful for me to see if you have an idea of (.) to find out more about you (.) is there anything else you think would be helpful for me to know just to (^^^^^^^) bigger picture (^^^^^^^) 54 P: I just wonder (what to do next) 55 D: yea right 56 P: it’s (^^^^^^^^) 57 D: yea (1.0) so shall we go back to (.) the pain which seems to be the main thing that Dr Bloggs asked me to see you about 58 P: yes 59 D: can you just give me a little bit more idea what’s been happening with that 60 P: yes uhm well it’s been getting worse really I’m taking all these painkillers ¼

Analytic points: D’s style of questioning borders on hyper-questioning (see turns 11–33), which does not allow P to nominate or elaborate on what concerns him most. D’s questions are partly unrelated to what P has just revealed. Some of the questions preempt the patient’s experience (e.g., turn 29), expecting the patient to confirm or disconfirm. This style of questioning is very different from what we saw in Extract A. Overall, one gets the sense that here D is pursuing his own history-taking agenda, as evidenced in turn 21 (‘‘will you just hold on to that and let me find out

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just a little bit more about you’’). Notice that D returns to this topic in 57 (‘‘shall we go back to the pain’’). In both extracts, patients’ circumstances have been framed in the wider family context, but there are significant interactional differences across the two styles of topic involvement. We have chosen to present the above two extracts that show contrasting styles of interactional involvement. Space does not permit us to offer a detailed discourse analysis of all aspects of the interaction, so we limit ourselves to a theme-oriented approach as suggested earlier. Having decided on the theme of involvement, we can notice that extracts A and B have different involvement patterns. Whereas in A the patient is allowed generous interactional space to narrate her concerns, extract B is characterized by a sequence of question–answer turns mainly around the doctor’s agenda. Although both consultations explore the family support system, they do so very differently and give this theme differential priority in the interaction. Communication about the illness within the family setting receives due attention.

Quality of Life Both the extracts above deal with quality of life issues, but they do so differently in interactional terms. Quality of interaction has been given a separate emphasis from quality of life, which is affected by the quality of interaction. Quality of life is seen as functions in specific domains, with the aim of minimizing distress through attention to symptoms, psychosocial, and existential concerns. Much of the patient disclosure relates to informing the physician of the factors that are impairing quality of life, and these factors form the basis of the areas to be addressed in the clinical management plan. The notion of ‘quality of life’ embraces almost everything, ranging from physical/functional and social/ economic to psychological/spiritual dimensions. A useful operational definition of quality of life is ‘the relation between expectation and experience’ (Calman, 1984; Carr et al., 2001). We assume that both life expectations and lived experiences are seen at the level of interaction. It is then possible to look for quality of life issues at the interactional plane, while allowing for individual variations. In the clinical encounter, different views of both expectations and experiences are bound to surface. We will be looking for the interplay of experience and expectation (i.e., quality of life) in terms of how past, present, and future scenarios are talked about. One research task will be to see the extent to which health professionals orientate their communication to the relation

between the expectations and experiences of individual patients and how patients respond to such critical moments. A distinction between quality-of-life outcome measures in clinical research and the management processes and communication issues that address quality of life in daily clinical practice is overdue. Given our focus on clinical practice, the following dimensions of communication need to be highlighted: identifying and prioritizing problems; facilitating communication; screening for hidden problems; facilitating shared clinical decision making; and monitoring changes or responses to treatment. We would suggest that a detailed study of quality of interaction can contribute to our understanding of quality of life measures. This is particularly relevant in the context of cancer patients, for whom quality of interaction with health professionals and family members prove critical to all aspects of personal and clinical decision making during their treatment and end-of-life care.

Concluding Remarks In the introduction we challenged the possible contributions that language and communication research can make to health care practice. One option is what we have displayed here – collaborative interdisciplinarity (Sarangi, 2002). The other option is longstanding ethnographic involvement in the research site so as to understand the very setting and the professional roles and identities (Candlin, 2003; Clarke, 2003; Cicourel, 2003). It does seem true that communication skills cannot be taught or researched generically by nonclinical experts alone, as they do not have a comprehensive understanding of the complexities of medical conditions and the various aims of a consultation. Although they may have specialized knowledge of language and communication, they may have little knowledge and understanding of factual clinical content, which is necessary for their analysis to be useful to practitioners. On the other hand, communication skills are usually being taught in a prescriptive and formulaic way, with no recognition of language and communication as a discipline (Sarangi, 2004). Although the quality of clinical interaction is seen as important in training professionals, the quality of interaction is not a topic of inquiry in its own right – but there is a pressing need to combine linguistic theory with clinical practice in the context of care giving.

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Medical Discourse: Developments, 16th and 17th Centuries M Gotti, Universita` di Bergamo, Bergamo, Italy ß 2006 Elsevier Ltd. All rights reserved.

medical books published in the years 1640–1660, 207 were in English (Webster, 1975: 267).

Introduction

Epistemological and Linguistic Changes

The increasing need to use the English language for the expression of specialized texts caused a heated debate in 16th and 17th century England, as the adoption of other languages (Latin, in particular) was considered to be no longer sufficient for this purpose. The two centuries taken into consideration here are very important for the development of English medical discourse, as the years 1500–1700 mark a remarkable period of increasing use of the vernacular for medical and scientific writing. Indeed, at the beginning of this period, Latin still had a dominant role. Moreover, an analysis of the combination of Latin and English in late-medieval English medical manuscripts reveals code mixing as a widely exploited discourse strategy, one that implies a century of bilingual readership (Voigts, 1996). At the end of this period, English prevailed, and the process of vernacularization can be described as largely complete by 1500, when we can find a full range of sophisticated university treatises on medicine in English in which Latin plays little or no role. Indeed, of the 238

Great epistemological and methodological developments took place in that period, in both medicine and surgery; old scholastic thinking began to be replaced by new patterns of thought and new methodologies based on observation and interpretation of physical phenomena. These developments determined the need for corresponding changes both in the ways of communicating the new discoveries attained by means of innovative procedures and apparatus and in the expressive tool to be used to describe and argue about the new phenomena observed and analyzed. The evolution of the methods adopted in the study of medicine and the development of new surgical procedures indicated a change not only in the approach to the interpretation of the issues analyzed, but also in the way in which phenomena ought to be described and opinions expressed. Criticism was made both of how language was employed in the various processes of medical research and, in particular, of the suitability of the tool itself for an accurate, precise expression of the concepts