“病理檢查證實是惡性腫瘤！”：從癌友確診敘述看台灣醫療人員顯要性與個人性之消失

＂The pathological examination verified it as a malignant tumor!＂ Discourse Analysis of the Loss of Medical Professionals' Visibility and Individuality in Cancer Patients' Diagnosis Narratives in a Taiwanese-based Online Forum

吳諾瑋 ； 蔡美慧 ； 王秀雲

《人文社會與醫療學刊》 5期 (2018/05) Pp. 79-114

摘要

十八世紀末現代醫院興起後，醫學知識的生產模式進入「醫院醫學時期(Hospital Medicine)」，病患被化約為細胞與病灶，逐漸消失於醫病關係中(Jewson 1976)。二十世紀下半期醫療體系經歷了「科技化(technoscientific)」轉型，朝向醫療複合體發展(Clarke et al 2003)，對醫病關係造成另一波改變，然而相關研究卻十分有限。另外，在網路發達的時代，網路健康論壇提供病友一個可於線上群聚集並分享個人經驗的重要社交平臺，而病患於平台上分享他們疾病經驗的敘事( illness narratives)提供我們另一種從病方角度探討醫療人員角色的管道。本文以臺灣國內著名的社交網路討論區-電子佈告欄(BBS)為語料來源，蒐集61個抗癌看板中癌症版友描述罹癌診斷的經歷(「確診敘事」)。透過言談分析，本文探討癌友如何稱呼(指涉)為其執行各種醫療行為的醫療人員?這些醫方指稱詞的使用模式如何反映癌友敘述的世界中，醫療人員所扮演的角色?主要結果如下。在真實世界中扮演所有醫療行為必要主事者的「醫療人員」，在癌友的敘述世界中有逐漸被「醫療地點」與「醫療工具」取代的趨勢，例如在描述操作性的醫療事件中，以地點做為敘述子句主題的比例最高(36%，“醫院幫我做了徹底的檢查”，而在確診性醫療事件中，則以工具出現於主題位置的比例最高(47%，“病理檢查證實是惡性腫瘤”)。我們稱此二現象為「操作機構化」與「確診器械化」，並論證當代台灣醫療走向龐雜而先進的複合體趨勢下，使得如癌症的重症診斷過程必須標準化與團隊化，卻也導致醫療人員顯要性與個人性的消失。

關鍵字

醫療人員執事性 ； 顯要性與個人性 ； 指稱詞 ； 確診敘述 ； 言談分析

並列摘要

As the production mode of medical knowledge in the late 18th century moved on to the stage of ＂hospital medicine＂ and ＂laboratory medicine＂, patients were generalized as lesions, and symptoms and disappeared from the medial cosmology (Jewson 1976). While the medical system in the late 20th century has gone through a second major change of ＂technoscientization＂, its impact on doctor-patient relationship has not fully been explored previously. Also, as internet health forums have become an important social media platform where patient groups gather, their online discourse, such as illness narratives, provides an alternative window to explore the roles of medical professionals from the patients' perspectives. Using discourse analysis, the current study examines 61 patients' narratives of their cancer diagnosis (＂diagnosis narratives＂) collected from a popular online bulletin board system in Taiwan. We examine two issues: how the medical professionals who had participated in the various medical events or procedures that patients have gone through are referred in the patients' diagnosis narratives, and how the discourse pattern of the use of these reference terms reflects the roles of the medical professionals in the patient's narrative world. Our main findings show that, in spite of the medical professionals' legitimate agency in all medical events that patients have gone through, such agency tends to be replaced by ＂instruments＂ or ＂institutions.＂ For examples, most of the topic positions of narrative clauses describing an operational event are taken by a medical institution (36%, e.g., ＂The hospital did a thorough examination for me＂), and that of clauses describing diagnostic events by a medical instrument (47%, e.g., ＂The pathological examination verified it as a malignant tumor＂). We term these two discourse patterns as ＂the institutionalization of medical procedures＂ and ＂the technoscientifization of diagnosis＂ and further argue that as the modern medical system in Taiwan has transformed into a 'medical complex' involving various specialties and high-tech equipment, it inevitably leads to a team-based and standardized diagnosis of severe diseases such as cancer and the disappearance of medical professionals' visibility and individuality.

並列關鍵字

medical professionals' agency ； visibility and individuality ； reference terms ； diagnosis narratives ； discourse analysis