醫師之溝通策略—以醫學中心之眼科門診為例

A Physician’s Communicative Strategies in an Ophthalmological Clinic in a Medical Center

許學旻(Hsueh-Min Hsu)

指導教授 ： 陳端容

國立臺灣大學/公共衛生學院/健康行為與社區科學研究所/碩士(2018年)

https://doi.org/10.6342/NTU201804097

摘要

本研究藉由剖析實際的醫病溝通，提供一個從醫療現場研究醫病關係的觀點，並關注於醫病溝通間醫師、病人與陪同者相互協商與共同建構的溝通過程。由於醫療參與者間知識與權力不對等，導致在看診時，彼此為了達到各自的溝通目的而使用不同的溝通策略。希望能藉由分析臨床上實際的問診過程，反映出台灣現今醫病關係的現況，進而增進醫病溝通的可能。
Armstrong (1984)從社會行為的角度出發，指出病人的觀點、病患的主體性是醫學與社會科學的研究重點。受到行為科學的影響，從七十年代起，醫病溝通的研究在西方已蓬勃發展數十年，雖然台灣的醫學教育與體系承襲西方醫學，但醫病溝通除了受到醫療參與者知識不平等與權力拉鋸的影響，文化與社會的因素也深具影響力。在台灣特殊的醫療環境之下，看診時間相對的短，如何能在一個具有時間壓力的情況下藉由交換資訊來完成有效良好的溝通，替病患正確的診斷，回答病患的擔憂，找到最適切的醫療處置，達到醫病共決，並增加病人遵醫囑的接受度，著實需要醫療參與者的智慧與相互配合。
本研究為觀察型的研究，並採用質化與言談分析的方式來分析門診間的口語溝通策略，藉由剖析醫師、病患與陪同者間共同構築而成的協商，來探究參與者實際的溝通目的。本研究在北部一間醫學中心的眼科門診執行，總共有68位患者參與本研究，28位男性，40位女性，陪同者共有23位，6位妻子、5位先生、9位女兒、1位兒子與1位女性友人。在問診過程中，醫師使用了至少13種口語溝通策略來溝通協商。這些溝通策略主要可以分為三個部分：(1) 提供訊息 (providing information)，(2) 醫療決定 (treatment decision-making)，(3) 藉由語言表達來弱化嚴重程度，或是拉近與聽者關係的其他口語溝通策略。其中，第三類的口語溝通策略出現的次數最多，佔的比例最高 (57%)，其次是治療決策的時候 (26%)，較少的是出現在資訊提供的階段，佔總體策略的16%。
本研究的目標是希望能呈現醫師面對不同患者在訊息提供與醫療決策的階段，為了特定的溝通目的，所使用的不同口語溝通策略。透過實際問診過程的分析，在台灣特殊的文化背景下，提供醫療參與者與研究者一個不同的視角，從實際溝通的內涵與醫療現場出發，剖析醫病協商的現況與重要性，以期在未來達到更平等、和諧的醫病溝通與醫病關係。

關鍵字

醫病溝通 ； 醫病言談 ； 醫師病人陪同者 ； 權力

並列摘要

This study investigates face-to-face doctor-patient communication and aims to provide a different viewpoint of doctor-patient relationships. It illustrates doctor-patient communication as a negotiated and co-constructed process between the doctor, patients, and patients’ companions. Due to their power asymmetry, the participants use different verbal strategies to achieve their communicative goals. Through examining the consultations, we hope to demonstrate the doctor-patient relationships in Taiwan and to find a way to improve doctor-patient communication.
Armstrong (1984) pointed out that the patient’s view and their subjectivity should be the focus of medical practice and social science research. Researches related to doctor-patient communication have incredibly increased in the past few decades in the West. Medical education and system in Taiwan have also adapted accordingly. Studies have shown that communication between doctors and patients is influenced by their institutional power asymmetry. In Taiwan, one consultation is relatively short so it needs effort and skills to achieve good communication under the time pressure. How can doctors exchange information, diagnose correctly, answer patient’s questions and relieve their concerns, give medical recommendations, and decide medical treatments with the patients becomes very important.
In this study, we analyze qualitatively through Discourse Analysis to show how the doctor, the patients, and their companions co-construct communication during their negotiations. This research is conducted in an eye clinic in a medical center in Northern Taiwan. There are in total 68 patients (28 males and 40 females), and 23 companions (6 wives, 5 husband, 9 daughters, 1 son, and 1 female friend) in this study. The doctor uses at least 13 kinds of verbal communication skills to negotiate with the participants. These communication strategies can be categorized into three parts: (1) providing information, (2) treatment decision-making, and (3) other verbal communication strategies. The frequency of other verbal communication strategies takes up 57% of all the verbal strategies. The strategies in treatment decision-making phase are 26%. In the stage of providing information, the frequency is 16%.
The goal of this study is to show how an experienced doctor uses different verbal communication strategies when facing different kinds of patients and for different communicative purposes. Through the analysis of the consultations and under our unique cultural and social background, the study provides a different perspective for us to understand the importance of doctor-patient communication and to create more equal and harmonious doctor-patient relationships in Taiwan.

並列關鍵字

doctor-patient communication ； medical discourse ； doctor-patient-companion communication ； power

參考文獻

Ainsworth-Vaughn, N. (1995). Claiming power in the medical encounter: the whirlpool discourse. Qualitative health research, 5(3), 270-291.

Annas, G. J., & Healey Jr, J. M. (1974). The Patient Rights Advocate: Redefinig the Doctor-Patient Relationship in the Hospital Context. Vand. L. Rev., 27, 243.

Anzilotti, G. I. (1982). The rhetorical question as an indirect speech device in English and Italian. Canadian Modern Language Review, 38(2), 290-302.

Armstrong, D. (1984). The patient's view. Social science & medicine, 18(9), 737-744.

Aronsson, K., & Rundström, B. (1988). Child discourse and parental control in pediatric consultations. Text-Interdisciplinary Journal for the Study of Discourse, 8(3), 159-190.