ABSTRACT
The main arena for medical communication can be most comprehensively viewed in terms of the doctor-patient relationship. The relationship between the patient and the doctor provides the foundations for establishing trust, rapport and understanding, explaining diagnoses, discussing prognoses, and negotiating treatment. The ways the doctor and patient use language to convey their perspectives determine how the patient’s problem is understood, as well as shaping the relationship, which can have a therapeutic value in its own right. Although there are earlier references to the nature and evolution of the relationship between
patient and doctor, the 1950s saw the start of a growing body of cross-disciplinary work to develop theoretical underpinnings of the patient-professional relationship, to produce insights into uses of language in the healthcare consultation, and to engage professionals and the public in debates to promote ‘good’ consulting behaviours and to involve patients and enable their voices to be heard. Several strands of work developed in parallel: the therapeutic nature of the doctor-patient relationship (Balint 1957); consultation activities and doctors’ consulting behaviours (Byrne and Long 1976); the concept of biopsychosocial medicine (Engel 1977); ethnographic observations of healthcare settings (e.g. Sudnow 1967). Balint’s (1957) work introduced the psychosocial element into understanding patients’ pro-
blems. Drawing on psychotherapeutic principles, Balint turned doctors’ attention to how listening to the patient and treating the patient’s language as relevant, diagnostically and therapeutically, can significantly enhance medical practice. Byrne and Long (1976) conducted a study of the primary care consultation, based on audio
recordings of over 2,000 consultations. Their research was the first to detail the structure and delivery of the healthcare consultation. They identified six consultation phases: establishing a relationship; discovering the reason for a patient’s attendance; conducting a verbal and/or physical examination; evaluating the patient’s condition; detailing treatment or further investigation; and closing. Byrne and Long’s analyses focused on doctors’ statements and practices, and treated doctors’ actions as causal. They were thus able to appraise the effectiveness of individual consultations, based on descriptions of how language is used and deployed by doctors. They observed, for example, that dysfunctional consultations tended to have less
silence. They also found that the fourth phase of the consultation (evaluating the patient’s condition) was accorded little attention by most doctors, who tended to move from examining the patient to detailing treatment ‘with hardly a word to the patient en route’ (Byrne and Long 1976: 50). Through their examination of doctors’ language use, they identified a spectrum of consulting styles, from doctor-centred to patient-centred. Sudnow (1967) conducted an ethnographic study of hospital practices in death and dying, in
two different hospitals. His observations of the words and actions of hospital staff showed how death and dying is differently pronounced for patients according to individual and sociodemographic characteristics, and how a hospital’s organisation impacted on forms of communication between staff, patients and their families. For example, Sudnow described how nurses approached the relative of a dying patient in such a way as to prepare them for what lay ahead and for meeting with the doctor, before any words were uttered. He recorded the words staff used to report a death to each other, and how their reports were differently phrased and pitched for relatives of the deceased. His identification of differential applications of terms such as ‘dead on arrival’, according to an individual’s social characteristics, highlighted social inequalities in death and dying. Understanding communication in healthcare consultations has evolved through a combi-
nation of disciplinary approaches and in response to particular societal expectations (e.g. what a patient wants from their doctor). Few of these early studies fall within the field of linguistics per se, but they all draw on language and communication to explain the complex processes housed within the doctor-patient relationship.
