In recent philosophy of mind a non-holistic view on concept possession, originally developed by Tyler Burge, has emerged as an alternative to holistic analyses of language mastery. The article discusses the implications of this view for analyses of communication in doctor—patient-interaction. The central question Burge's theory gives an answer to is this: to what extent must a doctor and a patient understand a medical term in the same way in order to communicate in the sense (...) that they express the same concept by the term? Many empirical studies have shown that patients do not, typically, understand medical terms in the same way as doctors they encounter. Holistic approaches therefore imply that doctors and patients seldom communicate. Burge's position, on the other hand, implies that it is sufficient that patients have a minimal understanding. In an important range of cases doctors can make sure that patients have a minimal understanding by being explicit about common dictionary definitions of the terms in question. (shrink)

Effective doctor patient relationships are predicated on doctors' relational engagement and affective/holistic communication with the patients. On the contrary, the contemporary healthcare and patient-clinician communication are at odds with the desirable professional goals, often resulting in dehumanization and demoralization of patients. Besides denigrating the moral agency of a patient such apathetic interactions and unprofessional approach also affect the treatment and well-being of the sufferer. Foregrounding multifaceted doctor-patient relationships, graphic pathographies are a significant cultural resource (...) which recreate the embodied moment of clinical encounters as they also lay bare qualitative tensions between patient' illness experience with doctor's professional understanding of the same. Taking these cues, the present article drawing theoretical postulates of Rita Charon, Deborah Lupton, and Havi Carel close reads Peter Dunlap-Shohl's My Degeneration: A Journey Through Parkinson's, Brian Fies' Mom's Cancer, and Stan Mack's Janet & Me: An Illustrated Story of Love and Loss to investigate the nature of doctor-patient relationship vis-à-vis communication and the implications of bad doctoring/communicative practices on patient identity and emotions. Furthermore, the article also examines the aesthetic and functional role of comics in bringing into relief the graphically mediated doctor-patient relationship. (shrink)

Hilary Putnam’s influential analysis of the ‘division of linguistic labour’ has a striking application in the area of doctor–patient interaction: patients typically think of themselves as consumers of technical medical terms in the sense that they normally defer to health professionals’ explanations of meaning. It is at the same time well documented that patients tend to think they are entitled to understand lay health terms like ‘sickness’ and ‘illness’ in ways that do not necessarily correspond to health (...) professionals’ understanding. Drawing on recent philosophical theories of concept possession, the article argues that this disparity between medical and lay vocabulary implies that it is, in an important range of cases, easier for doctors to create a communicative platform of shared concepts by using and explaining special medical expressions than by using common lay expressions. This conclusion is contrasted with the view that doctors and patients typically understand each other when they use lay vocabulary. Obviously, use of expressions like ‘sickness’ or ‘illness’ does not necessarily lead to poor communication, but it is important that doctors have an awareness of how patients interpret such terms. (shrink)

Doctor-patient interaction has gained increasing attention among sociologists and linguists during the last few decades. The problem with the studies performed so far, however, has been a lack of a theoretical framework which could bring together the various phenomena observed within medical consultations. Mikhail Bakhtin's philosophy of language offers us tools for studying medical practice as socio-cultural semiotic phenomenon. Applying Bakhtin's ideas of polyphonic, context-dependent and open-ended nature of human communication opens the possibilities to develop prevailing theoretical (...) and empirical approaches to the study of medical consultations. (shrink)

This paper throws some light on the nature of argumentation, its use and advantages, within the setting of doctor–patient interaction. It claims that argumentation can be used by doctors to offer patients reasons that work as ontological conditions for enhancing the decision making process, as well as to preserve the institutional nature of their relationship with patients. In support of these claims, selected arguments from real-life interactions are presented in the second part of the paper, and analysed (...) by means of a model of argumentation borrowed from classical rhetoric, and refined according to the modern orientation of the pragma-dialectic approach. (shrink)

The article focuses on talk and cognition in terms of action. It outlines methodological alternatives for approaches addressing meaning construction and the accounts people give of their actions. There are studies, rooted especially in phenomenology and ethnomethodology, that manifest the idea of intersubjective reality seen as achievements of situated actions. In this framework, conversation and communication are seen per se as significant forms of social action. Instead of intersubjective reality, often brought about with an inductive research method, the article argues (...) for instrumental reality as the context for understanding talk and cognition in terms of action. The aim is a method that studies multivoicedness of activity in terms of situated actions. The method integrates situational features in dialogue with the cultural-historical processes of meaning construction. It is based on the theoretical notion of activity as a system that emerges and changes in time and place through internal contradictions. In the context of instrumentality, dialogical processes are also considered historically emerging and internally conflicting processes of rationality. I discuss this method with data on conversations between a patient and a doctor at a primary health care consultation. The study considers medical knowledge less as a substance than as a historically produced perspective through which the rationality of problem solving is accomplished by doctor and patient. The study aims to break away from the epistemological dualism of conflicting domains of meaning: the one of medicine that is objective and the one of experience that is subjective. The context of instrumentality includes a working hypothesis of a zone of proximal development of the doctor-patient relationship. (shrink)

Hilary Putnam's influential analysis of the 'division of linguistic labour' has a striking application in the area of doctor-patient interaction: patients typically think of themselves as consumers of technical medical terms in the sense that they normally defer to health professionals' explanations of meaning. It is at the same time well documented that patients tend to think they are entitled to understand lay health terms like 'sickness' and 'illness' in ways that do not necessarily correspond to health (...) professionals' understanding. Drawing on recent philosophical theories of concept possession, the article argues that this disparity between medical and lay vocabulary implies that it is, in an important range of cases, easier for doctors to create a communicative platform of shared concepts by using and explaining special medical expressions than by using common lay expressions. This conclusion is contrasted with the view that doctors and patients typically understand each other when they use lay vocabulary. Obviously, use of expressions like 'sickness' or 'illness' does not necessarily lead to poor communication, but it is important that doctors have an awareness of how patients interpret such terms. (shrink)

As a way to advance integration between traditional readings of the medical encounter and argumentation theory, this article conceptualizes the doctor–patient interaction as a form of info-suasive dialogue. Firstly, the article explores the relevance of argumentation in the medical encounter in connection with the process of informed consent. Secondly, it discloses the risks inherent to a lack of reconciliation of the dialectical and rhetorical components in the delivery of the doctor’s advice, as especially resulting from the (...) less-than-ideal conditions of the internal states of the doctor and the patient, and the lack of symmetry in their status. (shrink)

Focusing on the multi-dimensionality of interactional settings, this study analyzes how the material world is a significant factor in the sequential co-production of the video-taped doctor—patient interactions. The analysis shows how a material artifact, the patient's file, is relevant in two ways: a) as a device which is employed in the sequential organization of the interaction. The patient's file is being used in the contexts of topic development and topic change. b) The file with its (...) specific physical and symbolic features is being co-produced and contested by both actors as a knowledge reservoir. Further inspection of the interactions in concert with theoretical reflections of the role of space and materiality suggests that interactions should be interpreted as happening in spatially arranged constellations of material objects and actors. In these both rigid and flexible constellations boundaries are established, access is distributed, and meaning is solidified. (shrink)

As a way to advance integration between traditional readings of the medical encounter and argumentation theory, this article conceptualizes the doctor–patient interaction as a form of info-suasive dialogue. Firstly, the article explores the relevance of argumentation in the medical encounter in connection with the process of informed consent. Secondly, it discloses the risks inherent to a lack of reconciliation of the dialectical and rhetorical components in the delivery of the doctor’s advice, as especially resulting from the (...) less than ideal conditions of the internal states of the doctor and the patient, and the lack of symmetry in their status. (shrink)

In an analysis of recent work on nudging we distinguish three positions on the relationship between nudging founded in libertarian paternalism and the protection of personal autonomy through informed consent. We argue that all three positions fail to provide adequate protection of personal autonomy in the clinical context. Acknowledging that nudging may be beneficial, we suggest a fourth position according to which nudging and informed consent are valuable in different domains of interaction.

The nature of the doctor-patient relationship as a keystone of care necessitates philosophical, psychological and sociological considerations. The present study investigates concepts related to these three critical views considered especially important. From the philosophical viewpoint, the three concepts of "the demands of ethics “,” ethical phenomenology and "the philosophy of the relationship" are of particular importance. From a psychological point of view, the five concepts of "communication behavior patterns", "psychic distance", "emotional quotient", "conflict between pain relief and truth-telling", (...) and "body language" have received specific emphasis. Lastly, from the sociological perspective, the three notions of "instrumental action", "communicative action", and "reaching agreement in the light of communicative action" are the most significant concepts to reconsider in the doctor-patient relationship. It should be added, however, that from the sociological point of view, the doctor-patient relationship goes beyond a two-person interaction, as the moral principles of doctors and patients depend on medical and patient ethics respectively. The theoretical foundations of the doctor-patient relationship will finally help establish the different dimensions of medical interactions. This can contribute to the development of principles and multidisciplinary bases for establishing practical ethical codes and will eventually result in a more effective doctor-patient relationship. (shrink)

McCabe & Healey argue that in patient‐psychiatrist interaction, the more the participants engage in repair, i.e., trying to fix potential misunderstandings, the better the outcomes of the interaction, as measured by treatment adherence and the quality of the Dr – patient relationship. This holds both for self‐repair, when psychiatrists fix their own utterances, as well as other‐repair, where patients try to fix the understanding displayed by the psychiatrist.

Despite what I wrote in my medical school applications, my relationship with medicine wasn't always the torrid love affair I made it out to be. Organic chemistry wasn't really my favorite class (or my second favorite, or my third). My heart didn't actually skip a beat as I waited for protein isolates to complete their snail‐paced race across an agarose gel. And while I certainly enjoyed the surgeries I scrubbed into as an undergraduate, even they lost their charm during the (...) fifth hour of standing at attention, hands glued to my chest, petrified I would break the sterile field or pass out from starvation. For me, a career in medicine was a leap of faith. I had to trust that those flashes of meaningful human interaction I experienced early on would increase in frequency and intensity over the course of my career. Fortunately, I have not been disappointed thus far. (shrink)

Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry (...) of authority, power and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care. Keywords: argumentation theory, informed consent, doctor-patient interaction, competency to consent, autonomy, medical paternalism. (shrink)

This article analyzes doctor–patient communication at admission interviews in an outpatient mental health care service at a public hospital in Buenos Aires, Argentina. These interviews are the first contact between professionals and patients, and they result in the admission or rejection of the latter into the medical institution. In particular, we observe how context, understood as a sociocognitive and scalar concept, is reshaped with gaze direction and agenda-setting through interaction, resulting in three hierarchical spaces which can be (...) represented as degrees in a scale: the public, the private, and the intimate level. This description will allow us to understand a series of communicative difficulties that may result from scale maladjustments, in which professionals interact with patients at different levels and therefore cannot give adequate feedback to satisfy mental health care needs. (shrink)

In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of “the” EPR needs to be replaced by an “unpacking” of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed individually. (...) Following from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three “models of patienthood” implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship. (shrink)

The purpose of this article is to present a case for the value of argumentation as an instrument of rational persuasion in doctor-patient (and general health professional–patient) communication. By doing so, I also emphasize the value of argumentation theory—as a body of knowledge devoted to the study of argumentation—both to enrich the study of doctor-patient communication and to enhance its quality by contributing to dedicated training courses for health professionals and patient education interventions. Argumentation (...) is used in health professional–patient interactions, and its significance in this context has been acknowledged in recent literature (see the collection of articles in Rubinelli and .. (shrink)

The relationship between a doctor and a patient is taken to be one of the most ethically significant dimensions of good medical care. After all, it is within the interactions that constitute this relationship that information is shared, that choices get determined, that reassurances are provided, that decisions are made and, ultimately, that care is given. Medical ethicists have devoted considerable effort to identifying different types of relationships, and in specifying their ideal components, most usually in general or (...) abstract terms. Indeed, I would suggest that medical ethicists are most comfortable when we are comparing different models of this relationship, or perhaps when advancing one account of this relationship that can provide the foundations for the most optimal approach to shared decision-making, for example by Sandman and Munthe.2 But, in truth, the doctor–patient relationship is most ethically interesting—and intellectually challenging—when scrutinised in its non-ideal forms. Ethicists who turn their attention to the front line of practice have demonstrated a tendency to see this relationship as one that is creaking at the seams, subject to manipulation or side-tracked entirely. So, is it the case that the doctor–patient relationship is under threat in contemporary medical practice? The answer to this question ought, I think, to be answered in the affirmative, though tentatively so. The role of medical ethicists is to identify precisely how such threats are materialising and to capture these in rich, detailed accounts of everyday medical encounters. Medical ethicists then also have a vital role to play in identifying and responding to these changes in a carefully reasoned way. Sometimes this is likely to involve pushing back and protecting those elements of the doctor–patient relationship that have fundamental value, regardless of context, changing social values, …. (shrink)

Though Congress passed the American Recovery and Reinvestment Act earlier this year, debate continues to swirl around the provision of funds for comparative effectiveness research. Critics warn that government bodies could use such research to dictate “appropriate” care and impose third‐party oversight so intrusive it would impinge upon the interaction between doctors and their patients. On the contrary, I believe that comparative effectiveness has the potential to strengthen the patient‐doctor relationship. How? By keeping all of us from (...) being blindsided by our own best intentions. (shrink)

Traditional moral theories of rights and principles have dominated medical ethics discussions for decades. Appeals to utilitarian consequences, as well as the principles of respect for autonomy, beneficence, and justice, have provided the standard vocabulary and filled the literature of the field.Recently on the bioethics scene, however, there has been some discussion of virtue, and, particularly within the nursing ethics literature, appeals are being made to the feminist ethics of care. This intimation of a shift in the wind may have (...) to do with postmodern doubt, or it may be attributable to the claim that virtue theory and the ethics of care are more appropriate to private interaction; theories of rights and justice are best applied to the political domain of public policy. (shrink)

The aim of this paper is to enhance doctors’ awareness of implicit understandings between doctors and patients in the context of pre-operative communication of risks. This paper draws on insights from the philosophy of language – in particular pragmatic analysis tools – that make explicit the implicit understandings of the interaction. Mastering not only _what is said_ but also _what is unsaid_ allows doctors to improve their communication with their patients. I suggest that being aware of the implications of (...) the interactions is useful for improving both the doctor’s and the patient’s experience, further strengthening the therapeutic alliance. In this article I analyze actual cases involving pre-operative evaluation before cardiac surgery from a philosophy of language perspective. The paper is structured as follows: a description of the relevant philosophy of language tools that I will apply; an overview of the risk-communication context; an explanation of the link between “the implicit dimension” and trust, addressing whether the doctor needs to convey the whole truth; and the analysis of real cases. In conclusion, I re-emphasize the importance of implicit meanings during risk communication. (shrink)

Against the usual paternalism, this article develops the proposition to structure the interaction between the doctor and the patient as an inter-subjective consultation. This means that the "information" of the patient prior to treatment, when "informed consent" is secured, as well as the actual medical treatment would have to be turned into an interaction between two responsible individuals. The "irresponsibility" of this patient, which is supposed to result from his "uninformedness", as is often argued (...) in favour of keeping to paternalism, does not have to lead to an interaction model of prescription and compliance. Even for the interaction with patients who are unable to understand or consent, the concept of dialogical interaction must be maintained counterfactually; it has only to be supplemented by the variant of "tutorial action". The prescriptive model of behaviour is extended by the obligation—even when the doctor is the sole decision maker—of acting in the well-understood self-interest of the patient and, if necessary, of providing evidence for this orientation of the treatment. Thus, the model of dialogical interaction is shown to be the comprehensive model, because it covers the interests of the doctor and of the patient. (shrink)

This article focuses on how solidarity is negotiated in interactions during medical visits between nurse practitioners and patients. Drawing on data from ethnographic field notes, audio-recorded interactions and interviews involving one NP and 20 patients, the article outlines ways in which the NP creates a sense of solidarity by lessening the social distance between herself and her patients. These attempts at solidarity do not correlate with what has been noted in previous studies of medical visits involving medical doctors and may (...) represent a difference in how both the NP and the patients view the NP as a mid-level provider. As NPs are taking on a more prominent role in the healthcare landscape, it is important to understand what the interactional norms are and how these may deviate from the norm set by MDs. (shrink)

Objective: To assess the opinions and practice patterns of obstetrician-gynaecologists on acceptance and use of free drug samples and other incentive items from pharmaceutical representatives.Methods: A questionnaire was mailed in March 2003 to 397 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.Results: The response rate was 55%. Most respondents thought it proper to accept drug samples , an informational lunch , an anatomical model or a well-paid consultantship from pharmaceutical representatives. A (...) third of the respondents thought that their own decision to prescribe a drug would probably be influenced by accepting drug samples. Respondents were more likely to think the average doctor’s prescribing would be influenced by acceptance of the items than theirs would be . Respondents who distributed drug samples to patients indicated doing so because of patients’ financial need and for their convenience and less so as a result of knowledge of the efficacy of the sample product . A third of respondents agreed that interactions with industry should be more strictly regulated.Conclusion: Obstetrician-gynaecologists largely indicated that they would act in accordance with what they think is proper regarding accepting incentive items from pharmaceutical representatives. Although accepting free drug samples was considered to be appropriate more often than any other item, samples were most commonly judged to be influential on prescribing practices. The widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully. (shrink)

As physicians encounter an increasingly diverse patient population, socioeconomic circumstances, religious values and cultural practices may present barriers to the delivery of quality care. Increasing cultural competence is often cited as a way to reduce healthcare disparities arising from value and cultural differences between patients and providers. Cultural competence entails not only a knowledge base of cultural practices of disparate patient populations, but also an attitude of adapting one's practice style to meet patient needs and values. Gender (...) roles, relationship dynamics and boundaries are culture specific, and are frequently shaped by religious teachings. Consequently, religion may be conceptualised as a cultural repertoire, or dynamic tool-kit, by which members of a faith adapt and negotiate their identity in multicultural societies. The manner in which Islamic beliefs and values inform Muslim healthcare behaviours is relatively under-investigated. In an effort to explore the impact of Islam on the relationship between patients and providers, we present an Islamic bioethical perspective on cross-gender relations in the patient-doctor relationship. We will begin with a clinical scenario highlighting three areas of gender interaction that bear clinical relevance: dress code, seclusion of members of the opposite sex and physical contact. Next, we provide a brief overview of the foundations of Islamic law and ethical deliberation and then proceed to develop ethicolegal guidelines pertaining to gender relations within the medical context. At the end of this reflection, we offer some practice recommendations that are attuned to the cultural sensitivities of Muslim patient populations. (shrink)

The latest book is a timely application of the Pragma-Dialectical argumentative approach to medical consultation. The book consists of six chapters, which are concerned with topics pertaining to resolving differences of the opinion in doctor-patient interaction. With the publication of the book, the authors have made new contributions to the field of doctor-patient argumentative discourse.

As physicians encounter an increasingly diverse patient population, socioeconomic circumstances, religious values and cultural practices may present barriers to the delivery of quality care. Increasing cultural competence is often cited as a way to reduce healthcare disparities arising from value and cultural differences between patients and providers. Cultural competence entails not only a knowledge base of cultural practices of disparate patient populations, but also an attitude of adapting one's practice style to meet patient needs and values. Gender (...) roles, relationship dynamics and boundaries are culture specific, and are frequently shaped by religious teachings. Consequently, religion may be conceptualised as a cultural repertoire, or dynamic tool-kit, by which members of a faith adapt and negotiate their identity in multicultural societies. The manner in which Islamic beliefs and values inform Muslim healthcare behaviours is relatively under-investigated. In an effort to explore the impact of Islam on the relationship between patients and providers, we present an Islamic bioethical perspective on cross-gender relations in the patient-doctor relationship. We will begin with a clinical scenario highlighting three areas of gender interaction that bear clinical relevance: dress code, seclusion of members of the opposite sex and physical contact. Next, we provide a brief overview of the foundations of Islamic law and ethical deliberation and then proceed to develop ethicolegal guidelines pertaining to gender relations within the medical context. At the end of this reflection, we offer some practice recommendations that are attuned to the cultural sensitivities of Muslim patient populations. (shrink)

It describes and explains the patient-centered model examining and evaluating qualitative and quantitative research. It comprehensively covers the evolution and the six interactive components of the patient-centered clinical method, taking the reader through the relationships between the patient and doctor and the patient and clinician. All the editors are professors in the Department of Family Medicine at the University of Western Ontario, London, Canada.

The global crisis of the COVID-19 pandemic has considerably accelerated the adoption of teleconsultation—a form of consultation between patient and health care professional that occurs via videoconferencing platforms. For this reason, it is important to investigate the way in which this form of interaction modifies the nature of the clinical encounter and the extent to which this modification impacts the healing process. For this purpose, I will refer to insights into the clinical encounter as a face-to-face encounter drawn (...) from the phenomenology of medicine (R. Zaner, K. Toombs, E. Pellegrino). I will also take into account a criticism that has been expressed by various contemporary phenomenologists (H. Dreyfus, T. Fuchs, L. Dolezal, H. Carel), namely, that due to the lack of physical proximity to the other in all types of online encounters, such encounters lack significant features that are present in face-to-face encounters, with the most important of these being the possibility of attaining an empathetic perception of the other and a sense of embodied risk. As these elements are essential features of the clinical encounter, the aim of this paper is to determine whether teleconsultation exhibits these features. To do that, I will integrate phenomenological philosophy with qualitative research drawing materials from both the philosophical tradition, particularly with respect to the concepts of the face-to-face encounter and embodied risk (A. Schutz and H. Dreyfus), and qualitative research study regarding patient experiences of teleconsultation. I will argue that teleconsultation does involve both the possibility of perceiving the other empathetically and the possibility of experiencing a sense of embodied risk. (shrink)

Nurses need to adapt to various interactional situations and design their talk for different recipients. One essential communicative task for nurses is to transmit information on test and measurement results both to the patient and to the physician. This article examines how nurses design their talk on numerical values according to the recipient and the activity. The nurse can deliver the information either plainly through numbers or by formulating some type of qualitative description of the value. The data consist (...) of 7.5 hours of video-recorded interaction in a Finnish hospital. Using conversation analysis, we demonstrate how the institutional roles and the ongoing activity sequence affect how nurses formulate their talk. When nurses discuss results with their patients, they typically use qualitative descriptions, whereas when they talk with doctors, the typical turn involves numeric information. It will be demonstrated that nurses construct their professional identity involving both care and medical expertise through their linguistic-interactional choices. (shrink)

A growing number of scholars have suggested that there is a unique I-You relation that obtains between persons in face-to-face encounters, but while the increased attention paid to the second-person has led to many important insights regarding the nature of this relation, there is still much work to be done to clarify what makes the second-person relation distinct. In this paper we wish to develop recent scholarship on the second-person by means of a phenomenological analysis of a doctor-patient (...) interaction. In such an interaction the doctor and patient continuously shift between the observational I-It and the interactive I-You, and recognizing the difference between observation and interaction not only helps to defend the claim that this relation is sui generis, but also uncovers the co-constitution of experience from within this relation. As we argue, engaging another second-personally involves a shared experience that is a result of incorporating the other’s mental states into one’s own while standing in the second-person relation. (shrink)

A growing number of scholars have suggested that there is a unique I-You relation that obtains between persons in face-to-face encounters, but while the increased attention paid to the second-person has led to many important insights regarding the nature of this relation, there is still much work to be done to clarify what makes the second-person relation distinct. In this paper we wish to develop recent scholarship on the second-person by means of a phenomenological analysis of a doctor-patient (...) interaction. In such an interaction the doctor and patient continuously shift between the observational I-It and the interactive I-You, and recognizing the difference between observation and interaction not only helps to defend the claim that this relation is sui generis, but also uncovers the co-constitution of experience from within this relation. As we argue, engaging another second-personally involves a shared experience that is a result of incorporating the other’s mental states into one’s own while standing in the second-person relation. (shrink)

Extending literature on health information to entertainment television, we analyze the prostate cancer narrative presented in the police drama, NYPD Blue. We explain how the physician-patient interaction depicted on the show followed (and sometimes did not follow) the medical dialogue model. Findings reveal that the producers of this show advocate a more dialogic model of medical interaction. Portrayals of incompetent, ineffective physicians are contrasted with the superior, effective efforts of other physicians. The audience learns that a non-dialogic (...) approach characterizes “bad doctors,” while the dialogic method typifies “good doctors.” Likewise, medical professionals can use such texts to enhance physician-patient interaction. (shrink)

The relations of power between healthcare-related institutions and the professionals that interact with them are changing. Generally, the institutions are gaining the upper hand. Consequently, the intellectual abilities necessary for professionals to pursue the internal goods of healthcare are changing as well. A concrete case is the struggle over sickness benefits in Sweden, in which theSwedish Social Insurance Agency(SSIA) and physicians are important stakeholders. The SSIA has recently consolidated its power over the sickness certificates that doctors issue for their patients. (...) The result has been a stricter gatekeeping of sickness benefits. In order to combat the inroads made by state institutions into sickness certification, and into the sphere of medical practice, some doctors have developed cunning “techniques” to maximize the chance to have their sickness certificates accepted by the SSIA. This article attempts to demonstrate that cunning intelligence—the ability of the weak to “outsmart” a stronger adversary—plays an important role in the practice of medicine. Cunning intelligence is not merely a defective form of prudence (phronesis), nor is it simply an instance of instrumental reason (techne), but rather an ability that occupies a distinct place among the intellectual abilities generally ascribed to professionals. (shrink)

Purpose: To explore the characteristics of the use of laughs and jokes during doctor-couple assisted reproductive technology visits.Methods: 75 videotaped doctor-couple ART visits were analyzed and transcribed in order to: quantify laugh and jokes, describing the contribution of doctors and couples and identifying the timing of appearance; explore the topic of laughs and jokes with qualitative thematic analysis.Results: On average, each visit contained 17.1 utterances of laughs and jokes. Patients contributed for 64.7% of utterances recorded. Doctor and (...) women introduced the majority of laughs and jokes. Visits with female physicians had significantly more laughs and jokes than visits with male doctors; no differences were found considering physicians’ age and years of experience, cause of infertility, and prognosis. Laughs and jokes were mainly recorded during history taking and information giving. Four core themes were identified, regarding the topic of laughs and jokes: health status, infertility treatment, organizational aspects, and doctor-patient interaction.Conclusion: Laughs and jokes are common in doctor-couple ART visits and are frequently used during the dialogue, covering a wide range of topics. Results seem to show that laughs and jokes are related to doctor’s personal characteristics, while are not associated with infertility aspects. Given the complexity of this communicative category, further studies are needed to explore the functions and the effects of laugh and jokes. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Patient, TeacherMarissa BlumI remember meeting Beatriz about 12 years ago when security was called to her office visit room by the fellow doctor-in-training who was seeing her. She was yelling loudly about her pain medications, causing a terrific commotion. I stepped in to relieve the fellow and tried to calm her down and move the visit along without anyone getting hurt or further upset. And from (...) then on, Beatriz was moved to my schedule from the fellow's for her monthly visits for her knee pain and refills of fentanyl and oxycodone. She had terrible knees and walked with a cane, almost always accompanied by her son. At one point, she came to our clinic asking to be seen but couldn't, and then fell onto her knees and rolled onto her back in the wait-room, clutching and waiving her cane, expelling expletives and railing at anyone who wanted to help but denying them that privilege. It was as though she relished exposing her pain and a lifetime of hardship for all to confront. I came down from my office to talk with her and when I couldn't convince her to get up on her own, we called EMS to assist and they took her away in an ambulance.For the first few years, I recoiled seeing her name on my schedule each month. I knew I would have to endure a barrage of labile emotions and complaints not just about her constant pain and feelings of inadequacy of her pain medications, but also about her other doctors and how they don't respond to her, or about how the rest of her family shows no care for her. Initially, these visits were hard because they were unpredictable and Beatriz also had bipolar disorder and maybe borderline personality too. I never knew which type of Beatriz I would walk in to see: Angry, tearful, lamentful, and all of those faces were difficult for me. But we met every month for years. During those visits, which almost always were attended by her son, who quietly sat by to either gently rebuff or passively agree with her, I learned so much about her and her very hard life. She was left to raise two children alone, unskilled and ill with hepatitis C, which led to liver cancer, followed later by breast cancer. She chose not to pursue additional therapy for breast cancer, expressing a fatalistic view of her life and intimating she in some way deserved the ailments that she developed. She saw me for disabling knee and hip arthritis that took away her independence and ability to scale the outdoor steps to her second-floor apartment and required the assistance of her son to dress, bathe and care for her. Beatriz never knew this, and I didn't share [End Page 18] it with her, but on one of my early morning drives into North Philadelphia, I saw her on a sun-baked unfriendly street, struggling to move around with her walker. She had many reasons to be angry, and the 30 minutes I spent with her every month became a catharsis for her to unload all that she felt.During my medical training, I encountered hundreds of patients—mostly all in the hospital setting—who might be characterized as difficult and understandably; no one who is relegated to the hospital setting, acutely or chronically ill and requiring inpatient care, could possibly be in the best mood of their lives. Somehow, it was easier for me to care for patients in these snapshot encounters that I controlled. I dictated my time in the room and didn't necessarily have to encounter the same challenging patient longitudinally, which made certain encounters much easier to bear. I realize now I wasn't fully processing the burdens carried by these patients in a way that enabled me to be a compassionate and fully present physician to them. It was an adaptation to the fast-paced life of residency, where one just has to get the job done and move on to the next task without time to process or reflect on difficult patient interactions. This is a... (shrink)

In an everyday private practice setting, regularly also existential topics will emerge from doctor-patient encounters. These are often questions of coping with life and lifestyle. To enable a thorough discussion of such topics, an implicit, and sometimes also explicit reference to a philosophical background is needed. Philosophical concepts to be used in this realm are discussed. An individual patient-doctor interaction is used as an example to demonstrate the doctor’s choice of hermeneutical and phenomenological philosophical (...) concepts. (shrink)

In an everyday private practice setting, regularly also existential topics will emerge from doctor-patient encounters. These are often questions of coping with life and lifestyle. To enable a thorough discussion of such topics, an implicit, and sometimes also explicit reference to a philosophical background is needed. Philosophical concepts to be used in this realm are discussed. An individual patient-doctor interaction is used as an example to demonstrate the doctor’s choice of hermeneutical and phenomenological philosophical (...) concepts. (shrink)

Based on two years’ ethnographic research on doctor-patient relations in urban China, this paper examines the causes of patients’ mistrust of physicians. I identify the major factors at the societal, institutional, and interpersonal levels that lead to patients’ mistrust of physicians. First, I set the context by describing the extent of mistrust at the societal level. Then, I investigate the institutional sources of mistrust. I argue that the financing mechanism of public hospitals and physicians’ income structures are the (...) most crucial factors in inducing patients’ mistrust. Hospitals’ heavy reliance on self-finance has basically caused public hospitals to run like private hospitals, resulting in blatant conflicts of interest between hospitals and patients. Related to this is physicians’ reliance on bonuses and commissions as part of their regular incomes, which has inevitably resulted in overtreatment and, hence, mistrust from the patients. At the interpersonal level, I describe how individual physicians’ attitudes toward and interaction with patients may also affect patients’ sense of trust or mistrust in physicians. In conclusion, I discuss the ethical implications of the mistrust problem, and suggest changes at the institutional and interpersonal levels to mitigate the problem. (shrink)

In China, state investment into public hospitals has radically decreased since the early 1980s and has brought on the dismantling of the healthcare system in most parts of the country, especially in rural areas. As a result of this overhaul, the majority of public hospitals have needed to compete in the so-called socialist market economy. The market economy stimulated public hospitals to modernize, take on highly qualified medical professionals, and dispense new therapies and drugs. At same time, liberalization has clearly (...) affected the attitude and behavior of both medical professionals and the general public. The public has many concerns about the healthcare system for various reasons: there are long hospital waiting lists, patients experience difficulties in obtaining an appointment to see a qualified doctor, and, over the past decades, there has been an increase in out-of-pocket healthcare expenditure. These and other changes in post-reform China have radically reshaped the doctor–patient interaction, which is increasingly eroded by tension and violence. (shrink)

This paper addresses two research questions. The first is theoretical: What is trust? In the first half of this paper we present a distinctive tripartite analysis. We describe three attitudes, here called reliance, specific trust and general trust, each of which is characterised and illustrated. We argue that these attitudes are related, but not reducible, to one another. We suggest that the current impasse in the analysis of trust is in part due to the fact that some writers allude to (...) these distinctions, but unclearly so, whilst others elide them altogether. The second research question focuses on doctor–patient interaction. Trust is often said to be central in medical encounters but this strikes us as too vague. The success of doctor–patient relations in part depends on adopting the most appropriate of the three attitudes we delineate. We argue that reliance is the appropriate attitude for most medical encounters. When circumstances do require trust, the distinction between specific trust and general trust is crucial. We describe medical encounters requiring specific trust. General trust is less often required in medicine; but it is appropriate in some cases and, when called for, it is called for strongly. (shrink)

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system–paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide ‘high-value, cost-conscious care’ (HVCCC), which proponents believe is the future of sustainable (...) medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors’ professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients–redefining the currency of value from monetary costs to a patient’s quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation. (shrink)

In the United Kingdom (UK), ethical guidance for doctors assumes a therapeutic setting and a normal doctor–patient relationship. However, doctors with dual obligations may not always operate on the basis of these assumptions in all aspects of their role. In this paper, the situation of UK occupational physicians is described, and a set of models to characterise their different practices is proposed. The interaction between doctor and worker in each of these models is compared with the (...) normal doctor–patient relationship, focusing on the different levels of trust required, the possible power imbalance and the fiduciary obligations that apply. This approach highlights discrepancies between what the UK General Medical Council guidance requires and what is required of a doctor in certain roles or functions. It is suggested that using this modelling approach could also help in clarifying the sources of moral conflict for other doctors with “dual obligations” in their various roles. (shrink)

Patients’ perception with regards to their use in medical teaching is an under-researched area in Pakistan. The objective of this qualitative, pilot study was to determine the perspectives of hospital admitted patients on their being used in the medical education of students in a private medical institution. An attempt to understand the dynamics of interactions between patients, students and doctors was also made and to see how this affected the doctor-patient relationship. A qualitative study with in-depth interviews was (...) conducted in a private medical college of Islamabad, Pakistan with a total of 20 adult patients. The focus was on their experiences with bedside teaching. This pilot study reveals interesting findings about patient-physician interactions in Pakistan. Patients had a traditionally passive role in medical education putting more onuses on the doctor to impart knowledge to the medical students. Patients comforted themselves in the knowledge that they were following Allah’s command when they were involved in the teaching of medical students. The apparent altruism of Pakistani patients in this study was influenced mainly by religious reasons, following the commandments of Allah to help develop future healers for humanity. The culture evident in the medical college where this study was conducted is reflective of the social power ladders that pervade Pakistani society. The positions of doctors and medical teachers in Pakistani society are hardly challenged to debate. Little attention has been paid to the values that influence the cultural and social frameworks within which Pakistani medical teachers, medical students and the patients function. (shrink)

Aim: Streamlining consent for low-risk comparative effectiveness research (CER) could facilitate research, while safeguarding patients' rights. Materials & methods: 2618 adults were randomized to one of seven consent approaches (six streamlined and one traditional) for a hypothetical, low-risk CER study. A survey measured understanding, voluntariness, and feelings of respect. Results: Participants in all arms had a high understanding of the trial and positive attitudes toward the consent interaction. Highest satisfaction was with a streamlined approach showing a video before the (...) medical appointment. Participants in streamlined were more likely to mistakenly think a signature was required. Conclusion: Streamlined consent was no less acceptable than traditional, signed consent. Streamlined and traditional approaches achieved similar levels of understanding, voluntariness and a feeling that the doctor–patient interaction was respectful. (shrink)

There is an increasing recognition internationally of the critical impact of communication within healthcare. The link between ineffective communication, patient dissatisfaction and critical incidents is well established. Family Planning New South Wales has sought to address patient-centred care and communication in its policy platform. This article reports on research conducted within FPNSW, which analysed the discourse features that constituted effective doctor–patient1 communication in sexual and reproductive health consultations. The principal aim of the research was to understand how (...) effectively messages were conveyed and received and to what degree patients were active participants in their own sexual healthcare. Analysed consultations were characterised by extremely high levels of communicative competence on the part of the doctors who integrated medical expertise with the development of interpersonal relationships with patients, thus positioning patients as active contributors to the consultations and to decisions about their ongoing treatment. The detailed linguistic analysis identified characteristic features of patient-centred communication that are essential to patient-centred care. These interactions demonstrate that communicating care is just as important as delivering care and involves a drawing together of the medical and the interpersonal in consultations. The article details strategies for interweaving medical knowledge and establishing rapport that can inform practitioner communication practices across different healthcare contexts. (shrink)