Tsai, Mei-Hui. 2006. Opening Hearts
and Minds: A Linguistic Framework for Analyzing Open Questions in
Doctor-Patient Communication (使君傾言:
醫病溝通中開放式問句之語言學分析.
Abstract
Medical
professionals use ‘open questions’ to avoid two prevalent and frustrating
communication problems: doctor-patient non-concordance and hidden agenda. This
research examines two issues. What information about patient problems are
doctors’ open questions designed to solicit? What semantic and syntactic
elements in an open question encourage patients to present their physical
problems and to reveal their psychosocial concerns?
Key words: discourse
analysis; doctor-patient communication; open questions; doctor-patient
non-concordance; hidden agenda; indefinite
摘要
因流鼻水而至醫院求醫者，其就醫動機可能不只為感冒而是擔心禽流感，這樣的動機通常不會在一開始就表達甚至隱而未提，也因此造成醫病雙方對於求醫目的與病情資訊之認知差異。問診教學建議醫師使用開放式問句避免上述溝通問題，但什麼樣的問句可開放到鼓勵病人傾言盡訴？本書從語言角度切入此議題，界定病情資訊之範疇，定義開放式問句並檢視其句法結構與語意成份。
關鍵詞：言談分析、醫病溝通、開放式問句、醫病認知差異、戴面具病人、話題範疇未定性
Abstract
Two
pressing communication problems in medical consultations are well-noted:
doctor-patient non-concordance and hidden agenda—doctors fail to identify
patients’ principle problems and patients fail to voice their major concerns.
These two problems often lead to inadequate and inefficient health care,
because what patients suffer from is not addressed and what patients care about
is not discussed. Open questions are advocated by medical educators as one of
the solutions to avoid these communication problems; however, far less
attention has been devoted to a systematic analysis of open questions. This
research aims to fill these deficiencies from two perspectives:
(1) What patient
problems are doctors’ open questions designed to elicit? That is, what are the
ranges of patient problems that open questions are to solicit so that
communication problems of non-concordance and hidden agendas can be avoided?
(2) How open is an open
question? That is, how are open questions linguistically structured in the way
that they offer discourse opportunities for patients to bring up all their
problems and concerns?
Extending from the above
two research foci are four inter-related questions.
(1)
What are patient problems?
(2)
What are open questions?
(3)
What are the semantic and syntactic components of open questions?
(4)
How are health-information-seeking utterances different from greeting
expressions?
By
reviewing communication problems documented in medical literature and examining
thirty video-taped medical encounters among doctors of family medicine, elderly
patients, and patients’ companions, situated in a teaching hospital in Southern
Taiwan, this research concludes the following: Patient problems are grouped
into two categories: biophysical and psychosocial problems including physical
abnormalities that patients experience, acknowledge, or not acknowledge;
lifestyle and significant social events contributing to patient’s sickness;
psychosocial concerns motivating patients’ health seeking behavior; and
expectation or desires formulated by patients to cure their disease and to
release their worries.
‘Open’
questions to solicit the two above categories of patient problems convey the
two core meanings of ‘non-directive/indefinite’ and ‘revealing/ventilating’.
Based on these two senses, three types of open questions are defined as general
open Qs, biophysical open Qs, and psychosocial open Qs. A psychosocial open Q
is designed to encourage patients to reveal the concerns they have or to
ventilate the pressures they have gone through. The proposition of a
psychosocial open Q contains semantic elements of ‘negative psychosocial
statuses’ or ‘non-neutral evaluation on patients’ psychosocial statuses’. By
verbalizing a negative situation (e.g., ‘did you find yourself emotionally
distressed recently’) or a non-neutral evaluation of the patients’ situation
(e.g., ‘no children are staying around to keep you company’ or ‘why did you
traveled so far for medical help’), doctors’ use of a psychosocial open Q
serves as a coherent discourse device for patients to bring up any psychosocial
situation that qualifies for either of the two elements.
The
core semantic component of general or biophysical open questions is
‘indefinite/non-directive’ A general open Q is defined as an utterance in which
the range of patient problems covers all possible patient problems without
mentioning a specific one (e.g., ‘what brings you here today’). A biophysical
open Q is defined as an utterance in which the range of patient problems covers
patients’ all possible biophysical status, including physical abnormalities,
medications, physical examinations report, or family health history and its semantic
proposition should not contain the mention of any specific biophysical status
(e.g., ‘what physical problems do you have’).
In
analyzing the syntactic elements of general or biophysical open Qs, seven
formats are identified, including ‘wh-Q’ format (‘what brings you here today’),
‘yes-no Q’ format (‘do you have any questions or concerns’), indefinite
enumeration format (‘do you have hypertension, diabetes, or anything like
that’), ‘tell me’ format (‘tell me the symptoms you have’), ‘any other’ format
(‘have any other’), ‘and’ format (‘and’). Among them, the ‘wh-word’ format is
the most common one. The ‘yes-no’ format, which is referred to as a ‘closed
question’ in the literature, is pragmatically an open Q. In some cases, an open
Q does not need to be in an interrogative form or intonation at all (e.g., the
‘tell me’ format’). In some cases, open questions are in syntactically
truncated forms (e.g., ‘any other’) or with the continuer marker (e.g., ‘and’).
All these formats contain the crucial semantic element of ‘indefinite’.
In
analyzing how health-information-seeking utterances are different from some
greeting expressions, a new category of ‘potential-health-related Q’ is added
and its potential effects are examined. It is concluded that doctors’ using
such an utterance (e.g., ‘you haven’t been to our hospital before’) may reshape
the greeting stage as a mixture of social greeting and medical information
seeking, triggering patients’ revelation of earlier visits, but did not
inhibiting the later use of a general open Q to officially start the
health-information-seeking stage.
Key words: discourse
analysis; doctor-patient communication; open questions; doctor-patient
non-concordance; hidden agenda; indefinite
摘要
在醫療諮商中，最常見且迫切的兩個溝通問題就是：醫師與病人對病人主要問題或求診目的認知差異 (non-concordance)與戴面具病人(未能直言求醫目的病人hidden agenda)。因為病人在看診過程，其所受的病痛以及心中擔憂沒有機會得到完整陳述此，因此往往導致不適當之診斷和效果差之治療，進而造成醫療資源浪費。為此，醫學教育主張'開放式問句/open questions '，避免上述溝通問題，然而文獻針對'開放式問句'缺乏系統性分析與研究，因此本研究提出以下兩個議題：
(1)醫師的開放式問句應該要引導出病人什麼樣的問題？換言之，開放式問句可以引導病人說出多少問題，如何的'開放'始可避免醫病間的認知差異和帶面具病人的情形？
(2)什麼樣的問句可開放到鼓勵病人傾言儘訴？也就是說，什麼樣語言結構的開放式問句才能提供病患機會，讓他們說出他們的問題和擔心的事呢？
從以上兩個問題可延伸以下四個相關子題：
(1)病患問題的範圍包括哪些？
(2)何為'開放式問句'？
(3) '開放式問句'之語意和句法成份為何？
(4) '蒐集醫療相關資訊的語句'和'表達問候之語句'有何差異?
本文結合醫療溝通問題相關文獻，並檢視在台灣南部某醫學中心家庭醫學科，所收集的30個問診案例 (其中包括醫師、老年病人和陪同者)，分析結果如下。
病患問題可分為兩類：生理問題(biophysical)和社會心理性問題(psychosocial)。前者指病人所經歷的身體不適，及病人已察覺或未察覺的異常生理狀況；後者指個人生活方式和社會事件所引發的擔憂或壓力、引發病人求醫的動機、與病人對於求醫所期望達到的目的或治療。
要引導出以上兩類病人問題，開放式問句必須包含兩個主要語意成份：'話題範疇未定性(non-directive/indefinite)'和'傾訴性(revealing/ventilating)'，以此二語意成份為基礎，我們定義出三種開放式問句的類型：一般性(general open Qs)、生理性(biophysical open Qs)、社會心理性開放式問句(psychosocial open Qs)。社會心理性的開放式問句的作用在於鼓勵病人說出他們的擔憂，或將他們經歷的壓力提出與醫師討論。社會心理性的開放式問句的內容包含了兩個語意要素：負面社會心理狀態(negative psychosocial statuses)，以及對病人社會心理狀態給予非中立性的評價(non-neutral
evaluation on patients’ psychosocial statuses)。負面的社會心理狀態(例如'汝敢會感覺最近心情卡無好')，還是對病人社會心理狀態給予非中立性的評價(例如'攏無共囝仔住做夥喔？'或是'汝那會來到遮遠看醫師？')。透過使用社會心理性開放問句，醫師製造了言談話題的相關性，引發病人自然聊起相關的社會心理方面狀況。
一般性或生理性的開放式問句的主要語意成份是'話題範疇未定性'。一般性開放式問句的定義為醫師的問句涵蓋病患所有可能的不適，而不是只針對某個問題，如'今仔日來什麼問題？'。生理性的開放式問句則是指醫師的問句涵蓋病人所有可能的生理狀態，包括身體異常，藥物使用，體檢報告或是家族史，而且問句語意內容並不指涉任何明確的生理狀態。
對於一般性或生理性的開放式問句，本文根據其句法上特徵，分為六類：1）疑問詞問句／wh-Q （‘今仔(來)(主要是)按那？’ ‘啊這遍(是/有)啥物問題？’ ‘汝有啥麼煩惱欸代誌？’）；2)是非問句／yes-no Q（‘你是毋是有煩惱的代誌？’ ‘你敢閣有其他欸問題？’ ‘你是毋是有啥物無爽快？’)；3)不限定列舉問句／Indefinite enumeration Q（‘汝有高血壓、糖尿病，還是有其他欸問題？’）；4) ‘請講’直述句／‘tell me’statement（‘汝將汝欸症頭攏講予我聽’）；5）‘閣有其他’短語／‘any other’ phrase（‘其他咧？’ ‘閣有無？’)；6）‘閣來’言談詞／口語詞‘and’ marker（ ‘閣來咧？’ ‘來咧？’）。
以上六種類型最常使用的形式是wh-Q形式。雖然在語言學，‘yes-no’的問話形式是歸為'封閉型問句'，但是從語用學的觀點，則可視為'開放式問句'。在有些種況下，'開放式問句'不一定要為疑問句句型或是聲調上揚的方式來表現，例如‘請說’實際為陳述句而非問句。另外，有的問句形式在句法上的表現是不完整句型，如' '啊擱有無’或者是用來延續對話的言談轉接詞‘擱來咧？’以上六個類型，都包含了基本語意成分-- '話題範疇未定性'。
在分析'蒐集醫療相關資訊的語句(health-information-seeking utterances)'和'表達問候的語句(greeting expressions)'之間的差異性，則需增加一個問句類型 '可能相關醫療問句(potential-health-related Q)'。本文研究發現，當醫師使用某些問句如詢問就醫史‘汝以前毋捌來過阮這間病院喔？’此句可能同時具有'社交問候'或是'蒐集醫療資訊'二種功能，若病人視之為後者，則可能引發病人直接敘述就診原因。但我們發現儘管醫師於開場階段以這類型的問句或語句和病人互動，並不會影響醫師後來再度使用一般性開放式問句，以正式性開啟'蒐集醫療相關資訊'的階段。