|An Online Journal of Modern Philology||ISSN 1214-5505|
Czech Scientific Contributions to Doctor-Patient Interaction Research
Doctor-patient interaction is an important process particularly in those cases where the diagnosis and following treatment is based primarily on the information acquired from such interaction. It seems, however, that in the Czech Republic the importance of understanding the process associated with doctor-patient interviews has not been taken into serious consideration. The presented review shows why Czech doctor-patient communication research should be viewed as rather unsatisfactory.
“...this subject [doctor-patient interaction] has not yet been credited with the attention it deserves, though a rising number of doctors and universities are now pursuing the subject of doctor-patient communication scientifically, a subject which has formerly far too often been expected to be ‘picked up’ by medical students and young doctors without any proper teaching” (Wynn 1995: 9).
Although written by a Norwegian doctor and linguist, the situation described above has much in common with the status and the level of doctor-patient (D-P) communication, its research, and teaching in the Czech Republic. There are few doctors, psychologists, and linguists who analyse the phenomenon of D-P interaction, and only a limited number of books, studies, and scientific articles have been written on the subject. As a result, Czech medical faculties and teachers of medicine lack reliable sources. Unfortunately, they are reluctant to design programmes to teach their students how to learn communication skills.
The situation is even more worrisome if we realise that more than one thousand complaints on the part of patients – that the Czech Chamber of Medicine resolves each year – are due to inadequate communication between doctors and patients. Czech doctors are especially criticised for not being able to interact with patients. They do not know how to engage the patient in conversation and/or how to deliver bad news. However, many people argue that the situation has never been critical and is still improving. For example, some medical magazines (TEMPUS MEDICORUM) offer descriptions of the complaints and an analysis of their causes. Moreover, the Czech Chamber of Medicine, in cooperation with Czech linguists and psychologists, organise courses of communication skills for its members in order to rectify what has often been neglected.
To bring evidence about the quality of books on the subject under discussion, I will now review five texts which are, to the best of my knowledge, the most important Czech studies about doctor-patient talk that have been published in recent years. These texts, written by two doctors, two psychologists, and one linguist, are accurate indicators of the present state of research on doctor-patient interaction, and reveal how Czech science has contributed to this research. My review is ordered chronologically, by date of publication.
The first book, entitled Rozhovor lékaře s pacientem [A Doctor-Patient Interview], was produced by Jaro Křivohlavý in 1995. The book is rather a manual, which is described by its author as “a textbook of harmonisation and improvisation”. It gives students of medicine practical instructions on medical encounters with patients. However, there is almost no theoretical background presented that is based on linguistic analysis. Consequently, the book omits deeper insights into the problems of D-P interviews. The text is divided into two main sections. First, the author outlines methods of how to talk with patients. He presents a brief summary of the research history of social psychology, stressing the fact that it is crucial to perceive both the verbal and non-verbal communication of the patient. Second, he explores what doctors should tell patients to help, motivate, and encourage them. It outlines the outcomes of health psychology and recommends several strategies for coping with stress.
Křivohlavý also distinguishes three principal parameters of the interview between the doctor and the patient, including three different angles from which the interview could be viewed and evaluated. (1) The parameter ‘I’ concerns information, its order, and strategy. Its aim is to create compliance, mutual understanding, and an atmosphere of friendliness. (2) The parameter ‘W’ stresses the importance of empathy and warm-heartedness for bridging the gap between the subjective and objective approach in doctor-patient discourse. (3) The parameter ‘P’ indicates that it is the patient, his/her emotional state, attitudes, and ability to adjust that should be understood as the most important aspect of D-P discourse.
The weakest point of the text is the fact that its content and structure are not based on authentic language data. No examples of authentic medical encounters are included. The study lacks any linguistic perspective and is too general. Nevertheless, it provides some advice on what to focus on and what to avoid during the interview between the doctor and the patient. Therefore it could serve the students and teachers of medical faculties as introductory material.
Unlike Jaro Křivohlavý, who is a psychologist, Petr Klimpl is a medical doctor. His book Psychická krize a intervence v lékařské ordinaci [Psychic Crises and Intervention in Doctor’s Surgery] was published in 1998 and is the first Czech medical monograph on the subject. Although the book consists of five chapters, only chapter one and chapter five are concerned with the problems associated with doctor-patient communication, and they thus serve only as reference material for those who need a stimulus for further research. Consequently, the study has the same disadvantages and shortcomings as the study discussed above. It is not based on naturally existing data, on language in real-life situations, and too much attention has been paid to verbalising the significance of medical encounters without giving clear examples.
Nevertheless, Klimpl’s text does have positive points worth mentioning. For instance, the author defines four basic functions that can be found in every medical interview. He identifies the communicative function, understood as authority, truthfulness, sympathy, and respect towards the patient; the diagnostic function; the informative function, stressing the importance of informing patients about risks of their treatment; and the consultative and therapeutic function. The author is well aware that particular functions may overlap, and he also gives an example of what is called ‘collapsed communication’.
Another useful aspect of the text is Klimpl’s division of questions, especially the subcategory of coercive questions. In his view, such questions force patients to talk about topics they may not care to discuss, such as subjects that are painful or unpleasant. Furthermore, Klimpl discusses ‘forbidden (taboo) topics’. He also draws the readers’ attention to the structure and linkage within the medical encounter.
Radkin Honzák’s book Komunikační pasti v medicíně [Communicative Traps in Medicine] was published for the first time in 1997 and was reprinted in 1999 with some corrections and supplementary material. As its subtitle suggests, the book is Praktický manuál komunikace lékaře s pacientem [A Practical Manual of Doctor-Patient Communication], and this label gives a true picture of what the book is about.
With a certain degree of simplification, we may say that the manual written by Radkin Honzák is the first comprehensive study about doctor-patient interaction written in the Czech language. It includes both the verbal and non verbal features of doctor-patient discourse, and discusses a number of means of communication. The author also introduces his experiences of working with physically and mentally handicapped people, and formulates rules for communication with blind, deaf, aggressive, and seductive types of patients. Several sections about the sentence structure and vocabulary choice are also incorporated into the text. The author argues that verbs such as ‘to try’, ‘to attempt’ are “a burial-ground for clear communication”. Patients usually promise to try, but, as a matter of fact, they often do not obey the doctor’s advice and recommendation. Similarly, the use of conditional sentences presupposes certain conditions that do not have to be understood clearly during the interview and may emerge as an obstruction later on.
Another element that can disrupt the medical consultation is the conjunction ‘but’. In Honzák’s view, ‘but’ should not be used, especially during the talk with patients suffering chronic diseases. The conjunction ‘but’ reflects the world only as black or white, and the patients may, as a result, lose their motivation and hope of future recovery. He also advocates the use of positive rather than negative formulations, and advises limited use of medical terminology.
In summary, the book Komunikační pasti v medicíně is of practical value. It is to be recommended not only as a reference book for those who are interested in particular aspects of D-P discourse, but also as a notable contribution to understanding the communication between doctors and their patients in general.
Olga Müllerová is possibly the only linguist who has accomplished to provide an accurate assessment of the present state of Czech doctor-patient communication. Her text Komunikace v lékařské ordinaci [Communication in Surgery] has been included as the first chapter into a larger study under the title Jak vedeme dialog s institucemi [Interaction in Institutional Contexts] published in 2000 and written with Jana Hoffmannová. In their book, they analyse social interaction and language use in a variety of institutional settings, including doctor-patient consultation, rest centres, and public meetings. Taken together, such conversational contexts give the authors a great opportunity to research key aspects of the interaction between ‘professionals’ and ‘clients’ in general. The methodology used is the application of conversational analysis, based on audio recordings of naturally existing data. However, both authors use only some features of this methodological approach, and some are omitted.
Although the chapter under review is named Communication in the Surgery, the title has not been chosen carefully. In fact, it discusses only interaction in the surgery of a paediatrician, which is, from a communicative point of view, a very specific type of talk. Paediatricians usually question not only their young patients but also their parents, and thus the communication is much more complex than, for example, in the surgery of gynaecologists, urologists, dermatologists or other specialists. As it is very difficult to describe this type of communication in detail, the author has selected only a few features which are considered to be the most significant. These are: lexical choice (technical vocabulary), grammar (person reference, time reference), turn design (selection of activity and selection of utterance shape), sequence organisation (adjacency pairs, turn taking, repair, interruption, and topic shift), structural organisation (opening and closing phases). In addition, Müllerová analyses the phenomenon of professional caution, asymmetry, and control over interaction.
According to Ivan Vodochodský, Müllerová has not been successful in fulfilling the aims of her research. In his opinion, she is more descriptive than evaluative, and offers conclusions which are not anchored in data neither in the works cited. He also criticises her summary as too general and not convincing. I agree that the interpretation of the recorded material is not detailed. However, compared to Křivohlavý, Klimpl, and Honzák, she is the first to analyse naturally occurring interactions in the setting under scrutiny, and she is also the first to present examples of these interactions.
The last book to be mentioned is Jan Vymětal’s text entitled Lékařská psychologie [Psychology of Medicine]. It serves as a textbook for students of medicine at Charles University. Moreover, it is used as the main text recommended for courses designed to teach students of bachelor’s programmes principles of medical psychology and psychotherapy. In contrast to the preceding books (except Petr Klimpl’s study Psychic Crisis and Intervention in Doctor’s Surgery), which have either the word interview or communication in their titles, Vymětal’s text differs. However much he stresses the importance of proper communication between the doctor and the patient for the successful treatment of the patient, his Psychology of Medicine describes doctor-patient interaction primarily from the standpoint of psychotherapy. For example, the sections on personality, motivation, anxiety, depression, aggression are the main body of his text.
Consequently, there are only two chapters out of twenty-two dealing with problems of medical encounters, the total number of their pages being thirty-one. As a result, the book lacks a detailed analysis of D-P talk, and the author confines his discussion only to the matter of roles of doctors and patients and types, dimensions, and phases of the interview. What is more important, he introduces his own division of questions and methods of asking. In addition, the book contains five appendices. In these supplements Vymětal includes five extracts from texts related to the ethics of medicine, including the Charter of Children Patient Rights, produced by the British organisation NAWCH (National Association for the Welfare of Children in Hospital), and Helsinki Declaration, officially approved by WHO (World Health Organisation) in October 2000.
By way of conclusion, let me emphasise the most significant points of the review. As can be seen, the number of Czech books on the subject of doctor-patient communication is limited. Their content is influenced by the professions of the authors, who are mainly psychologists or doctors, with only one book written by a linguist. As a result, the research and its following applications are based loosely on authentic language data, and lack a linguistic perspective and exemplification. Thus the contribution of Czech science to doctor-patient communication research still owes much to be desired.
Hoffmannová J., Müllerová O. Jak vedeme dialog s institucemi [Interaction in Institutional Contexts]. Praha: ACADEMIA, 2000.
Honzák R. Komunikační pasti v medicíně [Communicative Traps in Medicine]. Praha: Galén, 1999.
Klimpl P. Psychická krize a intervence v lékařské ordinaci [Psychic Crises and Intervention in Doctor’s Surgery]. Praha: GRADA, 1998.
Křivohlavý J. Rozhovor lékaře s pacientem [A Doctor-Patient Interview]. Brno: IPDVPVZ, 1995.
Vodochodský I. “Jak vedeme dialog s institucemi” [Interaction in Institutional Contexts]. Czech Sociological Review 2002. 38: 511-513.
Vymětal J. Lékařská psychologie [Psychology of Medicine]. Praha: Portál, 2003.
Wynn R. The Linguistics of Doctor-Patient Communication. Oslo: Novu Press, 1995.
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