Abstract
Objective
To explore diagnostic interaction to understand more about why some problems appear medically unexplained.
Design
A qualitative discourse analysis case study.
Setting
Encounters between women patients and general practitioners in primary healthcare.
Subjects
Microanalysis of two audiotaped consultations without a clear-cut diagnosis and opposing levels of mutuality between doctor and patient.
Main outcome measures
Descriptions of linguistic patterns in diagnostic interaction.
Results
Two patterns were identified demonstrating how different ways of speech acts contribute or obstruct diagnostic interaction and common ground for understanding. To invite or reject the patient into/from the diagnostic process, and to recognize or stereotype the patient may impose on how illness stories are perceived as medically unexplained.
Conclusion
Making sense of illness can be enhanced by inviting and recognizing the patient's story.
Keywords: Communication, diagnosis, family practice, interpersonal relations, knowledge, qualitative research, women
Diagnostic interaction can be a challenge for the general practitioner, as exemplified by medically unexplained disorders.
Talk is the most significant instrument for the clinician towards a diagnostic conclusion. By respectively inviting or rejecting the patient into/from the diagnostic process, and respectively recognizing or stereotyping the patient, the doctor may inflict the conclusion of illness as medically unexplained.
Patients come to terms with illness by mediating their illness experience. Even when a biomedical answer is not achieved, the co-creation of a meaningful illness story and a diagnostic term can make a difference for doctors and patients talking about chronic conditions.
General practitioners find medically unexplained disorders difficult to understand and manage [1], [2], and negative emotions dominate GPs’ accounts of patients with these disorders [3]. From our own clinical experiences, we know that disorders may appear unexplained when traditional diagnostic processes fail to provide a comprehensible answer to the doctor's questions regarding what is wrong and what can be done. In a previous study, we demonstrated how the doctor assumes a provisional standpoint in the decision-making process when the diagnosis is not immediately clear-cut [4].
Yet, talk – intricately intersubjective – is the most significant instrument for the clinician towards a diagnostic conclusion [5], [6]. In conversation, performances mutually shape one another from moment to moment, since what one person says constrains what is possible or intelligible for another to say next. Discussing knowledge production, people want to know and claim credibility, and knowledge is in the end based on acknowledgement. Code defines rhetorical spaces as social locations whose tacit imperatives structure and limit the kinds of utterances that can be voiced with a reasonable expectation of being heard and taken seriously [7]. Exploring questions of power and privilege, Code emphasizes the impact of such hidden rules for how we know one another, how knowledge of other people is constructed and circulated, and how its deliverances are enacted in social practice. The consultation is a specific social context for rhetorical spaces. Finding common ground through mutual understanding is a basic assumption in the patient-centred, clinical method [8], [9]. Our preconception was that “unexplainedness” may reflect inadequate diagnostic interaction within restrained rhetorical spaces. We therefore wanted to explore diagnostic discourse to understand more about why some problems become medically unexplained.
Material and methods
The study is based on qualitative microanalysis of two audiotaped consultations from general practice, drawn theoretically from material on 86 consultations described elsewhere [4]. Cases with women patients were purposefully chosen, since most patients with medically unexplained disorders are women [10]. Theoretical sampling was established by choosing two contrasting cases [11] without a clear-cut diagnosis where by consensus we rated the level of mutuality between doctor and patient as high or low [9]. Our theoretical preconception was that the perspective of mutuality would provide access to opposing patterns of discourse related to the notion of unexplainedness.
Discourse analysis assumes that language, action, knowledge, and context act as a unit, illustrating how the doctor and the patient are performing their roles during the consultation [12]. The tapes were transcribed verbatim by the first author. The first reading of a text is what Ricoeur calls a “naive understanding” [13], when the reader becomes familiar with the text in order to grasp the meaning as a whole. During this phase, the discourse was coded according to thematic episodes. The second reading of “comprehension” entails a more elaborated understanding of linguistic action. For this purpose we chose Nessa's method for transcription to a synopsis, identifying speech acts – doing things by means of talk [14]. The successive analysis of the two synopses focused on speech acts influencing the diagnostic process. This third reading is, according to Ricoeur, trying to interpret or construct meaning – in our case to highlight the linguistic interaction contributing to the dimension of medical unexplainedness during the diagnostic process. The theoretical perspectives of Code guided our interpretations [7].
Results
This section starts by presenting the synopses from consultation A (high mutuality) and B (low mutuality), representing the second reading. These are followed by systematic reflections on the linguistic patterns identified to have an impact on the diagnostic interaction, representing the third reading.
Synopsis of interaction
A – “What did you think then?”. The synopsis below presents a woman in her forties encountering an experienced male doctor. She suffers from chronic pain, and the first two episodes from a total of seven are drawn from a context of mutuality.
| Pain in the shoulder blade getting worse – problems in her job |
| 1/A D: incites “What can I help you with today?” |
| 2/A P: explains about strong pain in her back by the shoulder blade |
| 3/A D: asks what she thinks |
| 4/A P: says she thought of problems in her job, and wanted medical confirmation |
| 5/A D: replies “What do you think it is?” |
| 6/A P: expresses muscles and tendons, locked perhaps |
| 7/A D: wants to know her occupation and related difficulties |
| 8/A P: answers assistant at after-school care arrangement with daily physical handling |
| The doctor examines her shoulder and supports self-medication |
| 9/A D: wonders if she expects physiotherapy again? |
| 10/A P: confirms |
| 11/A D: replies he thought so |
| 12/A P: confesses she ironed laundry yesterday, unwisely |
| 13/A D: understands, and localizes a point |
| 14/A P: admits hesitatingly taking a painkiller |
| 15/A D: indicates she sounds as if excusing herself |
| 16/A P: explains she does not like pills, but a colleague insisted on relaxing the muscles |
| 17/A D: supports it as reasonable |
B – “I am not trying to create anything, but I am really not well”. The synopsis below constitutes episodes one and four out of five with a female patient and another experienced male doctor, drawn from a context of low mutuality. A regular patient in her fifties visits for pain in her arms and shoulder. She had breast surgery due to cancer and is concerned as to why she is not improving.
Several times the doctor mutters (“mmm”).
| The physiotherapist's point of view |
| 1/B D: incites, he gave her sick-leave recently due to pain in neck and shoulder |
| 2/B P: agrees and adds the arm, too |
| 3/B D: asks about her physiotherapy treatment |
| 4/B P: answers three |
| 5/B D: wonders what the physiotherapist said |
| 6/B P: says (sighing) that she thought the same as her at first |
| 7/B P: retells of subconscious tension in her musculature due to pain in the reconstructed breast |
| 8/B D: replies that women whose breast is operated on completely or partly experience such pain |
| 9/B P: mmm |
| 10/B D: states they always get a subconscious relationship to it |
| 11/B P: says she has handled it very well |
| 12/B D: mmm |
| About defending her point of view |
| 13/B P: starts to announce an issue… |
| 14/B D: interrupts she must extend the sick note |
| 15/B P: answers she must get well |
| 16/B D: says he will not deny her blood tests, but he does not expect anything |
| 17/B P: mentions she had a steroid injection and was told it could be rheumatic |
| 18/B D: implies it would have been symmetrical on both sides |
| 19/B P: defends that the other side is affected, too |
| 20/B P: remarks “I am not trying to create anything, but I am really not well” |
| 21/B D: wants her to concentrate on reality, and what it might be |
| 22/B P: replies she does not want to demand, but it seems strange she is not improving |
| 23/B D: says no clarification is stressful |
| 24/B P: replies in tears: “That is not what concerns me!” |
| 25/B D: mmm |
Reflection: patterns of diagnostic interaction
The reflection below focuses on patterns of diagnostic interaction identified in two different synopses from consultations with different levels of mutuality. Reading the synopses through, we looked for cues which could demonstrate how different ways of speech acts contribute or obstruct diagnostic interaction and common ground for understanding. Assuming that language, action, knowledge, and situation act as a unit [12], the analysis aimed to illustrate how the doctor and the patient perform their roles through language during the consultation.
We identified two distinctive, opposing patterns of interaction, depending on how the doctors involved the patient diagnostically, and how the patient seems to be perceived. In consultation A the patient is invited to negotiate diagnostically, while in consultation B the doctor shows no willingness to reassess the prime diagnostic judgement. Woman A confesses to ironing and taking a painkiller, while woman B displays defence and despair when her doctor declines diagnostic suggestions and her story. Below, we describe the nature and content of these interpretations in more detail.
Inviting or rejecting the patient into/from the diagnostic process?
The first pattern of diagnostic interaction concerns how the doctors involve their patients when collecting information. To respectively invite or reject the patient into/from the diagnostic process is a linguistic turn and precipitates a jointly or separately made diagnostic conclusion. In consultation A, the doctor incites to offer help, and opens the arena for his patient to present her agenda. She explains strong pain in her back around the shoulder blade.
Doctor and patient seem to agree on limitation and understanding of the pain's physical source and daily life effects (3–8/A). The patient speaks about resources and strategies in her everyday life used to manage the pain, portraying herself as a resourceful woman. Her evaluation constitutes the focus of the doctor's attention, and guides the examination. Through his invitation to participate diagnostically, a rhetorical space including her inputs as a source of knowledge is established. The doctor in consultation A is verbally supportive and attentive when the patient confesses to ironing and taking a painkiller (12–17/A). The patient's story is approved of even though it does not seem to produce any diagnosis.
In consultation B the patient's agenda is not really asked for. The doctor recalls her last sick-note, and the physiotherapist's remarks (1–5/B). The patient wants to express her opinion, but the doctor is not attentive (13–14/B). Disregarding her concerns, the GP rejects her from the space of negotiation, and they are both precluded from further judgements. New information is not validated as a relevant diagnostic element. The diagnosis is determined, and a rheumatic cause is discarded (16–19/B). The doctor does not manage to level the dialogue to her illness experience. Conclusions are not agreed upon, and lack of verbal support creates defence and despair (21–25/B).
Recognizing or stereotyping the patient?
The second pattern of diagnostic interaction demonstrates how the two doctors appear to perceive their patients. They recognize the pain, but their attention and solution towards patient and problem differ.
Woman B's recovery is painful and problematic, but her frustrations and sufferings are not accommodated. The doctor states that all breast-operated women develop subconscious tension, and this stereotyping notion seems to exclude her opinion (7–12/B). The evaluation is to continue the sick-leave, proposing no pain relief, or any individual strategy of care (13–16/B). She must fight for her place in the consultation (20/B). When told to be reality oriented, she tearfully declares that the breast is of no concern (21–25/B). The expert option focused on reality is patronising and humiliating, and this encounter is not based on mutual concessions.
Doctor A displays that he is familiar with the patient's illness. She is worried about using the painful arm and how that affects her work with physical challenges (4A). The doctor therefore focuses his attention to clarify her work (7–8/A), and expectations concerning therapy (9–11/A). This woman illustrates resources and ways of handling her chronic muscle pain, and the doctor values her knowledge. Her opinion is confirmed when she replies it must originate from muscles and tendons.
Discussion
Microanalysis of the discourse in two theoretically sampled consultations revealed two contradictory patterns of diagnostic interaction. Combining empirical findings with a theoretical framework, we propose the hypothesis that inviting and recognizing the patient during the diagnostic interaction could unlock the apparently unexplained disorders into more comprehensible conditions, while rejecting and stereotyping the patient could prevent achievement of common ground, tending towards unexplainedness.
Validity and interpretation
Interaction can never be fully understood by research methods. Exploring diagnostic discourse, we highlighted the verbal speech acts with Nessa's method for transcription to a synopsis [14]. Synopsis means summary, and the transcript is a specific interpretation, retold by the writer, who decides which parts of the verbatim text are to be regarded as action, and what kind of contextual interaction it reflects. The synopsis reflects an intermediate analysis, with the theoretical framework determining our interpretive perspective. Code challenges the objectivity of “a view from nowhere” [7]. Our analysis searched for aspects of discourse revealing interaction ruled by the rhetorical space of the consultation [7]. The consultation is a space mapped so as to produce uneven possibilities of establishing credibility and being heard. The hidden subjectivity of a privileged group of people – in this case doctors’ preconceptions of something being medically unexplained – becomes a tacit generalization ruling the consultation. However, says Code, objectivity requires taking subjectivity into account. People are knowable, and a knower is always somewhere. We have specifically been looking for interaction which makes a difference in this regard. An alternative framework would have offered other synopses.
Audiotaped consultations limited the access to non-verbal actions compared with videotaped talk. Yet, the sociolinguistic approach allowed interaction to be embodied by the use of verbs as key concepts during transcription. We were able only to convey what was said, while the intentions or the consequences of talk were not captured. Therefore, our conclusions regarding the diagnostic outcome of different approaches are not valid as causal explanations, but rather offer plausible proposals.
The analysis is based on only two consultations, but the issues we discuss are generally relevant in general practice. Mutuality was our point of departure, believed to contribute to or obstruct the diagnostic process. The two contrasting cases, representing opposing levels of mutuality, were chosen theoretically to study patterns of interaction of importance for diagnostic understanding. Hence, the issue of mutuality was a presupposition and choice of context, and not the result or explanatory value of our study.
Two single cases cannot be used to classify doctor A and doctor B as good or bad diagnostic performers. In this study, they illustrate how different processes of interaction are contributing factors to diagnostic work. In subsequent consultation, their performances might be reversed.
The patient's story world: a fundamental element of diagnostic understanding?
The patient-centred clinical method invites the doctor to explore the patient's and the doctor's agenda to create common ground [8]. Patients who present symptoms without physical pathology challenge existing biomedical models of diagnostic action [15]. Dichotomous diagnostic strategies aimed at classifying patients’ symptoms as either organic or functional make GPs sceptical about the seriousness of these patients’ conditions, while at the same time they fear that a physical disease might go unnoticed [16]. Complex disorders can acquire meaning through different ways of understanding [4].
Communication models have been presented to improve the GP's capacity for mutual understanding [9]. Recognition is an attitude expressing a basic respect for the other person as a subject, and as an authority on her own experiences [17]. Perhaps the most important ability patients have is their capacity to make sense of their illness [6]. Our data indicate that patients are ready to tell their illness story when they are allowed to. Patients have many ways of coming to terms with illness. One major way is to mediate their lived illness experience. Diagnostic work also needs to support the patient in coming to terms with what the condition means for her.
Speech acts illustrate how doctor and patient are performing their roles during the consultation [12]. Both patients and doctors claim power through talk, and this is crucial to the makeup of all medical encounters [6]. Awareness of communicative power claims can change the interaction. The patterns of diagnostic interaction we have presented demonstrate how speech acts influence common agreement. Inviting or repulsing the patient in the diagnostic process implies that you either accept or reject your diagnostic partner. Recognizing or stereotyping the patient concerns the doctor's ability to discover and understand the patient's individual story world.
The two doctors presented seem to talk and interact differently. While patient A is included diagnostically, patient B seems discredited. In consultation A the doctor managed to create space for his patient to describe her symptoms and problems related to that, while doctor B stereotyped his patient to despair. Stereotyping is often the first step on the way to an oppressive interaction, which is often difficult to recognise [18].
Both doctor's and patient's gender affect talk and interaction [19], [20], but the two patterns of interaction we have identified are neither restricted to encounters with unsolved diagnoses, nor to women patients. We wanted to gain an insight into the negotiation between doctors and patients in order to illuminate why doctors regard some disorders as medically unexplained. The majority of patients with these conditions are women, but male patients also suffer the risk of being rejected or stereotyped during the diagnostic process.
Implications
Diagnostic interaction and understanding are sometimes a major challenge for the general practitioner. Instead of just declaring a condition as unexplained, the doctor might consider on what level of understanding the illness becomes unexplained. Even when a biomedical answer is not achieved, the co-creation of a meaningful illness story with the patient as a source of knowledge can contribute to recognition and a sense of coherence for patients suffering from chronic conditions.
Acknowledgements
This study received funding from the Norwegian Research Council and the Research Unit at the County Hospital of Buskerud Trust in Norway.
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