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Construal of Trust
in the Dynamics of
Knowledge Diffusion
The Discursive
Construal of Trust
in the Dynamics of
Knowledge Diffusion
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List of Figures.............................................................................................. x
Preface ........................................................................................................ xi
Marina Bondi
DANIELE FRANCESCHI
UNIVERSITY OF PISA
1. Introduction
Spoken medical English has been investigated from three main
perspectives so far (Salager-Meyer 2014 and references therein). One
avenue of research has dealt with the analysis and development of oral
skills in non-native health professionals working or intending to work in
an English-speaking context. This approach is pedagogical in nature in
that it aims at improving competences as well as ESP teaching
methodologies and materials. A second line of research, which also has an
applied component to it, has focused on a less interactive type of spoken
discourse, i.e. the language of medical conference presentations, investigating
a number of different aspects, such as the juxtaposition of the verbal with
the visual (e.g. slides), the question-answer phase following the speech,
the differences between oral and poster presentations, etc. A third research
strand has specifically studied doctor-patient interactions, as well as
communication between patients and a range of other health professionals
including nurses, physiotherapists, alternative practitioners etc. (references
in Adolphs et al. 2004), mainly from a socio-linguistic perspective, taking
into consideration, among other aspects, how cultural and status
differences or gender diversity may result in conflictive encounters (also
Gotti et al. 2015).
The present paper examines doctor-patient conflict in an English L1
context and how it may be resolved through the adoption of certain
strategies by the doctor himself/herself, which, on the one hand, facilitate
comprehension of medical information and, on the other hand, manage to
294 Chapter Fourteen
create empathy and rapport between the parties. The latter elements have
been shown to play a fundamental role in improving the patients health
and medical care in a broad sense (Duffy et al. 2004). The analysis is
based on what can be regarded as representative examples of appropriate
and successful doctor-patient communication.
The paper is structured as follows. Section 2 presents the data and the
methodology used. Although the dynamics of doctor-patient interaction
have been widely investigated in the literature, research has traditionally
followed a mono-semiotic (verbal) approach, neglecting the bigger picture
of how meaning and trust are built in context (Candlin and Crichton 2013
for a thorough illustration of the concept of trust). Hence, the multi-modal
perspective of analysis adopted here. Section 3 describes those linguistic
elements in the dialogues under investigation, which appear to enhance the
effectiveness of the exchange between doctor and patient. Interestingly,
the three dialogues examined, albeit different in a number of ways, present
some common features at the lexical-semantic and pragmatic level,
resulting from deliberate decisions on the part of the doctor to ease
communication on important issues. Section 4 considers the non-verbal,
i.e. extra-linguistic, factors that also play a significant role for a better
understanding of medical information and, eventually, for the construal of
trust. The approach followed is thus multi-semiotic, since not only
language but also facial expressions, hand gestures and body movements
are observed and considered as contributing to meaning. Section 5 briefly
summarizes the results of the study and suggests possible future research
directions.
1
The database was prepared by Caring Ambassadors Program Inc., Oregon City,
OR (http://hepcchallenge.org), to give hepatitis C patients free access to doctor-
patient interviews with useful information about screening, diagnosis, treatment
and disease management. Many thanks to Lorren Sandt, Executive Director of
Caring Ambassadors Program Inc., for allowing me to use the interviews and some
images for my research.
Medical Knowledge Dissemination and Doctor-Patient Trust 295
options available to treat their medical conditions.2 The reason why these
three conversations in particular were chosen is because they appeared as
the ones that best fit my research goal, i.e. showing how the adoption of
certain communicative strategies may improve doctors counselling skills
and consequently have a positive impact on the outcome of their
consultations with patients (Fong Ha and Longnecker 2010 for a review of
the literature on doctor-patient communication). To address this specific
research objective, a very small specialized spoken corpus consisting of
approximately 6,650 words was created by manually transcribing and
annotating the conversations between three different doctors and one
patient who is initially refusing to start therapy for hepatitis C. Although
the data only makes up a mini-corpus,3 it provides interesting evidence of
what works for effective medical communication and patient
engagement. Both the doctors and the patient in the videos are native
speakers of American English.
The conversations were studied in minute detail from a multimodal
perspective. First, they were digitized into computer-readable form and
printed out in order to get a general feel for the data and to start
developing the analysis. At a purely linguistic level, the most interesting
features of discourse are the lexical-semantic and pragmatic choices that
the doctors make to gear conversation to the patients needs, while at the
same time maintaining their firmness and consistency of purpose.
Therefore, all the relevant words, phrases and expressions used by the
doctors to achieve this aim were assigned tags in order to mark their
functions. Since the analysis brought to light both hypothesised
phenomena as well as a number of unforeseen items, especially with
respect to extra-linguistic usages, the study may be considered as both
corpus-based and corpus-driven (Tognini-Bonelli 2001). As for the non-
verbal elements that accompany and reinforce speech, they were also
included in the transcription of the data, following the technique proposed
by Baldry (2000), Thibault (2000) and Baldry and Thibault (2006), which
brings together verbal text and visual image in addition to a description of
2
I personally contacted one of the doctors involved in the project, Dr. Lyn Patrick
(Medical Director at Progressive Medical Education, Irvine, CA,
www.progressivemedicaleducation.com), to know whether the conversations had
been prepared before filming them and whether the patients appearing in the
videos are really affected by the condition(s) described. I was assured that the
interviews were spontaneously conducted and that the interviewees are all patient
advocates who have (or had in the recent past) hepatitis C.
3
For reasons of space, it has not been possible to include the full dialogues here,
which are, however, freely accessible on-line at http://hepcchallenge.org.
296 Chapter Fourteen
the function of non-verbal behaviour (see Tables 14-1, 14-2 and 14-3 in
Paragraph 4).
The mark-up of the transcripts includes punctuation in order to make
the conversations easier to read and analyse, and those paralinguistic
elements, e.g. stress, pace and tone of voice, as well as extra-linguistic
factors, e.g. hesitations, pauses, smiling, etc., which are considered to be
relevant for the study.4
Finally, the decision to limit the observation and the analysis to a small
corpus was not just motivated by the need to examine the three chosen
conversations in the greatest detail possible. It was also dictated by the
nature of the transcription task itself, which is extremely labour-intensive
and time-consuming. It has been estimated that an hour of recording may
take up to ten or even twenty hours to transcribe (McCarthy 1998; Creer
and Thompson 2004). As a matter of fact, for the transcription, manual
inspection and annotation of 36 minutes of video-recorded conversations I
required approximately 12 hours. More time was then needed for the
analysis of the results.
4
The transcripts, however, are not completely objective, because there is other
information that may potentially be annotated, but which in fact is not because it is
not pertinent to my particular research aim. Transcripts are never complete and, to
a certain extent, may be viewed as an interpretation of the communicative
exchange (Bucholtz, 2000). Contact the author (daniele.franceschi@jus.unipi.it)
for samples of the annotated transcriptions.
Medical Knowledge Dissemination and Doctor-Patient Trust 297
(1) We have not seen the remission, in other words the getting rid of the
virus, just with alternative medicine.
(2) And Im wondering if you know anybody that has gone through
standard of care treatment with the, we call it adjunctive, meaning in
addition to standard of care, these adjunctive treatments.
(4) What our therapies can do is help minimize the toxicity or side effects
of standard of care therapy.
(5) There are some good studies that show that with weight loss and
exercise that can be reversed. [] there are good studies that show that
that can be turned around.
5
Andreas Vesalius (1543), De humani corpori fabrica.
6
The Latin-based terms are in bold, while their Anglo Saxon versions have been
underlined. It is also interesting to note that these reformulations are often
introduced by a word or phrase signalling that we are faced with a paraphrase,
transposing technical expressions into more popularized/ordinary ones. These
words or phrases have been italicized.
298 Chapter Fourteen
(6) And the things that can happen with cirrhosis include turning yellow.
(8) Another thing that can happen is you start accumulating fluid all over
your body.
(9) Your liver is up here under the ribs. We numb up the area of the skin
and we put the needle directly into the liver, we suck up a little piece of
liver and take it back out. [] And the piece of liver that we take out, its
about as thick as the lead in the lead pencil, not the pencil itself, just the
lead.
7
Since the patient uses primarily a colloquial register and informal words, e.g.
docs for doctors, bellies for abdomens, the doctors may feel the need to adapt
to his speaking style in order to avoid comprehension failure.
8
They have been put in bold in the examples provided.
Medical Knowledge Dissemination and Doctor-Patient Trust 299
(10) Well, turns out, if you get rid of the hepatitis C with treatment,
theres a good chance that your risk of cancer is gonna go way down.
(11) The biopsy itself, the needle is in there less than a second. Boom
boom, its done!
The ability on the part of the doctor to tune in with the patient, also at
the language level, appears to play a fundamental role in gaining the
patients trust and in stimulating his willingness to undergo treatment,
which culminates in his decision to accept the doctors advice (see
Paragraph 3.7 below).
3.2. Repetition
All the three doctors have a marked tendency to rely on the use of
synonyms and paraphrases in order to explain a certain concept in the best
way possible and to make sure that the patient understands what they are
talking about. This often results in the use of doublets (14) as well as of
lists of several items (15) that essentially express the same idea:
(14) Some patients with genotype two can even take fewer weeks of
therapy, but because you have significant fibrosis and scarring [].
(15) You know, working out in the farm, where you get injuries and sores
and cuts and bruises and scrapes, thats ways of again transmitting blood
between people that would be minor and nothing that you would pay
attention to, but potentially could have occurred [].
300 Chapter Fourteen
(16) [] when you have underlying, active sores, if you will, the hepatitis,
then the alcohol is much more damaging than it would be to a normal liver.
(17) Some of them already have very advanced disease, cirrhosis, which
would be at the one extreme of severe scarring damage to the liver.
3.3. Hedging
Doctors often need to attenuate the full semantic load of a certain
expression or the force of a speech act. This rhetorical strategy, known as
hedging (Lakoff 1972), may be used to mitigate the emotional impact of
a diagnosis, to make suggestions in a tentative manner so as not to be
perceived as too invasive, to communicate that there is no full
commitment to what is said, and so on (Frazer 2010 and references
therein).
In the conversations examined, the doctors are trying to convince the
patient that standard of care therapy is the best option for his present
condition, despite the possibility of a number of side effects that he may
experience while on treatment. The patient fears, for instance, that the use
of medication for hepatitis C will aggravate his PTSD and depression, for
which he is also being treated. Therefore, the doctors have to find a way of
encouraging this reluctant patient to follow their advice, while at the same
time dealing with his worries and taking his requests into consideration.
This results in what may be described as cautious communication, i.e.
characterised by a number of features aimed at softening the impact of
what is being said:
9
These descriptions have been underlined, while the conditions they refer to are in
bold.
Medical Knowledge Dissemination and Doctor-Patient Trust 301
(18) Well, the interferon side effects make you feel like you have [pause]
the flu, to some extent. Erm, you may have some loss of appetite, may
lose a little weight on treatment. Erm, the ribavirin might give you, oh,
sometimes a little funny taste in the mouth, sometimes a little soreness,
maybe some rash.
(19) It also looks like being stage three, which youve seen the model of
the liver and how the next stage is cirrhosis, which is the worst, you know,
stage that you can get to, kind of the final stage with hepatitis C, that your
condition which it sounds like you have had for a while, you know, that
case scenario was non-A non-B was hepatitis C from what we can tell.
(20) [] there was a recent study with acupuncture that actually just
showed that this is the case in people with hepatitis C.
(21) Now, I think its time for you to consider [pause] getting the hep C
treated and trying to get rid of that infection.
(23) Youve done some great things to control the other aspects, the
mental health, the alcohol.
(26) So thats something that is in your control for the most part in terms
of [].
(28) [] thats simple blood test, like youve had many times before.
(29) Hepatitis C can cause cirrhosis. And once you get to that stage
[pause] then you start having many problems. Right now you feel well.
But when you develop cirrhosis youll be well for a while, but as the
cirrhosis worsens [pause] theres many things that can happen to you
and your body. It can take away your life. And the things that can
happen with cirrhosis include [pause] turning yellow.
10
A metaphor is a rhetorical device based on a cognitive operation consisting in
making an implicit comparison between two unrelated domains, so that one
domain (source) allows us to understand and reason about the other (target)
(Lakoff and Johnson 1980, 1999 and Lakoff 1987, 1993). A metonymy, by
contrast, relies on a domain internal mapping, whereby the source domain is used
to provide access to the target, for which it stands (Kvecses and Radden 1998;
Ruiz de Mendoza 2000). A simile requires the explicit use of a comparative
particle, such as like or as, but is inherently a metaphor.
304 Chapter Fourteen
(31) Cos hepatitis C is more than one virus, if you will. There are different
subtypes, just like Ford has different kinds of cars, they are all Fords, but
ones a truck and ones an SUV etc. Hepatitis C has different subtypes.
(32) The combination of alcohol with active hepatitis, I look this as kind
of putting alcohol on a fire or putting gasoline on a fire, it just makes
the fire worse.
are several expressions in the dialogues signalling that the doctors are
indeed on the patients wavelength:
The next step is that of tentatively trying to help the patient to shift the
focus of his attention to possible alternatives, while at the same time
reminding him about the facts:
(37) And so what Im talking about is you, if you ever choose to do this,
this is completely up to you, standard of care therapy with a combination
of traditional Chinese medicine [].
(39) We have not seen the remission, in other words the getting rid of the
virus, just with alternative medicine.
(41) [] I think that all the published information in the medical literature
will bear that out.
This is a recurrent technique that the doctors use to seek their patients
compliance. What they are implicitly saying is that their positions are
officially recognized and accepted in the scientific community and are
therefore trustworthy.
306 Chapter Fourteen
(43) I mean, youre stage three now. We dont want you to get cirrhosis
or any of those complications.
(44) You and I can work together in terms of addressing dietary factors
and get you on a very specific exercise programme that can help reverse
that.
(45) Doc: But I think youre gonna do well, because youve done some
great things. One is youre taking care of yourself, with the mental health
and the counselling youre getting there and the second thing is youve
made a decision to control that alcohol. So I think, I think youre ready. I
think you should consider
Terry: So is there anything we have to do before I start or and when can we
start?
The construal of trust in the case under scrutiny must thus be seen as a
complex and dynamic process, which involves the development of faith on
the part of the patient both in the single doctors and in the medical
profession as a whole. Put differently, it is a micro-macro phenomenon
that eventually leads to the establishment of different but interrelated
orders of trust.
are clearly llimited and onnly indicativee of how non--verbal behav viour may
both replicatte semantic coontent and sommetimes even carry key ind dependent
meanings.
In the ffirst part of the
t video fraagment analyssed (Table 14-1), Dr.
11
Patrick remmains mostly silent while Terry is pressenting his problem.
p
After askingg him why hee came to con nsultation, thee doctor simp
ply listens
and shows hhim both verbbally and with h her attentivee gaze as welll as with
her noddingg that she is following wiith interest w what he is say ying. The
verbal compponent is redduced to a minimum
m heree and comm munication
develops maainly through the non-verbaal cues that thee doctor uses.
2 Ok Noddding (shows
undderstanding), lo ooking
straiight into patieents eyes
(shoows attention and
interrest), slightly worried
gazee, holding han nds
togeether with fing gers
interrtwined (show ws
willlingness to waait and
listeen)
11
I have inccorporated imaage frames intto the multimoodal transcriptiion of the
exchange, foollowing Baldryy (2000), Thib bault (2000) an
and Baldry and d Thibault
(2006), but I have not incluuded the patients turns, sincee the focus heree is on the
strategies useed by the doctorr to enhance com
mmunication annd rapport.
308 Chapter Fo
ourteen
3 Ok Noddding, smiling
g (shows
undderstanding and
sym
mpathy)
4 Smiiling (shows
conffidence) and looking
l
straiight into patieents eyes
(shoows interest) holding
h
handds together wiith
finggers intertwineed
(shoows willingness to
waitt and listen)
5 So, Can,
C Steeepling (as if beegging
Let me
m for aan answer), sqquinting
Theres a (loooking for an annswer
really
y thatt may not be easy to
impoortant findd for the patien
nt), head
piecee of slighhtly turned to the right
information
I need your
help with.
Her faciaal expressionss and hand gesstures are iconnic and metaphoric and
may well suubstitute wordds at this initiaal stage. She iis obviously worried
w at
the very begginning (imagge 1). The no odding later suuggests that she
s either
understands the patients point of view or agrees witth him (image 2 and 3).
The fact thaat her gaze iss fixed on hiis face and iss never distraacted also
M
Medical Knowleddge Disseminattion and Doctorr-Patient Trust 309
shows the ppatient that hiis narration iss worth listenning to. Holdiing hands
together witth fingers inteertwined (imaage 2 and 4) iis iconic for thet act of
waiting, so the patient gets
g the message that it iss his turn to speak. In
addition, thee doctors sm
miles communiicate that she is feeling com mfortable
in the patiennts presence and her upright position eexpresses streength and
confidence iin dealing witth a potentiallly difficult sittuation that th
he patient
may be in.
The use of metaphorric/iconic pictographs and kinetographs becomes
more systemmatic as the coonversation prrogresses (see Tables 14-2 and a 14-3)
and the docctor starts askiing questions and explainiing medical isssues and
options to tthe patient. Steepling (fingger tips touchhing each oth her as the
hands are pplaced out in front formin ng a church ssteeple-like structure),
s
which resembles the act a of prayin ng, appears to have a question
reinforcemeent effect. At the same tim me, she is carrefully lookin ng for the
right wordss to frame thhe question, as a is suggesteed by her looking up
(image 6).
The horiizontal movem ment of the do octors left hannd, instead, strresses the
concept of other people and is perforrmed exactly w while those twwo words
are being utttered. She alsso moves forw wards as to suuggest that shee is ready
and open too get the answ wer from her patient (imagge 7). Finally y, her left
hand starts moving up and down vertically, som mehow mimiccking the
behaviour of cutting something,
s which
w has tto be metap phorically
understood here as makinng a clear-cu ut decision. TThis gesture is indeed
performed w while using the
t verb deciide (image 8)). It looks ass if body
language woorked as a meeta-discourse hereh to emphaasize the impo ortance of
what is beinng said.
As the conversation moves
m on and the doctor neeeds to explain n medical
information and terminollogy to the paatient (Table 14-3), the usee of non-
verbal elem
ments is more frequent and d consistent. H Hand gesturess become
very importtant vehicles of expression. They tendd to accompaany those
words that are particularrly salient in the context oof the utterance or the
ones that thhe doctor beliieves require additional claarification. In n order to
give credit to the truth of the statem ments she maakes, for instaance, she
emphasises the word puublished by suddenly s opeening her han nds, thus
metaphoricaally illustratingg the concept of being avaiilable (image 9). 9 Iconic
pictographs are often useed to remind the t patient of anatomical feeatures as
well (imagee 10 and 11)), while kinetographs seem m to complement the
meaning of lexical items through a mo ore detailed ddescription off a certain
concept. Thhe idea of makking gradual progress
p in reesearch (imagee 12), for
example, is better exppressed with h the movem ments of th he hand,
metaphoricaally standing for the steps made, than with the phrasal verb
come up witth alone. Sim milarly, the terrm adjunctive is best explaained also
M
Medical Knowleddge Disseminattion and Doctorr-Patient Trust 311
by reproduccing the act off putting someething inside a container (im mage 13).
Perhaps we should then speaks of parad
discourse to reefer to the usee of these
non-verbal eelements, sincce their charaacteristic is thhat of actuallyy running
parallel to annd highlightinng the verbal meaning
m compponent.
12 The best
b ft hand moving
Left g to the
that we
w left,, then back,
havee been reprroducing the idea
i of
able to the steps made (ssupports
comee up notiion of coming g up
with in withh)
terms of
actuaal
reseaarch
[]
13 [] Liftting left hand and
stand
dard of prettending to putt
care sommething insidee a
treatm
ment conntainer (stressees the
with the, conncept of adjun nctive or
we call it in aaddition to)
adjunnctive,
mean ning
in
addittion
to
stand
dard of
care,, these
adjunnctive
treatm
ments
5. Conclusions
This chaapter has attem
mpted to show w the potentiall offered bothh by some
verbal strateegies and nonn-verbal behaaviours in hellping to build d rapport
with difficuult patients who
w are relucctant to follow w their doctorrs advice
and recomm mendations. Inn the case ex xamined, the ppatient is unw willing to
consider meedical therapyy for his cond dition, but is eventually convinced
c
that the bestt thing to do for him is to be treated ussing a standarrd of care
approach, deespite all the possible side effects that hhe fears. Such h decision
appears to hhave been faciilitated by a cllear understannding on the part
p of the
patient of thhe nature of hiis disease and of the possibble solutions to
o manage
it, in order to potentiallyy get into rem mission. Thiss process has required
Medical Knowledge Dissemination and Doctor-Patient Trust 313
skillful discussions and dialogue, aimed first of all at making sure that the
patient understood all the medical information and technical terminology
used to talk about his condition. This increased awareness seems to have
empowered him to be involved in decisions regarding his care, thus
viewing doctors in a less asymmetric way. The feeling of being on the
same level with the doctors has then led to increased trust and to the
resolution of the initial conflict.
Given the limited amount of the data analysed, it is not possible to
generalise the findings of this study, which however seem to show that a
certain communicative style potentially has a significant impact on the
level of patients adherence to the advice or treatment regime recommended
by the doctors. For this reason, future research should focus on the
development of more fine-grained guidelines for best communication
practice in the medical context, taking into consideration both the verbal
and the non-verbal dimension. It would be interesting, for instance, to
compare the scenarios examined here with similar ones in which the
doctors do not adopt strategies for effective and affective communication
and see whether or not, or to what extent, this impinges on the quality of
the doctor-patient relationship and, ultimately, medical care. My
impression is that the narrower the gap between doctors and their patients,
the greater are the chances of achieving the desired therapeutic outcomes.
The possibility for the doctor to master conflictive situations may arise
from his/her ability to use specific verbal and non-verbal techniques, some
of which have been presented above.
It is my persuasion that doctor-patient communication can be improved
through instructed attention to certain features of both spoken and body
language and to how their use is essential if a consultation is to go
smoothly.
References
Adolphs, Svenja, Brian Brown, Ronald Carter, Paul Crawford, and
Opinder Sahota. 2004. Applying corpus linguistics in a health care
context. Journal of Applied Linguistics 1 (1): 9-28.
Austin, John Langshaw. 1962/1975. How to Do Things with Words, edited
by Marina Sbis and James O. Urmson. Oxford: Oxford University
Press.
Baldry, Anthony. 2000. English in a visual society: Comparative and
historical dimensions in multimodality and multimediality. In
Multimodality and Multimediality in the Distance Learning Age, edited
by Anthony Baldry, 41-89. Milan: Edizioni Unicopli.
314 Chapter Fourteen