Map of life expectancy at birth from Global Education Project.

Monday, February 23, 2009

Molecules and substances

Ana notes, quite correctly, that trust is an important variable in speech act theory. I would go considerably further and say that the elucidation of speech acts is contingent on many dimensions of the relationship between the interlocutors, including not only trust but the rights and privileges the speaker accords the interlocutor, and presumes for himself or herself; the degree of regard or affection (or its opposite) from one to the other; the degree of intimacy and the location of boundaries; and shared history and context between the two.

Many speech acts speak for themselves, but sometimes any or all of those factors can be part of the determination of how to classify a speech act, or greatly affect its import. An example I commonly use is "It's cold in here," which looks like a statemetn of fact but is unlikely to be the kind of speech act we call a representative, because if the interlocutor is in the same room, she or he already knows the temperature. If this is said over the telephone, it might be a representative, but otherwise it could be an expressive -- e.g., a spouse complaining that the other keeps the thermostat too low, or simply a request for sympathy -- or a request to turn the thermostat up, or perhaps to cuddle. We would need to know a lot about the relationship and history of the interlocutors to accurately conclude what is intended.

Fortunately for my research team, physician-patient interactions are highly ritualized, bounded by cultural norms regarding the respective roles, and largely -- though by no means exclusively -- limited to a finite universe of subject matter. We can usually deduce the parameters of the relationship -- such as trust, regard, etc. -- from speech acts which are not problematic, and so have a basis for properly classifying those which may be more difficult. To the extent that norms and conventional boundaries are violated, or the relationship has a large load of history or unusual degrees of personal feeling, we can observe that from the data.

However, I don't know that we can always do this and we may be fooling ourselves a bit. In spite of the vast amount of research that has been done on physician-patient communication, there has been very little which concerns how doctors and patients view their ongoing relationships and how these develop and change over time, as opposed to breaking down invidivual encounters. Of course, encounters with specialists or in urgent care are often one-time or few time events. But other Dr-Pt relationships are extensive and intimate, within certain boundaries and in patterned ways. This is something I would like to understand much better.


kathy a. said...

this sounds very interesting. i'm not sure where you are headed with it, but from my point of view, there are huge qualitative differences in doctor/patient relationships that have little to do with the provider's medical expertise.

i've complained here before about doctors who made my head explode -- for example, the dude who delivered my daughter, never introduced himself, didn't believe i was in labor until too late to give me the meds i wanted [overseas military hospital]; or the neurosurgeon who didn't want to answer questions about my mother's stroke; and yadda ya.

but we've also been spoiled by some doctors who have a place in my heart, and for the most part, they earned that place with human touches that probably would not be available for viewing in a transcript of one visit. for example, my family has been with our family practice for close to 20 years now, and appreciate everyone asking after the kids and so on; and they still display the origami that my daughter made when one of the doctors died. when my dad died one early afternoon, his oncologist didn't bother to show up for a promised meeting that morning, but his PCP and the doctor's wife drove right away to the hospital to be with us. as disgusted as i was with my mother's neurosurgeon, i was devoted to her orthopedic surgeon -- who gave us all the information we wanted, and also had compassion and a sense of humor.

my nephew had brain cancer, diagnosed at age 9 and he died at 12. i did not like his oncologist at first -- she was very blunt and seemed harsh. but she was wonderful, hardworking, did her absolute best. when alexander reached the point where he was terminal, the cancer spreading throughout his brain, she arranged a meeting with all of the staff who were working with him and his family, to break the news gently but honestly. she made tea for the parents herself. she reminded them that she had promised to be honest, and to tell them if there was no longer hope. and etc., it remains my model of how to break the worst news. some weeks later, when alexander was in his final coma, she came to the house one evening and stayed most of the night -- he came very close to death that night. once things settled down a bit, she and the family cooked together. there is no way to describe how much those few late-night hours meant to alexander's family. they do not teach that in med school, and the ins cos don't recognize that code, but SHE was a fabulous doctor.

Anonymous said...

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Anonymous said...

yes it would be wonderful to understand it better...i only know a few of the studies, not my field, etc.

As a child psychologist (and see post above) I have been informally interested in those situations where the Dr role is distributed over many ppl - the dependent or incompetent patient and those who hold power over the treatment / actions / etc. undertaken to benefit those who don’t have their own decisionary powers (de facto, legally, etc.)

This situation is different from the standard situation of adult patient who ‘manages’ own health in coordination with a Doc. (Not saying one should study one or the other, whatever.) In these situations, the Dr role is not split exactly into parts, but is wafted out round and about.

As an anecdotal example, as a mother I found that I cared nothing for a Docs relational skills, or anything associated with that, was only interested in expertise, outcome, technique; though of course I played the role of ‘good mom’ which includes getting on with the doc, whatever it takes!

I did not even care much, or at all, if Doc ‘was good with kid’, though of course it is more pleasant when it is the case, child is reassured, less afraid, etc. My ‘mom’ attitude was focussed on getting the very best care, full stop.

mama, that man not nice, my son said - about the best hand surgeon in the canton. i said, he is the best for the job, he is cold, focussed on his job; the nurses you’ll see, are sweet, they will be with you all the time.

My own attitude to my own GP is quite different: I count on his understanding me, my life, my personality, my health insurance; I require, in fact, some validation from him.