臺灣博碩士論文加值系統

醫病溝通中的言談修復不只透露出病人對醫師言語內容的不確定感，也反映出醫師與病人的溝通斷層。根據台北市衛生局在2007年報告，多數醫療糾紛案例是由醫師與病人之不良溝通所引起。造成醫病溝通不良的原因乃醫師本身之不清楚陳述，可能造成其後病人對醫師處方及診斷的不確定感及誤解。Aronsson 和 Sätterlund 於1987年研究指出醫療過程中的溝通障礙會增加醫療成本，甚至造成醫療品質下降，言談修復為用來改善溝通障礙的一種方式。基於上述動機，本研究之目的為檢視在醫病溝通中發生哪些溝通問題以及醫師宜如何解決這些問題，以便繼續接下來之診斷及醫療處置。
本研究之研究議題有二：第一，病人以何種言談機制引發醫師的言談修復？這些言談機制在醫病溝通中的分佈為何？；第二，醫師以何種言談修復機制回應病人的言談引發機制？醫師言談修復機制之分佈為何？針對上述二項議題，本研究於台灣南部某教學醫院家庭醫學科，以錄影方式收集21個實際問診之語料，參與者包含17位醫師(平均年齡為34)以及21位病人(平均年齡為61)。在這21個實際問診中，本研究針對46組屬於「以病人引發、醫師自我修復」(本研究統稱此類為「言談修復組」)進行語料分析。此言談修復組包含三項要素：要素一為醫師之原始話語 (簡稱為T1); 要素二為病人之言談修復引發 (簡稱為T2); 要素三為醫師對病人引發所進行之言談修復 (簡稱為T3)。研究結果顯示：
(1) 「未標記之言談修復引發機制」(unlocatable repair initiators, 例如：Hann?) 以及「已標記之言談修復引發機制」(specified repair initiators, 例如：食啥物?) 為主要引發言談修復之機制。
(2) 醫師之原始話語多以「問句」結構組成(共有44組)並且這44組言談修復列皆發生在門診之資訊收集階段。
(3) 醫師以四種模式進行言談修復機制: 模式一，「主題還原」(佔25%); 模式二，「簡化」(佔53.57%)，其再分為二：「簡化並部份重覆T1」 (佔17.86%) 以及「簡短回應T2」 (佔35.71%); 模式三，「問句型態從封閉式問句改變成開放式問句」(佔14.29%); 模式四，「使用第二人稱單數你/汝」(佔7.14%)。
(4)醫師言談修復機制之主要前語境為病人之「未標記之言談修復引發機制」。
基於上述四項研究結果，本研究建議：
(1) 「資訊交換的精確性」在門診之資訊收集階段相當重要。
(2) 根據「已標記之言談修復引發機制」之語境顯示，當醫師與病人處於資訊交換 時，醫師能清楚提出問題主題或重點。
(3) 即便問題主題在先前已討論過，當醫師再次討論相同主題時，此主題應再次表明清楚以避免病人誤解。
(4) 問句型態的改變(從封閉到開放式問句)能讓病人之回答範圍較廣; (5) 當醫師詢問時，問題中加入人稱代名詞較能引起病人注意目前討論的話題或問題。
上所述，本研究提出二項主要結論，第一，詢問問題以及回答問題之精準性在門診的資訊收集階段相當重要; 第二，醫師改變問句類型成為開放式問句較能取得病人之廣泛資訊。要之，本研究提供一些關於醫師收集病人資訊時應注意之事項，希望藉此能改善醫師在收集資訊階段中詢問的技巧。

When conversation repair occurs in medical communication, it not only reflects the patient’s uncertainty, but also indicates the existence of communicational gaps between the physician and patient. According to a report from the Taipei City Government’s Department of Health (2007), most medical malpractice cases result from poor communication between physicians and patients. One of the reasons for the poor communication in this context is physicians’ unclear statements, which can lead to the patients’ incomprehension or misunderstanding of the prescribed medication or therapy. Aronsson and Sätterlund (1987) claimed that communicational blocks in medical encounters can increase medical care costs or worse medical care. The aim of conversational repair is to deal with communication blocks in order to improve communication between physician and patients, and thus the purpose of the present study is to investigate what communication problems occur in physician-patient communication, and how physicians resolve these communicational problems in order to carry out successful diagnoses and medical treatment plans. Two research questions are examined: (1) What are the patients’ discursive mechanisms in initiating physicians’ repair and what is the distribution of these mechanisms in response to physicians’ original utterances? (2) What discursive mechanisms are used by physicians to respond to patients’ initiations and what is the distribution of these mechanisms in response to patients’ repair initiations? To answer my two research questions, a total of 21 transcriptions from medical encounters in which 17 physicians, with an average age of 34 years old, and 21 patients, with an average age of 61 years old, were collected from the family medicine department of a teaching hospital in southern Taiwan. In the 21 cases, a total of 46 patient-initiated physician-repair sequences (hereafter ‘repair sequence’) are identified and analyzed in this study. Each repair sequence has three elements: (1) physician’s original utterance (hereafter ‘T1’), (2) patient’s repair initiation (hereafter ‘T2’), and (3) physician’s repair completion (hereafter ‘T3’). The results show that: (1) ‘unlocatable’ repair initiators such as ‘Hann?’ ‘Pardon?’ (69.57%) and ‘specified’ repair initiators such as ‘食啥物? /tsia̍h-siánn-mih?’ ‘eat-what-food?’ (30.43%) are the two main repair initiators used in response to physicians’ original utterances. (2) most physicians’ original utterances are questions (44 out of 46), and they are all situated in the information gathering stage of the medical encounters. (3) Four main patterns are presented in physicians’ discursive mechanisms corresponding to patients’ repair initiations: Pattern I ‘topic restoring’(25%), Pattern II ‘simplification(53.57%), which is further divided into ‘short reply to T2’ (35.71%) and ‘simplifying by partially repeating T1’ (17.86%), Pattern III ‘changing question type from closed to Wh-question’ (14.29%), and Pattern IV ‘the use of the second singular pronoun’ (7.14%). (4) Only the pattern ‘short reply to T2’ corresponds to specified repair initiators, while the other patterns correspond to unlocatable ones. Based on these findings, this study suggests that: (1) greater information accuracy with respect to the content of questions and ways of asking and answering is critical for successful information exchange in the information gathering stage of medical encounters. (2) Topic clarification during information exchange is crucial for successful communication between physician and patient, and this suggestion is based on the presence of a specified repair initiator is right before T1. (3) Physicians are encouraged to make their questions more clear, as this can help patients to understand them, and even if the topic of the current discussion has been indicated in prior turns, it is essential to present it again in subsequent utterances or questions. (4) Inviting for a wide range of patient responses’ about their diseases or concerns can be achieved by changing the question type from a closed ones to a relatively open Wh-questions. (5) Asking questions with a second singular pronoun such as ‘你/汝ni/li’ ‘you’ can draw patients’ attention to the current discussion. Based on these findings and suggestions, two main conclusions are derived from this study. One is that the accuracy of information exchange is vitally important in the information gathering stage of medical encounters, and this can be seen by the presence of topics in the physicians’ questions. Second, eliciting a wider range of patient responses can produce more effective physicians’ question, and this can be achieved by changing the question type. This study has some practical implications with regard to asking questions and responding in the information gathering stage of medical encounters, and thus can help physicians to improve their questioning techniques.

ABSTRACT (CHINESE) i
ABSTRACT (ENGLISH) iii
ACKNOWLEDGEMENTS vi
TABLE OF CONTENTS vii
LIST OF TABLES x
LIST OF EXCERPTS xi
LIST OF FIGURES xiv

CHAPTER ONE INTRODUCTION 1
1.1 Motivation and Background 1
1.2 Purpose of the Present Study 2
1.3 Research Questions 3
1.4 Definition of Terms 4
1.5 Preview of the Following Chapters 4
CHAPTER TWO LITERATURE REVIEW 6
2.1 Other-Initiation of Repair in Daily Conversations: Forms, Contexts and Implications of Other-Initiation 6
2.2 Other-Initiation Repair in Institutional Conversations: Teacher-Student Classroom Interaction as an Example 10
2.3 Other-Initiation Repair in Medical Encounters 13
2.3.1 Conversational Repair in Physician-Patient Communication 13
2.3.2 The Location of Repair Sequence in Medical Encounter 14
2.4 Discursive Mechanisms used in the Other-Initiation Repair Sequence in Daily and Medical Communication 16
2.4.1 Questioning Techniques 17
2.4.2 Repetition 19
CHAPTER THREE METHODOLOGY 23
3.1 Data Collection 23
3.1.1 Participants 23
3.1.2 Setting and Transcriptions 25
3.2 Analytic Frameworks 26
3.2.1 Patient-Initiation in Patient-Initiated Physician-Repair Sequences 26
(1) The Schema of Patient-Initiated Physician-Repair Sequence 26
(2) Patient-Initiation (T2) to Physician’s Original Question (T1) 28
(3) The Distribution of Patient’s Repair Initiation in Four Stages of Medical Encounter 31
3.2.2 Physician’s Discursive Mechanisms (T3) in Response to Patient’s Repair Initiations (T2) 34
(1) Topic of T3 35
(2) Tsao’s “Topic NP Deletion” 37
(3) Tsao’s (1979) Immediate Situation Use 38
(4) Left-Dislocation and Topicalization 39
(5) Moderate Questioning Technique 40
(6) Closed Questioning Technique 41
CHAPTER FOUR RESULTS AND DISCUSSION 42
4.1 ‘Unlocatable’ and ‘Specified’ Repair Initiators in Response to Physicians’ Original Utterances 42
4.1.1 ‘Politeness’ or ‘Accuracy’: What is Most Significant for the Information Gathering Stage of Medical Encounter? 45
4.1.2 The Significance of Topic Clarification in Terms of Specified Repair Initiators as a Response to Physician’s Original Question 51
4.2 Four patterns of physicians’ discursive mechanisms (T3) and their Distribution in Response to patients’ initiations (T2) 65
4.2.1 ‘Focal’ as a Salient Feature in Patterns I and II in Response to Patients’ Repair Initiations 71
4.2.2 Question Type Change for a Wide Range of Patients Responses 75
4.2.3 ‘Drawing Attention’: the Use of the Second Singular Pronoun ‘你/汝/ni/li’ (Pattern IV hereafter) 83
CHAPTER FIVE CONCLUSION AND IMPLICATIONS 87
5.1 Summary of Main Findings 87
5.2 Implications of the Present Study 89
5.3 Limitations of the Present Study 91
5.4 Suggestions for Further Studies 92
5.5 Contributions 93
REFERENCES 95
Appendix 104

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