Barry C A, Stevenson F A, Britten N, Barber N, Bradley C P
Department of General Practice and Primary Care, Guy's King's & St. Thomas's School of Medicine, King's College, London, UK.
Soc Sci Med. 2001 Aug;53(4):487-505. doi: 10.1016/s0277-9536(00)00351-8.
Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.
米什勒（《医学话语：医学访谈的辩证法》。新泽西州诺伍德：阿布雷克斯出版社）将哈贝马斯的交往行为理论应用于医疗互动中，展示了医学话语与生活世界话语之间的斗争是如何碎片化并压制了患者多方面、情境化且有意义的叙述。本文调查并批判了米什勒的前提假设，即这种情况会导致不人道、无效的医疗护理。我们采用了更复杂的数据收集策略，包括患者访谈、医生访谈以及转录的会诊记录，结果显示出比米什勒分析中更为复杂的关系。我们在35个全科医疗案例研究中发现了四种沟通模式。当医生和患者都仅使用医学话语（急性身体不适）时，这适用于简单单一的问题（纯粹医学模式）。当医生和患者都涉及生活世界时，更多的议程被表达出来（相互生活世界模式），患者被视为独特的个体（心理和身体问题）。最差的结果出现在患者使用生活世界话语但被医生使用医学话语忽视（生活世界被忽视）或阻碍（生活世界被阻碍）的情况（慢性身体不适）。该分析支持这样一个前提，即更多地运用生活世界话语会带来更好的结果，并能更人道地对待作为独特个体的患者。一些医生在不同的会诊中改变了沟通策略，这表明他们的行为可能是可以改变的。如果医生能够意识到处理慢性身体疾病以及心理疾病患者生活世界关切的重要性，那么就有可能为患者提供更好的护理。这将需要关注医疗保健系统的结构方面，以使医生能够完全在以患者为中心的模式下工作。
