Brookes-Howell Lucy Claire
Cardiff University, Department of General Practice, Centre for Health Sciences Research, Neuadd Meirionydd, Health Park, Cardiff CF14 4YN, UK.
Soc Sci Med. 2006 Dec;63(12):3080-91. doi: 10.1016/j.socscimed.2006.08.008. Epub 2006 Oct 11.
In the genetic counselling setting it is not uncommon for a client and genetic counsellor to be faced with uncertainty surrounding the exact diagnostic label to be assigned to the client's symptoms. The huge range of possible conditions/syndromes and the lack of definitive evidence available often combine to create diagnostic uncertainty or non-diagnosis (the assessment given where a genetic diagnosis of the client's symptoms cannot be confirmed at that point). This paper aims to explore the interactional management and negotiation of diagnostic uncertainty in the genetic counselling clinic in the UK. Through the application of discourse analytic tools (including reported speech, contrast and hedging) to transcripts of actual clinical interactions, the participants' use of evidence, and professional and client expertise, are examined and found to be key in the negotiation of diagnostic uncertainty. The complete data set for this research consists of transcripts of 18 clinical encounters between genetic counsellor and client. Two client cases are identified and analysed in detail in order to follow the pattern of interactional management of diagnostic uncertainty throughout the whole interaction. The findings suggest that, unlike other medical settings, clients within genetic counselling are able to actively participate in talk about diagnosis allowing, for the extent of non-diagnosis to be negotiated. This is particularly so during two moments in the interaction: the beginning of the clinic where the agenda is set, and towards the end of the clinic when a form of diagnostic assessment must be made. By providing an insight into the problematic interactional activity of giving a non-diagnosis this paper can contribute to discussions on genetic counselling practice. The analysis in this paper demonstrates how a genetic counsellor can manage the balance between accurate information-giving and empathy towards individual client needs for a diagnosis.
在遗传咨询环境中，客户和遗传咨询师面临难以确定为客户症状确切诊断标签的情况并不罕见。可能的病症/综合征种类繁多，且缺乏确凿证据，这常常导致诊断不确定性或无法确诊（即在当时无法确认对客户症状的基因诊断时给出的评估）。本文旨在探讨英国遗传咨询诊所中诊断不确定性的互动管理与协商。通过将话语分析工具（包括间接引语、对比和模糊限制语）应用于实际临床互动的记录文本，研究参与者对证据的使用以及专业人员和客户的专业知识，并发现这些是协商诊断不确定性的关键因素。本研究的完整数据集包括遗传咨询师与客户之间18次临床会诊的记录文本。为了追踪整个互动过程中诊断不确定性的互动管理模式，详细识别并分析了两个客户案例。研究结果表明，与其他医疗环境不同，遗传咨询中的客户能够积极参与关于诊断的讨论，从而就无法确诊的程度进行协商。在互动过程中的两个时刻尤其如此：会诊开始时设定议程，以及会诊接近尾声时必须进行某种形式的诊断评估。通过深入了解给出无法确诊这一有问题的互动活动，本文有助于促进关于遗传咨询实践的讨论。本文的分析展示了遗传咨询师如何在提供准确信息与体谅客户对诊断的个人需求之间取得平衡。
