Marchant-Haycox S, Salmon P
Department of Psychology, University College London, England, United Kingdom.
Psychosomatics. 1997 Sep-Oct;38(5):440-50. doi: 10.1016/S0033-3182(97)71421-X.
Patients commonly receive invasive investigation and treatment for subjective symptoms, but little is known about how this decision is reached. Therefore, the authors audiotaped the interactions of gynecologists with 88 patients presenting menstrual problems without confirmed physical pathology. From these, eight interviews that led to hysterectomy were chosen for detailed qualitative analysis, together with eight of those leading to other responses. Dialogues leading to hysterectomy were characterized by a framework dictated by the patient. She presented deteriorating subjective symptoms and psychosocial distress in a way that placed responsibility on the gynecologist. She imposed a biomedical model on the dialogue, which entailed presentation of an anatomical cause and a surgical solution, with criticism of conservative treatments. Interviews leading to conservative responses were, by contrast, characterized by a strategy whereby gynecologists established authority by confirming their ability to "look inside" the woman's uterus and see that it was normal. The results suggest a novel view of consultation in the absence of physical pathology. The patients and doctors in this study were opponents who used specific strategies to assert authority by emphasizing contrasting areas of expertise: knowledge of subjective symptoms vs. the inside of the body. The use of these strategies helps to explain whether hysterectomy is chosen as a response to menstrual problems in the absence of pathology.
患者常常因主观症状接受侵入性检查和治疗，但对于如何做出这一决定却知之甚少。因此，作者对妇科医生与88名有月经问题但未确诊有身体病变的患者之间的互动进行了录音。从中选取了8例导致子宫切除的访谈进行详细的定性分析，另外8例导致其他结果的访谈也一并分析。导致子宫切除的对话以患者主导的框架为特征。她以一种将责任归咎于妇科医生的方式呈现出不断恶化的主观症状和心理社会困扰。她在对话中强加了一种生物医学模式，即提出解剖学病因和手术解决方案，并批评保守治疗方法。相比之下，导致采取保守措施的访谈的特征是，妇科医生通过确认自己有能力“查看”女性子宫内部并发现其正常来确立权威的一种策略。研究结果表明了在没有身体病变情况下的一种全新的会诊观点。本研究中的患者和医生是对手，他们通过强调不同的专业领域：主观症状知识与身体内部情况，运用特定策略来维护自身权威。这些策略的运用有助于解释在没有病变的情况下，子宫切除是否会被选为应对月经问题的措施。
