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Suggestive markers of diagnostic strategy in medical discourse

N. V. Goncharenko

Volgograd State Medical University,

Volgograd, Russia

 

Professional experience of the doctor is not only the usage of medical technology, but also the particulars of doctor's personality and a number of communication skills, which allow to provide suggestive impact on the patient, create a relationship of trust between a doctor and a patient and lead to better therapeutic outcomes [1, 2, 4].

A dialogue between a doctor and a patient begins with medical diagnostics. To do the diagnostics means to recognize that in medical discourse is to define a disease on the basis of the thorough examination of the patient.

It is known that diagnostic strategy includes personal acquaintance of the doctor with the patient, an external examination of the patient, doctor's acquaintance with patient's complaints, collecting of his medical anamnesis (the learning of the patient's conditions of life, his earlier disease setting, whether the disease is hereditary and etc.), the collection of objective data on the physical health of the patient (cardiography, X-ray, blood pressure measurement, blood tests, etc.).

It is obviously that diagnostic strategy is informative strategy. A dialogue between a doctor and a patient is considered to be the leading method of diagnostics (collection of anamnesis). A method of obtaining of information can be verbal (questioning of the patient, a variety of probing questions that arise in the course of the conversation and the presentation of complaints by the patient) and non-verbal (examination of the patient) [1, с.123].

Collecting information usually starts with verbal communication, with the interrogation of the patient. In the process of verbal communication, the doctor gradually reduces physical distance: at some point of the conversation he leans closer to a patient or touches a patient's hand, avoiding sudden movements and rough touches. Thus, by giving the patient an opportunity to get used to reduction of interpersonal distance, the doctor prepares him for physical contact (palpation, percussion, auscultation).

As we see it, the medical checking up of a patient associated with physical contact, becomes easier if it is naturally included in the process of verbal communication. The process of obtaining information about a patient requires from a doctor the ability to formulate questions. The function of impact as an integral component of the suggestive function of interrogative sentence is implemented in achievement of a verbal response received as a response to a question. Above all, suggestive nature of questions is expressed by mandatory programming of the replica-response where the regulation is achieved due to the fact that the recipient has to give an answer (forced to answer) the question. Programming of the answer is one of the strategic objectives of the speaker with the help of which he forces the listener to continue the dialogue in the needed direction for himself.

An important point is that doctor's questions can be divided into close-type and open-type [3, 4]. So far as it is known, close-type questions are used to obtain specific information and usually assume the answer in a nutshell, confirmation or denial. For example: “Do you have a headache?", "When do you often have a cough, in the morning or in the evening?”, “Do you often have tonsillitis?”, “Is it difficult for you to breathe through the nose?” and so on.  

At our best guess, open-type questions allow to receive more deep, detailed answers, may include not only a description but also evaluation of symptoms, their subjective meaning for the patient, further details and data: “Give me more details about the pain”, “What is the difficulty in your breathing?”, “What are you doing to relieve their condition?”, “What do you gargling with?”.

It is vital to note that frequently Doctor's questions are similar to a clue, i.e. have a suggestive character: "Does the pain irradiate to the left arm?", "Do you have shortness of breath when walking?", "What kind of pain do you have, sharp or blunt?", "Do you associate deterioration of health with the lifting of heaviness or only with a change of the weather?", “Do the pain increase on swallowing?”.  Therefore, interviewing techniques applied by a doctor may be the way of suggestive influence in diagnostic strategy of medical discourse.

To determine the degree of suggestiveness in the formulation of the question, let us consider the typology of questions proposed by Ernst Kretschmer, a German psychologist [3]. The author identifies four types of questions, which read as follows:

1.    Please tell me what brought you here.

2.     Have you any pain or not?

3.     Do you feel any pain?

4.    You feel pain, isn't it?

The author calls type 1-question is devoid of suggestive tone, type 2 is the alternative wording of the question, type 3 is a passive suggestive question and type 4 is an active suggestive question [3].

According to the researcher, the first form of the question has a great advantage that creates an entirely free-of-bias-state of mind of the patient. But it seems to us, the disadvantage of this statement is that surveys of this type take quite long time, patients have unlimited opportunities to speak, mentioning the important things with many unimportant ones, and sometimes even forget to tell about the important ones. The author notes that the question of an alternative type 2 has the great advantage that it absolutely restricts the topic, saves time and allows the physician to bring the patient to needed condition for certain diagnostic questions. The doctor avoids deliberate suggestiveness by providing equal emphasis on both parts of the question. Intensive focus of the first part of the question can make the patient to think that the doctor does suggest severe pain to him. More favorable is polynomial elaborated formulation of the question, for example: “What kind of pain do you have: pressing, compressing or piercing?”, “If you are being late, can you run till the bus stop or quickly cross the street?”. Another question: “What disturbs: you get tired or feel pain in legs, or shortness of breath occurs, or the heart begins to beat?”.

According the author's opinion, some suggestive element is enclosed in each alternative question, as the physician uses it to direct patient’s attention to a certain point [3]. We agree with the researcher, that the third type of question contains an obvious suggestive moment. Under the influence of passive suggestive question, the patient may think that pain is included into the picture of the disease, and that he should be polite enough to respond positively in this sense, even if he does not feel any pain or pain is not significant. This type of question can easily persuade the patient to answer simply “yes”, but the question: “Do you have nothing hurts?” to answer “no”. Every time impressively asked alternative question is forcing the patient to concentrate. It should be noted that alternative questions are particularly valuable because they allow us to avoid wrong answers or misunderstanding caused by suggestion.

Finally, the researcher calls type 4 is an active suggestive question which has largely psychological characteristics of type 3, and suggests a very compulsive positive statement of a question [3].

In our view it is essential that these characteristics should be taken into account when the doctor has to deal with patients with a high degree of suggestibility and shyness, so a doctor determines the choice of a particular method of questioning according to the communicative peculiarities of patients. Depending on the available time, the doctor gives the patient the opportunity to speak freely or puts alternative questions for short. Intentionally a doctor does not use a passive suggestive question (type 3) often, because it is associated with some disadvantages and has no advantages. A doctor does not use active suggestive question hastily but uses it quite intentionally for certain indications: “Do you hurt so much when I bend your leg?”, “Do you feel pain when I'm here to press?” Or: “Does the pain disappear when I lift the leg in the calm extended state?”.  A doctor encourages a patient to certain answers by asking these questions.

To sum it up, we conclude that the knowledge of interviewing techniques and the ability of a doctor to conduct an active dialogue, to articulate meaningful questions, to ask suggestive and clarifying questions, to lead responses of a patient into the right direction, to concentrate his attention, to suggest a patient necessary information, all of these contribute to the successful course of the dialogue and the implementation of suggestive influence of communication in the medical discourse.

Bibliograph

  1. Гончаренко Н.В. Cуггестивные характеристики медицинского дискурса. Волгоград, 2015. 224 с.
  2. Жура В.В. Принципы организации "медицинского интервью" // Вестник Волгоградского государственного медицинского университета. 2005. № 4. С. 60-62.
  3. Кречмер Эрнст. Суггестивные вопросы // Медицинская психология. URL: http://www.psychiatry.ru/lib/53/book/53
  4. Mishler E. The Discourse of Medicine: Dialectics of Medical Interviews (Language and Learning for Human Service Professions). Norwood, N.J.: Ablex, 1984. 241 p.
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