The Language Teacher
05 - 2003
Pragmatics in Language for Specific Purposes Training:
A Focus on Medical Discourse
Sayoko Yamashita
Tokyo Medical and Dental University
Pragmatics studies how people produce and comprehend a communicative act or speech act in speech situations. The medical encounter is one such speech situation, and it is worth investigating in terms of pragmatics. In the field of medical discourse as ESP (English for Specific Purpose) or JSP (Japanese for Specific Purpose), learners' ability to master communicative skills in their professional field is particularly important. Many international medical residents or medical students struggle to master a target language in order to smooth their communication with patients (see Eggly, Musial, & Smulowitz, 1999). In this article, I would like to review the literature of medical encounters and consIder the relevance of this research to language for specific purpose training.
Doctor and patient communication has been studied extensively since the 1970s. While much of the cross-disciplinary literature on medical encounters is linguistically atheoretical, there are numerous books and articles devoted to the discourse of medical encounters which focus on power relations between patient and doctor using linguistic analysis (Ainsworth-Vaughn, 2001). Coulthard and Ashby (1975) studied medical interviews sociolinguistically, and showed patterns of information-seeking and control. They analyzed doctors' or patients' initiation, response, follow-up, and interruption, and found that the most frequent types of exchange are doctor-initiated information-seeking exchanges rather than patient-initiated information-giving exchanges. In a way, this is similar to classroom discourse, where the power relationship between teacher and students is unbalanced.
A much more detailed analysis of questions and answers in medical discourse (between physician and patient) was conducted using conversation analysis (West, 1993). Her findings suggest an asymmetric distribution of utterance-types by the initiation of questions and answers by physicians and patients. Mishler (1984) investigated the discourse of medicine or dialectics of medical interviews much more closely from a psychologist's point of view. He used a method of discourse analysis using transcriptions from video and audiotaped medical interviews. He developed a detailed, modified approach toward the use of transcription, which allows for a comparison of the two "voices," the voice of medicine and the voice of the ordinary world. In addition to regular features of utterances and turn taking, such as length and location of silences and overlaps between speakers, he used two different printer fonts, and treated shifts between voices as interruptions, whether they occurred within or between speaker turns. His study shed light on medical discourse and how it adopts the perspective of patients expressed in the voice of the everyday world. The relationship between gender and power of physicians and their patients is one of the major issues in studies of medical discourse. West (1990) studied how physicians formulate their directives to patients and how patients respond to those directives. She found that female and male physicians issue their directives in dramatically different ways. Their alternative formulations have consequences for patients' responses. She found in her study that male physicians used aggravated forms that emphasized differences between their patients and themselves, and showed hierarchical physician-patient relationships. On the other hand, female physicians employed mitigated directives, minimizing status differences between physician and patient. Ainsworth-Vaughn (1992) studied the ways topic transitions are made in physician-patient encounters in terms of power, gender, and discourse change. She found that reciprocal topic-transition activities, assumed to share power between physician and patient, and unilateral topic transitions, assumed to allocate power to the speaker, differ widely by the gender of the physician (see also Davis, 1993).
Tannen and Wallat (1993) studied doctor, mother, and child communication in a pediatric setting. In this setting, not only doctor and patient, but the patient's caretaker (mother) is involved, making the communication more complex. This sociolinguistic analysis revealed the complexity of cognitive, social, and emotional demands on the pediatrician posed by parent involvement in the examination of the child. Overlapping, competing, and conflicting frames are observed in all participants, and misunderstanding can result from choice of phrasing, intonation, and other linguistic and paralinguistic cues based on differing expectations.
As reviewed above, studies of medical discourse suggest a wide variety of topics in pragmatics and language teaching as a second language. Theory can be applied in practice in order to facilitate the learning of medical residents so that they become more able to communicate humanely with patients in the target language. Following are some specific training suggestions that could use the findings from this literature.
Using the "Initiation-response-follow-up" (I-R-F) framework, international medical students or residents do a role play in a clinical setting. They first focus on the appropriate expressions for I-R-F, then acceptable turn-taking and pauses between I-R and R-F.
Learning various types of questions and how to use them appropriately is also a useful exercise for medical students. Questions may be categorized, and merits and demerits of a referential question and a display question in a clinical setting may be discussed from a pragmatics point of view. The students may view the videos of the actual medical encounter.
Distinguishing between voices of medicine (professional language) and the everyday world (ordinary conversation) may be very important for medical students (see Mishler, 1984). International medical students must prepare to deal with at least two types of voice (doctor's voice and patient's voice)--and most likely, each voice is supported by its own unique language style. Role-plays can be conducted so that students can experience both doctor and patient roles in order to learn ideal communication styles.
Gender and power also exist in medical discourse. Interactions between doctors and patients of different or same gender may construct different power relationships. Activities may be assigned to the medical students so that they observe their seniors' medical practice and take notes about what they saw and heard in terms of pragmatics of gender and power relationships. Later they role-play the situation later.
Students in clinical practice encounter not only adults, but also children and their caretakers. Caretaker and child may use different pragmatic strategies (such as overlapping, competing, conflicting, etc.), and it is an excellent exercise to discuss, observe, and role play such situations.
The above are only a few examples. Additionally, students can observe or look at actual clinical practices by using video, or use role play scenarios in order to have opportunities to practice coping with medical, professional, and everyday life contrasts. Medical discourse provides rich resources for the teaching of pragmatics in general and specific guidance for the teaching of language for a specific purpose.
References
Ainsworth-Vaughn, N. (1992). Topic transitions in physician-patient interviews: Power, gender, and discourse change. Language in Society, 21, 409-426.
Ainsworth-Vaughn, N. (2001). The discourse of medical encounters. In D.Schiffrin, D.Tannen, & H. Hamilton (Eds.), The handbook of discourse analysis (pp. 453-469). Malden, MA: Blackwell.
Coulthard, M., & Ashby, M. (1975). Talking with the doctor, part 1. Journal of Communication, 25(3), 140-148.
Davis, K. (1993). Nice doctors and invisible patients: The problem of power in feminist common sense. In A. D. Todd & S. Fisher (Eds.), The social organization of doctor-patient communication (pp.243-265). Norwood, NJ: Ablex.
Eggly, S., Musial, J., & Smulowitz, J. (1999). Research and discussion note: The relationship between English language proficiency and success as a medical resident. English for Specific Purposes, 18(2), 201-208.
Mishler, E. (1984). The discourse of medicine. Norwood, NJ: Ablex.
Tannen, D., & Wallat, C. (1993). Doctor/mother/child communication: Linguistic analysis of a pediatric interaction. In A. D. Todd & S. Fisher (Eds.), The social organization of doctor-patient communication (pp.31-48). Norwood, NJ: Ablex.
West, C. (1990). Not just "doctors' orders": Directive-response sequences in patients' visits to women and men physicians. Discourse & Society, 1(1), 85-112.
West, C. (1993). "Ask me no questions...": An analysis of queries and replies in physician-patient dialogues. In A. D. Todd & S.Fisher (Eds.), The social organization of doctor-patient communication (pp. 127-147). Norwood, NJ: Ablex.
Sayoko Yamashita, Ed.D., currently teaches Japanese and English for specific purposes at Tokyo Medical and Dental University. She is Coordinator of the JALT Pragmatics SIG.
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