Medical as a discourse community
"Research
on interaction in medical encounters has moved from a framework that assumed a
static and institutional asymmetry between providers and patients"
(Barton, 2000). Barton explains that research on interaction in medical
encounters has moved from a framework that lacked action and lack of equality
between providers (physicians) and patients. Ellen Barton focuses on, "
the situated nature of two intertwined dimensions of the context of medical
encounters-expertise and compliance within the interactional practices of
referrals and accounts of referrals between medical professionals and
families" (Barton, 2000). In this research study, I will study medical conversations
shaped by a discourse community, meaning the language usage a physician
(expert) uses when speaking to a patient opposed to how the physician (expert)
speaks to the family. Within this research study I will focus on how the
patient feels about how the physician talks to the patient versus family.
Focusing if the patient complies (having compliance) with the treatment
prescribed by her physician (expert) versus non-compliant with the treatment
prescribed by her physician (expert) for her medical condition.
In
this research study, the relationship between Barton's study and this research
study is both focus on the compliance and non-compliance of what the physician
(expert) requires the patient to follow. Barton's research study is different
from this research study because it will be from an adult, the patient's point
of view opposed to a parental view regarding a child as the patient.
Ellen
Burton's research study focuses on, "specifically on families who have a
child diagnosed with a disability, and investigates a number of settings within
this experience," (Barton, 2000). Within this research study I will focus
on an adult patient with a medical condition known as Lupus, focusing on
her point of view of the way the physician speaks to her (as the patient)
opposed to the way the physician speaks to the patient's family. I will focus
on compliance and non-compliance of the patient with the physician's
requirements.
"In
medicine, compliance and non-compliance are technically defined in behavioral
terms as, "the extent to which a person's behavior coincides with medical
or health advice" (Barton, 2000). According to Barton, "Often-cited
examples of compliance and non-compliance in the medical literature include
taking medicine, attending appointments, following dietary restrictions,
performing self-examinations, etc." (Barton, 2000).
Within
this research study, compliance will be defined as the patient's communication
with the physician, taking the required medication and procedures that the
patient undergoes every time due to her medical condition. "When patients
were asked what aspect of the interaction had the most influence in increasing
their compliance behavior, most stated that it was having someone take the time
to talk to them, answer their questions and consider their concerns" (Barton,
2000).
"Discourse
is assumed to be designed and shaped to occur in particular sequential and
social contexts" (Barton, 2000). "When physicians make a referral,
their medical expertise provides them with a coherent model of the various
specialties and their domains" (Barton, 2000). Within this research study
the patient was referred to a Hematologist and then the Hematologist referred
the patient to a Gastroenterologist, who performs Endoscopy's. Each specialist
performs tasks that are within their area of expertise.
“Non-compliance, then, seems to be a
contextual dimension of major importance: its discovery affects the interaction
by triggering asymmetrical dominance by the medical professional in pursuit of
accepted standards of medical care for the child,” (Barton, 2000). Not only is
this research study focusing on compliance, non-compliance as well. With an
adult patient, who is able to make decisions on her own, there are times due to
the circumstances of the medical condition; the patient is often non-compliant
to certain treatments given by the physician.
“In the
following excerpts from a parent’s account of her daughter’s hospitalization,
for example, the physician probes repeatedly in interactional work that
attempts to develop a reliable account,” (Barton, 2000). In Barton’s observations, non-compliance
occurred inadvertently when the child was taken off medication, removed from a
psychiatric placement and not re-evaluated. The parent’s were unable to give a
reliable account for the physician (expert) with enough information to make
decisions about the child’s care.
“Because
of the lack of expertise displayed in the family’s accounts, this
responsibility has been shifted to staff,” (Barton, 2000). In Barton’s
observations, she focuses on a case when a family has a reputation for
intentional non-compliance. During one of her observations with a particular
appointment, a nurse tells her that, “This family is non-compliant as hell,”
(Barton, 2000). Barton’s observation
regarding the family’s non-compliance was, “Problematic accounts from families
known to be non-compliant, such as the family in (19) can be received in
markedly asymmetrical form,” (Barton, 2000).
Within
this research study, the patient had some encounters with her physician of being
non-compliant when the physician kept insisting on the patient to continue
taking a certain medication for a specific treatment. In this case the patient
was non-compliant because of the side effects that she was feeling from that
particular medication. According to
Barton, “ … if the non-compliance may be unintentional, as in…the physicians
interaction and actions become more authoritative, as the family which has
displayed its lack of expertise is turned over to the clinic staff” (Barton,
2000).
Methods
Within this research study I conducted two interviews with
an adult patient with a medical condition known as Lupus and her point of view
of how her physician speaks to her (as a patient) opposed to how the physician
speaks to the family. I will also focus on whether the patient has compliance
or non-compliance when it comes to the physician’s regimen, requirements for
treatment. The two interviews that I conducted each were thirty minutes long. Asking
questions regarding her medical condition and her perspective on how her
medical condition changed her from the beginning of being diagnosed with the
condition to how it evolved into what it is now. Focusing on when she was
compliant to her physician’s requirement and when she was non-compliant as well.
I also conducted an ethnographic study, which I observed the patient in a
Hematologist’s office while doing her weekly blood count. The ethnographic
study was twenty-five minutes long. “Ethnographic field research involves the
study of groups and people as they go about their everyday lives,” (Emerson,
1995).
In this research I will analyze the subcategories that
are part of compliance and non-compliance. The subcategories that apply to
compliance and non-compliance came from the interview response’s given by my
subject. Each subcategory for compliance was in agreement with Barton’s
research study because it focuses on communication, procedures and taking
medications. The subcategories for non-compliance came from the response’s
given by my subject; which focuses on side effects, I know more than the doctor
and fear. Within the interview questions
and responses provided by my subject, I noticed that two set of stories stood
out; which were Agency and Conflict, but each category has their own
subcategories.
Presentation of Data
and Analysis
In this research study, two interviews were performed
with MC (my subject) and I found within my subject’s responses that two
categories appeared with subcategories that support each one. I focus on the
two categories; which are compliance versus non-compliance and each subcategory
is supported by the interview responses that were provided by my subject.
Compliance: Within
the interview, my subject MC spoke about how she complies with the treatment
that her physician (expert) requires her to do, such as communication, telling
the physician whether or not the medication or treatment is benefiting or not
regarding her medical condition.
Compliance also appeared in our interview when she spoke about
procedures and appointments.
Communication: MC talks about how her physician wants her to
try many medications to if MC is able to tolerate them or not. In the example
below, MC refers to certain medications that she was either trying out or
taking as “crap,” a way of pointing out to her physician that she isn’t
tolerating the medication that was prescribed to her.
A:
What does the doctor say when you say you won’t take that crap anymore?
MC:
Sometimes he tries to give me another medication. Try this one, try this one,
but the results it’s particularly the same. Pain in the stomach, sick, but he
tries to always help me. Sometimes the medication works and I accept better
than the last one or I reject it. It all depends on my body, if it accepts it
or not. But I always try to tell him that I do or don’t do well and he helps
me. I can’t say that he doesn’t when it’s not true he has always helped me. At
times we become stubborn, but we move forward. But I always take the medication
he gives me and I try to explain my reaction whether good or bad.
Within the category Compliance, one of the subcategories
that appeared in the interview was about being compliant in taking
medications. MC describes how she is
compliant with the treatment her physician (expert) prescribes to her and her
reaction to each one.
Taking
Medications:
A:
What medication?
MC:
Ahh… it was so long ago. I took all possible type of medication for various
treatments. It was cortisone, pain medication for inflammation, sleeping pills
and…
A:
Tell me a story when you were happy with the treatment, your physician
prescribed to you?
MC:
in the beginning when I first began taking the injections, what’s the name?
A:
Humira
MC:
Humira, I was, I thought that I got to the moment of bettering my condition,
but unfortunately it only lasted about one or two months and then it went back
to the beginning.
A:
Describe to me more of what you mean about being happy with this treatment?
MC:
Oh, because I stopped having pains, my blood levels were stabilized; my
hemoglobin wasn’t that low and I was in a better state. I was able to live my
life freely. I still worked. After the day of 19th of December 2012,
it was when everything happened.
A:
And with this treatment of the Humira, how often did you do this treatment and
for how long?
MC:
It was
once, one injection, every two weeks for two months. But on the second month,
half way through I began feeling tired. I would become really tired especially
after going up a flight of stairs, whatever little thing I would do, I felt
tired. So I went to the doctors and the doctor said I can no longer take the
injections because it wasn't helping, it was only harming me. And from there
on, I kept going to the hospital, receiving blood transfusions.
In the first interview I asked my subject MC, when she
did not comply with the physician’s requirement, but the answer given by my
subject indicated both compliance and non-compliance, as both categories appear
within her response. For example:
A:
Okay, Can you tell me a story, when you as a patient did not comply with the
doctor’s requirement for your treatment?
MC: No, I haven’t failed with any treatment given
by the doctor. Just the Prednisone, I never liked that medication. I tried to
take it, I’m not saying daily (non-compliance),
but there were weeks that I would take it the full week, (compliance), but there were other
weeks that it wouldn’t settle right with me.
A:
Could you tell me more about your experience every time you were given a new
medication to try for your treatment?
MC:
If the doctor says I have to take it then I take it. But it’s the side effects
of that medication that I have to see to discuss with the doctor about how I
feel, if I feel well, if it’s the same thing as not taking anything and with
his experience he tries to help me. Certain new situations, I never refused
taking it, at times I say I don’t want it, it tastes horrible, I have stomach
pains, or I’m not going to take that crap.
Another subcategory
that came from the interview responses was about procedures and how she
complies with the procedures that are required for her to do. Not only was this
subcategory in the interview that was conducted between my subject and me, but
also in my ethnographic study. In my ethnographic study, I observed my subject
in a Hematologist office doing her weekly routine blood work. It’s a procedure
because MC needs to check her blood count every week by a specialist
(Hematologist) to make sure her hemoglobin, iron; red blood and white blood
cell levels don’t drop drastically.
Procedures:
A:
Now that you mentioned that, Tell me
about your experience every time you are required to go to the hospital and how
it affects you every time?
MC:
Every time I end up going to the hospital, it effects me morally, physically, and mentally because
it’s not one or two times, it’s various of times that I undergo the same
procedure and every time I tolerate less each time.
A:
Speaking about transfusions, could you explain to me how you feel every time
you get iron transfusions as well as blood?
MC:
When I get iron and blood, the first and second day I feel my immune system
down, but little by little as days go by I begin to feel more strength, I am
able to do more things around the house. And my state of being is different.
Just walking is the hardest thing for me because my bones hurt me a lot still.
I do have medication for pain (inflammation), but it hardly helps me.
MC gives a response about Endoscopy’s to one of the
questions asked during the interview. An Endoscopy is a procedure; it’s to look
inside a person’s internal organs using an endoscope.
MC:
Ahhh, it’s a critical medical condition because majority of the time I’m afraid
to bleed, end up in the hospital, get blood transfusions. I need to do the
treatment I need to do like go for Endoscopy’s, cauterization. All of this, I
can’t live normally; I don’t have quality of life.
A:
Hmmmm, How has your medical condition affect you and your family, in terms of
following with what the physician recommended?
MC:
Only when I do the Endoscopy, everyone wants me to automatically drink that
famous solution in my mouth. Just by that there’s disagreements, one says drink
it, another says drink and another says drink it, but I can’t. I have to scream
and say, “Stop it, let me, my head alone.”
Non-Compliance:
Side Effects: In the interview I
asked my subject MC if there was a time that MC did not comply with her
physician’s requirement.
A:
Okay, can you tell me a story when you as a patient did not comply with the doctor’s
requirement for your treatment?
MC:
No, I haven’t failed with any treatment given by my doctor. Just the
Prednisone, I never liked that medication. I tried to take it, I’m not saying
daily, but there were weeks that I would take it the full week, but there were
other weeks that it wouldn’t settle right with me.
In the second interview
I asked MC a question about sleeping pills and why MC doesn’t like taking them.
A:
How come?
MC:
I don’t like it, I never did. I feel sick with sleeping pills or relaxers. Just
the state of being apathetic and not have a sense of anything. The silence is
horrible.
I know more than the doctor: In
this particular case MC explains through her point of view that she may not
know a lot about medicine, but she knows how she feels while taking the
medication.
A:
Speaking about your physician, tell me more of when you and your physician
wouldn’t see things eye to eye when it comes to your condition?
MC:
When I don’t agree with the doctor, neither is the doctor in agreement with my
opinion; which in reality I don’t know anything about medicine, but I feel my
body and system, what’s wrong. And sometimes he says it’s mentally and I say
its not and he says that I have to take the medication to sleep and I hate
sleeping pills.
A:
And what would your doctor say when you would…
MC:
He would say that I'm stubborn and I said
stubborn is you because I know what I feel. I know that I have no knowledge
about medicine, but you don't know everything about my body and the way I react
or not. I began the treatment to a certain point, but after that point I can't
do it. And at times we have our encounters because I say one thing and he says
another. Because of the blood sugar levels was making me scared of eating,
afraid it'll rise. He would say it was all mental, it was me being paranoid.
I'm none of that, absolutely nothing
Fear: MC talks about how she is afraid of bleeding again, going to
the hospital and eating.
MC: Afraid yes, I was
afraid of eating, that part yes. I was afraid because of my diabetes. Now a day
when I do Endoscopy’s, is when I feel nauseous, I don’t want to eat, but that
is normal, but there was a time that I wanted to stop eating because of my
diabetes. And he would say I’m stubborn that I need to eat, I know I needed to
eat, but at the same time I was afraid of my diabetes.
A: Tell me a story when you weren’t happy with the treatment
your physician prescribed to you?
MC: Someone with the life condition that I have is never
happy because I live always being worried; if it’s today I’ll bleed or is it
tomorrow my hemoglobin is low. If it’s low, everything turns to be the same.
It’s transfusions, hospitals, etc. It’s a life that I have no quality at all. I
can’t do certain things that other people can do, I can’t work. I have to do
things much slower, yet I bleed. Many things I no longer can do, it’s
difficult.
While analyzing the interview, two
sets of stories stood out; which were Agency and Conflict. These two set of
stories are the main categories and within each category there are
subcategories that support why these two set of stories came from. Agency is a
set of stories where there is control and conflict are stories that are inner
and the understanding of what is going on. The subcategories that stood out from the
interview that are part of Agency were the responses that MC gave me about
having agency, when she felt she had agency, willingly to take medications, an
action that made MC has asserted agency such as not eating. Or when she tried
to have agency, arguing with the doctor about what she feels and dislikes when
it comes to medications. Conflict subcategories focus on medicine versus side
effects, side effects, and doctor’s orders versus how MC’s body feels.
Conclusion
“Expertise and compliance are
important parts of the context of medical encounters,” (Barton, 2000). In my data, as well in Barton’s research
study, supports that compliance and medical knowledge creates a certain kind of
discourse, a medical discourse. In my data, the point of view of the patient is
important when it comes to compliance versus non-compliance and how agency as
well as conflict plays a part within a medical discourse. Within my data, as
well as Barton’s research study, support the interaction between a physician
(expert) as well as the patient when it comes to treating a medical condition.
Limitations
In every data there are limitations and within
my research study there were limitations compared to Barton’s research study.
In my data, I only focused on the patient’s point of view regarding the way she
views her medical condition and the way her physician speaks to her. Another
limitation was that I only interviewed the patient, to have a more accurate
analysis I would need to interview the physician. One of the limitations or
differences between my data and Barton’s research study was that I focused on
an adult, a female, who is able to respond for herself even though her state of
being wasn’t very good. Which is different from Barton’s because she focused on
a child with disability and how the compliance versus non-compliance applied to
the child’s family. Within my data, the ethnographic study was limited to a
Hematologist office, for a more accurate analysis I would need to observe MC in
other places such as a hospital and the physician’s office. But for this
research study I did have my subject MC and the nurses from the Hematologist’s
office that helped me build my research study on medical discourse.
Works
Cited
Barton, E. L. (2000). The interactional practices of
referrals and accounts in medical discourse: expertise and compliance.
Emerson, R. M. (1995). Writing Ethnographic Fieldnotes.
