老年病患負面社會心理資訊呈現之前文脈絡與言談機制：以臺灣家醫科為例

Discourse Contexts and Mechanisms Relevant to Elderly Patients’ Presentation of Psychosocial Concerns--A Case Study Based in the Family Medicine Practice in Taiwan

醫病溝通互動中，取得病情相關的負面社會心理資訊（例如失業、離婚）除了可增進醫病關係，更助於醫師釐清病患的社會心理狀態（簡稱「負面社心」）為生理不適的致因或加重因素，然而此類資訊對有些病患卻是難以啟齒或察覺與生理不適之相關性，因此對大部分醫師而言，引導病人提供此類資訊是一大挑戰。本研究以南部某教學醫院家醫科醫師與老年病患的問診互動為語料，從語言學角度分析病患呈現負面社心資訊時，相關之前文脈絡與言談機制。我們主要發現如下：（一） 病患負面社心資訊的呈現很少由病患主動引發（14%），而是由醫師透過鋪陳負面社心氛圍而浮現（86%）；（二） 此鋪陳包含兩層並行機制：「時間的累積醞釀」與「語意的循序堆砌」，即醫師與病患須歷經多次發言來回，以及醫師發言用詞語意從中性（‘我想欲知影講你陰暗睏未去是攏咧想啥？’）、一般性負面（‘最近人敢會感覺足操煩？’）、漸進至具體性負面（‘敢有想著流目屎未？’）的三種引子；（三） 此二機制的運作反映了專業與常民對問診為「生理資訊的呈現先於社心資訊的呈現」的期待認知，並造就了「以生理話題引流負面社心資訊」的言談模式。上述的言談機制對於醫病溝通的啟發為：在問診過程中，醫師透過「時間的累積醞釀」及「語意的循序堆砌」所鋪陳的負面社心氛圍，即「以生理話題引流負面社心資訊」的言談模式，有助於鼓勵病患相關負面社心資訊的浮出台面。

Soliciting patients’ psychosocial concerns (e.g. unemployment or divorce) during the medical interview not only enhances doctor-patient relationship, but facilitates the doctor’s diagnosis as well. It helps doctors clarify whether the psychosocial status is a causative or aggravating factor for the physical discomfort. However, it appears to be a challenging task for most doctors since patients might not be aware of the connection between psychosocial status and physical discomfort or might feel reluctant to voice their psychosocial problems. With discourse data of medical interviews between family doctors and their elderly patients, this study examines the discourse mechanisms of how patients’ psychosocial concerns are presented during an interview. The main findings are presented as follows. First, patients seldom voluntarily initiate a topic of psychosocial issue and provide psychosocial concerns (14%). Most of the psychosocial concerns are presented following the negative psychosocial atmosphere created in doctors’ utterances (86%). Second, this negative atmosphere created in doctors’ utterances includes the concurrent mechanisms of “time accumulation” and “semantic accumulation”. In other words, it involves several turn takes in the conversation and the sequential use of prompts (i.e. doctors start from the use of neutral prompt, “I would like to know what you are thinking about when you fail to fall asleep at night”, to the use of general-negative, “have you been troubled recently?” or specific-negative prompts, “did the idea of suicide ever come to you”). Third, the concurrent mechanisms of “time accumulation” and “semantic accumulation” in doctors’ utterances reflect both the professional doctors and the general public’s perception and expectation that “the presentation of psychosocial information is preceded by the biomedical information in medical interviews”. This leads to the discourse pattern that “patients’ psychosocial concerns are ventilated via a topic of biomedical issue”. The implication of the above findings for doctor-patient communication is addressed in the following. During medical interviews, the negative psychosocial atmosphere created in doctors’ utterances through the mechanisms of time accumulation and semantic accumulation, i.e., soliciting psychosocial concerns under the guise of biomedical issue encourages patients to unveil their psychosocial status.