Multi-functional Role Of Companions In Doctor-patient Interaction

p.1

Multi-functional role of companions in doctor-patient interaction: A single case study

Abstract In the study of doctor-elderly patient communication, Adelman et al. (1991) noticed that 60% of the patients were accompanied to the medical visit by a third person, such as their grown children. Adelman et al. proposed a conceptual framework of the third person’s roles, namely patient advocator, passive participant, and antagonist. However, this framework, as Adelman et al. have emphasized, has not been empirically validated or extended in other cultures. Also, as most studies of discourse analysis are devoted to dyadic interaction, triadic interaction remains an area that needs more attention. To fill these gaps, a tape-recorded conversation of a Taiwanese medical interview is examined. The third person to be analyzed in this study is an adult daughter who accompanies her mother (54-year-old) to a visit with a male doctor of general medicine. With discourse analysis of the occurrences of deixis, referential terms, and code-switching in the doctor-daughter and mother-daughter dyads, this research provides discourse evidence in demonstrating the multi-functional role of the daughter. This role includes: 1) doctor facilitator, eg. serving as an example of healthy status (your daughter’s heart wall is like this thick, and yours is like this thick); 2) mediator between doctor and patient, e.g. restating or interpreting the doctor’s explanation to the patient (Mom, the doctor is saying .. now if you get fat, and your heart will be um .. not strong enough); and 3) patient advocate, e.g. arguing for the appropriate action that will benefit the patient (what if, did you see my mom’s face, it looks like now.now my mom’s face looks looks puffy).

p.2

“Mom, the doctor is saying…” -- The role of the daughter in a doctor-patient encounter in Taiwan

Abstract

In the study of doctor-elderly patient communication, Adelman et al. (1991) noticed that 60% of the patients were accompanied to the medical visit by a third person, such as their grown children. Adelman et al. proposed a conceptual framework of the third person’s roles, namely patient advocator, passive participant, and antagonist. However, this framework, as Adelman et al. have emphasized, has not been empirically validated or extended in other cultures. Also, as most studies of discourse analysis are devoted to dyadic interaction, triadic interaction remains an area that needs more attention. To fill these gaps, a tape-recorded conversation of a Taiwanese medical interview is examined. The third person to be analyzed in this study is an adult daughter who accompanies her mother to a visit with a male doctor of general medicine. By applying the framework of participant structure proposed by Rosenfeld (1996), a quantitative analysis of the daughter’s participation shows that even though the doctor-patient dyads play as the center of this triadic interaction, the daughter actively involves herself by invoking doctor-daughter dyads. A further qualitative analysis of the occurrences of deixis, referential terms, code-switching, and speech acts used in the doctor-daughter and mother-daughter dyads, reflect the multi-functional role of the daughter. This role includes: 1) doctor facilitator, eg. serving as an example of healthy status (your daughter’s heart wall is like this thick, and yours is like this thick); 2) mediator between doctor and patient, e.g. restating or interpreting the doctor’s explanation to the patient (Mom, the doctor is saying .. now if you get fat, and your heart will be um .. not strong enough); and 3) patient advocate, e.g. arguing for the appropriate action that will benefit the patient (what if, did you see my mom’s face, it looks like now.now my mom’s face looks looks puffy).

Besides the above findings, this study contributes to the areas of triadic interaction and doctor-patient communication in two ways. First, the use of personal deixis as identifier of participant structure is less applicable in pro-drop language, such as Mandarin and Taiwanese. Instead, code-switching serves as a better criterion in a bilingual speech community such as Taiwan. Second, this study refines the definition of the third person’s roles with three aspects: who initiates the third person’s participation, what speech acts are achieved in his/her participation and who benefits from his/her participation.

p.3

1. Introduction

There main purpose of this study is to set up a framework to analyze the participation and function of a third person in the doctor-patient encounter. Third person refers to the person who accompanies the elderly patients in their visit to a physician, such as the patient’s adult children, husband/wife, or hired helper. Since it is common that patients, especially elderly patient, are sometimes accompanied by a third person in their visit to a physician, it is important to know how the presence of the third person influence the dyadic doctor-patient interaction. In other words, what are the roles of the third person in medical encounters? Also, as most studies of discourse analysis are devoted to dyadic interaction, triadic interaction remains neglected. Thus, it is the purpose of this current study to set up a framework in analyzing the participation and function of the third person in doctor-elderly patient encounters. To achieve this goal, I will employ Rosenfeld’s (1996) framework of participant structure and Adelman’s (et al.) (1987) conceptual model of the roles of the third person.

The data to be analyzed in this paper is a first-visit medical encounter which takes place in a small town hospital in South Taiwan. The female patient at the age of 54 recently noticed an abnormal swelling of her legs and visited a doctor of general medicine in the company of her adult daughter, the researcher 1 . The male doctor is about 40. There are two languages used in this interaction: Mandarin, the official language, and Taiwanese, the local dialect. Both the doctor and the daughter are Mandarin-Taiwanese bilinguals, and the mother speaks and understands only Taiwanese. Most of the time, the conversation is conducted in Taiwanese, but sometimes the doctor code-switches into Mandarin which will be indicated by underlined text in the data transcription. The whole interview lasts about 10 minutes.

1

The intention of taping this encounter was to document oral interaction in general. This encounter was taped in the summer of 1996. At that time, the researcher had not yet taken any course on doctor-patient interaction. Thus she may considered an “innocent” informant in that sense.

p.4

The involvement of the patient’s daughter, i.e. the third person in this encounter, will be the focus of this study. The main body of this paper will be divided into two parts: the participation of the daughter (section 2), and the function of the daughter (section 3). In sections 2.1 and 2.2, I apply and modify Rosenfeld’s framework of participant structure in coding my Taiwanese data. Based on the resulting amount of participation that the daughter devotes to the interaction, I conclude that she plays a minor role, whereas the doctor and the patient play the major roles (2.3). Also, given the fact that most of the daughter’s participation is initiated by herself, instead of by the doctor or the mother, I argue that she is an active participant (2.4). Section 3 shift the focus to the function of the third person. A brief review of Adelman’s (et al.) proposal of the functions of the third person is introduced in 3.1. Based on some linguistics and discourse evidences, I concludes that the daughter plays three roles in this encounter: doctor facilitator (3.2), mediator between doctor and the patient (3.3), and patient advocate (3.4). Finally, in the conclusion section (4), a summary of the main finding is restated. Also, I relate the contribution of this research to the fields of discourse analysis and doctor-patient communication. Some possible extension for future study of doctor-patient communication in Taiwan are presented at the end.

2. The Participation of the Daughter In this section, I will introduce my coding system with the application of Rosenfeld’s framework of participant structure. In identifying the participant structure in the Taiwanese data, some linguistic and discourse criterion used in Rosenfeld’s English data will be modified (2.2). The result of the coding presents two quantitative aspects of the daughter’s involvement: the amount of her participation (2.3) and the initiation of her participation (2.4).

2.1 Participant Structure and Coding System

According to Rosenfeld, participant structure refers to the number and the role of parties who are either speaking (the addresser) or being addressed (the addressee) at a moment of talk. In the case where there are three participants involved, such as a

p.5

marital therapy section, the participant structure could be either dyadic or triadic. Rosenfeld’s analysis is presented as the following when applied to my data 2 .

1.

Doctor–Patient dyad: both the doctor and the patient are either the addresser or the addressee, while the daughter remains unaddressed.

2.

Doctor–Daughter dyad: both the doctor and the daughter are either the addresser or the addressee, while the patient remains unaddressed.

3.

Daughter–Patient dyad: both the daughter and patient are either the addresser or the addressee, while the doctor remains unaddressed.

4.

Doctor–Patient–Daughter triad: all three participants are speaking or being addressed.

Rosenfeld further distinguishes two types of shift of participant structure in terms of who initiates the shift. They are participant-initiated shift and other-initiated shift (p.84). In a current participant structure, a participant, either the addresser or the addressee, can initiate a shift of the structure by addressing another party and still keep his/her participant status. If the party who initiates the shift is not a participant in the current structure, such a shift of participant structure is termed as other-initiated shift. The following are illustrations of the above concepts and my coding system.

In excerpt 1, the patient complains to the doctor that her leg itches (line 1), it is coded as a doctor-patient dyad (hence D-P dyad). Her complaint is acknowledged by the doctor as shown by his using of repetition. Line 2 forms another D-P dyad. In my tally, line 1 and line 2 will be counted as two instances of D-P dyad. Also, I re-analyze the movement of the addressing direction by using arrows ( and ), as shown in the left column.

2

During this interview, there is a nurse present in the room who remains silent most of the time. Also, there are three instances that doctor constantly gets called by his cellular phone or pagers. Since my focus is on the interaction among the doctor, patient, and third-person companion, I will not take the participation of the nurse and the cellular phone into consideration in the data analysis. However, their participation is transcribed in the data.

p.6

Excerpt 1 3 movement of addressing direction P D X

Patient (P)

1

------>

(it) itches

2 3

<------

4D 4P

------>

Daughter (X)

(it) itches, that’s a sign of dermatistis, you see..there’s an indent /?/ this is

\------>

|------>

Doctor (D)

[since….(it) happened since a [this is, this is.this is…….second couple of days ago, I was not degree edema aware of it, I I ….for example at that time, there was a spot

Excerpt 1 (Chinese) 4 movement of addressing direction P D X 1

------>

2 3

<------

4D 4P

\------>

------> |------>

Patient (P) 啊會癢啦

Doctor (D)

Daughter (X)

癢啦, 彼皮膚炎欸現象,你看..有個 洞,/?/這是 [自…….自迄兩日仔按吶我 m [這是,這個就是.這個就是 ….. 知影講, 我我…..啊像講彼陣 二度水腫 一 gia (某個部位)

After the doctor acknowledges his receiving of the patient’s complaint, he immediately code switches into Mandarin to state that itching is a syndrome of dermatitis, as indicated by the underline in the transcription (3). However, since the patient does not speak Mandarin while her daughter does, the doctor’s code-switching is evidence of addressing to the daughter. The movement of addressing direction is from the doctor to the daughter in line 3. It forms a doctor-daughter dyad (hence D-X dyad) 5 .

3

Transcription symbols: [ indicate simultaneous utterance Underlined text : speaker is using Mandarin. Regular text: speaker is using Taiwanese. Texts within the ( ) in the English translation indicates that their equivalent Taiwanese is not uttered. = indicates no perceptible pause between utterance 4 The Chinese transcription is transcribed mainly in Chinese characters. In the case where no Chinese character is available, romanalization will be used. The romanalization follows TLPA, established by Taiwan Language Society. Underlined text indicates that the speaker is using Mandarin, while the regular text indicates the use of Taiwanese. 5 I will use X to represent the third person, who can be anyone, such as the patient’s husband, children, relative, hired helper etc. In this case, X refers to the patient’s daughter.

p.7

In other words, the doctor-patient dyadic structure in lines 1-2 is shifted to the doctor-daughter dyadic structure (3-4D). Since it is the active participant in the former

structure,

the

doctor,

who

initiates

this

shift,

it

is

coded

as

participant-initiated shift. Participant-initiated shift is indicated by the slash \------> in line 3 and is counted as one instance of participant-initiated shift by the doctor.

When the doctor continues to address the daughter that her mother’s swollen leg is on the stage of second degree edema (4D), the mother starts to give the information of when the swelling occurred (4P) by overlapping with the doctor’s statement. The mother’s overlapping shifts the doctor-daughter dyad (3-4D) into a doctor-patient dyad. Since the mother is not a participant in the D-X dyad, this shift initiated by her is coded as one instance of other-initiated shift by the patient. Other-initiated shift is indicated by the vertical line |-----> (4P).

The result of the coding of excerpt-1 result is as follows: 3 instances of D-P dyads (lines1, 2, 5) 2 instances of D-X dyads (lines 3, 4) 1 instances of participant-initiated shift (by the doctor) (line 3) 1 instances of other-initiated shift (by the patient) (line 5)

2.2 Linguistic and Discourse Evidences for Identifying Participant Structures

Based on her English data on marital therapy, Rosenfeld employs four types of evidences in identifying participant structures. They are (1) vocatives, (2) personal deictics, (3) context, and (4) discourse structure. Excerpt 2 is an example which shows that the therapist’s use of vocative (“Jack” the name of her client couple) and deictics (“you”) are indicators of therapist-husband dyad, instead of therapist-wife dyad, in the marital therapy encounter.

p.8

Excerpt 2 Therapist:

I think what Jack is – Jack what you’re saying is that you wanted to know what …

you’d like to understand why (Rosenfeld, 1996, p86)

However, the use of vocatives and personal deixis as evidence are less applicable in my Taiwanese data. In the following, I will first explain why they are not applicable. Then I will show how contexts, discourse structures and code-switching work as my primary evidence for identifying participant structure.

The use of vocative is seldom observed in my data. The only occurrence of the vocative is the daughter’s address term to refer to her mom (ma), which occurs two times in the whole interview. Other possible address terms, such as titles, e.g. i-seng (doctor), o-ba-sang (ma’am, usually refers to middle-aged woman ), or Tshuah thai-thai (Mrs. Tshuah, the patient’s last name) do not occur in this data at all. Also, the use of a first name, which is commonly observed in Rosenfeld’s data, does not seem possible in my data for two reasons. Generally speaking, the use of first name indicates there is a shared intimacy and rapport among participants in Taiwanese society 6 . However, this intimate relationship is absent in this medical context in which there exists a power difference - - the doctor possesses a higher social status than the patient who is older than the doctor, and thus it excludes the possibility for them to address each other with first names. The only possible use of a first name is for the mother to address her daughter. However, as we will see later, since the mother never addresses her daughter in the whole interview, it prevents the occurrence of first name 7 .

The second evidence that Rosenfeld employs is the use of personal deixis, such as “you” and “he/she”. However, both Taiwanese and Mandarin are pro-drop languages in which the subject of a verb can be left empty. That is to say, the personal deixis can 6

As I can recall, the use of first name is dictated by the elder generation to the younger generation, e.g. parents to children, but now there is a tendency for people of a certain shared rapport to use first names, e.g. among colleges, classmates, or friends. 7 Two other possible interpretations for the absence of using first names in this Taiwanese data are: (1) compared to the American society, Chinese society values authority more than equality, which can be conveyed by the use of first names, and (2) compared to the marital therapy interaction, clinical

p.9

always be deleted as long as the context or discourse structure helps the interpretation. For example, in excerpt 3, the doctor and the patient are talking about the patient’s swollen legs. There is no personal deixis used at all 8 . For example, when the doctor says “(Z) is swollen, (Z) didn’t hurt (Z-self)?”

(from line 1, excerpt 3) 腫腫啊 tsing-tsing-a, swell-swell-SFP 9

無撞著? bo-long-tioh no-hit

(Z) is swollen

(Z) didn’t Z-self?

Doctor talks to the patient: (your leg) is swollen (you) didn’t hurt (yourself), right? Doctor talks to the daughter: (your mom’s leg) is swollen (she) didn’t hurt (herself), right?

he could be addressing the patient or the daughter, as shown above. Thus, Z could be “your leg” or “your mom’s leg”. Given the restriction that personal deixis are usually omitted, discourse context and structure will be the main clues to identify the addressee. First, under the context of a medical interview, when the doctor indicates some physical problems, such as “Z is swollen”, it is reasonable to say that Z refers to the participant who undergoes swelling, i.e. the patient. Second, the doctor’s question in line 1 “didn’t hurt (Z-self)?” is responded by the patient, “yeah” (line 2), instead of by the daughter. Based on who responses to the doctor’s question, it is reasonable to say that the respondent, i.e. the patient, is the designed addressee of the doctor’s question. Thus, the discourse structure of question-answer pair helps to decide the participant structure 10 .

interaction requires less rapport between the service provider and the client. 8 The pronouns within the ( ) in the English sentence translation indicate that they are absent in the Taiwanese data. 9 SFP stands for sentential final particles. 10 My analysis in identifying participant structure is based mainly on the context and discourse structure. One possible drawback is that it does not totally clarify the possible referents. In a hypothetical situation, the doctor intends to address the patient’s daughter with the question: “(She) didn’t hurt (herself), right?” because for some reason he judges the patient is incapable of answering that question, e.g. due to the decreasing of mental ability which is common to most elderly patients. Out of his expectation, the patient answers the question because she wants to handle the problem by herself. Then the patient’s reply indicates an “other-initiated shift of participant structure.” However, this analysis will be missed if I only rely on question-answer pair--given the fact that the patient is the one answering the question, she is the designed addressee of the doctor’s question. Thus, the patient’s reply does not cause shift of participant structure.

p.10

Excerpt 3 P

1

D

X

Patient (P)

<------

Doctor (D)

Daughter (X)

(your leg) is swollen, (it) swelled, there’s an infection. (it) is swelled, (you) didn’t hurt (yourself), right? Did (you)?= 腫腫啊,腫腫啊,有發炎啊. 腫腫, 無撞著,無啦..hann?=

2

------>

=Yeah, (I) just don’t understand why (it) turned out like this for no reason? This one is fine but this one looks puffy. =hio, 啊是講無歹無歹誌慨按 內啊?這邊攏 ting kok kok (硬 邦邦). 啊攏像加足大 kho 咧 這隻

Other special linguistic evidence for identifying participant structures in this Taiwanese interaction is the occurrence of code-switching. As I have explained earlier, since both the doctor and the patient’s daughter can speak Mandarin, while the patient does not, each time the doctor code-switches into Mandarin it is a sign that he is addressing the daughter. As noted in excerpt 1, the doctor first responds to the patient’s complaint by repeating her words (it) itches in Taiwanese, and then he code-switches into Mandarin to name the disease and give evidence (2-3). His code-switching here is an indicator of the change of addressee 11 .

2.3 Amount of the Daughter’s Participation

11

One possible problem invoked from the use of code-switching to identify participant structure is the case when the doctor cannot find a counterpart of some medical terminology in Taiwanese, the local dialect. For example, he may code switch into Mandarin when he introduces the term “second degree edema,” simply because he can not translate it into Taiwanese. ( “second degree edema” occur four times in the whole interview, but never occurs in Taiwanese.) In that case, his code-switching into Mandarin is not motivated by his intention to addressing to the patient’s daughter.

p.11

Table 1 shows the total numbers of instances of three types of dyads and one type of triad identified in the whole interaction.

Table 1: Instances of dyadic and triadic participant structures dyads triads total 205 (97%) 3 (1%) 208 (100%) D-P dyads D-X dyads P-X dyads D-P-X triads total 128 (62%) 72 (35%) 5 (2%) 3 (1%) 208 (100%) D: Doctor P: Patient M: Daughter

Similar to the finding of Rosenfeld’s research on marital therapy, the triad exchange in this medical interview, i.e. D-P-X triad, receives a very low frequency of occurrence, 3%. It supports Rosenfeld’s claim that a triadic interaction is primarily composed of dyadic exchanges between any two of the three participants, with the third participant as the ratified but unaddressed one of the talk (p109). . Among the three types of dyads, D-P dyads receive the highest score of occurrence (62%). This is not marked, since doctors and patients are supposed to be the required participants of a medical encounter. The D-X dyads receive a lower occurrence frequency, 35%, which is about half of that for D-P dyads. The P-X dyads, similar to the D-P-X triads, almost do not occur (2%). In other words, this encounter is primarily composed of the conversation between the doctor and the patient. The doctor- daughter dyads play a minor role. The mother-daughter talks hardly occur.

Table 2 presents the total amount of participation that each of the three individuals contribute in this encounter, either as an addresser or addressee. The doctor scores the highest in the participation, addressing the patient or the daughter, or being addressed by them. In that sense, he is the center of the interaction. It reflects the fact that doctor is the required participant in such an institutionalized encounter.

Table 2: Total amount of participation of the three participants Doctor 203 (48.5%)

Patient 136 (32.5%)

Daughter 80 (19%)

Total 419 (100%)

p.12

Also, compared to her daughter, the patient has a greater amount of participation in this encounter. It suggests that the patient has a highly autonomous control in this encounter in two ways. On a mental level, she has a sound communication ability which allows her to handle communication effectively. This is evident since her linguistic performance can be judged as fluent. On a social-psychological level, she is able to work her communication ability even with the presence of her daughter. That is, the daughter’s presence does not prevent the patient from expressing herself.

So far, I have shown that the daughter plays a minor role in terms of the amount of participation that she contributes to this medical encounter. Since the daughter’s roles is the purpose of this study, in my next step of analysis, I will focus on the dyads in which she is involved, i.e. D-X dyads and P-X dyads.

2.4 The Initiation of the Daughter’s Participation

As Table 1 has shown, while the D-X dyads receive a secondarily high frequency of occurrence (35%), the P-X dyads have only 2% of occurrence, i.e. the mother and the daughter seldom address each other. Table 3 shows a dramatic reflection of this situation. Out of the 80 instances of participant structure in which the daughter is involved, a great amount of her participation (90%) is devoted to the D-X dyads and only 6% to the P-X dyads.

Table 3: The distribution of the daughter’s participation D-X dyads P-X dyads D-X-P triads total 72 (90%) 5 (6%) 3 (4%) 80 (100%) In my third step, I identify the initiator of the D-X dyads and P-X dyads. By initiator of a dyad, I mean the person who initiates a shift of participant structure. For example, in excerpt 4, the daughter addresses the doctor with the question "what is ‘retaining water’" (5). Her utterance changes the D-P dyads (1-4) into D-X dyads.

p.13

This shift of participant structure is coded as an "other-initiated shift" in Rosenfeld's term. I will refer to the role of the daughter in line 5 as the initiator of the D-X dyad.

Excerpt 4: Indent Test D-P P episode 1

2 3 4

[ [ [ [ [ [ [ [ [ [

D

X D-X episode

------>

<------------>

=how come that turns out like this?=

<------

=like retaining water,

6X 6D

<----------->

7D 7X

------> <------

9 10

11D 11P

[(it) swelled a little bit, (it) swelled, (it) swelled

<-----\------>

------> |------>

<------

13

------>

14D 14X 14P

------> <-----|------> ------>

------> |------>

17D 17X

18D 18P

[that means something is [“retaining water”? swollen.

------> <------

------> |------>

[right,

(it) itches

12

16D 16P

…”retaining water”? what is

] ] ] ] ] ] ] ] ]

|----->

15D

Daughter (X)

(it) looks a little bit.. like (its) retaining water=

<------|

[ [ [

Doctor (D)

=Yeah, (I) just don’t understand why (it) turned out like this for no reason? This one is fine but this one looks puffy

5

8

Patient (P)

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

(it) itches,that’s a sign of dermatistis, you see..there’s an indent /?/ this is [since (it) happened since [this is, this is. this a couple of days ago, I is…….second degree was not aware of it, I edema I ….for example at that time, there was a spot Really?= =yeah, second degree edema, you see,( it) does not happen to healthy people, you see, just press (it), you see [why . why does it happen?

[Does(it) happen on the other side?

[(it’s) all swollen

[Oh my God!

[(it) doesn’t happen to you, you see, does (it) happen to you? [if (it) happens to you, right?…

[/?/

[no, (it) won’t, right? [I don’t know, maybe I Does it occur to . to you? didn’t press (it) hard enough =[Does (it) happen to this =[no, (it) doesn’t, you side? see, this indent is still there

p.14

Excerpt 4: Indent Test (Chinese) D-P P episode 1

[ [ [ [ [

------>

2

[ [ [ [ [

<------

3 4

D

X D-X episode

=彼是按吶 hai 按內?=

------->

=hang 水欸

<------

6X 6D

<----------->

7D 7X

------> <------

9 10

] ] ] ] ] ]

------>

] ] ] ] ]

12

<------

13

------>

14D 14X 14P

------> <------

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

|------>

|------>

15D

------> ------> |------>

17D 17X 18D 18P

[/?/

------> <-----------> |------>

[彼就是有腫腫的啦,

[hang 水?

[有一點腫,水腫水腫

[henn

癢啦,彼 皮膚炎欸現象,你看..有 個洞,/?/這是

<------

] ]

16D 16P

…hang 水?什麼叫

啊會癢啦

|----->

\------>

11D 11P

Daughter (X)

小可 hang . hang . hang 水 欸=

<------|

[ [ [

Doctor (D)

=hio, 啊是講無歹無歹誌 慨按內啊?這邊攏 ting kok kok (硬邦邦). 啊攏 像加足大 kho 咧這隻

5

8

Patient (P)

[自…….自迄兩日仔按吶 [這是,這個就是.這個就 我 m 知影講, 我我…..啊 是 …..二度水腫 像講彼陣一 gia (某個部 位) 真欸喔?= =henn二度水腫, 你看正 常人不會啊,你看,隨便壓 一下,你看 [這 . 這是按吶欸?

[都腫起來

[噯唷!

[你不會嘛,你看你會嗎? [/?/ [啊這邊敢會?

[你會的話, 對不對? …

[不會嘛,你.你會嗎?=

=[啊這邊敢會?

[我啊知,我 teng 了無夠 力

=[不會啦,你看看,這個洞 到現在還在這裡

In line 10, the doctor shifts his addressee from the patient to the daughter, as indicated by his code-switching. It changes the D-P dyads (8-9) into D-X dyads (10-17). This shift of participant structure is coded as a "participant-initiated shift" in Rosenfeld's

p.15

term. I will refer to the role of the doctor in line 10 as the initiator of the D-X dyad 12 .

Based on my previous coding of dyads, lines 5-7X are coded as 5 instances of D-X dyads and lines 8-9 as 2 instances of D-P dyads. To enhance my analysis, I will refer from now on any series of exchanges of the same dyad as an episode. For example, the 5 instances of D-X dyads in lines 5-7X form a D-X episode which is indicated by the continuous brackets “ ] ”, and those in lines 8-9 form a D-P episode which is indicated by the continuous brackets “ [ ”. Those single D-P dyads in lines 11P, 14P, 16P, and 18P do not form an episode. In other words, this indent excerpt is composed of two D-P episodes (lines 1-4, lines 8-9) and two D-X episodes (lines 5-7X, lines 10-18D).

Table 4 is the resulting numbers of D-X and P-X episodes and the initiators of each of them. It shows that there are 22 D-X episodes composed of the 72 instances of D-X dyads in this medical encounter. While 19 of the D-X episodes (86%) are initiated by the daughter, only 14 % of them are initiated by the doctor. Also, there are 2 P-X episodes composed of the 5 instances of P-X dyads, and both of them (100%) are initiated by the daughter.

Table-4: Numbers of D-X and P-X episodes and their initiators D-X dyads (72) = D-X episodes (22) P-X dyads (5) =P-X episodes (2) initiated by D initiated by X initiated by P initiated by X 3 (14%) 19 (86%) 0 2 (100%) I have presented earlier that the D-P dyads are the dominating interaction of this encounter and the patient is the primary addressee of the doctor’s utterance. Neither the doctor nor the patient frequently address the daughter. Only 14% of the D-X episodes are initiated by the doctor, and none of the P-X episodes are initiated by the 12

That is to say, the term "initiator" of a current dyad does not distinguish whether the initiator is a participant or a non-participant of the previous dyad. For one reason, this distinction is not necessary in this paper. Almost all of the dyads in the whole interaction are either doctor-patient dyads or doctor-daughter dyads. The doctor is the center participant in these two types of dyads. Thus, the

p.16

patient. In other words, for the daughter to get herself involved in the interaction, she needs to break the dominating D-P dyads and initiate the D-X dyads (86%) and P-X (100%) for herself. With respect to this high frequency of self-initiation, I conclude that the daughter actively involves herself in the interaction, instead of passively waiting for the doctor or her mother to give her the floor.

2.5 Summary

First, based on the amount of dyads (Table 1) and the amount of participation (Table 2) that the three interactants contribute to this medical visit, I conclude that the D-P dyads are the primary participant structure. That is to say, the third person in this encounter, i.e. the daughter, plays a minor role. Second, given the fact that most of the episodes in which the daughter is involved is initiated by herself (Table 4), I conclude that she is an active participant.

3. The Functions of the Daughter In section 3.1, I will briefly review the conceptual model of the roles of the third person, proposed by Adelman et al. From sections 3.2 to 3.4, linguistics and discourse evidence will be presented to argue that the daughter plays a multi-functional role of doctor facilitator, mediator between doctor and patient, and patient advocate.

3.1 Functions of the Third Person

In their observation of physician-elderly patient interaction, Adelman et al (1991: 130) notice that about 60% of the elderly patients are accompanied by a third person, such as caregivers, adult children, or spouse, on their visit to a physician. Also, in their discussion of the triadic interactions among physicians, elderly patients, and

doctor-daughter dyads initiated by him is always a participant-initiated one, those initiated by the daughter are always other-initiated.

p.17

patient-companions, they propose a conceptual framework of the roles of the patient companion, whom I will refer to as "the third person".

Roles of the third person, proposed by Adelman et al. (1987:731) 1.

2. 3.

Advocate -patient promoter/activist -patient extender -patient-doctor mediator Passive participant Antagonist -Saboteur/underminer -Opportunist

Under this framework, there are three possible roles that the third person can play: advocator, passive participant, and antagonist. An advocate is a third person who shows support for the patient. There are three subtypes of advocates. They are patient promoter or activist, patient extender, and patient-doctor mediator. The patient promoters are "the most supportive of the patient's agenda for the visit."(p731). They actively and assertively encourage and empower the patients. Patient extenders act "as the voice of the patient." For example, they may act as a translator when the patients are not able to express themselves. The mediators support and encourage an effective patient-physician relationship. They bridge the gap between the doctor and the patient. In that sense, the mediators serve both the doctor and the patient. A passive participant is a third person who is present in a medical encounter but contributes very little to the conversation. An antagonist works against the patient, e.g. showing hostility toward the patient, ignoring the patient's concern, or taking advantage of the patient. There are two subtypes under this category. A saboteur or underminer works against the patient with overt or covert manner. An opportunist takes advantage on both the doctor and the patient.

To measure the role and effect of the third person in geriatric medical encounters, Adelman et al. adopt the system of Multidimensional Interaction Analysis (MDIA). With the MDIA system, they identify some global discourse patterns of the third person. For example, they found that patient promoters, compared to patient extenders,

p.18

pose more questions to physicians and show less abrupt changes of topics. Patient promoters do not refer to that patient as 'she' or 'him'. They correct physician's misattribution of symptoms to the aging process. (p733)

There are five potential deficiencies of Adelman’s (et al.) model. First, as noted by Adelman et al. themselves, the three roles of the third person are defined from the patients' perspective.(p731) The following is my example to illustrate this weakness. An adult child who shows support of the doctor's proposed treatment may be seen as a patient advocate from the doctor's view, but seen as a patient antagonist by the elderly patient whose refusal to accept the treatment is a strategy to gain the child's attention. Secondly, the roles of the third person in the duration of an encounter may be multiple since the interaction is dynamic. Thirdly, the distinction between a patient promoter and patient extender is rather vague. What degree of support paid to the patient qualifies a third person as a patient promoter or extender? Additionally, the quantitative results from MDIA can be strengthened if collaborated with a qualitative approach, such as the evaluation of speech acts involved in the third person's questions. Finally, as Adelman et al have emphasized, this hypothetical model has not been empirically validated. They require verification in clinical settings (p731). Thus, it is my attempt in this section to apply Adelman’s (et al) definition of the roles of the third person to my Taiwanese data. As you would recall, the results in Tables 1-2 suggest a high level of autonomy of the patient. She can handle the medical interview with the doctor in an effective way. She never feels the need to address her daughter during this interview. That is to say, her daughter’s presence is not required at all. Given this autonomy that the patient possesses, it would be interesting to see why the daughter’s presence sometimes supplants the patient’s chance of participation (Tables 3-4). Why does the doctor address the daughter instead of the patient? Why does the daughter actively volunteer herself in this encounter?

As the following analysis will reveal, the three functions that the daughter plays are similar to the advocate category in Adelman’s et al. framework. I will redefine the

p.19

roles of the daughter in terms of three aspects: the initiator of her participation, the speech acts achieved in her participation, and the party who benefits from her participation. The three roles are: 1)doctor-facilitator, whose participation serves mainly the doctor, 2) mediator between the doctor and the patient, who serves both the doctor and the patient, 3) patient advocate, who serves mainly the patient. 3.2 The Daughter as a Doctor Facilitator

The third person who plays a doctor facilitator mainly serves the doctor alone. This role is not discussed by Adelman et al. I single out this function since it serves mainly the doctor, which is in contrast to the function of a mediator, who serves both the doctor and the patient. I will present two excerpts to show that the daughter functions as a doctor facilitator.

As mentioned in excerpt 4, the doctor conducts an indent test. During this test, the doctor first presses the patient's leg and it results in an indent on her leg. Based on this test, he diagnoses the patient with second degree edema ”that’s a sign of dermatistis, you see .. there’s an indent /?/ this is this is . this is …second degree edema”(9-11D). At the same time, the daughter presses her own leg and it does not result in an indent. In line 13 the doctor directs the daughter’s attention (“you see”) to his comment "(the indent) does not happen to healthy people, you see, just press it, you see." Here, the doctor refers to the daughter as "healthy people". By presenting the contrasting phenomenon between the unhealthy status of the patient and the healthy status of her daughter, the patient’s intimate partner whom she can trust, the doctor achieves an expository speech act. He strengthens his diagnosis and makes it more persuasive. The doctor's reference to the daughter as healthy people reflects how he perceives her role in this encounter. She functions as a healthy example. Since this function is invoked by the doctor to facilitate his presentation of evidence, this role serves only the doctor. Thus, the daughter plays the role of doctor facilitator.

The doctor's perception of the daughter as a doctor facilitator is also evident in the

p.20

following excerpt. In line 1, the daughter initiates a D-X episode. She reminds the doctor that, besides, her mother’s swelling legs, her face looks puffy as well (1). The daughter’s statement prompts the doctor to give an extended monologue explanation of the chain reaction which starts with cardiomegalia and poor blood circulation and results in puffy legs and face. (This excerpt will be referred to as "chain-reaction" from now on.) To make this complicated medical knowledge more accessible to the daughter and the patient, the doctor uses an analogy. A swollen heart wall requires more energy to operate, just as a thick metal requires more energy to shape (5). Then he makes another contrast between a healthy heart and an unhealthy one, by addressing the daughter : "for healthy people (the thickness of the heart) is like this..and your mom's is like this" (5). Then he switches the addressee to the patient by saying: "your daughter's heart/?/her heart is like this big, and yours is like this big" (7) and "compare to the heart walls of healthy people, (they) are thin, and your heart wall is like this thick." (11) As observed in the previous excerpt, the doctor tries to explain what an unhealthy heart wall looks like in comparison to that of a healthy person. Again, the daughter’s role as healthy example is invoked by the doctor to facilitate his presentation of medical knowledge.

p.21

Excerpt 5: Chain-reaction P 1P 1X

D

<------|

------>

------> |------>

4

<------

5

------>

6D 6X

------> <------

7D 7P

Patient (P)

------>

2

3D 3P

X

------> |------>

8

<------

9

------>

10

<------

11

------>

Doctor (D)

=[if (I) eat /?/ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

Daughter (X) =what if, did you see my mom’s face, it looks like . now . now my mom’s face looks looks puffy=

=(it) looks puffy because the heart is swollen .. if the heart swelled .. (it) will [it’s not that (I) really gain weight, right?

[influence some other part .. other part, when your heart swells it can’t work, the wall of the heart wall is thick and heavy= =m-hng if it gets thick and heavy, like. if the metal is thick it requires more energy to shape it … the heart will .. (the heart wall) for healthy people (the thickness of the heart) is like this .. and your mom’s is like this

[the heart will . will swell, ok?=

[the heart will /?/

=[yeah, /?/ your daughter’s =[yeah, sometimes (I) sometimes I feel breathless, heart wall /?/ her heart is sometimes I feel breathless like this thick, and yours is like this thick, yeah, and you this .. the .. this is very . very .. thick yeah=

=m-hng= =very thick, very thick= =m-hng =compared to the heart walls of healthy people of, they’re) thin thin thin thin, and your ? is like this .. (your) heart ? is like this

p.22

Excerpt 5: Chain-reaction (Chinese) P 1P 1X

D

<------|

------>

------> |------>

4

<------

5

------>

6D 6X

------> <------

7D 7P

Patient (P)

------>

2

3D 3P

X

------> |------>

8

<------

9

------>

10

<------

11

------>

Doctor (D)

=無, 汝看我媽媽欸臉敢有 卡 . hio 我媽媽欸臉即嘛即 嘛像卡卡澎按吶=

=[食/?/ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

Daughter (X)

=卡澎是這心臟放大 .. 心 臟放大會 .. 影響 [彼 m 是正經肥喔 honn

[局部 .. 局部化的影響,汝 心臟放大著心臟無法度,心 臟 . 心臟肥厚, =henn 肥厚那打鐵都很用力嘛,心 臟就 .. 正常人就這樣 … 啊你媽媽是這樣 [心臟就 . 放大啦, honn=

[心臟咧//?

=[henn,有當時仔足 gau 喘 =[honn, /?/ 汝查某子/?/一 著啦,有當時仔足 gau 喘 欸心是按吶大,啊汝欸心是 按吶大, henn 啊汝這 ..這壁 honn 攏 . 蓋 .. 蓋厚按吶= =henn= =很厚啦, 肥厚啦= =henn= =跟正常人的壁是薄薄薄薄 欸,啊汝欸壁是按吶 .. 心 臟欸壁是按吶

3.3 The Daughter as the Mediator between the Doctor and the Patient

Mediators refer to the third person whose role serve both the doctor and patient, and bridge the gap between them. In the following, I will argue that the daughter functions as a mediator both from the doctor's perspective (3.3.1) and the daughter's own perspective (3.3.2).

3.3.1 The Daughter as the Mediator: from the Doctor’s Perspective

p.23

My first evidence is, again, from the indent test (repeated after this paragraph). As I mentioned earlier, right after the doctor presses the patient’s leg and it results in an indent staying on her leg (9), he immediately code-switches to the daughter all the way down (from lines 10-18D). Here, the daughter plays two roles simultaneously. She is the sole recipient of the doctor’s verbal information “that’s a sign of dermatistis, you see..there’s an indent /?/ this is. this is, this is. this is…….second degree edema” (9-11D). She is also the taker of the indent test at the request of the doctor: “you see, (the indent)

does not happen to healthy people, you see, just press (it), you see” (13) “you see, does (it) happen to you?” (15D) “no, (it) doesn’t, you see” (18D).

Excerpt 4: Indent Test (Chinese transcription on p.13) P

8 9 10

11D 11P

[ [

D

X

|------> \------>

------> |------>

<------

13

------>

14D 14X 14P 15D

------> <-----|------>

16D 16P

|------>

------>

------>

------> <------

17D 17X

------> |------>

Doctor (D)

Daughter (X)

(it) itches

<------

12

18D 18P

Patient (P)

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

(it) itches, that’s a sign of dermatistis, you see..there’s an indent /?/ this is [since (it) happened since a [this is, this is. this couple of days ago, I was is…….second degree edema not aware of it, I I ….for example at that time, there was a spot Really?= =yeah, second degree edema, you see,( it) does not happen to healthy people, you see, just press (it), you see [why . why does it happen?

[(it’s) all swollen

[Oh my God!

[(it) doesn’t happen to you, [/?/ you see, does (it) happen to you? [Does(it) happen on the other side?

[if (it) happens to you, right?… [no, (it) won’t, right? Does it occur to . to you?

=[Does (it) happen to this side?

[I don’t know, maybe I didn’t press (it) hard enough

=[no, (it) doesn’t, you see, this indent is still there

In the previous discussion, I state that the doctor recruits the daughter as sample of

p.24

healthy status to make his argument more convincing. However, all these arguments are presented in Mandarin which the patient does understand at all. If the doctor’s purpose of this indent test is to convince the patient what she has suffered, why does he bother to present his evidence exclusively to the patient’s daughter instead of to the patient? I will argue that by addressing the daughter alone, the doctor expects her to explain the indent test to the patient should the patient have any concerns about it. According to Adelman et al., the third person, who functions to facilitate an effective patient-physician communication, is defined as a mediator. Thus, the doctor’s expectation that the daughter will communicate with her mother reflects his perception of seeing her as a mediator.

Such an expectation from the doctor is more evident in the following example. Excerpt 6 is from the second visit in which the patient takes the X-ray examination and the doctor informs her of the result 13 . During this interaction, the doctor asks the patient if she feels any abnormality when she urinates (1). When the patient replies that she sometimes feels a burning sensation, the doctor explains that it might be a symptom of urinary passage infection, which could be caused by an inadequate way of cleaning the anus. He then suggests a more adequate way of cleaning. Here, the doctor is giving an explanation which may threaten the patient's face because the topic concerns a very personal issue. Also, as a male doctor, it is uncomfortable for him to advise his female patient on how to maintain her personal hygiene.

Excerpt 6 (from the second visit) P 1

2

13

[ [ [ [ [ [ [ [

D

X

Patient (P)

<------

------>

Doctor (D)

Daughter (X)

when you urinate, do you feel any stinging.. or burning? do you feel stinging? ..sometimes, if the weather is hot, (I) feel like burning sensation

My analysis does not include the interaction of the second visit. I quote this example since it clearly demonstrate how the doctor sees the daughter as a mediator.

p.25

3

[

<-----\------>

4D 4P

|------>

------>

5D 5P

|------>

------>

6

<------

7

------>

8

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

|------->------->

yeah that sometimes might ..because that girls..women’s urinary passage= =[and somtimes like, like, for example

=[ get easily infected, when excreting, most people tend to wipe back to front, it happens to a lot of people..haha..it’s easy to get infected that way..haha

[it’s like. like it doesn’t come out quickly

[it’s just a matter of changing your habit, yeah, because the passage is really short it got to be front to back

yeah, it got be front to back, you probably do it back to front..haha….you tell your mom, yeah you tell your mom it got to be front to back I have no idea at all of what are you two are talking about.

Excerpt 6 (Chinese) P 1

[ [ [

<------

2

[ [ [

------>

3

D

X

5D 5P

|------>

Daughter (X)

..有當時仔若講熱著按吶 \------>

|------>

Doctor (D) 啊放尿欸時陣會感覺刮刮. 燒燒..刮刮..啊放欸時陣會 感覺刮刮?

henn 彼是有欸時陣 ..因為女孩子的..女人的尿 道=

<------

4D 4P

------>

------>

6

<------

7

------>

8

Patient (P)

|------->------->

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

=[啊彼像講 honn, 像講.攏 =[很容易感染，擦大便的 像講 時候,很多人從後面往前擦 的,那個都有.哈哈.很容易 感染..哈哈 [禁,像 tsuann 啊禁未著按吶 [習慣性的問題,henn啦,因 啦 為尿道很短 [啊卜放放無啥

[愛向後 hann愛向後擦啦, 我看你 也向前擦啦,很多人都向前 擦啦..哈哈……..你跟你媽 媽講,henn你跟你媽媽講,擦 大便是從前面往後擦,

恁講那我攏聽無啦

p.26

The doctor purposefully avoids these face threatening effects and uncomfortable feelings with four strategies: 1) He attributes the problem of inadequate cleaning to most females. 2) He makes a joke of this phenomenon to reduce the embarrassment, as indicated by his laughing in line 4. 3) He excludes the patient by speaking Mandarin to the daughter when he comes to the embarrassing explanation in line 3:“yeah that sometimes might ..because that girls..women’s urinary passage get easily infected.” These explanations are totally missed by the patient, as indicated by her

complaint in line 8 ("I have no idea at all of what you two are talking about.") At the end of his explanation, the doctor explicitly ask the daughter to tell her mother his advice on how to maintain personal hygiene ("you tell your mother, yeah you tell your mom") (7).

It is obvious that the doctor's intention of initiating the D-X episode (3-7) is to have the daughter as the mediator. He explicitly asks her to deliver a sensitive but important issue with which he does not feel comfortable to inform the patient. In their hypothesis of the effect of a third person’s presence, Adelman et al. suggest that "issues concerning sexuality and other intimate personal and medical subjects (e.g. urinary or fecal incontinence) are unlikely to be discussed with the presence of a third person" (1991: 131). This instance presents a counterexample of this hypothesis. The presence of the third person, who is the female patient’s daughter in this case, helps the male doctor to handle a touchy issue which in turn benefits the patient as well.

In the above discussions (3.2, and 3.3.1), I argue that the doctor perceives the daughter as a doctor facilitator and a mediator. The discourse evidences for the basis of my argument are referential expression (e.g. healthy people), code-switching, and speech acts (e.g. expository ) achieved in the D-X episodes which he initiates. I have shown earlier that among the 22 D-X episodes, only 3 of them (14%) are initiated by the doctor (Table 4). Among the three, the indent episode discussed earlier is the only one extended in length by the doctor, which is evident by the discourse lines it takes up. This tiny amount of 14% reflects that the doctor is reluctant to shift his focus to the daughter. He sees the patient as the center of this encounter. He does not see the daughter as a required participant in this encounter. However, if it is necessary to get

p.27

her involved, the two roles in which she can best enhance this medical visit are doctor facilitator and mediator between himself and the patient.

In the following, I will shift the focus from the doctor’s perspective to the daughter’s: how does she perceive herself in this medical encounter.

3.3.2 The Daughter as a Mediator -- from her Perspective

I will argue that the daughter perceives herself as a mediator between the doctor and the patient with three pieces of evidence. As I mentioned during the indent episode (excerpt 4), the doctor uses Mandarin through lines 10 to 18D in addressing the daughter. However, the daughter, though a native Mandarin speaker, does not code-switch into Mandarin, which her mother neither speaks nor understands. The daughter’s refusal to use Mandarin can be interpreted as her intention to keep the patient partially informed of what is going on. By her insistence of using Taiwanese, she functions as a language mediator -- she receives the Mandarin input from the doctor and expresses her reaction in Taiwanese which will be in turn received by the patient as well.

The daughter's perception of herself as a mediator can be further supported with the only two P-X episodes that ever occurred in the whole interaction. Right after the indent excerpt, the doctor addresses the daughter with the information that the patient is now in the stage of second degree edema. Then he shifts to the patient by asking her if she has a hard time breathing while climbing upstairs (1). The patient does not reply immediately, as indicated by her repeating of the doctor's question and her pause (2P). At the same time, the daughter repeats the doctor's question to the mother (2X). The daughter hears the doctor's question, then addresses it to her mother as if she herself is the doctor. By doing so, the daughter establishes herself as a mediator between the doctor and the patient.

Excerpt 7 P

D

X

Patient (P)

Doctor (D)

Daughter (X)

p.28

1

------>

So, you are in the stage of second degree edema, I’ll tell you what ..when you climb upstairs, do you have hard time breathing?

<------/

2P 2X

3

[ [ [ [ [ [ [ [ [ [ [ [

------> <---------------|

[hard time breathing, while climbing upstairs?

[climbing upstairs .. Yeah, I had hard time breathing while climbing upstairs=

<------

=yeah, that means (your) heart is not strong enough /?/ this is cardiomegalia, yeah=

Excerpt 7 (Chinese) P

D

X

Patient (P)

<------/

[ [ 2P [ 2X [ 3 [ [ [

Daughter (X)

所以你這已經是二度水腫 了,我跟你講 . 汝平平常時汝爬樓梯爬 樓梯會喘無?

------>

1

Doctor (D)

[爬樓梯 . 爬樓梯是攏會喘 對啦=

------> <---------------|

[爬樓梯敢會喘? =henn 彼心臟無 kiau 好/?/ 這心臟放大欸.按吶啦=

<------

Upon receiving the patient's confirmation, the doctor states that her heart is not strong enough. He then relates her heart problem to second degree edema. The patient told the doctor about a terrible experience she had with her heart. Based on the patient's story of her heart problem and the fact that she had a hard time breathing, he diagnoses that she suffers from cardiomegalia. Then he goes on to give advice: the patient needs to lose weight. After several exchanges, the daughter initiates a question to which the doctor gives an extended but complicated explanation of the relation among edema, cardiomegalia, puffy faces, and losing weight (i.e. excerpt 5: chain-reaction). Then he receives a call on his cellular phone (line 1 in excerpt 8).

Excerpt 8 P

1

D

X

<----------------

Patient (P) ] ] ]

Doctor (D)

Daughter (X)

[yeah speaking..umm Big Brother I will be there tomorrow.. yeah yeah yeah

[Mom, he is saying..now if you get fat, and your heart will be um.. not strong

p.29

2 3 4

----------------> <----------------

5

6

---------------->

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

I’m sorry, I meant to, I meant to give you a call, huhuh

enough

not strong enough to /?/ (I’m) sorry..right= =yeah, so, for example, when climbing upstairs= =[oh, OK, thank you

=[yeah, sometimes (I) had hard time breathing, yeah right.

=[(you) will have hard time breathing=

=[thanks..thanks, thanks….OK, thanks, thanks (hang up the phone)

Excerpt 8 (Chinese) P

D

X

Patient (P)

1

<----------------

] ] ] ]

2

---------------->

]

3 4

<----------------

5 6

---------------->

Doctor (D)

Daughter (X)

[是..enn大哥我明天會 去,henn henn henn, 會去 ..henn 不好意思,我本來我 打給你的,哈哈哈

[媽,伊是講..汝即嘛人若大 koo 啊汝心臟著 honn 著 heir..無無無夠力啦

無夠力通/?/

] ]

[不好意思..對=

] ] ] ]

=[喔,好,謝謝

=啊所以講汝譬如爬樓梯= =[著會足喘=

=[henn 有當時仔足喘,對啦 =[謝謝..謝謝,謝謝…..好,謝 謝,謝謝 （掛斷電話）=

While the doctor is speaking on the phone, the daughter initiates a P-X episode (1). She addresses her mother by paraphrasing the doctor's statements: “Mom, he is saying..now if you get fat, and your heart will be um.. not strong enough yeah, so, for example, when climbing upstairs (you) will have hard time breathing”(lines 1, 4, and 5). The daughter's paraphrase not only recapitulates the doctor's previous points, but also simplifies the logic of the doctor's statements in the chain-reaction excerpt. What the daughter is doing here fulfills the doctor's expectations, that I have interpreted earlier in the indent excerpt, as to why he recruits the daughter as his information recipient – the doctor expects her to explain to her mother what he has said.

3.4 The Daughter as a Patient Advocate

p.30

A patient advocate refers to the active supporter of the patient’s agenda, thus his/her function is to mainly serve the patient 14 . I will illustrate this function of the daughter with three excerpts.

In line 1 of excerpt 9, the doctor advises the patient that she should not work too hard otherwise her heart can not take it. The patient admits that she always works too hard. At that point, the daughter interrupts the conversation and initiates a D-X episode. She volunteers the information: "did you see my mom’s face?..now my mother's face looks looks puffy"(3X). The doctor interprets her statement as a request for an explanation because he goes on to provide the extended explanation of the chain-reaction (4-8).

Excerpt 9 P 1

2P 2D 3P 3X

[ [ [ [ [ [ [ [ [

D

Doctor (D)

Daughter (X)

(you) can’t work too hard, if (you) keep working hard, (it )will…there’s no way to save=

------> <------

[I was thinking .. I was thinking mm=

------> <------|

------>

------> |------>

6

<------

7

------>

14

Patient (P)

<------

4

5D 5P

X

[m-hng

=[if (I) eat /?/ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

=what if, did you see my mom’s face, it looks like . now . now my mom’s face looks looks puffy = =(it) looks puffy because the heart is swollen .. if the heart swelled .. (it) will

[it’s not that (I) really gain weight, right?

[influence some other part .. other part, when your heart swells it can’t work, the wall of the heart wall is thick and heavy= =m-hng

if it gets thick and heavy, like. if the metal is thick it requires more energy to shape it … the heart will .. (the heart wall) for healthy people (the thickness of the

Unlike Adelman et al., I will not distinguish the role of patient promoter from that of extender, because of the vague boundaries between the two.

p.31 heart) is like this .. and your mom’s is like this

] ] (Lines 8-23 are deleted) 24

25P 25D 26 27

28P 28D

29D 29X

[ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [

<------

=[yeah, if you don’t pay attention to these syndromes, (it) will get worse and there’s no way, yeah

------> <------

[oh really=

=[/?/

[OK?

<------|

[if that’s the case, what if=

<------

[to save (your) life should be the top priority, otherwise, you earned money but for what?=

------> <------

=[yeah, so.what can be done?

<-----<------|

30

------>

=[once( you) die, you got nothing, how can you make more money? =[OK?

] ] ] ] ] ] ] ] ]

=[what.what if the heart, the heart, for example, you talk about losing weight, what if, if (it) gets worse, what will happen? what if=

=if (it) gets worse.you meet your maker, /?/, little by little, the heart can not make it=

Excerpt 9 (Chinese) P 1

2P 2D 3P 3X

[ [ [ [ [ [

D

X

Doctor (D)

Daughter (X)

足thiam未使啦,閣做thiam 著.…就沒法=

<------

[啊是講 .. 是講 honn=

------> <-----------> <------|

4

------>

5D 5P

Patient (P)

------> |------>

6

<------

7

------>

[m-hng =無, 汝看我媽媽欸臉敢有 卡 . hio 我媽媽欸臉即嘛即 嘛像卡卡澎按吶=

=[食/?/ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

=卡澎是這心臟放大 .. 心 臟放大會 .. 影響 [彼 m 是正經肥喔 honn

[局部 .. 局部化的影響,汝 心臟放大著心臟無法度,心 臟 . 心臟肥厚, =henn 肥厚那打鐵都很用力嘛,心 臟就 .. 正常人就這樣 … 啊你媽媽是這樣

(Lines 8-23 are deleted) 24

[

<------

=[henn, 汝症頭閣無注意著 =[/?/

p.32

25P 25D 26 27

28P 28D 29D 29X

[ [ [ [ [ [ [ [ [ [ [ [ [

愈來著無法度啊, henn ------> <------

[按吶呢啊=

[好無?

<------|

[按吶若=

<------

[愛顧命第一啦,汝賺錢嘛無 啥麼錄用啊=

------> <------

=[hio,按吶.按吶卜按若?

<------

30

<------|

------>

=[著無命啊卜閣按吶賺 錢?= =[honn

] ] ] ] ] ] ]

=[啊這若講心臟 . 若講: hier . 若講 . 譬如講汝講 愛減肥,啊若講無 . 若講愈 來愈嚴重欸按吶?若講=

=愈來愈嚴重著 . 烏彌陀 佛啊/?/慢慢啊心臟著無法 度=

After several exchanges, he conveys strong advice by directly addressing the patient: "to save (your) life should be the top priority, otherwise, you earned money but for what?" (27). At this point, the daughter initiates another D-X episode by raising her second concern in the form of a conditional statement: if losing weight does not improve the problem, what is going to happen ? (29X)

Both the daughter's utterances in these two D-X episodes achieves the speech act of seeking information which is related to the health problem of the patient: she points out the problem which the doctor should have noticed (the puffy face) and the concern which the patient should have anticipated (if losing weight does not improve the situation). In that sense, the daughter perceives herself as the advocate of the patient.

The daughter’s role as patient advocate is clearly illustrated by her use of deictic expressions "my mother" and "we" in the following two D-X episodes. As you would recall the main point of the doctor's advice is that the patient should lose weight. However, this advice does not sound reasonable based on the daughter's judgment. Her argument is that since her mother always works hard, instead of sitting around and doing nothing, why does she gain weight in the first place? ("but my mother is always . always busy with work” ) (lines 31-32 in excerpt 10) .

p.33

Excerpt 10 (a continuation of excerpt 9) P

D

X

31

<------

32D 32X

------> <------

33

------>

34

<------

35

------>

36

<------

37

------>

38X 38P 39P 39D

<-----|------> ------> ------>

40

<------

41

------>

54

<------|

55

------>

56

<------

Patient (P) ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

Doctor (D)

Daughter (X) and the um . but

[m-hng

[my mother is always.always busy with work, instead of .. (she) is not just sitting at home oranything like that, why why um (she’s) getting fatter and fatter?

getting fatter?= =yeah, why? =getting fatter, now, say after you reach 30 or 40 the adulthood, hng (you) eat the same stuff every day [yeah

[yeah=

=[when (I) eat when (I) eat, =when you eat, um not mentioning you’re getting (it) will old, say,you’re not eating like people of age 20= (pager rings at the same time) =m-hng whatever they eat..whatever they eat they don’t care= (lines 42-53 are deleted)

57

------>

58

|------>

59P 59X

------> <------

] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

=and and my my mother, (I) felt that my mother has a very normal diet, because we we are farmers, and= =yeah= =being farmers, and so (we) need to eat a lot= =yeah= =yeah, (I) was wondering =[(It) used to come to me, sometimes when (I) was hungry, yeah, (I) ate a lot, yeah right=

=[but (it) digests at the same time, but (it’s) strange, why (it) turn out like this?

p.34

Excerpt 10 (Chinese) P

D

X

31

<------

32D 32X

------> <------

33

------>

34

<------

35

------>

36

<------

37

------>

38X 38P 39P 39D

<-----|------> ------> ------>

40

<------

41

------>

Patient (P) ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

Doctor (D)

Daughter (X) 啊 hier . 啊 m 過

[henn

[guan 媽媽攏嘛攏.攏常咧做 工作,啊無講..啊 m 是講足 閒啊是按若,奈會奈會 hier 愈大 koo 欸?

大 koo 喔?= =henn 啊,奈會按吶?= =愈來愈大koo,汝即嘛人. 汝.中年三四十.十歲以後 hng 逐天食飯攏食同款欸食飯 [henn =[攏食飯攏食會

[henn= =[汝食飯,enn 汝 m 講汝年 歲到啊,若是講汝.二十幾歲 欸= 人(畢畢同時扣響起…) =henn= 食啥麼物件攏..食什麼物件 攏 m 免驚嘛=

(lines 41-54 are deleted) 54

<------|

55

------>

56

<------

57

------>

58

|------>

59P 59X

------> <------

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ]

=啊啊 guan guan 媽媽,感覺 guan 媽媽食飯嘛攏足.足正 常,因為 guan.guan 佇作田, 啊= =對啦= =作庶啊,啊所以愛食飯食 卡濟欸啊= =對啊= =hio 啦,想講= =[捌食飯 honn,有當時仔腹 肚 honn,夭像嘛是攏食真濟, 對啦=

=[啊嘛是有咧消化,啊奇怪 奈會?

The doctor responds to her argument by attributing her mother's weight-gain as a natural process of aging -- people, who are reaching 30 or 40 and eat whatever they want as if they were as young as 20, will gain weight (lines 35-41). At this point, the doctor stops his statement to answer a phone call. Right after the doctor finishes the phone conversation, the daughter poses the same argument and strengthens it with

p.35

more details. Since her mother works on the farm, she does eat a lot in each meal; however, her diet should not cause her to gain any weight since the farm tasks consume all her energy ("and and my my mother, (I) felt that my mother has a very normal diet, because we we are farmers, and being farmers, and so (we) need to eat a lot"(54-56). The daughter concludes her argument with the question: why does her mother gain weight in the first place (59X).

Both the daughter's arguments begin with "my mother (always)". Her choice of the possessive form "my" and the relationship term "mother", reveals her perception of seeing the patient among her personal relations. The daughter’s use of the plural pronoun "we" indicates that she aligns herself with the mother as being farmers. Her choice of the word "always" indicates that she is such an intimate partner of the patient that she knows all of the details of the patient’s life world. Given this intimacy that the daughter and the patient share and the daughter’s perceiving of the patient as part of herself, it is justifiable to say that the daughter is speaking for the patient. Thus, she functions as the patient advocate.

Also, the proposition of the daughter’s argument is a pursuit of a logical reason for the cause-effect of the patient's suffering -- are the patient's puffy face and legs the result or the cause of cardiomegalia? If the patient's gaining weight is the result of cardiomegalia, it does not make sense for her to lose weight 15 . Regardless of whether the daughter’s argument is medically correct or not, her argument is motivated by the benefit for the patient -- the patient needs to take the right action to save her life. In that sense, the daughter functions as the patient advocate who tries to pursue the best interests of the patient.

4. Conclusion

15

I do not intend to say that the daughter's argument is a correct reasoning. However, since most patients or third persons are concerned of the causes of diseases, and they tend to interpret the cause-effect relationship in terms of their life-world knowledge. Thus it is a challenge for physicians to persuade their patients to follow their advice or recommendation.

p.36

In quantifying the participant structures in which the daughter is involved, I find that even though the daughter contributes a minor portion of participation in this encounter, she actively involves herself in the interaction. By a qualitative examination of discourse elements, such as referential term, deixis, code-switching, and speech acts, three roles of the daughter are identified. These three roles are doctor facilitator, mediator between the doctor and the patient, and patient advocate.

The above analysis contributes to the field of discourse analysis in three ways. First, it supports Rosenfeld’s statement that triadic interaction is primarily composed of a series of exchanges of dyads, instead of triads. Also, the use of personal deixis as an identifier of participant structure is not applicable in a pro-drop language such as Taiwanese and Mandarin. Code-switching, instead, serves as a better identifier in a bilingual speech community as Taiwan. Finally, relying on Rosenfeld’s original framework, this study establishes a quantifying approach in measuring the third person’s participation.

This study contributes to the field of doctor-patient communication in three ways as well. First, it refines the definition of the third’s person’s roles with three specific aspects: who initiates the third person’s participation, what speech act is achieved by his/her participation, and who benefits from his/her participation. Second, the good use of the third person as doctor facilitator or mediator can actually enhance doctor-patient communication. For example, the doctor recruits the daughter, the intimate partner that the patient trusts, to present his medical arguments and to give a face-threatening advice such as the maintenance of personal hygiene. Also, a well-informed third person helps the patient comply the doctor’s advice in the life world, such as keeping a diet.

Besides the quantitative and qualitative framework that this single case study achieves, it also serves as a preliminary foundation for future study. Some issues to be extended from this study are: 1) How is the participation of the third person related to different stages of a medical encounter, such as history taking, diagnosis, and the scheduling of

p.37

the next visit? 2) How does code-switching play a role in a bilingual medical visit where most Taiwanese elderly speak only the local dialect in which the medical terms find no place? How does the role of the third person as interpreter between doctors and patients influence the interaction? 3) In this study, only three roles of the third person are identified. How would other categories, such as passive participant and antagonist, be identified with linguistic and discourse evidence? How would these roles interplay with each other? For example, can a third person play as a patient advocate and antagonist at the same time? These issues call for more data-based studies in the future.

References

Adelman, Ronald D; Greene, Michele G., Charon, Rita. 1987. The Physician-elderly patient -companion Triad in the medical encounter: The development of a conceptual framework and research agenda. The Gerontologist, 27.6: 729-734. Adelman, Ronald D; Greene, Michele G., Charon, Rita. 1991. Issues in physician-elderly patient interaction. Ageing and Society, 11: 127-148. Rosenfeld, Elif T. Participant structures in therapeutic discourse: an analysis of dyadic discourse in marital therapy. Ph.D. Dissertation in Georgetown University.

p.38

scheduling the next visit. This doctor-centered analysis is motivated by the general