Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care.
Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care.
复制标题
处理日常医疗遭遇中自我毁灭行为的叙述：健康促进、疾病预防和医疗保健话语。
DOI：
10.1016/0277-9536(93)90232-s
复制
发表时间：
1993
期刊：
影响因子：
--
通讯作者：
Britt,T
中科院分区：
文献类型：
--
作者：
Waitzkin,H;Britt,T
这项研究询问患者和医生如何处理需要采取预防措施的自我毁灭行为，如吸烟、吸毒和性行为。虽然有很多建议是关于医生应该如何通过咨询患者关于自我毁灭的个人习惯来鼓励健康促进和疾病预防，但很少有研究调查了实际的接触，以评估患者和医生如何就这些问题进行沟通，而且之前的研究很少考虑到自我毁灭习惯的社会背景。目前的研究受到越来越多的认识到叙事的影响，嵌入在医疗遭遇的社会文化背景中，作为医患沟通研究的重要分析焦点。我们的概念性工作从文学批评、批判理论和人文社会科学的叙事分析扩展到关注社会文化背景、意识形态、社会控制、潜在结构和医学遭遇话语表面边缘特征的元素。基于对医患沟通研究中定量和定性技术的批判性回顾，我们开发了一种具有系统标准的解释方法，以指导接触抽样、记录转录、转录解释和结果呈现。我们将解释方法应用于从336个涉及患者和初级保健内科医生的录音中随机抽取的50个会面。正如两个说明性的遭遇所显示的那样，医疗保健的话语在处理患者的自我毁灭倾向时加强了专业监督和个人控制的意识形态原则。语境问题在很大程度上仍然是话语的边缘特征，尽管它们与预防目标相关。叙述分析为研究医疗遭遇中自毁行为的处理提供了一种有用的方法。未来的研究应继续评估话语在处理自毁行为时的可变性，并应开始干预以测试不同话语风格的效果。保健话语的有意义改善部分取决于医学社会背景的艰难改变，包括解决导致药物滥用和其他形式自我毁灭行为的社会条件的政策。
This study asked how patients and doctors process self-destructive behaviors that warrant preventive action, such as smoking, substance use, and sexual practices. Although many suggestions have appeared about how physicians should encourage health promotion and disease prevention by counseling patients about self-destructive personal habits, few studies have examined actual encounters to assess how patients and doctors communicate about these matters, and prior research rarely has considered the social context of self-destructive habits. The present research has been influenced by a growing recognition of narratives, embedded in the sociocultural context of medical encounters, as an important analytic focus in the study of patient-doctor communication. Our conceptual work extended perspectives from literary criticism, critical theory, and narrative analysis in the humanities and social sciences to focus on elements of sociocultural context, ideology, social control, underlying structure, and superficially marginal features of discourse in medical encounters. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by two illustrative encounters, the discourse of health care reinforces ideologic principles of professional surveillance and individual control in dealing with patients' self-destructive tendencies. Contextual issues remain largely marginal features of the discourse, despite their pertinence to the goal of prevention. Narrative analysis provides a useful method to study the processing of self-destructive behavior in medical encounters. Future studies should continue to assess the variability of discourse in dealing with self-destructive behavior and should begin interventions to test the efficacy of differing discourse styles. Meaningful improvements in health-care discourse depend partly on difficult changes in the social context of medicine, including policies that address social conditions contributing to substance abuse and other forms of self-destructive behavior.