How does a Doctor Control the Problematic Situation at Medical Setting ?

本文旨在了解慢性病就医过程中存在的问题，以及医患双方如何共同应对。笔者在某医学院医院风湿病门诊检查室观察了医患互动，并对他们的对话进行了录音，发现他们在就医过程中需要处理两类问题：一是疾病轨迹的不确定性，二是药物副作用可能造成的危险。即使在今天，这些问题在类风湿性关节炎的药物治疗下也是不可避免的。另一个问题是，他们经常陷入两难境地，是严格遵守医保规则的限制，还是从用药或预约的数量上考虑患者的便利性。他们似乎设计了应对策略来控制这些问题。以下是典型的策略：坦率的交谈，没有技术术语，以便于检查目前的疾病轨迹阶段；谈判，以获得协议或满意，以继续合作工作。通过这次谈判，他们有时会在阴谋中使用制度规避，比如在没有真正诊断的情况下尽可能地写下处方。

This paper is to see what problems there are at the medical encounter of chronic illness and to find out how doctor and patient co-worked to cope with them. I observed doctor-patient interaction and taperecorded their conversation at examination room for out-patients of the rheumatics in a medical school hospital.I find two types of problematic situations which they have to manage during medical encounter process : One is the uncertainty of illness trajectory and the danger might be caused by side effects of medicine. These problems are even nowadays unavoidable under medical treatment for rheumatoid arthritis. Another problem is that they are often in a dilemma as to whether to obey strictly the restriction of health insurance rules or to consider patient's convenience in terms of the amount of medicine or appointment. They seem to have devised the coping strategies to control these problems. The followings are typical strategies : frank conversation without technical terms to make it easy to check the present illness trajectory stage ; negotiation to get the agreement or satisfaction enouth to continue the co-operative work. Through this negotiation, they sometimes use institutional evasion in conspiracy such as writting down prescription as much as possible without a real diagnosis.