1 Describing clinical symptoms
Our experience of the world around us must be shaped into grammatical structures if we want to share it with other people. In the case of a medical consultation, the way this exchange of information is managed is particularly crucial. Equally important is that meaning is communicated in a way that opens up rather than closes down the dialogue. The medical practitioner needs to use appropriate means to elicit information and the patient needs to describe symptoms clearly and include all the information that might be relevant. In order to enable such exchanges to proceed smoothly, communication skills training now forms a prominent part of the training of doctors in the UK.
Activity 1 Visiting the doctor
Imagine yourself entering a doctor’s consulting room or cubicle as a patient, then make notes on the following questions. (If you are yourself a medical practitioner of any kind, you may prefer to reverse the roles, or alternatively think about how your experience as a practitioner may affect your behaviour as a patient.)
- Who is likely to utter the first words and what might you expect them to be?
- How do you address each other, and what effect does this have?
- What grammatical means might the doctor use to establish the reasons for your visit?
- What grammatical means might you use to describe your symptoms?
Try to justify each of your responses in terms of what you know of the context and level of formality of a medical consultation.
Discussion
Below is an example answer, based on experience of the UK National Health Service, where patients often have a continuing relationship with their family doctors, or General Practitioners (GPs), over a period of years. Depending on your context, as well as your age and sex, your own experience may differ in any number of ways.
- After my name has been called at the GP practice, my doctor usually responds to a knock on her door and says: ‘(Please) come in!’ This bald imperative – or bluntly-stated command – is acceptable to us both, because I know the doctor has the controlling role in this clinical context. This is normally followed by an informal ‘Hello’, because she has known me for a long time.
- The doctor, who is female and slightly younger than me, usually addresses me by my first name, sometimes as part of the initial greeting, and, where relevant (e.g. when calling me at home to discuss medical matters) usually refers to herself by both first and family name. My instinct, because of the relative formality of our relationship, is to think of her as Dr X, so I usually avoid addressing her by name to circumvent the dilemma. I assume her first-naming of me is intended to put us on a more equal footing, which seems to work well for me in all but the reciprocity of naming! (If we were speaking one of the many languages, including French and Japanese, which make a grammatical distinction between the formal and the informal address systems we might mutually opt for the formal address form, in order to preserve the formality of the context and role relationships.)
- I would expect something along the lines of ‘So what brings you here today?’ or ‘How can I help you today then?’ I note that this implicit enquiry about my health is realised by a direct interrogative, again because the doctor is in the controlling role. The fact that it is quite likely to be preceded by an informal ‘so’ or followed by ‘then’ is partly a reflection of the fact this is an oral exchange, but also a implies a continuing dialogue, as I have been a patient of the same doctor for many years.
- I might begin with something like, ‘Well, I’ve been feeling rather dizzy when …’ or ‘I’m still a bit worried about the pain in …’. In other words, I would give myself agency in the utterance by the foregrounding of ‘I’, but would probably hedge – or soften - the statement (as in ‘rather’ or ‘a bit’) for fear of overstating my complaint and possibly as a way of showing some deference to the doctor’s role. I would expect an informal oral feature like ‘well’ to serve both as a link to the doctor’s question and as a ‘filler’ to give me thinking space in real time.
In other cultures, or indeed other UK GP practices, this scenario might of course play out entirely differently, and so your responses may have been very different from these. And if you see different doctors each visit, then it’s likely that the dialogue will remain at a more formal level than in this example.
Activity 2 Reflecting on contextual differences
If your responses were significantly different from the example answer, you may find it useful to reflect on why this was so. For example:
- Do you have a very different role relationship with your doctor (reflected in the interpersonal nature of the exchange)?
- Do you have reasons to be less direct or explicit in expressing certain kinds of medical concerns (partly an issue of your familiarity with the field, and therefore your confidence in using the specialist technology, as well as the nature of your relationship with the doctor)?
- Did you perhaps overlook the specifically oral nature of the exchange (a matter of mode)?
- Would you attribute these differences primarily to your personal relationship with the doctor, or is it more a matter of cultural conventions in your own context?
- Are you perhaps not a first-language user of English, or are you more likely to be using another language in your encounters with the doctor?
In the light of these, and any other, reflections, make any relevant additions to your notes. Keep your responses beside you to refer back to as you proceed through the rest of this week.
Activity 3 A typical GP visit?
Now compare your own responses and the example answer with the following genuine, but slightly abbreviated, consultation with a British family doctor or general practitioner (GP) in the 1970s. Do you notice any major differences and, if so, what aspects of the context do you think are responsible for these? Does the dialogue strike you as typical or not?
Context = UK GP practice. D = Doctor and P = Patient
D:
Come in. Hello. How are you?
P:
I feel shocking. You know, when I came to see you last week and you knocked those capsules off – well, every morning when I get up, and my head – Doctor, you could have amputated it. It was a terrible headache and it was as if someone was dragging my eyeballs out. So I took more tablets. I haven’t had anything since… […] I’ve had bags under my eyes and all stuffy and watery, and at the moment, all the top of my head here feels as though there’s pressure on it and I feel this stuff going down the back of my throat.
D:
Are you coughing any of it out?
P:
No I can’t cough it out as… when I blow my nose it’s clear.
D:
Is your nose blocked? Lie your head back and I’ll have a look.
P:
Just here and inside of my throat is always very tender and all under here… […] and my head feels as if it’s going to fall off.
D:
Well, I’ll give you a change of tablets for that and when you’re over this I’ll start you back on the capsules.
P:
Well, all the aches and pains have gone, apart from under my ribs.
D:
Well, leave it a week and come and see me again. It sounds as if it’s the cold that’s affecting your sinuses. Right, so a week from today.
P:
Bye bye, now.
Comment
You may have noted various indicators here of an established and apparently quite relaxed relationship between the GP and the patient. This may reflect the generally more stable and less time-pressured relationships between GPs and patients which prevailed at the time. However, you may still find it recognisable, especially if you visualise the patient as a particular kind of character. Linguistic indicators include:
- various features of informal speech (including ‘hello and ‘bye bye’, contractions like ‘it’s’ and ‘you’re’ and fillers like ‘well’ and ‘right’)
- a colloquial and non-technical/non-specialised choice of vocabulary on the part of not just the patient but the doctor too (e.g. I feel shocking, stuffy, stuff, coughing it out, when you’re over this, sounds as if)
- reference to an ongoing treatment programme (when I came to see you last week, so I took more tablets, start you back on the capsules, a week from today).
However, what is also apparent here, particularly in its abbreviated form, is the way in which the exchange is structured according to a number of generic ‘moves’. The next section considers this generic structure of the clinical exchange.