COMPANIONS OF ELDERLY PATIENTS – A SOCIOLINGUISTIC STUDY OF TRIADIC MEDICAL ENCOUNTERS IN SOUTHERN TAIWAN A Dissertation submitted to the Faculty of the Graduate School of Arts and Sciences of Georgetown University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Linguistics By Mei-hui Tsai, M.A. Washington, D. C. May 23, 2000 GEORGETOWN UNIVERSITY GRADUATE SCHOOL OF ARTS AND SCIENCES The doctoral dissertation#tfa©f&*fe thesis of ...Mei-hui..Tsai entitled Companions of Elderly Patients - A Sociolinguistic Study of Triadic Medical Encounters in Southern Taiwan submitted to the department/pKagxam of..Li.ni»u.i.?.t.?:S.? ;. in partial fulfillment of the requirements for the degree of....P.9.ctpr..pf .Philosophy in the Graduate School of Georgetown University has been read and approved by the Committee: Dr. Heidi Hamilton Dr. Deborah Schiffrin Dr. Deborah Tannen Date This dissertatiorutlxesisc has been accepted by the Graduate School of Arts and Sciences. Date Copyright 2000 by Mei-hui Tsai All Rights Reserved ii THE COMPANIONS OF THE ELDERLY PATIENTS – A CASE STUDY IN THE TRIADIC MEDICAL ENCOUNERS IN SOUTHERN TAIWAN Mei-hui Tsai, M.A. Mentor: Heidi E. Hamilton, Ph.D. ABSTRACT This dissertation investigates Taiwanese triadic geriatric encounters between doctors, elderly patients, and patients’ adult children who accompany patients on the first visit to their doctor. The two major goals of this research are to propose a systematic framework for analyzing the companion’s participation in providing information to the doctor and to account for the dynamic process of the doctor-patient-companion communication by following the principles of interactional sociolinguistics. The data to be examined are fifteen triadic encounters collected in the family medicine department of a teaching hospital in southern Taiwan. In this proposed framework, the companion’s participation is analyzed from four aspects that are grounded in the structural and interactional levels. There are four parts in iii this framework. The first part measures the discourse space of the patient party (i.e. the patient and the companion). The second part provides taxonomy of five categories of information provided by the patient party. The third part identifies eight discourse patterns of question-response sequences in which the patient party provides information to the doctor. The fourth part identifies six linguistic and interactional mechanisms that can initiate the companion’s participation. By using the above framework, some interactional patterns can be recognized from the quantitative results. Some of the major findings include the following. Most (80%) of the patients remain the primary information providers. However, when both the patient and the companion provide information, the patient hardly ever completes his or her reply to doctor’s questions prior to the companion’s intervention. It is also argued that the pedigree section in which the doctor gathers the patient’s family history is the most appropriate interactional context to recruit the companion. The related evidence includes the doctor’s use of eye contact, relationship deictics, and code-switching to Mandarin which the patient does not speak as initiation cues to prompt the companion’s participation. iv This research contributes to the field of discourse and medicine by taking interactional aspects into account when examining the participation of the companion. It also adds cultural meaning and medical professionals’ insights to the interpretation of the interactional patterns observed in the fifteen doctor-patient-companion triads. v ACKNOWLEDGEMENTS It would be impossible to mention all the people who brought this dissertation to completion. I sincerely thank each of them, though only some of them will be named here. I am greatly indebted to Georgetown University which granted me the fellowship to study within the renowned academic environment of the Sociolinguistics Program in the Linguistics Department. I am truly grateful to Prof. Deborah Schiffrin and Prof. Deborah Tannen. As committee members, their invaluable comments and critiques have to helped improve many parts of this dissertation. Their works and perspectives on interactional sociolinguistics and cross-cultural communication have provided me with the tools to analyze language and social interaction. I wish to express my deepest appreciation to my dissertation mentor Prof. Heidi Hamilton. Her ‘Discourse Analysis: Narrative’ and ‘Discourse and Medicine’ courses served as my introduction to the fields of discourse analysis and discourse and medicine. She encouraged me to participate in a team project of genetic counseling, from which I vi gained insights on team-work and skills in collaborating with medical professionals. Her positive attitudes, open-minded approach, and critical eye have been a source of inspiration as I hone my thinking and writing to finally bring this dissertation to fruition. I would also like to express my deep appreciation to Prof. Peter Patrick. As a teaching assistant to his course ‘Language and Social Life’, I learned the pedagogical skills it takes to guide students to appreciate the value and fun of sociolinguistics. As my advisor and the reader of my dissertation proposal and other writings, he has been a steady source of patient guidance and enthusiasm for my work. My former teacher Prof. Feng-Fu Tsao, Director of the Graduate Institute of Linguistics at National Tsing-Hua University, and Dr. Feng-hwa Lu, and Prof. Chih-jen Chang, Director of the Family Medicine Department at the Medical College of National Cheng Kung University (NCKU), must take special credit for this research. Without their open-mindedness and scholastic rigor and enthusiasm, this research would not have been possible in the first place. In that regard, I also thank the National Science Council, Taiwan, for its financial support of a part of my research. I wish to express my utmost appreciation to all the staff members of the Family vii Medicine Department at NCKU. The nurses served in the front-line of my data- collection in locating patients for me. I am also grateful to the doctors, patients, and companions who participated in my study. Allowing me to conduct my research meant allowing me into the intimacy of their lives, an extension of trust that I thank them for. The fifteen-month fieldwork at NCKU had a great effect on me both personally and academically. The scientific approach in the medical field sharpened my thinking (which is where I learned my first lessons in the statistics software SPSS and the presentation software Power Point). Observing doctor-patient communication within a family relationship has provided me a chance to reflect on great many truths about human interactions. Finally, my profound thanks to my M.A. thesis mentor Prof. Shun-chiu Yau who inspired and encouraged me to go for the Ph.D. study. I would also like to thank my dearest friend Sylvia Chou who has grown with me through my years at Georgetown and Yu-pei Lin who shared the process of my fieldwork in Taiwan. I can recall all the inspiring and intelligent conversations with them. Their support kept me moving ahead. To Andy Wung and Yu-sheng Hwang whose patience never failed with any stupid viii problems I had with the computer. Many thanks to the first readers and editors of my dissertation writing, Bill Fox, Roane Beard, and Alex Woods. The language exchange experience with them has been a very pleasant and productive experience for me. My deepest gratitude to my parents and my brothers. They never questioned my path and always show their unending patience for me. I thank them for their trust and support for my decision to study in the States, which is far from their experience, and a constant source of worry. My conversations with my mother, an illiterate but a witty language user of Southern Min, has inspired me a lot on the discourse analysis of Southern Min conversation. Her years of taking care of my grandparents before they passed away and my monthly companionship with her in the visit to her family doctor at NCKU are the naïve motivations for this research. These experiences offer me a very fundamental understanding of patient-caregiver relationship and doctor-patient- companion communication. ix For my parents This dissertation marks the end of my life as a student and the harvest of my parents’ hard work on the custard apple orchard. 獻給我的父母 此論文象徵我求學生涯的句點, 也是他們在釋迦園辛勤農作的碩果 x TABLE OF CONTENTS ABSTRACT iii ACKNOWLEDGEMENTS vi TABLE OF CONTENTS xi LIST OF TABLES AND FIGURES xvi Chapter 1. Introduction 1 1.0 Motivation 1 1.1 Two goals 4 1.2 Four research questions 8 1.3 A preview to the following chapters 10 Chapter 2. Literature Review 13 2.0 Introduction 13 2.1 The study of medical discourse 13 2.2 Communication in old age 18 2.3 Triadic interaction and the third person in medical triads 22 2.4 Participant structure in triads 26 2.5 Effect of the companion on doctor-patient communication 29 2.6 Patients and caregivers in Taiwanese family relationship 33 2.7 Studies on doctor-patient communication in other cultures 37 Chapter 3. Methodology for Data Collection and Analysis 41 3.0 Introduction 41 3.1 The approach of interactional sociolinguistics 41 3.2 My participation and observation at the field site 44 3.3 Consent form, videotaped data, and monitoring effect 47 3.4 The informants 49 3.5 The informants’ use of language and their names 53 3.6 Data transcription 57 3.7 Statistical methods 62 3.8 Playback interview with doctors 63 xi Chapter 4. The Amount of Participation by the Patient Party 66 4.0 Introduction 66 4.1 Definitions of ‘information’ and ‘information-providing acts’ 67 4.2 Definitions of ‘information-providing cycles’ and ‘non-information-providing cycles’ 69 4.3 The measurement of the patient party’s amount of participation 76 4.4 The process for statistics 77 4.4.1 Percentage number 77 4.4.2 Discrepancy between the patient and the companion 80 4.5 Results 83 4.6 Implication 87 4.7 Conclusion 89 Chapter 5.