The Loss of Agency of Medical Professionals in Modern Medical Complex: A Discourse Analysis of their Visibility and Individuality Constructed in Cancer Patients’ Diagnosis Narratives in a Taiwanese-based Online Forum

論文翻譯標題: 當代醫療複合體制下醫療人員主體性之消失:從言談分析探討台灣網路癌症病友確診敘事中所反映之醫療人員顯要性與個人性
  • 吳 諾瑋

學生論文: Master's Thesis


As the operation of modern health care systems has developed into a vast complex involving multiple specialties and advanced high-tech equipment this inevitably has impact on conventional physician-patient relationship This change however has received little attention in the literature While internet health forums have becomes an important social media platform where patient groups gather their online discourse such as patient narratives provides an alternative window to explore the roles of medical specialists from the patients’ perspectives Using discourse analysis the current study examines 61 patients’ narratives of their cancer diagnosis (‘diagnosis narratives’) collected from a popular online bulletin board system in Taiwan We targeted narrative clauses which describe any of the following three types of medical events: (1) informative events in which messages about certain medical events behaviors or practice are delivered (such as ‘葉醫生建議我去教學醫院/ Doctor Yeh suggested that I go to a teaching hospital’) (2) operational events in which the operation of a medical procedure or intervention was performed (such as ‘馬偕的醫生幫我做了徹底的檢查/ The doctor at the MacKay Hospital did a thorough examination for me’) and (3) diagnostic events in which news related to diagnosis or health check results were delivered (such as ‘醫生證實是惡性腫瘤/ (The doctor verified it as a malignant tumor’) We further classified the reference terms identified in this study into the following three levels of discernibility—the likelihood that the referent in the narrative clauses can be identified with its corresponding one in the real world: high-discernibility (‘葉醫生/ Doctor Yeh’ or ‘詹啟傑醫師/ Doctor Qi-Xian Zhan’ a pseudonym example) mid-discernibility (‘馬偕的醫生/ The doctor at the MacKay Hospital’) and low-discernibility (‘醫生/ the doctor’) While in the real world we would normally assume that these medical events would be performed by a medical professional with a discernable presentation of their name or specialty title (e g name tag or official chop on lab reports) we wonder in the patients’ narrative world whether they retain the same agency with their identity presented in the same discernible manner Specifically we focused on the following three research questions: (1)How are the medical parties linguistically referred to in the three medical event types in the cancer patients’ diagnosis narratives? (2)What are the discourse patterns of the use of the reference terms? (3)What are roles of modern medical professionals in Taiwan as reflected in the above discourse patterns? Our findings to research questions (1) and (2) are as follows (1) The agents who perform the three medical events are referred to in three noun phrase groups (‘NP’): medical professional NP (47% 184 instances) medical equipment NP (17% 67 instances) medical institution NP (15% 63 instances) and zero NP (i e not mentioned at all 21% 79 instances) Against our assumption only 47% of the time is a medical professional referred to with regard to what they did by an NP of their family name and professional title (e g ‘葉醫生建議我去教學醫院/ Dr Yeh suggested that I go to the teaching hospital’) Most of the time they are either not mentioned (21%) or replaced by a medical equipment NP (17% e g ‘病理檢查證實是惡性腫瘤/ The pathological examination verified it as a malignant tumor’) or a medical institution NP (15% ‘醫院幫我做了徹底的檢查/ The hospital did a thorough examination for me’) (2) In the narrative clauses which describe medical operational events the most frequently used NP in referring to the agent is medical institution NP (36% e g ‘另一間大型醫院就幫我做腹部超音波/ Another big hospital did an abdominal ultrasound for me” We termed this phenomenon ‘the institutionalization of medical procedures’ (3) In the narrative clauses which report diagnostic events the most frequently used NP in referring to the agent is the medical equipment NP (47% e g “病理檢查證實是惡性腫瘤/ The pathological examination verified it as a malignant tumor” We termed this phenomenon ‘the technoscientifization of diagnosis’ With regard to the discernibility of the reference terms we also observed the following two patterns (4) While the discernibility of the medical professional NP is generally low (73%) (5) that of the medical institution NP is high (52%) That is when a medical professional is mentioned as the agent of a medical event his/her (family) name is hardly mentioned (14%); instead he/she is very likely to be generalized as any or some doctor (73%) such as ‘醫生說:你是內膜癌一期/ the doctor said: You are a case of stage I endometrial cancer’ However when an institution is described as the agent of a medical event its name tends to be fully spelled out (52%) so that one has no trouble in identifying it in the real world (such ‘台安醫院門診診斷為良性/ the out-patient department at Tai-an Hospital gave a diagnosis of benign status’) The above five discourse patterns of how the agents i e the medical parties of three medical event types are referred to answered our research questions (1) and (2) They also led to our following two arguments in response to our third question regarding the roles of modern medical professionals in Taiwan: ‘team-based and standardized diagnosis of severe disease’ and ‘the disappearance of medical professionals’ visibility and individuality’ Argument (1): ‘team-based and standardized diagnosis of severe disease’: A diagnosis of a critical disease such as cancer has a great impact on patients’ life course and their rights to public or private medical resources To minimize medical uncertainty the subjective evaluations of specialists must be confirmed with a series of objective reports by high-tech medical equipment such as pathology exams or MRI images Access to these specialists and equipment is only possible in a tertiary care center Such a team-and-institution-based practice of oncology-related specialists accounts for the discourse patterns of “the institutionalization of medical procedure” and “the technoscientifization of diagnosis” we observed from cancer patients’ diagnosis narratives Argument (2): ‘the disappearance of medical professionals’ visibility and individuality’: Technically speaking all the medical procedures or interventions have to be operated by a human agent; for example the pathologist is the one who analyzes the body tissue and gives the lab report to confirm an oncologist’s initial impression In the patient’s journey of completing all the required procedures in this team-and-institution-based medical system the names or identities of the specialist they have physically encountered became less relevant in their diagnosis narratives Instead it is the medical procedures or interventions (i e the technoscientifization) they have received that confirm their status as cancer patients further endorsed by the title of the institution who owns these equipment This accounts for the low-discernibility of medical professional NP and the high-discernibility of medical institutions When patients describe the agent who performs the medical procedures on them they tend to construct this individual by the institution name he/she affiliates to and when patients report the agent who gives the final word on their diagnosis it is often the medical procedures that receive the credit In conclusion the medical professional’s agency in cancer diagnosis as observed in patients’ online narratives is becoming invisible or gradually yields to that of institutions and equipment Based on the linguistic expressions which refer to the agent of medical events that cancer patients had gone through till they received the diagnosis we observed discourse patterns that suggest the loss of the visibility and individuality of oncology-related specialists involved in the diagnosis process This linguistic construction however is solely based on the online social media where patients share their diagnosis stories How this de-individualization phenomenon is applicable in other contexts or how it reflects physician roles in other health care contexts are important questions for further studies
獎項日期2016 1月 25
監督員Mei-Hui Tsai (Supervisor)