Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor–patient communication in general practice
Introduction
The voice of the lifeworld refers to the patient's contextually-grounded experiences of events and problems in her life. These are reports and descriptions of the world of everyday life expressed from the perspective of a “natural attitude”. The timing of events and their significance are dependent on the patient's biographical situation and position in the social world. In contrast, the voice of medicine reflects a technical interest and expresses a “scientific attitude”. The meaning of events is provided through abstract rules that serve to decontextualize events, to remove them from particular personal and social contexts. (Mishler, 1984, p.104.)
In “The Discourse of Medicine: Dialectics of Medical Interviews” Elliot Mishler employs concepts from Jurgens Habermas’ Theory of Communicative Action, to make sense of the patterns of communication between doctors and their patients, in hospitals and private practice in America in the mid-1970s. In this paper we revisit the concepts with reference to a sample of British consultations recorded in general practice in the late 1990s. We have found the concepts to be very useful in teasing out the dynamics at play in medical communication and we have found support for Mishler's typologies of consultation. We have also uncovered evidence of different patterns of communication. We find support for Mishler's notion of a better model of medical care where space is given to the lifeworld, although we take issue with his terminology, in particular his use of the word inhumane.
Before presenting our data we will summarise the theoretical concepts of Habermas and show how these have been applied by Mishler, and others using his work.
Section snippets
The theory of communicative action
Habermas’ theory of Communicative Action1 posits a dialectical struggle between two types of rationality, which in turn produces two different types of world (Habermas, 1984). On the one hand, is communicative or value rationality, which inhabits the lifeworld, and on the other is purposive rationality, which inhabits the system. Habermas's project is a moral one
Mishler's voice of medicine and voice of the lifeworld
Mishler (1984) has drawn on Habermas's concepts and applied them specifically to the world of medicine (one aspect of the technocratic system in late 20th century western society — see Fig. 2).2 Here the system is the system of technological medicine. Strategic action is used to maintain its dominance. This strategic action takes the form of appropriating the
Methods
The data reported here were collected as part of a Department of Health funded project, ‘Improving doctor–patient communication about drugs. ’ The aim was to conduct an in-depth exploration of the expectations and perceptions of patients prior to consulting a general practitioner, to relate these to the behaviour of GPs and patients in the consultation and to describe the consequences with regard to any medicines prescribed.
Sample
We conducted a total of 62 case studies, comprising 62 patients visiting 20 doctors in the midlands and southeast England. These doctors responded to a mailing asking them to participate in a doctor–patient communication research study (once ethical approval had been obtained from 11 local health authority ethics committees). Sixteen per cent of those contacted agreed to take part. From this group of 101 doctors, we purposively sampled 20 to represent male and female doctors, in rural, suburban
Analysis
We have conducted several different analyses on these linked data case studies (see Stevenson et al., 1999) on shared decision-making processes; Britten et al. (2000) on misunderstandings between doctors and patients and Barry et al. (2000) on patients’ unvoiced agendas). In all of these analyses, and those conducted for this paper, we did the initial analysis on a case by case basis, linking the different data sources, before we amalgamated the cases and looked for common themes using Nudist
Differences in method between our study and Mishler's (1984)
There are a number of differences between the data collected here and that analysed by Mishler. Firstly, the samples were differently derived. His data were collected in the mid-1970s in the United States and consisted of both hospital outpatients and private practice data while our data were collected in general practice. The American doctors were all white males. Our sample comprised 50% women and included three Asian doctors.
Secondly, the complex and linked methodology of our project
Findings: the voices of medicine and of the lifeworld
In our 35 case studies we found four broadly different patterns of communication according to whether the voice of medicine or the voice of the lifeworld was used and by whom, doctor or patient. We have labelled these groups Strictly Medicine, Lifeworld Blocked, Lifeworld Ignored, and Mutual Lifeworld (see Table 1). The first two groups seem similar to those noted by Mishler (1984) so for reasons of space we will give more detailed examples of the last two groups, which are qualitatively
Strictly Medicine
The Strictly Medicine group comprised 11 patients in consultations with nine doctors. In these consultations doctors and patients spoke exclusively in the voice of medicine. The only exception was in three consultations where small children were accompanied by their mothers. Here both doctor and mother used the voice of the lifeworld solely when addressing the child, usually for the purpose of gaining co-operation for a physical examination.
The Strictly Medicine consultations appear similar to
Lifeworld blocked
The Lifeworld Blocked occurred in eight consultations with seven doctors. These appear similar to those consultations where Mishler reports seeing glimpses of the lifeworld. These glimpses were immediately suppressed as a result of the doctor using the structural sequence of question control illustrated above. These consultations had less successful outcomes. We rated three as outcome category 4 with significant problems. Most of these patients were consulting for chronic physical problems.
Fig.
Lifeworld Ignored
The Lifeworld Ignored is a group of seven consultations with six doctors. Here the patients talked either exclusively or for a large amount of the consultation in the voice of the lifeworld. However, the doctors completely ignored this and conducted the whole of their communication in the voice of medicine. Most of these patients had chronic physical problems and this group had the worst outcomes of any group. We rated 5 of the 7 in the poorest outcome category 4. Patients and doctors seemed to
Mutual Lifeworld
The Mutual Lifeworld group comprises nine consultations with eight doctors, in which both doctors and patients predominantly used the voice of the lifeworld. In three cases the voice of the lifeworld was used exclusively for the whole consultation. In the other six there was a mixture with both parties resorting to using both voices at different points in the consultation. Nearly all of the 10 psychological consultations fell into this group. Seven of the nine had a psychological presenting
Discussion
In 1984 Elliot Mishler suggested that there was an ‘Unremarkable Interview’ format for consultations between doctors and patients. He showed how doctors use strategic and manipulative methods in the consultation to maintain control of the dialogue. As a result medical communication was conducted almost entirely in the voice of medicine and the voice of the lifeworld was suppressed and fragmented. This pattern of communication fits very well with Habermas’ ideas about the system rationalisation
Conclusion
Mishler's theoretical ideas about the dialectical struggle between the voice of medicine and the voice of the lifeworld, provide a useful way of looking at doctor–patient communication. Through a more complex data collection strategy we have been able to elaborate on this idea to show more complex relations than he was able to illustrate from the use of consultation data alone.
Our analysis has shown that the doctors here seemed to switch their communication strategy depending on whether they
Acknowledgements
The study was funded by the Department of Health as part of the Prescribing Research Initiative. Any views expressed in this paper are those of the authors, not the Department of Health. Christine Barry is supported by an NHS Health Services Research Fellowship. Dr Stevenson is supported by Sir Siegmund Warburg's Voluntary Settlement.
We would like to thank all the participating receptionists, doctors and patients. We are grateful to delegates at the 1999 BSA Medical Sociology Conference and
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