Reflective Writing in Medical Practice: A Linguistic Perspective 9781783098248

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Reflective Writing in Medical Practice

LANGUAGE AT WORK Series Editors: Jo Angouri, University of Warwick, UK and Rebecca Piekkari, Aalto University Business School, Finland Language at Work is a new series designed to bring together scholars interested in workplace research. The modern workplace has changed significantly in recent years. The international nature of business activities and the increasing rate of mobility around the world create a new, challenging environment for individuals and organisations alike. The advancements in technology have reshaped the ways in which employees collaborate at the interface of linguistic, national and professional borders. The complex linguistic landscape also results in new challenges for healthcare systems and legal settings. This and other phenomena around the world of work have attracted significant interest; it is still common, however, for relevant research to remain within clear disciplinary and methodological boundaries. The series aims to create space for the exchange of ideas and dialogue and seeks to explore issues related to power, leadership, politics, teamwork, culture, ideology, identity, decision making and motivation across a diverse range of contexts, including corporate, healthcare and institutional settings. Language at Work welcomes mixed methods research and it will be of interest to researchers in linguistics, international management, organisation studies, sociology, medical sociology and decision sciences. Full details of all the books in this series and of all our other publications can be found on http://www.multilingual-matters.com, or by writing to Multilingual Matters, St Nicholas House, 31–34 High Street, Bristol BS1 2AW, UK.

LANGUAGE AT WORK: 2

Reflective Writing in Medical Practice A Linguistic Perspective

Miriam A. Locher

MULTILINGUAL MATTERS Bristol • Blue Ridge Summit

DOI: 10.21832/LOCHER8231 Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress. Names: Locher, Miriam A., 1972- author. Title: Reflective Writing in Medical Practice: A Linguistic Perspective/Miriam A. Locher. Description: Bristol; Blue Ridge Summit: Multilingual Matters, 2017. | Series: Language At Work: 2 | Includes bibliographical references and index. Identifiers: LCCN 2017000266 | ISBN 9781783098231 (hbk : alk. paper) | ISBN 9781783098255 (epub) | ISBN 9781783098262 (kindle) Subjects: LCSH: Medical writing. | Communication in medicine. Classification: LCC R119 .L63 2017 | DDC 808.06/661—dc23 LC record available at https://lccn.loc.gov/2017000266 British Library Cataloguing in Publication Data A catalogue entry for this book is available from the British Library. ISBN-13: 978-1-78309-823-1 (hbk) Multilingual Matters UK: St Nicholas House, 31–34 High Street, Bristol BS1 2AW, UK. USA: NBN, Blue Ridge Summit, PA, USA. Website: www.multilingual-matters.com Twitter: Multi_Ling_Mat Facebook: https://www.facebook.com/multilingualmatters Blog: www.channelviewpublications.wordpress.com Copyright © 2017 Miriam A. Locher. All rights reserved. No part of this work may be reproduced in any form or by any means without permission in writing from the publisher. The policy of Multilingual Matters/Channel View Publications is to use papers that are natural, renewable and recyclable products, made from wood grown in sustainable forests. In the manufacturing process of our books, and to further support our policy, preference is given to printers that have FSC and PEFC Chain of Custody certification. The FSC and/or PEFC logos will appear on those books where full certification has been granted to the printer concerned. Typeset by Nova Techset Private Limited, Bengaluru and Chennai, India. Printed and bound in the UK by the CPI Books Group Ltd. Printed and bound in the US by Edwards Brothers Malloy, Inc.

Contents

Figures and Tables Acknowledgements

viii xi

1

Reflective Writing in Medical Practice 1.1 Rationale for this Book 1.2 Aim and Scope 1.3 Structure of the Book

2

Context and Data 2.1 The SNSF Project ‘Life (Beyond) Writing’: Illness Narratives 2.2 The Linguistics Project and its Three Theoretical Fields 2.3 The Data Sets 2.3.1 Basel (2011) 2.3.2 Nottingham I (2010) and II (2011) 2.3.3 Expert texts (2009–2010) 2.3.4 Caveats and rationale for comparisons

10 10 13 16 16 21 26 28

3

The Choice of Themes: On Communication Strategies and Challenging Situations 3.1 Introduction and Methodology 3.2 Range of Themes Raised in the Reflective Writing Texts 3.2.1 Focus on the context of the encounter 3.2.2 Focus on the patient 3.2.3 Focus on the student or expert physician 3.2.4 Focus on the insights gained 3.3 Theme Distribution in the Three Corpora 3.4 Summary and Conclusions

30 30 31 33 36 40 42 45 49

4

Communication Skills in Action: From Keeping Eye Contact to Creating Rapport 4.1 Introduction 4.2 Teaching Communication Skills in Medicine at Basel and Nottingham v

1 1 3 8

51 51 51

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4.3

4.4 5

6

Quantitative Overview of Communication Skills 4.3.1 Methodology 4.3.2 The communication skills chosen for reflection, and their distribution Communicative Challenges: Discussion and Conclusions

Reflective Writing as Genre: A Text Linguistic Perspective 5.1 Introduction 5.2 Reflective Writing in Medical Practice and Theoretical Background on Genre 5.3 The Text Features of the Reflective Writing Corpus 5.3.1 Location 5.3.2 Topic focus 5.3.3 Visual aspects and layout 5.3.4 Length and structure 5.3.5 Discourse modes 5.3.6 Style and formality 5.3.7 Grammar 5.3.8 Lexis 5.3.9 Summary of text features 5.4 Evidence of Genre Mixing 5.4.1 Evidence of ‘reflection’ 5.4.2 Evidence of ‘narrative’ 5.4.3 Evidence of ‘medical case report’ 5.4.4 Other evidence of genre mixing 5.5 Summary and Conclusions Interpersonal Pragmatics in Reflective Writing 6.1 Introduction 6.2 Theoretical Background on Interpersonal Pragmatics and Relational Work 6.3 Evidence of Interpersonal Issues from the Theme and Communication Skills Analysis 6.4 Evidence of Awareness of Interpersonal Concerns 6.4.1 Raising awareness about the value of empathy and rapport 6.4.2 The presentation of self 6.4.3 The role of emotions 6.5 Emotions as a Challenge in Doctor–Patient Interaction 6.5.1 Emotion vocabulary 6.5.2 Emotions in context 6.5.3 Discussion 6.6 Summary and Conclusions

56 56 64 67 72 72 73 77 77 78 78 81 83 85 87 91 94 95 96 97 107 109 112 115 115 116 121 123 124 127 128 130 131 134 142 145

Content s

7

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Interpersonal Pragmatics and Identity Construction 7.1 Introduction 7.2 Definitions of Identity in Linguistics 7.3 Methodology 7.4 Distribution of Acts of Positioning within the Three Corpora 7.5 Acts of Identity Construction in Context 7.5.1 A student reflective writing text 7.5.2 Expert examples: Academic/scientist, mentor/educator and business person 7.6 Challenging Situations 7.7 Summary and Conclusions

148 148 149 152

165 167 170

8

Conclusions 8.1 Linguistic Insights Gained and Outlook 8.2 Potential Transfer to Teaching in the Medical Humanities

173 173 176

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Appendices 9.1 Consent Form and Questionnaire Basel 9.2 German Instructions for the Reflective Writing Task, Basel Corpus 9.3 English Instructions for the Reflective Writing Task, Nottingham Corpus 9.4 Spreadsheet for the Topic Analysis (Basel as Example) 9.5 Spreadsheet for Theme Analysis 9.6 Theme Catalogue, Ordered Alphabetically 9.7 The Basel Medicine Curriculum, Combining Social and Communication Skills (SOKO)

178 178

188

References Subject Index Author Index About the Author

190 201 203 206

157 160 160

181 182 184 185 186

Figures and Tables

Figures Figure 1.1 The interfaces between research disciplines that feed into this study

5

Figure 1.2 The focus of this book

7

Figure 2.1 Visualization of research design

13

Figure 3.1 Number of themes per text in the entire corpus

32

Figure 3.2 Number of themes per text according to the three sub-corpora (%)

32

Figure 4.1 The Calgary-Cambridge framework

53

Figure 4.2 Mention of different communication skills per text in percentage of appearance per text in all three corpora

64

Figure 4.3 Combined percentage for each corpus, indicating the weight of each communication skills group

65

Figure 5.1 The instructions for the Nottingham students

74

Figure 5.2 Text N-068 displays constructed dialogue, and no further sectioning other than paragraphs

80

Figure 5.3 Text B-04 displays section titles, subsections and constructed dialogue

80

Figure 5.4 Illustration of the layout of the columns ‘A Piece of My Mind’ (JAMA) and ‘On Being a Doctor’ (AIM)

81

Figure 5.5 Frequency clouds of the sub-corpora

93

Figure 7.1 Presence of acts of positioning in three corpora, ranked according to category viii

159

Figures and Tables

ix

Tables Table 2.1 The reflective writing corpus

17

Table 2.2 The Basel corpus

22

Table 2.3 The Nottingham corpus

25

Table 2.4 Expert corpus: 25 texts from JAMA and 25 texts from AIM, ordered according to record number 26 Table 3.1 Theme focus: Context of the encounter (ordered alphabetically)

33

Table 3.2 Theme focus: Patient (ordered alphabetically)

37

Table 3.3 Theme focus: Student/expert (ordered alphabetically)

40

Table 3.4 Theme focus: Insights (ordered alphabetically)

43

Table 3.5 Distribution of theme clusters in all three corpora

46

Table 3.6 Comparison of the thematic analysis of the reflective writing corpora (%)

47

Table 4.1 Basel SOKO curriculum for ‘social and communicative competencies’

55

Table 4.2 Clinical communication skills taught at Nottingham and Basel

57

Table 4.3 Examples of the tagged communication skills

58

Table 4.4 Occurrence of mention of communication skills in all three corpora

66

Table 5.1 The relation between text functions and text features

76

Table 5.2 MAT analysis (Nini, 2015a) showing the closest fit with a selection of text types for each dimension and the dimensional score

89

Table 5.3 The average scores of the frequency per 100 tokens of a selection of grammatical features in the Nottingham and Expert corpora and two of Biber’s (1988) genres

90

Table 5.4 MAT analysis showing which of Biber’s (1989) eight text types is the closest fit for each text

91

Table 5.5 The 30 top keywords, ordered according to their log-likelihood values and showing their frequency (using Wordsmith, 5% threshold)

92

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Table 5.6 Text features of the reflective writing corpus

95

Table 6.1 Theme focus on the patient and the student/expert

121

Table 6.2 Clinical communications skills tagged in the corpus (previously presented as Table 4.2)

123

Table 6.3 Planalp’s (1998) overview of emotional cues

135

Table 6.4 Dimensions of analysis of emotions within interpersonal pragmatics

144

Table 7.1 Author identity categories in all three corpora

152

Table 7.2 Presence of acts of positioning in the three corpora, ranked according to category (%)

158

Table 9.1 Codebook

186

Table 9.2 ‘Organ-based modules of the Basel undergraduate medical programme’

188

Table 9.3 Basel SOKO curriculum, ‘social and communicative competencies’

189

Acknowledgements

This book was made possible by the funding for the interdisciplinary project ‘Life (Beyond) Writing’: Illness Narratives (No. 126959, No. 144541, 2009–2013) from the Swiss National Science Foundation, to whom we are very grateful. I would like to thank the team members Franziska Gygax (literary and cultural studies), Alexander Kiss (medicine), Regula Koenig (linguistics) and Claudia Steiner (medicine) from the University of Basel, and Victoria Tischler (medicine/psychology) from the University of Nottingham for their collaboration on the project in general and their feedback on our sub-project in particular. Regula Koenig was employed as a project member in linguistics for the entire four years and has been especially instrumental in supervising the project’s coding tasks, without which many of the chapters of this book could not have been written. Although she moved on to non-academic pursuits in 2013 and was not involved in writing up the results of our study, I thank her for her excellent work and write in the first-person plural to acknowledge her contribution. The project is indebted to the English Department of the University of Basel for hosting the project and contributing to the funding of workshops and guest lectures that allowed us to discuss our ideas with Brigitte Boothe, Trisha Greenhalgh, Brian Hurwitz, Srikant Sarangi and Peter Schulz. We thank these scholars for their input and time. We would like to express our gratitude for the inspiring discussions started by the contributors to the symposium Narrative Matters in Literature, Linguistics and Medicine: Michael Bamberg, Brigitte Boothe, Lisa Diedrich, Franziska Gygax, Annette Kern-Stähler, Alexander Kiss, Gabriele Lucius-Hoene, Julia Notter, Femi Oyebode and Anna Thiemann. This symposium inspired a collection edited by Gygax and Locher, published in 2015 (Narrative Matters in Medical Contexts across Disciplines, John Benjamins). This project has also benefited tremendously from input from the students in the ‘Illness Narratives’ seminar, who helped develop research questions (Autumn term 2010): Cordula Berger, Ellen Brugger, Sarah Degen, Janine Meier, Anja Rohrer and Andrea Röthlisberger. We are grateful to the many interns from the Basel MA in Language and Communication, who dedicated many working hours to tagging and coding: Ellen Brugger, Olga Brühlmann, Florence Bühler, Evelyne Iyer-Grüninger, Dino Kuckovic, Nathalie Meyer, xi

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Ruth Partl and Andrea Wüst. Special thanks go to Janine Meier, whose pilot study in her MA thesis had an impact on how the genre analysis chapters in this study progressed, to Aline Bieri, Denise Kaufmann and Andrea Wüst, who helped with editorial checks, to Sixta Quassdorf, who translated some of the Basel examples, and to Jen Metcalf, who proofread the manuscript. Thanks are also due to Daria Dayter, who patiently and competently helped us with corpus linguistic challenges, and to Mirjam Weder, who compiled and generously shared a German reference corpus that allowed us to conduct a keyword analysis of the Basel texts. Our sincere thanks go to the Journal of the American Medical Association (JAMA) and the Annals of Internal Medicine (AIM) for giving us access to the doctors’ narratives that form one part of the data collected for this study, and to the many students who allowed us to access their reflective writing texts, which form the second part of our data corpus. We thank Alexander Kiss and Victoria Tischler, without whom there would not be any data to collect in the first place, and the general practitioners in Basel, who consented to the reflective writing task being written in connection with the students’ internships in medical practices. My gratitude goes to the co-authors and the reviewers of the following articles, which address issues expanded on and revisited in this study, and to the publishers for allowing us to reprint passages from them: Gygax, Franziska, Koenig, Regula, & Locher, Miriam A. (2012) Moving across disciplines and genres: Reading identity in illness narratives and reflective writing texts. In Rukhsana Ahmed & Benjamin Bates (eds) Medical Communication in Clinical Contexts: Research and Applications (pp. 17–35). Dubuque, IA: Kendall/Hunt. Locher, Miriam A. (2015) “After all, the last thing I wanted to be was rude”: Raising of pragmatic awareness through reflective writing. In Barbara Pizziconi & Miriam A. Locher (eds) Teaching and Learning (Im) Politeness (pp. 185–209). Berlin, Germany: de Gruyter. Locher, Miriam A. & Koenig, Regula (2014) “All I could do was hand her another tissue” – Handling emotions as a challenge in reflective writing texts by medical students. In Andreas Langlotz & Agnieszka Soltysik Monnet (eds) Emotion, Affect, Sentiment: The Language and Aesthetics of Feeling (pp. 215–236). Tübingen, Germany: Gunter Narr. Locher, Miriam A., Koenig, Regula & Meier, Janine (2015) A genre analysis of reflective writing texts by medical students: What role does narrative play? In Franziska Gygax & Miriam A. Locher (eds) Narrative Matters in Medical Contexts Across Disciplines (pp. 141–164). Amsterdam, Netherlands: John Benjamins.

Acknowledgement s

xiii

Since none of the above four papers worked on the entire reflective writing corpus, and the papers answer fewer questions than those tackled in this monograph, we hope the present text offers many new insights. Finally, my thanks go to Jo Angouri, editor of the new series Language at Work from Multilingual Matters, and to the anonymous reviewers for their helpful comments. All remaining faults are my own. Miriam A. Locher Basel, February 2017

1

Reflective Writing in Medical Practice

1.1 Rationale for this Book This book is about the linguistic analysis of written reflective writing texts that were produced in the context of medical education or medical practice. The texts were collected from medical students from the University of Basel and the University of Nottingham, and are supplemented by a corpus of texts written by doctors for columns published in medical journals. We1 explore what topics and communication skills the authors write about, how the narratives develop, how these texts are shaped, what genres influence their composition, how relational work surfaces in them and how the writers linguistically create their identities as experts or novices. We offer our analysis as a contribution to linguistic theory as well as to teaching in medicine. As linguists, we are interested in spoken and written texts of all shapes and with all kinds of functions. We therefore could not resist when, in 2008, Alexander Kiss, one of the medical faculty members who teaches communication skills to medical students at the University of Basel (Switzerland), approached my colleague Franziska Gygax (literary and cultural studies) with a corpus of texts he thought could be of analytical interest to scholars in the humanities. Kiss was referring to a task that all students had to fulfil in order to gain credit for their communication skills course: they had to write a text about an encounter/conversation with a patient that they had met during their internship at a general practitioner (GP) practice and who had made an impression on them. Reflective writing – texts written to critically examine one’s own practice, conduct or position – has been recognized as a valuable tool in teaching in the discipline of medicine for some time, but is still not widely used according to Branch and Paranjape (2002: 1185). For example, it is argued that introspection leads to greater awareness of what one has learnt (in this case, the communication skills strategies) and allows 1

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students to shape their analytical powers. Students are thus encouraged to use reflection to understand their new community of practice. Wald (2015) adapts Sandars’ (2009) definition of reflection, which captures this aspect of learning and future application: Reflection is a metacognitive process including connecting with feelings that occurs before, during, and after situations with the purpose of developing greater awareness and understanding of self, other, and situation, so that future encounters with the situation including ways of being, relating, and doing are informed from previous encounters. (Wald, 2015: 697; Wald added the italicized words to Sandars’ 2009 definition) Since both Alexander Kiss and Franziska Gygax were longstanding members of a committee in charge of organizing medical humanities events at the University of Basel, the potential of these texts for linguistic analysis quickly became apparent. The linguists joined the team and we decided to explore these texts in detail in order to learn from them for the development of teaching modules, and because the texts are interesting in their own right from a linguistic perspective. Locher, Kiss and Gygax designed an interdisciplinary project entitled ‘Life (Beyond) Writing’: Illness Narratives that combines literary analysis of life writing texts (autobiographies/novels), analysis of medical reflective writing texts as described above, and the transfer of these findings to teaching in the medical field. The Swiss National Science Foundation (SNSF) funded the project for four years from 2009 to 2013. This endeavour is outlined in greater detail in Chapter 2. This book is about the linguistic branch of the project and reports on the results of the analysis of the reflective writing texts. The corpus for this study consists of texts from three sources. The first is the Basel corpus which consists of reflective writing texts written in German by students at the University of Basel. We were fortunate to find a research collaborator in Victoria Tischler, who led the communication skills courses for medical students at the University of Nottingham, and who also included the reflective writing task in her curriculum. This resulted in a parallel corpus of reflective writing texts written in English by medical students at the University of Nottingham. These student texts are supplemented by a selection of texts published by doctors in the journal columns ‘A Piece of My Mind’ (the Journal of the American Medical Association, JAMA) and ‘On Being a Doctor’ (the Annals of Internal Medicine, AIM). The chosen texts fulfil the requirement of being reflective and about an encounter with a patient who made an impression on the writer. It is important to point out that none of the texts in our corpus was explicitly written for linguistic analysis; their function is either fundamentally educational or to invite professional introspection. This means that we have a corpus of naturally occurring data and can contribute to the study of language in use.

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1.2 Aim and Scope We position our study within the field of medical humanities and – generally speaking – within the linguistic area of discourse analysis, which draws on genre analysis and corpus linguistics. It is worthwhile taking the time to set out this interface. According to the extensive description published on the website of the Centre for Medical Humanities at Durham University in the UK (accessed 22 November 2012),2 the medical humanities can be defined as follows: ‘Medical humanities’ is the name given to a so-far rather diverse field of enquiry. Its object is medicine as a human practice and, by implication, human health and illness, and the enquirers are, basically, people working from the perspectives of humanities disciplines. Thus ‘medical humanities’ denotes humanities looking at medicine, looking at patients, and – crucially – looking at medicine looking at patients. The way medicine conceives and represents patients shows up in the way that it treats patients. Therefore ‘medical humanities’ isn’t the name of a further humanities discipline, but is simply the name of a field of enquiry, albeit a very significant and intriguing one. The disciplines actually involved in it are familiar humanities and social sciences disciplines, having in common both an interest in individual experience (which in this context means individuals’ experiences of health, illness, disability, diagnosis, treatment and care), and a recognition that subjective experience can be a legitimate source of knowledge. At present, history, literature studies, theology, anthropology and philosophy are prominent among the disciplines that engage in medical humanities. If they act separately and in isolation from one another, then ‘medical humanities’ is just a list. But it becomes far more interesting when these disciplines’ perspectives are combined [in] a genuinely interdisciplinary way. [A paragraph on medical ethics has been omitted]. In medical ethics, other humanities disciplines joined philosophy in looking for a richer way of tackling normative questions about what doctors ought to do. Similarly in ‘medical humanities’ a range of humanities disciplines join together in looking for more richly-textured ways of understanding medicine as a practice, and understanding health, illness and medical care in relation to individual subjective experience. One of the most interesting challenges in terms of interdisciplinarity will be to embrace biological scientists in co-enquiry with us as humanities scholars. Taking embodied human nature seriously in the medical context

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requires aspects of scientific literacy as well as existential literacy, and it requires bringing them together creatively. This is a challenging task but one that is worthwhile and important in the search for more realistic expectations of the contribution of medicine to human flourishing. Source: HME, March 2009.

The important points we can take from this description of the medical humanities3 are as follows: (1) it brings the perspective of disciplines from the humanities to medical practice as an object of study; (2) it calls for interdisciplinarity; and (3) despite extensive publications on the language of medical practice, the 2009 definition does not yet mention the discipline of linguistics. As Davis (2010) points out, there is indeed a longstanding tradition of looking at language and communication in doctor–patient or caretaker– patient interaction. Davis (2010) identifies four distinct groups of researchers who study language use in medical contexts: Linguists who study health discourse […] Clinical linguists are interested in understanding language so that they can more effectively treat those with language disorders. They form a branch of linguistics which can incorporate pragmatics, discourse, or sociolinguistic perspectives. They are medically-trained clinicians who work with people in the role of patient or client, seeking to remedy or ameliorate a particular language condition or disorder. Many clinical linguists are speech pathologists or audiologists who want to focus on the study of language qua language as well as on patient applications. Health communications studies specialists research the ways that language is used in (real-world) clinical settings from the disciplinary perspective of Communications Studies. They focus on both communications within healthcare and also about healthcare, targeting a range of audiences, which can include patients, healthcare and medical personnel, community members and policy makers. Finally, clinicians (medical practitioners such as doctors, nurses, etc.) form a fourth group. They include persons who are trained in clinical practice in medicine, nursing, dentistry, pharmacology, and the like and they study language in order to enact more effective care and achieve more favorable patient outcomes as a result of better communication. (Davis, 2010: 382, emphasis in original) Davis (2010: 382) goes on to say that, ‘[d]espite the fact that each of these groups studies language use in medical settings, the differences in their foci

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and ultimate research goals make the distinctions between them important’. At the same time, there is a lack of awareness of research results from the other disciplines. If we take this point up and add it to the research desideratum of interdisciplinarity quoted in the extensive definition of medical humanities above, it becomes apparent that the study of the linguistic aspect of medical practice that we will endeavour to explore in this book can only benefit from drawing on different research traditions. For our study of naturally occurring written data, we can eclectically draw on the traditions pursued in health communication studies, interpersonal pragmatics, discourse analysis, genre studies and stylistics, the study of narrative in various disciplines, and corpus linguistics (see Figure 1.1). Furthermore, it is important to acknowledge that the literature in linguistics that focuses on the study of face-to-face interaction and naturally occurring data has a long tradition of drawing on sociology and anthropology as propagated by conversation analysis and discourse analysis, and as developed in interactional sociolinguistics. In this project, we are of course dealing with written texts produced in a particular context. We look at the texts as a fixed product (in the sense that we do not witness their genesis), but are aware that the text itself is in dialogue with what came before and what comes afterwards. The student texts are triggered within an educational context and are explicitly about the past (i.e. an encounter with a patient in the context of an internship and the communication skills course) and are (at least in part) written for the communication skills instructor or GP. The expert texts also report on a past interaction and reflect on it for a professional peer audience. In addition, the subject the students and doctors write about is interactive and they are invited to reflect on communication skills. This allows us to draw not only on the literature on interaction and

Figure 1.1 The interfaces between research disciplines that feed into this study

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the negotiation of meaning in interaction, but also on traditions that deal with teaching communication skills in medical practice, with written narratives and with genre. We draw on the study of text types and genres in order to establish how best to classify the essence of reflective writing texts, acknowledging the contribution of corpus linguistics and cognitive linguistics for this field, and the influence of discursive psychology in the framework that is our inspiration for working on linguistic identity construction. We will elaborate in detail on the theoretical background and methodological steps in the individual chapters that deal with particular research questions. At this stage, we will simply say that our methodology is qualitative, in that the categories we work with (e.g. topic choice, identity categories, elements of narratives) are primarily interpretative and functional rather than formal and structural. In order to best capture the nature of our corpora, we use quantification whenever we can gain further understanding from this process, and we use traditional corpus linguistics methods whenever appropriate. Finally, we discuss our results and their potential for transfer to teaching with our collaborators Victoria Tischler (for the Nottingham data) and Alexander Kiss (for the Basel data). Since we are dealing with texts written by students and doctors on doctor–patient communication, our data might lead to false expectations. We should point out from the start that we are not concerned with the following list of issues, either because they are not our focus of study or because our data cannot answer them. This book is not about: • • • •

establishing whether students have poor English or poor German; establishing whether students write good or bad texts; establishing whether doctors can write aesthetically pleasing texts of literary quality; researching doctor–patient interaction by looking at the texts written by the students and doctors.

The first two points about the use and level of English and German are valid points of interest for applied linguists, but are not the focus of this study. Nor do we explore the more literary question of aesthetics. With respect to the last point, we should stress that we will identify the topics of the texts, but we will not take the rendition of events in the texts at face value as reports on ‘what really happened’. If we had wanted to study doctor–patient interaction in itself, we would have had to use an entirely different research design and, for example, use video-tapes and observations of the interactions as they unfold. In other words, the reported interactions of the present study cannot be used to establish how doctor–patient interaction works but rather how the writers reflect on interaction. This will offer valuable insights in itself.

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Figure 1.2 The focus of this book

We strongly believe that the texts available to us for research deserve to be studied in their own right from a linguistic perspective. We will systematically explore the areas mentioned in Figure 1.2, all of which we wish to contribute to on both a descriptive and theoretical level. This book is about: •

•

•

Genre analysis: In order to better understand the reflective writing texts, we will explore how we can best describe the function and form of these texts by drawing on a number of text types that might have influenced their production. Since ‘narrative’ is such a fundamental discourse unit for both medicine and daily life, we will pay special attention to highlighting the narrative elements in the texts. Interpersonal pragmatics: As suggested in Locher and Graham (2010b: 2), interpersonal pragmatics is especially interested in studying the interpersonal side of communication in situ. Working in particular with the concept of ‘relational work’, i.e. the work individuals invest in ‘the construction, maintenance, reproduction and transformation of interpersonal relationships among those engaged in social practice’ (Locher & Watts, 2008: 96), we are interested to see how the writers evoke norms of conduct and appropriateness and frames of expectations when describing the doctor–patient encounters. Linguistic identity construction: With first-person narratives in particular and reflective writing texts in general, writers have to position themselves within their texts vis-à-vis others. We are interested in how writers creatively employ language to create identities and in how they deal

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with the challenges this task poses. This research focus combines insights from genre analysis and the study of interpersonal processes, and thus constitutes a link between the research fields. These areas of research are introduced further in Section 2.2 and will be discussed in the book in a number of chapters as outlined in the next section.

1.3 Structure of the Book Chapter 2 explains the background to the project ‘Life (Beyond) Writing’: Illness Narratives so that the reader can better appreciate how literary analysis, linguistics and medicine joined forces. We then go on to introduce the linguistic project and to present the data sets for this project in greater detail. Chapter 3 addresses the first research question we will answer in this study: What do the authors of the texts choose to write about? Answering this question is important because it tells us what the authors consider to be worth writing about. The students are asked to reflect on a conversation/ encounter with a patient who made an impression on them, but are not given any further guidance that may restrict their choice. It is therefore interesting to see what the students choose to focus on in their texts and what the doctors choose to focus on in their journal columns. The knowledge gained here will be important for lecturers who are interested in seeing what the students and doctors consider noteworthy and reportable. Chapter 4 explores the following research question: What is the connection between the communication skills that the students were taught and those that are mentioned in the texts? The chapter thus makes a link between the teaching input and what the students make of the task, and also focuses on particularly challenging communicative situations. In Chapter 5 we discuss genre in order to gain a more in-depth understanding of the composition of the texts. The students are told that they will engage in ‘reflective writing’, and the doctors are also likely to have been exposed to this term before submitting their texts to the journals. Our research questions are thus as follows: What exactly is a ‘reflective writing’ text in our context? What other genres does this text type draw on? We assume that we will encounter hybrid texts which potentially draw on a number of other text types, such as the narrative, the medical case report, the essay or exam text and the drama text. Since ‘narrative’ is key to all three disciplines involved in this project (linguistics, literary studies and medicine), we pay special attention to the core (reportable) event that the writers choose to reflect on. Chapter 6 revisits the communicative situations and the communication skills mentioned in the texts, and asks the following: How does the relational

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side of communication, as discussed in interpersonal pragmatics, surface in the texts? While concerns about politeness and rudeness are not mentioned explicitly in teaching, relational issues appear as a primary concern for the students. Since emotions are key to interpersonal processes, we discuss their role in the texts in more depth. Chapter 7 continues the discussion of interpersonal concerns and introduces the topic of linguistic identity construction and positioning. Here we argue that the authors need to introduce the characters in their reports by means of language. In doing so, they make choices as to how to describe and position characters vis-à-vis others. The reflective writing task is quite challenging for the authors with respect to writing about their past actions and their present reflections on these past actions. We thus pose the following research questions: What evidence of relational work that results in identity construction can we discover? How do the students deal with the tensions that might arise when having to portray oneself in a negative or positive light in the past/present? This chapter will also allow us to make links to the narrative element of the reflective writing tasks discussed in Chapter 5, since character positioning is a crucial element of narratology. Finally, Chapter 8 discusses what we have learnt from this study and what it has added to genre studies (including narrative), the study of interpersonal pragmatics, and linguistic identity construction. We will also raise questions as to what lessons we have learnt regarding transfer to teaching and where to go from there.

Notes (1) Regula Koenig was employed as a project member in linguistics for the entire four years of the project funded by the Swiss National Science Foundation that is at the heart of this book. While she moved on to non-academic pursuits in 2013 and was not involved in writing up the results of our study, she was especially instrumental in supervising the coding tasks of the project, without which many of the chapters of this book could not have been written. For this reason, I write in the first-person plural to acknowledge her contribution to the project. See also the Acknowledgements. (2) See http://www.dur.ac.uk/cmh/medicalhumanities/ (accessed 22 November 2012). (3) Crawford et al. (2015: 1–2) argue that it is time to add the term ‘health humanities’ to the field, since it is more comprehensive and incorporates the study of the interface of all health-related professions and their interface with the humanities.

2

Context and Data

2.1 The SNSF Project ‘Life (Beyond) Writing’: Illness Narratives The growing interest in and awareness of the function and role of narratives in our lives has affected almost all academic disciplines and scientific research communities. The study reported in this book is part of a larger, interdisciplinary research project that was funded by the Swiss National Science Foundation (SNSF) from 2009 to 2013 and also has ‘narrative’ as its central theme. It is entitled ‘Life (Beyond) Writing’: Illness Narratives.1 It is worth explaining this title in detail. It refers to two key issues in our interdisciplinary research project: ‘life writing’ is an umbrella term (used in today’s autobiography studies) that illustrates the prominence and diversity of autobiographical writing (e.g. diaries, letters, essays, memoirs, photography and websites); our lives are permeated with life-writing texts. Inserting the preposition ‘beyond’ between ‘life’ and ‘writing’ alludes, on the one hand, to an author potentially living on in his/her text after his/her death, which is even more pertinent in a narrative recounting the experience of a terminal illness. On the other hand, ‘life beyond writing’ also refers to the fact that writing/telling a narrative always involves an interaction between writer and reader/listener, and that the ‘life’ of a vis-à-vis who is not writing is inherently present. ‘Narrative’ is a broad term and there are different schools of narrative analysis that mainly involve literary theorists, linguists and anthropologists. In spite of the many different definitions (for overviews, see Fludernik, 2009; Gygax & Locher, 2015b; Lucius-Hoene & Deppermann, 2004; Martinez & Scheffel, 2002), there is a general agreement, namely that a narrative must ‘involve the recounting of an event or events, […]. And second that these events can be either real or fictitious’ (Hawthorn, 2000: 225), or can even be projected, i.e. future stories (Georgakopoulou, 2007, 2013). Literary studies have traditionally explored issues of narrative, in particular related to prose texts. Any narrative text imposes an order on events (whether they are fictional 10

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or not) and is a representation that is never identical to the event it actually recounts. Linguistics, in particular the more recent branch of sociolinguistics and especially discourse analysis, has raised questions about the role of narrative in communication and the structure of oral narratives as well as about the emergence of small or even tiny stories (cf., for example, Dayter, 2016; De Fina, 2003; De Fina & Georgakopoulou, 2012; Georgakopoulou, 2007; Johnstone, 1990; Klapproth, 2004; Labov, 1972, 1997). In addition, narrative plays a crucial role in anthropological research. Numerous studies in literature, linguistics and anthropology have emphasized that narrative is one of the key constituents of human identity and self-representation. (The notion of ‘narrative’ in linguistics will be taken up in more detail in Chapter 5.) Medicine is another field in which narrative has always been crucial, since a patient visiting a doctor usually presents his or her medical problem in a narrative while the doctor listens to and interprets the ‘story’. In spite of the numerous stories being told to medical professionals, most doctors are not trained to interpret the patients’ stories as narratives or to be alert to specific uses of metaphors, narrative structures and other discursive signs. Only in recent years, in the fairly new field of medical humanities, has narrative become acknowledged as an issue that must be explored and theorized in depth. For example, literary scholars and professors of medicine, such as Rita Charon (Columbia University), have started to teach medical students how to read narratives and have established curricula in narrative medicine. In addition to courses on literary topics in connection with illness, the curricula also cover philosophical themes, the arts, and courses that teach medical students to write about their own experiences (cf. Alderson & Bateman, 2002; Charon, 2006, 2014; Greenhalgh, 2006; Greenhalgh & Hurwitz, 1998; Hawkins & McEntyre, 2000). Within this field, scholars such as Hunter (1991) and Hurwitz (2006, 2010) point to the fundamental narrative core of the medical case report and its importance in medical practice – of which practitioners are often not aware. The interdisciplinary research project ‘Life (Beyond) Writing’: Illness Narratives comprises the disciplines of literary and cultural studies, linguistics and medicine, and is built on three pillars. The first pillar is the literary and cultural approach, which provides insights into the complex representations of illness in literary narratives and deals with the cultural and social constructions of illness. The numerous literary illness narratives published in the past 30 years have initiated debates and theories about this genre. Of course, people – above all, writers – have always written down their experiences of illness, but the last three decades have seen an unusually high number of these publications. Examples of such texts are Audre Lorde’s (1996 [1988]) A Burst of Light, Sandra Butler and Barbara Rosenblum’s (1991) Cancer in Two Voices, Gillian Rose’s (2011) Love’s Work, and Harold Brodkey’s (1996) This Wild Darkness (discussed in Gygax, 2015a). Since many of these texts are autobiographical, the field of autobiography studies has become influential in

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theorizing and exploring the specificities of illness narratives. Moreover, apart from analyzing the cultural and social contexts of such narratives, it is also important to investigate the medical issues and in particular the ways in which the patient/autobiographer writes about them. The results can be used to bridge the gap between the patient’s personal experience of illness and its (bio)medical dimension. Furthermore, literary narratives, with their powerful aesthetic impact, do more than just mirror the experience of a patient/autobiographer; such narratives always contain imaginary realms which hint at a potential of humankind that can often only be expressed through art. The aesthetics of literary texts can express matters that are otherwise hidden from us but nevertheless reveal insights into human experience – such as illness. Using this insight in medical communication facilitates a more holistic approach to illness and improves the relationship between patient and doctor. Franziska Gygax is the principal literary studies scholar working on this project. Her discussions and interpretations have been published in Gygax (2013a, 2013b, 2015a, 2015b) and her input also helped shape the linguistic part of the project. Further scholars who have provided the project with input from a literary and cultural studies perspective are Brancher (2015), Diedrich (2015) and Kern-Stähler and Thiemann (2015). The second pillar is the linguistic analysis of narratives written by thirdyear medical students from the University of Basel on an encounter with a patient who particularly impressed them (which they all have to write after completing intensive communication skills training), and the study of comparative corpora of such texts written in English by second-year students from the University of Nottingham. The insights offer crucial information about the specific ways in which future doctors respond to and interpret a patient’s narrative and reflect on their own situation and responses. This corpus is supplemented by a number of texts by professional practitioners, who reflect on their working experience in the journal columns ‘A Piece of My Mind’ ( Journal of the American Medical Association, JAMA) and ‘On Being a Doctor’ (Annals of Internal Medicine, AIM). Just as in the case of the analysis of literary narratives, the reflective writing corpora thus consist of written texts that have been carefully composed and reflected on by their authors. As already outlined in Section 1.2, the areas of (1) genre analysis, in particular narrative, (2) interpersonal pragmatics, and (3) linguistic identity construction will be explored in detail. For the third pillar, the results of the linguistic and literary analyses were discussed with Alexander Kiss (University of Basel) and Victoria Tischler (University of Nottingham), both of whom are involved in communication skills training for medical students and in the medical humanities courses at their respective medical schools. The purpose of the discussion was to use the results to reflect on current and future training in communication skills for both medical students and practising doctors. We thus hope that our results will have a practical benefit for the medical humanities.

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Figure 2.1 Visualization of research design Notes: Horizontal arrows = interdisciplinary exchange; vertical arrows = flow of results.

Figure 2.1 shows the three research pillars that make up the project ‘Life (Beyond) Writing’: Illness Narratives. • • •

Pillar I. Autobiography and illness (discipline: literary and cultural studies). Pillar II. Written reflections on doctor–patient interactions by medical professionals (discipline: linguistics). Pillar III. Application of literary and linguistic insights to medical teaching (discipline: medicine).

During the research process, which ran from 2009 to 2013, the three teams were in constant contact in order to develop research tools and methodologies, and to discuss results. The focus of this book is on the second, linguistic pillar of this project. While we will briefly mention how the results of our project can be transferred to teaching in the medical schools (transfer to Pillar III; see also Kiss & Steiner, 2011; Oyebode & Tischler, 2015), we refer the reader to Franziska Gygax’s (2013a, 2013b, 2015a, 2015b) publications on the literary aspect of the project, and to our joint work on the interdisciplinary interface (Gygax & Locher, 2015b; Gygax et al., 2012, 2013).

2.2 The Linguistics Project and its Three Theoretical Fields As previously mentioned, this study will look at reflective writing texts from medical practice in order to yield results for three main research

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interests: (1) genre analysis, (2) interpersonal pragmatics, and (3) linguistic identity construction. In addition, we hope that, by improving teaching materials for doctor–patient communication, some of the results will flow back into the medical practice from which the texts were collected. The linguistics project draws on literature from all of these topics and combines this reading in a meaningful way. The study of genre is particularly pertinent for our data sets. While reflective writing can be defined as texts that are written to critically examine one’s own practice, conduct or position (Branch & Paranjape, 2002: 1185; Wald, 2015: 697), and that generally describe an event, reflect on it and draw a conclusion (Hampton, 2010a, 2010b; Watton et al., 2001), how these parts develop is less straightforward. We follow Busse (2014a, 2014b) and Bax (2011), who point out the fuzzy boundaries of genres that are characterized by intertextuality (see Chapter 5 for further information). The student texts are the result of a written task that the students had to complete for their communication skills instructors or for the doctors in whose GP practice they did their internship. From the outset, we can formulate a number of expectations about which text types might influence the composition of these texts, which ultimately end up as hybrid texts. For example, we can argue that the student writers have evaluation in mind when composing their texts and thus orient their writing towards the instructor as an addressee. Since they are required to reflect on past experience and communication behaviour, we expect there to be reflective elements. As students have a great deal of experience with exam situations and essay writing, we might find elements that lean towards these two models. The students receive a detailed set of instructions that asks them, for example, to use constructed dialogue (see Section 2.3). For this reason, elements of playwriting might emerge. Since we are dealing with medical practitioners, we assume that the case report text type might play a role when patients are introduced. Finally, we argue that narrative resurfaces throughout the texts and thus deserves particular attention. In linguistics, ‘narratives’ have been intensely studied since the 1970s after the seminal work of Labov, Fanshel and Waletzky (Labov, 1972, 1997; Labov & Fanshel, 1977; Labov & Waletzky, 1967). While early approaches focused on identifying structural elements and patterns of everyday narratives (i.e. the syntax of narrative), current research has stressed the importance of the narrative of personal experience as a fundamental human discourse unit. It allows individuals to make sense of what is happening to them by drawing analogies and by transforming their experiences into stories, which crucially entail an element of evaluation (e.g. Johnstone, 1990; Klapproth, 2004). Klapproth (2004: 103) maintains that narratives actually serve two main functions: (1) a cognitive need: ‘narratives are a means of structuring and processing personal human experience’; and (2) a social need: ‘narratives are a means of communicating such experience to others and thus

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sharing it’ (emphasis in original). Current research has also moved away from studying only oral, personal-experience narratives, so the actual definition of what linguists consider a narrative has become somewhat blurred (Dayter, 2016; De Fina, 2003; De Fina & Georgakopoulou, 2012; De Fina & Schiffrin, 2008; Georgakopoulou, 2007). While the data in this study cannot be classified as traditional (oral) personal-experience narratives, the texts can nevertheless be studied as transformations of past experience and reflections on this experience which often include projections of future (changed) behaviour. This means we can apply the tools that have been developed in narrative analysis over the last decades, and discuss to what extent the texts do or do not qualify as narratives in their own right and to what extent they exploit our expectations about narratives. Our exploration of genre and the particular text types evoked will allow us to achieve a better understanding of the creative ways in which the students complete the assignment. The same questions will be raised for the columns written by the doctors, who have a different target audience, i.e. their expert peers, and who are familiar with the format of the journal columns. Our corpus also lends itself to exploration from an interpersonal point of view. We are interested in studying the described interactions in terms of their incorporation into the norms of particular social practices (e.g. the communities of practice approach, Eckert & McConnell-Ginet, 1992a, 1992b; Wenger, 1998). This study will therefore investigate how particular norms and obligations that are tied to the interactants’ understanding of the moral order and their roles in the contexts described surface within the texts. Furthermore, many of the texts focus on situations that are challenging from a communicative point of view and evoke strong emotions, which means that adopting an interpersonal pragmatics perspective is particularly suitable. For this purpose, we can also draw on the extensive literature from linguistic and health communication studies that has dealt with face-to-face interactions between doctors and patients or between health professionals and lay persons, that has looked at communication in e-health contexts (e.g. Davis, 2010; Locher, 2006; Pilnick, 1999; Sarangi, 2010; Sarangi & Clarke, 2002; Silverman & Peräkylä, 1990; von Raffler-Engel, 1989) and that has discussed narratives from an interpersonal perspective in health contexts in particular (e.g. Harrison & Barlow, 2009; Kouper, 2010; Labov & Fanshel, 1977; Semino et al., 2014; Thurnherr et al., 2016). Identity construction is another focus of linguistic research that has been studied in relation to narratives as well as independently (e.g. Bucholtz & Hall, 2005; De Fina, 2003; Locher, 2008). In these recent discourse studies, identity is seen as ‘intersubjectively rather than individually produced and interactionally emergent rather than assigned in an a priori fashion’ (Bucholtz & Hall, 2005: 587). This means that we take identity as emergent in the texts we study and can thus focus on the use of linguistic strategies to create identities of, for example, students, doctors, experts, novices and patients.

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Since this understanding of identity construction is fundamentally interpersonal, and since we are looking at written texts of a reflective nature, we will combine insights from the first two fields of exploration with the study of identity construction. This outline of the three fields in linguistics to which this study aims to contribute is of course brief and incomplete. It serves merely to illustrate how the linguistics part of the SNSF project positions itself. More thorough introductions to the theoretical underpinning of the fields and concepts, and to the methodological steps used to answer the research questions, are given in each chapter. Our next step is to describe the data sets with which we work in all analytical chapters.

2.3 The Data Sets There are several data sets for this study: Basel, Nottingham (I & II), and the expert texts. In all sub-corpora, medical students (novices) and medical professionals (experts) reflect in writing on an interaction with a patient. They transform a past experience into a written text and submit this text to a readership. This target readership differs somewhat. The expert texts were written for a general public and fellow experts, and were published as columns in medical journals. In the case of the Basel texts, the reflective writing exercise is a required part of a university assessment within the medical humanities. The Nottingham students submitted their texts to their medical communication skills teacher, who collected the texts specifically for our project. The student texts have a clearly reflective and didactic function, whereas the expert texts have a reflective and peer-sharing function. The students expressly agreed to be part of this study, and we have approval from the journals to study the columns for research purposes. All student and patient names have been rendered anonymous.2 In the case of the expert texts, we provide the author names to acknowledge the published nature of the columns. Table 2.1 shows that our corpus consists of 278 texts (338,543 words) and gives an overview of its composition. The following sections explain the collection process and characteristics of the sub-sets.

2.3.1 Basel (2011) As explained in the introduction, the starting point of this project was the Basel reflective writing task that medical students in their third year (ca. 22 years of age) were asked to produce on a memorable doctor–patient interaction during their internship at a GP practice. This resulted in the interdisciplinary project discussed here. The instructors of the compulsory communication skills course took advantage of the fact that the students were engaged in an internship at a GP practice during the same semester. This made it easy to ask

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Table 2.1 The reflective writing corpus

Total words Mean Standard deviation Max. words Min. words No of texts

Basel Nottingham I (2011) (2010)

Nottingham II (2011)

Expert texts JAMA and AIM (2009–2010)

Total

26,301 674 178 1007 265 39

141,671 1300 438 3041 397 109

62,534 1251 377 1904 526 50

338,543

108,037 1350 372 2695 356 80

278

them to reflect on what they had learnt with respect to communication skills taught in the course and in light of their own growing experience. However, in 2009, just after the project had been granted funding and was getting ready to start the first data collection, the medical curriculum in Basel changed, moving the internship to a later semester and thus separating the communication skills course from the practical experience. Since the medical humanities committee of the University of Basel was reluctant to drop the reflective writing task – having recognized its value for practitioners in training – it was made a compulsory part of passing the internship (rather than the communication skills course). As a result, our data collection was delayed by one year, which means that there is only one set of Basel texts rather than the two in the case of the Nottingham corpus (see Table 2.1). The students submitted the texts electronically to the faculty of medicine, where the communication skills unit was in charge of checking and keeping track of the assignments. They were also encouraged to discuss their reports with their GPs. When the students submitted their texts in April and May 2011, they were at the end of their fourth year of a six-year medical degree (three years for a Bachelor of Medicine, plus three years for a Master of Medicine). In Basel, students experience encounters with patients through a training programme called Lernen am Projekt (‘learning on the project’), where they visit different institutions in small groups in their first year of Bachelor studies and then write reports. Regular clinical student–patient interaction starts from the fourth year of studies (first year of the Master’s) within the scope of what is called a one-to-one tutorial in a GP’s office. Students are required to work at and actively participate in the GP practice for half a day per week during a six-month period. Students also need to meet requirements in various communication skills modules that consist of lectures and small group learning sessions over four years from the start of the first Bachelor’s year to the end of the first Master’s year (Kiessling & Langewitz, 2013; see also Section 4.2 and Appendix 9.7). One module consisted of a reflective writing

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task, which was then attached to the GP internship, as explained above. In 2011, the reflective writing task asked students to write about an encounter with a patient who made a particular impression on them (in German: eine Begegnung mit einem Patienten, der Sie besonders beeindruckt hat). The exact formulation of the task changes every year. During their communication skills training, students are confronted with various medical scenarios in which they practise social and communicative skills and learn the following: how to manage emotions effectively, deliver information, summarize and reflect on information, handle patient deaths, conduct general communication (medical history), structure information, speak to third parties, conduct patient-centred communication, and handle declarations of consent (describing and presenting content, and obtaining consent). During the communication skills training course and the internship, students can practise various methods that include role playing and consultations with simulated and real patients. Students are video-recorded on several occasions with the aim of discussing their behaviour and performance, and of providing them with feedback from professionals. Every academic year, students take Objective Structured Clinical Examinations (OSCEs) on various communication tasks (see Kiessling & Langewitz, 2013). The students were given fairly detailed instructions for the reflective writing task. They received them before their internship started, both in electronic form and during an information meeting. They were asked to submit their texts electronically to the medical faculty and the supervising GP. If they wanted to be part of our study, they had to fill in a consent form and a questionnaire about themselves, providing information on their first and second languages and location of upbringing (see Appendix 9.1 for the consent form and questionnaire). Overall, 39 students agreed to be part of this study (about 30% of the entire year). The instructions read as follows in the translated English version (the German original can be found in Appendix 9.2). Instructions for Reflective Writing Learning targets: – Precise observation of an encounter with a patient – Precise description of the situation – Independent reflection on the encounter – Conclusions about future contacts with patients Reflections on the communication with a patient who made a lasting impression The questions below are meant as guidelines for the compilation of the reflective writing texts.

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Situation: * Describe the patient (age, relevant diagnosis, first impression – appearance, posture, language, anything else noticeable, etc.). * Describe in which context the encounter took place (what was the reason for the encounter?). * Describe what you talked about by using verbatim speech (the exact words) as much as possible. If you cannot remember the exact wording, reconstruct the dialogue for the crucial moments as well as possible. * Describe how you felt after the encounter. Reflection: The following questions should help you to structure your reflections. * The uniqueness of the encounter (a) Why do I remember this particular encounter so well? (b) What was so special about the patient or my behaviour that I remember it so well? * Communicative aspects (a) Did I communicate with the patient as I intended to? (b) Did the conversation proceed as planned? (c) If yes, why and in what ways have I achieved this? (d) If no, what went wrong and what could I have done differently? Conclusions: * What have I learnt from this encounter? * What would have helped me to manage/shape the encounter in a better way? * What aspects of my behaviour and language will I change in order to improve my next encounter with a patient with a similar problem? Hints for writing the text Please anonymize the names of all parties involved. For crucial moments in the conversation, indicate reported speech in the following way: Mrs. XY: ‘and none of the doctors told me anything about a mistake; they wanted to simply not talk about it and I now have to suffer for it. That’s outrageous, isn’t it?’ Student: Mrs. XY:

‘You are very angry, aren’t you?’ ‘Yes, of course I am! If they had properly told me and had apologized, it would have been only half as bad.’

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Mrs. XY:

‘… and then the surgeon said it will be all my fault if the operation won’t succeed; as I didn’t have the best conditions, and being so overweight, the situation is always difficult.’

Student:

‘yes, a doctor shouldn’t say anything like this.’

[Administrative pointers] The instructions begin by indicating the students’ general learning targets, which are to draw conclusions for future behaviour after having precisely analyzed a past communicative encounter. The guidelines then ask students to think back to an encounter with a patient who made an impression on them. The students need to describe the situation and the interactants involved. They are explicitly invited to use constructed dialogue in order to evoke the past situation, and there is also a passage that gives guidelines on how to present constructed dialogue on the page. The second element of the task is reflection. They are encouraged to discuss why the patient and situation was unique and thus to judge it, and also to particularly focus on the communicative aspects of the situation and their own behaviour. The final element is to ensure transfer to the present. The students should reflect on what they have learnt, how the situation could have been handled better or differently, and what they would change in the future if a similar situation were to occur. Note that the pointers on how to present constructed dialogue include a passage that describes a problematic experience (while the ‘patient who left an impression’ is not described in a positive or negative manner in the instructions). The guidelines end with administrative pointers on how to handle the submission of the text file. In order to learn more about the students, we asked them to answer a number of brief questions. In addition to enquiring about gender and age, we were particularly interested in their first language(s). We also wanted to know whether the students grew up and were socialized in a Germanspeaking (Swiss) context. This was relevant to us for our qualitative close reading in case the students made ‘culture’ a topic. A translation of the relevant part of the questionnaire reads as follows: 3. Languages Here we want to know more about your linguistic background. 3.1 What mother tongue(s) do you speak? Ticking several options is possible: ⚪ ⚪ ⚪

High German Swiss German (Dialect) French

⚪ ⚪ ⚪

English Spanish Serbian

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3.4 3.5 3.6

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⚪ Italian ⚪ Croatian ⚪ Rumantsch ⚪ Bosnian ⚪ Other If you have chosen ‘other’, please specify: ________________ What other languages do you speak? (Second language, e.g. learned at school or abroad)? Ticking several options is possible: [same selection as in 3.1] If you have chosen ‘other’, please specify: ________________ If German is NOT your mother tongue, for how many years have you been speaking it? In years: _______________________ Where did you go to school? Indicate cantons or countries: ____________________________

Table 2.2 gives an overview of the main results from the questionnaire. We can see that 69% of the students who agreed to be part of the study are female; 87% of the students are between 22 and 24 years of age, and 13% are 25 or older. When looking at their first languages, 95% of the Basel cohort is German-speaking; only two people indicated that they did not have German among their first languages. This very homogeneous picture is also supported by the fact that all but two of the German-speaking students grew up in a German-speaking environment. Six students listed French as a first language. English was listed twice, and Armenian, Malayalam, Italian and Spanish were each listed once. Thirty students only selected one option as a first language, thus portraying themselves as monolingual, while 16 students are bilingual and one student is trilingual.

2.3.2 Nottingham I (2010) and II (2011) We were fortunate to find a collaborator in psychologist Victoria Tischler, who had been teaching communication skills to first- and secondyear medical students at the University of Nottingham for some years, and who has been working at the interface of health/medicine and arts for a long time (see, for example, Crawford et al., 2010, 2015; Mills et al., 2014; Oyebode & Tischler, 2015; Tischler, 2010, 2015; Young et al., 2015). Since her students also do attachments in GP practices and interact with patients during regular hospital visits, Tischler agreed to use the reflective writing task in her course in order to improve and consolidate knowledge about communicating with patients. The task was optional for students as they already had other tasks3 to complete for assessment purposes. The texts were uploaded to the same official electronic submission portal as for regular university assessments, and were dealt with by the same communication skills teacher (Tischler).

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Table 2.2 The Basel corpus Basel (n = 39)

n=

%

Male Female Age 22 Age 23 Age 24 Age 25 +

12 27 10 11 13 5

31 69 26 28 33 13

What mother tongue(s) do you speak? Ticking several options is possible: Armenian 1 English 2 French 6 German (both H + D)* 37 Italian 1 Malayalam 1 Spanish 1

3 5 15 95 3 3 3

Monolingual (excl. H/D difference)* Bilingual Trilingual

77 41 3

German for 0–5 years German for 6–10 years Grew up in German-speaking country Grew up elsewhere n.a.

30 16 1 1 1 34 4 1

85 10 3

*High (Standard) German and Swiss German (dialect) were conflated. We gave the students the option of choosing between High German (i.e. Standard German) and the Swiss German dialect because many would identify more with the dialect when asked about their first language. Of the 37 German speakers, four selected both options, two selected only High German, and 31 picked only the dialect.

When the students submitted their texts, they were in their second year of a five-year medical degree (three years for a Bachelor of Medical Sciences [BMedSci], plus two years for a Bachelor of Medicine, Bachelor of Surgery [BMBS]). They had had clinical interaction through an attachment at a GP practice and during regular hospital visits. Prior to the writing task, they had completed a clinical communication skills module in the first year of the course. This first module introduced them to reflective writing and asked them to identify types of communication skills from a transcript of an interview they had conducted and audio-recorded with a patient at the GP practice. They reflected on the communication skills they used, the impact that

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these had on the interaction with the patient, and any implications for their clinical communication in the future. In the second clinical communication skills module, during which they produced the reflective text, students were introduced to more challenging forms of communication (e.g. communicating with patients with mental health problems, learning difficulties or hearing impairment, and explaining medical information to lay people). The sub-corpora Nottingham I (n = 80) and II (n = 109) from 2010 (34% of 238 students) and 2011 (43% of 256 students) resulted in a total of 189 texts written in English.4 The English translation of the Basel instructions from 2009 were taken as a template for producing the texts. There are some minor differences in the arrangement of wording compared to the Basel 2011 version, but the students are expected to complete the same task overall.

Reflections on communication with a patient Instructions: Think about which conversation/encounter with a patient impressed you most. The questions listed below will help you to structure your thoughts about this encounter from memory. Those questions marked with an * must be addressed. The other questions can be chosen if relevant to the specific context of the described situation. Before you start writing up your text, write down everything that you remember about the encounter. Then you can proceed according to the points listed below. Situation: [equivalent content as in Basel, see above] Reflection: The following questions should help you to structure your reflections. [equivalent content as in Basel, see above] Aims: [equivalent content as in Basel, see above] Hints for writing the text For crucial moments in the conversation, indicate reported speech in the form of drama dialogue: [same example, see above] How did I feel during the conversation and afterwards? For example: I was absolutely crestfallen afterwards. During the conversation, I never knew what was okay to say. Am I allowed to criticize a surgeon? Did he really say what the patient reported, or is this only the patient’s version? Was it

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wise to encourage the patient to speak more about her experience or should I have stopped it? I didn’t dare put an end to it because I didn’t want to appear like yet another ‘bad doctor’. What would I change for the next interaction? … [Administrative pointers] The main difference is in the introductory paragraph, which gives more information on how to organize the writing process. There is an additional paragraph under Hints for writing the text that shows how the task describe how you felt after the encounter could be addressed, using a problematic encounter as an example. The questionnaire on linguistic background (submitted together with the consent form) shows that 63% of the Nottingham contributors were female, and 92% were aged between 19 and 21 (Table 2.3). The list of languages to choose from was adapted for Nottingham to include English, Arabic, Bengali, Cantonese, French, German, Greek, Hindi, Japanese, Malay, Mandarin, Punjabi, Urdu and Welsh – in order to reflect the more international composition of the Nottingham cohorts. The students were able to add further languages. Eighty-eight percent of the students gave English as one of their first languages. The other first languages include European languages, but, importantly, also many Asian and some African languages. Table 2.3 The Nottingham corpus No I (n = 80)

%

No II (n = 109)

%

No I + II (n = 189)

Male 25 31 44 40 69 Female 55 69 65 60 120 Age 18 1 1 1 Age 19 26 33 30 28 56 Age 20 34 43 55 50 89 Age 21 14 18 15 14 29 Age 22+ 2 3 5 5 7 n.a. 4 5 3 3 7 What mother tongue(s) do you speak (ticking several options is possible)?: Arabic 3 4 1 1 4 Bengali 1 1 1 Bulgarian 1 1 1 Cantonese 3 4 1 1 4

% 37 63 1 30 47 15 4 4 2 1 1 2

(Continued)

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Table 2.3 The Nottingham corpus (continued) No I (n = 80) Dhivehi English French German Greek Gujarati Hindu Hokkien Ibu Japanese Konkani Korean Malay Mandarin Portuguese Punjabi Russian Sinhala Swahili Tamil Telugu Thai Urdu Welsh Bilingual Trilingual More than four English for 0–5 years English for 6–10 years English for 11–15 years English for 16–20 years Grew up in UK only Grew up elsewhere n.a.

%

66 1 1

83 1 1

2 1

3 1

1 1

1 1

1 3 1 1 2 1

1 4 1 1 3 1

2 2

3 3

9 1 1 3 1 3 8 67 8 5

11 1 1

84 10 6

No II (n = 109)

%

No I + II (n = 189)

%

1 100

1 92

1 3 3 1

1 3 3 1

1

1

5

5

1 2

1 2

1 2 4 1 5 3 1 40 2 1 1 5 2 5 92 15 2

1 2 4 1 5 3 1 37 2 1

1 166 1 1 1 5 4 1 1 1 1 1 8 1 2 4 1 1 2 4 1 7 5 1 49 3 2 4 6 5 13 159 23 7

1 88 1 1 1 3 2 1 1 1 1 1 4 1 1 2 1 1 1 2 1 4 3 1 26 2 1

84 14 2

84 12 4

The percentage of people who identified themselves as multilingual is 26 for bilingual, two for trilingual and one for more than four languages. Of those who identified English as not belonging to one of their first languages, only four students had between zero and five years of learning, while all others identified as having had six or more years of schooling in English. Eighty-four

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percent reported having grown up in the UK, meaning the vast majority of the students in this study were familiar with British interactional norms.

2.3.3 Expert texts (2009–2010) The texts written by students are supplemented by a comparable subcorpus of reflective writing texts written by health professionals. With the permission of the journal editors, these texts were taken from the archives of two well-established medical journals that include a medical humanities perspective. The Journal of the American Medical Association (JAMA)5 has been running the column ‘A Piece of My Mind’ as one of its many subsections since 1980. ‘On Being a Doctor’ is the second column from which texts were selected. It is published in the Annals of Internal Medicine (AIM),6 which has been running the column since 1990. The texts in both columns are generally submitted by health experts/physicians and report on personal experiences related to medical practice. The topics reflected upon in these texts are wide ranging and include reflections on ethical dilemmas, doctors being in the role of patients, doctors whose children are ill, and doctors reflecting on encounters with patients who made an impression on them. In order to keep the selection as comparable to the students’ texts as possible, we chose (1) only columns that contained a reflection on an encounter with patients who made an impression, and (2) texts written by physicians. From the columns published in 2009 and 2010, we selected 25 each from AIM and JAMA, and aimed for a balance between male and female contributors. As a result, we have a sub-corpus of texts written for the wider health professional community (as opposed to the communication skills instructor, the research team, or the GP responsible for the internship in the case of the student texts) and from an experienced health professional perspective (rather than that of a novice). Table 2.4 gives an overview of the 50 texts published between 2009 and 2010 that were selected for analysis. Table 2.4 Expert corpus: 25 texts from JAMA and 25 texts from AIM, ordered according to record number Corpus-#

Article title

Journal

Year

Vol.

Sex

E-01 E-02 E-03 E-04 E-05 E-06 E-07 E-08

The Tyranny of the Measuring Cup Take the Rabbits Giving Up Beyond the Numbers My Father’s Voice Why Geriatrics? Advice Quite by Chance

JAMA AIM JAMA JAMA JAMA AIM AIM AIM

2009 2009 2009 2009 2009 2010 2010 2010

301 151 301 301 301 152 152 152

m m m m m f f m

(Continued)

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27

Table 2.4 Expert corpus: 25 texts from JAMA and 25 texts from AIM, ordered according to record number (continued) Corpus-#

Article title

Journal

Year

Vol.

Sex

E-09 E-10 E-11 E-12 E-13 E-14 E-15 E-16 E-17 E-18 E-19 E-20 E-21 E-22 E-23 E-24 E-25 E-26 E-27 E-28 E-29 E-30 E-31 E-32 E-33 E-34 E-35 E-36 E-37 E-38 E-39 E-40 E-41 E-42 E-43 E-44 E-45 E-46

The Birthday Gift What Bugs You? Can We Agree to Disagree? A Gift of Time Curtains Going Home A Party Before Dying Don’t Touch Me Jobs The Heart of the Matter Morning Rounds in the Neighborhood A Paucity of Physicians More Things in Heaven and Earth The Other Person A Family Affair – Revisited Final Visit Do Something Disclosure [1] Identity Theft Letter to a Father in Jail Jade Fresh Eyes Disclosure [2] With Appreciation Lost in Translation A Mother in Haiti Worn Part-time Medicine The First Wake Exposing Physicians Dying to Talk Honor, Home, Heritage, and HIV The ‘Right’ to Fall The Long Goodbye Inshala The Name of a Champion Fault The Show

AIM AIM JAMA JAMA JAMA JAMA AIM JAMA JAMA JAMA AIM JAMA JAMA JAMA AIM AIM JAMA AIM AIM JAMA AIM AIM JAMA JAMA AIM AIM JAMA JAMA JAMA AIM JAMA AIM JAMA AIM AIM AIM AIM AIM

2009 2010 2009 2009 2009 2009 2010 2009 2009 2009 2010 2009 2009 2009 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2009 2010 2010 2009 2009 2009 2009 2009 2010 2009 2009 2009 2009 2009

150 153 302 302 302 302 152 302 302 302 152 302 302 302 152 152 303 152 152 303 153 153 303 303 150 153 303 301 301 150 301 150 303 150 150 150 150 151

f f f f m f m m m m f m m m m f f m f m f f f m m f f f f f f m f f m m m m

(Continued)

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Ref lec t ive Wr it ing in Medical Prac t ice

Table 2.4 Expert corpus: 25 texts from JAMA and 25 texts from AIM, ordered according to record number (continued) Corpus-#

Article title

Journal

Year

Vol.

Sex

E-47 E-48 E-49 E-50

Taking Responsibility for Lung Cancer Red Sox Cap Hope A Role in Transition

AIM JAMA JAMA AIM

2009 2010 2010 2009

151 304 304 151

f f f m

2.3.4 Caveats and rationale for comparisons When comparing the Basel and Nottingham sub-corpora, it is clear that we do not have ideally matched sets of texts. For example, the education systems are not exactly the same in Basel and Nottingham. The Basel students are older and more homogeneous with respect to their cultural and linguistic background than the UK students are. The sets of student instructions are not ‘verbatim’ translations in all aspects. We have no comparable background information on the health professionals who wrote the reflective writing columns in the journals. Also, the experts engage in a somewhat different task when writing their columns, i.e. they are not writing for evaluation or a project, but rather to share their experience with the professional community. However, we believe that the situation in which the different authors write permits comparison on some levels. In the case of the students, we are dealing with beginners in the medical profession. They have had basic training in applying communication skills, and have had their first experiences of interacting with patients. The health professionals also write about an encounter/situation that left an impression on them; otherwise they would not have chosen to write about it. We have made sure that the situations all contain interaction with a patient. The expert and Basel corpora contain data that are naturally occurring since the texts played a role in the students’ learning process and evaluation, and were thus written for purposes other than linguistic analysis. In the case of the Nottingham corpus, the students submitted their texts for the medical humanities project and were not necessarily aware of the linguistic focus. Naturally occurring data is by definition messy, but it is also rich in phenomena that the researchers did not think of in advance. We are thus convinced that our data sets offer abundant opportunities for research. We should also explain why we opted for a combination of data sets written in different languages and why we decided to supplement them with the columns written by health professionals. The combination of German and English texts developed dynamically from our different research profiles. As we are primarily affiliated with the English department and linguistics, but also work in the medical humanities in Basel, it was easy to reach out to the English-speaking world to find a partner. Victoria Tischler’s motivation for

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29

adopting the reflective writing task for her Nottingham students came from the genuine wish to improve teaching and contribute to the medical humanities at her institution and in research. It will be interesting to see whether we find differences in the topics that the students raise or in the ways in which they compose their texts. It is important to us, however, to stress that we are dealing with three cohorts of students and that we do not wish to make any generalizations about culture or the ways in which the ‘Swiss’ do things compared to the ‘British’ students. For this reason, we will talk about the ‘Basel students’, the ‘Nottingham students’ and the ‘health professionals’ or ‘experts’ who wrote the columns. For the purposes of brevity, we often refer to the components of the corpus as Basel, Nottingham and Expert.

Notes (1) We would like to acknowledge Franziska Gygax’s contributions to parts of Section 2.1, which draws on sections from our SNSF project description. See also Gygax and Locher (2015b) for an introduction to the topic of illness narratives, which is the theme of our jointly edited collection, Narrative Matters in Medical Contexts across Disciplines, which was inspired by the SNSF project. (2) The Basel study received approval from the ethics committee of both cantons of Basel. In the case of the Nottingham data, the study did not have to undergo official ethical screening as this research was considered to be part of educational studies rather than medicine. (3) They had to complete a summative assessment by submitting a piece of coursework which consisted of narrative writing based on evidence from patient interviews. In this coursework, they chose a topic which they found interesting, e.g. communicating with children, and wrote a narrative account of an interaction or interactions that they had had with patients. See Oyebode and Tischler (2015) for a discussion of this task. (4) The Nottingham data collection took place twice during the project and was not delayed as it was in Basel, where changes to the curriculum resulted in the loss of texts from one year (see Section 2.3.1 for details). (5) The following information on JAMA can be accessed online (http://jama.jamanetwork.com/public/About.aspx; 29 November 2012): ‘JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world. The online version is made freely available to institutions in developing countries. […]’ Its key objective is ‘to promote the science and art of medicine and the betterment of the public health’, and the journal lists its critical objectives as including ‘to inform readers about the various aspects of medicine and public health, including the political, philosophic, ethical, legal, environmental, economic, historical, and cultural’. (6) The AIM website (http://annals.org/public/about.aspx: 29 November 2012) describes the journal as follows: ‘Established in 1927 by the American College of Physicians (ACP), Annals of Internal Medicine is the premier internal medicine journal. Annals of Internal Medicine’s mission is to promote excellence in medicine, enable physicians and other healthcare professionals to be well informed members of the medical community and society, advance standards in the conduct and reporting of medical research, and contribute to improving the health of people worldwide. To achieve this mission, the journal publishes a wide variety of original research, review articles, practice guidelines, and commentary relevant to clinical practice, healthcare delivery, public health, healthcare policy, medical education, ethics, and research methodology. In addition, the journal publishes personal narratives that convey the feeling and the art of medicine.’

3

The Choice of Themes: On Communication Strategies and Challenging Situations

3.1 Introduction and Methodology To get a feeling for our data sets, our first step is to ask what the novice and expert physicians actually choose to write about. As was shown in Chapter 2, the Basel and Nottingham instructions for reflective writing texts ask students to write about an encounter with a patient who made a particular impression on them, and the example given is that of a problematic encounter. The students are further asked to reflect on how they felt. In the case of the expert texts, the selection criteria for us were that the writer was a professional health expert and that he/she described an encounter with a patient. While the instructions for the students might lead them to focus on problematic encounters, it is nevertheless interesting to see what recollection the students and experts choose to engage with, and what scope the topics have. At a later stage, we can use this knowledge to develop questions about communication skills, identity construction and narratives. To establish what a text is about, one must engage with it in detail through qualitative close reading and assessment. We established what the texts were about in two steps: •

Step 1: Establishing the range of topics: By reading each text closely, we developed a catalogue of topics bottom-up and continuously added to it. Once the set of topics was complete (39 main categories, some of which contained sub-categories, so that 92 categories could potentially be tagged), we designed spreadsheets for the different corpora. The spreadsheets were used by two to three independent coders per corpus to keep track of their results (for an example, see Appendix 9.4). After training these raters, coder agreement was established and reached over 70% for a set of 30

The Choice of Themes

•

31

topics (but not all sub-categories), i.e. 26 topics for Basel, 22 for Nottingham I, 34 for Nottingham II. The expert topics only had three topic choices that occurred often enough to establish reliability. This overview of topics then led to the development of themes in Step 2. Step 2: Focusing on main themes: Since the fine-grained topic analysis kept track of all the issues raised and reflected on, it was not easy to glean a simple answer to the question as to what the text is about from Step 1. For this reason, we aimed for a reduction. From 27 themes distilled from the fine-grained topic analysis (see Appendix 9.5), we aimed for a reduced selection of between one and three themes per text (allowing up to six themes for particularly complex texts). The coders (Regula Koenig and three student interns) reached this reduction by consensus. In other words, they decided on the most important themes per text by discussion rather than independent coding (see MacQueen et al., 2008; Namey et al., 2008).

In both steps, we coded for the presence and absence of a topic/theme. We kept track of what prompted our assessment by indicating line numbers, but did not establish how often a category emerged in any given text. The theme categories will be illustrated and discussed in the next section.

3.2 Range of Themes Raised in the Reflective Writing Texts Texts could be tagged for multiple themes because they do not focus on a single reportable event as in most classic oral narratives (Labov, 1997), but potentially contain reflections on more than one point (see Chapter 5 for an analysis of genre and text composition). Figure 3.1 shows that one to three themes were sufficient to describe what was happening in a text in 85% of all cases (n = 236). In a further 13% (n = 36), four labels were used. Just 6% of the texts were tagged with more than four themes. When looking at the distribution within the sub-corpora (see Figure 3.2), it is clear that one to three themes per text is enough to describe the expert corpus. In contrast, the student texts raise more diverse issues within a single text. We will now illustrate the 27 themes that emerged and for which the team reached a consensus on their occurrence in a particular text. For discussion, we have bundled the themes in clusters according to their similarity of focus. (For ease of reference, they are also listed alphabetically in Appendix 9.6.) The following four clusters emerged in the set of themes and could be combined with one another: (1) focus on the context of the encounter; (2) focus on the patient; (3) focus on the student or expert physician; and (4)

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Ref lec t ive Wr it ing in Medical Prac t ice

120

109

100 86 80 60 41

36

40 20

5

1

0 1 theme

2 themes

3 themes

4 themes

5 themes

6 themes

Figure 3.1 Number of themes per text in the entire corpus (n = 278)

focus on the insights gained. In addition, an open theme category allowed us to incorporate special texts. In what follows, we will explain and illustrate the foci and their themes. In Section 3.3 we will discuss their distribution. All excerpts are left as they were in the original texts; no stylistic or typographical changes have been made, but in some cases we use italics to highlight points of interest. We will use multiple excerpts to illustrate several themes at once. As a result, the themes are not always introduced in the strict alphabetical order used in Tables 3.1–3.4.

70

62

60 46

50 37

40

34

30 30 20 10

26

23

14

13 8 3

0

3 2 0

0 1 0

4 themes

5 themes

6 themes

0 1 theme

2 themes

Basel: % in 39 texts

3 themes

Nongham: % in 189 texts

Expert: % in 50 texts

Figure 3.2 Number of themes per text according to the three sub-corpora (%)

The Choice of Themes

33

3.2.1 Focus on the context of the encounter The first cluster of themes revolves around the contextual and interactional parameters of the encounter with the patient (Table 3.1). As explained, themes can emerge in more than one passage of the text and are roughly meant to establish what the text is about. For illustration purposes, we only cite short text passages in this section to give an impression of what prompted a theme label. Text B-09 is written in German by a 22-year-old female student from Basel. The text describes the anamnesis and follow-up meeting with an 80-year-old female patient who was suffering from amyotrophic lateral sclerosis and was accompanied by her son. The text was tagged as ‘setting’ because it focused on the challenge of several people being present during the interaction (the son accompanying the patient), and as ‘history taking’, as shown in Excerpt 3.1.

Excerpt 3.1 Ausserdem hat auch die Interaktion zwischen ihr und ihrem Sohn bei mir einen bleibenden Eindruck hinterlassen. Sie sind ein eingespieltes Team, beide können sich aufeinander verlassen. […] Eine zusätzliche Herausforderung sah ich anfangs auch darin, dass ihr Sohn anwesend war. Als ich zum ersten Mal die Anamnese bei ihr erhob, dachte ich, dass Table 3.1 Theme focus: Context of the encounter (ordered alphabetically) Theme Communication strategies

Description in the codebook

Encounter is memorable because of a particular communication strategy that was used; please specify here what strategies they refer to. Criticism (of/by student, GP, patient) Criticism of something by someone. Cultural differences Cultural differences between him/herself and patients; if patient encounters are different because the patients come from a different cultural background. History taking The main theme is about how to take a history/how the student takes a history. Language problems/speech impediment Problem with language (due to hearing difficulties, different languages being spoken, not being able to pronounce clearly, etc.). Setting Encounter was memorable due to a special setting/specific setting issue. Time constraints The main theme is that there is not enough time, or the fear that there won’t be enough time in the future.

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es schwierig sein würde das Gespräch zu dritt richtig zu strukturieren. Aber in dieser Konstellation ging dies ohne Probleme. Der Sohn fügte zum Teil einige Kommentare hinzu oder fragte bei gewissen Dingen nach. Sonst hielt er sich im Hintergrund. (B-09) ‘Moreover, the interaction between her and her son left me deeply impressed. They are a well-oiled team, both have absolute confidence in each other. […] Initially, I saw it as an additional challenge that her son would be present during the consultation. When I did my first anamnesis, I thought that it will be tricky to structure the conversation well among the three of us. Yet in this constellation, it was no problem at all. Sometimes, the son added some comments or asked for some more details. Otherwise, he kept himself in the background.’ In addition to cases where several people were involved in the encounter, ‘setting’ was also tagged in the corpus when the following occurred: the students foregrounded special circumstances such as whether the encounter took place in a hospital or was a home visit; the students noted that several languages were involved, that patients were caretakers of others, or that special social circumstances were involved (e.g. poverty, different social background of patient; see Appendix 9.5). Furthermore, Text B-09 was tagged as foregrounding the experience of ‘communication strategies’ that worked (building rapport and trust, and taking enough time for the encounter; see also Appendix 9.5). It was also tagged as ‘other’ because the student was impressed by the patient’s positive attitude towards her condition. Examples for both tags can be seen in Excerpt 3.2:

Excerpt 3.2 Ich habe aus der Begegnung mit Frau K. einiges gelernt. Im Bezug auf die kommunikativen Aspekte dieses Gesprächs ist mir klar geworden, wie wichtig es ist, sich auf einen anderen Gesprächsrhythmus einzulassen und nicht ungeduldig zu wirken. Zum anderen habe ich gemerkt, wie viel eine gute Beziehung und ein Vertrauensverhältnis zum Patienten ausmacht. Da ich Frau K. mehrere Male gesehen habe, war ich zum Schluss nicht mehr nur die Studentin, die sie zusätzlich befragt, sondern eine Gesprächspartnerin, mit der sie über ihre Probleme reden kann und der sie vertraut. Ausserdem war es für mich sehr beeindruckend zu sehen, wie Frau K. mit ihrer Krankheit umging. Meiner Meinung nach ist es sehr wichtig, der Patientin Anerkennung für ihre Haltung entgegenzubringen. (B-09) ‘I have learnt a lot from meeting Ms K. With respect to the communicative aspect, I have understood how important it is to be open to the [patient’s] rhythm of the conversation and not to appear impatient. Furthermore, I am now aware to what extent a good contact to the

The Choice of Themes

35

patient and a relationship of trust counts. As I saw Ms K several times, in the end I was no longer the student who asked her additional questions, but a conversational partner with whom she can talk about her problems and whom she trusts. Moreover, it was very impressive for me to see how Ms K handled her illness. In my opinion, it is very important to show the patient recognition for her poise.’ Text N-024 was written by a 19-year-old female student and, with 2603 words, is one of the longer texts in the corpus (the mean for her cohort is 1350 words). Her text is one of just five that were tagged with five labels. One tag is from the cluster about focusing on the patient (‘special condition’ – the student reports on a patient with Down’s syndrome; see below) and one is from the cluster about focusing on the student (‘student/expert emotions’, see below). From the ‘context’ cluster, the tags are ‘setting’ (several participants are present, i.e. the mother accompanying her son), ‘communication strategies’ and ‘time constraint’. Excerpt 3.3 shows the aspect of ‘time constraint’:

Excerpt 3.3 The conversation lasted thirty minutes, this long time allowed me to establish a rapport and obtain an accurate history. If it were a full explanation task I would need even more time as it’d be delivered at a slower pace for James to understand. As a Doctor I will have to get through everything in half the time! I believe this comes with practice as I’ll start figuring out trends in patient behaviour and my communication skills will come naturally. (N-024) ‘Cultural differences’ and ‘language problems/speech impediment’ are both shown in Text E-24, which was written by a male MD working in the United States. He reflects on how the two years he spent in a Spanishspeaking country help him when working with patients who have Spanish as their mother tongue, as shown in Excerpt 3.4.

Excerpt 3.4 Never did I think learning Spanish in high school and college would make such an impact. I spent 2 years in a bilingual medical school in Puerto Rico, and it allowed me to learn new customs and expressions that offer daily cultural insights into patients’ perception of disease. It also cemented a linguistic foundation that is valuable in many aspects of my professional life. Foremost, it has enabled me to make unique connections with patients in a language that is neither my mother tongue nor part of my IndianAmerican heritage. Learning Spanish has allowed me to bridge a

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linguistic and cultural divide that often separates physicians from patients who do not speak English. (E-24) Finally, the category ‘criticism (of/by student, GP, patient)’ could have been placed under the patient or student focus. However, since a number of different participants (student, doctor, patient, attendant) could criticize or be criticized, this theme is listed in the ‘context’ cluster.1 Excerpt 3.5 from Text N-059 shows how the 20-year-old female author is quite critical of the consultation she witnessed between a female patient and the doctor with whom she was working.

Excerpt 3.5 Throughout her hesitant tries, the doctor looked at her with a scrunched up face and shook his head from time to time. This did not help the patient at all. If anything it made her more flustered and possibly embarrassed. The doctor demonstrated poor communication and rapport building leading to the patient feeling more alienated. […] Overall I thought the doctor could have done a much better job of tailoring this consultation to the patient resulting in her feeling more comfortable and thus more satisfied. (N-059) The focus on the context thus comprises seven themes which highlight quite different contextual aspects, such as parameters of setting, history taking, communication strategies, time constraints, language problems/ speech impediment, cultural differences and criticism.

3.2.2 Focus on the patient The second cluster foregrounds the patient and turns his/her characteristics into reportable themes (see Table 3.2). Text N-077, written by a 20-yearold male student, was tagged with five labels: ‘communication strategies’, ‘student/expert emotions’ (see below), and three tags from the ‘patient’ cluster. The text is about an encounter with a 70-year-old retired gentleman, who came to the GP clinic for a relatively minor issue. During the consultation with the student, the patient reveals that his daughter recently died of breast cancer (‘bereavement’) and the student is impressed with how openly and cooperatively the patient shares this experience with the student (‘patient is open’, ‘patient is cooperative’; see Excerpt 3.6).

Excerpt 3.6 I remember this particular encounter so well, not only because of the desperately sad story the man told, but because of how jovial and friendly the man was, and how well we got on. He was a very easy gentleman to talk to and I enjoyed my time with him. The interview was very intense

The Choice of Themes

37

Table 3.2 Theme focus: Patient (ordered alphabetically) Theme

Description in the codebook

Bereavement Impact of illness on patient’s life

Patient is dealing with the loss of someone. They talk about how and in what ways the illness has an impact on the patient or on the relatives of the patient. Patient emotions The encounter is memorable because of the emotions which the patient felt (positive or negative); e.g. the patient is very positive despite being so ill, which is memorable to them. Patient independence is important It is important to the patient to be independent. Patient is cooperative Patient is very cooperative and helpful. Patient is difficult Patient is memorable because he/she is aggressive, non-communicative, non-compliant/doesn’t want the treatment, is depressed or shy … Patient is open Patient was very open, or opened up during the encounter. Severe/terminal illness Patient suffers from a severe or even terminal illness and this is considered the main theme. Special conditions The illness/condition of the patient is special in some way.

due partly to the small size of the room and our proximity to one another, and I think this may be another reason it was so memorable. My behaviour shocked me a little as I am not normally too keen to listen to tales of bereavement as I find I do not have much in the way of calming words to offer, but on this occasion I found myself happily listening to the patient and consoling where I could. His language was frank and straight forward, and I appreciated this and responded with the same openness and honesty. (N-077) Text N-004 by a 19-year-old female student was tagged with four labels: ‘communication strategies’ (primarily focusing on rapport) and three tags from the ‘patient’ cluster. Excerpt 3.7 contains the category ‘impact of illness on patient’s life’, which was chosen because the text discusses the student’s realization of how the female patient’s life is affected by suffering from multiple sclerosis. This is especially evident in the way the patient displays emotions (‘patient emotions’) and in how the patient stresses that her independence is crucial to her (‘patient independence important’).

Excerpt 3.7 The patient talked at length about the coping strategies she employed in replacement for medical support such as her increasing practice of yoga,

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swimming and going for walks with her dog, as these measures provided her with a distraction, and she believed that this would be sufficient to counteract the progression of her multiple sclerosis. From talking to this patient, it seemed evident that retaining a sense of autonomy and independence features highly in terms of importance for her, as it allows her to maintain a sense of individuality, and it appeared that the patient felt slightly resentful of the fact that her condition sometimes compromised this. […] At the more initial stages of the conversation, it seemed that the patient was demonstrating a defensive attitude, through her adamant display of disapproval of the need for medical therapy and I feel that this attitude may have been representative of a conflicting inner emotional state, resulting from anxiety pertaining to her disease, but also due to selfimposed pressure to not outwardly show her distress to her family, to avoid worrying them. However, by demonstrating acceptance of her views served to dissipate this shielding attitude as she began to share some of the concerns that she felt difficult to mention at the beginning of the discussion. For instance, the patient gradually admitted to the materialisation of depressive symptoms when she felt that the psychological burden from the physical disability of her disease was slowly starting to overwhelm her capacity to carry out her normal daily chores. (N-004) The ‘patient is difficult’ category is demonstrated in Text N-037, which was written by a 20-year-old female student. As she describes in Excerpt 3.8, her patient does not comply with his blood-pressure medication regimen, and her consultation with him confirms his stubborn streak.

Excerpt 3.8 This particular patient was in his late fifties and, like most of the patients I have encountered in my clinical experience, suffered from hypertension. […] The reason this patient is memorable to me is because, despite the fact that he was suffering from severe sleep apnoea and would frequently wake up gasping for breath, he was refusing to adhere to his blood pressure medication and the diet plan the GP had given him. A childhood asthmatic, I discovered that over the past few weeks his sleep had been disturbed by these attacks of tightness in the chest and breathlessness. The last time he entered the surgery, his blood pressure had been 145/95. When I took it again, it was 150/95. My task in this instance was to explain to him the significance of the measurements for his blood pressure, the specific actions of his blood pressure medication and to glean from him the reasons as to why he was not adhering to his prescription. […]

The Choice of Themes

39

I found interviewing this patient frustrating at times because he was so stubborn, which is probably why I remember him so well. I found it difficult to empathise with him because while I felt confident that he should take his medication and go on the diet, he seemed so opposed to it. I tried to overcome this difficulty in building rapport by asking him the relevant questions based on both his feelings and his knowledge, and I subsequently learned that his reluctance to take medication stemmed from his upbringing. (N-037) Text E-39 illustrates the ‘severe/terminal illness’ category. The text was written by a female oncologist who describes the difficulties she encountered when answering the patient’s question about how he will die (Excerpt 3.9). Throughout her text, she focuses on the communicative challenges that these situations pose for doctors.

Excerpt 3.9 Breathing heavily, he drags his body up the bed. The sliding covers reveal wasted muscles, parched skin. ‘I have something I must ask you. I want you to tell me how I will die.’ Perhaps he catches a flicker of hesitation on my face for he adds, ‘I have asked a few doctors, but no one wants to’. (E-39) Text N-024 (see also Excerpt 3.3) on the anamnesis with a Down’s syndrome patient illustrates the ‘special condition’ label, since the student highlights the fact of the patient’s condition right at the very beginning of her text (Excerpt 3.10).

Excerpt 3.10 I had the pleasure of talking with James*, a 27 year old male. He came in, accompanied by his Mother, to review his blood test results for his thyroid levels. When he walked into the consultation room, the first thing I noticed was that James had Down’s syndrome (DS), and it was this that made this encounter different to any other encounter. I had never conversed with a patient who had DS, how was I going to deal with it? What would I have to do differently? What would the Mother’s role be? As he sat down, James gave me the biggest smile and winked. The Mother told him off because “that’s James’ flirtatious way of greeting the opposite sex!”, to which we all laughed. My anxiety settled straight away and I was now looking forward to the next thirty minutes with James and his Mother. (N-024, emphasis in original) As has become clear, the focus on the patient is much less heterogeneous than the focus on context. Here, the patient forms a clear anchor point around which the nine themes introduced in this section revolve.

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3.2.3 Focus on the student or expert physician Table 3.3 displays the six categories that were tagged within the ‘student/ expert’ focus. At times the informants foregrounded the themes of their ‘experience’ and ‘professional behaviour/expertise’. The latter category is about both knowledge and professional behaviour, while the first tag was assigned for instances in which (a lack of) experience was made an issue. Text N-164 was written by a 20-year-old female student and is about taking the patient history of a 64-year-old woman. From the patient record, the student expected the patient to talk about chronic back pain, but the reason for the patient’s visit was a bloody discharge from her left nipple. The student reports that she felt she lacked experience (I felt under qualified) when faced with the potential diagnosis of breast cancer (Excerpt 3.11).

Excerpt 3.11 On asking about family history, I discovered her mother had died due to breast cancer aged 72. It was at this point I panicked. I knew that Mrs M thought she had developed the same cancer that had killed her mother, and it sounded quite likely to me also despite not knowing very much on the diagnosis and common symptoms. I felt underprepared and under qualified to deal with a situation like this, and I felt any confidence in my ability to take a history from a patient who was distressed melt away. (N-164) The same student also talks about how to behave professionally (‘professional behaviour/expertise’) and that her own emotions (‘student/expert emotions’) got in the way of her doing so (Excerpt 3.12). Table 3.3 Theme focus: Student/expert (ordered alphabetically) Theme

Description in codebook

Experience

The main theme is that they lack experience in something or that their experience with something has helped in the encounter. The encounter is memorable because they discovered they were judging the patient/GP/illness, etc. The student was prejudiced against the patient/illness; if the first impression turns out to be wrong. The main theme is about professional behaviour or how expertise (or its lack) can make a difference in the encounter. The main theme is what they felt like (positive or negative emotions possible). The encounter was successful and thus memorable to them (they have to state explicitly that it was successful).

Judgemental attitude revealed Prejudice/first impression falsified Professional behaviour/ expertise Student/expert emotions Successful encounter

The Choice of Themes

41

Excerpt 3.12 I tried to appear unperturbed by her appearance and evident concern. Her distress made me uncomfortable, but I knew I had to maintain a level of professionalism so I took a deep breath and attempted to begin to take a full history. […] I had been expecting a history of joint pain and I was presented with something that sounded much more serious. I tried to hide this as best as I could, took a deep breath and continued. I tried to maintain an air of professionalism by resuming taking a full history, while trying not to reveal my own emotion but to reflect empathy and compassion in my non verbal behaviour. (N-164) The writers also talked about how their own ‘prejudice’ was revealed and ‘first impressions falsified’, and how a ‘judgemental attitude’ emerged. The two categories could co-occur or appear independently. In Text N-131, a 20-year-old male student reports on an encounter with a patient who he suspected of having diabetes or something relating to obesity such as CHD [coronary heart disease]. As it turned out, the patient suffered from severe asthma. In the reflection part (Excerpt 3.13), the student concludes:

Excerpt 3.13 I have learnt from this counter [sic] that I really should not judge patients as soon as I enter the room. I knew this beforehand, but still stereotyped the patient as bad diet no exercise. I could not be more wrong, here was a patient eager to exercise and do everything she could but this dreadful condition prevented her from this. It’s so easy to stereotype people and we continue to do it despite our best intensions. If I was to take anything away from this encounter it would be to work even harder to not stereotype patients. (N-131) The specific mention of the student’s emotional reaction to the encounter was already noted in Text N-024 (Excerpt 3.14), which was about a patient with Down’s syndrome, and in Text N-077 (Excerpt 3.15), which was about a patient who had lost his daughter to breast cancer.

Excerpt 3.14 As it’s possible to see, I experienced lots of emotions from the start to the end. I felt very emotionally connected to the Mother as I could relate to her situation. The effects of Doctor’s poor knowledge on DS saddened me, so I got books out on DS from the library and am taking a Mental Health First Aid Course! I was very shocked and disappointed about the number of assumptions I held, but am grateful I had the opportunity to get an insight to a patient with DS, so that I have now become more non-judgemental and eliminated the idea that DS patients are hard to talk to. It was in fact easier for me to start a conversation with James

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than with other people I know, with James there was ‘no ice to break’. Overall I felt successful for facing a new challenge. (N-024)

Excerpt 3.15 I tried to express my sympathy as much as I could but there was little I could say that seemed to be appropriate to such tragic news. After the encounter I felt incredibly sad and full of respect for the patient, who remained so calm and collected throughout our interview, despite the terrible things that he had just had to re-live through. I was deeply saddened by the encounter and I couldn’t help feeling terribly sorry for the man, who seemed such a good person. I cannot think how the patient must feel, although I hope that I, in a small way, offered a little support and a friendly ear to listen to his tales. I think he was happy to talk to me and glad of a decent conversation with somebody new. He seemed to have come to terms with what happened and was very reasonable and realistic. I would like to think he left the surgery feeling slightly more cheerful after our conversation, as it did include laughter and I think that the patient enjoyed my company and conversation. (N-077) Finally, the ‘successful encounter’ tag was assigned when the writers described memorable encounters with patients as a success story. In Excerpt 3.16, the 20-year-old male student reveals that he was apprehensive about interviewing a child, and then reports the success of the encounter.

Excerpt 3.16 I was initially very nervous before the interview. I have extensive experience with adults and the elderly but comparatively much less with children. I was doubting myself hours before and I had horrible thoughts of awkward silences, confusion and it perhaps all going horribly wrong. […] I was overjoyed. The interview had been a success and I had overcome my fears. I had also thoroughly enjoyed the whole experience and I learnt so much. (N-108) In the same way as the ‘patient’ theme cluster yielded insights on patients, the six themes in the ‘student/expert’ cluster tell us more about the student/expert writers.

3.2.4 Focus on the insights gained The ‘focus on insights’ cluster is particularly important for the reflection element of the texts (Table 3.4). The reflection is often the result of taking elements of the above three clusters into account (e.g. focusing on both the patient and the health practitioner). However, independent insights were

The Choice of Themes

43

Table 3.4 Theme focus: Insights (ordered alphabetically) Theme

Description in the codebook

Individuality of patients/patients differ

They discuss that patients are individual, that each patient differs, even if they have the same illness. Gaining the perspective of the patient/ being able to grasp that perspective/ being given that perspective = important to understanding the patient. Preparation (e.g. reading the patient’s file beforehand) would have been helpful/ has been helpful/would be important for future encounters (linked to ‘experience’). Reality (the encounter) is different from what they learned in theory/class. Recognizing that the patient needs to be treated as a whole, not just medical/ clinical aspect but also the psychosocial part of illness needs to be treated.

Patient’s perspective is important

Preparation is helpful/important

Textbook vs. reality Value of holistic approach

also formulated at times, so specific labels were developed for insights that were foregrounded. The ‘individuality of patients/patients differ’ category is demonstrated in a text by a 19-year-old male student who reports on taking the history of a 46 year old Caucasian male with severe osteoarthritis in need of two knee replacements. The student explains how he went through the motions of taking a patient history by rote, only to be shaken during the interview by the ‘impact of illness on patient’s life’ and his own emotions in reaction to the story. Excerpt 3.17 is taken from the ‘aims’ section, in which the student reflects on what he has learnt.

Excerpt 3.17 The main aim for future consultations is to treat every patient as an individual as I do not know their personal circumstances. Whilst they may be suffering from a common condition, it is suffering none the less and I need to treat everyone equally as a person. I should not categorise the patient on their condition. (N-157) Text B-35 is written by a 24-year-old female student from Basel. Her text was tagged with three labels: ‘patient’s perspective important’, ‘preparation helpful/important’ and ‘other’ (difficult situation of disabled people). The student reports on a consultation with a person suffering from multiple sclerosis who shared the problems he encountered at the workplace. Excerpt 3.18

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illustrates how the student realizes that she learnt much from eliciting the patient’s perspective. She argues that she should have been better prepared for the consultation by reading the patient file and preparing for the issues via preparatory reading.

Excerpt 3.18 Das Schöne an diesem Gespräch war, dass ich einmal die Sichtweise des Patienten kennenlernen konnte. In den Medien und bei den Debatten heisst es immer, dass grosse Bemühungen unternommen werden um Behinderte in den Alltag zu integrieren. Jedoch beurteilen einzelne Betroffene, dass sie die Situation anders wahrnehmen. Es wäre jedoch gut gewesen, wenn ich schon im Vorhinein seine Geschichte gekannt hätte und mich in die jetzige Arbeitssituation für Menschen mit Behinderungen im Kanton Basel hätte einlesen können. Das nächste Mal werde ich versuchen mich schon vorher mit der ganzen Situation bekannt zu machen. (B-35) The nice thing about the conversation was the opportunity to get to know the perspective of the patient. In the media and in public debates they keep saying that great efforts are made to have disabled people participate in ordinary every-day life. Yet some of the concerned say that they perceive the situation differently. It would have been better, however, if I had known his history beforehand and if I had been able to inform myself about the present job situation for disabled people in the canton of Basel. Next time, I’ll try to acquaint myself with the whole subject earlier. Some texts stressed that the actual encounter differed from what is generally described in textbooks on doctor–patient interaction. This kind of reflection was tagged as an insight in itself (‘textbook vs. reality’; Excerpt 3.19).

Excerpt 3.19 I was pleased with the way the communication was going in the interview, I was ticking off the points on my mental Calgary-Cambridge model, she was a non-smoker, drank the odd glass of wine, and had no other additional medical problems. However this patient didn’t fit the tick box list. It is very tempting to forget that you have a real person in front of you, and it’s not some sort of simulation where you have to try and elicit all the necessary information to complete the tasks and win the game. (N-118) Finally, the ‘value of holistic approach’ tag is illustrated in Excerpt 3.20, which comes from a text written by a 25-year-old male Basel student (B-22). He reports that he conducted an anamnesis with his GP tutor and prematurely diagnosed a patient with a severe condition because he ignored other aspects of the patient’s symptoms.

The Choice of Themes

45

Excerpt 3.20 In diesem Moment wurde mir mein vorschnelles Denken bewusst und mich ereilte die Gewissheit andere wichtige Dinge völlig ausser Acht gelassen zu haben. Ich war mir so dermassen sicher, sodass ich gar nicht mehr richtig zuhörte was sonst noch gesprochen wurde, der Fall war ja „klar“. Leicht beschämt verabschiedete ich mich von Herrn [name] und wartete das nächste ET [Einzeltutoriat] ab. Es wäre besser gewesen nicht den Kopf „auszuschalten“ und noch nach den letzten fehlenden Hodgkin-Puzzle Teilchen zu suchen. Ein gründlichereres erheben der Anamnese war ganz klar angezeigt. Die psychosozialen Einflüsse habe ich komplett ausgeblendet, was mir erst im Nachhinein so richtig bewusst wurde und mit dem Schreiben dieses Berichtes nochmals in fast peinlicher Art und Weise. In Zukunft werde ich versuchen den Patienten ganzheitlicher zu betrachten und nicht in Panik auszubrechen in ähnlichen Situationen. (B-22) ‘In that moment, I became aware of my hasty thinking and I was overcome by the certainty that I had entirely overlooked other things. I had been so completely sure of myself that I no longer listened properly to what else had been said. The case seemed ‘clear’. Slightly embarrassed, I said Good Bye to Mr [name] and waited for the next ET [tutorial with the GP]. It would have been better not to ‘switch off’ my brains and instead to look further for the last missing Hodgin puzzle parts. It is clear that a more thorough anamnesis would have been called for. I was entirely blind to the psychosocial influences, a fact I only became aware of afterwards and almost to an embarrassing degree once I started to write this report. In the future, I will try to look at patients holistically and not to start panicking in similar situations.’ ‘Focus on insights’ was the final theme cluster. The fact that this cluster emerged as relevant shows how important the reflective elements of the texts are – an issue we will return to below.

3.3 Theme Distribution in the Three Corpora Having illustrated the 27 themes which can be grouped into four clusters that each represent a specific focus, we can now discuss their distribution within the corpus. Table 3.5 shows that ‘context’ theme tags were distributed in 38% of all 692 assigned tags. This was followed by ‘patient’ themes (27%), ‘student/expert’ themes (19%) and ‘insight’ themes (6%). The ‘other’ category accounted for just 11% of all the assigned tags.

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Table 3.5 Distribution of theme clusters in all three corpora

Focus on context Focus on patient Focus on student/expert Focus on insights Other Total

Total # of tags

% of occurrence within all tags

259 186 133 41 73 692

38 27 19 6 11 100

It would be premature to argue that these results imply that reflection is not much of a concern in the corpus; the tags represented in this cluster are about specific insights gained, but reflection could also take place in relation to any of the other themes. However, it is noteworthy that the patient receives more attention than the student. From this initial distribution, we can also see that we need to unpack the individual clusters again in order to answer the question of what our informants chose to write. For this reason, we will now return to the 27 themes. Table 3.6 compares their distribution in all three corpora and in the corpus as a whole. The numbers reported refer to the percentage of texts that contained the tag. The penultimate column shows the total assigned tags per category. Seven themes are used in more than 10% of all texts. Not surprisingly, ‘communication strategies’ ranked highest overall (61%, 170 texts). This is because the student texts were written for communication skills courses. These texts constitute 228 of the 278 texts. As the drop in percentage for the expert narrative shows (only 26% compared to 71% for Nottingham and 56% for Basel), ‘communication strategies’ was less prominent in the expert texts. The ‘other’ category is next in the overall ranking, but stands at just 26% and was thus used in 73 texts.2 In almost all cases, ‘other’ was used in combination with the other themes, which means that we can leave these cases aside in our discussion for the time being. The next two themes refer to the important role that the emotions experienced by the student or displayed by the patient played in choosing a memorable encounter. The students’ emotions played a role in 21% (59 texts) and the patients’ emotions were highlighted in 18% (51 texts). The importance of emotions is a crucial finding that merits further discussion (see Section 4.4 and Section 6.4.3). Next in the ranking are ‘special conditions’ (17%, 47 texts) and ‘impact of illness on patient’s life’ (12%, 34 texts). ‘Setting’ was the last theme category that was tagged in more than 10% of the overall corpus (12%, 33 texts). The grey highlighting in Table 3.6 shows the theme categories that occur in more than 9% of the texts in each corpora, and aims to showcase the differences

The Choice of Themes

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Table 3.6 Comparison of the thematic analysis of the reflective writing corpora (%); grey highlighting indicates percentages equal to or more than 10, ordered according to total frequency Theme

Basel: % of 39 texts

Nottingham: % of 189 texts

Experts: % of 50 texts

Total # of tags in all corporaa

% of occurrence in 278 texts

Communication strategies Other Student/expert emotions Patient emotions Special conditions Impact of illness on patient’s life Setting Professional behaviour/expertise Experience Patient is open Prejudice/first impression falsified Successful encounter Patient is difficult History taking Criticism (of/by student, GP, patient) Language problems/ speech impediment Individuality of patients/patients differ Value of holistic approach Cultural differences Time constraints Patient is cooperative Textbook vs. reality Patient’s perspective important Severe/terminal illness

56

71

26

170

61

64 23

22 17

14 34

73 59

26 21

10 15 3

23 17 15

8 16 8

51 47 34

18 17 12

13

14 6

4 14

33 18

12 6

8 3 5

2

17 17 16

6 6 6

28 13 5

2

7 7 3 7

2 2 2

16 15 13 14

6 5 5 5

6

2

12

4

5

3

6

10

4

10

3

10

4

3 10 3 3

2 3 2 1 2

12 4 8 6

9 8 8 7 7

3 3 3 3 3

3

2

6

7

3

15

(Continued)

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Table 3.6 Comparison of the thematic analysis of the reflective writing corpora (%); grey highlighting indicates percentages equal to or more than 10, ordered according to total frequency (continued) Theme

Judgemental attitude revealed Preparation helpful/ important Bereavement Patient independence is important Total a

Basel: % of 39 texts

Nottingham: % of 189 texts

Experts: % of 50 texts

Total # of tags in all corporaa

% of occurrence in 278 texts

3

3

7

3

15

1

7

3

3

3 1

6 1

2

692

The total number of tags for each row corresponds to the total number of texts that contained the tag; since a text can contain more than one tag, the grand total (n = 692) is larger than the total number of texts (n = 278).

between them. The Nottingham corpus features the same themes in the top seven positions as the whole corpus does, but gives the emotions of the patient more weight (23%, compared to 10% for Basel and 8% for the experts). In the case of the Basel corpus and the top seven themes in the general ranking, the students focus less on the ‘impact of illness on patient’s life’ and choose other themes more frequently. In fact, the number of themes that reach the 10% threshold is higher than in the other two corpora – 12 themes appear to be repeatedly worth writing about. Concerning the focus on insights, we find ‘preparation is helpful/important’, ‘individuality of patients/ patients differ’ and the ‘value of holistic approach’. This might indicate that the reflective aspect of the writing task is given more space. The ‘context’ focus appears in ‘history taking’, while ‘successful encounter’ is drawn from the student focus, and ‘patient is open’ and ‘patient is cooperative’ are taken from the patient focus. Regarding the expert corpus, the author’s emotions are the most prominent theme (34%, 17 texts), and the patient’s emotions are less written about (8%, four texts). Communication strategies still feature in second position (26%, 13 texts), even though the two journal columns from which the 50 texts were taken were not written for a communication skills course. ‘Impact of illness on patient’s life’ and ‘setting’ are both below 10%, while ‘special conditions’ is another theme that occurs in a high position in both this corpus and in the others. The expert texts pay more attention to ‘professional behaviour/expertise’ (16%, eight texts) and ‘cultural differences’ (12%, six texts) than the other two corpora do.

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3.4 Summary and Conclusions This first analysis chapter set out to present a content analysis of the reflective writing texts in order to identify what the texts are about. From a list of topics that was compiled bottom-up, 27 themes were developed to help describe the content of the texts. We found that the texts could be described with one to three themes in 85% of all cases. Furthermore, only a handful of themes were used in more than 10% of the cases, which means that we can describe the scope of themes in the corpus as a whole and the individual differences that emerge in the sub-corpora. For the entire corpus, the top seven themes are: ‘communication strategies’, ‘student/expert emotions’, ‘patient emotions’, ‘special conditions’, ‘impact of illness on patient’s life’, ‘setting’ and ‘other’.3 While some results of the theme distribution were to be expected, others were more surprising. For example, the high ranking of ‘communication strategies’ among the Basel and Nottingham students can be explained by the context and formulation of the task behind the student texts. However, it was not initially clear that the expert texts would also focus on communication to the same degree (only the theme of ‘student/expert emotions’ ranked higher for the experts). In contrast, we did not expect the emphasis on student/expert and patient emotions to emerge as themes in their own right to this extent – despite the fact that mentioning feelings was part of the Nottingham instructions. From this initial overview of themes, we can derive a number of issues that bear further scrutiny: •

•

•

It is clear that the ‘communication strategies’ theme is of interest to linguists working in pragmatics, but it is also an issue for the writers themselves. In Chapter 4, we will thus look more closely at what communication skills the students and experts write about and how they make connections to the input received in the clinical communication skills courses. The reflective part of the texts needs further investigation since it is the raison d’être of the writing task. As mentioned above, reflection occurs not only on the themes mentioned in the ‘insights’ cluster, but also throughout the text. In order to do justice to the composition of the texts, Chapter 5 will offer a genre analysis of the corpus. The thematic importance of emotions also deserves further exploration. This is because the taught communication skills of creating rapport and showing empathy require emotional involvement. It is also because the role of emotions is a crucial theoretical element within interpersonal pragmatics. We will therefore revisit the concept in Chapter 4 when discussing challenging communicative situations, and in Chapter 6 when looking at evidence of relational work in the form of meta-pragmatic comments.

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•

Finally, it will be interesting to explore a number of themes in more detail in connection with identity construction and role understanding. For example, ‘criticism’, ‘professional behaviour/expertise’, ‘prejudice/ first impression falsified’, ‘(lack of) experience’, and ‘revealing emotions’ are delicate issues with respect to persona management and will be revisited in Chapter 7.

Notes (1) The decision to present ‘criticism’ in the ‘context’ theme cluster is not problematic for the quantitative analysis since only 14 texts were tagged in this manner. Table 3.5 in Section 3.3 shows that 259 tags were distributed within the ‘context’ theme cluster, which means that the ‘criticism’ theme does not skew the overall description. (2) The overall share of ‘other’ tags was just 11% (of 692 assigned tags). The ranking reported here is higher since the percentage refers to the number of texts in which the tag was assigned. (3) Recall, however, that the JAMA and AIM columns are generally wider in topic scope and that the 50 texts in the expert corpus present a sub-corpus that matches the student corpora (see Section 2.3.3).

4

Communication Skills in Action: From Keeping Eye Contact to Creating Rapport

4.1 Introduction One of the findings from Chapter 3 was that the students do not merely name communication skills (a practice to be expected since they write their texts for the communication skills teacher), but rather make them one of the central themes of their texts. The experts also choose communication as one of their themes, which is maybe more surprising as they do not write their texts for a communication skills course. In 71% of the Nottingham texts, communication skills were one of the main concerns of the texts (see Table 3.6 above). This was the case in 56% of the Basel texts and in 26% of the expert texts. These findings – both alone and in combination with the general interest in communication skills within linguistics – show that these skills should be studied further.1 In this chapter, we explore the following research question: What is the connection between the communication skills that the students were taught and those that are mentioned in the texts? We will thus explore issues of communication skills in greater detail, and will begin by discussing the teaching input that the students receive and that we expect the experts to be familiar with (Section 4.2). We will then look at the actual communication skills chosen for reflection (Section 4.3). In the last section, we discuss the results and zoom in on a number of challenging communication situations that are raised in the corpus (Section 4.4).

4.2 Teaching Communication Skills in Medicine at Basel and Nottingham The fact that communication skills are important for the medical professions is hardly a new insight. Blatt et al. (2014: 295) summarize two major 51

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findings of the body of research on communication in medicine: ‘communication matters to patient care’ and ‘communication skills can be taught and learned’. This section can neither give a review of the research on communication in doctor–patient interactions in linguistics (see, for example, Collins et al., 2011; Hamilton & Chou, 2014; Harvey & Koteyko, 2013; journals such as Communication & Medicine), nor an overview of the history of teaching communication in medicine, its development and its success (in Silverman et al., 2013 [1998]: x, the authors speak of over 400 articles published every year in this field2). Instead, we will refer to a number of textbooks and models that also informed the Basel and Nottingham curricula so that we can better understand the backdrop against which the student cohorts write their reflective writing texts. In his foreword to Skills for Communicating with Patients by Silverman et al. (2013 [1998]), Suchman (2013) puts the importance of communication skills on the same level as biomedical knowledge: Nothing in healthcare is more important than good communication. Healthcare is by definition interpersonal – one person seeking care from another. Without good communication, healthcare is at best wasteful and at worst dangerous. Everything depends upon the degree to which the patient and clinician understand each other accurately, develop a shared understanding of the patient’s illness and commit to work together on a course of treatment. We’re not talking about good bedside manner here, a quaint term that connotes a nice but optional flourish. We’re talking about clinical outcomes. Every bit of biomedical technology (the hard stuff) must be deployed within a social context of effective communication and relationships (the soft stuff) if it is to be safe and successful. There are no exceptions. The time of disdaining communication skills as ‘touchy feely’ is over. Communicative competence is a critical component of clinical competence, and the commitment to assess and improve one’s communication competence is a core element of professionalism. (Suchman, 2013: viii) This importance of communication for the medical professions is reflected in available teaching material and guidelines. There are longestablished classics on medical communication, such as the CalgaryCambridge guides that were developed over decades by a team of dedicated physicians in Canada and the UK (see Kurtz & Silverman, 1996; Kurtz et al., 1998, 2003; Silverman et al., 2013 [1998]). Further recent teaching material for nurses and physicians is provided by, for example, Candlin and Roger (2013) and – in German – Bechmann (2014). In the case of Basel, Langewitz and his team have made an influential contribution to communication skills being included in the medical curriculum at many universities (e.g. Kiessling

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& Langewitz, 2013; Langewitz, 2011, 2012). All of these textbooks and contributions were written by researchers who have been working in this field for decades.3 The Calgary-Cambridge guides present a skills-based consultation model which highlights the communication skills that health professionals and in particular physicians can learn, and emphasizes the dynamics of interaction. The model is based on empirical research and introduces 73 skills organized into phases. Health professionals can choose from these and adopt the ones that are pertinent to the interaction in question (Silverman et al., 2013 [1998]: 29). In Figure 4.1, we see the five phases in boxes (initiating the session, gathering information, physical examination, explanation and planning, closing the session) and two arrows on either side which represent the concurrent pillars of providing structure and building the relationship. Bechmann (2014: 197) confirms that the proposed skills can be adapted for different types of interactions between health experts and patients, and that all of them can be structured into phases. Similarly to keeping up to date with medical research and developments, communication in medical practice is thus a recognized and fundamental pillar for health practitioners. Making room for teaching communication skills in an overloaded biomedical curriculum (not to mention medical humanities courses such as ‘medicine and literature’ and ‘medicine and film’; see Kiss et al., 2015) is a rather different story. This project was lucky to find two universities where teaching communication skills is compulsory and has been given the necessary importance for some time. In order to better understand what the students write about in their texts, we wanted to see what

Figure 4.1 The Calgary-Cambridge framework (Silverman et al., 2013 [1998]: 19)

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they were taught in the communication skills courses, and what concepts the courses introduced. As reported in Section 2.3.2, the students in Basel are exposed to communication skills teaching for several years during their medical studies. In an article explaining the curriculum in Basel, Kiessling and Langewitz (2013) show that Basel places a great deal of value on social and communication skills (abbreviated as SOKO in German) and on a holistic approach to medicine. Two of the four basic competencies at Basel concern the following fields: The Bachelor and Master programme in Basel consists of both a core curriculum and special study modules. In the Bachelor programme, the core curriculum includes organ-based modules and a longitudinal curriculum called ‘basic competencies’ (BC) which covers four areas: 1. practical skills, diagnostic and therapeutic procedures, 2. social and communicative competencies (SOKO), 3. scientific competencies, and 4. humanities and medical ethics. (Kiessling & Langewitz, 2013: 11) According to Kiessling and Langewitz, [t]he aim of the Basel SOKO curriculum is to train students to gather correct and complete data (e.g. history taking) and to share information with patients in order to enable them to act as well-informed partners in the decision making processes [Langewitz, 2011, 2012]. A limited number of communication techniques are trained that are then applied in different combinations to cope with different complex tasks such as breaking bad news or shared decision making. In principle, the techniques can be divided into two categories: ‘opening space’ and ‘limiting space’. The task is, therefore, not necessarily to give patients room for an infinite narrative [Kumagai, 2008] but to provide students with techniques to manage encounters with different focal points. (Kiessling & Langewitz, 2013: 12) We can thus assume that teaching social and communication skills is not l’art pour l’art, but rather has the clear aim of improving medical practice overall. Table 4.1 is taken from Kiessling and Langewitz (2013) and shows the SOKO modules for the first four years of study (SJ). Appendix 9.7 contains the corresponding organ-based curriculum. The students receive input on the following: delivering information, summarization and reflection exercises, general communication exercises (medical history), structuring, speaking with third parties, patient-centred communication, effective management of emotions, patient death, and declaration of consent (describing and presenting content as well as obtaining consent). They practise skills in several contexts during explicit communication training sessions (including role play and

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Table 4.1 Basel SOKO curriculum for ‘social and communicative competencies’

Source: Kiessling and Langewitz (2013: 15).

consultations with simulated and real patients) and during their internship. The analysis of their video-taped interaction and OSCE exams on various communication tasks accompany the students throughout their studies. Two concepts that are repeatedly referred to in Basel are the WWSZ acronym and the NURSE mnemonic. WWSZ stands for Wiederholen – Warten – Spiegeln – Zusammenfassen (‘echo, wait, mirror, summarize’4) and is at the heart of patient-centred communication (Kiessling & Langewitz, 2013). The mnemonic NURSE is introduced to help students handle emotions. It stands for ‘naming emotion, understanding emotion, respecting=showing respect for

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the patient, supporting, exploring emotion’ (Kiessling & Langewitz, 2013: 14; see also Back et al., 2007; Smith, 2002). As mentioned earlier, the Nottingham medical students wrote their texts for the clinical communication skills module that they took in the second year of a five-year medical degree. This module introduced the students to more challenging forms of clinical communication (communication with patients with mental health problems, learning difficulties or hearing impairment, and explaining medical information to lay people). In the previous year, they had completed a clinical communication skills module that exposed them to topics such as how to structure a clinical interview, how to use different question types, how to signal empathy, 5 how to build rapport, how to use non-verbal communication and how to understand the roles of doctor and patient. During this first-year module, they also received input on the importance of reflective writing and learnt how to identify types of communication skills from a transcript and to reflect on communication skills. In addition to input from these courses, the students also gained hands-on experience of clinical interaction during an attachment at a GP practice and through regular hospital visits. In addition to fulfilling internal course requirements, the students also need to pass an OSCE, in which they demonstrate communication skills while being assessed by an examiner. In discussion with Tischler, a set of communication skills were identified as being part of the core teaching aims for the medical students in this module (see also Maguire & Pitceathly, 2002). Judging by this list, Basel and Nottingham have the same teaching scope. We can therefore present a merged list of taught communication skills for analysis (see Table 4.2 below), which will be discussed in the next section.

4.3 Quantitative Overview of Communication Skills 4.3.1 Methodology The communication skills listed in Table 4.2 present the merged teaching at Basel and Nottingham. We have split the skills into groups that differ in their general pragmatic orientation. Group 1 deals with a general stance that the students should be able to adopt flexibly. Group 2 covers transactional skills such as delivering information, structuring the consultation, listening, mirroring, and summarizing the patient’s positions (in order to elicit confirmation or acquire further information). The skills in Group 3 highlight relational and interpersonal issues such as creating rapport and building trust, or showing empathy and sympathy. Finally, Group 4 covers non-verbal skills that are also taught as an important part of successful doctor–patient interactions and can serve both interpersonal and transactional purposes.

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Table 4.2 Clinical communication skills taught at Nottingham and Basel (1) General skills • Adapt/be flexible (2) Transactional skills • Deliver information/explain • Give patient time/conversational space • Listen • Mirror • Structure/signpost • Summarize • Use questions (3) Interpersonal skills • Be patienta • Create rapport/build trust • Empathize • Involve the patient • Reassure and reinforce • Show patients their resources and strengtha • Sympathize • Use (social) chit chat (4) Non-verbal skills • Respond to verbal and non-verbal cues • Spatial arrangement (e.g. moving chairs so that there are no barriers) • Use body language/tone of voice • Use non-lexical utterances a

These categories were not explicitly taught, but were tagged in the corpus because they emerged as pertinent.

All texts that contained the theme ‘communication skills’ (see Chapter 3) were also tagged with respect to the communication skills listed in Table 4.2. The categories ‘reassure and reinforce’ and ‘spatial arrangement’ did not occur, while ‘sympathize’ was mentioned numerous times but was not systematically differentiated from ‘empathize’ in the coding process (mainly because the students did not consistently separate the two concepts). ‘Respond to verbal and non-verbal cues’ was subsumed under the other nonverbal categories. We added the category ‘be patient’ and ‘show patients their resources and strength’ (Group 2) bottom-up since these strategies seemed to be of concern to the students who raised them when describing their communication processes. We also allowed the open category ‘other’ for issues that did not match any of the taught skills or that did not warrant a bottom-up category of their own. Our quantitative analysis recorded the presence or absence of the mention of clinical communication skills in each text but did not count how often a skill was mentioned in a text. The examples in Table 4.3 give an overview of the categories. An example could

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Table 4.3 Examples of the tagged communication skills (multiple labelling was possible in the examples, but is not displayed here) General skills

Examples

Adapt/be flexible

Hopefully I will be less anxious and more confident in talking to patients about why they are upset although I appreciate that not all patients will react in the same way in these types of encounters therefore I must be flexible in my approach to them. (N-085) I need to learn to be much more flexible, and adapt my interview technique so it is appropriate for each different patient. (N-118) Examples

Transactional skills Deliver information/explain

Give patient time/ conversational space

Listen

Mirror

Structure/signpost

Student: ‘Is it alright if we go ahead with that then?’ (We had just explained the examination) (N-102) Eve’s husband asked me why the CT scan hadn’t revealed the insects. I expected this particular question, for which I prepared a response. I explained that the insects were too small to be detected by CT. He insisted on knowing why I couldn’t give his wife this treatment at my clinic. I explained that I was not familiar with this treatment, although I had heard about it and was glad that it was successful. (E-10) Beim nächsten Gespräch werde ich noch mehr darauf achten, dass ich am Anfang den Patienten noch etwas mehr frei erzählen lasse. (B-34)/’Next time, I will be more careful still to let the patient speak freely at the beginning of the conversation.’ The change in Mr X brought out a more empathetic side of me, and I found myself slowing down the pace of the interview and giving him more time to speak. (N-093) I was able to talk him for a good while aswell [sic] and as it seems that things in hospital can be very rushed at times he may have appreciated someone just taking the time to listen to his troubles. (N-018) Again I used non-lexical utterance in order to allow the patient to keep talking whilst confirming I was listening and the use of a relatively open question again allowed her to tell her side of the story. (N-020) Ich fühlte mich sicher in der Kommunikation mit der Patientin, weil ich ihre Sorgen und Ängste spiegeln und auf sie eingehen konnte. (B-11)/’I felt confident in communicating with the patient because I was able to echo her worries and fears and thus to respond to her.’ I mirrored her actions by smiling and laughing when she did and this seemed to encourage her even further. (N-027) Im Alltag hätte ich vermutlich noch etwas besser strukturieren müssen, damit ich zeitlich schneller durchgekommen wäre. (B-04)/’Presumably, in workday life, I should have better structured the conversation to proceed more quickly.’ (Continued)

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Table 4.3 Examples of the tagged communication skills (multiple labelling was possible in the examples, but is not displayed here) (continued) Transactional skills (cont.)

Examples

Structure/signpost

However, I did not explicitly signpost the interview, failed to talk about her ideas, concerns and expectations, repeated things she already knew and also asked her leading questions […] (N-10) Ich habe dann das Gespräch kurz zusammengefasst und den Patienten noch untersucht. (B-34)/’I briefly summarised the conservation and then examined the patient.’ Once I had felt that I got the relevant information, I summarized to the patient what I had perceived of her problem to which she was satisfied that the correct information had been relayed. (N-025) Ich hätte z.B. noch eine offene Frage zu den Schmerzen stellen können, bevor ich mit den direkten Fragen begann. (B-34)/’For instance, I could have asked an open question about the pain before I started with the direct questions.’ It became evident that it was going to be difficult to ascertain any significant information by using open questions as the patient was unwilling to reflect or actively disclose information. (N-012)

Summarize

Use questions

Interpersonal skills

Examples

Be patient

Wenn ich mich selbst einmal in einer solchen Gesprächssituation befinde, werde ich versuchen möglichst viel Geduld aufzubringen die Gefühle der Patientin zu verstehen und ihr meine Unterstützung auszudrücken. (B-13)/’If one day, I will find myself in such a situation of communication, I will try to be as patient as possible in order to understand the feelings of the patient and in conveying my support.’ It is so important to be patient at all times and be sure not to use a condescending tone of voice, or speak louder than necessary. (N-115) Sie fasste volles Vertrauen in mich, öffnete sich mir gegenüber und erzählte mir alles. (B-33)/’She fully trusted me, opened herself to me and told me everything.’ Ich denke, dass man bei einem solchen Patienten sehr viel Zeit investieren muss, um eine gewisse Basis für das Vertrauen zu schaffen. Erst ab diesem Zeitpunkt kann man dann eine richtige Anamnesen machen und danach dementsprechend richtig anfangen zu therapieren. (B-27)/’I think that one should invest much time in such a patient to form a certain basis for trust. Only then can one do a correct anamneses and afterwards properly start with a therapy.’

Create rapport/ build trust

(Continued)

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Table 4.3 Examples of the tagged communication skills (multiple labelling was possible in the examples, but is not displayed here) (continued) Interpersonal skills (cont.)

Examples

Create rapport/ build trust

However, having said that, this ‘chat’ between me and Mrs S allowed me to build rapport and I felt that I was able to get information from Mrs S more easily now as she was feeling a lot comfortable talking to me about her conditions and how they were affecting her life. (N-083) I sensitvely listened to Mr X, recognised his sadness and attempted to show empathy towards him by leaning forward whilst talking to him and by maintaining eye contact thoughout the encounter. I also used empathetic language such as – ‘That must have been dificult for you.’ to make Mr X feel that I was listening to what he had to say. (N-006) Upon reflection, I wish I had used more empathy in order to reassure him and decrease any possible anxiety he had. (N-091) I constantly tried to encourage the child and parents to elicit their perspectives but this meant I had to carefully manage the triadic relationship between myself the child and the parent to make sure that the child wasn’t excluded in anyway. (N-145) It was a challenging consultation as the patient was difficult to engage. (N-181) Ich möchte dann, dass die Patienten mit den eigene Ressourcen und Kraft wieder Hoffnung und Freude am Leben finden. (B-02)

Empathize

Involve the patient

Show patients their resources and strength

Use (social) chit chat

Non-verbal skills Respond to verbal and non-verbal cues

Mir hat das Gespräch gezeigt, dass es manchmal gut sein kann, wenn man dem Patienten die vorhandenen Ressourcen spiegelt, damit ihm wieder bewusst wird, was er eigentlich noch hat. (B-04)/’The conversation showed me that sometimes it can be very good to show the patient his available resources so that he realises what he still has.’ (B-04) I felt that this consultation was more like a chat rather than the history taking which I had become accustomed to when talking to patients. (N-083) He was obviously sick of being in hospital so to be able to have a chat with someone for a while may have been a bit of a distraction. (N-018) Examples One example of this was my inability at the time to use enough verbal responses and non-lexical utterances to reassure the patient that I was actively listening to his concerns. (N-002) Throughout the conversation, certain aspects of the patient’s nonverbal communication were noteworthy for their consistency – lack of facial expressions, eye contact, and engaging posture. (N-012) (Continued)

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Table 4.3 Examples of the tagged communication skills (multiple labelling was possible in the examples, but is not displayed here) (continued) Non-verbal skills (cont.)

Examples

Use body language/ tone of voice

I sensitvely listened to Mr X, recognised his sadness and attempted to show empathy towards him by leaning forward whilst talking to him and by maintaining eye contact thoughout the encounter. (N-006) It is so important to be patient at all times and be sure not to use a condescending tone of voice, or speak louder than necessary. (N-115) I used open questions, clarified things that was not clear, used nonverbal behaviour such as non-lexical utterance like ‘uh-huh’, ‘okay’ and ‘yes’, listened to her attentively and maintained a good eye contact and body posture for most parts of the interview. (N-005) One example of this was my inability at the time to use enough verbal responses and non-lexical utterances to reassure the patient that I was actively listening to his concerns. (N-002)

Use non-lexical utterances

be tagged with more than one label, although this is not pointed out specifically in the table. Excerpts 4.1 and 4.2 show how the writers mention and reflect on their communication skills in context. The categories are given in diamond brackets (all examples are quoted verbatim; no changes have been made to the texts apart from bold highlighting and the addition of the diamond brackets).

Excerpt 4.1 I feel I communicated well with Mr X and I feel the conversation proceeded as planned. As I mentioned earlier, depression is a unique condtion and can very easily give individuals a sense of helplessness. Routine tasks become intolerable as concentration fades and unhappy thoughts intrude on our lives. I sensitvely listened to Mr X, recognised his sadness and attempted to show empathy towards him by leaning forward whilst talking to him and by maintaining eye contact thoughout the encounter. I also used empathetic language such as – “That must have been dificult for you.” to make Mr X feel that I was listening to what he had to say . After the encounter I realised that patients are invividuals with individual needs and emotional responses. What maybe be normal for someone may be the opposite for somone else. Therefore it is important to be prepared and spend time over a consultation especially with patients as vulnerable as Mr X, to gain all the important signs and symptoms. (N-006, emphasis and tagging added)

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Excerpt 4.1 is taken from a reflection part in which the student discusses how she communicated with a person who suffers from depression. The lexemes highlighted in bold were assigned to one of the clinical communication skills introduced above. While the text clearly lists the skills taught, the student also evaluates their use and, in the last sentences of the quoted passage, stresses what she has learnt. Excerpt 4.2 is taken from a text by a Basel student who wrote about her experience of practising taking the history of a male patient in his seventies. The reason for the visit was a check-up on his kidney function, but the patient shares his history freely and also talks about depression and loneliness. The excerpt shown here comes from the reflection and the conclusion part.

Excerpt 4.2 Ich fand das Gespräch im Grossen und Ganzen eigentlich ganz gut. Zuerst habe ich ihm Raum gegeben, um sein Leiden zu schildern und dann habe ich zum arztzentrierten Gespräch gewechselt. Beim patientenzentrierten Gespräch hat Herr X sehr viel von sich aus erzählt, so dass ich viele Informationen z.B. auch über die Familienanamnese zu einem früheren Zeitpunkt erfuhr, als es die strukturierte Anamnese vorgibt. Aus diesem Grund musste ich immer wieder auf dem Blatt rumspringen, damit ich wenigstens schriftlich die Ordnung einigermassen einhalten konnte. Vor dem Gespräch habe ich die Einteilung auf dem Blatt schon vorgenommen, so dass es mir während dem Gespräch einfacher viel das vom Patienten Gesagte zu strukturieren . Bei der Familienanamnese habe ich versucht das NURSE etwas anzuwenden. Ich wollte ihm Verständnis entgegenbringen für seine Situation und ihm seine Ressourcen aufzeigen (Kinder, Enkel, Nachbarn, Verwandte) . Mit dem Satz: „Einsamkeit ist leider ein sehr häufiges Problem bei älteren Menschen!” wollte ich ihm eigentlich zeigen, dass er damit nicht alleine ist, aber im Nachhinein bin ich mir nicht mehr so sicher, ob es passend war in dieser Situation, da es ja in dem Moment um ihn ging und nicht um irgendeine Statistik. Herr X hat sich Mühe gegeben, dass er bei der Systemanamnese nicht zu viel sagt, aber ich hatte den Eindruck, dass es ihm ziemlich schwer fiel sich zurückzuhalten. Einmal musste ich Ihn auch daran erinnern, dass ich ihn im Anschluss an das Gespräch noch gerne untersuchen möchte und wir daher etwas vorwärts machen müssten . Im Alltag hätte ich vermutlich noch etwas besser strukturieren müssen, damit ich zeitlich schneller durchgekommen wäre.

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[…] Mir hat das Gespräch gezeigt, dass es manchmal gut sein kann, wenn man dem Patienten die vorhandenen Ressourcen spiegelt, damit ihm wieder bewusst wird, was er eigentlich noch hat. (B-04, emphasis and tagging added) ‘Overall, I think the conversation went rather well. First, I gave him time to describe his medical condition and then I changed to the doctor-centred conversation. During the patient-centred part, Mr X told me very much so that I already gained a lot of information, for instance, about a family anamnesis at an earlier occasion, as is required by the rules for structured anamnesis. For this reason, I repeatedly had to hop around the page so that at least in writing some order could be maintained. Prior to the conversation, I already arranged the page so that it was easier to structure what the patient was saying . When doing the family anamnesis, I tried to apply NURSE. I wanted to express sympathy for his situation and show him his resources (children, grandchildren, neighbours, relatives) . My comment ‘loneliness is regrettably a very frequent problem of the elderly’ was actually meant to show him that he was not alone with this issue. Yet afterwards, I wondered whether it was appropriate to say it as in that moment, he was important and not some statistics. Mr X tried not to say too much during the system anamnesis, yet I had the impression that it was rather hard for him to hold himself back. Once, I also had to remind him that I wanted to examine him after the conversation and therefore we had better move forward a little . Presumably, in workday life, I should have better structured the conversation to proceed more quickly . […] The conversation showed me that sometimes it can be very good to show the patient his available resources so that he realises what he still has. ’ The student who wrote Text B-04 describes how she employed a number of communication skills strategies (‘give patient time/conversational space’, ‘structure/signpost’, ‘empathy’, ‘show patient their resources and strength’), and combines this with observations about how it worked out. For example, she mentions that keeping the structure of the interview clear for herself was

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challenging since the interview progressed differently from how it was outlined on her chart. She also realized that the comment about loneliness, which she quoted verbatim in a passage not shown here and which she made in order to express empathy, might have been misunderstood as turning the focus away from the individual and towards statistics. In the beginning of the conclusion part, which comes after the ellipsis, she reiterates that showing the patient the positive side of his situation was helpful.

4.3.2 The communication skills chosen for reflection, and their distribution In this section, we report on the quantitative results of tagging communication skills strategies. First, we find that it is quite common for the students to reflect on more than one communication skill in their texts. This was already evident in the excerpts shown in the previous section, where the students often mention or reflect on more than one strategy within the same sentence. In the case of Nottingham (the light grey section in Figure 4.2), 88% of the texts reflect on two to seven strategies, while 44% reflect on either four or five. Communication skills were not a central theme in just 2% of the texts. In the case of Basel, although students were clearly asked to focus on communication, 28% of the texts do not have communication as their central aspect. Nevertheless, 65% of all texts mention between one and four skills, and 9% mention more than five. This in itself means that the 80 70 60 50 40 30 20 10 0

Basel: % of 39 texts

0 2 3 4 5 6 7 8 9 1 skill skills skills skills skills skills skills skills skills skills 28

21

23

13

8

3

3

3

21

23

11

8

Nongham: % of 189 texts

2

5

12

13

Expert: % of 50 texts

70

18

8

4

4

1

Figure 4.2 Mention of different communication skills per text in percentage of appearance per text in all three corpora

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students are aware of the complexity of their interactional encounters. The experts, however, mention communication skills more sparingly overall (as already shown in Chapter 3): only 30% talk about them, and their texts never mention any more than four skills. Secondly, regarding the four groups of communication skills established above, Figure 4.3 displays the combined percentages by adding up the percentages for each communication skills group per category. This display allows us to see the weight of each group within the overall corpus. We can see that all three corpora peak at the interpersonal and the transactional skills. Finally, in terms of the type of communication skills mentioned, Table 4.4 shows the detailed listing of each skill in per cent for each corpus. The grey shading highlights the categories that are the most prominent in each corpus. In the case of Basel, we see that among the many options the students can choose to write about, they particularly focus on ‘create rapport/build trust’ and ‘empathize’ from the interpersonal skills group, and ‘give patient time/conversational space’, ‘use questions’ and ‘structure/signpost’ from transactional skills. ‘Give patient time/conversational space’ is in fact the most frequently used category, with 26% of all Basel texts referring to it. For Nottingham, we see similar choices: ‘create rapport/build trust’ and ‘empathize’ from interpersonal skills, and ‘use questions’ and ‘structure/signpost’ from transactional skills. However, the category ‘give patient time/ conversational space’ only occurs in 3% of the texts. Furthermore, ‘use body language/tone of voice’ (serving both interpersonal and transactional purposes) occurs as frequently as the two interpersonal skills. In fact, the Nottingham corpus mentions this skill most overall. Looking at their 300 250 200 147 150 130 100 50 19 3 0 0 General

81

95

51

13 6 Non-verbal

12

28 12

44 16 Interpersonal Expert: combined %

Basel: combined %

Transaconal

Other

Nongham combined %

Figure 4.3 Combined percentage for each corpus, indicating the weight of each communication skills group

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Table 4.4 Occurrence of mention of communication skills in all three corpora; the most important categories for each sub-corpus are highlighted in grey Group

Type of communication skill

Basel % of 39 texts

Nottingham % of 189 texts

General Interpersonal

Adapt/be flexible Create rapport/build trust Empathize Involve the patient Show patients their resources and strength Use (social) chit chat Be patient Use non-lexical utterances

3 18

19 60

21

61 4

4

4 10 12

4

5

8 8

59 23

6 2

8

8

4

26

3

2

8 21 3 23 28

2 54 2 54 51

4 12

Non-verbal

Transactional

Use body language/ tone of voice (Active) listening Deliver information/ explain Give patient time/ conversational space Mirror Structure/signpost Summarize Use questions Other

Expert % of 50 texts 8

5

distribution, ‘empathy’, ‘create rapport/build trust’ and ‘use body language/ tone of voice’ are mentioned in 60% of all texts; ‘use questions’ and ‘structure/signpost’ occur in 54% of the Nottingham texts. The Basel and Nottingham corpora differ in how they weight the individual skills. While none of the skills is discussed in more than 26% of the Basel texts, Nottingham clearly singles out the five strategies just mentioned. This means that the Basel cohort is less homogeneous than the Nottingham cohorts with respect to the issues selected for discussion. The expert corpus mentions communication skills substantially less frequently than the other two. Nevertheless, we find the mention of ‘create rapport/build trust’ here as well (in 8% of all expert texts), followed by ‘use body language/tone of voice’.

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4.4 Communicative Challenges: Discussion and Conclusions These quantitative results give us an idea of the importance that the students give to both interpersonal and transactional communication skills. The fact that the two top-ranking skills – ‘create rapport/build trust’ and ‘empathize’ – are from the interpersonal group suggests that we should look more closely at evidence of relational work in the corpus. This will be explored further in Chapter 6. In the current section, we will revisit some of the findings of the quantitative analysis, and discuss them in connection with the thematic analysis presented in Chapter 3 and the teaching input presented in Section 4.2. The instructions for the students asked them to write about an encounter with a patient who made a lasting impression (see Section 2.3). They did not specify whether this encounter should be a positive or a negative experience. Readers might have spotted that the excerpts in Table 4.3 report on both successful and less effective applications of communication skills. The students often report that they forgot to use suitable strategies or that they were not entirely successful in following through with them. For example, the excerpt used to illustrate the category ‘respond to verbal and non-verbal cues’, reproduced as Excerpt 4.3 for convenience, is actually embedded in a detailed discussion of what worked and did not work during a consultation.

Excerpt 4.3 As the history taking progressed, I discovered some deficiencies in my communication skills. One example of this was my inability at the time to use enough verbal responses and non-lexical utterances to reassure the patient that I was actively listening to his concerns: [constructed dialogue follows] (N-002) Further on in this excerpt (not shown here), the student highlights how she found it difficult to show appropriate empathy and manage her own emotions. Her text will be analyzed in detail in Section 7.5, which focuses on linguistic identity construction and positioning. As already established in the thematic analysis of the corpus (Chapter 3), the texts often discuss the role of emotions independently, both with respect to the patients’ emotions (Basel: 10%; Nottingham: 23%; Experts: 8%) and the students’/experts’ emotions (Basel: 23%; Nottingham: 17%; Experts: 34%; see Table 3.6). These emotions are often elaborated on in connection with communication skills, since the surfacing of emotions arguably creates a challenging communicative situation. The most-mentioned interpersonal communication skills – ‘create rapport/build trust’ and ‘empathize’ – both clearly involve emotions, which means this co-occurrence is maybe not all that surprising. Since managing one’s own emotions and responding to the

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patient’s is such a key theme within the reflective writing corpus and such a vital part of healthcare professions, we will look at the role of emotions separately in Chapter 6. Throughout their studies, both student cohorts receive separate input on situations that pose particular communicative challenges. Special attention is given to communicating with patients with mental health problems, learning difficulties or hearing impairments, and to explaining medical information to lay people, speaking to children, breaking bad news and dealing with emotions. These aspects also mirror the literature in general, which also lists challenging communicative situations in connection with the following: talking to old and young patients and to patients from different religious, social and cultural backgrounds; multilingual situations; situations which involve relatives as well as the patient and the doctor; situations where symptoms cannot be medically explained; telephone interviews; and the problem of time constraints (e.g. Bechmann, 2014; Blatt et al., 2014; Silverman et al., 2013 [1998]). Indeed, despite their still rather limited exposure to patients and thus limited first-hand experience, the students mention many of these communicative challenges in their texts, as do the experts. From the list of challenging situations mentioned above, the thematic analysis in Table 3.6 (Chapter 3) shows that emotions, language problems/speech impediments, cultural differences, special conditions, severe and terminal illness and time constraints all occur as main points of discussion in the texts.6 For example, in Excerpt 4.4, an expert writes about the challenge of delivering bad news on the telephone:

Excerpt 4.4 In 30 years of practicing emergency medicine, I have had my share of giving bad news to patients, telling relatives of the death of loved ones, explaining medical problems, and grieving with families. In fact, I have even written about how to tell bad news to patients and family, but I have yet to master this process over the phone—it is cold and sterile and difficult—I hate it, yet I had to do it. (E-18) The author stresses how uncomfortable (cold and sterile and difficult) the telephone is, and that he deeply dislikes the medium. In Excerpt 4.5, the expert writes about time constraints and the value of making enough time for patients:

Excerpt 4.5 Time is something that doctors and patients can GIVE to each other, like gifts with a personal signature. This gift of time is multiplied beyond the face-to-face encounter. Outside the medical office visit, the doctor’s words, tone and impression are magnified, scrutinized in conversations patients

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have with family and friends, who inevitably ask, “What did the doctor say?” While what the doctor said may not have been good news, at least the way in which it was said could provide a measure of comfort. Julie’s metaphor of the physician as sprinter and patient as marathon runner still brings a smile to my face on busy days in the oncology clinic. Time pressures have only intensified in the past decade. Office visits are sometimes rushed and often leave both physician and patient feeling dissatisfied. While it can be argued that even seconds of compassion make a difference and empathic responses can be delivered quickly and with the precision demanded of other therapeutic procedures, we need to acknowledge that important conversations still take time. One simply cannot speed through a family meeting. Our patients and their loved ones deserve our respect and the gift of our time. (E-12, emphasis in original) Students also mention the issue of time on numerous occasions. For example, some show awareness of being in a training situation that allows them more time for history taking than they will get when working, as shown in Excerpts 4.6 and 4.7:

Excerpt 4.6 I had a lot of social chit chat with Mrs S and although it resulted in the consultation taking longer, I believe that it allows that doctor to build a good relationship with the patient and this in my opinion is quite important, however in the future I will try to keep the time constraints in mind and will try to take the history efficiently in less time while trying to build a good doctor patient relationship as well. (N-083)

Excerpt 4.7 Bei dieser Konsultation ist mir eine gute Mischung zwischen authentischer und fachlicher Kommunikation geglückt. Eine grosse Rolle spielte dabei sicherlich der Zeitfaktor. Als ET-Student hat man viel Zeit und somit die Möglichkeit besonders umfassend auf den Patienten einzugehen. (B-15) ‘During this consultation I managed to achieve a good mixture between authentic and factual communication. A crucial role in this was clearly the time factor. As a tutorial-student one has a lot of time and thus the possibility to pay attention to the patient in a particularly comprehensive manner.’ They also often discuss time management per se and argue that they would spend more time or less time in future encounters on particular phases of their consultation, as can be seen in Excerpts 4.8 and 4.9:

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Excerpt 4.8 I could have managed the encounter in a better way if I had more time. My colleague and I did not complete the entire interview; we were afraid that because of this, we may have missed something else important entirely. If we had more time, or if we learnt to manage our time, we could’ve handled the condition in a more efficient manner. (N-088)

Excerpt 4.9 Wenn ich mir mehr Zeit genommen hätte vor der Konsultation die KG durchzugehen, hätte ich mir einen besseren Überblick verschaffen können und von Anfang an die Erwartungen und Bedenken von Frau X realistisch einschätzen können. (B-20) ‘If I had taken more time to read the [patient history] ahead of the consultation, I could have gained a better overview and more realistically assess Mrs X’s expectations and concerns.’ In a small number of texts, the students explicitly refer to the theoretical frameworks that they received in their training. Three Basel students refer to the NURSE mnemonic for handling emotions, and one refers to both WWSZ and NURSE, as evidenced in Excerpt 4.107:

Excerpt 4.10 Ich konnte dank den WWSZ- sowie NURSE-Techniken, die angesprochenen Probleme schildern und weiter erforschen. (B-11) ‘Thanks to the WWSZ and the NURSE techniques I could describe and further explore the described problems.’ In the case of the Nottingham corpus, 22 texts refer to the CalgaryCambridge guide. Two such excerpts are shown here:

Excerpt 4.11 I think the encounter made me realise that sometimes we are so eager to find out what symptoms the patient is presenting with and how to reach a diagnosis that we forget to use a holistic approach such as suggested by the Cambridge Calgary Guide and view the patient as a person, finding out about their family life, their living situation, how they are feeling about themselves. (N-046)

Excerpt 4.12 I feel that I would have succeeded more in this consultation if I had better kept to the Calgary-Cambridge guide. Possibly most importantly from this, I totally forgot about summarising as I was so busy thinking

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of other things to ask the near silent child. If I had summarised, then maybe the boy would have added or changed any details that I missed or got wrong and this would have provided me with a little more information. (N-155) Excerpts 4.11 and 4.12 show that the mention of the guide is combined with further observations, such as the importance of a holistic approach and the communication strategy of summarizing. It bears repeating that this analysis and discussion is neither exhaustive in terms of the communicative challenges of doctor–patient encounters reported in the corpus, nor representative of the challenges that doctor– patient encounters entail in general. The corpus is of course limited in that the student sub-corpora only reflect the as-yet narrow experience of their authors, while the expert corpus of just 50 texts cannot adequately reflect the diversity of concerns that are raised in the journal columns. Nevertheless, the analysis presented in this chapter displays a rich variety of communicative challenges and concerns. These will be further explored in Chapters 6 and 7, which address issues linked to interpersonal pragmatics.

Notes (1) This chapter draws in part on the following two publications, which deal with the Nottingham corpus only: Locher and Koenig (2014) and Locher (2015a). (2) Silverman et al. (2013 [1998]: 3) also mention the American Academy on Communication in Healthcare (AACH) and the European Association for Communication in Healthcare (EACH) as further sources. (3) Despite this long tradition, Brown and Bylund (2008: 38) deplore the fact that studies on teaching success in this field rarely define ‘communication skills’ and often work with quite fuzzy concepts. (4) In Kiessling and Langewitz (2013: 12), the sequence is ‘wait, echo, mirror, summarize’ (WEMS). (5) While empathy is an affective state, the point is not just (or not necessarily) to feel empathy but to signal this state to the recipient. As ‘empathic communication skills’, Brown and Bylund (2008: 44) mention acknowledging, normalizing and validating a patient’s emotional response as well as encouraging the expression of the patient’s feelings and praising the patient’s efforts to cope with the medical condition. See also Pounds (2010, 2012) on assessing empathy in medical training. (6) The numbers in Table 3.6 show that these categories are one of the main themes of a text (rather than the text just mentioning them in passing). (7) As mentioned in Section 4.2, WWSZ is a German acronym for Wiederholen – Warten – Spiegeln – Zusammenfassen (echo – wait – mirror – summarize); NURSE stands for ‘naming emotion, understanding emotion, respecting = showing respect for the patient, supporting, exploring emotion’ (Kiessling & Langewitz, 2013: 14; see also Back et al., 2007; Smith, 2002).

5

Reflective Writing as Genre: A Text Linguistic Perspective

5.1 Introduction As explained in Chapter 2, our corpus of reflective writing texts was compiled in connection with an interdisciplinary project on ‘illness narratives’. Within the literary part of this project, we also explore literary texts by authors who write about their experience as patients. In addition to these so-called autopathographies (Hawkins, 1993), other narrative forms deal with the experience of illness, and we ‘very loosely apply the term illness narrative’ to the texts in our reflective writing corpus as well (Gygax & Locher, 2015b: 5). However, while acknowledging the crucial role of narrative within the corpus, we should not forget that the texts are primarily reflective in nature and have an educational function in the case of the student texts and a peer-sharing function in the case of the expert texts – rather than a social sharing or coping function. This chapter1 addresses the following research questions: What exactly is a ‘reflective writing’ text in our context? and What other genres does this text type draw on? We will look at the composition of reflective writing texts and will pay special attention to the importance of genre mixing and the notions of ‘reflection’ and ‘narrative’ therein. The methodology employed is descriptive, in that we systematically describe parameters used in linguistic genre analysis. We also draw on corpus linguistic methods such as frequency lists, keyword analysis and collocations in order to better understand the corpus and the composition of the texts. In Section 5.2, we will begin by reviewing aspects of the literature on reflective writing in medical practice, and we will also see how the important notion of ‘genre’ is discussed in linguistics. Section 5.3 presents a systematic overview of the genre features of the corpus, while Section 5.4 addresses questions of genre mixing by considering how essays, medical case reports, drama texts and narrative genres influence the texts. 72

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5.2 Reflective Writing in Medical Practice and Theoretical Background on Genre According to Branch and Paranjape (2002), Reflection in medicine – the consideration of the larger context, the meaning, and the implications of an experience and action – allows the assimilation and re-ordering of concepts, skills, knowledge, and values into pre-existing knowledge structures. When used well, reflection will promote the growth of the individual. While feedback is not used often enough, reflection is probably used even less. (Branch & Paranjape, 2002: 1185) While the authors argue that there is not yet enough reflection implemented in medical education, its value is clearly recognized (see, for example, Wald, 2015; Wald & Reis, 2010; Wald et al., 2009). This quote is taken up by Monash University (2012) on a website dedicated to reflective writing in the medical professions: In medical and health science courses you are required to produce reflective writing in order to learn from educational and practical experiences, and to develop the habit of critical reflection as a future health professional. (Monash University, 2012) The text goes on to explain that ‘[r]eflective writing may be based on: description and analysis of a learning experience within the course’; ‘description and analysis of a past experience’; ‘review of your learning or course to that point’; or ‘description and analysis of a critical incident’ (Monash University, 2012). The structure of these texts is based on three steps: description, interpretation (or reflection) and outcome (or conclusion) (Hampton, 2010a, 2010b; for an extended version, see Watton et al., 2001). It is important to stress that reflective writing does not only occur during the education phase at universities. As the quotation above highlights, the students are encouraged to ‘develop the habit of critical reflection as a future health professional’ (Monash University, 2012). Indeed, reflective writing is a tool often used by professionals to monitor their continual learning processes (Brady et al., 2002; Mann et al., 2009; Monash University, 2012; Shapiro et al., 2006). Watton et al. (2001) quote Gibbs (1988) on the importance of reflection: It is not sufficient simply to have an experience in order to learn. Without reflecting upon this experience it may quickly be forgotten, or its learning potential lost. It is from the feelings and thoughts emerging from this reflection that generalisations or concepts can be generated. And it is generalisations that allow new situations to be tackled effectively. (Gibbs, 1988: 9)

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This means that reflective writing can be a lifelong tool that helps professionals of any kind to keep learning from their experience. As described in Chapter 2, both the University of Basel and the University of Nottingham have made reflective writing tasks for medical students part of their curricula. The students receive detailed instructions on how to compose their text. These can be summarized as follows: • • •

The students are asked to write about a conversation/encounter with a patient that made the biggest impression on them during their attachment at a GP surgery or in a hospital. They are asked to introduce/describe the situation and the characters of the chosen episode, and to use constructed dialogue for key passages. They are asked to reflect on their communication skills and emotional reactions, and to draw conclusions about future behaviour.

The detailed instructions ask the students to pay particular attention to communication skills and to include reflections on the feelings and emotions that were part of the experience. Figure 5.1 gives an idea of the level of detail (see also Appendix 9.2 and 9.3) and also shows that the students are encouraged to use constructed dialogue (see Tannen, 1989) to illustrate their encounters. Furthermore, the labels ‘description’, ‘reflection’ and ‘conclusion’,

Figure 5.1 The instructions for the Nottingham students Notes: The designations ‘description’, ‘reflection’ and ‘conclusion’ have been added. See also the Appendix for full details on the Basel/Nottingham instructions.

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which were added to Figure 5.1 for illustration purposes only, clearly structure the task in line with the reflective writing philosophy. The columns ‘A Piece of My Mind’ (JAMA) and ‘On Being a Doctor’ (AIM) from which the 50 expert texts are taken do not have the same educational aims as the Basel and Nottingham reflective writing texts. Nevertheless, they clearly show a reflective practice and are intended to be instructive for the professional medical readership. While we cannot expect these texts to follow the description-reflection-conclusion pattern to the same extent, it is interesting to see how reflection is built into the composition of the texts, which are written to share personal insights on the medical profession with peers. Using the term ‘reflective writing text’ seems to imply that there is in fact such a genre which can be systematically described. In this study, the term is primarily used as shorthand for the types of texts studied here. However, reflective writing texts can take many shapes. Wald et al. (2009: 830), for example, mention ‘journaling, field notes, and other student-generated narratives’. As many researchers point out, defining ‘genre’ in linguistics is clearly no straightforward task (see Bax, 2011; Corbett, 2006; Giltrow, 2013; Giltrow & Stein, 2009; Schubert, 2012) and this is also the case for reflective writing. Linguistic approaches to genre developed out of literary and folklore studies (see Swales, 1990: 33–44) and can be found within discourse analysis, corpus linguistics and text linguistics (see Schubert, 2012: 14). Corbett (2006: 27) argues that a number of very productive research strands exist. In systemicfunctionalist linguistics, researchers are concerned with collecting ‘comparable texts and attempts to find in them predictable, goal-oriented elements that are characterized by similar realizational patterns’ (Corbett, 2006: 31). The new rhetoricians are more interested in a genre’s historical context, while applied linguists focus on genres in order to be able to ‘teach generic conventions to novices’ (Corbett, 2006: 31). We might add that corpus linguistics in general has furthered our understanding of genres with respect to corpusderived grammars and to methodology (Biber, 1988, 1989; Biber & Conrad, 2009; Biber et al., 1999; Conrad & Biber, 2001a, 2001b). Here we follow Bax’s (2011: 44–45) definition of ‘genre schema’, which is a ‘mental construct which we draw on as we create and interpret actual text’ (similar to schemas/frames/scripts/activity types albeit in written form; Bateson, 1954; Goffman, 1974; Levinson, 1992). This means that we are ultimately dealing with a cognitive concept and that interactants assess the degree of prototypicality of a text, i.e. the ‘actual manifestations of language in the world’ (Bax, 2011: 27), when they encounter it in a particular context in order to make sense of it (Bax, 2011: 39). It is important to point out that this approach allows texts to be fuzzy and unstable and to demonstrate textual hybridity (see also Busse, 2014a, 2014b). Indeed, ‘[t]exts draw on our mental ideas of genres, but may differ from those genres in various creative ways, or may mix genres creatively for particular and communicative purposes’ (Bax, 2011: 27).

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Following Swales (1990: 46), the communicative purpose or function of a genre is its most distinctive feature. Textually speaking, this function can be achieved in different ways. Bax (2011: 57) speaks of a distinction between genre (functionally defined) and discourse mode. He argues that ‘[d]iscourse modes do not have unique functions in themselves but enter into many genres’. For example, discourse modes can be narrating, describing, informing, arguing, interacting, etc.2 and these modes can be combined and have many different functions when they form genres such as ‘conversation’, ‘classroom lesson’, ‘novel’, ‘weather forecast’ and ‘recipe’. In addition to these discourse modes, Bax (2011: 60–61) argues that ‘[t]he function of a genre then guides the features of the genre. These features include the location, structure, layout, style, lexis, grammar, and other aspects’. By way of example, Bax (2011: 50) discusses the ‘recipe’ genre, whose function is ‘to inform us quickly and efficiently how to prepare a particular dish’. This function determines the set of features summarized in Table 5.1. Table 5.1 The relation between text functions and text features Features

Example: Recipe genre

Location Topic focus Visual aspects and layout Pictures, position of different parts, diagrams, colours

In a magazine or recipe book How to prepare food

Length Structure Subjects/agents/focus [discourse modes] Who is actually doing the actions? Subjects of the verbs? Style and register Formal or informal? Related to any particular professional domain? Grammar Tense (past, present, future) Syntax (word order) Length of sentences Lexis Any jargon or technical language? Source: Abbreviated from Bax (2011: 50).

Frequently starts with a bold title and has pictures, perhaps with various colours to make it attractive Typically no longer than one page Title, picture, ingredients, instructions, etc. Imperatives. The ingredients are in describing discourse mode and the instructions in the interacting discourse mode. Typically relatively informal

Imperatives, some conditionals (if it is tender, then …) Standard, but simple Simple short sentences Cooking terms, names of foods, weights and measures

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In order to establish the features of our reflective writing corpus, we will now analyze the same nine features proposed by Bax (Section 5.3). We will supplement this analysis with insights from corpus linguistics (Biber, 1988, 1989; Nini, 2015a, 2015b), and will then turn to the hybridity of the genre by looking at what evidence of genre mixing we can find in the corpus (Section 5.4).

5.3 The Text Features of the Reflective Writing Corpus While Bax (2011: 50) notes that the function of a recipe is ‘to inform us quickly and efficiently how to prepare a particular dish’, the main function of the texts in all three sub-corpora is to help the students/experts learn from an experience in the past by reflecting on communication skills (in the case of the Basel and Nottingham sub-corpora) and on insights gained (in the case of the expert texts). Taking Bax’s (2011: 50) table of features as inspiration, we will now discuss them in turn.

5.3.1 Location The student texts were submitted in digital form to the instructor, and their location is a non-public archive. The texts exist as printouts for safekeeping and analysis and (ideally) the students retain their texts as part of their personal (non-institutional) learning portfolio. The expert texts are accessible for the professional community online in the journal archives. These locations tell us much about the intended readership. While it is clear that reflective writing should primarily benefit the writers themselves, submitting these texts to university staff or publishing them in a journal also entails an element of assessment or scrutiny. In the case of Basel, the students write the texts as a compulsory written assignment that they must complete during their internship at the GP surgery. They submit the text to the faculty of medicine, where the communication skills unit keeps track of and checks the assignments. The students are also encouraged to discuss their reports with the GPs. The target audience is thus both GPs and members of the medical faculty. For Nottingham, the situation is slightly different. While the students submitted a creative writing task to their communication skills teacher for credit (not analyzed here), they completed the reflective writing task as an additional exercise and allowed us to use the texts for research. As the instructions ask students to reflect on their communication skills and to submit the paper via the university’s official electronic submission portal to their communication skills teacher, the target audience is this specific teacher and the research team of which she is a part. (We will show evidence for the importance of this intended readership in Chapter 7, where

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we discuss acts of positioning.) Finally, the physicians who write for the two journal columns (which have a long tradition of publishing reflective writing within the medical humanities) do not only write for their own insights but also to share them with the target physician readership.

5.3.2 Topic focus The general topic is given, in that the students are requested to and do reflect on an encounter with a patient who made a particular impression on them. The selection criteria for expert columns were designed to match this (see Section 2.3.3). However, the instructions do not specify which encounter to write about, so the students are free to select an experience for reflection. As established in Chapter 3, the students write especially frequently about communication strategies, their own or the patients’ emotions, special conditions, the impact of illness on a patient’s life, and setting (see Table 3.6). The experts share some of these concerns and write about their emotions, communication strategies, professional expertise, special conditions and cultural differences (see Table 3.6). We can also state that the instructions for the student texts and the purpose of the journal columns create a narrative framework because they involve recalling a personal experience. This narrative framework and the reflective backbone of the texts will be further explored in Section 5.4.

5.3.3 Visual aspects and layout We often instantly form a hypothesis about what genre a text belongs to merely by looking at how it is presented on the page. Bax’s (2011: 50) example of a recipe mentions a bold title, pictures, colours, a list of ingredients and measurements, and the structured instructions as identifying features. In the Basel and Nottingham sub-corpora, one of the most striking visual features of the layout is the inclusion of constructed dialogue. The instructions ask for this particular feature and also provide a specific example. In the case of 30 Basel texts (77%) and 165 Nottingham texts (87%), the students comply with this request and include constructed dialogue in theatre script format, i.e. it is not only reported within a paragraph and commented on, but is also visually set off from the main text. Excerpt 5.1 is a case in point:

Excerpt 5.1 Situation: * Describe the patient (age, relevant diagnosis, first impression – appearance, posture, language, anything else noticeable, etc.) Mr. B is X years old, Caucasian an retired. He has a multitude of significant health problems, lives alone in a flat complex opposite to his general practice and quite likes his own company and privacy. On first

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meeting, Mr. B seemed up tight and slightly annoyed that we were disrupting his day: Mr. B: [Student]: Mr. B: [Student]: Mr. B:

“Oh! Hello! I just got a call from reception saying someone was coming up but you rang the bell at the same time so you made me rush, I can’t rush! Come on in then.” “Thank you, Mr B. We are sorry, we did try to ring the buzzer downstairs..” “What?” “[louder voice] Sorry for disturbing you, we did try the buzzer a few times!” “Oh! No I didn’t hear it, it may be broken. Well come on then, I’m just watching the snooker but I that’ll have to wait now. What have you come for?”

Mr. B was tidy and well dressed. His flat was neat and his living room was full with video tapes, CDs cupboards and boxes of records; alongside these sat a large hi-fi system, plasma screen, blu-ray player and sky box. (N-072, very beginning) From a visual point of view, the inclusion of constructed dialogue is actually more of a defining feature for the corpus than the inclusion of section titles is. This is because many students chose not to use any section titles to structure their text visually. Figures 5.2 and 5.3 show two typical layouts in the student corpora. The print is too small to read, but the figures are intended to give a visual impression of the texts. For the Basel sub-corpus, 27 texts (69%) are presented as an essay, without any subsections or headers (with the exception of the inclusion of constructed dialogue). In 10 texts (26%), the students use the headers given in the instructions (situation, reflection, aims; or variants thereof; see Situation at the beginning of Excerpt 5.1), while the remaining two texts (5%) use a dialogic presentation by not only taking up the suggestions for section headers, but also by including all the guiding questions found in the instructions, to which they then give a responses (see *Describe the patient ..: in Excerpt 5.1 and Figure 5.1). In the case of Nottingham, the distribution is very similar: no text sectioning in 124 texts (66%), only title sectioning in 43 texts (23%), Q&As/ bullet points in nine texts (5%), and a combination of title sectioning and Q&As/bullet points in a further 13 texts (7%). The absence of section titles or Q&As/bullet points derived from the instructions does not mean that the texts themselves were not structured, merely that the visual markers were missing. The articles written by the experts are not organized with the same visual features as the student texts. For example, there are no subsections or

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Figure 5.2 Text N-068 displays constructed dialogue, and no further sectioning other than paragraphs

Figure 5.3 Text B-04 displays section titles, subsections and constructed dialogue

Q&As/bullet points that the authors can systematically work through. Instead, the titles of the articles are given more weight than in the student texts. On the one hand, this is because the layout of the columns ‘A Piece of My Mind’ and ‘On Being a Doctor’ sets the title off in bold face and large

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Figure 5.4 Illustration of the layout of the columns ‘A Piece of My Mind’ (JAMA) and ‘On Being a Doctor’ (AIM)

font; on the other hand, the phrasing of the titles is idiosyncratic, catchy and raises the readers’ interest – in contrast to the technical titles ‘situation’, ‘reflection’, ‘aims’ used in the student corpus (for the list of titles used in the expert texts, see Table 2.4). The columns end with the writer’s name and address, bibliographic information and a disclaimer. Figure 5.4 juxtaposes one text from each column to illustrate their layout. Constructed dialogue is also a crucial element for the expert texts, which abound with quotation marks and reported speech. However, this feature is rarely presented in theatre script, i.e. we rarely find passages that are specifically set off from the main text. The only exceptions are seven texts (14% of 50 texts) that use this visual means of structuring text. In two more texts, italics are used to insert thoughts and extracts from letters in passages that are set off from the main text.

5.3.4 Length and structure The student texts are one to four pages in length according to our layout, while the expert texts are one to two pages. The number of words is more telling and, as Table 2.1 informed us in Chapter 2, the Basel texts have a mean length of 674 words (SD = 178), the Nottingham texts have a mean length of 1321 words (SD = 413) and the expert texts have a mean length of

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1251 words (SD = 377). The Nottingham and expert corpus are thus closer to each other than the texts in the Basel corpus, which occupy the shorter end of the spectrum. Generally, the structure of the student texts follows the classic reflective writing paradigm of description-reflection-conclusion/aims as suggested by the instructions and no matter what layout and visual presentation choices were made. The students thus start with a description of the encounter and then analyze what happened during the encounter. Often the description part already contains some discussion and insights, which are then revisited in the final part where the students draw lessons from the past for the future. Excerpt 5.2 is a passage that occurs immediately after the first instance of constructed dialogue (see also Figure 5.2) in which the student responds to a crying patient by saying, Are you O.K.?

Excerpt 5.2 After the encounter, I felt that I should have handled the whole situation better, starting from when the patient started crying. In hindsight, the question, ‘Are you O.K?’ was unnecessary as the patient was clearly not alright. I could have offered her a tissue or at least asked her about her home and work life first before asking her more about the vertigo. (N-068, Lines 26–29) Later in the text, the student gives more information on how the encounter proceeded and also reflects on how the communication went. She starts the conclusion part with: From this encounter I have learnt (Line 62, not shown here) and writes two paragraphs on insights and future behaviour. Finally, she ends the text by referring back to the reason for choosing this memorable encounter, i.e. a distressed and emotional patient, and projects future behaviour.

Excerpt 5.3 If I ever find myself in this situation again, I could maybe offer the patient a clean tissue, or comfort her by putting my hand on her shoulder. This lets the patient know that I am here to listen and that I am ready to stay with her for as long it takes her to say what she wants to say. (N-068, Lines 78–80) Even in the texts that follow the section heading and bullet points of the instructions quite closely, as in B-04 in Figure 5.3, analysis is already evident in the paragraphs on the situation. In Excerpt 5.4, the student writes about an encounter with a patient who had lost many family members, suffers from depression and nevertheless appeared to be positive. With regard to how she felt after the consultation, the student reflects as follows:

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Excerpt 5.4 Ich hatte ein gutes Gefühl, da ich mir wirklich die Zeit nehmen konnte, um ihn zu befragen und er sehr offen war. Ich hatte den Eindruck, dass er es geschätzt hat, dass sich Jemand so Zeit für ihn genommen hat. (B-04, Lines 45–47) ‘I had a good feeling because I really could take my time to ask him and he was very open. I had the impression that he appreciated that somebody had so much time for him.’ In other words, the students often blur the line between presentation (‘situation’) and reflection/conclusion. The experts write more creatively since, unlike the students, they are not following any kind of ‘script’ and the texts thus appear less schematic. For example, there is generally no explicit reference to a task such as ‘write about an encounter with a patient who made an impression on you’, but we do see elaborate compositions designed to fend off the ‘so what’ question (Labov, 1997). In other words, the choice of which encounter to write about is also an important angle for the writers of the expert texts. It is generally the reflection part (or parts) that explains the choice and analyzes the interactions. It is also striking that the texts invariably conclude with a more polished ending, for which Excerpt 5.5 is a case in point:

Excerpt 5.5 In the end, just like our other conversations, the one about death and dying requires us to set aside our own judgments and present an open mind and a ready ear to patients. Even if we will not deserve their praise for a cure, we will have earned their gratitude for easing the process of death. (E-39, very end) The author completes her column in such a way that the text is nicely wrapped up by revisiting the gist of the text.

5.3.5 Discourse modes Regarding the discourse modes employed, we find a mixture of narrating, describing and arguing, which together make up the reflective writing corpus. Following Smith (2003: 23), the narrating discourse mode ‘presents a sequence of events and states that have the same participants and/or causal or other consequential relation … They occur in a certain order, which is crucial for understanding’ (as quoted in Bax, 2011: 66). Bax (2011: 66–67) adds that the narrating mode often displays sequencing or time adverbs (‘then’, ‘suddenly’, ‘so’) and focuses on past events that dynamically develop within the story timeline. Furthermore, Bax (2011: 65–77)

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mentions structural elements of written and oral narratives as reported in the work of literary and linguistic scholars. However, he is careful to point out that these features do not all have to co-occur in order to argue that the text contains elements of the narrating mode. We will return to the importance of narrative in Section 5.4.2. Here we will demonstrate the narrating mode with Excerpt 5.6, which comes at the very beginning of Text N-175.

Excerpt 5.6 As I entered the nurse’s office, I noticed the patient. A small boy of seven, huddled in his mother’s arms, with a panicked expression on his face. As he sat there, his sister stood across from him, a look which I can only describe as consternation on hers. With a short, number 2 haircut, the boy looked like a typical schoolchild in a totally alien environment, the last place someone wants to be. The GP took me aside a moment, and quietly informed of the situation. The boy had a bead stuck inside his right ear canal. The bead had almost completely obstructed the canal, and it had to come out. (N-175, very beginning) The first paragraph of N-175 starts in medias res. An ‘I’ enters the ‘stage’, where we already find a scene unfolding. The writer nicely transports the reader back in time to a nurse’s office, into which the student enters. The location and the characters of the scene are introduced (the ‘I’, the patient, his sister, the GP). In addition, the medical problem is reported in such a way that we assign the words to the GP. Importantly, actions happen in sequence, e.g. the student enters the nurse’s office, takes stock of the situation and is then briefed by the GP. In a Labovian (1997) analysis, we can say these paragraphs present the orientation phase. For this reason, we can also make a case for the presence of the describing discourse mode. In Bax’s (2011: 90) terms, ‘in the describing discourse mode there is less a focus on events than in narrating, and more focus on people, places and things’. For example, the description of the haircut of the patient would fall into this category. Finally, the arguing discourse mode is crucial for the reflective writing corpus. In this mode, we find ample use of verbs of opinion (‘feel’, ‘believe’, ‘think’) and linking words (‘however’, ‘but’, ‘nonetheless’) (Schubert, 2012: 99). Excerpt 5.7 (which is taken from the same reflective writing text as Excerpt 5.6) and Excerpt 5.8 demonstrate this use (think, believe, however, perhaps if).

Excerpt 5.7 This patient was definitely one of the more outstanding ones in my memory. For one, the uniqueness of the situation contributed to this.

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Rather than a short consultation in a room, there was action, back and forth, and plan, and adaptations to that plan. I think that another major factor was that I was forced to communicate with a patient in distress, as well as with his family, and unusual experience. […] The main points I took away from this encounter, was that, especially with children, you can’t always develop a true rapport in a short consultation. With so much going on, and especially a clear goal and objective, there simply wasn’t enough time or incentive to ask where the patient went to school, or what his favourite food was. Perhaps if I had been brought into the consultation earlier, and had seen the boy from minute one, I could’ve developed more communication with him. (N-175, reflection and concluding part, emphasis added)

Excerpt 5.8 The patient history didn’t go as I intended, it wasn’t slick or well sign posted and it took much longer than anticipated. I normally explore what the patient says a lot more and stick to the clinical aspects more. However, by not doing this I think I achieved more and both I and importantly the patient got more out of the encounter. […] In hindsight I believe I became too enthralled with the patients “story” to actually gain an understanding of him overall. (N-185, reflection part, emphasis added) The combination of narrating, describing and arguing is thus instrumental in realizing the reflective writing texts in all three sub-corpora.

5.3.6 Style and formality Discussing style and formality is always a matter of relating findings to other corpora. However, without making any absolute claims, we can state that the writers in all three corpora adhere to fairly formal, standard written language in the description and reflection parts of their texts, and use standard orthography. The language register is interspersed with medical terminology, mention of body parts and – in the case of the expert corpus – vocabulary derived from the semantic field of ‘family’ (see lexis in Section 5.3.8). For Nottingham and Basel, two more issues emerge as noteworthy with regard to the presented dialogues. The Nottingham corpus includes noticeably non-standard, written forms as a stylistic means for character positioning in some of the constructed dialogues. This feature is also present, although to a lesser degree, in the expert corpus (Bamberg, 1997; Davies & Harré, 1990; see Chapter 7). Excerpt 5.9 from N-074 is a case in point:

Excerpt 5.9 Me:

“I noticed you were rather reserved earlier when the Doctor asked you questions, yet you seem to be able to talk to me quite easily. Do you know why this is?”

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Patient: “I dunno. I don’t think he really gets it. I kinda feel like I’m wasting his time.” Me: “And why do you think this?” Patient: “Well I’m not actually ill am I. Just feeling down. It’s not really the Doctor’s job to deal with people like me. He should spend his time with people who really are ill.” Me: “I see. I’m sorry you feel like that.” (N-074, emphasis added) In Excerpt 5.9, the constructed dialogue contains oral features such as contracted informal forms (dunno, kinda) and a tag question (am I?). The patient uses these oral features, while the student (Me) does not. This creates a difference between the two speakers on a linguistic level. In the Basel corpus, it is worth mentioning that the constructed dialogues are rendered in High (Standard) German, i.e. in the same standard of German as is used for the rest of the text. However, it is highly unlikely that an encounter between two Swiss people from the German-speaking region of the country would be conducted in Standard German, since the dialects are used for everyday interactions. Nevertheless, transforming the recalled encounter from a dialect situation to a standard-language situation is not particularly surprising since the Swiss education system uses Standard German in written contexts. Furthermore, the instructions also give an example in Standard German. Only a few students explicitly mention the dialect; for example, the writer of B-10 comments on the dialect at the end of his description of the patient in Excerpt 5.10:

Excerpt 5.10 Seine normal wirkende Körperhaltung lässt noch nichts erahnen. Ich weiss noch nicht, warum der Patient heute gekommen ist, und habe als Ausgangslage lediglich die Information der kürzlichen Tonsillektomie. Auf meine Aufforderung hin beginnt der Patient dann mit seinen Ausführungen, in schweizerdeutschem Dialekt: „Ich hatte vor 2 Wochen diese Mandel-Operation. Die ist gut verlaufen. Nun habe ich alle diese Medikamente, welche ich nehmen muss. Für die Schmerzen. Und ich wollte mal fragen, ob ich die noch alle brauche, oder ob man da etwas absetzen kann?“ „Also Sie hatten vor 2 Wochen eine Mandel-Operation. Und nun möchten Sie wissen, ob Sie alle Ihre Medikamente noch nehmen müssen?“ „Ja“ (B-10, emphasis added) ‘His posture seems normal and does not yet betray anything. I don’t know yet, why the patient has come today. For a start, I’ve only got the information of a recent excision of the palatine tonsils. Following my invitation, the patient starts explaining himself in Swiss German dialect. “Two weeks ago, I had my tonsils operated. The operation went well. Now, I’ve got all these drugs, which I’m supposed to take. Against the

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pain. And I wanted to ask if I still need all of them or if one can stop with some.” “Well, you had an operation on your tonsils two weeks ago. And now you want to know, if you still need all the pharmaceuticals?” “Yes”’ While the student flags the reported language of the patient as dialect, the language then displayed is actually Standard German. We will briefly revisit the use of constructed dialogue, its impact on style and its use for character positioning in Section 5.4.2.

5.3.7 Grammar In an exploratory study, Meier (2012) focused on an analysis of eight texts from the Nottingham corpus in order to establish syntactic features of the corpus. She found that the texts are primarily written in the simple past, followed by the simple present. The present constructions particularly occur in the constructed dialogues, and the future tense is primarily found in the descriptions of future conduct. She found hardly any passive constructions. In order to expand this analysis, we used Nini’s (2015a) Multidimensional Analysis Tagger (MAT) to explore grammatical features further. This type of corpus analysis was not available for German, so we cannot offer a comparison with the grammar of the Basel corpus and will thus focus on the Nottingham and expert corpora. Nini’s program uses the Stanford Tagger (Toutanova et al., 2003) annotation and then draws on Biber’s (1988, 1989) 67 grammatical features and algorithm in order to compare specific corpora along six dimensions of variation that can be combined into a number of distinguishable text types. This comparison allows us to point to a selection of grammatical features that are noteworthy in our reflective writing texts. Biber’s (1988: 122) six dimensions are ‘involved versus informational discourse’ (Dimension 1), ‘narrative versus non-narrative concerns’ (Dimension 2), ‘context-independent discourse versus context-dependent discourse’ (Dimension 3), ‘overt expression of persuasion’ (Dimension 4), ‘abstract versus non-abstract information’ (Dimension 5) and ‘online informational elaboration’ (Dimension 6) (see also Nini, 2015b). Each of these dimensions has a set of grammatical features that co-occur. With respect to dimensions, Biber and Conrad (2009) explain that each dimension has: both ‘positive’ and ‘negative’ features. These are actually two groupings of features: the positive features occur together frequently in texts, and the negative features occur together frequently in texts. The two groupings constitute a single dimension because they occur in complementary

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distribution: when the positive features occur with a high frequency in a text, that same text will have a low frequency of negative features, and vice versa. (Note that the positive and negative designations are mathematical, arising in the factor analysis; they are not evaluative.) (Biber & Conrad, 2009: 247) Biber (1989) found that the distribution of the features in the different dimensions combines to describe a set of texts. As Biber and Conrad (2009: 223) put it, ‘[e]ach of these dimensions represents a group of features that co-occur: the features – as a group – are frequent in some registers and rare in other registers’. The MAT analysis plots our reflective writing corpus against a selection of text types derived from Biber (1988) (conversation, broadcasts, prepared speeches, personal letters, general fiction, press reportage, academic prose and official documents) along the six dimensions and also draws on the eight text types established in Biber (1989): intimate interpersonal interaction, informational interaction, scientific exposition, learned exposition, imaginative narrative, general narrative exposition, situated reportage and involved persuasion. The output of the MAT analysis suggests the closest text type for the reflective writing corpus vis-à-vis these genres and also allows us to look at each dimension and even at each text separately. In addition, the program suggest grammatical features that might be worth exploring. We will take each of these steps in turn. According to the MAT analysis, the best overall fit for the Nottingham corpus is the involved persuasion text type, while the best fit for the expert corpus is general narrative exposition. Table 5.2 lists the six dimensions separately and shows which genres are closest to the two English corpora.3 As we can see, the two corpora do not overlap entirely. While narrative genres are present in both corpora, we also see genres that are more oral in nature (prepared speeches, broadcasts) and those that are more formal (academic prose and official documents). Since the values can be negative as well as positive, the dimensions where we see a strong difference and/or a higher or lower value among the two corpora bear further comment. This is especially the case with Dimension 1. The Nottingham corpus scores much higher for Dimension 1 (7.04) than the expert corpus (−2.63). This difference, however, is not due to the use of pronouns, as could be suggested, since their distribution is fairly similar. Firstperson pronouns and third-person pronouns both occur frequently (see Table 5.3), which may be due to the reflective nature of the texts favouring firstperson usage and to the narrative element that might tend towards thirdperson pronoun usage (see also the keyword analysis in Section 5.3.8, which shows first-person pronouns to be typical). With respect to grammatical features, the Z-score analysis suggests looking at predicative adjectives, the occurrence of seem and appear, infinitive clauses and split infinitives for Nottingham. For the expert corpus, only the

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Table 5.2 MAT analysis (Nini, 2015a) showing the closest fit with a selection of text types for each dimension and the dimensional score Description of Biber’s (1988) dimensions

Nottingham corpus: closest fit overall (Biber, 1989); Score

Expert corpus: closest fit overall (Biber, 1989); Score

Dimension 1 is called informational versus involved production. It ‘represents a dimension marking high informational density and exact informational content versus affective, interactional and generalized content’. (Biber, 1988: 107) Dimension 2 distinguishes between narrative versus non-narrative concerns. ‘It might also be considered as distinguishing between active, event-oriented discourse and more static, descriptive or expository types of discourse. […] narrative concerns [are] marked by considerable reference to past time, third-person animate referents, reported speech, and depictive details; non-narrative concerns, whether expository, descriptive, or other, [are] marked by immediate time and attributive nominal elaboration’. (Biber, 1988: 109) Dimension 3 is called explicit versus situation-dependent reference. It distinguishes ‘between highly explicit, context-independent reference and nonspecific, situation-dependent reference’. (Biber, 1988: 110) Dimension 4 is called overt expression of persuasion and ‘marks the degree to which persuasion is marked overtly, whether overt marking of the speaker’s own point of view, or an assessment of the advisability or likelihood of an event presented to persuade the addressee’. (Biber, 1988: 111) Dimension 5 concerns the distinction between ‘informational discourse that is abstract, technical, and formal versus other types of discourse’ and is referred to as abstract versus non-abstract information. (Biber, 1988: 113) Dimension 6 distinguishes ‘discourse that is informational but produced under real-time conditions from other types of discourse’; its label is online informational elaboration. (Biber, 1988: 113)

Prepared speeches 7.04

Broadcasts −2.63

Prepared speeches 2.3

General fiction 3.39

Prepared speeches 1.93

Prepared speeches 1.9

Personal letters 3.5

Prepared speeches 0.28

Press reportage 1.1

Press reportage −0.2

Academic prose 0.75

Official documents −0.43

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Table 5.3 The average scores of the frequency per 100 tokens of a selection of grammatical features in the Nottingham and Expert corpora and two of Biber’s (1988) genres Grammatical feature [Stanford Tagger; Biber label] First-person pronouns [FPP1; 1PRON] Second-person pronouns [SPP2; 2PRON] Third-person pronouns [TPP3; 3PRON] Nouns [NN] Word length [AWL; not present] Attributive adjectives [JJ; JJATR] Predicative adjectives [PRED; JJPRED] Agentless passives [PASS] Seem/appear [SMP; not present] Private verbs [PRIV] Suasive verbs [SUAV] Infinitives [TO; INF] Split infinitives [SPIN; SPINF]

Nottingham corpus

Expert corpus

Biber (1988): fiction

Biber (1988): academic

6.2

5.94

2.75

0.48

0.9

0.62

1.14

1.14

4.7

5.45

6.61

6.61

15.23 4.35 5.3

19.91 4.49 6.51

20.81

26.91

5.68

8.91

1.32

0.84

0.76

0.75

0.6 0.28

0.76 0.12

0.52

1.52

2.91 0.62 2.79 0.04

1.88 0.52 1.83 0.02

1.74 0.32 1.38 0.02

1.19 0.42 1.55 0.01

split infinitive is mentioned. Table 5.3 lists these features and also compares them to two of Biber’s genres: fiction (including sub-genres) and academic. Compared to those two genres, the frequent use of first-person pronouns is most remarkable. In connection with this, we see an increase in predicate adjectives and fewer passives. Private verbs (e.g. feel, guess, learn, realize) and suasive verbs (e.g. agree, propose, suggest) are also used more frequently than in the fiction and academic genres. We can hypothesize that both features are due to the reflective element of the texts. Table 5.4 shows which of Biber’s eight text types fits best for each text. It suggests that, overall, the Nottingham corpus is closest to involved persuasion texts4 (in 85% of all texts), but also leans towards imaginative narrative5 (11%), and has only a small number of texts that are close to general narrative exposition6 and informational interaction.7 In the case of the expert corpus, we see that 58% of the texts are closest to general narrative exposition, followed by involved persuasion (24%) and imaginative narrative (18%). In Section 5.4, we will explore the traces of different text types within our corpus further.

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Table 5.4 MAT analysis showing which of Biber’s (1989) eight text types is the closest fit for each text Closest text type General narrative exposition Imaginative narrative Informational interaction Involved persuasion Total

Nottingham corpus: # of texts 6 20 2 161 189

%

Expert corpus: # of texts

%

3 11 1 85

29 9

58 18

12 50

24

5.3.8 Lexis The last feature we will consider is lexis. In order to understand the composition of the vocabulary of the reflective writing texts, we will look at each corpus by drawing on frequency lists of the sub-corpora. We will work with keyword analysis and will manually screen the corpus for particular lexical fields. Using the program Wordsmith, we first compiled word frequency lists for the Basel corpus (n = 26,301 words), the entire Nottingham corpus (n = 249,708 words) and the expert corpus (n = 62,534 words), and then conducted a keyword analysis. Keywords show which words in a set are statistically more typical than in another set. This allows the researcher to find the distinct vocabulary and to detect themes (for this well-documented methodology in corpus linguistics, see Baker, 2010; Scott, 1997; Stubbs, 2001). Using Wordsmith, we compared all non-lemmatized words (including stop words) to reference corpora in order to establish the set of words that are characteristic of the reflective writing corpora. The German reference corpus for the Basel corpus was compiled and made available by Weder (2016).8 The Nottingham corpus was compared to the words in the British National Corpus World edition. The reference corpus for the expert corpus was the Open American National Corpus. Table 5.59 shows the 30 most typical words and how often they occur (ordered according to their log-likelihood values) for each sub-corpus. For all three corpora, the pronouns I and my/me feature prominently. Their importance can be explained by the focus on first-person reflection in the corpus, although the pronouns do not always refer to the narrator, but may also appear in the constructed dialogue when the patients are given a voice. We also see evidence of the doctor–patient encounter in both English corpora (patient, student, interview, consultation, GP/doctor/physician, history (taking), questions, conversation, asked, etc.) and in the Basel corpus, while the reflective element of the texts is prominent in the first 30 keywords only for the Nottingham and expert corpus (felt, feel).

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Table 5.5 The 30 top keywords, ordered according to their log-likelihood values and showing their frequency (using Wordsmith, 5% threshold) Sub-Corpus

30 top keywords

Basel

ich (I), 959; Gespräch (conversation), 159; Frau (Mrs), 209; mir (me, dative), 214; mich (me, accusative), 199; Patientin (patient, female), 123; sie (she), 470; Patienten (patients), 126; habe (have), 191; Herr (Mr), 100; war (was), 220; sehr (very), 173; Patient (patient, male), 64; er (he), 261; Begegnung (encounter), 61; hatte (had), 115; X, 48; Situation (situation), 69; Anamnese (anamnesis), 34; Schmerzen (pain), 34; XY, 30; gut (good), 85; ihr (her), 92; hat (has), 202; Arzt (doctor), 32; hätte (would have), 45; Eindruck (impression), 40; etwas (something), 76; dass (that, conj.), 288; da (here, because), 96 patient, 3775; I, 10125; GP, 587; consultation, 650; her, 3251; me, 2156; encounter, 564; student, 736; interview, 656; didn’t, 312; felt, 960; my, 1905; she, 2760; was, 5068; doctor, 572; questions, 541; conversation, 383; feel, 642; wasn’t, 152; rapport, 199; communication, 379; history, 542; about, 1540; medical, 388; to, 9697; had, 2410 her, 901; she, 706; my, 807; I, 1885; me, 402; had, 558; his, 545; physician, 94; patient, 145; was, 870; he, 477; clinic, 64; medical, 105; patients, 167; doctor, 62; Mr, 79; Mrs, 50; chest, 44; pain, 62; physicians, 58; hospital, 77; room, 88; family, 132; medicine, 56; am, 90; felt, 61; chemotherapy, 34; him, 153; care, 113; wife, 68

Nottingham

Expert

Tag clouds of the 100 most frequent words after the removal of stop words (e.g. articles, conjunctions and prepositions) gives us a similar picture (Figure 5.5; created in NVIVO). The words are shown in alphabetical order and their respective size indicates their frequency. The charts once again nicely illustrate the semantic fields of the patient encounter (e.g. Basel: Anamnese, Begegnung ‘encounter’, Krankheit ‘illness’, patient, situation; Nottingham: patient, GP, student, [patient] history, consultation, hospital; Expert: patient, physician, care, treatment), the focus on communication (e.g. Basel: erzählte ‘told’, fragen ‘asked’, Gespräch ‘conversation’, Konsultation ‘consultation’; Nottingham: communication, interview, question, rapport, talk; Expert: asked), and the reflective part of the task (e.g. feel, felt/fühlte, think/ denke in all three sub-corpora). Interestingly, the expert corpus adds the semantic field of family and kin, which is not present in the student corpora (keywords: family, grandmother; frequency list: family, mother, husband, wife). As well as using these words to refer to patients who are accompanied by their family members, the physicians also often use them to reveal their personal situation, an aspect which is not present in the student corpus to the same extent. Scanning the frequency lists of the sub-corpora further (excluding stop words such as articles, pronouns, prepositions and conjunctions), we wanted

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Figure 5.5 Frequency clouds of the sub-corpora Notes: First 100 words, excluding stop words, ordered alphabetically; larger size indicates higher frequency.

to get a rough understanding of their composition by manually tagging for body parts, medical jargon, emotion words and a set of reflection words. Two raters went through the lists manually and tagged the presence of these categories. We are quite aware that this method can only yield a very crude approximation of the vocabulary composition since it was impossible to distinguish between, for example, back used as a noun or as a preposition on the basis of the word lists only. The raters might also have missed some lexemes. While looking at word lists out of context is an obvious disadvantage, we still believe that exploring the lists in this manner gives us a basic understanding of the overall vocabulary composition of the texts. In the case of Basel, medical jargon was most frequent, accounting for 15% of the words in the list (n = 1718), while body parts only accounted for 1% (n = 168). For Nottingham (n = 108,017 words), we found that medical jargon (ca. 11%; n = 12,285) and words for body parts (ca. 1.3%, n = 1470) were striking. In the case of the expert corpus (n = 29,441), the distribution is fairly similar: 11% of the words were explicit medical jargon (n = 3210) and 3% referred to body parts (n = 848). Often, these lexical items only occurred once or twice, meaning they did not appear high up in the keyword list and frequency analysis. Examples for this from the Nottingham corpus are, for body parts: elbow, 2; eyelid, 2; lip, 13; fists, 1; forearm, 1; forehead, 1; larynx, 2; organ, 1; toes, 1; visage, 1; and for medical jargon:

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aneurysm, 1; anginas, 1; angiography, 1; angioplastic, 1; anorexia, 1; antibodies, 1; apnoea, 1; appendectomy, 1; arrhythmia, 1; bronchiectasis, 1; bronchodilators, 1. The most frequently mentioned body parts in the Nottingham corpus included: back, 247; eye, 121; hand, 101; face, 96; eyes, 81; heart, 78; head, 69; leg, 56; hands, 52; ear, 41. And the most frequent medical vocabulary included: patient, 3826; consultation, 651; GP, 593; doctor, 580; medical, 388; patients, 380; condition, 246; hospital, 204; surgery, 160; medication, 131; health, 125; symptoms, 121; doctors, 113; blood, 111; disease, 99; treatment, 87; diagnosis, 86. Taken together, the mention of body parts and the medical jargon make up a considerable share of the lexis used in all three sub-corpora. The same can be said for the occurrence of the many emotion words (with positive, neutral or negative connotations, see Section 6.5)10 that, together with reflection words, make up another 5% (n = 5846) of the frequency lists for Nottingham (stop words excluded), 5% for the expert corpus (n = 1317), and 9% for the Basel corpus (n = 988). Often, these words also appear in the top 100 words overall. The examples from the Nottingham corpus show the 23 words that appear more than 50 times: felt, 960; feel, 642; think, 577; feeling, 248; empathy, 142; happy, 139; comfortable, 135; upset, 128; feelings, 119; believe, 112; worried, 98; sorry, 94; emotions, 81; emotional, 78; confidence, 60; confident, 59; thinking, 55; calm, 54; confused, 54; nervous, 54; concerned, 53; involved, 50; worry, 50. The emotion and reflection words are listed together here because we cannot, on the basis of the word list alone, make any meaningful decision as to whether words such as felt/feel/feeling refer to emotions or processes of reflection. The high occurrence of words such as feel, think, believe once again points to the reflective nature of the corpus.

5.3.9 Summary of text features Looking at the nine text features proposed by Bax (2011), we can see how combining them allows the texts to fulfil the function of reflective writing. Table 5.6 gives a rough overview. In general, we can see that the two student corpora are fairly similar in their instantiation of features and that the expert corpus is comparable to it. This can be explained by the detailed composition instructions for the students’ task and also by the similar experience that the students bring to the task. In the case of lexis, we find a difference, in that the expert physicians draw on the lexical field of family and kin, which is not an issue for the students. The individual features are of course not unique to the corpus as a whole or to the individual sub-corpora, so we will turn to evidence of genre mixing in the next section.

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Table 5.6 Text features of the reflective writing corpus Features

Basel/Nottingham

Location

Digital text submitted by students Published column in two to instructor medical journals Reflection on an encounter with a patient who made a particular impression on the writer Title of column as Dialogue sequences (BS: 77%; informative part; no further Nott.: 87%); Sectioning (Nott.: visual features other than 66% no sectioning; headers and/ paragraph structure or Q&As present in 34%; BS: 69% no sectioning; headers and/or Q&As present in 31%) Basel: mean = 674 words, s.d. = Expert: mean = 1251 178; Nottingham: mean = 1321 words, s.d. = 377 words, s.d. = 413 Basel/Nottingham: descriptionLess schematic in reflection-conclusion/aims composition than student corpora; main point repeated and nicely wrapped up at end Narrating, describing, arguing Written Standard English Standard German/English with with standard orthography standard orthography in description and reflection part; some use of non-standard forms in constructed dialogue in the Nottingham texts Use of first- and thirdUse of first- and third-person person pronouns; split pronouns for Nottingham and infinitives Basel; further features for Nottingham: predicative adjectives, seem and appear, infinitive clauses and split infinitives Semantic fields of medical encounter, communication and reflection; noticeable share of medical jargon, body parts and reflection and emotion vocabulary; family and kin vocabulary in the case of the expert corpus

Topic focus Visual aspects and layout

Length

Structure

Discourse modes Style/formality

Grammar

Lexis

Expert

5.4 Evidence of Genre Mixing When the Nottingham students write their texts, we assume that this is probably the first time they have encountered reflective writing in their medical training. Since we can also assume that reflective writing is rarely taught in schools before university or professional training,11 we argue that this is the very beginning of exposure to this text genre. Since many students will thus

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be unfamiliar with this text type, they are likely to look for analogies in other genres.12 For Basel, we can make a similar case. As stated above, when we think of genre as a cognitive concept representing a prototype, students are likely to draw comparisons with other text types to which they have already been exposed. We assumed that a candidate for such an analogy would be the traditional essay written in English or German classes. Students might also be reminded of drama texts because of the constructed dialogue shown in the instructions – and, because they are asked to recall an encounter with a patient who made a particular impression on them, they might also draw on their knowledge of (oral) narratives. Furthermore, they might refer to aspects of the medical case report. With the expert texts, we assume that writers who submit their texts to the journal are familiar with the columns and orient their writing towards the personal element required.13 In our close reading of the texts, we looked for evidence of genre mixing that might draw on these or other genres. In what follows, we primarily explore the mixture of genre elements that we found in the students’ reflective writing corpus, and supplement our analysis with insights from the expert corpus.

5.4.1 Evidence of ‘reflection’ We start by stating once again that the main function of the student texts is reflection. While this is of course the intended aim of the task, it is noteworthy that the students also adhere to it. This is visible on a number of levels. First of all, the general composition of the texts follows the content organization proposed in the instructions: description-reflection-conclusion/aims. This means that the students choose a past experience which they recall for the purposes of reflection (rather than story-sharing or other purposes) and we can find passages in the texts that are primarily dedicated to the aim of this reflection, as shown in Excerpts 5.7 and 5.8 above. As discussed with respect to lexis in Section 5.3.8, the students’ vocabulary choices also highlight processes of reflection (feel, think, believe; conjunctions such as however). Finally, the analysis of acts of positioning, which we will present in detail in Chapter 7, reveals that the students carefully project different identities that can be linked to the act of reflection. They differentiate between the ‘individual in the past’ (before or during the encounter narrated in the text) and the ‘individual in the present’ (at the time of writing the text). In a last step, they often present an ‘individual projecting alternative actions in past or future’ (vis-à-vis what really happened in the encounter) in order to show that they have learnt from their experience. Excerpt 5.11 is a case in point. It is the last paragraph of the text, and shows the student describing what she has learnt.

Excerpt 5.11 From this encounter I have learned a lot more about dealing with patients who have issues with compliance, as well as how to deliver information

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effectively. I do think I achieved my initial aims in part, as I managed to explain the information regarding the patient’s blood pressure and medical advice effectively enough to change their attitude to treatment; however, I noticed a vital shortcoming in my communication skills toward the end of the conversation. I elicited the patient’s depth of understanding of their condition without addressing their concerns or expectations. As these may have been a cause for their lack of adherence, I missed out on the opportunity to resolve this issue. By simply asking an open question like “Can you tell me how you feel about the medication?” I could encourage the patient to volunteer more information with regards to their condition and therefore formulate a method of action unifying both the ideals of doctor and patient. (N-037) The student reflects on what she did not do well in the past, I elicited the patient’s depth of understanding of their condition without addressing their concerns or expectations, but is also careful – from her present, informed perspective – to project a future remedy. In this way, the student ensures that the reader understands that a reflection process has taken place. These acts of positioning are also employed in the expert corpus, which shows that – despite the expert texts having no primary educational purpose – the elements of reflection and of sharing this reflection with the medical community are strong. However, the expert texts do not rigidly follow the structure of description-reflection-conclusion/aims. In fact, the composition of the expert texts is much freer and often more creative, as the format is not predetermined by any institutional task (other than that of adhering to the purpose of the journal columns; see also Section 5.3.4). In sum, this means that we are fundamentally dealing with reflection, no matter how many or what evidence of other genre features we may find in the texts.

5.4.2 Evidence of ‘narrative’ While reflection is the main purpose of the student task and a strong component of the expert texts, there is no denying that the texts include narrative passages that contain a fundamental narrative core (a ‘reportable event’, Labov, 1997). This is because the students are asked to recall a personal experience as a way of sharpening their reflection skills. In the same vein, the purpose of the columns published in AIM and JAMA is to give the experts an outlet for sharing personal experiences related to ‘being a doctor’ and for sharing ‘a piece of their mind’. Furthermore, the 50 texts in the expert corpus were chosen to match the student corpora and thus focus on an encounter between a physician and a patient or patients. However, in choosing a memorable past experience, the students and experts are not finished with their task; they need to retell the episode in such a way that the reader

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(i.e. the communication skills teacher or the peers reading the columns) can also understand what happened. Consequently, the texts include story-telling elements, which are the focus of this section. Although we are in no way claiming that we are dealing with instances of personal oral narratives in the Labovian (1997) sense, the concepts introduced in his framework are nevertheless helpful in approaching our written data. According to Labov (1997), the elements of an oral, personal narrative are abstract, orientation, complicating action, evaluation, resolution and coda. While the abstract and coda are optional, the body of an oral narrative is composed of the following: narrative clauses which move the story on; orientation clauses which set the scene of the story world (place, time, characters, further background information); and evaluation passages which reveal the narrator’s stance regarding the reported event (see De Fina & Georgakopoulou, 2012; Johnstone, 1990; Labov, 1997). However, these elements are less strictly separated from each other than one might assume at first glance. Evaluative stance can be revealed throughout the narrative and is not restricted to separate sections only (e.g. Labov, 1997: 403), and narrative clauses may also contain elements of orientation, etc. In what follows, we will revisit these elements to see if and how they are instantiated in the corpus. Labov and Waletzky (1967) and Labov (1997: 398) argue that oral personal narratives contain a ‘reportable event’ since the tellers want to fend off the ‘so what’ question and since this reportable event guarantees that the audience will listen. The students in the corpus are also asked to think about which conversation/encounter with a patient impressed you most, rather than to report on a routine encounter. This means that their texts need to explain why they chose this particular encounter and why they have singled it out as memorable and worth discussing. As the structure of the text follows the description-reflection-conclusion pattern, it does not invite a high-point narrative (Labov, 1997; Labov & Waletzky, 1967), which allows readers to find out about the point of a chosen episode themselves during the often dramatic re-enactment of a story in an oral context. In the reflective writing texts, we find explanations for the reportability of an encounter in a number of locations, such as in the abstracts at the very beginning, and in the reflection and conclusion sections. Excerpts 5.12 and 5.13 show explanations for reportability at the very beginning of two student texts.

Excerpt 5.12 The patient I have chosen to write about is the one with whom I recorded the interview last year. As it was my first encounter with a real patient as a medical student, it feel it was somewhat momentous. I remember feeling under a lot of pressure and very nervous, as this was my last GP visit before the coursework was due in, and so I absolutely had to do it on that day. I had also built up this moment a lot in my head and had been thinking about

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it and getting anxious, and so my performance may have reflected this. (N-133, very beginning, emphasis added)

Excerpt 5.13 The patient encounter which made the greatest impression on me during my clinical visits was a consultation with a 45 year old woman who came into the GP surgery for a renewal of her sick note entitling her to time off work. I remember this consultation particularly well as this was the first experience I had of dealing with a patient who lost composure and was visibly very upset. I had never seen a patient who was so emotionally vulnerable and I found it a difficult situation to handle. (N-016, very beginning, emphasis added) In Excerpt 5.12, the student explains that the chosen encounter was the very first doctor–patient interaction that she engaged in as a medical student. It is striking that the student’s emotions during this encounter are particularly highlighted. In Excerpt 5.13, in contrast, it is the patient’s emotions that trigger the memory. The student explains that the difficulty of knowing how to handle them was what made this particular event memorable. By giving the reasons for their choice at the very beginning, the students prime the reader to pay special attention to the issues raised later in the text. Excerpts 5.14–5.17 illustrate explanations for reportability in the reflection sections and in the conclusions, where reportability and the ‘moral’ of the text are often revisited.

Excerpt 5.14 I remember this encounter clearly because it was the first time I interviewed a young child. It was quite different to how it expected it would be. I think this is because most of my previous experience in communicating with children of this kind of age has been with children who I know or have spent some time building a relationship and trust with, so they are comfortable talking to me. Also, I have not had any experience in communicating with children in a context where I need to obtain information from them. Altogether the circumstances of this kind of encounter create a very different dynamic to a situation where I am talking to child just to play with them. (N-076, reflection section)

Excerpt 5.15 The patient was very unique because he was willing to share his personal stories with me about when he became hard of hearing, how this affected him, his family life, his current conditions, a surgery he will be having very soon, etc. […]. What touched me most is that although he was facing

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many health problems and feared of whether or not he will survive the surgery, he said he always had his family which looked after him. […] I could see that he really loved his family and so could guess that his family is very warm. I also love my family and so it was very touching to have a patient, like him, talk about how being loved and cared by family members are so important for one to keep on living. (N-180, reflection section)

Excerpt 5.16 Ultimately, the message I take from this encounter was simply; as students, as healthcare practicioners, as a primary source of support, guidance, and as physicians we must be willing to adapt to every flavor of patient. And it was his last words to me before our brisk interruption that left a lasting impression that to this day guides my studies and my medical demeanor. Mr X: “It was like hell those few months, nobody cared, nobody stopped, I was lost and trapped in my own mind without a ladder to escape my son. You as a doctor, you’ve got no idea mate, how much is held in your hands. All it would have taken was one doctor to care and it might have changed my life.” (N-007, conclusion part, very end)

Excerpt 5.17 Today I was reminded of the importance of acknowledging what I can do as a physician. Sometimes there is nothing to work up, but there is never “nothing left to do”. Just being there is sometimes the best and only panacea we can provide. (E-25, end of text, emphasis in original) In Excerpt 5.14, the student explains that the situation was memorable because it was the first time she had interacted with a young child in the role of a medical student. She notes that the professional encounter aimed at gaining information differs from interacting with children in a play context in which trust has been built beforehand. In Excerpt 5.15, the student highlights the patient’s openness and the value that the patient placed on his family ties. This latter aspect resonated particularly strongly with the student, who acknowledges that he also considers family support as crucial. In Excerpt 5.16, the student closes his text by first summarizing his take-home message – we must be willing to adapt to every flavor of patient – and then, in a nice rhetorical move, he gives the last word to the patient (Mr X) to illustrate this point further. Here, we can argue that the final paragraphs of the text work as coda to the previously discussed encounter. In the three examples from the experts, we see neatly phrased summaries of the gist of the texts. For the expert in Excerpt 5.17, the main message – and what she chose to write about – is that the physician’s presence and caring can be ‘doing

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something’ even when no medication or other interventions could prolong the patients’ lives. The expert returns to this point at the very end of the text and thus highlights it as the main point of her text. What is immediately apparent in all these explanations for reportability is that evaluation is a crucial element because it reveals the writers’ stance regarding the chosen episode. Having discussed some evidence for a ‘most reportable event’, we can now turn to the other structural elements of oral narratives that play a role in the reflective writing corpus. When we look at the instructions for the reflective writing task, we can see that the students are asked to situate their encounter and to introduce the protagonists. The instructions are as follows: Situation: • Describe the patient (age, relevant diagnosis, first impression – appearance, posture, language, anything else noticeable, etc.). • Describe in which context the encounter took place (what was the reason for the encounter?). • Describe what you talked about by using verbatim speech (the exact words) as much as possible. If you cannot remember the exact wording, reconstruct the dialogue for the crucial moments as well as possible. • Describe how you felt after the encounter. The first two bullet points in the instructions refer to ‘orientation’ (Johnstone, 1990; Labov, 1997), in that the students are asked to introduce the characters and the context of the episode. This creation of a story world is fundamental to storytelling (Johnstone, 1990). We saw an example of this in the very first paragraph of Text N-175 in Excerpt 5.6 above. Excerpt 5.18 is another case in point:

Excerpt 5.18 The Patient (Mr X) was a middle aged man, in to get his ears cleaned out by the nursing staff (this is routine for him and happens every few months). The first thing that struck me about him was how friendly he was – I had been explaining to the patient beside him in the queue that I was a medical student in to practise history taking/explanation at the ENT clinic, the patient I was talking to was then called in for her consultation. Slightly crestfallen I looked around for someone else to interview, it was at this point Mr X invited me over, saying “well common then, you can talk to me!” I was more than happy to oblige. He was certainly not offering out of loneliness (he was in with his wife), but rather a genuine desire to help me with my work. He later told me that he often talked to medical students and quite enjoyed it. (N-014, very beginning)

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In Excerpt 5.18, the student introduces the patient as a middle aged man and specifies why he was at the clinic. The student also mentions that he introduced himself as a medical student, who was there to practise history taking/ explanation at the ENT clinic. As the text continues, we learn about more protagonists, since there was another patient beside him and the patient’s wife as well. With respect to location, the student reveals that he had approached another patient before – thus implying that there was a queue of patients to be called in for consultation and that the encounter did not take place in the more private consultation room. At the end of Excerpt 5.18, we read that [h]e later told me that he often talked to medical students and quite enjoyed it. This is a leap forward in time, in that the student reveals information gained later in the encounter. Further examples of story world creation can be found in Excerpts 5.19 and 5.20:

Excerpt 5.19 Als ich ihn das erste Mal sah, machte er einen etwas eigenartigen und kauzigen Eindruck auf mich. Er hat beim Sitzen wie beim Gehen eine etwas vorgebeugte Haltung und ist nicht mehr so sicher auf den Beinen, aber trotzdem noch einigermassen mobil (kann selber 15 min ins Dorf spazieren). Er hat einen verwilderten und ein wenig ungepflegt wirkenden Bart und Haare, die wie vom Winde verweht in alle Richtungen schauen. Beim Sprechen nuschelt er für mich zu Beginn ziemlich unverständlich in einem Thurgauer Dialekt, was auch deshalb etwas gewöhnungsbedürftig war, da ich Thurgauer Deutsch nicht so mag. (B-19) ‘The first time I saw him, I thought that he was a somewhat odd fellow. While seated or walking, he bends slightly forward and is not very sure on his legs anymore. Nevertheless he is tolerably mobile (he can walk the 15 minutes to the village). He has a wild and seemingly untended beard and hair, which were tousled from the wind and pointed at all directions. When speaking, at first he mumbled something unintelligible for me in a Thurgau dialect, which I needed to get used to since I don’t like the Thurgau German that much.’

Excerpt 5.20 When Mr X entered the room I immediately realised that he was distressed. His eyes were blood shot like he had been crying, his head was stooped low to avoid eye contact and was quite slow in his movement. Mr X had not been looking after himself very well and his appearance was quite dishevelled. He had not shaven, his hair was untidy and his clothes and hands weren’t very clean. As he sat down to talk to me, he had a drooped posture and continued looking down towards his hands unless asked a question. As he spoke he was quite tearful, his language was simple and he tended to repeat himself quite a lot. (N-006)

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In these two examples, the writers position the protagonists of the interaction (the students themselves as the ‘I’-observers, and the patients) and pay particular attention to their appearance, behaviour and actions. In addition, the examples both contain comments on language. In Excerpt 5.19, the student refers to an Eastern Swiss dialect from the canton of Thurgau and admits that his problems in understanding this dialect might have to do with his dislike of it (and with the patient’s mumbling). The mention of the dialect also reveals that the language spoken during the encounter is not Standard German, a fact usually lost in the Standard German renditions of the encounters. In Excerpt 5.20, the student describes the patient’s language as simple and adds this detail to the plethora of negative observations about the patient. While the students were explicitly asked to set the scene for the texts, the expert texts cannot do without this fundamental strategy of story world creation either. As will be discussed below in connection with evidence for the medical case report (Section 5.4.3), the expert texts also predominantly start in a narrating mode and set the scene of the story world in similar ways to those we have just described for the student texts. Excerpt 5.21 is a case in point:

Excerpt 5.21 While it thundered and rained outside one Thursday evening, I sat comfortably in my office reading a new report on TB. According to the article, the incidence of TB has increased recently in China, especially in the elderly population. (E-47) In Excerpt 5.21, which is the very beginning of the text, we get a location marker (an office), a time indication (Thursday evening), information on the weather (thunder), and the activity (reading an academic report on TB) of the narrator, who is the occupant of the office and expert enough to read medical reports. While not every text goes into detail about the location and time, they do usually maintain the raw backbone of story world creation with at least character positioning (the patient(s) and the student/expert) and implied information on location. The concept of narrative clauses, i.e. sentences that are temporally bound to appear one after the other and to move the plot forward (Labov, 1997), can also be applied to the texts in our corpus. We can indeed find such instances as in Excerpt 5.18 above quite easily: Slightly crestfallen I looked around for someone else to interview, it was at this point Mr X invited me over, saying ‘well common [sic] then, you can talk to me!’ I was more than happy to oblige. However, since the overall structure of the student texts is guided by the pattern of description-reflection-conclusion, the narrative core, when defined as a sequence of narrative clauses leading to a high point, is often very short within the overall composition of the text. This means we can only speak of nuclear narratives. The above-quoted instructions for the student texts also ask the students to use constructed dialogue in the composition of their texts. This is

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motivated by the focus on communication skills and the idea that the students will reflect better on the different turns in an attempt to reconstruct the interaction as well as possible. However, at the same time, constructed dialogue is a well-documented strategy for involving the listener/reader and creating suspense in oral narratives (e.g. Tannen, 1989). This is because it transports the listener/reader back in time. It can also be a stylistic means of leaving the evaluation of actions to the addressee of the narrative, who is invited to witness the interaction and draw his or her own conclusions. It can also simply be a way of moving the plot forward by letting the characters reenact the actions (see Hamilton, 1998; Tannen, 1989). We have already seen that students sometimes use constructed dialogue to position the patients by assigning non-formal speech to them, as in Excerpt 5.9. In Excerpt 5.16, the patient uses terms such as my son and mate, which gives the interaction an informal flavour and positions the patient as older than the student. It is striking that the sequences of constructed dialogue are rarely used to move the plot forward on their own. Instead, the passages are usually preceded or followed by comments that explain what the constructed dialogue should illustrate, as in Excerpts 5.22 and 5.23.

Excerpt 5.22 I started off the consultation by introducing myself, asking for consent and the reason why he was here to see his GP. He then directed his eyes to me, kept silent for a few seconds, and began uttering words. Then, the conversation continued for about fifteen minutes with mixed moments of speech and silence. The following shows what we talked about during the encounter. Some of these are verbatim speech and some are just a summarization of certain parts of the encounter. Patient: Student: Pt:

“It’s this pain in my stomach again. And the surgery I will be having … I might not survive the surgery. … I don’t know whether I will be able to live pass it.” “You will be alright. Don’t worry, I am sure your GP will be able to help you”, Yeah…. and the doctors. I keep finding new doctors but most of them seemed to not really know what they were doing. They just kept giving me drugs and didn’t explain to me what is going on with me. It is a mystery, really … until I end up seeing this doctor…” (N-180, emphasis added)

Excerpt 5.23 Ich:

„Grüezi Frau H., mein Name ist [name], mich kennen Sie ja bereits.“ Frau H.: „Ja, Grüezi!“ (und lächelt mich freundlich an) Ich: „Wie geht es Ihnen?“

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So beginne ich das Gespräch, während der Arzt die Patientendatei auf seinem Computer öffnet. (B-26, emphasis added) ‘I: Ms H.: I:

Grüezi [Hello] Ms H., my name is [Name]; you’ve already met me. Yes, Grüezi! (and she smiled at me in a friendly manner) How are you [second-person plural, V-form]?

This is how I start the conversation while the doctor opens the patient history on his computer.’ In Excerpt 5.22 the student uses a number of constructed dialogue passages to illustrate the preceding summary of the first part of the interaction. The student in Excerpt 5.23 tells the readers This is how I start the conversation and thus informs them what the constructed dialogue should illustrate. A recurring pattern with constructed dialogue is the sequence ‘introduction, constructed dialogue, reflection’, as illustrated several times in Excerpt 5.24:

Excerpt 5.24 After introducing myself and obtaining consent for the interview, I initiated the consultation with the open question “The doctor mentioned that you are involved in charity work, could you tell me a little more about that please?” This allowed the patient to tell her story. […] Throughout the interview I empathised with the patient to let her know that I understood how difficult it must have been for her. Using phrases like “that must have been very difficult for you” and “I imagine that was just devastating news?” enabled me to connect with what the patient was saying. An example of the consultation in which I used empathy is: Me: Patient: Me: Patient: Me:

If you wouldn’t mind, would you be able to tell me how the diagnosis of your son made you feel? Well, it was very distressing especially as I had gone through it all before. I felt empty inside – I knew what was to come. I can imagine that it must have been an extremely difficult time for you It really was and it still upsets me now I understand

Personally, I think that the patient appreciated my empathy and supportive approach as it allowed her to talk more openly about a very emotional subject. (N-078, emphasis in original)

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In this brief extract, the writer of N-078 always precedes the constructed dialogue with a brief explanation of why it is included, and follows it with an explanation of its effect. As a result, the constructed dialogue is thoroughly embedded within the reflective text and its main purpose is to illustrate what is reflected rather than to move the plot forward. This pattern is especially noticeable in the student texts. The expert narratives adhere less strictly to this pattern, probably because the writers have more freedom to place reflection throughout the text. Now that we have established that we can usefully apply concepts developed in the field of oral personal narrative to our corpus in order to identify elements of the narrative genre in the composition of the texts, it is worth pointing out that the students are also asked to think about the future. In other words, rather than only reflecting on past behaviour, the students can use the texts to project their future behaviour as well. Usually, this is done in the final sections of the texts. In Gygax et al. (2012), we describe one such text in which a student quite carefully employs different methods of identity construction, projecting different roles in connection with the learning stages, such as ‘medical student’, ‘student of communication skills course’, ‘individual in the past’, ‘individual in the present’, ‘novice doctor’ and ‘individual projecting alternative actions in past or future’ (see Chapter 7). The last category is exemplified in Excerpts 5.25–5.28:

Excerpt 5.25 In future interviews, I will definitely structure my interview better to gain more from the patient and add more flow to my interview technique. A more linear progression through the history would be key to developing a sound structure to the interview: e.g. History of presenting complaint, past medical history, drug history etc. I will also ensure I follow the “open-closed cone” to reduce use of leading questions and ensure that I structure the interview correctly in terms of question-type. I will explore the patient’s ideas, concerns and expectations (ICE) during the interview to ensure I fully appreciate the patient’s perspective. Finally, I will close the interview by summarizing, to make sure the patient has not left out any vital information. I will also make sure that the patient has got everything out of the interview that they were expecting. (N-099, very end, emphasis added)

Excerpt 5.26 In the future, I will improve my use eye contact with patients and be more confident when speaking to the blind or patients other sight disabilities. I felt that through most of the conversation, I was looking at the patient’s mother for reassurance, that I was saying the right things and not insulting him. I feel that I need to improve upon my confidence and then I will make a much better medical student and thus a better doctor. (N-142, very end, emphasis added)

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Excerpt 5.27 In Zukunft werde ich versuchen den Patienten ganzheitlicher zu betrachten und nicht in Panik auszubrechen in ähnlichen Situationen. (B-22, very end, emphasis added) ‘In the future, I will try to look at patients more holistically and not to start panicking in similar situations.’

Excerpt 5.28 During this time of health care reform discussions, it is worrying that life-saving events for patients such as Ms Jones may become more difficult as health care costs increase and the number of uninsured patients rises. Yet doing the “right thing” for our patients must always be our guiding light as we debate the solutions to our health care problems. (E-18, very end, emphasis added) These mini scenarios of how the student’s or expert’s future encounters with patients might unfold are clearly not fully fledged narratives. However, it could be argued that they constitute small stories (see, for example, Bamberg, 2004; Georgakopoulou, 2007, 2013), or at least that the reflective texts contain strong narrative passages and future projections. Our analysis of narrative features within the reflective writing corpus clearly shows the influence of this important genre on the texts – be it with respect to the main reportable event, the creation of story worlds or the future projections. We will return to this point in the conclusion of this chapter.

5.4.3 Evidence of ‘medical case report’ A further genre prototype that we hypothesized would potentially influence the reflective writing texts is the medical case report (or case history/case study). This genre pertains to a written medical practice that is used to pass on knowledge about a particular patient and his or her condition to colleagues in a succinct way (see Cohen, 2006; Hurwitz, 2006; Taavitsainen & Pahta, 2000). A medical case report contains the following: a patient description, including demographic information and the patient’s medical, family and social history; diagnostic data; medication history; and details on the patient’s diet (Cohen, 2006: 1889–1890). This is followed by the case discussion, in which the author is to ‘explain how and why decisions were made’ (Hall, 2003: 89). Authors typically follow a chronological order so that fellow doctors can come to their own conclusions about the condition and treatment options (Cohen, 2006: 1889; Hall, 2003: 88). While Taavitsainen and Pahta (2000: 71–73) and Hurwitz (2006: 236) report that earlier case reports contained the voices of the doctor and patients and details of their emotional reactions, current usage transforms the narratives of the encounters into

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neutral, informative, biomedical texts (see also Hunter, 1991) in which the voice of the author is depersonalized. Since a narrative contains (at least implied) evaluation by definition, and since the required reflection is first-person oriented, we wondered whether the students would lean towards the medical case report in an endeavour to adhere to a more clearly (bio)medical practice and, consequently, to appear as medical professionals (see Oyebode & Tischler, 2015, for a discussion of the reluctance of medical students to engage in writing of a similar kind). While we have seen that some students begin their texts with a passage that leans more towards the narrative genre (as illustrated in the excerpts in Section 5.4.2), other students indeed start in the vein of a case report, i.e. they use a comparatively neutral summary of information known about a patient. Excerpts 5.29–5.31 exemplify this use:

Excerpt 5.29 Description of patient: The patient, Frank, was male and 43 years old. The GP described him as having behavioural problems since childhood, learning difficulties and depression. His carer also told me he was on the autistic spectrum. His epilepsy was severe, and he had seizures in his sleep. He was on anti-epileptic drugs that helped reduce the seizures but didn’t eliminate them all together. He had also experienced a worsening of health over the last 2 years, with days when he would seem very unstable on his feet and poorly, without any known cause. The patient on first appearance looked very vacant and lethargic, not engaging with either myself of his carer. (N-084, very beginning)

Excerpt 5.30 The patient was female and 30 years of age. She was a smoker, and drinks socially. She looked dishevelled, was of normal weight, and not very small or very tall. Her native language was English. She had quite a ‘common’ accent. She didn’t stand tall … but slouched slightly. (N-105, very beginning)

Excerpt 5.31 The patient was an elderly man, of about 75. He had hearing problems, and suffered from a repetitive depressive disorder, and had been committed to a mental hospital at several points during his life. He also walked with a stick, and was hunched over a bit and unsteady on his feet. (N-151, very beginning) However, only 17 of the 189 Nottingham texts (9%) use this type of fairly neutral and enumerative beginning reminiscent of the medical case report. This is despite the fact that the instructions quoted above (Describe the patient (age, relevant diagnosis, first impression – appearance, posture, language,

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anything else noticeable, etc.)) could also lead us to expect the flavour of a medical case report. Instead, the students orient their texts towards a narrative beginning, and play with it to a greater or lesser extent. This may be because they have not yet had much experience with medical case reports during their attachments and studies. It might also be due to the focus on evaluation and reflection, which is also requested in the instructions and which does not occur at the beginning of typical medical case reports (see Hurwitz, 2006; Taavitsainen & Pahta, 2000). For the Basel corpus, we get a similar picture, with only four of the 39 texts (10%) starting with a paragraph that is reminiscent of the classic case report. In the case of the expert corpus, it is only three of the 50 texts (6%). This trend may have to do with the focus on personal experience in both the student and the expert texts.

5.4.4 Other evidence of genre mixing Evidence of other genres in the reflective writing genre mix is clearly evident in the corpus, but it is less pronounced than that of reflection, narrative and the medical case report. For one, we can find traces of the traditional essay that the students might remember from their school days. We argue that we find hints of this in the visual structure of the texts because the students do not use any section titles to structure their work in 66% (Nottingham) and 69% (Basel) of the texts (see Section 5.3.4). This absence of headers (but not the three steps of description-reflection-conclusion) might be reminiscent of school essay writing, where it would be unusual to work with section titles (Hampton, 2010b). Furthermore, the clear adherence to the structure proposed in the instructions can also be explained by the fact that the students ‘fulfil a task’ for university. Oyebode and Tischler (2015) report that creativity is not valued by their students and not considered to be part of medical practice. Maybe this is why many students take care to fulfil the requirements listed in the instructions step by step. The occasional mention of the teacher to whom the texts are submitted also places the texts firmly in the educational realm. However, the Nottingham students only explicitly mention essay writing in four cases, and the Basel students never use Aufsatz, the German equivalent. In the case of the experts, we find 12 mentions of essay in eight texts. Of those instances, six occur in the acknowledgements or dedication section. We thus get a higher proportion of explicit mentions of the essay genre in the expert corpus than in the student corpus. While we do not want to read too much into the use of the word essay itself, we are confident in claiming that the connotations of an essay point towards the humanities rather than biomedical science and practice. We can also say that the student texts contain elements of ‘drama’ or ‘theatre’ scripts, in that the students employ constructed dialogue. While constructed dialogue is a typical element of oral narratives (see Section 5.4.2), we are dealing with written versions. The instructions ask the

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students to use constructed dialogue, and also suggest presenting the dialogue in the form of a theatre script. Once again, students predominantly adhere to this by displaying the oral exchanges on which they want to reflect separately from the main text (see, for example, Excerpts 5.22–5.24 above). Excerpts 5.32–5.33 show how some students even add stage directions.

Excerpt 5.32 Patient: Student: Patient: Student: Patient: Student: Patient: Mother: Patient: Student:

“My throat and my nose and here” [puts hand to chest] “How long has it been sore for?” “I’m not sure” “Ok. Have you had any medical problem in the past?” “My heart when I was little” “Can you tell me a bit more about that?” “I dunno” [shrugs shoulders unsurely and looks over to her mother] “Show the doctor your scar” “Ok.” [pulls up t shirt proudly to reveal scar from open heart surgery] “Wow, that looks exciting! Can you tell me a bit more about it?” (N-017, emphasis added)

Excerpt 5.33 Ich fragte: Ehefrau des Patienten (übersetzt schnell und ängstlich): Ich: Ehefrau des Patienten (übersetzt): Ich: Ehefrau des Patienten (übersetzt): I asked: Wife of the patient (translates quickly and in a scared manner): I: Wife of the patient (translates): I: Wife of the patient (translates):

„Schwitzen Sie in der Nacht so stark, sodass sie das Pyjama wechseln müssen?“ „Ja, das hat er.“ „Hatte er Fieber in der letzten Zeit?“ „JA!“ „Fühlt er sich müde und erschöpft?“ „JA!“ (B-22, emphasis added) ‘Are you [V-form] sweating to such an extent at night that you have to change your pyjamas?’ ‘Yes, he has’ ‘Has he been running a fever recently?’ ‘Yes!’ ‘Did he feel tired and exhausted?’ ‘Yes!’

In Excerpt 5.32, the directions rendered in italics describe body language and physical action. In 5.33, the student also describes the linguistic act of

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translation within the stage directions. His words are translated by the wife of the patient, who responds for her husband, but only the translated response is indicated.14 In other words, two turns are missing in the rendition of the dialogue every time. In other instances, the writers also use stage directions to describe pauses between turns and hesitations, or they explain who is addressed in conversations that include more than two people (e.g. [to little girl], N-109, not shown here). Paying attention to body language is one of skills the students learn during their communication skills course, as shown in Chapter 4. It is interesting to observe that the stage directions are presented in the simple present in the examples above, as this is typical of drama notation. In the constructed dialogues, the story takes place in the here and now, while the reflective part surrounding the dialogue is written in the simple past. McIntyre (2006: 78) describes stage directions as ‘extra-dialogic’ because they ‘form the character’s speech in some way’. They are graphically separated from the dialogue and are usually in parenthesis or italicized (McIntyre, 2006: 78). However, some students put the stage directions in the past tense. In Excerpt 5.34, the student describes the patient’s movements as reinforcing his verbal rendition of feeling low:

Excerpt 5.34 Patient:

“I’ve just been feeling really low for the last couple of months now. I came in a few weeks ago and the Doctor gave me tablets but they didn’t make the slightest bit of difference. Then the day before yesterday it just all got too much. I couldn’t take it anymore. Just wanted to disappear.” [Patient reverted to a closed position here, folded his arms across his body and bowed his head down] (N-074, emphasis added)

Using the past tense in the stage directions deviates from a typical drama script, but its inclusion in the rendition of this past experience noticeably increases the clarity. While one of the requirements for the reflective writing task is the use of constructed dialogue, the example given in the instructions does not contain stage directions. The students thus move beyond the given task and draw on their knowledge of genre conventions for presenting dialogue. In the case of the expert corpus, we have already reported that constructed dialogue is an important element of the texts and we do find evidence of drama notations. However, we find hardly any descriptions of action or body language in the form of stage directions that would evoke the genre of drama scripts further. Instead, we often find dialogue interlaced with the description of actions and feelings pertaining to the scene described, as in Excerpts 5.35–5.37:

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Excerpt 5.35 Days later, I raced to the ICU, coffee in hand, after Mrs D requested that a nurse page me. “He’s waking up!” she cried, grabbing me by both arms and shaking me with the force and glee of a teenaged girl, my coffee splashing onto my coat. I watched as the ICU resident extubated Mr D, as he coughed and spit his way back to independent breathing. (E-35)

Excerpt 5.36 I was anxious to see Dawn. “Let’s go in”, I said, waving the residents toward the door. “If she is going home we’ve a lot to arrange. Snow is predicted up north.” I slowly followed them into the room. (E-03)

Excerpt 5.37 The patient sat next to his wife during the interview. There was a sense of vacancy in his eyes, and yet, a sense of knowing lay there, too. “Yes, he has trouble remembering things, he repeats things more, is quieter…”, reported his wife. “Are you noticing any dificulty with your memory?” I asked him. He responded very slowly, staring ahead at my white coat. “No, I think it is about the same, maybe down a bit, but I’m not a medical student anymore.” “Do you have any children?” I asked. “Yes, 2, or no, I guess that’s 3 …”, he replied vaguely and glanced toward his wife for direction. I hesitated. (E-38) The descriptions of the actions are not yet reflections on the interaction (which come later), but they make the described scenes more vivid by adding more detail. They appear in the past tense and stand in stark contrast with the dialogue in the present tense. The way these scenes are worked into the overall flow of the text is thus more reminiscent of fiction in general than of drama in particular.

5.5 Summary and Conclusions In this chapter, we explored our texts through the lens of genre analysis in an attempt to better understand the compositional patterns found in our corpus. Our analysis of the textual features and the genre mixing of the texts in the reflective writing corpus revealed a number of issues. First, the crucial aspect of reflection is evident in the focus on a personal experience, in its discussion from the first-person perspective, and in the choice of vocabulary. In the student texts, the focus is strengthened through the structure of the text, with its sequence of description-reflection-conclusion. Following Bax (2011), who argues that a text’s main function is also crucial to determining its genre, we can firmly state that our corpus is made up of reflective writing texts not only in name but also in fact.

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Having established this, it is important to stress that not every student and expert composed their texts in exactly the same way. Some leaned more towards a narrative and personalized reflection, while others drew more on the medical case report and a more distanced reflection (see Meier, 2012). We also found traces of the essay, the theatre script and conventions of writing fictional dialogue. Far from being exceptional, mixing genre features in this way is quite common and well known to genre scholars (see Bax, 2011; Corbett, 2006; Giltrow, 2013; Giltrow & Stein, 2009; Schubert, 2012). However, without denying the prominence of reflection, what seems undeniable is the importance of narrative for our text corpus. This observation goes beyond stating that we find evidence of the narrating mode in the texts. Instead, the entire reflective text hinges on one or more of the author’s personal experiences, which means that they have to textually recall these episodes. We are therefore confronted with miniature narratives as well as with longer narrative passages within the texts, where story worlds are created, including the evocation of the episode’s location in space and time and the introduction of the characters. These miniature stories include at least the patient and the author/medical student, while more elaborate versions also introduce the reader to the patient’s GP, carer, spouse, siblings and parents. Despite the fact that the stories recounted are not personal, oral narratives, Labov’s (1997) terminology is helpful in pinpointing narrative elements within the overall composition of the texts (see also Semino et al., 2014). In particular, the reportable event, the explanations given for the choice of this event, and the miniature orientation passages are so fundamental to the texts that without them the reflection would not work. Finally, we pointed out that the conclusion sections allow the students to develop small future scenarios in which they position themselves as future actors (Georgakopoulou, 2007, 2013). The experts also use this strategy, although to a lesser extent (see also Chapter 7). The importance of ‘narrative’ for the medical profession is indeed quite fundamental, as many scholars have pointed out in the past (see, for example, Alderson & Bateman, 2002; Charon, 2006, 2014; Charon & Montello, 2002; Greenhalgh, 2006; Greenhalgh & Hurwitz, 1998; Gygax & Locher, 2015a; Hawkins & McEntyre, 2000; Hunter, 1991; Hurwitz, 2006, 2010). The reflective writing practice is a tool that also contains a strong narrative core, which medical practitioners can learn to appreciate (Oyebode & Tischler, 2015). In fact, the medical students are encouraged to engage in it on a regular basis and to make it an ongoing part of their professional lives, just like the writers of the columns ‘A Piece of My Mind’ and ‘On Being a Doctor’ have already done. As character positioning and the creation of a story world are fundamental elements within our corpus, we will return to this again in Chapter 7, where we look at identity construction. First, however, we will explore how aspects of relational work manifest themselves in the texts.

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Notes (1) This chapter draws in part on Locher et al. (2015), which, however, only looked at the Nottingham corpus and not at the entire data set. (2) Bax (2011: 55) reviews work by Bain (1877), Werlich (1976), Smith (2003), Bhatia (2004) and Fairclough (2003), who all mention ‘descriptive’, ‘narrative’ and ‘argument’ as discourse modes. In addition, Bain (1877) lists ‘expository’, Werlich (1976) ‘instruction’ and ‘exposition’, Smith (2003) ‘information’ and ‘report’, Bhatia (2004) ‘instructions’, ‘explanations’, ‘reporting’, ‘evaluation’ and ‘persuasion’, while Fairclough (2003) adds ‘conversation’ (see Table 3.2 in Bax, 2011: 55). (3) The scores are taken from the MAT dimension analysis table, while the closest register fit is taken from the dimensional graphs. (4) According to Nini (2015b), the category ‘involved persuasion’ contains ‘spontaneous speeches, professional letters, interviews’, and is characterized by a ‘high score on D4, unmarked scores for the other Dimensions’. (5) According to Nini (2015b), the catgory ‘imaginative narrative’ contains ‘romance fiction, general fiction, prepared speeches’, and is characterized by a ‘high score on D2, low score on D3, unmarked scores for the other Dimensions’. (6) According to Nini (2015b), the category ‘general narrative exposition’ contains ‘press reportage, press editorials, biographies, non-sports broadcasts, science fiction’, and is characterized by a ‘low score on D1, high score on D2, unmarked scores for the other Dimensions’. (7) According to Nini (2015b), the category ‘informational interaction’ contains ‘faceto-face interactions, telephone conversations, spontaneous speeches, personal letters’, and is characterized by a ‘high score on D1, low score on D3, low score on D5, unmarked scores for the other Dimensions’. (8) Weder (2016) compiled the German corpus from 550 texts (302,818 tokens, 45,083 types) collected from 2000 to 2016. They include 100 news messages from Swiss and German businesses, 100 newspaper articles from Switzerland, Germany and Austria, 100 reader comments to online newspaper articles from Switzerland, Germany and Austria, 50 blog articles by private individuals and NGOs, 100 Swiss political party texts and 100 introductions to academic articles within the humanities. (9) The values for Nottingham differ slightly from the ones published previously in Locher and Koenig (2014), since a different program with a different threshold and a different reference data file were used to compile the frequency list. (10) The list shows a wide scope of emotion words ranging from those with negative connotations to those that have either neutral or unclear connotations. See Locher and Koenig (2014) and Sections 4.4 and 6.5 for more information on emotions. (11) This observation is based on the assessment by Victoria Tischler and on her experience with the students. (12) As mentioned in Section 5.2, the students receive a brief introduction to reflective writing and also see sample texts that help explain their task. (13) Recall that the 50 texts in the expert corpus were chosen to match the student corpus and thus contain an encounter between a physician and a patient (see Section 2.3.3). (14) It is interesting to note that the student first addresses his patient directly (Sie, V-form of you) and later asks his wife about him (er, he).

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Interpersonal Pragmatics in Reflective Writing

6.1 Introduction In Section 4.2, Suchman (2013) was quoted as giving equal importance to biomedical knowledge and to communication skills for medical professionals. He also highlights that ‘[h]ealthcare is by definition interpersonal’ and that embracing this view is critical for developing professionalism (Suchman, 2013: viii). Recognizing this and reflecting on one’s professional behaviour is one of the purposes of making the Basel and Nottingham students engage in reflective writing. Indeed, we find evidence of such awareness on numerous occasions in our corpus. For example, one of the Nottingham students writes, ‘After all, the last thing I wanted to be was rude’ (N-144), which expresses a concern about how he did not want to come across in the (novice) doctor–patient interaction that he describes. Comments such as these point to expectations about norms of behaviour and open a window to understanding interpersonal concerns. While the teaching of clinical communication skills does not explicitly include raising awareness of politeness issues on a theoretical level as discussed in linguistics, the students nevertheless raise concerns about relational and interpersonal issues in their reflections. These are of interest to scholars in interpersonal pragmatics and to (im)politeness scholars in particular. What we witness, then, is that the students are in the process of recognizing and developing their own community of practice norms (Eckert & McConell-Ginet, 1992a, 1992b; Wenger, 1998) with respect to actions as well as relational work. In this chapter, we explore the following question: How does the relational side of communication surface in the texts? We particularly focus on how young professionals gain the knowledge of pragmatics that they acquire with a fairly straightforward teaching method, and how the students themselves link their insights to (im)politeness concerns. Wherever relevant, we will also draw on insights gained from the expert corpus. The chapter1 first turns to the theoretical background, i.e. to the field of interpersonal pragmatics and the study of relational work (Section 6.2). After 115

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this, we will revisit some insights gained in the previous chapters on the pervasiveness of interpersonal concerns (Section 6.3). This is followed by a qualitative analysis of a sub-corpus with respect to relational work, which is supplemented by insights gained from the entire corpus (Section 6.4). As the role of emotions emerges as a crucial concern in the corpus overall, Section 6.5 will give special attention to emotions. The chapter concludes with observations on reflective writing as a tool for raising awareness of pragmatic issues and skills.

6.2 Theoretical Background on Interpersonal Pragmatics and Relational Work This chapter explores the reflective writing texts from the perspective of acquiring pragmatic knowledge and especially the role of relational work therein. As previously defined, ‘relational work’ refers to the work individuals invest in ‘the construction, maintenance, reproduction and transformation of interpersonal relationships among those engaged in social practice’ (Locher & Watts, 2008: 96). Originally developed within politeness research, this concept allows us to work with the notion of face (Brown & Levinson, 1987 [1978]; Goffman, 1974, and others2) by describing face-maintaining, face-challenging and face-aggravating strategies of relationship negotiations. This dynamic approach to studying the interpersonal side of communication is still interested in politeness concerns, but is equally interested in studying how any other emic judgement of behaviour (such as rude, uncouth, impolite, polished, refined) is employed and comes about. The approach also posits a connection between negotiating face concerns, identity construction, and societal and local norms of conduct: [Face] is understood here as a metaphor that allows us to conceive of the fundamental need of interactants to engage in positioning themselves vis-à-vis others (see Locher, 2008). How this face is presented or taken up is what constitutes relational work, i.e. here we are interested in the particular choices interactants make and the dynamics of the unfolding event. As a result, interactants engage in identity construction. While identity is seen as a fundamentally emergent concept, it is acknowledged that interactants draw on complex and multifaceted representations of the self developed in previous interactions, which they negotiate and renegotiate in emergent interaction (for example, the potentially competing concepts of the self as social agent daughter, mother, partner, teacher, scholar, musician, etc.). (Locher, 2013: 147) Human beings are social in nature and judge their own and other people’s interactions according to their understanding of particular cognitive frames.3

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Frames (see also schema/script/activity type; Bateson, 1954; Goffman, 1974; Levinson, 1992; Tannen, 1993; Section 5.2) entail knowledge of action sequences in a particular situation with a particular aim in a specific context. This includes an understanding of the rights and obligations that they associate with particular roles of the participants. Interactants have acquired this knowledge through socialization. For example, the students in our corpus embark on their journey of becoming doctors with preconceived ideas of how doctors ‘should be and act’ and what they should ‘do’. During their training, however, they might find themselves in situations where these ideas clash with their newly gained experience and they have to adapt their understandings. In other words, while frames provide a cognitive backdrop for interpretation, they are nevertheless dynamic and historically embedded.4 Looking back at the history of the (im)politeness field, we can state that Robin Lakoff (1973: 296), as the earliest linguist to specifically put politeness on the research agenda, made it quite clear that ‘[j]ust as we invoke syntactic rules to determine whether a sentence is to be considered syntactically wellor ill-formed, and in what way it is ill-formed if it is, and to what extent, so we should like to have some kind of pragmatic rules, dictating whether an utterance is pragmatically well-formed or not, and the extent to which it deviates if it does’. This led her to combine Grice’s (1975) Cooperative Principle with a Politeness Principle. In the same vein, Brown and Levinson (1987 [1978]) and Leech (1983) later also build on the Cooperative Principle in their attempts to discover pragmatic rules or constraints (see Kádár & Haugh, 2013; Locher, 2012, 2013, for recent overviews of the history of politeness research). These early and by now classic studies on politeness are still used today, but the field of (im)politeness studies also received a boost in interest in the late 1990s and the 2000s, with many scholars contributing to the theoretical discussions. What is termed the discursive approach to the study of (im)politeness is not a unified approach in its direction, but it has helped the field to become more dynamic (see, for example, Linguistic Politeness Research Group, 2011). In addition to discussions on methodological decisions and a more interdisciplinary approach (see Locher, 2012), a number of points have been raised over the last few years and are presented here in no hierarchical order (for recent overviews, see Kádár & Haugh, 2013; Locher, 2012, 2013, 2015b): •

• • •

the scope of interest now includes impoliteness and rudeness phenomena as well as politeness, meaning the entire field of relational work is now being studied (from face-enhancing to face-maintaining and facechallenging behaviour); the rigid form-function correlation between indirectness and politeness is questioned; the historicity and cultural embeddedness of the moral order is highlighted; the dynamic negotiation of norms of interaction in situ is stressed;

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the complex interface between societal ideologies of conduct and local norms is taken into account; the complex interplay between understandings of roles within a particular interaction, politeness and identity construction is recognized; the role of emotions within this context is recognized as requiring further research.

For our purposes here, an especially important achievement of recent theoretical discussions is that they have drawn attention to the negotiability of the emic understandings of evaluative concepts such ‘polite’, ‘impolite’, ‘rude’, etc. – and, in connection with this, that they have highlighted the embeddedness of the observed social practices within their local situated framework of the moral order (see, for example, Kádár & Haugh, 2013: 95; Locher, 2015b). Locher and Schnurr (2017) give an overview of (im)politeness research as discussed in the health literature. They find that much of the research on face-to-face encounters and on written interactions between lay people and health professionals, and between peers within the field of health discourse, touch on the following issues: • • • •

the face-threatening potential of many interactions in a health context; the negotiation of roles pertaining to health interaction in dynamic encounters; the creation and maintenance of trust and expertise; the importance of counselling, providing advice, providing information, etc. (Locher & Schnurr, 2017: 698)

From an interpersonal perspective, the health context is thus of particular interest because the activities that the interactants engage in are often of a face-threatening nature for the patients – a fact of which the health professionals are well aware. 5 As a consequence, passing on knowledge about how relational work can be achieved is potentially of interest to health professionals. Returning to our particular corpus of reflective writing, we can ask how interpersonal concerns come to the fore in the texts that deal with doctor– patient interactions. To answer this, we need to stress the insight, asserted in all (im)politeness theories, that pragmatic knowledge is closely tied to context. Scholars have pointed out that we are not born with pragmatic competence; rather, people need to learn it through socialization processes (see, for example, Ochs, 1988, 1999; Pizziconi & Locher, 2015b; Rose, 2000: 28–29).6 This assumption can easily be brought into line with Scollon and Scollon’s (1990, 2001) work on what they term the ‘discourse system’, with the idea of communities of practice (Eckert & McConell-Ginet, 1992a, 1992b; Wenger, 1998), and with work on identity construction (Bucholtz & Hall, 2005, 2010; Hall & Bucholtz, 2013), as we will explain in what follows.

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Scollon and Scollon (1990), like Lakoff (1973) above, argue that people acquire, through socialization, rules of conduct that are often subconscious. This is analogous to the acquisition of first-language grammatical rules that not all native speakers can express on a meta-level. Importantly, Scollon and Scollon (1990: 285) highlight that these rules are deeply ingrained and closely tied to a person’s understanding of self. This observation has also been made with respect to the notion of frames, the knowledge of which is contained in a discourse system: in socialization processes, people learn about ways of behaving, and from these past experiences they develop expectations about action sequences and about the rights and obligations of the conversational partners. Typically, people become more aware of these expectations about appropriate behaviour in intercultural communication situations or in situations of conflict where people are at cross-purposes. Such awareness may also surface in situations where people are specifically asked to reflect on communication, as is the case in the data for this study. Scollon and Scollon (1990: 261) identify a number of discourse areas in which different patterns for different groups of people can be observed: ‘the presentation of self, the distribution of talk, information structure, and content organization’. They then report how Athabaskan-English speakers (i.e. speakers who have been socialized as Athabaskans) and speakers of English socialized in the ‘dominant, mainstream American and Canadian Englishspeaking population’ (Scollon & Scollon, 1990: 261) potentially misunderstand each other on an interpersonal level because they adhere to different discourse systems (with both parties striving to maintain and adhere to their own discourse systems) despite the fact that both speak English. For example, they mention that there are different tolerance thresholds for pauses, for selfpraise, and for making predictions between the two groups. The argument is that both groups have developed expectations about how to behave and they notice when their conversational partners do not follow the same norms. Without a conscious awareness that there are equally valid discourse systems among different people, this might lead to negative assessments of the conversational partners and to stereotyping (see also the work by Gumperz & Roberts, 1978, on ‘developing awareness skills for interethnic communication’). In fact, in the approach to (im)politeness studies proposed by Locher and Watts (2005, 2008), these judgements are a key element of the proposed theoretical framework. It is argued that judging others on their use of relational work results in them being seen as rude, impolite, uncouth, polished, polite, etc. These assessments are linked to judgements about the person as such, which means that we can detect a close link to identity construction and the moral order (Locher, 2008, 2012; Spencer-Oatey, 2007; see also the insights from anthropological linguistics on the link between metapragmatic comments and personhood, Agha, 2007; Lo & Howard, 2009). Scollon and Scollon (1990: 285) argue that, because the discourse system is closely tied to a person’s understanding of self, people cannot easily shed

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expectations about how interaction should happen when they are engaged in different practices. This retaining of expectations about behaviour and linguistic patterns is a phenomenon that has also been described in terms of pragmalinguistic transfer and sociopragmatic failure (e.g. Béal, 1994). GarcíaPastor (2012) reports the following: Pragmatics in language learning has typically been conceived as pragmalinguistics and sociopragmatics. Pragmalinguistics has been identified with a set of linguistic resources [e.g. indirectness, routines, hedges] for conveying illocutionary and interpersonal meanings (Leech, 1983; Thomas, 1983). In turn, sociopragmatics has been equated with the socio-cultural factors underlying the use of these resources across contexts (ibid.). (García-Pastor, 2012: 13, italics in original) So, when L2 learners transfer pragmatic strategies from their L1 into their L2 usage, they have not yet acquired the understanding that the pragmatic strategies differ (let alone acquired the knowledge of L2 pragmatic strategies). Misunderstandings are likely when the different discourse systems differ (e.g. giving different importance and weight to different types of facethreatening acts, or assessing distance and closeness differently; Béal, 1994). However, we do not even have to move to intercultural situations in order to find clashes of discourse systems. One can also make a case for arguing that different communities of practice7 may develop different norms and expectations about roles and adequate behaviour. These differences might be barely perceptible or rather large (see, for example, Culpeper, 2008: 30, on different types of norms). Making the link to the data studied here, one could state that becoming a professional health practitioner also entails learning how to behave in a particular way in the British or Swiss health system and that this suggests that the problems experienced by the medical students in this study have to do with negotiating different identities as students and novice doctors (see Gygax et al., 2012; Chapter 7). One method employed in medical education to raise awareness and understanding of how a practice works is of course reflective writing. As previously discussed, this type of writing involves three steps: description, interpretation (or reflection) and outcome (or conclusion) (Hampton, 2010a, 2010b; Watton et al., 2001; see Chapter 5). Gibbs’ (1988: 9) comments on the link between reflection and learning, quoted in Section 5.2, bears repeating here: It is not sufficient simply to have an experience in order to learn. Without reflecting upon this experience it may quickly be forgotten, or its learning potential lost. It is from the feelings and thoughts emerging from this reflection that generalisations or concepts can be generated. And it is generalisations that allow new situations to be tackled effectively. (Gibbs, 1988: 9)

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While the purpose of reflective writing can be to reveal insights on all levels of interaction, it can also help raise practitioners’ awareness of relational issues. In what follows, we study reflective writing texts from an interpersonal pragmatics perspective. This means that we assume that the texts will show evidence of relational work, which is part of pragmatic competence and closely tied to the presentation of self (see Bucholtz & Hall, 2005, 2010; Hall & Bucholtz, 2013; Locher, 2008, 2012; SpencerOatey, 2007).

6.3 Evidence of Interpersonal Issues from the Theme and Communication Skills Analysis In our discussion of the reflective writing corpus so far, we have already encountered a number of issues that can be linked to the interpersonal rather than transactional side of communication. In this brief section, we will summarize these findings as a backdrop for our ensuing discussions. In Chapter 3, we analyzed what the texts are about, i.e. what themes the students and experts choose to focus on in their reflections. Acknowledging that the interpersonal and transactional are intertwined and cannot be easily separated (Fill, 1990; Watzlawick et al., 1967), we first have to recognize that all of the 27 themes entail a relational side. However, some lean more towards the interpersonal side of communication than the transactional, and vice versa. For example, the themes in the group which concentrates on the context of the encounter lean more towards the transactional side.8 In the case of the focus on insights, we can see a mixed picture. With respect to the focus on the patient and the focus on the student/ expert, the tendency is to foreground interpersonal issues. Table 6.1 repeats the names of the themes from the latter two groups for convenience’s sake.

Table 6.1 Theme focus on the patient and the student/expert Focus on patient

Focus on student/expert

Bereavement Impact of illness on patient’s life Patient emotions Patient independence important Patient is cooperative Patient is difficult Patient is open Severe/terminal illness Special conditions

Experience Judgemental attitude revealed Prejudice/first impression falsified Professional behaviour/expertise Student/expert emotions Successful encounter

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We argue that the themes in these two theme clusters have a strong interpersonal orientation because the positionings of the interactants within the text are often of a delicate nature with respect to the notion of face. For example, when writers write about being overwhelmed by emotions or being insecure about handling their own emotions, when they admit to having been prejudiced and judgemental or when they admit to lacking in expertise, they are making themselves vulnerable to a reader potentially critical of their ‘professional doctor persona’. When they write about successful encounters and acquiring or applying experience, they are enhancing their persona which, however, might be face-threatening nevertheless depending on what role the display of modesty holds within a particular culture. In the same vein, positioning the patients in their scenarios in particular ways (as open, cooperative, difficult, emotional, etc.) and discussing the student’s/expert’s reaction to this within the scenes reveals how relationships are being negotiated. In Chapter 7, we will further explore this line of argumentation, which combines the study of identity construction with relational work. With regard to the communication skills studied in Chapter 4, we can also state that they all contain both transactional and interpersonal elements, but that there is a cline between skills that foreground transaction and interpersonal concerns. We grouped the skills into four clusters, as shown again in Table 6.2. Within the interpersonal group of communication skills, we established that ‘create rapport/build trust’ and ‘empathize’ were among the top skills chosen for discussion by the Basel and Nottingham students, and that they also appear to a certain degree in the expert corpus (see Table 4.4 above). In addition, the writers also noted how they often used non-verbal skills to create empathy and build rapport/trust, as in Excerpts 6.1 and 6.2:

Excerpt 6.1 One example of this was my inability at the time to use enough verbal responses and non-lexical utterances to reassure the patient that I was actively listening to his concerns. (N-002)

Excerpt 6.2 I sensitvely listened to Mr X, recognised his sadness and attempted to show empathy towards him by leaning forward whilst talking to him and by maintaining eye contact thoughout the encounter. (N-006) This report shows that our previous discussions have already yielded several results relevant to interpersonal pragmatics and demonstrates that the corpus is rich in interpersonal issues, which means a closer look is warranted.

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Table 6.2 Clinical communications skills tagged in the corpus (previously presented as Table 4.2) (1) General skills • Adapt/be flexible (2) Transactional skills • Deliver information/explain • Give patient time/conversational space • Listen • Mirror • Structure/signpost • Summarize • Use questions (3) Interpersonal skills • Be patienta • Create rapport/build trust • Empathize • Involve the patient • Reassure and reinforce • Show patients their resources and strengtha • Sympathize • Use (social) chit chat (4) Non-verbal skills • Respond to verbal and non-verbal cues • Spatial arrangement (e.g. moving chairs so that there are no barriers) • Use body language/tone of voice • Use non-lexical utterances a

These categories were not explicitly taught, but were tagged in the corpus because they emerged as pertinent.

6.4 Evidence of Awareness of Interpersonal Concerns Having established the importance of interpersonal issues in our previous analytical steps, we now turn to a qualitative case study of evidence of awareness of interpersonal concerns in order to explore relational work further. In general, the study of relational strategies cannot be easily quantified in a holistic manner.9 This is due to the fundamentally qualitative nature of the strategies and to their interconnectedness. Relational strategies occur on all levels of a text. They can be explored by taking into account the embeddedness of texts in their context, the composition of texts using paragraphs and arguments, syntax and lexical choices, etc. As the medical students were asked to specifically reflect on their communication skills and how they felt during or after the interaction (see Section 2.3), these data lend themselves particularly well to a study of metapragmatic comments on

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relational work. We have chosen data from the Nottingham corpus since it is our largest corpus, and we were particularly interested in finding out whether we could identify evidence of the acquisition of pragmatic knowledge of relational work. Our methodology involved close readings of the first 50 Nottingham texts through an interpersonal pragmatics lens (cf. Locher & Graham, 2010a) within the framework of relational work (cf. Locher, 2012; Locher & Watts, 2005, 2008). This means that we conducted close readings in order to see how relational work develops in context. One of our student interns (Andrea Wüst) and myself (Locher) read the texts and highlighted passages that discussed relational issues beyond the results of the theme analysis (Chapter 3) and the discussion of communication skills (Chapter 4). From these passages, we then jointly developed a number of recurrent themes, which illustrate what the students say they learnt with respect to relational issues. This analysis has not been quantified further and serves the function of theme identification. From this qualitative close reading of 50 texts, three major issues emerged: (1) The importance/value of rapport and empathy. (2) The presentation of self. (3) The role of emotions. In many cases, the students did not discuss these issues in isolation but in combination. This will also be visible in the examples chosen for illustration. We will draw on examples taken from texts beyond the first 50 in the Nottingham corpus in instances when they can illustrate a point particularly well.

6.4.1 Raising awareness about the value of empathy and rapport The first theme deals with reporting on raising awareness about the value of empathy and rapport. In clinical communication, empathy is portrayed as a tool for enhancing rapport and therefore building relationships with patients. Clinicians are advised to develop empathy for its therapeutic benefits such as encouraging disclosure and reducing anxiety, for its positive impact on adherence to treatment, and because ‘patients’ emotional needs’ should be seen as a ‘core aspect of illness and care’ (Halpern, 2003: 673). Excerpt 6.3 is taken from a text in which the student gives the following reason for choosing the described encounter: I remember this encounter because of the way the patient came into the surgery room looking perfectly fine with no outward signs of illness and then proceeded to break down in front of me as she explained how long she had been feeling under the weather (N-019). The student then explains how he was asked to see the patient on his own in order to take her history and report it to the GP. He starts his reflection part in the following way:

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Excerpt 6.3 The thing I think is unusual about this interview is how empathy is such a powerful tool at both eliciting a person’s true emotions and establishing a rapport with them. […] I also think my facial expression played a major role in how the conversation proceeded as when I mirrored the patient her true feeling came out. Also when I reassured the patient, I smiled which in turn made her smile and feel more secure in the fact people cared. […] I also used empathy to great effect, I think my facial expressions and eye contact were key in this. (N-019) The passage shows that this student does not simply report that he used empathy and established rapport. He also attempts to explain how he achieved this (facial expression, smiling, eye contact). (This is in contrast to quite a number of students, who did not go beyond mentioning key concepts.) It is not clear whether empathy is a genuine feeling in this example. In their text on vital clinical communication skills, Maguire and Pitceathly (2002) introduce empathy under the label of being supportive: Use empathy to show that you have some sense of how the patient is feeling (‘the experiences you describe during your mother’s illness sound devastating’). Use educated guesses too. Feed back to patients your intuitions about how they are feeling (‘you say you are coping well, but I get the impression you are struggling with this treatment’). Even if the guess is incorrect it shows patients that you are trying to further your understanding of their problem. (Maguire & Pitceathly, 2002: 698) This discussion leaves open the possibility that the practitioner does not actually feel for the patient. Crucially, however, the student in the above example evaluates the strategies mentioned and informs the reader that empathy is a powerful tool at both eliciting a person’s true emotions and establishing a rapport with them. This same learning experience is reported by the student who composed N-056, in which she describes a history taking experience with a 72 year old [C]aucasian female, who was particularly mistrustful of doctors.

Excerpt 6.4 I was quite shocked and concerned as to the lack of trust that the patient had in doctors after the remarks that the patient kept making and the feelings that she was expressing. However, although the patient seemed to dislike doctors on the whole, she seemed to be very friendly towards me and another colleague who also took the patient’s history after me. It seemed that she was very pleased by the fact that we came across to her a lot more friendlier and caring as she kept remarking that we were ‘very nice girls’ and said ‘I don’t mind talking to you’. Although I previously knew

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that establishing rapport with a patient was one of the most important things that a doctor should do when taking a history and talking to a patient, I do not think that until this encounter with this patient, I realised quite how important it was. I also did not realise how much impact the way in which a doctor comes across to a patient impacts on the way they think about other doctors on the whole, and how trusting or untrusting of other doctors they may become. It was also scary to think how much this trust would impact upon a patient’s treatment and how they respond in terms of compliance to a doctor’s advice. It is worrying to think that this patient may refuse to have essential vaccinations such as the flu vaccine, especially due to her old age, in the future due to these past encounters with doctors, whose intentions she probably just misunderstood. (N-056, emphasis added) In Excerpt 6.4, we see that the student grasps the importance of rapport not only because she went through the experience at the time, but also – and this is the didactic purpose of reflective writing – because she is made conscious of it by the act of reflecting and reporting on the encounter. This reporting on an understanding of why rapport matters that goes beyond knowledge learnt from textbooks was a recurring theme in this and other texts. It is further illustrated by a number of students who explicitly make a link between creating rapport and patient compliance, and thus adhere to a rational means-end assessment about rapport as an interpersonal clinical communication skill:

Excerpt 6.5 From my past experience I have found patient’s can be quite guarded of the information I want, and only after I had developed a sufficient rapport with them were they willing to divulge this information. […] From this encounter I have learnt the importance of keeping a conversation flowing to aid the development of rapport with the patient and therefore to elicit the information I needed from him. (N-021, emphasis added)

Excerpt 6.6 Therefore in future even though doctors have limited time to spend with each patient in a consultation, I will aim to develop a good rapport with patients since this will both make it easier to take a history and increase the likelihood of adherence in patients because the patient will want to discuss their problem with me and allow plenty of time for them to ask questions. (N-045, emphasis added) In Excerpts 6.5 and 6.6 the students report that building rapport allows them, as doctors, to better pursue their objective of gathering information (which they need to make their diagnosis) and to increase the likelihood of patients adhering to treatments. While these students seem to imply that

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information gathering is the main purpose of history taking (and some doctors would probably agree, but see Halpern, 2003 above), they report on their insights that an interpersonal communication strategy simplifies their task. This is in line with the above-quoted position proposed by Suchman (2013: viii), who, however, points out that one without the other cannot succeed. As Silverman et al. (2013 [1998]: 8) say, ‘[t]he prize on offer from communication skills training is improved clinical performance’ and ultimately ‘improved health outcomes’.

6.4.2 The presentation of self Excerpt 6.4 above also illustrates the second main interpersonal issue that emerged in the sub-corpus: the presentation of self (see Scollon & Scollon, 1990, 2001; Chapter 7), which is connected to interpersonal consequences of communication on relationships and to the challenge of finding the right level of relational work. The author of N-056 writes that I also did not realise how much impact the way in which a doctor comes across to a patient impacts on the way they think about other doctors on the whole, and how trusting or untrusting of other doctors they may become (directly after the highlighting). What she stresses here is that she realized that how one speaks and behaves has an impact on how one is seen and, in addition, that people apply assessments of how one speaks and behaves to an entire occupational group. This awareness can go in both directions: the student’s own behaviour as a future doctor has an impact on how doctors will be seen, and the student is judged in light of how doctors were perceived in the past. Interestingly, the student writes that the patient is quite happy to talk to her and implies that this was because she and her colleague were still considered to be very nice girls rather than mistrusted doctors. Furthermore, the student makes a direct link between creating rapport and patient compliance and thus also gives a rational rather than an emotional reason for creating rapport. All in all, Excerpt 6.4 nicely illustrates that the student becomes aware of issues around the presentation of self, membership categorization, and the dynamics of identity construction in this new community of practice into which she is being socialized. This leads her to realize that finding the right level of relational work is an achievement and has consequences for future interactions. Worrying about the presentation of self and establishing a professional identity is a recurring theme in the corpus and is often accompanied by explicit metapragmatic comments on relational work. Excerpts 6.7–6.10 illustrate some of these instances.

Excerpt 6.7 Certain aspects of my own non-verbal communication could also have been changed to build rapport and come across as a open figure - examples include, smiling, looking interested and nodding. (N-012, emphasis added)

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Excerpt 6.8 In Part 3, I laughed politely when she said that she has Indian blood in her. I did that just to maintain the rapport between us. She did not mind me doing that but maybe some other patients would. […] I will try to keep it to a nice polite smile next time just to avoid patient feeling that I was laughing at them. (N-005, emphasis added)

Excerpt 6.9 I will also try and adapt my language to mirror words used by the patient to build rapport and help keep us on the same level. I must find the balance between empathetic and patronising responses for example by refraining from phrases like “poor you” when the patient describes something negative and use something like “That must have been hard for you.” This will show empathy yet not demean the patient. (N-008, emphasis added)

Excerpt 6.10 I have learnt how difficult and how emotionally demanding some consultations can be. I wasn’t aware of how much of an effect the patient’s upset would have on me; in the future I will try to remain empathic but I must also be aware of maintaining a professional amount of distance. (N-085, emphasis added) In Excerpt 6.7, the author of N-012 reports that he will strive to be an open figure in the future. The author of N-005 in Excerpt 6.8 uses meta-language about relational work (laughed politely, a nice polite smile) to describe her past and future behaviour in an endeavour to make sure that the patient does not feel as if he/she is being made fun of through potentially inappropriate laughter. This shows that she is aware of the risk of being misunderstood when striving to maintain the rapport. A similar awareness is demonstrated in Excerpt 6.9, where the student explains that the same sign can be interpreted as empathic or patronizing, which means that her behaviour can result in positive or negative evaluations. In Excerpt 6.10, the student contrasts showing empathy with maintaining professional distance, which reveals the underlying ideology that maintaining distance, rather than showing empathy, is a key element of a professional stance (see Section 6.5.2 for a discussion of this text). The students who wrote Excerpts 6.7–6.10 thus also report on realizing that their behaviour has consequences for their presentation of self and that finding an adequate way of expressing oneself is challenging. The topic of identity construction and positioning will be further elaborated on in Chapter 7.

6.4.3 The role of emotions The third theme identified in the 50 texts is the role of emotions. This corroborates the findings presented in Chapter 3, where two separate

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themes were found to be ‘patient emotions’ and ‘student/expert emotions’. While we expected the students to reflect on emotions (the instructions explicitly ask them to report on their feelings), it is nevertheless noteworthy that they often chose encounters that specifically deal with their own and the patients’ emotions, and that they recurrently report on emotions in connection with interpersonal issues. For example, in Excerpt 6.10 above, the student reports on an encounter with a patient whose emotional reaction affected the student to the point that she became emotional as well and struggled between showing empathy and keeping distance. In Excerpt 6.4 above, the reported insights on the value of rapport and empathy are embedded in a discussion of how shocked and concerned the student was about the patient’s obvious lack of trust in doctors. There are many other examples in which the students discuss their feelings of unease and distress, or mention worrying about not behaving appropriately – as is the case in Excerpts 6.11–6.13:

Excerpt 6.11 I felt like I was explaining something to a child, although it was effective, I was scared he might feel patronized and so it was a challenge for me to perceive whether or not he felt this way. In the end I realized he had taken no offence in the way I explained it. (N-022, emphasis added)

Excerpt 6.12 This was slightly frustrating as I didn’t feel I was being rude or was acting in any way that would make the patient act so defensively and distant. (N-009, emphasis added)

Excerpt 6.13 The first thing that struck me was that the patient sort of mumbled when speaking due to his illness. This made the encounter tricky, but also rather awkward for me as I wasn’t sure whether to keep asking him to repeat things or just nod in a clueless manner. After all, the last thing I wanted to be was rude, and unfortunately this played on my mind throughout the interview. (N-144, emphasis added) In Excerpts 6.11–6.13, the students report negative feelings10 (being scared, frustrated, insecure) and link these to projected assessments of their behaviour by the patient. In other words, they assume that the patient will judge their behaviour and might find it patronizing or rude. It has been argued that this connection between emotions and the act of judging one’s own and other people’s relational work is a crucial element in interpersonal pragmatics, since emotions are key to arriving at an assessment (Culpeper, 2011; Langlotz & Locher, 2012, 2013, 2017; Locher & Koenig, 2014; Locher & Langlotz, 2008; Spencer-Oatey, 2007, 2011). The

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examples also give further evidence of the link between the presentation of self and metapragmatic comments on relational work, and nicely illustrate how the interactants take their own and the addressees’ perspectives into account. While ‘politeness’ and ‘rudeness’ are not explicitly mentioned in teaching, the students bring up these concepts in connection with the mention of emotions and identity construction in the form of metapragmatic comments. A lexical search in the Nottingham corpus shows 29 occurrences of ‘patronis/zing’ or ‘patronis/ze’ in 14 texts where the students report wanting to avoid appearing patronizing. In 14 texts, rudeness (n = 19) is mainly mentioned with respect to self, i.e. the students do not talk about rude patients but about wanting to avoid appearing rude themselves. Mention of polite behaviour occurs in 17 cases in 14 texts, and impoliteness is not mentioned at all.11 Culpeper (2011) made similar observations about the prevalence of ‘patronizing’ and ‘rude’ as first-order lexemes in his collection of reports on incidents that caused offence. Our qualitative close reading of the first 50 texts in the Nottingham corpus revealed three concerns: the importance of rapport and empathy, the presentation of self, and the role of emotions. The discussion of the excerpts shows how intricately intertwined these concerns are. We will elaborate more on the presentation of self in Chapter 7. First, though, we will shed more light on the surfacing of emotions in the entire corpus.

6.5 Emotions as a Challenge in Doctor–Patient Interaction As reported above, the qualitative analysis of the first 50 Nottingham texts found that emotions are a crucial concern for students. This finding is corroborated for the entire corpus by two results from previous analyses. As reported in Chapter 3, the theme categories that have to do with either the patient’s emotions (Basel: 10%; Nottingham: 23%; Expert: 8%; Table 3.6) or the student’s/expert’s emotions (Basel: 23; Nottingham: 17%; Expert: 34%; Table 3.6) are important in the corpus. The students raise the specific theme of emotions and how to cope with them, rather than just mentioning emotions in the reflective parts of the texts (recall that the instructions mention reflections on emotional reactions, and that Wald’s [2015: 697] definition of reflection highlights the involvement of feelings in the reflective process). This high percentage of emotion themes confirms that it is challenging for medical professionals to deal with emotional patients and with their own emotional reactions to patients. Furthermore, a closer look at the communication skills mentioned in the texts shows that ‘empathy’ (Basel: 21%; Nottingham: 61%; Expert: 4%; Table 4.4) is mentioned as one of the most frequent communication skills. This is followed by ‘create rapport/build

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trust’ (Basel: 18%; Nottingham: 60%; Expert: 8%; Table 4.4). As both skills crucially involve managing emotions, this further corroborates the importance of dealing with emotions and shows that it is a critical part of professional training. Building on these findings, we will now look at the surfacing of emotions within the corpus in more detail. As one of the experts in our corpus so aptly puts it:

Excerpt 6.14 Physicians are partial to terms such as fix, cure, and conquer. The medical student counts a successful rotation as one with procedures; the resident is triumphant when he clinches the diagnosis; the attending likes nothing more than an efficient ward round of patients whose medical and social issues are “sorted”. Absent from this narrative of professional development is a cohesive way in which to deal with the disappointment, frustration, and plethora of emotions that accompany our perceived failure at conquering disease and suffering. (E-39) What we see in Excerpt 6.14 is a succinct discussion of the importance of emotions and a plea to pay more attention to them. In order to elaborate on this, we will first present a quantitative analysis of the emotion vocabulary used in the corpus. This analysis complements the discussion on lexis in the chapter on genre (Section 5.3.8). Secondly, we will present a close reading of how emotions surface in one particular text.

6.5.1 Emotion vocabulary In Section 5.3.8 on lexis, we presented the 100 most frequent words and the keywords of the corpus. From this overview, it was not yet possible to glean the important role of emotions. Perusing the word lists further confirmed the semantic fields of patient encounter, the focus on communication skills, and the reflective part of the task. In addition, we found that names of body parts, technical medical vocabulary and emotion words define the corpus. To illustrate the matter of emotion words, we will focus on the Nottingham corpus once again. It bears reiterating that looking at word lists out of context is an obvious disadvantage, but will nevertheless give us a basic understanding of the overall vocabulary composition of the texts. The percentages reported below are thus merely an approximation, due to the limitations of analyzing the word list which reports reflection and emotion together (e.g. out of context, it is unclear whether the verb feel or the noun feeling refer to the semantic field of reflection or emotion).12 The lexemes that indicate either emotions or reflection occur with an overall frequency of about 5% (n = 5846), which is lower than for medical

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jargon, which reaches 11%. Many of the individual lexemes occur quite frequently. The following list is ordered according to overall frequency within the Nottingham corpus: felt, 960; feel, 642; think, 577; feeling, 248; empathy, 142; happy, 139; comfortable, 135; upset, 128; feelings, 119; believe, 112; worried, 98; sorry, 94; emotions, 81; emotional, 78; confidence, 60; confident, 59; thinking, 55; calm, 54; confused, 54; nervous, 54; concerned, 53; involved, 50; worry, 50; anxious, 48; embarrassed, 47; sympathy, 43; angry, 41; frustrated, 40; sad, 40; pleased, 38; sensitive, 37; feels, 36; empathetic, 35; fear, 32; emotionally, 31; mood, 28; satisfied, 25; empathise, 24; glad, 24; shy, 24; worrying, 24; annoyed, 23; frustrating, 23; love, 23; believed, 22; comfort, 22; emotion, 21; frustration, 21; guilty, 21; judge, 21; brave, 19; grateful, 19; afraid, 18; loved, 18; sympathetic, 18; stress, 17; empathize, 15; anger, 14; disappointed, 14; happier, 14; satisfaction, 14; comforting, 13; polite, 13; upsetting, 13; worries, 13; apprehensive, 12; unhappy, 12; upbeat, 12; ashamed, 11; distressing, 11; fears, 11; lonely, 11; pleasure, 11; sympathise, 11; annoying, 10; desperately, 10; judgemental, 10; pleasant, 10; saddened, 10; stressed, 10 From this list we see there is a surprisingly broad scope of emotion words, ranging from those with negative connotations (Nottingham: 22%, n = 1278) and positive connotations (Nottingham: 23%, n = 1312) to those that have either neutral or unclear connotations out of context (Nottingham: 56%, n = 3238). These groups will be illustrated in turn. In the list of emotion words with negative connotations, we can make out clusters of word fields that are notable because of their comparatively high frequencies: ‘worry’ (n = 185), ‘being upset’ (n = 143), ‘frustration’ (n = 87), ‘nervousness’ (n = 67), ‘sadness’ (n = 62), ‘embarrassment’ (n = 60), ‘anxiousness’ (n = 55), ‘confusion’ (n = 54), ‘fear’ (n = 52), ‘anger’ (n = 41) and ‘stress’ (n = 40). While the list itself does not yield any insights into whether these emotions were assigned to the patient or the student, the mere range of them is noteworthy. The emotion words with positive connotations are equally varied in scope in the Nottingham corpus. The most frequent clusters are around ‘empathy’ (n = 240), ‘comfort’ (n = 181), ‘happiness’ (n = 165), ‘confidence’ (n = 120), ‘sympathy’ (n = 83), ‘calmness’ (n = 69), ‘pleasantness’ (n = 64) and ‘satisfaction’ (n = 43). The frequent mention of ‘empathy’ can be explained by the fact that this concept not only refers to genuinely felt emotions but also to a strategy taught in the communication skills module, which recommends that students use it to enhance their rapport with patients. To illustrate the use of negative and positive emotion words in context, we present extracts from a text written by a 20-year-old female medical

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student from Nottingham, who gives both English and Thai as her first languages (N-088). The encounter is about a meeting between the student, her colleague and a patient who impressed the student with her positive attitude. The patient is a dancer with diabetes whose legs were amputated. The student starts the text by setting a dark scene in Excerpt 6.15. For ease of reference, these excerpts include line numbers.

Excerpt 6.15 1 It was a dark, rainy morning when my colleague and I visited the patient 2 during our first hospital visit of the year. [371 words: Description of the history taking, the feeling of shock and being at a loss at learning that the patient had been a dancer whose legs had been amputated (“I felt shocked”; “I was lost as to how to react”)] 36 I was really sad to hear that, a dancer who no longer had legs! That 37 must’ve felt awful. My colleague and I failed to find appropriate 38 consoling words for the patient. We stayed silent. I was at lost. [sic.] 39 40 But we did try to [b]e empathetic, offering kind words of support 41 and understanding as the interview went on. I nodded and mirrored the 42 patient’s slight gestures and frowns, hoping to convey my empathies. (N-088, emphasis added) The student says this was the first time she had seen a fresh amputee and that she felt shocked and sad. Acknowledging that the dancer’s fate must feel awful, the student reports that she failed to react well. In the ensuing interview, however, both students manage to employ communication skills (italics, Lines 40–42) to display empathy. The student explicitly states that the tragic fate of the dancer was not why [she] remembered the encounter so vividly (Line 16, not shown here). Instead, the student is affected by the patient’s positive and optimistic outlook. Excerpt 6.16, which comes after several passages of constructed dialogue, illustrates this nicely (note the repeated use of metaphors):

Excerpt 6.16 57 I felt a revitalizing energy from the patient. She was strong. I sawer 58 as powerful and hopeful. She would never let something like this 59 ‘drag [her] down’. I was taken aback, surprised, and proud of the 60 optimism all at the same time. 61 She was marvelous. 62 The patient herself must’ve felt proud as well. She was smiling 63 brightly, laughing, and her speech and language was uplifting. She 64 must’ve felt that she could not give up, even with this condition, and so 65 she refused to feel down. (N-088, emphasis added)

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In Excerpt 6.16 we witness how the patient’s emotions directly affect the student. In addition, and from a stylistic point of view, the description of the student’s emotions as a reaction to the patient’s fate are the leitmotif for the composition of the text. The patient’s worldview is so uplifting that the student’s emotions also change as a consequence. Finally, there is a set of words that concern reflection and emotion, and have neutral or ambiguous connotations out of context (as mentioned above, analyzing word frequency out of context makes it hard to assign these lexical items to either emotions or reflections only). Particularly striking are the clusters around ‘feel’/’feelings’ (n = 2005), ‘think’ (n = 641) and ‘believe’ (n = 146). Think and feel also belong to the 100 most frequent words in the Nottingham corpus overall (excluding stop words).

6.5.2 Emotions in context Having established that emotions are an important theme in the corpus, that they are often discussed in connection with communication skills and that there is a wide range of emotion words, we will now illustrate how emotional stance (cf. Matoesian, 2005) is created in one particular student text, which combines writing about both the patient’s and the student’s emotions. The theoretical framework for our analysis is inspired by Planalp’s (1998) work on emotional cues in face-to-face interaction. Table 6.3 shows that these cues are multimodal and cover vocal, verbal, body, physiological and facial cues. When taken together, they constitute a ‘composite signal’ which is created ‘online’ and designed to be identified by the recipient (Clark, 1996: 178–179; for overviews of emotional cues, see Langlotz & Locher, 2012, 2013, 2017; Locher & Langlotz, 2008; Ochs & Schieffelin, 1989). In our data, we have to rely entirely on the linguistic power of evoking emotional stance. In other words, the writers use language for the emotional verbal cues listed in Table 6.3 but they can also choose to use language to report on and describe the other cues (vocal, body, physiological, facial) in retrospect. Text (N-085) was written by a 20-year-old female student with English as a first language. The main issue described in the chosen encounter is the role and impact of the patient’s and the student’s emotions on how the encounter develops. In addition, the student focuses in particular on empathy as a communication skill in the reflective parts of the text. The chosen encounter is about a patient who becomes very distressed during the consultation due to her condition (a persistent viral infection and pregnancy) and starts crying. The student recounts that she does not know how to handle this outburst. The patient becomes even more upset when a blood test is required, as she has severe phobias of needles and blood. At this point the patient’s emotional cues intensify as she starts to scream and hyperventilate. After the encounter, the student feels emotionally drained and is not satisfied

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Table 6.3 Planalp’s (1998) overview of emotional cues Class of cues

Forms of realization

Vocal cues

Voice quality: low, loud, slow, fast, trembling, high-pitched, monotonous, animate voice Language-specific emotion vocabularies, metaphors, speech acts Emotional discourse practices, e.g. therapeutic discourse Animated, energetic movement Physical actions: throwing things, making threatening movements, kissing, caressing Gait: walking heavily, lightly, arm swing, length/speed of stride Body posture: stiff/rigid, droopy, upright Hands/arms gestures: hand emblems, clenching hands or fists Blushing, pupil dilation, heart rate, breathing, skin temperature Facial expressions of emotions through forehead and eyebrows, eyes and eyelids, and the lower face (mouth, lips, labionasal folds)

Verbal cues Body cues

Physiological cues Facial cues

Notes: See also Langlotz and Locher (2012, 2013, 2017).

with how she dealt with the situation. The text is reproduced here as Excerpt 6.17, with line numbers for ease of reference. Lexical patient emotion cues () and student emotion cues () are indicated in diamond brackets and italics.

Excerpt 6.17 N-085 (emphasis and coding added) 1 2 3 4 5 6 7 8 9

As the patient stood up and walked towards the consultation room I guessed that she was around 35 years old. Her face was slightly flushed and she was holding a tissue – I assumed that she was coming to the surgery about a cold or flu. She entered the room and sat down; under the bright lights of the consultation room I noticed how much the patient reminded me of my neighbour. As ‘Dr Name’ looked for her notes I saw that the patient was sat towards the front of her chair with her legs crossed looking towards the floor. but it struck me that .

10–17 [Summary of information on the patient’s condition provided by Dr Name] 18 Dr Name left the room to get a syringe for some blood tests. I was left 19 alone with the patient who was becoming : 20 21 22 23 24 25

Patient: Student: “It’s OK” Patient: “It’s just … this has been going on for so long and And things I would normally take, you know like Echinacea, I can’t with being pregnant.” Student: “It must be really difficult.”

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26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

< EP The patient began to cry.> I wanted to break the silence but couldn’t think of anything to say to make her feel better. I reached into my bag and leaned towards the patient as I handed her a tissue. that I couldn’t do anything to help her. After the patient had left Dr Name asked me if I was OK. It was easier in hindsight to think I should have said “I understand why you are upset” but I wasn’t sure that I did understand. At the time I was concerned with ; but in reflection, the patient probably wouldn’t have been that critical of the exact phrasing I used and . I know that this encounter was and I can only imagine that I hope that

45 46 47 48 49 50 51 52 53 54

As I gain more experience talking to patients and relatives who are distressed and In the future I think I will be better equipped for this type of situation where hopefully I will be able to After speaking to Dr Name and consulting relevant literature I have also learned the value of a brief silence. This can give the patient an opportunity to discuss their feelings or simply for everyone concerned to reflect.

55 56 57 58 59 60 61 62 63 64 65 66

I feel that this encounter was memorable because it was the first time that was alone with . I tried to adopt a As the consultation progressed The patient revealed that she was as she had had to take time off due to her illness and would then be going on maternity leave. Later, Dr Name began to prepare the patient for blood to be taken, when she realised what was happening – I knew how but I couldn’t make it better. Between she explained that she

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67 had severe phobias of both needles and blood. All I could do was 68 < EP hand her another tissue. > 69 70 71 72 73 74 75 76 77 78 79 80 81

I didn’t communicate with the patient as I had intended. I didn’t anticipate how difficult it would be for me to remain calm and say something comforting to the patient. As the conversation between the patient, Dr Name and myself continued the I had been hoping that it would have been the opposite to this. On reflection I think that

82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

< EP I have learnt how difficult and how emotionally demanding some consultations can be. I wasn’t aware of how much of an effect the patient’s upset would have on me; in the future I will try to remain empathic but I must also be aware of maintaining a professional amount of distance.> As I have mentioned previously, this encounter has also taught me that sometimes a silence can be helpful in getting the patient to discuss their emotions and concerns with you. I don’t think I could have been any more prepared for this encounter. Learning about the theory behind communication in these situations was useful but seemed to go completely out of the window when I was actually presented with a I think now that I have been in this situation I will be more capable of shaping such an encounter in the future. Hopefully I will be in talking to patients about why they are upset although I appreciate that not all patients will react in the same way in these types of encounters therefore I must be flexible in my approach to them.

Looking at the visual presentation of Excerpt 6.17 alone, the sheer amount of italics, which signal the patient emotion cues () and the student emotion cues (), is quite striking. Since this text is about how an encounter with a distressed patient did not go smoothly, it is perhaps not surprising that the text is brimming with emotion cues. We can group them into cues that display mental states, cues about actions that index emotions, passages where an interpretation taking context into account helps identify emotional stance, and the use of constructed dialogue to convey emotional stance. Furthermore, the explicit discussion of emotional contagion and empathy also conveys emotional stance. In what follows, we will illustrate these groups in turn.

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The student assigns emotional mental states to the patient and to herself during the encounter by employing verbal cues from language-specific emotion vocabularies. Excerpts 6.18–6.23 show a selection:

Excerpt 6.18 She smiled but it struck me that she looked unhappy. (Lines 8–9, emphasis added)

Excerpt 6.19 I was left alone with the patient who was becoming more and more upset (Lines 18–19, emphasis added)

Excerpt 6.20 I felt awful that I couldn’t do anything to help her. […] (Lines 31–32, emphasis added)

Excerpt 6.21 I tried to adopt a soothing tone of voice when speaking and felt desperate to say something to make her feel better. (Lines 56–58, emphasis added)

Excerpt 6.22 This made the patient even more upset, I felt utterly helpless. (Lines 61–62, emphasis added)

Excerpt 6.23 The fear in her eyes made me feel even worse – I knew how scared and upset she was but I couldn’t make it better. (Lines 64–66, emphasis added) The student uses emotion adjectives and collocations as verbal cues of emotional stance (unhappy, upset, scared, feeling awful/desperate/helpless), describes a vocal cue (soothing tone of voice) and a facial/physiological cue (fear in her eyes). The student not only assigns mental states by means of emotion vocabulary to herself and the patient, but also stresses how the patient’s distress affects her own emotional state. As a consequence of the patient’s distress, the student feels awful, desperate and helpless. This is primarily because the student feels that she cannot adequately help the patient. Indirectly, the student thus highlights her expectations that a doctor should be able to improve the patient’s situation (I couldn’t do anything to help her, Line 32; make her feel better, Line 58; I couldn’t make it better, Lines 65–66). The fact that doctors often cannot actually help patients (medically or emotionally) is rarely talked about, as doctors are usually trained to intervene. In contrast, Johansen et al. (2012), in a study on GPs treating terminally ill cancer patients in Norway, point out that acknowledging a shared humanness can enable a doctor to simply ‘be’ with a terminally ill patient for whom medical intervention is no longer effective. This requires an understanding of both

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physiological and existential suffering, which is often absent in biomedical training. The student also uses the description of actions to signal the patient’s and her own emotions:

Excerpt 6.24 She smiled but it struck me that she looked unhappy. (Lines 8–9, emphasis added)

Excerpt 6.25 The patient began to cry. (Line 26, emphasis added)

Excerpt 6.26 I reached into my bag and leaned towards the patient asking if she needed a tissue. (Lines 30–31, emphasis added)

Excerpt 6.27 Later, Dr Name began to prepare the patient for blood to be taken, when she realised what was happening she screamed and began to hyperventilate. (Lines 62–64, emphasis added)

Excerpt 6.28 Between her sobs she explained that she had severe phobias of both needles and blood. All I could do was hand her another tissue. (Lines 66–68, emphasis added) The emotion cues in these examples once again represent lexical items that have emotional connotations (smile, cry, scream, hyperventilate, sobs). However, a number of actions are indexical of showing concern and empathy in the context of such an encounter (lean towards the patient, offer a tissue).13 The student recalls these actions (body cues and speech acts) that indexed emotional stance at the time and reports them by means of language. In other instances, the student describes a situation in words that only become emotionally charged when interpreted in context:

Excerpt 6.29 I found it difficult to know what to say: I had no idea of how someone in this situation would feel and I didn’t want to sound insincere or make matters even worse. (Lines 26–28) The sentences in Lines 26–28 describe an emotional situation in which the student could be described as feeling helpless and worried about doing the right thing, but the words in themselves are not strongly emotionally indexical. In addition, the student employs a more indirect means of evoking the patient’s emotional state by using constructed dialogue (cf. Tannen, 1989).14

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By presenting the patient as using her own words to signal emotional distress, the emotions are enacted rather than assigned:

Excerpt 6.30 Patient: “I’m sorry about all this.” (Line 20, emphasis added)

Excerpt 6.31 Patient: “It’s just … this has been going on for so long and I can’t cope anymore.” (Lines 22–23, emphasis added) The literature on oral narratives of personal experience reports that constructed dialogue can be used to create immediacy and listener involvement, and can move the narrative plot forward (Tannen, 1989; see also Sections 5.4.2 and 5.4.4). Rather than summarizing or paraphrasing a dialogue, the listeners are invited to draw their own conclusions (Hamilton, 1998). However, the student who is creating the story world of her memorable encounter does not use the passage with constructed dialogue to advance the story much. Instead, she uses it as an illustration to lend her own assessment of the patient’s unhappiness more credibility, since it is the patient herself who implies that she is desperate (I can’t cope anymore, Lines 22–23). In the reflective passages, the student explicitly highlights that she was surprised about the force of the emotional contagion (also note the use of the container metaphor in the first example):

Excerpt 6.32 I know that this encounter was emotionally draining for me and I can only imagine that it was ten times worse for the patient. (Lines 40–42, emphasis added)

Excerpt 6.33 I wasn’t aware of how much of an effect the patient’s upset would have on me. (Lines 83–84) She explicitly refers to the use of empathy as a strategy that she tried to employ in order to counteract the distressing situation:

Excerpt 6.34 I hope that by at least offering her a tissue and showing some empathy towards her this made her feel slightly better. (Lines 42–44) The communication skills course introduces the students to the use of empathy as a strategy that can be signalled verbally and non-verbally. Empathy is encouraged in clinical communication as a powerful tool for enhancing rapport and thus for building relationships with patients. Empathy is a type of

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emotional resonance that students and clinicians are advised to develop, as it has therapeutic benefits such as encouraging disclosure and reducing anxiety (Halpern, 2003). Students are advised to try and imagine the patient’s experience by emotionally attuning to verbal and non-verbal cues that they can express via, for instance, their tone of voice or use of emotive language. (See also the student’s attempt in N-088 to draw on strategies that signal empathy in Excerpt 6.15, Lines 40–42.) In addition, the student suggests that showing (more) empathy and being more confident, less anxious and embarrassed could be solutions for handling future situations in a more satisfying way:

Excerpt 6.35 As I gain more experience talking to patients and relatives who are distressed I will become more confident & less anxious. I realise that my anxiety wasn’t helpful in this situation and could have made the patient feel worse. In the future I think I will be better equipped for this type of situation where hopefully I will be able to reassure the patient by saying something like “I understand that you are upset”. (Lines 45–50, emphasis added)

Excerpt 6.36 On reflection I think that I should have felt less embarrassed about saying the wrong thing. I should have just used more empathic statements and provided more of an opportunity for the patient to discuss how she felt. I think that as long as I was sincere the patient would not have been offended by my discussing her distress. Although afterwards I have consoled myself with the fact that at least the patient felt comfortable enough in the consultation to remain there, continue talking to us and show her emotions. (Lines 74–81, emphasis added)

Excerpt 6.37 Hopefully I will be less anxious and more confident in talking to patients about why they are upset […] (Lines 94–95, emphasis added) In developing these future scenarios, the student discusses the potential emotional consequences that a change in her communicative behaviour might have. Finally, the student also points out that showing too much empathy might have a negative effect:

Excerpt 6.38 I wasn’t aware of how much of an effect the patient’s upset would have on me; in the future I will try to remain empathic but I must also be aware of maintaining a professional amount of distance. (Lines 83–86, emphasis added)

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Finding the balance between empathizing and not being drawn into an emotional situation at the expense of the medical practitioner’s own health is indeed a difficult task. The student uses the phrase maintaining a professional amount of distance to refer to this challenge. However, students also often use this or similar phrases not only to express concern for their own health, but also because they are worried that they cannot remain professional if they get too drawn into the emotional world of the patient.

6.5.3 Discussion So how can these insights be related to the more general topic of reflective writing in medical training and to the corresponding challenges of emotion management? Erickson and Grove (2008: 707) convincingly argue that all interaction between people involves the need to manage emotions. Drawing on Hochschild’s (1983) work, they propose making a distinction within emotion management between ‘emotion work’ ‘to refer to the management of emotion in personal interactions (e.g. with family and friends)’ and ‘emotion labour’, which ‘should be used only in occupational contexts where one is managing emotions because it is part of what the job requires’ (Erickson & Grove, 2008: 707). In healthcare and therapy contexts, the need to address the patient’s emotions is particularly prominent as patients are given help in coping with and managing their emotions (Erickson & Grove, 2008: 707). Learning how to manage one’s own emotions, however, is also part of learning about the practice. In their review of work on nursing, Erickson and Grove (2008) show that conflicting norms are at play. On the one hand, ‘we generally expect that our doctors and nurses approach our healthcare with a certain level of empathic concern’ and, on the other hand, ‘emotional detachment, neutrality, and/or emotional control’ are taught as ‘fundamental to providing quality care and to preserving their own health and well-being’ (Erickson & Grove, 2008: 712). It is exactly this dilemma that the student describes in her description of neutrality and empathy above. This points to the importance of making emotional labour a topic in medical teaching. In an overview of the interface of (im)politeness and emotion research, Langlotz and Locher (2017) report on the tension between ‘feeling’ rules and ‘display’ rules: According to Hochschild (1979, 1983) two types of socially appropriate emotional behaviour must be distinguished. One the one hand, we must learn feeling rules, i.e. we must learn how to feel in a specific situation. For example, medical doctors must learn to express empathy with their patients without, however, feeling with them all the time (see also Locher & Koenig, 2014). Flight attendants must learn to project being in charge and positive even in highly stressful periods. Such feeling rules are

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closely related to display rules (Ekman & Friesen, 1975). According to Andersen and Guerrero (1998: 54): ‘these products of emotional socialization involve a learned response that modifies spontaneous emotional displays to be socially appropriate.’ Thus, flight-attendants must put on a smile even if they feel exhausted, whereas doctors should signal empathy about their patients’ fate even if they cannot and should not feel sad about all their patients’ misfortunes. The knowledge about feeling rules and display rules is stored in the form of corresponding cognitive schemata that are activated for judging and appraising the appropriateness of a given social situation. This tension between experiencing emotions or indeed experiencing a lack of emotions, and knowing what is expected in terms of feeling and display rules is one of the challenges facing health professionals. Medical educators have of course long recognized the need to provide medical students with guidance on dealing with emotions. For example, Nottingham has developed special teaching input on communicating with patients who are distressed. In Basel, they teach the NURSE mnemonic (‘naming emotion, understanding emotion, respecting = showing respect for the patient, supporting, exploring emotion’ [Kiessling & Langewitz, 2013: 14; see also Back et al., 2007; Smith, 2002]) and thus make emotional management an important part of the teaching input. Dealing with emotions is a legitimate concern for students on their way to becoming doctors. On the one hand, they are encouraged to find ways of expressing empathy with patients (e.g. Maguire & Pitceathly, 2002) and, on the other, they are warned to avoid ‘compassion fatigue’ in order to prevent burn-out when struggling with the demanding job and their own emotions that come with it (see, for example, Pfifferling & Gilley, 2000). It is striking that these students, who are only reporting on their first experiences in the field, already single out a topic which will be problematic for them throughout their careers – thus putting their finger on an important aspect of their profession at a very early stage. As a final point in this discussion on emotions, Table 6.4 (adapted from Langlotz & Locher, 2017) summarizes the different levels on which emotions surface and can be discussed by analysts. The dimensions listed in Table 6.4 are not presented in any particular hierarchical order, as they are interlaced. Emotions per se can be described according to their type, intensity and duration. Consider, for example, the mention of verbs such as smiling, crying, screaming, hyperventilating and sobbing, which indicate different intensities and duration of emotions in our sample Text N-085 in Excerpt 6.17. Communicative cues, such as the verbs just mentioned and as further described in Table 6.3 and illustrated in Excerpts 6.18–6.38, help us to gauge emotional stance. These cues give us access to the student’s reported and reconstructed emotions, and to the patient’s assumed emotions as discussed

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Table 6.4 Dimensions of analysis of emotions within interpersonal pragmatics Dimension

Characteristic

Emotion

Type Intensity Duration Communicative Repertoire of verbal and cues non-verbal cues to display emotion [see Table 6.3] Cognition Frames/scripts

Social norms

Appraisal of: (a) the use of communicative cues: How are you talking to me? (b) the adherence to/ violation of norms: That’s (not) the way to communicate in this situation. (c) the transactional state relative to communicative goals: That’s not the way to achieve our transactional goals. (d) the ongoing relationship: The chemistry between the two of us is not working. Feeling rules

Display rules

Emotional socialization

Relationship building

Relational work (positioning, footing, etc.)

Source: Adapted from Langlotz and Locher (2017).

Why/what Establish types of and degree to which emotions are displayed in interaction. Analyze how people establish emotional stance within their reflective writing texts. Explore frames/scripts of situationally appropriate (emotional) behaviour and situationally appropriate emotional display. Such frames constitute the benchmark for appraisal. Trace cognitive processes of evaluating a situation as the basis for an emotional reaction.

Investigating conventions/norms of appropriate emotional states in a given situation. Investigating conventions/norms of appropriate emotional display in doctor–patient interaction. Learning of feeling rules and display rules according to cultural norms with health discourse. Study the interactional negotiation of relationship against the normative background of these norms (enhancing versus reducing sense of relationship).

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by the student. They are also, however, a window for understanding social norms and frames. As we discussed in Section 6.2 when we introduced the concept of relational work, social norms are tied to frames (schemata, scripts, etc.) about expectations of how interaction usually takes place. They constitute cognitive concepts that are linked to the community of practice in question. For example, the student above describes actions around a GP consultation, which is one form of doctor–patient interaction. The student discloses that she knows about social norms concerning revealing and sharing emotions (feeling rules and display rules) that are particular to this doctor–patient interaction. Excerpt 6.17 reveals a perceived clash between showing emotions and appearing professional. The students have acquired this knowledge through emotional socialization and are now discussing it on a meta-level. Finally, as a result of this interaction, the students engage in identity construction and relationship building (crucially entailing acts of appraising) – a topic we will explore further in the next chapter.

6.6 Summary and Conclusions In this chapter, we explored the reflective writing corpus through an interpersonal pragmatics lens by focusing on the question of whether we can find evidence of awareness raising and the acquisition of pragmatic knowledge in the student texts. By revisiting results from the previous chapters, we have shown that interpersonal concerns do surface prominently in the corpus. In a second step, a qualitative case study on the Nottingham corpus revealed a number of themes that emerge as important for the students: raising awareness about the value of empathy and rapport, and the presentation of self and the role of emotions. The recurring stress on the role of emotions throughout this study led us to look into this issue in more depth before illustrating all the raised concerns with the help of a close reading of one particular reflective writing text. Despite the fact that the Nottingham course for which the texts in the case study were written does not teach pragmatics or issues of (im)politeness explicitly on a meta-level, the focus on communication skills nevertheless allows the students to address and learn about pragmatic issues that are pertinent to norms of behaviour in their community of practice. The choice of topics alone reveals that the students do not see doctor–patient interactions as only focusing on the transactional side of communication. Of all the communication skills, they choose to report most on rapport and empathy, and make their own and their patients’ emotions a topic in its own right. They thus reflect that, as future doctors, they will not only be confronted with the biomedical side of their profession, but will also have to learn to become good communicators and to handle the considerable emotional strain that their profession entails.

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In addition to and intertwined with the role of emotions, the use of empathy and the creation of rapport, the students also discussed the presentation of self. The data revealed rich emic understandings of relational processes and their connection to identity construction. The students reflect on the difficulty of striking a balance between appearing professional and appearing genuinely involved (as pointed out by Erickson & Grove, 2008, above), and on avoiding appearing patronizing or rude. It is argued that these real-life examples are more useful than any textbook example for helping medical students develop an understanding of interpersonal pragmatic processes. The combined analyses of the surfacing of emotions in the student texts illustrated that students are aware of the emotional challenges of their profession very early on in their training. The role of emotions emerges as an important issue in the descriptive/narrative part of the texts as well as in the reflective parts. As illustrated through the analysis of one text, when creating an emotional stance in their text, students can draw on verbal cues and they use language to describe vocal (soothing tone of voice), body (lean towards somebody, offer a tissue), and physiological/facial cues (fear in her eyes). Finally, they use constructed dialogue to allow the patients to express their emotions themselves. The lexicon analysis shows that a wide variety of emotions are discussed and that positive and negative connotations are equally present. To conclude, reflective writing tasks can be considered a good first step in making people aware of their subconscious expectations about their roles and their behaviour in different communities of practice. By writing about an encounter that they experienced themselves, the writers are put in the position of experts, which empowers them. The issues that emerge can then be discussed with a supervisor or in class, depending on the context in which the task is performed (see Wald et al., 2009, on feedback). Becoming aware of one’s discourse system and of the assumptions about rights and obligations that pertain to roles we take for granted in our daily lives is argued to be the first step in learning about new and different situations. Learning about (im)politeness is thus not a task that we can tick off after having managed to acquire the grammar system of our first language, nor does it only apply in intercultural contexts in which a second language is involved. Instead, the process of learning about (im)politeness is closely intertwined with social interaction in different contexts, and each individual is constantly challenged throughout his or her lifetime to adapt to new situations and to engage in relational work of the face-maintaining, face-aggravating or face-enhancing type, depending on the interpersonal and transactional goals of the encounter.

Notes (1)

This chapter draws in part on the following two publications, which dealt with the Nottingham corpus only: (1) Locher (2015a) and (2) Locher and Koenig (2014).

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(2) The concept of face was introduced to linguistics by Goffman (1974) and was primarily made current in pragmatics by Brown and Levinson’s (1987 [1978]) seminal study on politeness. However, face has been a contested concept for many decades now and many scholars are helping to refine its definition. For recent discussions, consult Bargiela-Chiappini (2006), Spencer-Oatey (2007), Arundale (2013) and Garcés-Conejos Blitvich (2013). (3) The notion of frame referred to here is the interactional (see references in main text) and not the semantic one (see Fillmore, 1968). (4) This dynamic understanding of frame is important in our analysis as we do not use this concept in the sense of assuming that the interactants simply take on preprepared roles with pre-given lines, as Davies and Harré (1990: 52–55) imply in their criticism of Goffman’s (1974) notion of frame and use of the stage metaphor. (5) In the SNF project Language and Health Online, a Basel research team led by Locher explores the link between identity construction, relational work and health in a number of online contexts. For references, see https://language-health-online. unibas.ch/. (6) This does not mean that conduct following particular norms cannot be taught. In Pizziconi and Locher (2015a), we and the other contributors to the collection review the literature on this extensive topic. (7) Scollon et al. (2012: 9) argue that the concept of ‘communities of practice’ refers ‘to bounded groups of people (defined, respectively, by the texts they use and by the practices they engage in together), whereas discourse systems refer to broader systems of communication in which members of communities participate’. (8) The exception is ‘criticism’; see the comments on this in Section 3.2.1. (9) When quantifying relational strategies, scholars usually focus on a selection of relational strategies, such as the means of syntactic or lexical mitigation. (10) The students also write about positive encounters and thus do not exclusively report on problematic experiences. (11) Section 6.4.2 deals with the Nottingham corpus only. However, in the case of the Basel corpus, none of the students used the most obvious translations (höflich, unhöflich, zivilisiert, grob, etc.). This is surprising as the chosen topics in the two corpora are so similar and the concerns raised are comparable. One of the reviewers suggested that the difference might be due to the concepts having a potentially ‘higher cultural salience for the Nottingham students’. The expert corpus shows no occurrences of the lexemes ‘patronizing’ and ‘rudeness’, and no derivatives of ‘impoliteness’. Mention of polite behaviour occurs in two cases in one text only. In other words, there is less explicit meta-comment on (im)politeness in the expert texts. This may have to do with the fact that the selected topics are slightly different and that the doctors are not beginners in their profession and thus might worry less about how they come across to their patients. (12) Two raters went through the word lists manually (see Section 5.3.8). (13) Interestingly, at the first mention of tissues in line 3, it is the patient who is holding one. The mention of this tissue is a foreshadowing that the patient is in distress, but the student is careful to point out that she first interpreted this sign as indexing a cold rather than distress (I assumed that she was coming to the surgery about a cold or flu, Lines 3–4). (14) The instructions for the reflective writing task explicitly ask the students to use constructed dialogue (see Sections 2.3, 5.4.2 and 5.4.4). The presence of constructed dialogue is thus not surprising – but how it is used is of interest to our study.

7

Interpersonal Pragmatics and Identity Construction

7.1 Introduction In this chapter,1 we continue exploring interpersonal concerns that arise in the reflective writing corpora. While in Chapter 6 we introduced the notion of interpersonal pragmatics and relational work, and zoomed in on the evidence of awareness raising and the acquisition of pragmatic knowledge, Chapter 7 focuses primarily on acts of positioning and identity construction. As the definition of relational work implies, linguistic choices have impacts on and/or are expressions of the relationships that interactants have or wish to create. As scholars in interpersonal pragmatics, we thus pose the following research questions: What evidence of relational work that results in identity construction can we discover? How do the students deal with the tensions that might arise when having to portray oneself in a negative or positive light in the past/ present? A straightforward link between identity construction and the reflective writing texts can be established through their narrative core. As already discussed in Section 5.4.2, any reflective writing text faces the challenge of transforming past experience so that the addressees can understand the background aspects that are important for creating the story world. In addition to location and time, positioning the protagonists who appear in the texts is an important aspect of this process as story worlds are created with only a few words. Consider Excerpt 7.1 from one of the expert columns (AIM). It uses indexical categories to position the narrator of the text:

Excerpt 7.1 Women wear many hats. Two of mine are physician and mother. On most days, these roles are very separate, but at times the boundaries blur. My most difficult moments as a physician arise when, mother to mother, I must tell a woman that her child has died. Fortunately, as a physician in the United States, I do not have to do this every day. (E-34) 148

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The author’s lexical choices immediately position her as a woman, a physician, a mother and a person working in the United States. In fact, this passage occurs at the very beginning of the column entitled Mother in Haiti (AIM, published in 2010), and thus sets the scene for the entire text. The mention of Haiti in such close proximity to the mention of the United States also creates expectations about cross-cultural comparisons. In this chapter, the main focus is on the described transformation of the writers. We argue that the reflective angle of the texts encourages the writers to create a past and present (reflecting) persona and, ideally a future, projected persona. We are interested in the extent to which this is the case in our corpora and in the ways in which positioning is achieved. Section 7.2 provides background on theoretical tenets in the study of identity construction. This is followed by an explanation of our methodological approach (Section 7.3). After this, we will first present an overview of the distributional patterns of different identity positionings in the corpus (Section 7.4), before moving on to an in-depth discussion of one text in order to show how acts of positioning can develop (Section 7.5). At the end of the chapter, we will return to a brief discussion of challenging communication situations and their links to relational work and identity construction.

7.2 Definitions of Identity in Linguistics The discussion of identity in linguistics has a long tradition and covers approaches in neuroscience, discursive psychology, stylistics, (interactional) sociolinguistics, conversation analysis and discourse analysis (for overviews see, for example, De Fina, 2010, 2013; Mendoza-Denton, 2002). In discourse analysis and interactional sociolinguistics, just as in the field of literary and cultural studies, it is now acknowledged that in any encounter involving two or more participants, ‘we are forever composing impressions of ourselves, projecting a definition of who we are, and making claims about ourselves and the world that we test and negotiate in social interaction’ (Riessman, 1990: 1195). Thus, ‘identity’ is a concept inherent to every social interaction and to narratives of such interactions. Similarly to literary studies, interactional sociolinguistics no longer considers the concept of identity to be a fixed entity assigned to people in an a priori fashion. Rather, it is seen as an emergent product of interaction (see the emergence principle below, Bucholtz & Hall, 2005; Hall & Bucholtz, 2013). In interaction, language is just one – albeit a very important – means of constructing identity. As Davies and Harré (1990: 46) argue, an ‘individual emerges through the processes of social interaction, not as a relatively fixed end product but as one who is constituted and reconstituted through the various discursive practices in which they participate’. Individuals do not assume stable identities that are anchored in their psyche or fixed by their

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membership of specific social categories. Hence, identities are ‘intersubjectively rather than individually produced and interactionally emergent’ (Bucholtz & Hall, 2010: 18). Within positioning theory, identity construction is understood as ‘the social positioning of self and other’ (Bucholtz & Hall, 2005: 586; see also Bamberg, 1997). Thus, Davies and Harré (1990: 52) hold that ‘positioning’ and ‘subject position’ ‘permit us to think of ourselves as a choosing subject, locating ourselves in conversations according to those narrative forms with which we are familiar and bringing to those narratives our own subjective lived histories through which we have learnt metaphors, characters and plot’. Thinking about identity as acts of positioning can help us to explain ‘discontinuities in the production of self with reference to the fact of multiple and contradictory discursive practices and the interpretations of those practices that can be brought into being by speakers and hearers as they engage in conversations’ (Davies & Harré, 1990: 62). In addition, positioning theory can help us to see how individuals create coherence and reinforce their sense of self by choosing to position themselves in certain ways. By positioning ourselves and others in interaction, ‘we are thus agent (producer/director) as well as author and player and the other participants co-author and coproduce the drama. But we are also the multiple audiences that view any play’ (Davies & Harré, 1990: 52).2 However, the act of positioning does not have to be intentional. Positioning involves several major processes (Davies & Harré, 1990): 1. Learning of the categories which include some people and exclude others, e.g. male/female, father/daughter. 2. Participating in the various discursive practices through which meanings are allocated to those categories. These include the story lines through which different subject positions are elaborated. 3. Positioning of self in terms of the categories and story lines. This involves imaginatively positioning oneself as if one belongs in one category and not in the other (e.g. as girl and not boy, or good girl and not bad girl). 4. Recognition of oneself as having the characteristics that locate oneself as a member of various sub classes of dichotomous categories and not of others i.e. the development of a sense of oneself as belonging in the world in certain ways and thus seeing the world from the perspective of one so positioned. This recognition entails an emotional commitment to the category membership and the development of a moral system organised around the belonging. 5. All four processes arise in relation to a theory of the self embodied in pronoun grammar in which a person understands themselves as

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historically continuous and unitary. The experiencing of contradictory positions as problematic, as something to be reconciled or remedied stems from this general feature of the way being a person is done in our society. (Davies & Harré, 1990: 47) In this line of reasoning, we can look at acts of positioning as instantiations of relational work because these acts can only function in a contrastive manner between the self and either other people or other projected selves (past, future, etc.). (See the relationality principle below, Bucholtz & Hall, 2005.) Bucholtz and Hall (2005) build their understanding of identity construction on Davies and Harré’s (1990) work and translate it into five principles which show the complexity of identity construction. These principles stress that identity emerges in interaction (emergence principle) and is a relational phenomenon (relationality principle). Identity is indexed (indexicality principle) in processes of positioning through which interactants attempt to position self as well as other (positionality principle). Indexicality is achieved both through the use of lexical items ‘which include some people and exclude others, e.g. male/female, father/daughter’ (Davies & Harré, 1990: 47), 3 as well as through ‘[p]articipating in the various discursive practices through which meanings are allocated to those categories’ (Davies & Harré, 1990: 47). Identity construction only ever yields a partial insight into identity (partialness principle). Crucially, acts of positioning can be contradicted, challenged and/or reconfirmed in previous and subsequent interactions, and are influenced by competing (cultural) discourses. Acts of positioning in reflective writing texts written by medical students and doctors are at the heart of our analysis in this chapter. As outlined earlier, in the field of medicine, reflective writing is now acknowledged as an important part of the learning process in medical studies (e.g. Bolton, 2010; Brady et al., 2002; Mann et al., 2009; Shapiro et al., 2006; Wald, 2015; Wald & Reis, 2010; Wald et al., 2009). It provides future doctors with ways of evaluating their behaviour and it encourages self-criticism. We were interested in the potential dilemmas of identity construction that this text type creates for the students and doctors. The student texts were written for evaluation by the communication skills tutor. This poses a dilemma for the students since they have to reflect on a past experience that might reflect badly on their skills, but they nevertheless might wish to project a competent identity for evaluation (i.e. a student who has learnt from the past experience). In the case of the medical experts, they might publicly project an identity that runs counter to the notion of an ideal expert/professional, which is potentially face-threatening for them. As outlined above, we will first establish what kind of positionings occur and how they are distributed (Section 7.4), and then move on to a close reading of one particular text (Section 7.5).

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7.3 Methodology In order to systematically tag our corpus for acts of author positioning, we first conducted a qualitative content analysis of the texts to develop a catalogue of different types of identities that the students/experts evoked. Once this list was complete, two coders analyzed a selection of texts individually and the following comparison confirmed high reliability for all codes (above 75%). Then all the texts were systematically categorized. The authors positioned themselves in 12 different ways, as illustrated in Table 7.1. A passage could be labelled as containing more than one positioning act. The categories are illustrated in turn to explain our reasoning. The first two categories are particular to the two student corpora as the writers explicitly evoke their roles as ‘medical student’ (Excerpt 7.2) and even refer specifically to the ‘communication skills course’ of which the reflective writing task is a part (Excerpt 7.3). Table 7.1 Author identity categories in all three corpora Type # 1 2 3 4 5 6 7 8 9 10 11 12

Identity category: Narrator as … medical student (vis-à-vis his/her general practitioner and patients) student of the communication skills course (vis-à-vis his/her communication skills tutor and conversational partners) (novice or expert) doctor (vis-à-vis his/her patients, the patients’ relatives, or nurses) academic/scientist (referring to research aspects) mentor/educator (referring to educational aspects) business person (referring to business aspects) private individual (vis-à-vis his/her professional self) cultural individual (embedded within a specific cultural background) gendered individual (being male or female made salient in the text) individual in the past (before or during the encounter narrated in the text) individual in the present (at the time of writing the text) individual projecting alternative actions in past or future (vis-à-vis what really happened in the encounter)

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Excerpt 7.2 After greeting her, the GP proceeded to ask her if it was alright for me, a medical student to sit in during the consultation and ask her a few questions about her condition. (N-025, emphasis added)

Excerpt 7.3 I was quite surprised by how much I could empathize with Mr. X and how I was able to sustain a conversation with him until the GP joined us. [mention of communication skills strategies] (N-006, emphasis added) In Excerpt 7.2, the student reports how the GP engages in other-positioning in front of the patient by referring to the author as a ‘medical student’. This is an act of explicit labelling, which highlights the learner role both for the reader of the text and for the patient in the recounted scene. In Excerpt 7.3, however, the identity positioning is not made explicit through self-labelling, but becomes apparent in an implicit way since the student refers to communication skills strategies that were taught during class. In this way, the student complies with the reflective writing task and aligns herself with the communication skills course. Expertise is at the heart of the ‘doctor’ category. We used the same tag for novice-doctor positionings and expert-doctor positionings. Both could be applied by students and experts alike. Examples can be seen in Excerpts 7.4–7.6.

Excerpt 7.4 This particular consultation has stood out in my mind, as I have never encountered a patient that was so unwilling to communicate with me during a consultation. [emphasizing professional experience] (N-009, emphasis added)

Excerpt 7.5 I transitioned back to a discussion of her hypertension and the possibility of increasing her diuretic. She replied, “Doctor, we could do that, if you think we should […]”. (E-04, emphasis added)

Excerpt 7.6 I was in practice only three months when I met him. I had just finished my cardiology fellowship and, insecure about my lack of experience, strove for a serious, professional demeanor. My tie was straight, shirt pressed, white coat starched and buttoned. Above all, I sought to establish and maintain the boundaries of the patient-physician relationship. (E-32, emphasis added) In Excerpt 7.4, the student highlights that past experience has already been gained as indicated through the use of present perfect. In Excerpt 7.5, constructed dialogue is used to let the patient position the medical expert as

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a ‘doctor’, thus highlighting the difference in roles between the two. In addition, the use of medical jargon evokes expertise. Finally, Excerpt 7.6 demonstrates that the experts also mentioned lack of expertise when evoking the ‘doctor’ positioning. Excerpts 7.7 and 7.8 illustrate the ‘academic/scientist’ category as a further facet of the medical expert identity by referring to academia explicitly and by mentioning the literature as part of the medical field:

Excerpt 7.7 I have come to accept, during my 16 years as an academic haematologist, that I frequently do feel like I am giving up. (E-03, emphasis added)

Excerpt 7.8 We may hone our examination skills, comply with screening recommendations, and keep current with the literature […]. (E-08, emphasis added) The ‘mentor/educator’ category can refer to positionings in which further roles within the medical expert hierarchies are evoked. In Excerpt 7.9, for example, the mention of a senior resident points to differences in expertise, while in Excerpt 7.10 the writer explicitly refers to our students, thus highlighting her role as an educator.

Excerpt 7.9 As I started down the hall to the next patient’s room, the senior resident stopped me and asked, “Why are we giving up?” […] Looking up at the waiting residents I finally replied, “Well, there are worse things than death.” (E-03, emphasis added)

Excerpt 7.10 If we simply draw cathedrals of medical knowledge and therapeutics for our students, we shall miss the human soul that comes to us for succor. (E-27, emphasis added) The ‘business’ category refers to acts of positioning that foreground medical practice and that go beyond expertise. In particular, these acts highlight the monetary and administrative constraints which affect the practice of medical experts. In Excerpt 7.11, the expert refers to medical tasks that are not recognized within the system and that raise issues that affect her understanding of herself as a primary care physician.

Excerpt 7.11 The voices of opposition were still clamoring in my head. “Got to stay on schedule.” “We need to focus on higher priorities.” “There’s no credit for toenail clipping with performance measures or, for all practical purposes, pay.” This internal debate, which lasted just moments, brought into

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striking relief the tension I feel as a primary care physician. Tracking numbers is all the rage today: there are numbers on patient satisfaction surveys and numbers on insurance company scorecards, as well as numbers of patient visits and numbers of RVUs, on which my salary – more numbers – depends. (E-04) The next three identity categories go beyond the medical expert positionings and draw on more private, cultural or gendered positionings. In the case of the ‘private individual’ category, the writers reveal aspects of themselves that have to do with their family lives or their personal opinions and values. In Excerpt 7.12, the student evokes her role as a daughter by mentioning her parents. Similarly, the writer in Excerpt 7.13 explicitly draws on his father’s voice and thus positions himself as a son. In Excerpt 7.14, the student says she enjoys spending time with young children.

Excerpt 7.12 Also, the fact that he was only a few years older than my own parents really hit home as well. (N-018, emphasis added)

Excerpt 7.13 […] instead of drawing on my formal training and extensive experience as a physician and health services researcher, my mind was responding to an older, an only partly conscious, influence, the voice of my father saying, “Young people might die, but old people have to.” (E-05, emphasis added)

Excerpt 7.14 I had expected to feel fairly comfortable talking to her because I enjoy spending time with young children; however, I found it difficult to engage with her it was much harder to make conversation than I had expected. (N-076, emphasis added) The ‘cultural individual’ category was tagged in cases where cultural or linguistic differences shaped the interaction. In Excerpt 7.15, the student explicitly mentions cultural differences, and the writer in Excerpt 7.16 highlights racial differences in the neighbourhood where she worked.

Excerpt 7.15 Being a non-English speaker has put me in dilemma to choose the right word to the right person in the right situation. Cultural difference between my hometown and United Kingdom has somehow posed a constraint in my communication skills. (N-039, emphasis added)

Excerpt 7.16 As a young, white, female physician, I never wore my white coat for fear of further “sticking out” in a very urban, poor, predominately black neighborhood in Washington, DC. (E-19, emphasis added)

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The ‘gendered individual’ category is used for passages where the sex or the gendered role of the writer is important. This is the case in Excerpt 7.16, where the word female is used as one of many self-labels for positioning. Excerpt 7.1, which appears in the introduction to this chapter, evokes the identities of women in general, and of mothers and physicians in particular. The final three categories have to do with the genre of the texts, as they foreground reflection. The categories ‘individual in the past’ and ‘individual in the present’ capture the fact that the authors – as first-person narrators – distinguish between who they are ‘now’ at the time of writing, and who they were ‘then’ during the episode that they recount. In Excerpt 7.17, the writer uses the time indexical at the time to refer to how she felt in the past. In Excerpt 7.18, the author gives details about the past situation and her actions during the recounted episode.

Excerpt 7.17 I was surprised by how I felt the care of Mr. X was one of my main concerns at the time and I realized the importance of establishing and maintaining a good relationship for the optimum care of Mr. X. (N-006, emphasis added)

Excerpt 7.18 We spent 15 minutes talking about a rash on her face, recent laboratory work, her blood pressure … and her mother. (E-04, emphasis added) In Excerpt 7.19, the writer focuses on the act of remembering the chosen encounter at the time of writing. In Excerpt 7.20, the narrator draws conclusions in the present about the past encounter.

Excerpt 7.19 I think that I remember this encounter well as it was very successful and was one of the first times that I’d seen a patient on my own and feel that I’d actually completed the full process as a qualified doctor would, as opposed to when taking a history getting stuck at the diagnosis stage. It was also in a field that I am particularly interested in so this added to my personal interest in the patient. (N-050, emphasis added)

Excerpt 7.20 In the end, I have come to understand that those are the times when I need to be less of a physician in order to be more of one. (E-03, emphasis added) Given that these texts concern reflective writing, it is not surprising that they also contain the category ‘individual projecting alternative actions in past or future’:

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Excerpt 7.21 Therefore I should have been more patient and used more non-lexical utterances and adjusted my language in addition to my body language such as leaning towards the patient and smiling to create a relaxed and friendly atmosphere where the patient could express his views. (N-046, emphasis added)

Excerpt 7.22 Next time I will be more careful when I want to show sympathy towards the patient and not use the first word that comes to mind necessarily. (N-049, emphasis added) Excerpts 7.21 and 7.22 nicely illustrate past and future reflection – as indexed first in the verb phrase should have been and then with the time deixis next time.4 The presented list of acts of positioning was tagged for presence or absence within the individual texts. This means that we did not establish how often the strategies were employed within a particular text, but whether or not they were used in the first place.

7.4 Distribution of Acts of Positioning within the Three Corpora Table 7.2 shows the distribution of the types of identities evoked in the Basel corpus, the Nottingham corpus and the expert corpus. This means that all 278 texts were tagged as outlined in Section 7.3. For ease of comparison, the frequencies are indicated in per cent. Before discussing the individual categories, we can state that we never tagged fewer than three acts of positioning per text, and never more than eight (see the last three rows in Table 7.2). On average, we found 6.1 (Basel), 5.7 (Nottingham) and 4.6 (Expert) acts of positioning per text. Table 7.2 and its visualization in Figure 7.1 nicely show how some acts of positioning are used only by the students and others only by the experts. For the students, these categories are ‘medical student’ (97–99%) and ‘student of the communication skills course’ (95–99%). This can be explained by the explicit reflective task that the students were given for the educational context described. The three categories that were exclusively used by the experts were ‘academic/scientist’ (34%), ‘mentor/educator’ (18%) and ‘business person’ (14%). While the two student-only categories were evoked in almost all texts (95–99% of the texts contained these categories), the expert-only categories were less frequent (14–34%). One could hypothesize that the students did not evoke the expert-only categories because they have not yet experienced or gained more extensive knowledge of these sides

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Table 7.2 Presence of acts of positioning in the three corpora, ranked according to category (%) Identity category: Narrator as … 1 2

medical student student of the communication skills course 3 (novice or expert) doctor 4 academic/scientist 5 mentor/educator 6 business person 7 private individual 8 cultural individual 9 gendered individual 10 individual in the past 11 individual in the present 12 individual projecting alternative actions in past or future Average # of positionings per text Range of # of acts of positionings Mode

Basel Nottingham Expert (% of 80 texts) (% of 189 texts) (% of 50 texts) 97 95

99 99

87

39

38 13 100 100 85

36 5 1 100 99 92

100 34 18 14 74 20 10 100 82 10

6.1 3–8

5.7 3–8

4.6 2–7

6

6

4

to ‘being a doctor’. A similar hypothesis about the lack of exposure to the reality of a particular experience could be applied to the ‘gendered individual’ category. While this category is absent from the Basel corpus and appears in just 1% of the Nottingham corpus, it occurs in 10% of the expert texts. The ‘doctor’ category (either novice or expert) was evoked least frequently by the Nottingham students (39%), while the Basel students (87%) made ample use of this positioning type. Strikingly, we tagged this category for all expert texts. At first sight, one might mistakenly assume that the experts only use this category to highlight their expertise and superiority. However, as shown in Excerpt 7.6 above, a doctor can also introduce the ‘doctor’ category by evoking a lack of experience. The reflective nature of all three corpora can be seen in the categories ‘individual in the past’ (100% for all) and ‘individual in the present’ (82– 100%). The fact that only 10% of the expert texts are tagged for the category ‘individual projecting alternative actions in past or future’ can probably be explained by the fact that the experts do not have to show their readers that

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120 100 80 60 40 20

Basel: % of 80 texts

Nottingham: % of 189 text

individual projecting alternative actions in past or future

individual in the present

individual in the past

gendered individual

cultural individual

private individual

business person

mentor/educator

academic/scientist

(novice or expert) doctor

student of the communication skills course

medical student

0

Expert: % of 50 texts

Figure 7.1 Presence of acts of positioning in three corpora, ranked according to category

they will change their future behaviour or that they know what they should have done differently in the past. For the students, however, this last step in the reflective process is crucial and they probably assume that the instructor will expect to see it. Finally, three of the categories are less dominant within the corpus. ‘Private individual’ only occurs in 36–38% of the student texts. This might reflect the fact that the students do not think ‘being a doctor’ includes one’s private life. This is in stark contrast to the experts, who evoke this category in 75% of their texts, and who often address the tensions between their private lives and their lives as a doctor. However, as Chapter 6 showed, it would be wrong to imply that the students do not reveal their personal stance. For example, the students do not shy away from sharing their feelings of insecurity or surprise. The ‘cultural individual’ category is also evoked most by the experts (20%, compared to 5% and 13% of the students), while ‘gendered individual’ does not feature much at all (again, it occurs most in the expert texts, with 10%). In order to discuss these results and to illustrate a number of these categories in context, we will look at one particular text, which used six of the 12 categories.

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7.5 Acts of Identity Construction in Context In this section, we will revisit the different acts of positioning that we introduced in Table 7.1, using a text from the Nottingham corpus (N-002, written by a female student), and then look at a number of acts of positioning that were typical for the expert texts.

7.5.1 A student reflective writing text For ease of reference, Text N-002 is first reproduced in full in Excerpt 7.23 and relevant passages are referred to by line numbers during the analysis.

Excerpt 7.23 N-002 (emphasis in original) 1 It is said that experience is a substantial source of knowledge. This has been 2 reflected personally through the valuable skills acquired throughout clinical 3 visits in improving my communication as a medical student. 4 5 6 7 8 9

One example of this transpired through taking a history of a very memorable individual during my first year of university. His was 50 years of age and had entered the GP surgery with an excruciating chest pain, fatigue and loss of breath. When I offered to interview him I didn’t acknowledge the severity of his symptoms. This experience made realize the importance of developing good communication skills and their impact on the doctor-patient relationship.

10 Upon first meeting Mr. X, it was easy to sense his fears and distress about the 11 symptoms he was experiencing. The introduction played out as following: 12 13 14 15 16 17

Student: Hi my name is [name], I’m a first year medical student and I would like to take a clinical history. Is that ok? Mr. X: (coughs) That’s fine. Student: So what seems to be the problem? Mr. X: I can’t go on duck…I’ve got this really bad pain in my chest…it’s unbearable…

19 20 21 22 23 24

The patient had trouble speaking due to interruptions from coughing and breathlessness. Additionally his tone of voice indicated his frustration with his condition. Considering this situation in retrospect, I felt almost intimidated by the reality of the pain and suffering this individual was going through. Prior to this, the only history taking experience had practiced simulated settings in which perfectly healthy students would take on the role of the patient.

25 26 27 28 29

As alarming as it was at first, this encounter was a crucial eye-opener. It made me realize the importance of learning to cope with a real patient’s anxiety as well as one’s own trepidation in dealing with such situations. In the future I would confirm whether the patient was truly comfortable and if there was anything I could do to make the process of interviewing easier for him.

30 As the history taking progressed, I discovered some deficiencies in my

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31 communication skills. One example of this was my inability at the time to use 32 enough verbal responses and non-lexical utterances to reassure the patient that I 33 was actively listening to his concerns: 34 35 36 37 38 39

Student: So where do you feel the pain? Does it spread anywhere? And is there anything that makes it worse? Mr. X: Well…it’s all over my chest, and it’s the breathlessness that’s the worst. I can’t exercise because I can’t catch my breath…it’s horrible. Student: Have you had any previous conditions similar to this? Mr. X: I’ve recently suffered from a hear attack…

40 41 42 43 44 45 46 47 48 49 50 51 52

The absence of any vocal response to the patient’s answers may have characterised the interview as being more rigid instead of demonstrating that its purpose was to help the patient. I personally felt as though I unintentionally came across as cold and detached as I failed to acknowledge his communication. As it was my first experience with a patient I was unsure how to approach the emotional aspect of taking a history. Though I truly felt sympathy for the patient and his situation, I couldn’t express it very well. I felt guilty and inept for not being able to do so. This was enhanced by the intensity of Mr. X’s symptoms and emotional distress. When Mr. X exhibited his frustration for not being able to exercise I should have conveyed my true emotions of empathy to build up a better rapport with him. In consultations since I have tried to incorporate a human element of relating to the patient and clarifying his/her feeling and expectations.

53 In contrast to previous simulated interviews where most of the information about 54 the patient was fairly easy to find out, in this real-life situation I faced several 55 obstacles trying to investigate Mr. X’s problem. and background knowledge. 56 Student: Moving onto drug history, are you on any medication? 57 Mr. X: I’m on this one pill called fruse-something… 58 Mr. X’s wife: I think its frusemide. 59 60 61 62 63 64 65

In this example I was unable to get a proper drug history from the patient. However I now realize the importance of doing so as the patient may have been on other prescriptions that could have worsened the symptoms of his condition. Additionally I was unsure about the significance of furosemide (loop diuretic) at the time. It was only after the interview I found out that it is used by patients with heart failure to reduce oedema. This demonstrated the importance of having a good level of background information in improving skills in taking a history.

66 67 68 69 70 71 72

Concluding the session also felt very incomplete as far as building a rapport with the patient was concerned. Though he seemed quite content with the interview, I wanted it to have gone better in terms of investigating and demonstrating empathy. Upon further discussion with the GP I found out that the patient was suffering with chronic heart failure. Though I could sense through the patient’s symptoms and emotions that the cause was quite serious I was not expecting something so severe.

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73 74 75 76 77 78 79 80 81 82

Looking back on this scenario I would definitely express more empathy and acclimatize myself with the situation and its meaning. Additionally it was a good indicator of the level of skill in communication I had at the time and pointed out areas in which I needed to improve. It also demonstrated the role of a doctor in supporting patients both medically and emotionally during the prognosis of a condition. Overall it proved to be an important lesson learned in dealing with real patients and real clinical scenarios. Since it has also helped me improve on skills that were originally lacking and now that I reminisce about it in my second year, I feel as though I have progressed a lot with the valuable aid of the communication skills module.

In this text, the female narrator encounters a patient at the GP practice who has excruciating chest pain, fatigue and loss of breath (Lines 6–7). During the encounter, she feels intimidated by the patient’s suffering. In her discussion of the situation, she notes that she did not do justice to the severity of the symptoms. She writes that the encounter made her realize the importance of learning to cope with a real patient’s anxiety as well as one’s own trepidation in dealing with such situations (Lines 26–27). She adds that this encounter was a crucial eye-opener for her and that she has greatly improved her communication skills since. In Excerpt 7.24, which occurs at the very beginning of the text, the narrator positions herself as a ‘medical student’ as well as a ‘student of the communication skills course’. In addition, she uses the past tense to indicate the difference between her past self (her position as a character in her own narrative) and her present self (her reflective self at the time of writing). Furthermore, the positionings occur in the form of a meta-comment within the narrative (in the following, the identity positionings are numbered according to the categories in Table 7.1):

Excerpt 7.24 It is said that experience is a substantial source of knowledge. This has been reflected personally through the valuable skills acquired throughout clinical visits [1] in improving my communication [2] as a medical student [1]. (Lines 1–3, categories added) The narrator chooses identity positionings that correspond to the expectations contained in the instructions for the reflective writing assignment, and to the demands of the situation she is writing about. She thus positions herself as an autobiographer who recognizes her dual role as a medical student and a student of communication skills, as well as her target audience (the communication skills teacher). In addition, she adheres to the restrictions of the genre (reflective writing) by choosing to think back on her past self from her present position.

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Excerpt 7.25 is taken from the part where the narrator reconstructs the dialogue between herself and the patient. She again positions herself as a ‘medical student’ by assigning the speaker tag student to herself in the stage directions of the constructed dialogue and by referring to herself as a medical student in the dialogue.

Excerpt 7.25 Student [1]:

Hi my name is , I’m a first year medical student5 [1] and I would like to take a clinical history [1; 3]. Is that ok?

Mr. X:

(coughs) That’s fine.

Student [1]:

So what seems to be the problem? [3]

Mr. X:

I can’t go on duck…I’ve got this really bad pain in my chest…it’s unbearable (Lines 12–17, categories added)

By using the standard introduction with the open question what seems to be the problem?, she also assumes the position of (novice) ‘doctor’ since she is dealing with a patient on her own. She thus assumes the position of expert vis-à-vis her patient. It is understood, of course, that she is still an unqualified doctor, as indicated by the fact she labels herself as a student. The student goes on to report that despite feeling a lot of sympathy for the patient, she was unable to show this and thus feels that she has failed:

Excerpt 7.26 Though I truly felt sympathy for the patient and his situation, I couldn’t express it very well. I felt guilty and inept for not being able to do so [1; 2; 3]. This was enhanced by the intensity of Mr. X’s symptoms and emotional distress. When Mr. X exhibited his frustration for not being able to exercise I should have conveyed my true emotions of empathy to build up a better rapport with him [2]. (Lines 45–50, categories added) Even at this early stage of her medical career, the narrator already recognizes that one of the main tasks for health professionals is to ‘respond to the vulnerability, destitution and nakedness of the other’ (Shildrick, 2002: 88). This engagement with her patient, ‘the other’, from a professional position creates a dilemma for the narrator in the episode described, as she realizes that she cannot entirely fulfil the expectations that come with her role. She is unable to offer the medical and emotional assistance that the patient needs, and is overwhelmed by the overall situation (see Higgins, 1987 on the clash between actual, ideal and ought self). The communication problem described in the text could not be resolved at the time of the encounter. Only later, during the reflective writing process,

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does the student offer an analysis and a solution. The writer frames her narrative with different identity positionings to overcome the dilemma of having to write about an encounter that was perceived as problematic, while also having to present herself in a favourable light to the communication skills tutor. In the short introduction (Excerpt 7.24 above), she presents herself as a former and inexperienced self in the past. Her actual narration of the encounter starts when she writes about her meeting with a patient. At the very end of her text, she concludes by returning to her initial positioning of an inexperienced ‘past me’ and wraps her discussion up.

Excerpt 7.27 Looking back [11] on this scenario I would definitely express more empathy and acclimatize myself with the situation and its meaning [1; 2]. Additionally it was a good indicator of the level of skill in communication I had at the time [1; 2; 10] and pointed out areas in which I needed to improve. It also demonstrated the role of a doctor in supporting patients both medically and emotionally during the prognosis of a condition [3]. Overall it proved to be an important lesson learned [1; 2; 11] in dealing with real patients and real clinical scenarios. Since it has also helped me improve on skills [11] that were originally lacking [1; 2; 10] and now that I reminisce about it in my second year [11], I feel as though I have progressed [11] a lot with the valuable aid of the communication skills module [2]. (Lines 73–82, categories added) In her first sentence, the narrator starts by indicating future action with the conditional (I would). In addition, she not only refers to her past inexperienced self (the level of skill in communication I had at the time; skills that were originally lacking), but also emphasizes that she has progressed. She positions herself as a current and more experienced ‘present me’, which allows her to save face vis-à-vis her communication skills tutor. Via the compliment contained in the phrase with the valuable aid of the communication skills module (Line 82), the student also implies appreciation of the instructor and thus engages in otheroriented face-enhancing relational work. In sum, the tension arising from the fact that she chose to write about an encounter that potentially shows her in a negative light is resolved by framing the narrative with different identity positionings. This framing allows the student to merge conflicting identity positionings within the narrative in a productive and meaningful way. Overall, it is important to state that the students do not, of course, position themselves in an empty space. Their acts of positioning always occur in the context of who is present and with whom they interact in their chosen episode, and in the context of their audience, i.e. the instructor of the course (as shown in Excerpt 7.27). As shown above, they often assume two or more positionings at the same time in order to adapt to the situation. For example, in a patient encounter where the GP is also present, the students may choose

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to position themselves as medical students vis-à-vis their tutor, but also as (novice) doctors when talking to their patients. In addition, there are many other aspects of a student’s identity which might not normally overlap with the professional setting but which will nevertheless affect some of the positions that the student may choose to raise in the text depending on the topic chosen. We labelled these occurrences as ‘private person’ and as ‘cultural individual’.

7.5.2 Expert examples: Academic/scientist, mentor/educator and business person As the quantitative analysis showed, three categories were used exclusively by the experts: ‘academic/scientist’ (34%), ‘mentor/educator’ (18%) and ‘business person’ (14%; Table 7.2). As we could not show them in context in the previous section, which dealt with a student text, we will now illustrate their use with the text entitled Part-time Medicine, in which all three categories were tagged – in addition to ‘doctor’, ‘private individual’, ‘individual in the past and individual in the present’. In this text, the author asks herself is there anything inherently wrong with working in medicine part-time? Her opening paragraphs make it clear that she feels guilty when her patients cannot reach her on her days off, and that she sometimes feels as if she is somehow shirking the Hippocratic Oath. As the text goes on, she describes the disadvantages and advantages of working parttime and pleads for more acceptance for part-time work as one of many options open to doctors. In her case, working part-time allowed her to develop a second career in writing. Throughout the text, she talks about herself as a doctor, reveals aspects of her private life (for instance, that she has an independent career as a writer and has three children), and reflects on her changing reasons for working part-time (‘individual in the past’/‘individual in the present’). In Excerpt 7.28, the author illustrates her busy days at work as a doctor:

Excerpt 7.28 It is at these times that being a part-time physician feels as if I’m somehow shirking the Hippocratic Oath. I’m not there for my patients all the time like a physician should. During my “on” days, I work furiously like my colleagues, seeing all of my patients, squeezing in anyone who calls or shows up, supervising residents and students, following up on test results, returning phone calls, filling out medical forms, writing letters for disability, housing, school, and work. (E-36) By listing all the different tasks, she primarily positions herself as a doctor, but also mentions that she is an educator (supervising residents and students).

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The fact that she also reads academic literature is shown when she uses studies to back up her argument:

Excerpt 7.29 Between 10% and 20% of physicians define themselves as “part-time”, [Footnotes 1–3] and pediatrics leads the pack for specialties conducive to part-time work. Patient trust and satisfaction with part-time physicians appear to be similar to that with full-time physicians. Part-time physicians report less burnout, higher satisfaction, and a greater sense of control than full-time physicians.[Footnote] The small studies that have been done on clinical outcomes suggest that part-time physicians achieve outcomes comparable to those of their full-time counterparts, and might even be more efficient.[Footnote] But, not surprisingly, part-time academic physicians fall behind their full-time colleagues in terms of promotion and tenure.[Footnote] Academic physicians view part-time faculty members as less committed, though they concede that part-timers ought to be considered for promotion and even given extra time, if needed, to achieve tenure. [Footnote] (E-36) These two paragraphs are the only paragraphs in the text (which comprises 21 paragraphs in total) that contain footnotes and that draw on the academic genre. By quoting published sources as warranting strategies (Richardson, 2003; Rudolf von Rohr, 2015), the author creates and draws on expertise. This adds ‘academic’ to the ongoing, multi-faceted identity construction.6 Finally, the ‘business person’ category is reserved for instances of identity construction that specifically highlight the monetary and administrative constraints which affect the practice of medical experts. In the case of Text E-36, this can be seen in Excerpt 7.30:

Excerpt 7.30 Even though my voice mail greeting clearly states which days I’m not in the clinic and that I won’t be getting messages on those days and provides the phone number required for immediate attention, it is not uncommon to find messages with real urgency when I return to the office several days later. Here, the author describes how she manages the transition between her two jobs and that she uses her voicemail greeting to tell her patients that she is working part-time and will not have access to the messages until she returns to the clinic. This administrative task of managing the voicemail messages is part of her routine as a doctor. All in all, the text entitled Part-time Medicine draws a varied and vibrant picture of the narrator. The text manages to evoke a competent doctor

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identity which, however, is supplemented by further positionings derived from her second job (a writer) and her family life (three children). As we pointed out in the quantitative overview, the expert texts use the ‘private individual’ category in 74% of the texts, while the students only use it in 36–38% of their texts (Table 7.2). This might reflect the different purposes of the texts (a student assignment versus a text written for peers), but it also shows that the experienced doctors talk about themselves in a more holistic manner.

7.6 Challenging Situations Research in interpersonal pragmatics is often combined with politeness research. This is because, when interactants get their relational work right, it can result in positive assessments of their persona (and vice versa). In Chapter 6, we saw that many students are particularly keen to avoid appearing rude and that the meta-pragmatic comments in their texts show a developing awareness of norms of conduct. These observations are linked to face concerns, so we will now return to some of our findings from Chapter 3, where our analysis of the themes in the texts revealed that many have the potential to be particularly face-threatening. These themes include ‘criticism’, ‘professional behaviour/expertise’, ‘prejudice/first impression falsified’ and ‘(lack of) experience’. In addition, admitting to having emotions and feeling insecure might be considered face-threatening for the authors as well. In what follows, we will use a number of examples to briefly show how the writers address face concerns in these situations and what role the reflection parts play therein when engaging in identity construction. In Excerpt 7.31 from Text N-085, which we discussed in detail in Section 6.5.2, the writer talks about the patient’s emotions and about her inexperience and insecurity in dealing with them. For ease of reference, the excerpt is reproduced here with line numbers:

Excerpt 7.31 N-085 26 27 28 29 30 31 32 33 34 35 36

The patient began to cry. I found it difficult to know what to say: I had no idea of how someone in this situation would feel and I didn’t want to sound insincere or make matters even worse. I wanted to break the silence but couldn’t think of anything to say to make her feel better. I reached into my bag and leaned towards the patient asking if she needed a tissue. She smiled as I handed her a tissue. I felt awful that I couldn’t do anything to help her. After the patient had left Dr Name asked me if I was OK. I explained that I found it difficult knowing what to say when the patient started to cry. It was easier in hindsight to think I should have said “I understand why you are upset” but I wasn’t sure that I did understand. At the time I was concerned with

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37 38 39 40 41 42 43 44

sounding insincere or even patronising; but in reflection, the patient probably wouldn’t have been that critical of the exact phrasing I used and might have been comforted and felt more able to discuss her feelings with me. I know that this encounter was emotionally draining for me and I can only imagine that it was ten times worse for the patient I hope that by at least offering her a tissue and showing some empathy towards her this made her feel slightly better.

45 46 47 48 49 50

As I gain more experience talking to patients and relatives who are distressed I will become more confident & less anxious. I realise that my anxiety wasn’t helpful in this situation and could have made the patient feel worse. In the future I think I will be better equipped for this type of situation where hopefully I will be able to reassure the patient by saying something like “I understand that you are upset”.

The author does open up and present a vulnerable face by admitting to feeling insecure and being inexperienced (Lines 26–34, 36–44). However, this effect is offset by the reflection process, in which the student contrasts her ‘past me’ with her ‘present me’ (in hindsight, Lines 34–35; at the time, Line 36) and ‘future me’ (As I gain more experience, Line 45; In the future, Line 48). Earlier, we highlighted an identical strategy in Text N-002 in Section 7.5.1. Both students thus use the reflective part of the assignment to save their own face and engage in positive identity management. The use of reflection as a face-saving strategy also occurs in Excerpt 7.32, which we encountered previously when illustrating the thematic categories ‘prejudices were revealed and first impressions falsified’ and ‘judgemental attitude’:

Excerpt 7.32 I have learnt from this counter [sic] that I really should not judge patients as soon as I enter the room. I knew this beforehand, but still stereotyped the patient as bad diet no exercise. I could not be more wrong, here was a patient eager to exercise and do everything she could but this dreadful condition prevented her from this. It’s so easy to stereotype people and we continue to do it despite our best intensions. If I was to take anything away from this encounter it would be to work even harder to not stereotype patients. (N-131, previously shown as Excerpt 3.13) Once again, the reflection part allows the student to show that he is aware of his previous stereotypical behaviour and thus allows him to save his own face by showing progress and change. Reflection as a face-saving strategy also works in cases where criticism is directed at third parties. In Text N-110, a female student writes about an

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encounter with a patient who was diagnosed with MS five weeks prior to their meeting. During the history taking, the patient starts crying and the student is equally emotionally distressed, trying to hold back her own tears. Excerpt 7.33 starts after the patient has revealed a lack of information on the part of the physician who diagnosed her.

Excerpt 7.33 N-110 (emphasis in original) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

My eyes filled with tears and I tried my best not to start crying. I should have shown more empathy here by saying “This must be so difficult for you”, but was trying desperately to hold my tears. Eventually I continued. “Can you tell me more about your diagnosis?” With a hint of anger she said “The consultant just told me that I have MS five weeks ago and if the symptoms spread to inform him.” Me: “is that all he said?” I could not believe that is all she got from the doctor. I felt angry for her. She deserved more, because was not just the next NHS number referred to neurology. She is human. With feelings and fears that needed to be taken into account and adhered to. She looked distressed and frightened because she knew nothing about her condition. Patient: “I just need to know more. This is why I came here.” Me: “I still can’t believe the consultant in the hospital told you only that when you were diagnosed. This is wrong. He could have been more helpful” She sensed the anger in my tone. When I reflect back now, my actions were inappropriate. I should not have criticized the clinician in front of the patient for couple of reasons. Firstly, she could have been lying to me or even due to her distress at the point of diagnosis she may not have remembered everything she could have been told. Secondly, I was not present to confirm, even further it was inappropriate and unprofessional. However, at this moment in time my emotions were beyond my control. This is something that I need to focus on and not allow my feelings and attitudes dictate my reactions hence interfering with my professionalism. Expressed emotions are important to show empathy to the patient and make them feel understood and comfortable, but not to interfere with clinical judgements.

The student said she clearly felt outraged that the patient was not properly informed about her condition (Lines 9–14, 21) and also voices this explicitly in the reported dialogue addressed to the patient (Lines 8, 17–19).

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By doing this, she publicly criticizes a doctor, a fact which she later assesses as inappropriate (Line 22). In the ensuing reflection part, she thus invests a substantial number of lines in re-establishing her face as a member of the same group, who can see different sides of a problem and who has learnt from the experience. The reflection part thus mitigates her criticism of her behaviour, which she describes as rash and premature in hindsight. In Lines 27–33, she further expresses her desire to better control her own emotions. This explanation also works as a face-saving strategy on her part since she appears to believe that she made herself vulnerable by revealing her emotions, which she now judges as interfering with her professionalism (see also the discussion of N-085 in Section 6.5.2 for a similar observation). This section has shown that the writers of reflective texts of this nature engage in intricate acts of saving their own face. When reflecting on their actions, they also reflect on their relationships with the others (be it the interactants described in the chosen episodes or members of the target audience) and thus employ relational work.

7.7 Summary and Conclusions To summarize, the students and experts address the challenge of reflective writing by drawing on a range of acts of positioning and thus create different projections of themselves. While the number of acts of positioning is potentially infinite, we established a finite set of 12 recurring acts that covered the three sub-corpora (see Table 7.2). About half of these acts occurred in all subcorpora, while a small number were unique to each corpus. We hypothesized that these differences were due to the different genesis and target audience of the texts, and to the different levels of experience of ‘being a doctor’. Furthermore, the audience they write for is a mixed one. In the case of the students, they not only have to address their communication skills tutor (who will eventually evaluate their narrative), but they also (potentially) address their GPs and fellow medical students. In the case of the experts, they address their peers who read the column. Therefore, their different roles might clash with or complement each other, which means the identity construction in the texts is rich. Writing a reflective text requires the students and experts to engage with different aspects of their identities that are often tied to their institutional roles in the encounters (e.g. medical student, communication skills learner, reflective practitioner, medical expert/doctor; see Sarangi (2010: 50) on the ‘repertoire of professional role categories (role-set)’), as well as acts of positioning that go beyond the institutional setting (e.g. private, cultural, gendered individual). In all cases, the writers engage with ‘the other’ in complex processes of alignment and disalignment. We found that

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it was particularly in the reflection sections that the authors counteracted any potentially negative evaluations of the reported event by using their linguistic skills to carefully craft several identities and differentiate between a past and present persona. They thus juxtapose conflicting acts of positioning and solve potential dilemmas by engaging in efforts to save their own face. Thinking about different facets of roles that may be in conflict with each other is part of the learning process that the reflective writing task aims to achieve. Wald (2015) points out that no clear epiphany is necessary to engage in successful reflective writing: Nguyen et al. (2014) emphasized that reflection is a process, not an outcome. An epiphany may not necessarily emerge, even if the learner appears to be the proverbial ‘one epiphany short of a paradigm shift’. Thus, within an IRW [Interactive Reflective Writing] exercise about a patient care experience, a student’s conclusion of ‘I’m still trying to figure it out’ does not obviate critical reflection and may very well indicate sophisticated reflection. (Wald, 2015: 698) We might add that a smooth presentation of a polished identity is also not necessary for reflective writing to work. The three sub-corpora presented in this study are evidence of a process of identity construction that is full of contradictions and insecurities which result in intricate text compositions. While some texts might indeed present a more coherent set of acts of positioning, it is the texts that show the author struggling to make sense of contradictory facets that particularly catch the eye and might, it could be argued, be truest to the purpose of reflective writing.

Notes (1) This chapter draws in part on a publication in which we combine a literary and linguistic approach to the study of identity construction (Gygax et al., 2012); the linguistics analysis, however, only draws on one of the three corpora, whereas the present chapter explores all three. (2) Davies and Harré (1990) use the drama metaphor in a dynamic sense and criticize Goffman’s (1974, 1981) use of the stage metaphor and role within a frame for being too static. See Chapter 6, note 4 for comments on our dynamic understanding of frame within this study. (3) See the notion of membership categorization devices in conversation analysis (e.g. Antaki & Widdicombe, 1998; Fitzgerald, 2015; Hester & Eglin, 1997; Sacks, 1992). (4) At first glance, the categories ‘individual in the past’, ‘individual in the present’ and ‘individual projecting alternative actions in past or future’ might bear resemblance to psychological concepts proposed by Higgins (1987: 320–321, emphasis in original): ‘(a) the actual self, which is your representation of the attributes that someone (yourself or another) believes you actually possess; (b) the ideal self, which is your representation of the attributes that someone (yourself or another) would like you, ideally,

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to possess (i.e. a representation of someone’s hopes, aspirations, or wishes for you); and (c) the ought self, which is your representation of the attributes that someone (yourself or another) believes you should or ought to possess (i.e. a representation of someone’s sense of your duty, obligations, or responsibilities).’ This categorization was developed to predict ‘which types of incompatible beliefs will induce which kinds of negative emotions’ (Higgins, 1987: 320). Since these categories are argued to be the three main domains of self, they are not compatible with the approach to identity construction presented here, which established textual identity positionings bottom-up. Nevertheless, the concepts of the ideal self and the ought self are clearly particularly relevant for our corpus, as the writers project future identities of how they should ideally behave. Our thanks go to one of the anonymous reviewers for pointing out Higgins’ work. (5) The student writes here that she is a first year medical student. At the time of writing the text, she was in the second year of her studies. Usually, students wrote about patient encounters that happened in their second year. (6) In the student corpus, footnotes were not used to cite sources, but the students did refer to the course literature when referring to the communication strategies in some instances.

8

Conclusions

This book is part of a larger interdisciplinary research endeavour in the medical humanities: ‘Life (Beyond) Writing’: Illness Narratives, which was funded by the Swiss National Science foundation (2009–2013). The focus here was on the linguistics sub-project in which the participants worked on a corpus of 278 reflective writing texts by medical students and doctors who wrote about an encounter with a patient who left an impression on them. In what follows, we will revisit the aims of the linguistics study and discuss potential transfer to the medical field.

8.1 Linguistic Insights Gained and Outlook The corpus of reflective writing texts proved to be a rich resource for a linguistics study. In addition to establishing what the texts were about from a content point of view (Chapter 3), and what communication skills the writers discussed (Chapter 4), we approached three research fields in greater detail: genre analysis, interpersonal pragmatics and, related to the latter, identity construction. Chapter 3 involved a content analysis of all the texts in the corpus, which resulted in a set of 27 themes that could be combined with each other. Among the top themes of the texts were ‘communication strategies’, ‘student/expert emotions’, ‘patient emotions’, ‘special conditions’, ‘impact of illness on patient’s life’ and ‘setting’. The 27 themes were thematically grouped into four focus areas (clusters): (1) focus on the context of the encounter; (2) focus on the patient; (3) focus on the student or expert physician; and (4) focus on the insights gained. With respect to methodology, establishing themes was challenging since the students touched on many different issues within the same text. This richness, however, was also one of the findings that shaped the rest of the study. Far from being a simple descriptive background chapter, the insights gained on the chosen topics helped us understand the corpus and develop and refine the research focus of the ensuing chapters, which all built on the content analysis. For example, we found that writing about ‘communication strategies’ and the patients’ and the writers’ own emotions were concerns that the writers raise themselves; they are not 173

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simply research topics that we chose for the present study. These concerns were taken up again in Chapter 4 on communication skills and in Chapter 6 on interpersonal pragmatics. Starting from the finding in Chapter 3, which showed that the students not only mention communication skills but also make them one of the primary concerns of the texts, we went on to examine which communication skills the students talk about and which communicative situations they consider challenging (Chapter 4). The methodology for establishing the range of communication skills allowed us to describe the scope of what the students write about, and to focus on pertinent concerns. Our discussion was informed by the communication skills teaching in Basel and Nottingham and listed a set of skills that were explicitly taught. It transpired that the Basel group was more heterogeneous in their selection of communication skills for discussion, while the Nottingham students all focused on similar communication skills. Both Basel and Nottingham students make particular mention of ‘create rapport/build trust’ and ‘empathy’ from the interpersonal skills, a fact that was taken up for further study in Chapter 6. While the experts’ columns were not written in connection with the issue of ‘communication skills’ per se, the experts nevertheless write about them in some cases. Once again, ‘create rapport/build trust’ proved especially noteworthy. The chapter ends with a discussion of challenging communicative moments as raised by the writers, which involve the following: the difficulty of showing appropriate empathy and managing one’s own and the patients’ emotions; language problems/speech impediment; cultural differences; special conditions; severe and terminal illness; and time constraints. The genre analysis in Chapter 5 was motivated by our desire to better understand the compositional patterns of the texts. We used a mixed methodology for this chapter (ranging from close readings to methods of corpus linguistics), which allowed us to better understand the text type and to make comparisons. Following Bax’s (2011) scheme of genre description, we offered a detailed comparison of the three sub-corpora. This revealed, among other features, that the lexicon of the texts typically contained medical jargon and mention of body parts. Allowing for mixing of prototypical elements of different genres, we also showed that reflective passages are indeed key to the texts and are also the raison d’être of the texts in the first place. In addition, there is a strong narrative element which prompts the aspect of reflection in the texts. This finding again provides evidence of the fundamental importance of narrative for medical practitioners (see Charon, 2014). While these commonalities are defining, we nevertheless find creative variation within the texts. Other genres touched on in the texts were the medical case report, the (student) essay, the theatre script, and conventions of writing fictional dialogue. As pointed out earlier, mixing features in this way is common and well documented by genre scholars (see Bax, 2011; Biber &

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Conrad, 2009; Corbett, 2006; Giltrow, 2013; Giltrow & Stein, 2009; Schubert, 2012). In Chapters 6 and 7, we took the fact that many of the texts raise interpersonal concerns as a motivation to explore the corpus from the perspective of interpersonal pragmatics. Chapter 6 looked at whether the reflective texts contained evidence of raising pragmatic awareness. By conducting close readings of 50 texts, we identified a number of common findings: raising awareness about the value of empathy and rapport, the presentation of self and the role of emotions. Since the role of emotions emerged as a theme throughout the study, we gave particular attention to emotion vocabulary and the emergence of emotions in context. The texts convincingly demonstrate that the students are confronted early on with the interpersonal side of their profession, as well as with the challenges that emotional drain might pose throughout their careers. Furthermore, the texts bear witness to how the writers struggle to negotiate expectations of what it means to be a doctor. This last aspect of identity construction was the focus of Chapter 7, in which we found and systematically tagged 12 different identity types that the writers evoked in their texts. We established that the student cohorts behaved similarly to one another and differently from the expert group. However, there was also a set of acts of positioning that all three groups shared. Importantly, acts of positioning have to be seen as acts of alignment and disalignment with respect to ‘the other’, meaning they should be studied in context. For this reason, we offered close readings of passages that contained pertinent instances of the writers negotiating expectations of their role. Many of the writers chose to solve potential clashes of acts of positioning from within the reflective passages. We argued that these negotiations are part and parcel of the reflective writing task. We suggest that the theoretical concept of ‘acts of positioning’ might be interesting to instructors of reflective writing courses and to developers of course materials. Alerting writers to the linguistic possibilities of positioning might enhance their reflective awareness. We hope that this brief summary of the main findings of the linguistics study of the reflective writing corpus has shown how the discussion builds up in incremental steps. While this is partly due to the chosen methodology, it also reflects the extent to which the different notions and concepts are interrelated. For example, establishing the genre of the corpus is fundamentally informed by the genesis and topic of the texts; the narrative episodes recounted influence the genre and prompt character positioning and reflections on identity construction; and the communication skills discussed by the writers have a fundamental interpersonal side which can be explored from an interpersonal pragmatics perspective with respect to identity construction and the role of emotions therein. Throughout this study, we combined a quantitative approach aimed at identifying patterns with close readings of how the different notions develop in context. While this

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combination is not the only way to approach a corpus, we strongly believe that in this case it yielded more holistic results and allowed us to better understand the complexity of the corpus. For the future, scholars adopting a similar research design could expand it to also include a linguistic analysis of the feedback on the reflective writing texts in the teaching context. This step was not possible in our case, but it has been recognized as crucial from an educational perspective (see, for example, Kiss & Steiner, 2011; Wald & Reis, 2010). Furthermore, there is a need for comparative studies of reflective writing produced in different professional contexts. It will be interesting to see what other professionals choose to focus on and whether similar interpersonal concerns emerge when discussing expectations of different professional roles. Finally, the intricate interlacing of understandings of ‘identity’ with emotions and interpersonal concerns bears further scrutiny (for pointers, see Langlotz & Locher, 2012, 2013, 2017; Locher & Langlotz, 2008).

8.2 Potential Transfer to Teaching in the Medical Humanities According to Charon (2014: 246), ‘Narrative medicine proposes that narrative acts – having a sense of story, telling, listening, reading, writing, witnessing, imagining, remembering – are at the center of clinical care’. She later goes on to argue that: The skills that might enable one to do these complex tasks in the face of illness are, I suggest, narrative skills – the capacities to cohere fragmented facts and findings into meaning, to recognize and convey what is being heard in another’s account of illness, and to offer oneself as a witness to suffering. (Charon, 2014: 247). Reflecting on the reflective writing corpus discussed in this study, it is clear that the students and experts employ such skills and engage in narrative medicine. They give voice to their patients and to their own role in and understanding of the encounters. As we mention in Gygax et al. (2012): [The] reflective writing texts by medical students provide possibilities of teaching future doctors to listen to the other and to be able to reflect on the self and its positions/identities when being engaged in a dialogue with patients. Furthermore, reflecting on their own different positions and on the ones of the vis-à-vis enables future medical doctors to ‘empathize with the patient’s perspective, [and] to adopt patient-centered approaches in the delivery of medical care’ (Khorana et al., 2011: 468).

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[…] Reflective writing also encourages students to remain self-critical beyond the writing task and to adopt a reflective practice in their professional lives (Epstein, 1999). They are ‘enabled to let go and rewrite assumptions, taken for granteds [sic], ossified notions of themselves, and take greater responsibility for actions, thoughts and feelings, even ones of which they were previously unaware’ (Bolton, 2010: 252). Furthermore, students have the possibility to give ‘voice’ to other characters and to explore their relationship with those characters in different ways. This process again encourages students to adopt their patients’ perspectives and to look at doctor–patient interactions from another point of view. (Gygax et al., 2012: 32) In addition, we might add that their texts in themselves should be heard. Studies such as the present one can benefit medical instructors who are interested in what students with a fairly limited experience of ‘being a doctor’ find particularly noteworthy and/or problematic, and what experts with sometimes years of experience feel is worth sharing. For example, while it is clearly no new finding that the role of emotions is important in medical professions, we were able to show that the students raise this concern early on and that they struggle to find an adequate way of dealing with their own and their patients’ emotions. Emotions have such a fundamental role in communication that their impact should be theorized in teaching even more than is already the case. The clashes of expectations regarding understandings of one’s professional role that the analysis of acts of positioning revealed also show that the students might benefit from meta-discussions about what it means to ‘be a doctor’ as they develop a professional identity (see Wald, 2015). For example, a text such as N-085, in which a student perceives a clash between appearing professional (and distant) and allowing emotions to surface (discussed in detail in Chapter 6), could be read in a focus group and used as a prompt for discussing role understandings and expectations. Real-life examples, as provided by both the student and expert texts, will serve as good encouragement for new and established practitioners to engage in reflective writing. We hope that this book can also serve as a resource for such practitioners.

9

Appendices

9.1 Consent Form and Questionnaire Basel

Fragebogen für Basler Medizinstudierende Elektronische Einverständniserklärung des Probanden zur Teilnahme an einer SNF-Studie • •

Bitte lesen Sie dieses Formular sorgfältig durch. Bitte fragen Sie, wenn Sie etwas nicht verstehen oder wissen möchten.

Titel der Studie: ‘Eine qualitative, linguistische Studie über “Written reflections on doctor-patient interactions by medical professionals” anhand von “Reflective Writing”-Texten Basler Medizinstudierender’ Sponsor: Schweizerischer Nationalfonds, Wildhainweg 3, Postfach 8232, 3001 Bern Ort der Studie: Universität Basel Prüferin: Prof. Dr Miriam Locher • •

• • •

Ich wurde vom unterzeichnenden Prüfer schriftlich über die Ziele und den Ablauf der Studie informiert (siehe auch: http://illness-narratives. unibas.ch/). Ich habe die zur oben genannten Studie abgegebene schriftliche Probandeninformation gelesen und verstanden. Meine Fragen im Zusammenhang mit der Teilnahme an dieser Studie sind mir zufriedenstellend beantwortet worden. Ich hatte genügend Zeit, um meine Entscheidung zu treffen. Ich weiss, dass meine persönlichen Daten nur in anonymisierter Form an aussenstehende Institutionen zu Forschungszwecken weitergegeben werden Ich nehme an dieser Studie freiwillig teil. Ich kann jederzeit und ohne Angabe von Gründen meine Zustimmung zur Teilnahme widerrufen. Ich 178

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habe keine Nachteile für mein Studium zu erwarten, wenn ich auf die Teilnahme an dieser Studie verzichte. Falls Sie an der Studie mitmachen, füllen Sie bitte die folgende Einverständniserklärung und den Fragebogen zu Ihrer Person aus (ca. 5 Minuten). Ihr Reflective Writing-Text wird dann anonymisiert aus gewertet. Bei Fragen oder Problemen wenden Sie sich bitte an: regula. [email protected]. Vielen Dank für Ihre Teilnahme! Um zum Fragebogen zu gelangen, bitte unten auf ‘Fragebogen’ klicken. Bei diesem Fragebogen werden Ihre Angaben anonymisiert abgespeichert.

Bitte füllen Sie den folgenden Fragebogen zu Ihrer Person und die Einverständniserklärung aus (dies dauert ca. 5 Minuten). Bei Fragen oder Problemen wenden Sie sich bitte an [email protected]. 1

Einverständniserklärung Ihre persönlichen Daten werden nur in anonymisierter Form zu Forschungszwecken verwendet. Sie nehmen an dieser Studie freiwillig teil und können jederzeit und ohne Angaben von Gründen Ihre Zustimmung zur Teilnahme widerrufen. Sie haben keine Nachteile für Ihr Studium zu erwarten, wenn Sie auf die Teilnahme an dieser Studie verzichten. 1.1 Nachname, Vorname Diese Angabe wird gebraucht um Ihren Fragebogen mit Ihrem Reflective Writing-Text zu verlinken. Danach wird in jedem Fall anonymisiert: _________________ 1.2 Einverständnis Hiermit erkläre ich mich einverstanden, dass mein Gedächtnisprotokoll zur Forschung in den ‘Medical Humanities’ verwendet wird, vorausgesetzt dass mein Name sowie die Namen der anderen Beteiligten (PatientIn, HausarztIn, Ortsnamen) anonymisiert werden. ja nein 1.3 Weitere Informationen Für eine spätere Befragung bzw. für spätere Nachfragen seitens der ForscherInnen stehe ich zur Verfügung nicht zur Verfügung. 1.4 Ergebnis Über das Ergebnis der Forschung möchte ich gern informiert nicht informiert werden. ○ ○

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Allgemeine Fragen Hier stellen wir Ihnen allgemeine Fragen zu Ihrer Person. 2.1 Ihr Alter in Jahren: __________ 2.2 Ihr Geschlecht: O männlich; O weiblich 2.3 Sind Sie in einem deutschsprachigen Raum aufgewachsen? ja nein 2.4 Wenn ja, wo?: _________________ 2.5 Wenn nein, wo wuchsen Sie auf?: _______________ ○ ○

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Sprachen Hier möchten wir mehr über Ihren sprachlichen Hintergrund erfahren. 3.1 Welche Muttersprache(n) sprechen Sie? Mehrfachnennungen sind möglich: Hochdeutsch Englisch Schweizerdeutsch (Dialekt) Spanisch Französisch Serbisch Italienisch Kroatisch Rumantsch Bosnisch Andere 3.2 Falls Sie bei der Sprachangabe soeben ‘Andere’ ausgewählt haben, spezifizieren Sie bitte: ________________ 3.3 Welche weiteren Sprachen sprechen Sie (Zweitsprache, z.Bsp. in Schule oder Ausland gelernt)? Mehrfachnennungen sind möglich: Hochdeutsch Englisch Schweizerdeutsch Spanisch Französisch Serbisch Italienisch Kroatisch Rumansch Bosnisch Andere 3.4 Falls Sie bei der Sprachangabe soeben ‘Andere’ ausgewählt haben, spezifizieren Sie bitte: ________________ 3.5 Falls Deutsch nicht Ihre Muttersprache ist, seit wie vielen Jahren sprechen Sie es? Anzahl Jahre: _______________________ 3.6 Wo haben Sie die Schulen besucht? Angabe der Kantone oder Länder: ________________________________________ ○

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Herzlichen Dank für Ihre Teilnahme an dieser Studie! Bemerkungen zu diesem Fragebogen: _____________________

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9.2 German Instructions for the Reflective Writing Task, Basel Corpus Instruktionen für Reflective Writing Begegnung mit einem Patienten, der Sie besonders beeindruckt hat. Die untenstehenden Fragen dienen als Hilfe zur Erstellung des Reflective Writings: Situation: * Beschreiben Sie die/den Patientin/en (Alter, wesentliche Diagnosen, Ihr erster Eindruck, äussere Erscheinung, Körperhaltung, Auffälligkeiten, Sprache etc.). * Beschreiben Sie, in welchem Kontext Sie das Gespräch geführt haben (Grund für das Gespräch). * Beschreiben Sie, worüber Sie sich ausgetauscht haben, mit möglichst viel wörtlicher Rede. Wenn Sie sich nicht mehr erinnern, rekonstruieren Sie den Dialog möglichst genau in den wesentlichen Passagen. * Beschreiben Sie, wie es Ihnen nach dem Gespräch ging. Nachdenken: 1. Das Besondere der Begegnung a) Warum ist diese Begegnung bei mir ‘hängen geblieben’? b) Was war denn so speziell entweder an dieser Patientin oder an meinem Verhalten? 2. Kommunikative Aspekte a) Habe ich mit der Patientin so kommuniziert, wie ich das wollte? b) Hat das Gespräch den Verlauf genommen, den ich mir vorgestellt hatte? c) Wenn ja, warum, und wie habe ich das erreicht? d) Wenn nein, was hätte ich anders machen können? Schlussfolgerungen: * Was habe ich aus dieser Begegnung gelernt? * Was hätte mir geholfen die Begegnung besser/anders zu gestalten? * Was werde ich bei der nächsten Begegnung mit einer ähnlichen Patientin versuchen anders zu machen? Formale Hinweise: Bitte anonymisieren Sie die Namen aller Beteiligten. Muster für die Wiedergabe der wörtlichen Rede einer entscheidenden Phase im Gespräch:

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Frau XY:

„… und keiner der Ärzte hat mir irgendetwas von einem Fehler erzählt; die wollen das einfach verschweigen und ich muss das nun ausfressen. Das ist doch eine Sauerei???…“ Studentin: „Sie sind ziemlich wütend, hab’ ich den Eindruck?“ Frau XY: „Ja, natürlich bin ich wütend! Wenn die mir das wenigstens mitgeteilt und sich entschuldigt hätten, wäre alles halb so schlimm.“ Frau XY: „… und dann sagte der Chirurg, es wäre alles meine Schuld, wenn die Operation nicht wie geplant gelingen würde; ich würde halt nicht die besten Voraussetzungen mitbringen. Bei so viel Übergewicht wäre das immer schwierig!“ Ich: „Ja, das sollte ein Arzt nicht sagen.“

9.3 English Instructions for the Reflective Writing Task, Nottingham Corpus Reflections on communication with a patient Instructions: Think about which conversation/encounter with a patient impressed you most. The questions listed below will help you to structure your thoughts about this encounter from memory. Those questions marked with an * must be addressed. The other questions can be chosen if relevant to the specific context of the described situation. Before you start writing up your text, write down everything that you remember about the encounter. Then you can proceed according to the points listed below. Situation: * Describe the patient (age, relevant diagnosis, first impression – appearance, posture, language, anything else noticeable, etc.) * What was the reason for the encounter? * Describe what you talked about by using verbatim speech (the exact words) as much as possible. If you cannot remember the exact wording, reconstruct the dialogue for the crucial moments as well as possible. 1. Describe how you felt after the encounter. 2. Try to describe how the patient might have felt after the encounter. Reflection: The following questions should help you to structure your reflections. *1. The uniqueness of the encounter a) Why do I remember this particular encounter so well? b) What was so special about the patient or my behaviour and language comportment that I remember it so well?

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*2. Communicative aspects a) Did I communicate with the patient as I intended to? b) Did the conversation proceed as planned? c) If yes, why and in what ways have I achieved this? d) If no, what went wrong and what could I have done differently? Aims: * What have I learnt from this encounter? * What would have helped me to manage/shape the encounter in a better way? * What aspects of my behaviour and language will I change in order to improve my next encounter with a patient with a similar problem? Hints for writing the text For crucial moments in the conversation, indicate reported speech in the form of drama dialogue: Mrs. XY: ‘And none of the doctors told me anything about a mistake; they wanted to simply not talk about it and I now have to suffer for it. That’s outrageous, isn’t it?’ Student: ‘You are very angry, aren’t you?’ Mrs. XY: ‘Yes, of course I am! If they had properly told me and had apologized, it would have been only half as bad.’ Mrs. XY: ‘… and then the surgeon said it will be all my fault if the operation won’t succeed; as I didn’t have the best conditions, and being so overweight, the situation is always difficult.’ Student: ‘Yes, a doctor shouldn’t say anything like this.’ How did I feel during the conversation and afterwards? For example: I was absolutely crestfallen afterwards. During the conversation, I never knew what was okay to say. Am I allowed to criticize a surgeon? Did he really say what the patient reported, or is this only the patient’s version? Was it wise to encourage the patient to speak more about her experience or should I have stopped it? I didn’t dare put an end to it because I didn’t want to appear like yet another ‘bad doctor’. What would I change for the next interaction? … [Administrative pointers]

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9.4 Spreadsheet for the Topic Analysis (Basel as Example)

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9.5 Spreadsheet for Theme Analysis The themes are based on the topics but are fewer in number. The bold categories refer to the sections in the texts in which the themes are likely to occur; they do not represent super-categories.

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9.6 Theme Catalogue, Ordered Alphabetically Table 9.1 Codebook Theme

Description in the codebook

Bereavement

If the patient is dealing with the loss of someone

Communication strategies

If the encounter is memorable because of a particular communication strategy that was used; please specify here what strategies they refer to

Criticism (of/by student, GP, patient)

If the main theme involves criticism of something by someone

Cultural differences

If the student mentions cultural differences between him/herself and patients; if patient encounters are different because the patients come from a different cultural background

Experience

If the main theme is that they lack experience in something or that their experience with something has helped in the encounter

History taking

If the main theme is about how to take a history/how the student takes a history

Impact of illness on patient’s life

If they talk about how and in what ways the illness has an impact on the patient or on the relatives of the patient

Individuality of patients/ patients differ

If they discuss that patients are individual, that each patient differs, even if they have the same illness

Judgemental attitude revealed

If the encounter is memorable because they discovered they were judging the patient/GP/illness, etc.

Language problems/speech impediment

If the main theme is a problem with language (due to hearing difficulties, different languages being spoken, not being able to pronounce clearly, etc.)

Patient emotions

If the encounter is memorable because of the emotions which the patient felt (positive or negative), e.g. the patient is very positive despite being so ill, which is memorable to them

Patient independence important

If it is important to the patient to be independent

Patient is cooperative

If the patient is very cooperative and helpful

Patient is difficult

If the patient is memorable because he/she is aggressive, non-communicative, non-compliant/ doesn’t want the treatment, is depressed or shy… (Continued)

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Table 9.1 Codebook (Continued) Theme

Description in the codebook

Patient is open

If the patient was very open, or opened up during the encounter

Patient’s perspective important

Gaining the perspective of the patient/being able to grasp that perspective/being given that perspective = important to understanding the patient

Prejudice/first impression falsified

If the student was prejudiced against the patient/ illness, if the first impression turns out to be wrong

Preparation helpful/ important

If preparation (e.g. reading the patient’s file beforehand) would have been helpful/has been helpful/would be important for future encounters (linked to ‘experience’)

Professional behaviour/ expertise

If the main theme is about professional behaviour or how expertise (or its lack) can make a difference in the encounter

Setting

If the encounter was memorable due to a special setting/specific setting issue [a catalogue of subcategories is provided; see Appendix 9.5]

Severe/terminal illness

If patient suffers from a severe or even terminal illness and this is considered the main theme

Special conditions (depression, Asperger’s syndrome, etc.)

If the encounter is memorable because the illness/ condition of the patient is special in some way

Student/expert emotions

If the main theme is what they felt like (positive or negative emotions possible)

Successful encounter

If the encounter was successful and thus memorable to them (they have to state explicitly that it was successful)

Textbook versus reality

If they mention that the reality (the encounter) is different from what they learned in theory/class

Time constraints

If the main theme is that there is not enough time, or the fear that there won’t be enough time in the future

Value of holistic approach

Recognizing that the patient needs to be treated as a whole; not just medical/clinical aspect but also the psychosocial part of illness needs to be treated

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9.7 The Basel Medicine Curriculum, Combining Social and Communication Skills (SOKO) Table 9.2 ‘Organ-based modules of the Basel undergraduate medical programme’

Source: Reproduced from Kiessling and Langewitz (2013: 13).

Appendices

Table 9.3 Basel SOKO curriculum, ‘social and communicative competencies’

Source: Reproduced from Kiessling and Langewitz (2013: 15).

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Subject index

abstract 98 anamnesis, see history taking arguing mode, see mode

face-maintaining 116–117, 146, 170 face-threatening 118, 120, 122, 151, 167 frame 7, 75, 116–117, 119, 145, 147, 171

case report 8, 11, 14, 72, 96, 103, 107–109, 113, 174 coda 98, 100 coder agreement 30 communication skills 1, 2, 5–6, 8, 12, 16–18, 21, 22–23, 26, 28, 30, 46, 49, Ch. 4, 74, 77, 97, 104, 106, 111, 115, 121–123, 124, 125, 126, 127, 130, 131, 132, 133, 134, 140, 145, 151, 152, 153, 155, 162, 164, 170, 173, 174, 175 community of practice 2, 115, 127, 145 complicating action 98 content analysis 49, 152

genre 3, 5, 6, 7, 12, 14, Ch. 5, 156, 162, 166, 174–175 grammar 87–91 health humanities 9 high-point 98, 103 history taking 33, 34, 36, 39, 44, 45, 48, 54, 63, 67, 69, 101, 102, 125, 127, 133, 160, 186 identity construction 6, 7, 9, 15–16, 67, 106, 113, 116, 118, 119, 122, 127, 130, 145, 146, Ch. 7, 175 (im)politeness 115–121, 130, 142, 145, 146, 147 interpersonal pragmatics 5, 7, 9, 15, 49, Ch. 6, Ch. 7, 175

describing mode, see mode display rule 142–143, 144, 145 emotion 9, 15, 18, 36, 37, 40, 41, 46, 48, 49–50, 54, 55, 67–68, 70, 71, 74, 78, 82, 93, 94, 99, 107, 116, 118, 121–124, 128–146, 163, 167–170, 173–177 emotional drain 175 empathy 39, 41, 49, 56, 57, 60, 63, 64, 65, 66, 67, 69, 71, 94, 105, 122, 123, 124–127, 128, 130, 132, 133, 134, 137, 139, 140–146, 153, 161, 163, 164, 168, 169, 174, 175, 176 essay 8, 14, 72, 79, 96, 109, 113, 174

keyword analysis 91 lexis 91–94 medical humanities 3–5, 11, 12, 26, 53, 78, 176 meta-pragmatic awareness 49, 128, 145, 147, 162, 167, 177 mode 76, 83–85, 95, 103, 113 arguing 76 describing 76 narrating 76, 103, 113

face 116–117, 122, 146, 164, 147, 167, 168, 170–171 face-aggravating 116, 146 face-enhancing 116–117, 146, 164

narrative 1, 5, 7, 8, 9, 10–15, 31, 72, 73, 78, 84, 87, 88, 90, 97–113, 140, 146, 148, 149, 150, 175, 176 201

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narrative clause 98, 103 narrative medicine 11, 176 NURSE 55, 70, 71, 143 orientation 84, 98, 101, 113 politeness, see (im)politeness positioning 78, 85, 96, 97, 103, 113, 116, 122, 128, Ch. 7, 175, 177 rapport 34, 37, 49, 56, 59, 65, 66, 67, 122, 124–130, 132, 140, 145–146, 174, 175 reflection 2, 20, 26, 42, 46, 49, 72–75, 82, 94, 96–97, 98, 106, 108, 109,

112–113, 120, 130, 131–132, 134, 156, 167, 168, 170–171, 174–175 relational work 1, 7, 9, 49, Ch. 6, 148–149, 151, 164, 167, 170 role 15, 56, 106, 146, 147, Ch. 7, 170–171, 176, 177 script 75, 78, 81, 83, 109–110, 111, 113, 117, 144, 145, 147 stance 98, 128, 134, 137, 138, 139, 143, 146, 159 style 85–87 WWSZ 55, 70, 71

Author index

Agha, Asif 119 Alderson, Tom St J. 11, 113 Andersen, Peter A. 143 Antaki, Charles 171 Arundale, Robert 147

Cohen, Henry 107 Collins, Sarah 52 Conrad, Susan 75, 87–88, 175 Corbett, John 75, 113, 175 Crawford, Paul 9, 21 Culpeper, Jonathan 120, 129, 130

Back, Anthony L. 56, 71, 143 Bain, Alexander 114 Baker, Paul 91 Bamberg, Michael G. W. 85, 107, 150 Bargiela-Chiappini, Francesca 147 Barlow, Julie 15 Bateman, Hilarie 11, 113 Bateson, Gregory 75, 117 Bax, Stephen 14, 75–77, 78, 83, 84, 94, 112, 113, 114, 174 Béal, Christine 120 Bechmann, Sascha 52, 53, 68 Bhatia, Vijay 114 Biber, Douglas 75, 77, 87–88, 89, 90, 91, 174 Blatt, Benjamin 51, 68 Bolton, Gillie 151, 177 Brady, Donald W. 73, 151 Branch, William T., Jr. 2, 14, 73 Brancher, Dominique 12 Brodkey, Harold 11 Brown, Penelope 116, 117, 147, Brown, Richard F. 71 Bucholtz, Mary 15, 118, 121, 149–150, 151 Busse, Beatrix 14, 75 Butler, Sandra 11 Bylund, Carma L. 71

Davies, Bronwyn 85, 147, 149–151, 171 Davis, Boyd 4, 15 Dayter, Daria 11, 15 De Fina, Anna 11, 15, 98, 149 Deppermann, Arnulf 10 Diedrich, Lisa 12 Eckert, Penelope 15, 115, 118 Eglin, Peter 171 Ekman, Paul 143 Epstein, Ronald M. 177 Erickson, Rebecca J. 142, 146 Fairclough, Norman 114 Fanshel, David 14, 15 Fill, Alwin 121 Fillmore, Charles J. 147 Fitzgerald, Richard 171 Fludernik, Monika 10 Friesen, Wallace V. 143 Garcés-Conejos Blitvich, Pilar 147 García-Pastor, María Dolores 120 Georgakopoulou, Alexandra 10, 11, 15, 98, 107, 113 Gibbs, Graham 73, 120 Gilley, Kay 143 Giltrow, Janet 75, 113, 175 Goffman, Erving 75, 116, 117, 147, 171 Graham, Sage L. 7, 124 Greenhalgh, Trisha 11, 113

Candlin, Sally 52 Charon, Rita 11, 113, 174, 176 Chou, Wen-ying Sylvia 52 Clark, Herbert H. 134 Clarke, Angus 15 203

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Grice, H. Paul 117 Grove, Wendy J. C. 142, 146 Guerrero, Laura K. 143 Gumperz, John J. 119 Gygax, Franziska 1, 2, 10, 11, 12, 13, 29, 72, 106, 113, 120, 171, 176–177 Hall, George M. 107 Hall, Kira 15, 118, 121, 149, 150, 151 Halpern, Jodi 124, 127, 141 Hamilton, Heidi E. 52, 104, 140 Hampton, Martin 14, 73, 109, 120 Harré, Rom 85, 147, 149, 150–151, 171 Harrison, Sandra 15 Harvey, Kevin 52 Haugh, Michael 117, 118 Hawkins, Anne Hunsaker 11, 72, 113 Hawthorn, Jeremy 10 Hester, Stephen 171 Higgins, E. Tory 163, 171–172 Hochschild, Arlie R. 142 Howard, Kathryn M. 119 Hunter, Kathryn Montgomery 11, 108, 113 Hurwitz, Brian 11, 107, 109, 113 Johansen, May-Lill 138 Johnstone, Barbara 11, 14, 98, 101 Kádár, Dániel Z. 117–118 Kern-Stähler, Annettte 12 Khorana, Alok A. 176 Kiessling, Claudia 17, 18, 52, 54–56, 71, 143, 188, 189 Kiss, Alexander 1, 2, 6, 12, 13, 53, 176 Klapproth, Danièle 11, 14 Koenig, Regula 9, 31, 71, 114, 129, 142, 146 Koteyko, Nelya 52 Kouper, Inna 15 Kumagai, Arno K. 54 Kurtz, Suzanne M. 52 Labov, William 11, 14, 15, 31, 83, 84, 97–98, 101, 103, 113 Lakoff, Robin Tolmach 117, 119 Langewitz, Wolf 17, 18, 52, 53, 54, 55, 56, 71, 143, 188, 189 Langlotz, Andreas 129, 134, 135, 142, 143, 144, 176 Leech, Geoffrey 117, 120 Levinson, Stephen C. 75, 116, 117, 147 Linguistic Politeness Research Group 117

Lo, Adrienne 119 Locher, Miriam A. 7, 10, 13, 15, 29, 71, 72, 113, 114, 116, 117, 118, 119, 121, 124, 129, 134, 135, 142, 143, 144, 146, 147, 176 Lorde, Audre 11 Lucius-Hoene, Gabriele 10 MacQueen, Kathleen M. 31 Maguire, Peter 56, 125, 143 Mann, Karen 73, 151 Martinez, Matias 10 Matoesian, Greg 134 McConnell-Ginet, Sally 15 McEntyre Chandler, Marilyn 11, 113 McIntyre, Dan 111 Meier, Janine 87, 113 Mendoza-Denton, Norma 149 Mills, Jonathan K. A. 21 Monash University 73 Montello, Martha 113 Namey, Emily 31 Nguyen, Quoc Dinh 171 Nini, Andrea 77, 87, 89, 114 Ochs, Elinor 118, 134 Oyebode, Femi 13, 21, 29, 108, 109, 113 Pahta, Päivi 107, 109 Paranjape, Anuradha 1, 14, 73 Peräkylä, Anssi 15 Pfifferling, John Henry 143 Pilnick, Alison 15 Pitceathly, Carolyn 56, 125, 143 Pizziconi, Barbara 118, 147 Planalp, Sally 134, 135 Pounds, Gabrina 71 Reis, Shmuel P. 73, 151, 176 Richardson, Kay P. 166 Riessman, Catherine Kohler 149 Roberts, Celia 119 Roger, Peter 52 Rose, Gillian 11 Rose, Kenneth R. 118 Rosenblum, Barbara 11 Rudolf von Rohr, Marie-Thérèse 166 Sacks, Harvey 171 Sandars, John 2

Author inde x

Sarangi, Srikant 15, 170 Scheffel, Michele 10 Schieffelin, Bambi 134 Schiffrin, Deborah 15 Schnurr, Stephanie 118 Schubert, Christoph 75, 84, 113, 175 Scollon, Ron 118–119, 127, 147 Scollon, Suzanne Wong 118–119, 127, 147 Scott, Mike 91 Semino, Elena 15, 113 Shapiro, Johanna 73, 151 Shildrick, Margrit 163 Silverman, David 15 Silverman, Jonathan 52, 53, 68, 71, 127 Smith, Carlota 83, 114 Smith, Robert Charles 56, 71, 143 Spencer-Oatey, Helen 119, 121, 129, 147 Stein, Dieter 75, 113, 175 Steiner, Claudia 13, 176 Stubbs, Michael 91 Suchman, Anthony L. 52, 115, 127 Swales, John 75, 76

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Taavitsainen, Irma 107, 109 Tannen, Deborah 74, 104, 117, 139, 140 Thiemann, Anna 12 Thomas, Jenny 120 Thurnherr, Franziska 15 Tischler, Victoria 2, 6, 12, 13, 21, 28, 29, 56, 108, 109, 113, 114 Toutanova, Kristina 87 von Raffler-Engel, Walburga 15 Wald, Hedy S. 2, 14, 73, 73, 130, 146, 151, 171, 176, 177 Waletzky, Joshua 14, 98 Watton, Pete 14, 73, 120 Watts, Richard J. 7, 116, 119, 124 Watzlawick, Paul 121 Weder, Mirjam 91, 114 Wenger, Etienne 15, 115, 118 Werlich, Egon 114 Widdicombe, Sue 171 Young, Rhea 21, 155

About the Author

Miriam A. Locher is Professor of the Linguistics of English at the University of Basel, Switzerland. In her work she combines an interest in interpersonal pragmatics, relational work, (im)politeness, and advice-giving in health and CMC contexts. Her publications include Power and Politeness in Action (2004), Advice Online (2006), and the edited collections Impoliteness in Language (2008, with D. Bousfield), Standards and Norms of the English Language (2008, with J. Strässler), Interpersonal Pragmatics (2010, with S. Graham), Teaching and Learning (Im)politeness (2015, with B. Pizziconi), Narrative Matters across Disciplines in Medical Contexts (2015, with F. Gygax), and Pragmatics of Fiction (2017, with A.H. Jucker) as well as special issues on CMC and politeness ( Journal of Politeness Research 6, Pragmatics, with B. Bolander and N. Höhn). She is currently working on an SNF project on Language and Health Online and on the connection between emotional display and relational work with A. Langlotz. She has published several articles with B. Bolander on relational work in Facebook.

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