Mitigation in english language doctor - patient interaction

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Mitigation in english language doctor - patient interaction

T. I. Gribanova

Senior Lecturer, Department of Grammar and History of English, Faculty of the English Language, Moscow State Linguistic University

Компенсационные тактики в англоязычном медицинском дискурсе (на примере общения между врачом и пациентом)

Т. И. Грибанова

старший преподаватель кафедры грамматики и истории английского языка факультета английского языка Московского государственного лингвистического университета

В данной статье рассматриваются особенности употребления компенсационных тактик в устной разновидности современного англоязычного медицинского дискурса. Анализируются компенсационные операторы (хеджи, буши и щиты) и средства их выражения в процессе общения между врачом и пациентом. Описываются наиболее типичные лексические и грамматические (морфологические и синтаксические) компенсационные средства и их сочетания, выявляется зависимость их выбора от прагматической цели говорящего в процессе коммуникации.

Ключевые слова: англоязычный медицинский дискурс; общение между врачом и пациентом; компенсационные тактики; компенсационный оператор; компенсационное средство.

The present article considers the problem of mitigation in English oral communication belonging to medical discourse, namely interaction between doctors and patients. The three mitigating operators (hedges, bushes and shields) and their language representation are analyzed. Various lexical and grammatical mitigating devices and their combinations are traced, which enables the author to establish interrelation between a particular means used and the pragmatic task set in the course of interaction.

Key words: English medical discourse; doctor-patient interaction; mitigation; mitigating operator; mitigating device

mitigation english language

Introduction

In the present article mitigation is analyzed from a functional perspective with a focus on the use of specific operators and their actual power in real communication.

The issue of mitigation can be considered in terms of linguistic and socio-linguistic rules. This approach makes it possible to trace a functional connection between two types of mitigation. One implies weakening the speaker's commitment to the truth of the proposition of the utterance, while the other implies a reduction of the interlocutor's obligation to perform the requested act. This connection is realized at a syntactic and morphological level.

Being a pragmatic-rhetoric category, mitigation connects the following types of aspects:

the pragmatic aspect and the praxeological aspect, when mitigation is analyzed either as a process or a result, thus reflecting a link between doing and effective doing, between grammar and rhetoric [Caffi 2007, p. 94]. Within the framework of speech act theory mitigation bridges illocution and perlocution [Leech 1983]. These bridging enables speakers to decide what is appropriate in a given situation: they anticipate certain consequence of the speech act and choose the most effective strategy [Ezeh 2016];

cataphora and anaphora: mitigation can be either a preparatory strategy, which provides for the main speech acts, or a following strategy, which is a form of “repair”. The latter can be achieved by means of one or a number of moves syntactically independent though pragmatically interconnected [Caffi 2007; Riekkinen 2013];

the social aspect and the individual psychological aspect, which can be realized through the distinction between social and individual politeness [Brown and Levinson 1987; Geyer 2008].

This makes reference to the distinction drawn by Giles between practical means and relational means [Giles et al. 1979], which allows to speak about two functions of mitigation:

the interactional function (when mitigation serves mainly instrumental needs to maintain the achievement of communicative aims);

the identity building function (when mitigation serves mainly relational needs to monitor the emotive distances between the participants in the communication.

Thus, the first task of the present research to show through the discussion of authentic samples from English language interaction between doctors and patients that mitigation operates in a multi-level way. Since the speech act might be face-threatening, mitigation can serve both the speaker's protection and the interlocutor's protection including different conversational strategies which support the interlocutor and the co-production of conversation, to more complex textual technics. The negative consequence of the act for the interlocutor, since the act might be face-threatening, is one of the aspects involved.

The second task of the investigation is to explore the use of mitigating devices within the three main mitigation operators: `bushes' (on the propositional content), `hedges' (on the illocution) and `shields' (on the deictic origin of the utterance).

The third task is to discuss mitigation in terms of its functions, namely, the interaction effectiveness and the identity building, i. e. in terms of the instrumental and the relational dimension.

The samples presented in the Results and Discussion section will show that the use of appropriate mitigating operators and devices enables the speaker to realize his / her pragmatic aim, providing the interactional effectiveness of communication.

Methodology

The research is carried out within the following trends of modern linguistics: functional grammar, discourse analysis, pragmatics and mitigation theory.

Results and discussion

This section deals with samples of doctor-patient interaction with a focus on different ways of expressing mitigation. The material for the analysis is comprised of fifty samples as part of authentic medical conversations. The analysis covers mitigating strategies affecting micro-linguistic phenomena within single utterances which often correspond to single speech acts. An attempt is made to specify the interdependence of interactional parameters involving both instrumental and relational aspects.

As it was stated above, mitigation is studied through the functioning of the three operators: bushes, hedges, shields.

Bushes

Bushes, as a mitigating device, focuse on the propositional content to make a speech act less precise [Austin 1962; Takhtarova 2009]. The attenuating operation centers on the interactional parameter `precision' [Bazzanella et al. 1991], the pragmatic counterpart of Lakoff's logical- semantic concept of `fuzziness' which is at the basis of his notion of `hedge' [Lakoff 1972]. In the present research the term `hedge' refers to attenuating devices focusing on illocution, while `bush' is used for mitigators reducing precision of the propositional content. This approach makes it possible to shift from a semantic to a pragmatic perspective, to contrast between precision and imprecision used to reduce responsibility for the utterance.

Let us look at the example below. This is a conversation between a doctor (D) and a patient (P) discussing a medical remedy for the disease:

I'll give you some cough syrup to take, two table spoons

P Some syrup in digestion

D. Two table spoons per day

P Whatever (Archives of Internal Medicine, Researchgate.net)

This example is a kind of preparatory strategy, pre-phase of the action. The doctor pronounces his words as he is about to write a prescription. He uses the verb `to give' as a mitigated option of the verb `to prescribe'. He also uses the indefinite pronoun `some' to make the preference act in the prescription fuzzy. The patient immediately grasps this idea and, after showing her agreement by repeating the doctor's words she reinforces the referential vagueness by adding the word `whatever': she insists on having something prescribed, anything that is effective. The pronoun `some' has the function of reducing the unpleasantness of the prescription, downgrading obligation imposed on the patient, and indirectly mitigating her possible worries about her illness.

The next example containing bushes is an understatement in diagnosis, which is an act of assessment, a verdictive speech act in Austin's terms [Austin 1962].

D. Yours isn't a real fracture, only a strain.

P. Just a touch.

D. Just a touch. (Archives of Internal Medicine, Researchgate.net)

The doctor makes an attempt to mitigate the diagnosis by using an understatement and a minimizer in the predication (`yours isn't a real fracture, only a strain"). Then he accepts the definition suggested by the patient (`just a touch'). The doctor's mitigation is reformulated through the patient's mitigation on which agreement is finally reached. This proves to be a case of `accommodation' [Giles and Coupland 1991]: the powerful participant adapts his code to the weaker participant's code. This convergence concerns styles as well: the patient mitigates the diagnosis using a bush `just a touch', which makes this style more colloquial.

The results of such interaction are as follows. On a referential level, the health problem is defined as non-prototypical and therefore not particularly serious. On a relational level, not only the social but also the psychological distance between the interlocutors is diminished. The coproduction of the diagnosis through using the same informal minimizer contributes to building a cooperative climate between the doctor and the patient and making their relationship friendlier.

Hedges

In hedges mitigation centers on illocution:

D. I'd propose to you if you want a special remedy - to see if I can make you sleep. (Archives of Internal Medicine, Researchgate.net)

The mitigating devices found in this example are the following:

`I propose to you", a hedged performative, where the verb in the conditional form is a weaker option as compared to the indicative form `I propose'; this is a case of internal mitigation [Blum-Kulka et al. 1989];

`if you want", a routine formula, a “consultative device” [Blum- Kulka et al. 1989, p. 19];

`to see if I can make you sleep', a supportive postponed move, a case of external mitigation, which according to Blum-Kulka, applies the negative politeness principle by appealing to the interlocutor as a rational partner who cannot be forced to do something that she does not fully understand [Blum-Kulka 1992, p. 267]

From a relational point of view, the doctor presents the therapy choice as his personal merits (thereby indirectly affirming his strong role in the given situation). Moreover, he formally downgrades his directive to a proposal, which it is up to the patient to accept, thus shifting parts of his responsibility on to the patient. This means a redefinition of the patient's role as slightly less passive.

Here we can see certain interdependence between the following parameters: knowledge, power and role in the same speech act. While the parameter of knowledge is lessened, the parameter of power is downgraded. The given example illustrates the interrelation of the three parameters - epistemic certainty, social power and psychological distance - within one speech act, thus proving its complex nature.

Shields

Shields as mitigating devices have deictic origin: the `I-here-now' triad is at the core of every utterance [Buhler 1934]. In this case the speech act is mitigated not by explicit linguistic means but through backgrounding and de-focalizing strategies, or even by the deletion of the utterance source. This idea is to some extend based on Brown and Levinson's pragmatic- linguistic notion of `impersonalization mechanisms' [Brown and Levinson 1987, p. 273], as well as on Jespersen's `emotional element' (the speaker's willingness to either include her/himself in the utterance or being excluded from it). Jespersen identified different forms of personal deixis and connected their use with de-responsibilization [Jespersen 1924, p. 215], which in the present research is considered central to mitigation.

Shields realize attenuation by means of the three basic components of the deictic origin. Shields on the first component, the `I' element, are represented by cases where the act is ascribed to someone else, or where the author is omitted, as in impersonal sentences or agentless passive constructions. Similarly, the `you' element can be omitted, when no reference is made to the actual addressee of the message.

The other two components of the triad (here-now) can be labeled `spatio-temporal' [Caffi 2007, p. 107]. In this case a narrative replaces a sequence focusing on another space or time, sometimes even within an imaginable context.

The example below illustrates a `non-I' strategy of objectivization:

D. There's an valvular pneumothorax - it is written here. (Archives of Internal Medicine. Researchgate.net)

The given utterance is ascribed to some other impersonal source, due to which it is made more authoritative and unquestionable by the channel (written) and by the use of a medical term. Responsibility is shifted to another source, which results in weakening the doctor's personal commitment to his diagnosis. Moreover, no reference is made to the two interlocutors: neither `I' nor `you' are mentioned. At the same time the disease is accurately identified, which means the importance of the parameter `precision of propositional content'. Thus, while the cognitive informativeness and the argumentative power of the act are reinforced, the overall relational effect is downgraded.

The next example deals with negotiations about responsibility for what is said and done. Here the shields perform two different functions, those of downgrading based on impersonalization, and reinforcement based on objectivization:

P There are no thoughts.

D. There aren't.

P. There is no capacity of thinking. There are no thoughts. There is no emotivity. There is no capacity of reaction to stimuli from the environment. There isn't - I don't know -

D. So you have destroyed your mind.

P But I have (polemical quotation of D's words), it is: it has been. It has. Now I wouldn't want to take the whole responsibility. (Archives of Internal Medicine, Researchgate.net)

At the beginning the patient speaks of her feeling as a matter of fact. Her utterance is objectified through the use of the pattern `there is / there are'. The patient is watching her thoughts from the outside, as an external observer. The doctor (a psychoanalyst) reformulates the patient's words making them more personified and thus reinforced. The patient changes her mind and, after a false start, where she echoes the doctor's words in a polemical tone, she uses other shields (passive and impersonal structures) to create a `generic person' [Caffi 2007, p. 110]. Since it proves not enough to express her refusal to take the full responsibility for the action mentioned, she makes her point explicit.

A typical shield in doctor-patient interaction is the personal pronoun `we'. It is often labeled `inclusive we' as a positive politeness strategy [Brown and Levinson 1987]. This means provides mutual understanding as well as solidarity between the interlocutors. The example below is a directive, where the pronoun `we' is used, though it is `pseudo-inclusive we' [Haverkate 1992]:

D. We must do an X-ray of your lungs. (Archives of Internal Medicine. Researchgate.net)

Here the shield (the pronoun `we') focuses on both the `I' and the `you': a solidarity `we' means both `I suggest an X-ray' and `you must do an X-ray'. Thus the shield signals at personal involvement on the part of the doctor, though avoiding an explicit prescription. At the same time the shield is on the addressee, whose individual obligation is weakened.

The second mitigating device used in this example is the modal verb `must'. Modal devices can be both mitigating and reinforcing depending on the context and the criterion of analysis. From a logical point of view the agent-oriented `must' is a downgrader compared to impersonal and more objective `it is necessary'. However from a psychological point of view, `must could be seen as an upgrader with respect to `it is necessary', which sounds less immediate from the partner's view point.

The examples above illustrate the use of deictic shields, those based on the negation of one of the aspects of the deictic triad `I-here-now'. They work by a substitution (one utterance is replaced by another bearing a `non-I', `non-here', `non-now' features) and are in paradigmatic opposition to other unmarked elements in a given context.

Conclusions

The language data discussed in the given article confirmed that mitigation affects various linguistic levels and involves different interactional dimensions, both cognitive and emotive.

There is a connection between mitigation and its potential relational impact. The effects of mitigating devices include both instrumental and relational aspects, which can be either mutually reinforcing or conflicting. Mitigating devices expressed by a range of lexical-grammatical means (pronouns, modal, passive structures, mood forms, conditional clauses, etc.) can be used singly or in clusters, their choice can be guided by anticipating the consequences of the speech acts, being a preparatory or a repair strategy.

Mitigation can be realized in different ways. Bushes weaken the proposition, hedges downgrade the illocution, while shields help to avoid the self-ascription of the utterance (which is ascribed to another source or another situation).

While bushes and hedges show different degrees of epistemic commitment to the proposition and degrees of endorsement of one of illocution dimensions respectively, shields are sort of yes-no devices (`I' / `non-I', `now' / `non-now', `here' / `non-here') centered on the core of the utterance act, its deictic origin. What is involved in shields is not a downgrading of the quality of some interactional dimension, but an emotive clash between expectations and the actual choice.

Thus mitigation may increase or reduce distance between the interlocutor, being an important interactional recourse for the monitoring and mutual adjustment of emotive communication.

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