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系統識別號 U0026-0302201201000500
論文名稱(中文) 醫師社會心理性開放式問句的應用與病人及陪同的相對回應—以台灣家醫科為例
論文名稱(英文) Doctors’ Use of Psychosocial Open Questions and Patient Parties’ Responses-in the Context of Family Medicine in Taiwan
校院名稱 成功大學
系所名稱(中) 外國語文學系
系所名稱(英) Department of Foreign Languages & Literature
學年度 100
學期 1
出版年 101
研究生(中文) 張椀婷
研究生(英文) Wan-Ting Chang
學號 K2697121
學位類別 碩士
語文別 英文
論文頁數 91頁
口試委員 指導教授-蔡美慧
口試委員-高實玫
口試委員-許甘霖
中文關鍵字 社會心理性開放式問句  病患  陪同者  病史階段  家族史階段  社會心理問題 
英文關鍵字 open questions  psychosocial open questions  health outcomes  patients  companions  family history stage  medical history stage  elderly patients  psychosocial problems  patient-centered communication 
學科別分類
中文摘要 現代文明的進步是社會發展的必然趨勢,但也間接促使社會變遷更加激烈與迅速,致使現代人常因生活忙碌、精神壓力龐大而引發適應不良,甚至嚴重影響心理健康。愈來愈多人受到心理問題困擾,已是不容置疑的事實,相關文獻也指出在所有求診的病患當中,有三分之一是為了社會心理問題而來 (Parkerson et al., 1995; Gulbrandsen et al., 1998; Boerma & Verhaak, 1999)。然而,這些日益普遍的社會心理問題在問診過程當中卻最容易為醫師所忽略,當這些問題沒有適時獲得抒發,病患容易對就醫結果產生不滿 (Beckman & Frankel, 1984; ten Have, 1989; Barry et al., 2000; Bell et al., 2001; Tsai, 2006)。有鑑於此,要創造醫病雙方良好的溝通環境,醫師不單需要將病患的生理問題納入考量,更需要兼顧病患的心理健康。本研究將針對醫師如何使用社會心理性開放式問句,與病患及陪同者的回應兩部份作探討。為求深入探討,本研究提出以下四個研究問題: (1) 藉由比較Tsai (2006)所提出的三大類開放式問句——一般性、生理性、社會心理性——來探討此三類開放式問句在診間使用的比例與環境為何? (2) 針對在不同環境下出現的社會心理性開放式問句,病患及陪同者的回應又是如何? (3) 面對生理性與社會心理性開放式問句,病患及陪同者的回應是否不同? (4) 社會心理性開放式問句又可分為哪幾類? 病患及陪同者的回應又是如何?
針對以上四個研究問題,本研究於台灣南部某教學醫院家庭醫學科,以錄影方式收集25個實際問診的語料,當中參與者包含了11位醫師 (平均年齡為35),病患人數為25位 (平均年齡為73),25位病患皆為初診,百分之八十八的病患有一到兩位家屬陪同就醫。研究結果顯示社會心理性開放式問句: (1) 使用頻率與環境上:一般性問句佔39.23%,生理性開放式問句佔36.92%,兩者的使用比例較為頻繁,而社會心理性開放式問句佔23.85%,出現頻率相對較低。另外,社會心理性開放式問句平均出現於醫師收集病患的病史階段(48.4%)與家族史階段(51.6%)中; (2) 回應方式上: 於此兩種情境中,結果發現病患及陪同者對社會心理性開放式問句的回應方式並不相同——在家族史階段的回應方式通常較為明確 (例如:肯定或否定回答),然而在病史階段通常較不明確 (例如:疑惑或反問); (3) 回應態度上: 病患及陪同者對待生理性 (多肯定詳答) 與社會心理性開放式問句(少肯定詳答,多簡答、否定、與遲疑)並不相同; (4) 分類上:社會心理性開放式問句又可細分為三類,分別是生活改變(例如:最近生活有什麼改變嗎?)、居住狀態(例如:有什麼特別的原因你自己一個人住嗎?)或負面心情(例如:最近你有在擔心什麼事情嗎?)。另外,對於生活改變,病患及陪同通常能提供最多資訊、其次是居住狀態、最後才是負面心情。根據以上結果,本研究提出四項建議: (1) 建議醫師如果想要深入了解病患的社會心理問題,病史與家族史兩階段是較為適當的環境;(2) 相較於病史階段,家族史階段似乎又更為恰當。原因在於:社會心理性開放式問句與家族史階段的環境依存度較高,醫師發問時較不會顯得突兀,病患及陪同者的回答意願自然明顯提高; (3) 當病患及陪同者出現簡答、否定、與遲疑這三種回應方式時,可能代表另有隱情,醫師需多加留意;(4) 病患及陪同者對於與生活改變相關的社會心理性開放式問句往往能夠提供較多資訊,醫師可多加利用。另外一方面,當問題涉及較為沉重的負面心情時(如:親人過世、自殺念頭),醫師最好避免使用抑或謹慎處理。
綜合以上的分析與討論結果,我們可以發現無論對醫師或病患(及陪同者)而言,如何處理敏感度較高的社會心理問題都是一大挑戰。因此,本文建議兩大重點:(1)使用時機上:家族史階段;(2)使用種類上:與生活改變相關的社會心理性開放式問句。以上兩項建議可協助醫師有技巧地探問社會心理問題,進而有效減輕在過程中可能帶來的矛盾與衝突,並提高病患及陪同者的回答意願。
英文摘要 With today’s drastic social and environmental changes, people are involved in a recurring cycle of exhausting work and fleeting material pleasures. Under such conditions, people are more likely to suffer from psychosocial problems derived from maladaptation to such changes, which may further affect their physical and mental health. Health-affecting psychosocial problems are inherent in medical encounters and present among one third of patients for consultations (Parkerson et al., 1995; Gulbrandsen et al., 1998; Boerma & Verhaak, 1999). However, such problems are not always presented, and often easily overlooked by doctors. These psychosocial problems (e.g. change in social life, financial situations, living alone, fear of death, the loss of a spouse, aging, specific concerns or expectations, and so on) may result in patient dissatisfaction with health outcomes if left unaddressed (Beckman & Frankel, 1984; ten Have, 1989; Barry et al., 2000; Bell et al., 2001; Tsai, 2006). Therefore, the involvement of patients’ psychosocial problems is a crucial aspect of comprehensive medical care, and a vital step towards a more patient-centered communication. Given its significance, the current study aims to examine how doctors utilize psychosocial open questions to probe patient concerns by observing the interaction among doctors, patients and patients’ companions (patient parties hereafter). To explore this issue, there are four research questions examined, as follows. (1) What are the frequency distributions of Tsai’s (2006) general open questions (e.g. ‘why are you here today?’), biophysical open questions (e.g. ‘what are your symptoms?’) and psychosocial open questions (e.g. ‘are you worried about any problems recently?’) in medical encounters? (2) What is the relationship between psychosocial open questions in different contexts and patient parties’ various responses? (3) What are patient parties’ response patterns to biophysical and psychosocial open questions? (4) What are the subcategories of psychosocial open questions and patient parties’ responses to these subcategories? To examine these questions, transcriptions of 25 video-recorded medical encounters collected in the context of family medicine practice at a teaching hospital in southern Taiwan were observed. The participants included 11 doctors with a mean age of 35 years old (ranging from 29 to 40) and 25 elderly patients with a mean age of 73 years old (ranging from 62 to 81). All the 25 patients were visiting their doctors for the first time, and 88% of them were accompanied by one or two family members. The results of this work show that (1) the occurrence of psychosocial open questions (23.85%) was less frequent than general (39.23%) and biophysical open questions (36.92%), and a total of 31 psychosocial open questions were equally distributed in the medical history stage (48.4%) and family history stage (51.6%); (2) the ways that the patient parties tended to explicitly or not explicitly respond to psychosocial open questions in the two stages were different, based on whether these questions were relevant to local contexts; (3) by comparing responses to doctors’ biophysical an psychosocial open questions, patient parties responded to biophysical and psychosocial open questions differently based on four patterns, including ‘affirmative responses containing only information,’ ‘affirmations alone,’ ‘negations alone,’ and ‘delays before responses’; and (4) there are three subcategories of psychosocial open questions identified, including psychosocial open questions for ‘life changes’ (e.g. ‘are there any changes in your life recently?’), ‘unusual living arrangements’ (e.g. ‘do you have any special reasons to live alone?’), and ‘psychosocial distress’ (e.g. ‘are you worried about any problems recently?’); furthermore, patient parties tended to provide more descriptions of their problems to ‘life changes,’ less descriptions to ‘unusual living arrangements,’ and delays or repair initiators to ‘psychosocial distress.’ The above findings suggest that (1) the family history and medical history stages may be appropriate when doctors attempt to pose psychosocial open questions; (2) the family history stage may be more appropriate for doctors to ask psychosocial open questions, because a relevant context may facilitate doctors’ tasks of eliciting patients’ psychosocial concerns; (3) the three response patterns (i.e. ‘affirmations alone,’ ‘negations alone,’ and ‘delays before responses’) could be treated as hints that the patient parties may have unmentioned concerns; and (4) to ask effectively the subcategories of psychosocial open questions, doctors can have more use of ‘life changes’ and less or careful use of ‘psychosocial distress,’ especially the topics related to death information (e.g. the loss of a family member or having thoughts of committing suicide). Based on the above findings and suggestions, two major points are emphasized. First, the initiation of psychosocial open questions may be more appropriate in the family history stage during medical interviews. Second, the use of psychosocial open questions for ‘life changes’ may help doctors elicit more detailed information from patient parties. The implications of the present study are beneficial for medical educators, professionals, or doctors seeking to better probe patients’ psychosocial problems during medical interviews.
論文目次 ABSTRACT (CHINESE) i
ABSTRACT (ENGLISH) iv
ACKNOWLEDGEMENTS vii
TABLE OF CONTENTS viii
LIST OF TABLES xi
LIST OF EXCERPTS xii
LIST OF FIGURES xiii

CHAPTER ONE INTRODUCTION 1
1.1 Motivation and Background 1
1.2 Purpose of the Present Study 3
1.3 Research Questions 4
1.4 Definition of Terms 5
1.5 Preview of the Following Chapters 7

CHAPTER TWO LITERATURE REVIEW 9
2.1 Patient Problems: Biophysical and Psychosocial 9
2.2 Closed and Open Questions 12
2.3 Categories of Open Questions 17
2.4 Nonverbal Responses: Silence and Laughter 20

CHAPTER THREE METHODOLOGY 22
3.1 Data 22
3.1.1 Participants 22
3.1.2 Setting and Transcriptions 25
3.2 Analytic Frameworks 25
3.2.1 Frequency Distributions of General, Biophysical,
and Psychosocial Open Questions 26
3.2.2 Relationship between Psychosocial Open Questions
in Different Contexts and Patient Parties’
Responses 39
3.2.3 Patient Parties’ Response Patterns to
Psychosocial and Biophysical Open Questions 42
3.2.4 Subcategories of Psychosocial Open Questions and
Patient Parties’ Responses to These Subcategories
45

CHAPTER FOUR RESULTS AND DISCUSSION 49
4.1 Frequency Distributions of General, Biophysical, and
Psychosocial Open Questions 49
4.1.1 The Use of Psychosocial Open Questions in the
Present Study 51
4.2 Relatedness (High vs. Low) to Local Contexts and
Patient Parties’ responses 57
4.2.1 Coherence in Spontaneous Interaction 60
4.3 Patient Parties’ Response Patterns to Psychosocial
and Biophysical Open Questions 61
4.3.1 Face Need and Face-threatening Effects 64
4.4 Subcategories of Psychosocial Open Questions and
Patient Parties’ Responses to These Subcategories 69
4.4.1 Degrees of Sensitivity to the Three Subcategories
of Psychosocial Open Questions 72

CHAPTER FIVE CONCLUSION AND IMPLICATIONS 76
5.1 Summary of Major Findings 76
5.2 Implications of the Present Study 78
5.3 Limitations of the Present Study 80
5.4 Suggestions for Further Studies 82
5.5 Contributions 83

REFERENCES 84
APPENDIX A 91
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