Communication StudyShame, honor and responsibility in clinical dialog about lifestyle issues: A qualitative study about patients’ presentations of self
Introduction
Doctor–patient dialog is an essential aspect of treatment and prevention in general practice [1], [2], and the patient's story has more influence on diagnosis than do findings from clinical examination and lab results [3]. The consultation involves not only medical problem-solving or disease prevention, but is also a social encounter that includes negotiations about identity, authority, and knowledge. Verbal and nonverbal cues have strategic and emotional purposes for those involved. The rules of the dialog are regulated by the roles of doctor and patient [4]. Discourse includes speech acts (utterances with performative action) and turn-taking (who speaks next), and these serve more or less conscious and legitimate ends [5], [6]. The goals of doctor and patient may not be symmetric and are sometimes not even compatible.
Foucault described how disciplinary attitudes are mediated to people, often by experts, but also by public authorities. His term ‘governmentality’ denotes the impact of ideas and technologies on populations and individuals, and the ways in which these constitute the subjectivity of those affected [7]. Power is exercised through discursive practices by expert professions whose social authority legitimizes their messages. Symbolic power exercised in this way is more subtle than social power coerced through oppression. An obese person, for example, will be unable to escape the subtle disciplinary practices mediated by cultural discourse, and this also permeates the medical consultation [7], [8].
Clinical dialog about lifestyle evokes responses related to identity and values, most noticeably on the patient's behalf. Doctors engage in health promotion, yet patients are not always ready to internalize lifestyle advice [9], [10]. While it is usually the patient who introduces a symptom or health problem to the doctor, the roles may shift when it comes to lifestyle consultations [11]. Complying with preventive guidelines, the general practitioner (GP) looks for opportunities to address sensitive questions which are not initiated by the patient [12]. Too often such discourse is perceived as degrading or humiliating [13], [14]. Some doctors may be reluctant to address lifestyle issues, thinking that they might disgrace the patient or create a moral distance [15], [16]. Others admit that they use rhetoric to manipulate patients, or discourse that relies on scare tactics to deliberately evoke feelings of guilt and shame [17].
Smoking and alcohol use are sensitive matters in medical consultations [18]. Discussion of these topics is potentially face-threatening. ‘Face’ is the image of one's self in terms of approved social attributes that others may share [19]. In describing any state of affairs, a person is simultaneously engaged in a ‘presentation of self’ [20]. A person conveys an impression of himself or herself by what Goffman terms ‘performance’ [21]. This does not indicate that the presentation is false or rehearsed, but rather it is a mode of situating oneself as favorably as possible in the eyes of the other. A presentation of self will usually incorporate and exemplify values that are socially appreciated and it tends to be idealized to some extent to fit such perceptions [21]. It is also fitted to the situation at hand and to the expectations connected to it. Embarrassment emerges in a person whose representation of self is discredited and practices intended to protect the presentation of self are constantly enacted.
In a consultation, the patient performs a presentation of self in order to achieve a working consensus with the doctor. The empirical evidence described above indicates that the patient might be especially at risk of threats to face and embarrassment in consultations dealing with lifestyle issues. In our study, we explore how patients enact presentations of self in general practice consultations addressing lifestyle.
Section snippets
Design
We conducted a qualitative observational study with analysis of video-recorded consultations interpreted with theories of social interaction.
Material – Participants
We conducted our study in Danish general practice. We drew empirical data from video-recorded consultations which included discussions about physical activity, diet, smoking, and weight. We used ‘specific preventive consultations’, which are common in Danish general practice. Most of them are annual checkups of chronic disease. According to the Danish GP
Results
Patients demonstrated responsibility for lifestyle issues by presenting themselves with an orientation toward responsibility. They described how they were taking care and doing their best. If one lifestyle issue was considered problematic, some patients shifted attention to another one, of which they were more proud. In areas where they were not doing well, some patients revealed shame for not acting responsibly. In such cases, patients spoke of themselves in terms of self-deprecation or
Validity issues
Interview studies have demonstrated that some patients are happy with health habits that do not conform to current advice [9]. The absence of similar findings in our study is striking, but may be explained by study design. Our sample included GPs with a particularly high level of preventive work in their practices. Patients who disapprove of such a focus may have changed to the list of another GP. The lack of clearly stated pride in non-conformity with health advice may also be due to our
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