Being involved : Patient participation in health care

Sammanfattning: The problem focussed on concerns interaction in health and medical settings between patients and health care professionals. The issues studied relate to patient participation and influence in face-to-face encounters with professionals, and to patient evaluation of selected aspects of their experiences of modem health care.In the theoretical background, it is argued that the health care setting is an example of a communicative situation characteristic of modem society in which people who vary in communicative power and expertise interact. Institutionalized communication thus typically involves encounters between the general public- often referred to as laymen - and one or more experts representing the views and traditions of an institution. At a general level, the central concern of the study is one of making visiblethe patients' reactions and of scrutinizing their possibilities of making themselves heard.The methodological approach utilized is multidisciplinary. In the ftrst two articles, a discourse analytic study of patient-physician interaction is reported; and in the latter three articles an epidemiological approach to the study of patient perceptions of various aspects of health care is used. The empirical material consists of two sources of data. For the analysis of patient-physician interaction a corpus of 20 medical interviews in a hospital clinic of internal medicine has been used. The second set of data - forming the material for the epidemiological study- was collected by means of questionnaires given to a sample of 666 persons undergoing surgery.The results in the first two articles focus on salient features of the interaction patterns of patient-physician dialogues. It is shown how social distance is negotiated through the use of specific forms of adress, and how requests and feedback are introduced so as to avoidface-threatening situations. It is also shown how such politeness moves can cause ambiguity in the dialogue. In the second article, the role of lifestyle habits (smoking and drinking) in clinical decision-making is studied. It is shown that the information elicited on such health hazards is vague and that the decision as to when and how to go into such issues seems to follow certain patterns representing physicians' implicit assmnptions as to the tendency of different groups to smoke and drink. In the epidemiological studies, the results reveal that ofl the whole the patients seem satisfied with their involvement in the decision to have an operation and report having the influence they expected. These results are discussed in terms of patient and health care professionals' prevailing expectancies with respect to patient influence. The results also show that the more satisfied the patients were with the outcome of the operation and the post-operative care process, the more inclined they were to state that they had been actively involved in the decision to have surgery. It is also shown that there is considerable discrepancy between patient reports and health care professionals' registration of complications after surgery.The results are discussed in tenns of the concept of 'voice' and the differences between the 'voice of medicine' and the 'voice of the lifeworld'. It is argued that the problem of people's involvement in health encounters and decision-making cannot be reduced to an issue of merely increasing the information provided. Attending to the problems and definitions perceived as significant in the 'voice of the lifeworld' is essential if modem health care is to deal with its traditional task of curing disease as well as its new challenge of preventing poor health.