Discursive strategies for addressing patients’ disalignment with diagnosis in online medical consultations in China

Introduction

A new era of medical consultation – online medical consultation (OMC) – has been ushered in (Singh et al., 2018), owing to technological advancements in healthcare industry. OMC here refers to Internet-based remote medical consultation which involves not only advice/information-giving, but also medical agendas, such as diagnosis, treatment recommendation and prescription (see Al-Mahdi et al., 2015). Since this mode of consultation emerged around the beginning of this century, it has rapidly progressed (Thompson et al., 2012). The online mode of medical consultation will gain more popularity, particularly in times when the coronavirus epidemic makes access to medical institutes difficult. While OMC has been increasingly common around the world, China also sees a promising growth in OMC services, which is believed to be able to solve the problems of Chinese healthcare system (Milcent, 2018).

One of the serious problems of Chinese healthcare is the public mistrust of doctors (Chan, 2018; Yan, 2018). The problem of mistrust is significantly related to doctors’ income structures; that is, bonuses and commissions constitute part of their regular income. This kind of income structures very often leads to overtreatment (Chan, 2018), which is closely associated with the reliability of doctors’ diagnosis in physical healthcare services. OMC services in China thus have an increasingly important role to play in providing a platform for patients and their caregivers to get a second opinion as well as a first opinion (Singh et al., 2018). It is reported that patients tend to view diagnostic information provided by doctors as negotiable (Ijäs-Kallio et al., 2010). This may pave the way for expressing disalignment with doctors’ diagnosis.

Patients’ expressions of disalignment may be varied in relation to communicative modes. When patients’ disalignment occurs in face-to-face medical encounters, it is often passive – displayed through paralanguage such as silence, thus lacking accounts (Bergen et al., 2018; Yao and Ma, 2017), or through minimal response, such as unmarked acknowledgement tokens (Koenig, 2011; Stivers, 2005a; Yao and Ma, 2017). While silence and other non-verbal cues cannot be capitalized on to take a stance of disalignment in text-based OMC interactions, active expressions of disalignment – discursive acts that questions or challenges doctors’ statements (see Stivers, 2005b) – would have to be employed in online contexts.

In addition, patient involvement is more central in OMC context than in face-to-face settings, and doctor authority may be less salient (see Lu and Zhang, 2019; Suler, 2004). Distinctive authority roles and time constraints featured in face-to-face medical consultations may affect patients’ capability and willingness to express their disalignment or argument with their doctors (Labrie, 2019). By contrast, in the online context, a person’s own high status or authority may have less impact on his/her online presence and influence, even if the addressees know the offline status and power of the person (Suler, 2004). Moreover, the consulting time is more flexible and less constrained in online environment, which leaves more room for patients to express disalignment. Thus, text-based OMC interaction has great potential for studying patients’ disalignment and doctors’ responses to the disalignment at a discursive level.

However, studies on patients’ disalignment and its management in OMC context are, to my best knowledge, absent in the literature. To contribute to filling this gap, the present study examines discursive practice of patients’ disalignment and discursive strategies of doctors for dealing with the disalignment in a Chinese e-healthcare website.

Discourse-based OMC studies

Very few past studies have paid attention to the communicative value of online medical discourse, and these studies have only started to appear very recently. Some of these have examined the discursive features of doctors’ messages (see Locher, 2010; Mao and Zhao, 2019; Zhao and Mao, 2019). Some have studied the identity construction of OMC participants (see Fage-Butler and Anesa, 2016; Mao and Zhao, 2018). Others have investigated empathic communicative acts by doctors (see Pounds, 2018; Pounds and Pablos-Ortega, 2015; Zhang, 2020). Overall, discourse-based studies on e-healthcare services are still in their infancy.

It is noted that when giving advice in online space, health experts adopt different linguistic strategies to avoid threatening patients’ face (Locher, 2010). Besides, mitigation strategies are observed in online doctors’ answers to patients’ questions, which can perform the function of rapport management (see Mao and Zhao, 2019). Generally, these findings, to some degree, indicate rapport-building or -maintaining efforts made by doctors in delivering online healthcare services. In fact, it is noted that rapport management is one of the interactional features of online discussions about health problems and illness (Angouri and Sanderson, 2016; Landqvist, 2016). These studies suggest that discourse produced by doctors in online medical services can be said to aim at achieving a harmonious communication style with patients. Such communication style has an increasingly important role to play in clinical contexts worldwide with the highlight of patient-centred and relationship-centred care that value empathic communication (see Rider et al., 2014; Silverman et al., 2013). It is noted that, in Chinese online healthcare services, doctors integrate empathic expressions in the institutional task of problem solving (Zhang, 2020), and the discursive positionings of doctors and of patients/caregivers help establish an affective relationality, which contributes to a positive image of the doctors and the patients/caregivers and to the empowerment of patients/caregivers (Zhang, forthcoming). It would be thus noteworthy to examine how doctors respond to patients’ disalignment in online environment so as to find out whether these responses are also consistent with a harmonious communication style.

Disalignment and its management in doctor-patient interaction

Patients’ disalignment with health professionals has an important role to play in doctor-patient communication. A lack of patient negotiation or disalignment prevents patient-centred communication and may have a negative impact on patient adherence and compliance (Arnold et al., 2012). Patients’ disalignment with doctors should be encouraged rather than be neglected or avoided, because it plays an important role in reaching mutual alignment or agreement between patients and doctors (see Labrie, 2019). Moreover, it is believed that interactional disalignment is a necessary step contributing to patients’ understanding (Burbaum et al., 2010). In a word, the vital role of patients’ disalignment has been highlighted in the literature, which links to extensive studies on patients’ disalignment in face-to-face medical encounters.

It is widely recognized that patients often express disalignment with their doctors, both in western contexts (see Lindström and Weatherall, 2015; Peräkylä, 2002) and China (see Pritzker and Liang, 2018; Yao and Ma, 2017; Zhao and Ma, 2020). Disalignment in face-to-face consultations is frequently externalized by means of paralinguistic or non-verbal cues, such as silence (see Koenig, 2011; Lindström and Weatherall, 2015), stand-alone head nod (Koenig, 2011), nervous or suppressed laughter (see Haakana, 2001; Landmark et al., 2017; Pritzker and Liang, 2018) together with looking down (see Haakana, 2001; Landmark et al., 2017). Delay in a patient’s response can also indicate non-alignment (Schegloff, 2007). In addition, patients’ disalignment can be seen in a set of embodied resources, such as withholding pain displays (see Galatolo and Fasulo, 2018) and glottal cutoffs (i.e. glottally cutting off their initial response to doctors’ question) (see McArthur, 2019).

While previous studies indicate that patients’ disalignment in face-to-face medical consultations tend to be associated with non-verbal and embodied behaviours, some have found that patients’ expansion of their response to doctors’ question and patients’ presentation of additional information are also associated with their disalignment (see Gill, 1998; Heritage and Raymond, 2012; Robinson and Heritage, 2006; Stivers and Hayashi, 2010; Zhao and Ma, 2020). For instance, answering ‘more than the question’ is viewed as a practice of disalignment in medical settings (see Bonnin, 2014). Such disalignment is usually expressed based on patients’ own experience of illness or/and lifeworld (see Lindström and Weatherall, 2015). That is, on the basis of their non-expert knowledge, patients tend to report symptoms or health problems that do not support doctors’ diagnoses in order to indicate their disalignment (Heath, 1992; Peräkylä, 2002, 2006). In general, drawing from prior studies, patients’ disalignment is characterized by paralinguistic elements and patients’ expression of their ‘lay expertise’.

When it comes to addressing patients’ disalignment in face-to-face settings, doctors, both in Chinese and Western contexts, often repeat, clarify or justify the initial proposal (Kushida and Yamakawa, 2015; Landmark et al., 2017; Yao and Ma, 2017; Zhao and Ma, 2020), use wh-questions biased towards patients’ acceptance or alignment, add alternative options or proposals (Kushida and Yamakawa, 2015; Landmark et al., 2017; Yao and Ma, 2017) or terminate the on-going sequence to impose acceptance onto patients (Zhao and Ma, 2020). Those discursive strategies are employed with the purpose of eliciting patients’ alignment, some of which indicate that doctors take advantage of their ‘expert power’ (French and Raven, 1959) to take control over the negotiation of patients’ disalignment. The approach to eliciting acceptance from patients seems to treat patients’ disalignment as just resulting from their need for an acceptable treatment recommendation, suggests or speculative diagnosis. However, patients’ disalignment may result from their emotional concerns, such as the worry of side effects (Bergen et al., 2018; Koenig, 2011). In fact, expressions of disalignment can be linked to negative emotional display (see Langlotz and Locher, 2012). That said, identified discursive strategies for dealing with patients’ disalignment in extant literature are hardly associated with addressing the affective aspect of patients’ disalignment in both Chinese and Western contexts. Thus, more work needs to be done to explore possible discursive strategies that can be adopted by doctors to cope with patients’ disalignment, in particular strategies related to the affective dimension.

Based on the overview above, two research questions are proposed: (1) what discursive resources are adopted by patients to disalign with their doctors’ speculative diagnosis; (2) in response to the patients’ disalignment, what discursive strategies are adopted by doctors. Before presenting related findings, I first explain the analytical approach – stance-taking (Du Bois, 2007), along with data-related information in the following sections.

Analytical approach

This study takes an interactional discourse analysis approach to data analysis, drawing upon the notion of stance, in particular the (dis-)alignment aspect of stance-taking (Du Bois, 2007). Stance is understood as a social actor’s explicit or implicit expression of his/her personal knowledge, attitudes, feelings, beliefs, evaluations, judgements or commitment towards a topic represented in discourse or other semiotics under discussion with an addressee (a reader or a hearer) in an interactive context (Barton and Lee, 2013; Biber and Finegan, 1989; Du Bois, 2007; Du Bois and Kärkkäinen, 2012). Stance in this study is highlighted in terms of its intersubjectivity. That is, stance emerges from interactions between interlocutors; it includes not only speaker-based subjectivity, but also hearer-oriented intersubjectivity (Kärkkäinen, 2006). Stance taking is ‘achieved dialogically through overt communicative means, of simultaneously evaluating objects, positioning subjects (self and others), and aligning with other subjects’ (Du Bois, 2007: 163). In this view of Du Bois, stance-taking mainly involves stance subjects, evaluation objects and (dis)alignment. Stance subjects in the current study include patients and doctors; and stance object doctors’ speculative diagnosis.

Du Bois’s stance-taking can be either positive (i.e. alignment) or negative (i.e. disalignment). The convergence (i.e. alignment) and divergence (i.e. disalignment) are treated as a continuum, rather than two poles (Du Bois, 2007). In the current study, I focus on the disalignment dimension of stance-taking. Drawing upon the view of Du Bois (2007), alignment can be generally understood as being close to the pole of agreement, or, in other word, along the scale or range of agreement. Following this view, disalignment is understood as being along the range of disagreement.

The analytical process is as follows. At first, patients’ expressions of disalignment are identified through tracking ‘the turn-by-turn interactive development’ (Muntigl and Horvath, 2014: 329) in each OMC. That is, if a patient’s response to his/her doctor’s speculative diagnosis suggests or shows that the patient does not agree to or has doubt about the diagnosis, this response is identified as the patient’s disalignment. This disalignment presumably affects the subsequent turn exchanges in terms of accomplishing a medical agenda at hand. In particular, the disalignment can affect a doctor’s response. The doctor may evaluate the stance-object – his/her original speculative diagnosis – and take up a position to align or dis-align with the patients’ expression of disalignment, such as revising the original speculative diagnosis with the purpose of eliciting acceptance or insisting on the original speculative diagnosis. The doctor’s stance-taking in response to the patient’s disalignment may be mediated through certain discursive strategies. Thus, the next step is to examine doctors’ responses to patients’ disalignment with the purpose of finding out interactional strategies adopted by doctors. By interactional strategy, here it refers to how doctors qualify or legitimate their speculative diagnosis with which their patients have disaligned, or how doctors mitigate patients’ disalignment to avoid dealing with the disalignment per se.

Data

A hundred one-to-one instant messaging text-based consultations were selected from archived OMC texts that were posted on the ‘question-answer’ section of a widely used e-healthcare platform. ¹ The average number of turns and characters per OMC is 27 and 674, respectively, and the total number of doctors involved in the dataset is 100. The archived consultations on the OMC website are publicly available for viewing. Doctors contributing to this OMC website are health professionals who work in hospitals offline. Their professional information is posted on the website, which includes a profile picture and full name for each doctor, along with his or her professional affiliation, educational background, professional title, specialization, work seniority and the average responding time to an e-patient’s initiating message. With the help of such information, a doctor’s professional identity can be verified by patients. Patients are also free to select any doctor they want for a consultation. Each OMC involves only one patient and one doctor, and the consultation fee ranges from RMB 0 to RMB 200. Patients can evaluate and comment on their doctors’ performance after an OMC is finished or closed.

For data sampling, Anesa and Fage-Butler’s (2015) online data selection criteria – interactivity and recency – are adopted. Regarding interactivity, OMC cases that have less than four turns were excluded. Concerning recency, OMC cases that were initiated before 2017 were excluded. The first 100 OMC texts that met the two criteria were selected from the archived OMC texts (the number 100 is thought of as quite decent for a qualitative study from the author’s point of view). Each selected OMC text was examined by the analytical approach mentioned in the last section. The findings of this analysis are presented in the following section.

Findings

Among the 100 OMC texts, 13 presents both doctors’ speculative diagnosis and patients’ disalignment with the diagnosis, and each of these OMCs involve a different doctor. Among these OMCs, 12 doctors adopt discursive strategies to legitimate their speculative diagnosis or mitigate patients’ disalignment (one doctor does not address his/her patient’s disalignment).

This study finds that patients can make use of four resources to express disalignment with their doctors’ speculative diagnosis. These resources include: (1) referring to the results of medical tests that patients have received from healthcare services offline, (2) referring to medical knowledge that patients have acquired on the Internet, (3) referring to another online doctor’s speculative diagnosis and (4) referring to patients’ own medical history. To address patients’ disalignment, four discursive strategies are adopted by doctors: (1) popularizing biomedical knowledge related to the health problem under discussion, (2) providing reassurance, (3) expressing empathic understanding of patients’ disalignment, and (4) avoiding taking the responsibility of re-considering an original speculative diagnosis. These findings are presented in detail in the following subsections.

Discussion and conclusion

When it comes to studying disalignment, associated with dominance and power, understanding local context is of fundamental importance (Spencer, 2018). The importance of understanding context or local sites when interpreting medical interactions has also been underscored (see Timmermans and Almeling, 2009; Wilce, 2009). This study situates the examination of patients’ disalignment and its management in the China-specific context. As mentioned in the Introduction section, patients’ distrust of doctors is a most serious problem in current patient-doctor relationships in China (Yan, 2018). The mistrust between patients/caregivers and doctors has caused tension between patients/caregivers and doctors (Chan, 2018). Chinese medical professionals have faced increasingly frequent workplace violence which has become a serious issue (Hall et al., 2018; Hu et al., 2014). The significant increase in medical disputes and violence against medical professionals in China makes doctors more cautious when interacting with their patients. Nowadays, owing to increased access to online health information/communication and medical knowledge, Chinese patients no longer always play an obedient role in medical encounters and doctors no longer always have the control over a medical encounter (see Lau et al., 2016; Yao and Ma, 2017; Zhao and Ma, 2020). In fact, the medical professional authority is being threatened by different socioeconomic factors, such as growth in patient consumerism, eroding trust in doctors, emergence of direct-to-consumer advertising and patient-centred care (McKinlay and Marccau, 2008; Timmermans, 2008).

In addition, the digital world has the feature of ‘deprofessionalisation’ which challenges the traditional discursive practices (Trevitt et al., 2001). The deprofessionalisation is likely to be reinforced by the e-commerce model for the Chinese OMC platform from which the data in this study are collected. On the e-commercialised OMC website, medical consultations are traded between doctors and patients. In this commercialization and commodification of healthcare, patients are empowered to take control of their health/illness (see Goldstein and Bowers, 2015; Rowe and Moodley, 2013).

The empowerment of patients may in turn have some effects on the way patients communicate with their doctors in OMC context. This is evidenced in the findings of this study. While previous studies situated in face-to-face Chinese and Westerns settings find that patient’s resistance or disalignment is mainly based on their illness/lifeworld experiences or experiential evidence, the present study finds that patients capitalize on hard evidence to express disalignment. This leaves little room for doctors to question the rationality or legitimacy of such disalignment because the evidence is based on scientific fact like medical tests and medical history, or (presumably) reliable sources (e.g. a previously consulted OMC doctor). Despite the empowerment, mitigation is observed in patients’ expressions of disalignment. The mitigation of disalignment is achieved through patients distancing themselves from the disalignment, specifically through using reported speech (see excerpt 2 and 3) and expressing uncertainty in their disalignment (see excerpt 4). The mitigation phenomenon here matches with the rapport-building/maintaining environment of online health communication, which is mentioned in Section 2.

More interestingly, in response to patients’ disalignment, instead of just asserting their knowledge and/or authority, doctors take advantage of the opportunity of addressing patients’ disalignment to manifest their understanding of the disalignment. This is achieved through providing reassurance and manifesting empathy, as well as reacting to the disalignment empathically by popularizing certain mechanics of illness to make it easier for patients to understand medical knowledge. These ways of managing patients’ disalignment are in line with the harmonious communicative style observed in online doctors’ messages in previous studies, which is mentioned in Section 2. Furthermore, the empathic expressions match the e-commercial model of the OMC website. This is because in a commercial context customer satisfaction should be of high priority, and doctors’ empathic communication can improve patient customers’ satisfaction with healthcare services (Howick et al., 2018).

In addition, while it is noted that popularizing biomedical information is one of the functions of ‘ask-a-doctor’ forums (see Anesa and Fage-Butler, 2015), the present study finds that popularizing biomedical knowledge per se can perform the pragmatic function of dealing with patients’ disalignment with doctors’ speculative diagnosis. While previous studies on face-to-face medical encounters find that when doctors’ proposal is resisted or dis-aligned by their patients, doctors usually revise the proposal or provide alternatives (Koenig, 2011; Kushida and Yamakawa, 2015), the present study finds that doctors sometimes do not make any discursive efforts to elicit acceptance or to justify the original speculative diagnosis. Instead, they delegate the diagnosis to face-to-face healthcare services. These findings thus enrich existing literature in relation to online doctor-patient interaction.

To conclude, this paper has advanced the literature on patients’ disalignment and doctors’ management of the disalignment by identifying different ways of expressing disalignment and managing the disalignment in OMC interactions. What is particularly noteworthy about the findings is that some doctors capitalize on popularization of science and empathic expressions to cope with patients’ disalignment, rather than just relying on manipulative ways to elicit patients’ acceptance as inferred in the literature (see Kushida and Yamakawa, 2015; Landmark et al., 2017; Zhao and Ma, 2020). The present study may facilitate a better understanding of how patients express their disalignment and how doctors address the disalignment in OMC interactions in which non-verbal cues cannot be used to express and manage disalignment. Besides, this study presents discursive strategies that can be beneficial as well as useful for health professionals (or else medical students) to address patients’ expressions of disalignment in both online context and face-to-face settings.