The nature of expert communication as required for the general practice of medicine: a discourse analytical study

This study examines the nature of expert communication as it is required by the Royal Australian College of General Practitioners (RACGP) for the General Practice of Medicine, and as it is illuminated by fine grained analysis of the discourse of videorecorded consultations submitted to the RACGP by experienced practitioners seeking College Fellowship. -- Analysis focuses on a narrow selection of whole consultations representing three types of clinical scenarios that are considered by practitioners themselves to be particularly communicatively challenging and, as a consequence, revelatory of communicative expertise. These challenging sites include consultations where the patient's expressed reason for presentation masks hidden emotional or psycho-social concerns, those involving disparate doctor-patient agendas, and triadic consultations involving reticent adolescent patients, accompanied by a third party. -- In all instances, analysis is carried out in light of RACGP examiners' global ratings and evaluative comments on the candidate-doctor's performance with particular reference to the parameter 'communication and rapport'. The objective is to uncover discursive evidence for these judgements, as well as to offer grounded explanation of how broad categories of communicative expertise, as perceived by examiners, are actually achieved in interaction. -- The discourse analytical study at the heart of the thesis is embedded within an ethnographic project that has informed the analytical process, providing directions along which to look that align with professional concerns. 'Focal themes'(Roberts & Sarangi, 2005) which are salient in the discourses on communication that circulate in the profession, specifically empathy, rapport, and finding common ground, are a prime focus for the analysis. Discourse analytical findings offer evidence for how these themes are interactionally, collaboratively, and cumulatively accomplished, and how they interplay in purposeful ways in the specific, challenging encounters under study to shape the trajectory of the consultation. -- Ethnographic data from observations of training and from interviews with a range of selected participants has also highlighted those 'professional stocks of interactional knowledge' (Peräkylä & Vehviläinen, 2003) concerning patient-doctor interaction that are to be found in text books, training manuals, and curriculum documents, and that are invoked in clinical teaching and examiner training. Findings include descriptions of how such abstract normative models, communication guidelines, mnemonics and associated exemplar phrases play out in situ, how they are transformed and expanded upon in practice, and how their salience and substance is challenged in co-constructed, situated interaction. -- In this study, clinical communication emerges as complex, co-constructed, multi-modal interaction. The communicative expertise of doctors is displayed through the discursive choices that they make in specific, local interactional contexts, in response to the moment and in pursuit of relational and clinical goals. It is displayed not only by way of language but by actions accomplished through other semiotic means including, gaze, gesture, posture, shifting body orientation and ways with tools. -- The study concludes by suggesting that discourse analysis, by making visible and available for discussion the actions that General Practitioners actually perform in specific, challenging situations offers a resource for reflection that is of practical relevance and value for medical educators, examiners and practitioners. A model for incorporating discourse analysis into the clinical communication curriculum is outlined. A place for discourse analysis in examiner training is suggested.