By Sari Pietikäinen, Alexandra Jaffe, Helen Kelly-Holmes, Nik Coupland
Sociolinguistics from the Periphery "presents a fascinating book about change: shifting political, economic and cultural conditions; ephemeral, sometimes even seasonal, multilingualism; and altered imaginaries for minority and indigenous languages and their users"
A patient tries to explain a problem to his doctor, but the doctor doesn’t seem to be listening. A foreign nurse has trouble communicating with her patient due to her language skills. The media exaggerates the threat of a virus sweeping the world. Millions of people search the internet every day for solutions to their health problems but can they trust the advice they’re reading online? These are some of the practical situations presented in this broad and insightful book on health communication by Harvey and Koteyko. It explores communication between patients and their health professionals, draws out our understanding of health and illness, and shows how applied linguistics can provide useful tools to analyse the language of health and healthcare.
Healthcare is a problem for modern societies, as governments are conscious of the rising costs of treatment and the growing expectations of the population for quality care. How we think about health and healthcare is important, and the authors peel back layers of our talk and writing to understand how discourses around well-being, sickness and treatment are formulated, reproduced and accepted in wider society.
The book is aimed at postgraduate linguistics students interested in health communication and those interested in how to approach research in this field. Each chapter starts with issues and problems in the real world, analyses actual language data of health practice, and discusses relevant linguistic theory. The book also includes short tasks and activities for reflection and discussion. It is divided into three general sections: spoken health communication, written health communication, and computer-mediated health communication.
Spoken health communication (Part I) begins with the classic doctor-patient consultation, the first port of call in community-based health, where a patient with a problem seeks advice and treatment from a general practitioner. But sometimes the different expectations and perspectives in both the patient and the doctor can lead to communication difficulties in the consultation. As doctors tend to do most of the asking, and patients most of the responding, asymmetrical conversations occur. Power and control in the consultation mainly lies with doctors, who are backed by professional authority, but the authors show that patients can also ask questions and negotiate their way through a consultation. The doctor is not the only health professional dealing with patients, as we also encounter the nurse, the psychiatrist, the physiotherapist and even the hospital chaplain in this section. All of them have different encounters with patients, and we are privy to their conversations and to the different ways they see the world, the roles they each play and how that impacts their relationship with patients. The interpersonal work of building relationships between patients and health professionals occurs via language, and the reader is introduced to a range of tools for analysing this language, including critical discourse analysis, conversation analysis, Grice’s Co-operative Principle and four conversational maxims, and narrative theory. The three chapters in this first section of the book also explore the concepts of the ‘voice of medicine’ and the ‘voice of the lifeworld’ (Mishler 1984). The voice of medicine represents the institution of health with its biomedical worldview, the world that many health professionals are trained in. This is contrasted with the commonsense and everyday understanding of health from the patient’s perspective, or the ‘lifeworld’, where other parts of our lives, such as the social and economic, can affect health, and vice versa. The section concludes with a discussion about how people construct their identities and how narratives convey our self-image and provide a way to understand our experiences.
The next section, written health communication (Part II), builds on the kinds of narratives health professionals, the media and communication professionals construct for patients and the general public. The patient record is the transformational document that brings patients ‘into being’, where value judgments about health are also translated into the language of scientific objectivity. But is it really objective? The authors show that for psychiatric patients, the official record can be a collaborative moral evaluation from their treating health professionals, that is, those who have the power to detain or release them into the community. The print media, with the guise of objectivity, presents health issues in metaphoric language that influences our understanding. Through the prominent use of war and military metaphors in media articles, bird flu and other viruses are presented as a new biological enemy that must be eradicated. This emotive language can lend itself, the authors argue, to hasty government policy in response to the perceived need to act against a health ‘invasion’. This section also includes an in-depth review of the medicine information leaflet, which reveals different voices simultaneously reaching out to the patient, from the informative expert to the strict authoritarian. These three chapters traverse linguistic features such as account markers, the passive voice and agent deletion, de-personalising language, epigrammatic appraisals and technical terminology. There is also a discussion of the difference between ‘illness’ and ‘disease’ and the challenges of conveying health risks. This section also highlights differences between spoken and written language, and discusses theories such as social constructionism, framing, conceptual metaphors, and systemic functional linguistics.
The final section of the book, computer-mediated health communication (Part III), is focused on the online health world, where anyone can interact in an internet health forum and anyone can ask for health advice. It is also a world where identities are created purely via onscreen language, and negotiating these identities, for the health professional and layperson alike, involves working around different dynamics. For online support groups, expertise and authority is constructed from the egalitarian and anonymous space of the internet forum. Each participant needs to create legitimacy, solicit advice, provide reasonable advice, and accept or reject advice from others. They present themselves and establish their identity via onscreen language. This interpersonal work also requires language strategies that highlight the concepts of face and politeness as the norms of online interaction are created. In forums where people seek help online from health professionals, it is the experts who need to convey credibility and authority when responding to questions. The case of Lucy, an American advice column run by a group of health professionals, demonstrates how the single identity of Lucy emerges via consistent and standard language used in responses. The authors discuss different models of online behaviour and interaction and draw attention to the concept of Communities of Practice (Wengar 1998). The two chapters in this section also introduce language corpora and quantitative methods of linguistic inquiry, such as keywords and concordance analysis.
The authors provide extra resources at the back of the book: a commentary on selected tasks throughout the chapters, a short appendix on transcription systems, a glossary, a list of further reading, references, and an index.
For any linguistics student new to the field of health communication, this book is a great place to start. The eight chapters cover interesting contemporary issues, surveying topics across spoken, written and computer-mediated health communication. The authors have certainly fulfilled, and gone beyond, their aims of exploring language practice in health. They present the best of what linguistic analysis can offer researchers, with case studies and discussion about different methods, theories and the insights these provide into the world of health and healthcare.
One of the strongest themes running throughout the book is the constant battle between the biomedical perspective and the social perspective on health and healthcare. At the beginning of the book we have the ‘voice of medicine’ vs. the ‘voice of the lifeworld’ (Mishler 1984), where the doctor appears more interested in the biological and physical cause and condition of a patient’s problem than listening to how the condition affects the patient’s life, or how other issues in the patient’s life may have impacted, or even created, the condition. We have ‘disease’ vs. ‘illness’ in the chapter on the patient record, where the personal and lived experience of being sick, or illness, is translated into a written medical state of disease, a specific pathology afflicting a human body (“Has evidence of mild congestive heart failure” [p. 99, originally from Kleinman 1988]). And in the case of domestic abuse, using biomedical language leads to a complete lack of the social perspective – only the body is affected on the written record, and the person as a whole is not acknowledged (“Pain on the mouth after was hit by a fist about 5 hours ago” [p. 104, originally from Warshaw 1989]). The effect of this disembodied language is serious – by removing the agent or actor (the owner of the ‘fist’), and also, by taking away the object or receiver of the action (the owner of the ‘mouth’), responsibility is also removed. Physical abuse becomes an injury ‘reduced to and represented by body parts’ (p. 105) in the biomedical world, and in this example, even takes away all notion of the social circumstances surrounding the abuse.
This book is very good at demonstrating how the social perspective of health and healthcare is overlooked, and advocates for its inclusion in health practice. The authors show how dominant the biomedical perspective is, with the perceived backing of science, authority and power, but also how it isn’t as objective as most people would like to believe. As a product originating from the discipline of applied linguistics, this book sits squarely within the ‘soft’ sciences, where qualitative and nuanced personal narratives, experiences, and a diversity of perspectives are valued. For postgraduate linguistics students already exposed to the kind of research methods typical of the social sciences, this book is an excellent example of the range of linguistic research that can be applied to health practice. I would hope that health professionals also find this book valuable, but suspect that those more grounded in the ‘hard’ sciences and unfamiliar with linguistic analysis could find the shift to the social perspective a large leap into a different paradigm. Nevertheless, the increasing focus on patient-centred care in health policy (e.g. NHS Institute of Innovation and Improvement 2012; Australian Commission on Safety and Quality in Health Care 2011; International Alliance of Patients’ Organizations 2007; Committee on Quality of Health Care in America, Institute of Medicine 2001) often starts with actually listening to the patient, and this book is a reminder of how important that is towards effective treatment. By situating health as a social issue, rather than a purely medical one, the authors clearly show that many factors, such as social status, power, and how people project their own identity, need to be considered beyond specific pathologies.
The authors ask readers to directly reflect on their own practices, and to think about how we view health and sickness and what we expect from our health professionals. They are careful to emphasise that healthcare issues cannot be simply reduced to linguistic behaviour alone. Analysing and reflecting on the language we use in health can shed light on our beliefs, values and assumptions. Do we think of the health professional as a ‘curator of specimens’ or as a ‘carer of human beings’ (Charon 1986, cited on p. 107)? The language we use to answer this question reflects our health perspective, and I would bet most people would prefer the latter.
The book does include elements that could have benefited from better editorial and editing decisions. I found some of the topics in tasks outdated, for example, the one seeking framing devices in media articles about swine flu in 2009 could have been left as a more generic exercise. I keenly felt the absence of a discussion about health literacy, that is, the knowledge and skills needed by a person to make sense of, and act appropriately on, health information. It was mentioned briefly in the chapter on the patient information leaflet (p. 155) but is an essential component to health communication. A short concluding chapter, or even a few pages, to tie everything together and retrace the journey throughout the book would have been very useful too. There was also, on average, one typo in every chapter. However, these are minor blemishes in a wide-ranging and insightful book.
Australian Commission on Safety and Quality in Health Care. 2011. Patient-centred care: improving quality and safety through partnerships with patients and consumers. Sydney: ACSQHC.
Charon, Rita. 1986. To render the lives of patients. Literature & Medicine 5. 58-74.
Committee on Quality of Health Care in America, Institute of Medicine. 2001. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press.
International Alliance of Patients’ Organizations. 2007. What is patient-centred healthcare? A review of definitions and principles. London: IAPO.
Kleinman, Arthur. 1988. The illness narratives: suffering, healing and the human condition. New York: Basic Books.
Mishler, Elliot G. 1984. The discourse of medicine: dialectics of medical interviews. Norwood: Ablex.
NHS (National Health Service) Institute of Innovation and Improvement. 2012. Transforming patient experience: the essential guide. Coventry: NHS Institute of Innovation and Improvement.
Warshaw, Carole. 1989. Limitations of the medical model in the care of battered women. Gender & Society 3. 506-517.
Wengar, Etienne. 1998. Communities of practice: learning meaning and identity. Cambridge: Cambridge University Press.
ABOUT THE REVIEWER:
Mae Hurley works in health policy and communication and has an honours degree in linguistics from the University of Sydney. She's taught English as a Second/Foreign Language, tutored Cross-cultural Communication and consulted to business and government on plain language. Her research interests include discourse analysis, health literacy, systemic functional linguistics and multiculturalism. She writes about language issues on her blog: www.misslinguistics.com.