Family Practice Vol. 19, No. 5, 484-488
© Oxford University Press 2002
Health Services Research |
‘I’ and ‘we’: a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations
Department of Primary Care and General Practice, The University of Birmingham, Birmingham, UK.
Mr JR Skelton, Department of Primary Care and General Practice, The University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; E-mail: j.r.skelton{at}bham.ac.uk
Skelton JR, Wearn AM and Hobbs FDR. ‘I’ and ‘we’: a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations. Family Practice 2002; 19: 484–488.
Received 26 July 2001; Revised 15 February 2002; Accepted 13 May 2002.
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Abstract |
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Background. It is widely accepted that ‘partnership’ with patients is desirable, and that patients should be enabled to participate in decisions, but it is not clear to what extent doctor–patient interactions represent partnership in action.
Objective. Our aim was to measure aspects of doctor–patient interaction through the deployment of the first person pronouns ‘I’, ‘me’, ‘we’ and ‘us’ in general practice consultations.
Methods. The study design was a concordance-based language analysis of spoken data. Concordancing software was used to interrogate a database of 373 consultations with 40 doctors in UK general practice. The frequency and function of first person pronouns used in these consultations were scrutinized. Concordancing enables identification of strings of text with similar lexical properties and uses specialized statistics to assess relationships between words and phrases (‘collocates’ being words commonly found together) as well as their patterns of use (MI, mutual information, describes the likelihood of two words or phrases being associated). Analysis is therefore quantitative and qualitative.
Results. Doctors use the word ‘we’ far more often than patients or companions do (doctors 23.5% and patients 2.9% of all personal pronoun occurrences). Doctors are far less likely to use ‘I’, after which a verb of thinking is usually selected (38 collocates with MI >3). However, after ‘we’, doctors select verbs of physical activity or auxiliary verbs. Three types of doctor use of ‘we’ were distinguished: to include patients ("you and I"), exclude them ("we doctors" or "we as a practice") or to mean "all of us as human beings".
Conclusions. The findings suggest a prototypical pattern of interaction in primary care: Patient: I suffer. Doctor: I think. We will act. This, within the current paradigm which values partnership between doctor and patient, might seem encouraging; but there is evidence to suggest that power relationships in the consultation may still be unequal.
Keywords. Communication, general practice, language, lexical concordance, patient-centredness.
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Introduction |
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Advice to doctors on how to communicate with patients has, since Ley’s seminal work which was summarized in the late 1980s,1 centred on such issues as ensuring an appropriate setting, providing opportunities for patients to speak, avoiding jargon and the like. These are now standard features of what is taught as good communication,2,3 and studies4,5 and reviews6,7 echo similar messages.
Most of these features have in common the fact that, because doctors have been made conscious of them, they are relatively easy for them to control, and easy for doctors who are not specialists in communication to understand. Most features are also designed to promote a patient-centred atmosphere, with ‘patient-centredness’ often being defined wholly or partly in terms of just these surface characteristics.8–10 However, it seems likely both that there are other relevant features of patient-centredness, and of good consulting style, and also that one cannot consult well merely by the mechanical performance of the behaviours represented here. To take a simple example, it is a truism of communication skills courses that ‘making eye contact with the patient’ is somehow ‘good’; yet it is also clear that some patients will find eye contact intimidating, or unduly intimate, and so on.
One possibility, therefore, is to search for evidence of good style in different areas. For example, it makes sense to look at the language the patient uses: this after all is beyond the doctor’s direct control, and may therefore reveal that, for example, however well the doctor is adhering to the norms of what is taught as good style, s/he is nevertheless being perceived as difficult to interrupt or contradict or negotiate with, and, therefore, is in fact perceived as a powerful, authoritative figure. Alternatively, for example, areas of the doctor’s own language might be considered over which s/he has less conscious control (such as their markers of hesitation), or of which s/he is less aware.11
One such area is the use of the pronouns ‘I’, ‘we’, ‘me’ and ‘us’. Little work has been done on this apparently small area, but as the word ‘I’ in particular is one of the most common words in all spoken language, it has a natural prominence. Moreover, selection between ‘I’ and ‘we’ is perhaps the most common, straightforward choice between language alternatives which doctors make. In particular, there is a standard distinction between inclusive ‘we’ ("you and I") and exclusive ‘we’ ("we doctors, but not you patients") which is of potential interest: inclusive ‘we’ from doctors and patients might be evidence of partnership in the consultation: it might mean "we will work together to solve the problem".
These words therefore form the basis of this study.
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Methods |
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This study is part of a larger project exploring the language of the general practice consultation. Forty GPs from 21 practices, in the West Midlands region of the UK, audiotaped consecutive consultations. All practices which were approached agreed to participate, and individual GPs volunteered to have their surgeries recorded. Patients gave written consent or declined to participate on arrival for their appointment. Consultations were transcribed verbatim and imported into the lexical concordancing program, ‘Cobuild’ (details of the software are described elsewhere11). In addition to actual language, transcribers were permitted to describe other activities (laughter, physical examination, writing at the computer, etc.) where these were of >1 s duration, and where the nature of the non-verbal activity was certain. The final database consisted of 373 consultations. GPs were of differing levels of experience (from GP registrars in their training year to established principals); 28 were male and 12 were female. Ethical approval was granted; participating patients gave written consent, which was confirmed orally at the start of the consultation.
Concordancing programs interrogate large databases of text for the presence or absence of words or phrases, and the context in which they appear. The basic computer output can be manipulated with respect to length of context. The word or phrase around which the search is made is termed the ‘node’ or ‘nodal expression’.
Concordancing programs are word or phrase centred. They have the capacity to work with large databases, and respond to queries such as "show me all examples of the phrase ‘I think’ followed within 10 words by the phrase ‘we should’". ("I think . . . you should . . ." is a recognized way of giving polite advice.12 The pronoun is changed to ‘we’, here, to see to what extent advice-like phrases are offered using ‘we’ rather than ‘you’.) A basic printout is shown at Table 1
. (The program can also show longer stretches of text as required, essential to contextualize the examples.)
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Standard statistical measures are not normally considered appropriate for data of this kind.13,14 One common measure employed instead—described at a very basic level here—is mutual information (MI). This concept derives from information theory, and in effect asks the question: "given the presence of X, how much more likely is Y to occur?" (the similarity to Bayesian procedure has often been observed).15 If X and Y were distributed randomly throughout the data, we could measure how likely it is that they would, by chance, appear side by side. The extent to which they actually appear together compared with chance is MI. This in turn can be used as a measure of how likely it is that a particular phrase is of interest.
Just as, in standard statistics, there are conventions about what may attract the label ‘significant’, so for MI a score of >3 is, purely conventionally, deemed to be of interest. For example, ‘pressure’ in ordinary language is likely to co-exist with a large number of words. However, the words ‘blood’ and ‘pressure’ appear in the database with high frequencies (in fact, 545 and 304, respectively), and the presence of the word ‘pressure’ is a very good predictor of the word ‘blood’: thus the phrase ‘blood+ pressure’ has a high MI score (9.9031), indicating, as one would expect, that it is typical of this setting.
Further details of the study population and the Cobuild program are available elsewhere.11,16 All examples of the words ‘I’, ‘we’, ‘me’ and ‘us’ in the database were considered, together with their collocates. (A collocate is a word which occurs in the immediate textual environment of another; for example, ‘kith’ only collocates with ‘and kin’.) The database has already been studied in detail for use of jargon and relative verbosity of doctors and patients as markers of patient-centredness, and, in the case of both markers, was found to show doctors working in a relatively patient-centred manner.9
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Results |
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Individual doctors contributed a mean of 9.33 consultations (range 2–23, SD 4.31), with 29/40 contributing between 6 and 15. The mean number of words per consultation was 1742 (total number of words = 649 692). The mean number (percentages) of words spoken by different parties per consultation was: doctors 933 (54%) and patients 794 (46%); other parties, e.g. nurses, contributed <1%.
Table 2 gives basic figures for the distribution of these pronouns in the database. Doctors are far more likely than patients or companions to use the word ‘we’, and far less likely to use the word ‘I’. Doctors selected ‘we’ on 23.5% of occasions when they used a first person pronoun; patients and companions selected ‘we’ on 2.9% of such occasions. ‘Me’ is used much more frequently by patients and companions (68.8% of total appearances of this word in the database), while ‘us’ is much more likely to be used by a doctor (72.1%).
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Table 3
shows main collocates for ‘I’ and ‘we’ listed by MI score. After ‘I’, doctors are likely to select a verb of thinking/knowing. On 58 occasions where patients solicit an opinion or advice, the doctor responds in this way, for example:
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<P> Are you sure I’m not going mental am I? <laugh> <D> Right I don’t think so
<D> [the heart pounding] is very common especially in women <P> Why? <D> I don’t know
After ‘we’, however, doctors are likely to select either a verb of doing (rather than thinking) or an auxiliary verb, and this in turn is likely to be followed by a verb of doing. (An auxiliary verb is one which cannot stand on its own, e.g. ‘can’, ‘must’ ‘will’, etc., or certain uses of ‘be’ and ‘have’). On 111 occasions, doctors use the phrase "What I think we’ll do . . .". Patients are likely to select a verb of doing after both ‘I’ and ‘we’.
With ‘me’, the collocates immediately to the left differed substantially for doctor and patient. For the doctor, seven of the 10 most frequent collocates were requests for the patient to do something: remind me (MI = 8.3572), show me (7.5280), tell me (6.8467), etc. For the patient, all 10 of the highest collocates to the left show the patient as the recipient of action: killing me (MI = 7.4928), calling me (7.3407), gave me (7.2152), etc.
Three types of doctor use of ‘we’ were distinguished. First, it was used to include the patient, to mean "you and I". Secondly, it was used to exclude the patient, to mean, for example, "we doctors" or "we as a practice". (Many other languages have different pronouns to distinguish inclusive and exclusive ‘we’.). Thirdly, it was used to mean "all of us as human beings", e.g. "we’re all subject to the ageing process"; this is also an inclusive use. When a doctor uses ‘us’, what is meant on most occasions is "us as a practice".
However, though it was very clear that the categories were well motivated, in that there were many examples which could clearly be assigned to only one of them, there were too many doubtful cases, particularly with respect to the first two categories, to make any quantifiable statement possible. Often, for instance, in a phrase such as "what we can do is get you referred as soon as possible . . .", it is not clear whether the doctor means to include or exclude the speaker—an anticipated response by the patient could equally well be (on the assumption of exclusion) "Thank you doctor" or (on the assumption of inclusion) "OK that’s fine".
There are 112 instances where the doctor says ‘we’ and the patient responds with ‘thanks’ or ‘thank you’, for example:
<D> OK, we’ll do that then. <P> Thanks very much. Thank you very much
<D> . . . we’ll talk about it again in a few days time <write> <P> Thank you ever so much indeed doctor
On the other hand, there are 127 instances where the doctor’s ‘we’ is followed by an ‘OK’ from the patient:
<D> [if your mood] starts getting low again <P> right . . . <D> then we can start you back on them <P> OK
<D> . . . if that doesn’t improve things then come back to me and we’ll look into it further <P> OK
It is apparent, however, that where ‘thank you’ is concerned, the patient’s tone might range from courteous acknowledgement of the doctor’s co-operation to gratitude for his or her condescension. Equally, for ‘OK’ the mood can range from rational consent to unreflective acquiescence.
On the other hand, when patients and companions used ‘we’, they never meant "you and I, together, doctor". The ‘we’ of the patient is always their family or social group.
One further collocation was noted. The phrase ‘we’ll’, which is strongly associated in English with ‘taking or planning action’,17 is used 604 times by doctors, and 37 times by patients and companions.
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Conclusions |
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Doctors are very much more likely than patients or companions to use ‘we’ and, on many of the occasions on which they do, an inclusive interpretation is plausible. Furthermore, doctor selection of ‘I’ is associated with verbs of thinking, and of ‘we’ with verbs of doing (with or without a modal auxiliary such as ‘can’, ‘could’, ‘may’, ‘might’, etc.), while in contrast patients and companions use ‘I’ followed by reference to a verb of doing. These findings suggest prima facie that the following is the prototypical pattern of interaction in primary care:
P: I suffer
D: I think
We will act
This, judged by contemporary norms of what is appropriate communication in consultation is, on the surface, encouraging. The patient brings the problem, the doctor brings rational expertise to bear on it, and offers partnership in action.
However, the fundamental ambiguity of the doctor’s use of ‘we’ may undermine this as a conclusion, i.e. the doctor may or may not aim to be inclusive, and may or may not be perceived as doing so by the patient. A simple way of disambiguating is, of course, for the doctor to use ‘you and I’ rather than we. Moreover, the clear difference between doctor and patient use for ‘we’, and indeed the considerable difference in distribution, strongly suggest in themselves a difference in the power structure of the consultation. The fact in particular that patients and companions do not include doctors in their use of ‘we’ argues strongly that they do not perceive doctors as participants in care, but as conduits or co-ordinators of care.
Further, the frequency with which doctors (not patients or companions) use ‘we’ll’ to initiate a discussion of action decided suggests that doctors retain the right to nominate what topics are to be discussed, and when a topic is to be changed. Since there are, of course, many ways of performing both these functions, the evidence here is speculative.
The overall picture, therefore, is of considerable differences in the selection of ‘I’ and ‘we’. The fact that patients and companions never included the doctor when they said ‘we’ is particularly interesting, and—from the point of view of patient partnership—disappointing. Also, where doctors are concerned, the use of ‘we’ showed a systematic ambiguity at the heart of the consultation, which at worst may permit doctors to feel they are inclusive when in fact they are not.
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Acknowledgments |
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This research is funded by a programme grant from the Sir Siegmund Warburg Voluntary settlement.
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References |
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1 Ley P. Communicating with Patients: Improving Communication, Satisfaction and Compliance. London: Chapman Hall, 1988.
2 Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Teaching and Learning. Oxford: Oxford University Press, 1984.
3 Myerscough PR. Talking with Patients: A Basic Clinical Skill. Oxford: Oxford University Press, 1992.
4 Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. J Am Med Assoc 1997; 277: 350–356.
5 Ford S, Fallowfield L, Lewis S. Doctor–patient interactions in oncology. Soc Sci Med 1996; 42: 1511–1519.[Web of Science][Medline]
6 Roter D. Which facets of communication have strong effect on outcome—a meta-analysis. In Stewart M, Roter D (eds) Communicating with Medical Patients. Newbury Park (CA): Sage, 1989.
7 Ong LML, de Haes CJM, Hoos AM, Lammes FB. Doctor–patient communication: a review of the literature. Soc Sci Med 1995; 40: 903–918.[Web of Science][Medline]
8 Henbest RJ, Stewart M. Patient-centredness in the consultation. 2: Does it really make a difference? Fam Pract 1990; 7: 28–33.
9 Mishler E. The Discourse of Medicine: Dialectics of Medical Interviews. Norwood (NJ): Ablex, 1984.
10 West C. Routine Complications: Troubles with Talk Between Doctors and Patients. Bloomington (IN): Indiana University Press, 1983.
11 Skelton JR, Hobbs FDR. Concordancing: use of language-based research in medical education. Lancet 1999; 355: 108–111.
12 Leech GN, Svartvik J. A Communicative Grammar of English, 2nd edn. London: Longman, 1994.
13 Stubbs M. Collocations and semantic profiles: on the cause of the trouble with quantitative studies. Funct Lang 1995; 2: 23–55.
14 Church K, Gale W, Hanks P, Hindle D. Using statistics in lexical analysis. In Zernik U (ed.). Lexical Acquisition. Englewood Cliff (NJ): Erlbaum, 1991: 115–164.
15 Van Rijsbergen CJ. Information Retrieval. London: Butterworths, 1979.
16 Skelton JR, Hobbs FDR. Girl talk: co-operative language and physician gender in the primary care consultation. Br Med J 1999; 318: 576–579.
17 Palmer FR. Modality and the English Modals. London: Longman, 1979.
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