Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication (original) (raw)
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Psychology & Health, 27, 378-393., 2012
Type 2 diabetes is a metabolic disorder characterised by chronically elevated blood glucose and a high risk of cardiovascular and other complications. Self-management is central to diabetes care and includes taking regular exercise, low-fat/sugar diet and blood glucose monitoring. However, little is understood about how people with diabetes make sense of self-management. Our aim, therefore, is to explore the process of ‘getting one's thoughts straight’ in relation to illness self-management for women with poorly controlled type 2 diabetes. Eight women were recruited from two hospitals in the North of England. Each was interviewed using a biographic-narrative method. Narratives were analysed using a dialogical approach. We use Bakhtin's concepts of voice, official and unofficial truth, and internally persuasive discourse to explore how participants considered, struggled with, and, sometimes, acted upon self-management. We demonstrate how the truth by which participants lived shifted as they encountered new perspectives and experiences. The accounts revealed tension between official, authoritative voices, typically concerned with optimal illness control and unofficial voices that speak at a lived, embodied level. In conclusion, we suggest moving beyond the notion of self-management towards a conceptualisation of life with chronic illness that includes personal goals, values and embodied experience in context.
Speaking Through Diabetes: Rethinking the Significance of Lay Discourses on Diabetes
Medical …, 2010
The disproportionate prevalence of Type II diabetes mellitus among the poor sug- gests that, in addition to lifestyle factors, social suffering may be embodied in diabetes. In this article, we examine the role of social distress in narratives collected from 26 Mexican Americans seeking diabetes care at a public hospital in Chicago. By linking social suffering with diabetes causality, we argue that our participants use diabetes much like an “idiom of distress,” leveraging somatic symptoms to dis- close psychological distress. We argue that diabetes figures both as an expression and a product of social suffering in these narratives. We propose that increasingly prevalent chronic diseases, like diabetes, which are closely associated with social disparities in health, may function as idioms for psychological and social suffer- ing. Such findings inform the anthropological literature and emerging clinical and scientific discourse about the roles of stress and psychological distress in di...
Communication during patient-provider encounters regarding diabetes self-management
Family medicine
Diabetes is a common chronic illness with potentially severe complications. The risk of complications is reduced through controlling blood sugar, lipids, and blood pressure. While medical intervention is important, substantial self-management on the part of patients is required to achieve good control. Patients often find self-management difficult, particularly diet and exercise modification. Clinicians face barriers as well, including lack of time, poor reimbursement, and difficulty changing their clinical practice patterns. We hypothesized that a strong focus on readily measured disease indicators competes with patients' agendas relating to symptoms and their day-to-day social context. We recorded clinical encounters to study communication about self-management in context. Recordings were transcribed verbatim and analyzed, primarily using a grounded theory approach. We found that clinicians often focused their communication on quantitative measures such as blood pressure and g...
Doctor talk and diabetes: towards an analysis of the clinical construction of chronic illness
Social Science & Medicine, 1998
AbstractÐDuring the last two decades the illness narrative has emerged as a popular North American literary form. Through poignant stories, well-educated patients have recounted their struggle with disabling diseases as well as with the hospitals and health care bureaucracies from whom they seek service. However, much less has been written about the doctor's narrative construction of chronic diseases either in the process of learning medicine or through diagnosing, treating and counseling chronically ill patients. Indeed, following Kleinman's lead, the physician's narrative has been narrowly viewed as a discourse on the veri®able manifestations of pathophysiology. Drawing on contemporary theories of storytelling Ð including the conception of narrative as conversational interaction Ð the present paper argues that doctor narratives are equally complex if quite dierent than patient stories. Indeed, through an analysis of doctor talk centering on diabetes mellitus collected in several distinct venues Ð case presentations, narrative interviews and medical consultations Ð it is argued that physician stories not only employ very evocative tropes, but that these stories combine didactic, rhetorical and soterological elements in the telling. The research was conducted at two, urban family practice training sites in Chicago. #
This article uses the theoretical and methodological framework of Grounded Practical Theory (GPT) to provide a lens for analyzing and interpreting discourse as a situated form of social action in routine Type 2 diabetes visits. Drawing on a total data-set of 400 audio-recorded routine visits, we randomly selected 55 visits for qualitative analysis. In this article, we use Conversation Analysis to document communication techniques, which we in turn use as evidence to ground our claims within the GPT framework. We use two single cases of interaction to analyze communication techniques physicians use when recommending a change from oral medication to insulin. We argue treatment intensification is a key moment in health communication to reflect about patient centeredness because physicians can find themselves in an interactional dilemma: while insulin may effectively help control unstable disease, an insulin recommendation may simultaneously counter patient values and treatment preferences. Our analysis suggests that physicians use what we call interactional sensitivity to balance medical need and patient preferences when making medical decisions by tailoring their communication according to the local situation and the patient’s larger illness trajectory. We propose that interactional sensitivity is a type of communication work and a quality of patient- centered communication characterized by the theoretical relationship between tailoring communication to the contingencies of the local interaction and the global illness trajectory. Overall, this article contributes to health communication scholarship by proposing a normative model for reflecting on how physicians negotiate challenging interactions with patients during routine chronic illness visits.
Medical Anthropology Quarterly, 2000
The disproportionate prevalence of Type II diabetes mellitus among the poor suggests that, in addition to lifestyle factors, social suffering may be embodied in diabetes. In this article, we examine the role of social distress in narratives collected from 26 Mexican Americans seeking diabetes care at a public hospital in Chicago. By linking social suffering with diabetes causality, we argue that our participants use diabetes much like an "idiom of distress," leveraging somatic symptoms to disclose psychological distress. We argue that diabetes figures both as an expression and a product of social suffering in these narratives. We propose that increasingly prevalent chronic diseases, like diabetes, which are closely associated with social disparities in health, may function as idioms for psychological and social suffering. Such findings inform the anthropological literature and emerging clinical and scientific discourse about the roles of stress and psychological distress in diabetes experiences among underserved groups.
Issues of Cause and Control in Patients’ Accounts of Type 2 Diabetes
Health Education Research, 2006
Patients experience considerable difficulties in making and sustaining health-related lifestyle changes. Many Type 2 diabetes patients struggle to follow disease risk-management advice even when they receive extensive information and support. Drawing on a qualitative study of patients with Type 2 diabetes, the paper uses discourse analysis to examine their accounts about disease causation and disease management, and the implications for how they respond to their condition and health services advice. As it is a multifactorial disease, biomedical discourse around Type 2 diabetes is complex. Patients are encouraged to grasp the complicated message that both cause and medical outcomes related to their condition are partly, but not wholly, within their control. Discursive constructions identified from respondent accounts indicate how these two messages are deployed variously by respondents when accounting for disease causation and management. While these constructions (identified in respondent accounts as ‘Up to me’ and ‘Down to them’) are a valuable resource for patients, equally they may be deployed ina selective and detrimental way. We conclude that clear messages from health professionals about effective disease management may help patients to position themselves more effectively in relation to their condition. More importantly, they might serve to hinder the availability of inappropriate and potentially harmful patient positions where patients either relinquish responsibility for disease management or reject all input from health professionals.
Misunderstandings about illness and treatment among patients with type 2 diabetes
Journal of Advanced Nursing, 2005
Journal of Advanced Nursing 49(2), 146-154 Misunderstandings about illness and treatment among patients with type 2 diabetes Aims. This paper reports a study whose aim was to describe the misunderstandings that Swedish patients with type 2 diabetes have about their illness and treatment. Background. It is well known that patients with type 2 diabetes need extensive support and education to learn to manage and live with their illness. However, a Swedish survey has shown that only 34% of these patients had good metabolic control. Despite intensive education and support, misunderstandings about both the illness and treatment seem to be common. Furthermore, patients are currently complaining that health care services sometimes obstruct rather than support selfcare and learning. Methods. We videotaped 18 authentic encounters between a patient with diabetes and a physician, or a diabetes nurse. Patients then viewed the video and reflected on what took place during the consultation. Video-recordings and transcribed reflections were analysed thematically. Results. Five themes emerged from the analysis: (a) Type 2 diabetes is not 'real diabetes'; (b) Complications-horror visions or suppression; (c) Self-monitoring of blood glucose and medication is a routine, not a learning tool; (d) Diet-the important thing is to reduce fat and (e) 'Physical exercise is good, they tell us'. Four of the 18 patients showed no misunderstandings. Misunderstandings of diabetes and its treatment were thus common and numerous, despite regular checkups and good access to care. The patients adhered to prescribed regimens but did not know why they performed many routines or how they could benefit from them. Conclusion. The results show that misunderstandings of illness and treatment were common. We suggest that diabetes educators should base their education on this variation of understanding, using a phenomenological approach to learning. Reflecting on this kind of varied experiences can be a powerful tool to help people to move from 'novice to expert' and apply basic routines to new situations.
Controlling diabetes, controlling diabetics: moral language in the management of diabetes type 2
Social Science & Medicine, 2004
Contemporary management of diabetes places heavy emphasis on control, particularly control of blood sugars and of food consumption. Interviews with people living with diabetes type 2 show how identity and social relationships are negotiated through what is often a contradictory language of control, surveillance, discipline and responsibility. People frequently discuss diabetes-related behaviour in terms that position themselves or others as disobedient children, or as wicked or foolish adults. These references occur alongside appraisals of the physical and social complexity of ''compliance'' with diabetic regimes and in some instances the difficulty of achieving effective control over blood sugar levels. Efforts to protect themselves from the stigmatising potential of diabetes may inadvertently undermine the agency of people who are already coping with a demanding discipline and a potentially disabling or life-threatening disease. r
This article is based on original ethnographic research among college students aged 18–25 living with insulin-dependent type 1 diabetes. I investigate how moral language in medical treatment settings and social environments informs patients’ experiences of managing their diabetes. Moral language about choice, control, responsibility, and risk was regularly used to describe daily diabetes management habits. Young adults with diabetes internalized a moral imperative to prioritize health. This moral obligation to health contributed to participants’ conceptions of self and influenced participants’ characterizations of other people with diabetes (PWD). Since the mid-twentieth century, the clinical approach to diabetes care has relaxed; however, some harmful assumptions linking patient character to his or her ability to comply with a prescribed treatment regimen still circulate in the culture of type 1 diabetes care. While failing to take insulin or to check blood sugars can lead to dangerously high or low glucose levels in the body, language tying patient worth to treatment compliance fails to show the complexity of striking a balance between hypervigilance and negligence in daily diabetes care rou- tines.