Giving voice to the lifeworld. More humane, more effective medical care? Aqualitative study of doctor-patient communication in general practice

Mishler (The discourse of medicine. The dialectics of medical interviews. N orwood, NJ: Abler), applying Habermas's theory of Communicative Action to m edical encounters, showed how the struggle between the voice of medicine an d the voice of the lifeworld fragmented and suppressed patients' multi-face ted, contextualised and meaningful accounts. This paper investigates and cr itiques Mishler's premise that this results in inhumane, ineffective medica l care. Using a more complex data collection strategy, comprising patient i nterviews, doctor interviews and transcribed consultations we show more com plex relations than emerged from Mishlers analysis. We found four communica tion patterns across 35 general practice case studies. When doctor and pati ent both used the voice of medicine exclusively (acute physical complaints) this worked For simple unitary problems (Strictly, Medicine). When both do ctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psy chological plus physical problems). Poorest outcomes occurred where patient s used the voice of the lifeworld but were ignored (Lifeworld Ignored) or b locked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic ph ysical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patie nts as unique human beings. Some doctors switched communication strategies in different consultations. which suggests that their behaviour might be op en to change. If doctors could be sensitised to the importance of dealing w ith the concerns of the lifeworld for patients with chronic physical condit ions as well as psychological conditions, it might be possible to obtain be tter care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient -centred model. (C) 2001 Elsevier Science Ltd. All rights reserved.