‘Let Mum have her say’: turntaking in doctor–parent–child communication

Abstract

Recent legislation in the Netherlands requires that children should play a part in decision making regarding their own health care. So far, however, little attention has been given to the child’s participation in medical interviews. In order to get a grip on aspects of asymmetry and control in doctor–parent–child communication, the present study explores the turntaking patterns in this triad at the general practitioner’s surgery, and makes a comparison over the years. Videotaped observations of 106 medical interviews taken over a period of almost 20 years have been analyzed by means of the Turn Allocation System. The results show that the child’s control in the medical consultation is rather limited, though, over the years, the child participates more actively. The child’s conversational contribution appears to be strongly related to the age of the child. An important finding is the difference in the way GP and parent accommodate their turntaking patterns to the child; parental control appears to be constant over the years, and is not related to the age of the child, whereas the GP is considering the child’s age. The results are discussed in terms of implications for medical practice and health education.

Introduction

Traditionally, children did not have a say in medical consultations. Most studies on medical communication have concentrated on the dyad doctor–adult patient, and the child’s contribution to the medical encounter has hardly been considered a point of interest [1], [2], [3], [4], [5]. However, recent legislation, such as the Medical Treatment Agreement (WGBO) in the Netherlands, requires patients to participate actively in decision making concerning illness and treatment [6], [7], and it is increasingly acknowledged that children too should be involved in decisions about their own health care [8], [9], [10], [11].

The issue of asymmetry in doctor–patient interactions is one of the key-themes in the field of medical discourse [12], [13], [14], [15]. The asymmetrical character is reflected, amongst other things, in the way the communication between doctor and patient is structured in terms of conversational contribution and processes of turn-allocation [14], [16], [17], [18], [19]. In the case of a juvenile patient, it is a matter of double asymmetry, the physician embodying both institutional and adult authority. Adult–child discourse is inherently not symmetrical, because of differences in status and in domain specific knowledge, including communicative competence [20], [21].

Over the last three decades some important changes have taken place in doctor–patient communication in general. The development of the patient-centred approach and demands regarding shared decision making and informed consent evoked a shift in the participant roles in medical consultations [6], [7], [22], [23], [24], [25]. As a result, the nature of the doctor–patient relationship has developed from a very asymmetrical towards a more egalitarian relationship, and patients have become more emancipated and autonomous over the years [26], [27], [28]. One might hypothesize that these changes would also affect the interaction in the doctor–parent–child triad.

The few studies that did pay attention to doctor–child communication, suggest that the child’s control in medical conversation is rather limited [29]. During medical encounters children only occupy a small portion of the discourse space [2], [4], [30], [31], although the child’s contribution seems to increase over the years [32], [33]. Physicians tend to elicit information from children, but exclude them from diagnostic and treatment information [34], [35], [36]. The doctor’s conversational style in interaction with the child is, by and large, restricted to the affective domain, such as social behaviour and joking [1], [5], [30], [31]. In addition, children often seem to be excluded from direct interaction with the doctor by a controlling parent [4]. This negation of the child as an active participant does not seem to match with the development towards ‘shared decision making’, with an increased preference for the child’s participation in treatment decisions [8], [9], [10], [11].

Changes in doctor–patient communication, and the specific role of the child in medical interaction can also be seen as an expression of major social changes that have taken place. Parenting has become less repressive and authoritarian, and adult–child interactions are increasingly characterized by a greater openness to the child [37], [38]. The preference of a growing participation of the child is in line with the development of children as fellow citizens [39].

This change has been confirmed in developmental cognitive studies that underline that children can play a far more active role in taking initiatives when negotiating the aim and process of the interaction with adults than has been assumed [40], [41]. Further, children also appear to be able to understand more about health and illness concepts [42], [43], [44], [45]. A more direct communication between physician and child would contribute to a better relationship in terms of satisfaction and compliance, and a better health experience [1], [43], [44].

This study focuses on the child’s participation in doctor–parent–child interactions during the medical interview. Since little is known yet about the specific role of the child in this triad, our first objective is to provide a detailed description of the turntaking patterns in doctor–parent–child communication. Turntaking in conversation is an important element in defining and establishing relationships, and presents the opportunity to explore the amount of asymmetry between participants [14], [16], [17]. A useful distinction for conversational practise is made by Linell et al. [17] and Linell and Luckmann [14], by formulating four categories of control or dominance: ‘quantitative control’ (in terms of conversational contribution); ‘turntaking control’ (in terms of turn allocation and turntaking); ‘semantic control’ (in terms of the topic of conversation); and ‘strategic control’ (in terms of strategic interruptions). In this study we will focus on aspects of quantitative control, turntaking control, as well as strategic control.

Our second aim is to look for changes in the turntaking patterns. Considering the developments in doctor–patient communication in general, and the changes in adult–child interaction during recent decades, it seems relevant to make a comparison over the years. One might expect a less controlling GP and parent in the course of time.

In addition to the difference in participant status, the child’s communicative competence may influence the extent of his/her participation in medical conversation. Communicative competence, or pragmatic competence, implies conversational logic and the understanding of conversational structure, especially the ability to respond to questions and directives [46]. These conversational skills develop with age, and school-age children gradually learn the appropriate use of turntaking devices [21], [47], [48], [49]. As conversational skills increase with age, as well as children’s concepts of health and illness, one might expect older children to participate more substantially in the medical interview.

Summarizing, the following research questions will be addressed in this study.

• How can the turntaking patterns in doctor–parent–child communication be characterized in terms of quantitative, turntaking, and strategic control?

• Have any changes taken place in these turntaking patterns over the years?

• How does the child’s age affect turntaking in this triad?