p.

Multi-functional role of companions in doctor-patient interaction: A single case study

Abstract

In the study of doctor-elderly patient communication, Adelman et al. (1991) noticed that 60% of the
patients were accompanied to the medical visit by a third person, such as their grown children.
Adelman et al. proposed a conceptual framework of the third person’s roles, namely patient advocator,
passive participant, and antagonist. However, this framework, as Adelman et al. have emphasized, has
not been empirically validated or extended in other cultures. Also, as most studies of discourse analysis
are devoted to dyadic interaction, triadic interaction remains an area that needs more attention. To fill
these gaps, a tape-recorded conversation of a Taiwanese medical interview is examined. The third
person to be analyzed in this study is an adult daughter who accompanies her mother (54-year-old) to a
visit with a male doctor of general medicine. With discourse analysis of the occurrences of deixis,
referential terms, and code-switching in the doctor-daughter and mother-daughter dyads, this research
provides discourse evidence in demonstrating the multi-functional role of the daughter. This role
includes: 1) doctor facilitator, eg. serving as an example of healthy status (your daughter’s heart wall
is like this thick, and yours is like this thick); 2) mediator between doctor and patient, e.g. restating
or interpreting the doctor’s explanation to the patient (Mom, the doctor is saying .. now if you get fat,
and your heart will be um .. not strong enough); and 3) patient advocate, e.g. arguing for the
appropriate action that will benefit the patient (what if, did you see my mom’s face, it looks like
now.now my mom’s face looks looks puffy).
 p.2

“Mom, the doctor is saying…” -- The role of the daughter

in a doctor-patient encounter in Taiwan

Abstract

In the study of doctor-elderly patient communication, Adelman et al. (1991) noticed that 60% of the
patients were accompanied to the medical visit by a third person, such as their grown children.
Adelman et al. proposed a conceptual framework of the third person’s roles, namely patient advocator,
passive participant, and antagonist. However, this framework, as Adelman et al. have emphasized, has
not been empirically validated or extended in other cultures. Also, as most studies of discourse analysis
are devoted to dyadic interaction, triadic interaction remains an area that needs more attention. To fill
these gaps, a tape-recorded conversation of a Taiwanese medical interview is examined. The third
person to be analyzed in this study is an adult daughter who accompanies her mother to a visit with a
male doctor of general medicine.
By applying the framework of participant structure proposed by Rosenfeld (1996), a quantitative
analysis of the daughter’s participation shows that even though the doctor-patient dyads play as the
center of this triadic interaction, the daughter actively involves herself by invoking doctor-daughter
dyads. A further qualitative analysis of the occurrences of deixis, referential terms, code-switching,
and speech acts used in the doctor-daughter and mother-daughter dyads, reflect the multi-functional
role of the daughter. This role includes: 1) doctor facilitator, eg. serving as an example of healthy
status (your daughter’s heart wall is like this thick, and yours is like this thick); 2) mediator between
doctor and patient, e.g. restating or interpreting the doctor’s explanation to the patient (Mom, the
doctor is saying .. now if you get fat, and your heart will be um .. not strong enough); and 3) patient
advocate, e.g. arguing for the appropriate action that will benefit the patient (what if, did you see my
mom’s face, it looks like now.now my mom’s face looks looks puffy).

Besides the above findings, this study contributes to the areas of triadic interaction and doctor-patient
communication in two ways. First, the use of personal deixis as identifier of participant structure is less
applicable in pro-drop language, such as Mandarin and Taiwanese. Instead, code-switching serves as a
better criterion in a bilingual speech community such as Taiwan. Second, this study refines the
definition of the third person’s roles with three aspects: who initiates the third person’s participation,
what speech acts are achieved in his/her participation and who benefits from his/her participation.
 p.3

1. Introduction

There main purpose of this study is to set up a framework to analyze the participation
and function of a third person in the doctor-patient encounter. Third person refers to
the person who accompanies the elderly patients in their visit to a physician, such as
the patient’s adult children, husband/wife, or hired helper. Since it is common that
patients, especially elderly patient, are sometimes accompanied by a third person in
their visit to a physician, it is important to know how the presence of the third person
influence the dyadic doctor-patient interaction. In other words, what are the roles of
the third person in medical encounters? Also, as most studies of discourse analysis are
devoted to dyadic interaction, triadic interaction remains neglected. Thus, it is the
purpose of this current study to set up a framework in analyzing the participation and
function of the third person in doctor-elderly patient encounters. To achieve this goal,
I will employ Rosenfeld’s (1996) framework of participant structure and Adelman’s
(et al.) (1987) conceptual model of the roles of the third person.

The data to be analyzed in this paper is a first-visit medical encounter which takes
place in a small town hospital in South Taiwan. The female patient at the age of 54
recently noticed an abnormal swelling of her legs and visited a doctor of general
medicine in the company of her adult daughter, the researcher 1 . The male doctor is
about 40. There are two languages used in this interaction: Mandarin, the official
language, and Taiwanese, the local dialect. Both the doctor and the daughter are
Mandarin-Taiwanese bilinguals, and the mother speaks and understands only
Taiwanese. Most of the time, the conversation is conducted in Taiwanese, but
sometimes the doctor code-switches into Mandarin which will be indicated by
underlined text in the data transcription. The whole interview lasts about 10 minutes.

1
The intention of taping this encounter was to document oral interaction in general. This encounter
was taped in the summer of 1996. At that time, the researcher had not yet taken any course on
doctor-patient interaction. Thus she may considered an “innocent” informant in that sense.
 p.4

The involvement of the patient’s daughter, i.e. the third person in this encounter, will
be the focus of this study. The main body of this paper will be divided into two parts:
the participation of the daughter (section 2), and the function of the daughter (section
3). In sections 2.1 and 2.2, I apply and modify Rosenfeld’s framework of participant
structure in coding my Taiwanese data. Based on the resulting amount of participation
that the daughter devotes to the interaction, I conclude that she plays a minor role,
whereas the doctor and the patient play the major roles (2.3). Also, given the fact that
most of the daughter’s participation is initiated by herself, instead of by the doctor or
the mother, I argue that she is an active participant (2.4). Section 3 shift the focus to
the function of the third person. A brief review of Adelman’s (et al.) proposal of the
functions of the third person is introduced in 3.1. Based on some linguistics and
discourse evidences, I concludes that the daughter plays three roles in this encounter:
doctor facilitator (3.2), mediator between doctor and the patient (3.3), and patient
advocate (3.4). Finally, in the conclusion section (4), a summary of the main finding
is restated. Also, I relate the contribution of this research to the fields of discourse
analysis and doctor-patient communication. Some possible extension for future study
of doctor-patient communication in Taiwan are presented at the end.

2. The Participation of the Daughter

In this section, I will introduce my coding system with the application of Rosenfeld’s
framework of participant structure. In identifying the participant structure in the
Taiwanese data, some linguistic and discourse criterion used in Rosenfeld’s English
data will be modified (2.2). The result of the coding presents two quantitative aspects
of the daughter’s involvement: the amount of her participation (2.3) and the initiation
of her participation (2.4).

2.1 Participant Structure and Coding System

According to Rosenfeld, participant structure refers to the number and the role of
parties who are either speaking (the addresser) or being addressed (the addressee) at a
moment of talk. In the case where there are three participants involved, such as a
 p.5

marital therapy section, the participant structure could be either dyadic or triadic.
Rosenfeld’s analysis is presented as the following when applied to my data 2 .

1. Doctor–Patient dyad: both the doctor and the patient are either the
addresser or the addressee, while the daughter remains unaddressed.
2. Doctor–Daughter dyad: both the doctor and the daughter are either
the addresser or the addressee, while the patient remains unaddressed.
3. Daughter–Patient dyad: both the daughter and patient are either the
addresser or the addressee, while the doctor remains unaddressed.
4. Doctor–Patient–Daughter triad: all three participants are speaking or
being addressed.

Rosenfeld further distinguishes two types of shift of participant structure in terms of

who initiates the shift. They are participant-initiated shift and other-initiated shift
(p.84). In a current participant structure, a participant, either the addresser or the
addressee, can initiate a shift of the structure by addressing another party and still
keep his/her participant status. If the party who initiates the shift is not a participant in
the current structure, such a shift of participant structure is termed as other-initiated
shift. The following are illustrations of the above concepts and my coding system.

In excerpt 1, the patient complains to the doctor that her leg itches (line 1), it is coded
as a doctor-patient dyad (hence D-P dyad). Her complaint is acknowledged by the
doctor as shown by his using of repetition. Line 2 forms another D-P dyad. In my
tally, line 1 and line 2 will be counted as two instances of D-P dyad. Also, I
re-analyze the movement of the addressing direction by using arrows ( and ), as
shown in the left column.

2
During this interview, there is a nurse present in the room who remains silent most of the time. Also,
there are three instances that doctor constantly gets called by his cellular phone or pagers. Since my
focus is on the interaction among the doctor, patient, and third-person companion, I will not take the
participation of the nurse and the cellular phone into consideration in the data analysis. However, their
participation is transcribed in the data.
 p.6

Excerpt 1 3
movement of
addressing
direction
P D X Patient (P) Doctor (D) Daughter (X)

1 ------> (it) itches

2 <------ (it) itches, that’s a

3 \------>
sign of dermatistis, you
see..there’s an indent /?/ this is

4D ------> [since….(it) happened since a [this is, this is.this is…….second

4P |------>
couple of days ago, I was not degree edema
aware of it, I I ….for example
at that time, there was a spot

Excerpt 1 (Chinese) 4
movement of
addressing
direction
P D X Patient (P) Doctor (D) Daughter (X)
1 ------> 啊會癢啦

2 <------ 癢啦,
3 \------>
彼皮膚炎欸現象,你看..有個
洞,/?/這是

4D ------> [自…….自迄兩日仔按吶我 m [這是,這個就是.這個就是 …..

4P |------>
知影講, 我我…..啊像講彼陣 二度水腫
一 gia (某個部位)

After the doctor acknowledges his receiving of the patient’s complaint, he

immediately code switches into Mandarin to state that itching is a syndrome of
dermatitis, as indicated by the underline in the transcription (3). However, since the
patient does not speak Mandarin while her daughter does, the doctor’s code-switching
is evidence of addressing to the daughter. The movement of addressing direction is
from the doctor to the daughter in line 3. It forms a doctor-daughter dyad (hence
D-X dyad) 5 .

3
Transcription symbols:
[ indicate simultaneous utterance
Underlined text : speaker is using Mandarin. Regular text: speaker is using Taiwanese.
Texts within the ( ) in the English translation indicates that their equivalent Taiwanese is not uttered.
= indicates no perceptible pause between utterance
4
The Chinese transcription is transcribed mainly in Chinese characters. In the case where no Chinese
character is available, romanalization will be used. The romanalization follows TLPA, established by
Taiwan Language Society. Underlined text indicates that the speaker is using Mandarin, while the
regular text indicates the use of Taiwanese.
5
I will use X to represent the third person, who can be anyone, such as the patient’s husband, children,
relative, hired helper etc. In this case, X refers to the patient’s daughter.
 p.7

In other words, the doctor-patient dyadic structure in lines 1-2 is shifted to the
doctor-daughter dyadic structure (3-4D). Since it is the active participant in the
former structure, the doctor, who initiates this shift, it is coded as
participant-initiated shift. Participant-initiated shift is indicated by the slash \------>
in line 3 and is counted as one instance of participant-initiated shift by the doctor.

When the doctor continues to address the daughter that her mother’s swollen leg is on
the stage of second degree edema (4D), the mother starts to give the information of
when the swelling occurred (4P) by overlapping with the doctor’s statement. The
mother’s overlapping shifts the doctor-daughter dyad (3-4D) into a doctor-patient
dyad. Since the mother is not a participant in the D-X dyad, this shift initiated by her
is coded as one instance of other-initiated shift by the patient. Other-initiated shift
is indicated by the vertical line |-----> (4P).

The result of the coding of excerpt-1 result is as follows:

3 instances of D-P dyads (lines1, 2, 5)
2 instances of D-X dyads (lines 3, 4)
1 instances of participant-initiated shift (by the doctor) (line 3)
1 instances of other-initiated shift (by the patient) (line 5)

2.2 Linguistic and Discourse Evidences for Identifying Participant Structures

Based on her English data on marital therapy, Rosenfeld employs four types of
evidences in identifying participant structures. They are (1) vocatives, (2) personal
deictics, (3) context, and (4) discourse structure. Excerpt 2 is an example which
shows that the therapist’s use of vocative (“Jack” the name of her client couple) and
deictics (“you”) are indicators of therapist-husband dyad, instead of therapist-wife
dyad, in the marital therapy encounter.
 p.8

Excerpt 2

Therapist: I think what Jack is – Jack what you’re saying is that you wanted to know what …

you’d

like to understand why (Rosenfeld, 1996, p86)

However, the use of vocatives and personal deixis as evidence are less applicable in
my Taiwanese data. In the following, I will first explain why they are not applicable.
Then I will show how contexts, discourse structures and code-switching work as my
primary evidence for identifying participant structure.

The use of vocative is seldom observed in my data. The only occurrence of the
vocative is the daughter’s address term to refer to her mom (ma), which occurs two
times in the whole interview. Other possible address terms, such as titles, e.g. i-seng
(doctor), o-ba-sang (ma’am, usually refers to middle-aged woman ), or Tshuah
thai-thai (Mrs. Tshuah, the patient’s last name) do not occur in this data at all. Also,
the use of a first name, which is commonly observed in Rosenfeld’s data, does not
seem possible in my data for two reasons. Generally speaking, the use of first name
indicates there is a shared intimacy and rapport among participants in Taiwanese
society 6 . However, this intimate relationship is absent in this medical context in
which there exists a power difference - - the doctor possesses a higher social status
than the patient who is older than the doctor, and thus it excludes the possibility for
them to address each other with first names. The only possible use of a first name is
for the mother to address her daughter. However, as we will see later, since the
mother never addresses her daughter in the whole interview, it prevents the
occurrence of first name 7 .

The second evidence that Rosenfeld employs is the use of personal deixis, such as
“you” and “he/she”. However, both Taiwanese and Mandarin are pro-drop languages
in which the subject of a verb can be left empty. That is to say, the personal deixis can

6
As I can recall, the use of first name is dictated by the elder generation to the younger generation, e.g.
parents to children, but now there is a tendency for people of a certain shared rapport to use first names,
e.g. among colleges, classmates, or friends.
7
Two other possible interpretations for the absence of using first names in this Taiwanese data are: (1)
compared to the American society, Chinese society values authority more than equality, which can be
conveyed by the use of first names, and (2) compared to the marital therapy interaction, clinical
 p.9

always be deleted as long as the context or discourse structure helps the interpretation.
For example, in excerpt 3, the doctor and the patient are talking about the patient’s
swollen legs. There is no personal deixis used at all 8 . For example, when the doctor
says “(Z) is swollen, (Z) didn’t hurt (Z-self)?”

(from line 1, excerpt 3)

腫腫啊 無撞著?
tsing-tsing-a, bo-long-tioh
swell-swell-SFP 9 no-hit

(Z) is swollen (Z) didn’t Z-self?

Doctor talks to the patient: (your leg) is swollen (you) didn’t hurt (yourself), right?
Doctor talks to the daughter: (your mom’s leg) is swollen (she) didn’t hurt (herself), right?

he could be addressing the patient or the daughter, as shown above. Thus, Z could be
“your leg” or “your mom’s leg”. Given the restriction that personal deixis are usually
omitted, discourse context and structure will be the main clues to identify the
addressee. First, under the context of a medical interview, when the doctor indicates
some physical problems, such as “Z is swollen”, it is reasonable to say that Z refers to
the participant who undergoes swelling, i.e. the patient. Second, the doctor’s question
in line 1 “didn’t hurt (Z-self)?” is responded by the patient, “yeah” (line 2), instead
of by the daughter. Based on who responses to the doctor’s question, it is reasonable
to say that the respondent, i.e. the patient, is the designed addressee of the doctor’s
question. Thus, the discourse structure of question-answer pair helps to decide the
participant structure 10 .

interaction requires less rapport between the service provider and the client.
8
The pronouns within the ( ) in the English sentence translation indicate that they are absent in the
Taiwanese data.
9
SFP stands for sentential final particles.
10
My analysis in identifying participant structure is based mainly on the context and discourse
structure. One possible drawback is that it does not totally clarify the possible referents. In a
hypothetical situation, the doctor intends to address the patient’s daughter with the question: “(She)
didn’t hurt (herself), right?” because for some reason he judges the patient is incapable of answering
that question, e.g. due to the decreasing of mental ability which is common to most elderly patients.
Out of his expectation, the patient answers the question because she wants to handle the problem by
herself. Then the patient’s reply indicates an “other-initiated shift of participant structure.” However,
this analysis will be missed if I only rely on question-answer pair--given the fact that the patient is the
one answering the question, she is the designed addressee of the doctor’s question. Thus, the patient’s
reply does not cause shift of participant structure.
 p.10

Excerpt 3
P D X Patient (P) Doctor (D) Daughter (X)

1 <------ (your leg) is swollen, (it) swelled,

there’s an infection. (it) is
swelled, (you) didn’t hurt
(yourself), right? Did (you)?=

腫腫啊,腫腫啊,有發炎啊. 腫腫,
無撞著,無啦..hann?=

2 ------> =Yeah, (I) just don’t

understand why (it) turned out
like this for no reason? This
one is fine but this one looks
puffy.

=hio, 啊是講無歹無歹誌慨按
內啊?這邊攏 ting kok kok (硬
邦邦). 啊攏像加足大 kho 咧
這隻

Other special linguistic evidence for identifying participant structures in this

Taiwanese interaction is the occurrence of code-switching. As I have explained earlier,
since both the doctor and the patient’s daughter can speak Mandarin, while the patient
does not, each time the doctor code-switches into Mandarin it is a sign that he is
addressing the daughter. As noted in excerpt 1, the doctor first responds to the
patient’s complaint by repeating her words (it) itches in Taiwanese, and then he
code-switches into Mandarin to name the disease and give evidence (2-3). His
code-switching here is an indicator of the change of addressee 11 .

2.3 Amount of the Daughter’s Participation

11
One possible problem invoked from the use of code-switching to identify participant structure is the
case when the doctor cannot find a counterpart of some medical terminology in Taiwanese, the local
dialect. For example, he may code switch into Mandarin when he introduces the term “second degree
edema,” simply because he can not translate it into Taiwanese. ( “second degree edema” occur four
times in the whole interview, but never occurs in Taiwanese.) In that case, his code-switching into
Mandarin is not motivated by his intention to addressing to the patient’s daughter.
 p.11

Table 1 shows the total numbers of instances of three types of dyads and one type of
triad identified in the whole interaction.

Table 1: Instances of dyadic and triadic participant structures

dyads triads total
205 (97%) 3 (1%) 208 (100%)
D-P dyads D-X dyads P-X dyads D-P-X triads total
128 (62%) 72 (35%) 5 (2%) 3 (1%) 208 (100%)
D: Doctor P: Patient M: Daughter

Similar to the finding of Rosenfeld’s research on marital therapy, the triad exchange
in this medical interview, i.e. D-P-X triad, receives a very low frequency of
occurrence, 3%. It supports Rosenfeld’s claim that a triadic interaction is primarily
composed of dyadic exchanges between any two of the three participants, with the
third participant as the ratified but unaddressed one of the talk (p109).
.
Among the three types of dyads, D-P dyads receive the highest score of occurrence
(62%). This is not marked, since doctors and patients are supposed to be the required
participants of a medical encounter. The D-X dyads receive a lower occurrence
frequency, 35%, which is about half of that for D-P dyads. The P-X dyads, similar to
the D-P-X triads, almost do not occur (2%). In other words, this encounter is
primarily composed of the conversation between the doctor and the patient. The
doctor- daughter dyads play a minor role. The mother-daughter talks hardly occur.

Table 2 presents the total amount of participation that each of the three individuals
contribute in this encounter, either as an addresser or addressee. The doctor scores the
highest in the participation, addressing the patient or the daughter, or being addressed
by them. In that sense, he is the center of the interaction. It reflects the fact that doctor
is the required participant in such an institutionalized encounter.

Table 2: Total amount of participation of the three participants

Doctor Patient Daughter Total
203 (48.5%) 136 (32.5%) 80 (19%) 419 (100%)
 p.12

Also, compared to her daughter, the patient has a greater amount of participation in
this encounter. It suggests that the patient has a highly autonomous control in this
encounter in two ways. On a mental level, she has a sound communication ability
which allows her to handle communication effectively. This is evident since her
linguistic performance can be judged as fluent. On a social-psychological level, she is
able to work her communication ability even with the presence of her daughter. That
is, the daughter’s presence does not prevent the patient from expressing herself.

So far, I have shown that the daughter plays a minor role in terms of the amount of
participation that she contributes to this medical encounter. Since the daughter’s roles
is the purpose of this study, in my next step of analysis, I will focus on the dyads in
which she is involved, i.e. D-X dyads and P-X dyads.

2.4 The Initiation of the Daughter’s Participation

As Table 1 has shown, while the D-X dyads receive a secondarily high frequency of
occurrence (35%), the P-X dyads have only 2% of occurrence, i.e. the mother and the
daughter seldom address each other. Table 3 shows a dramatic reflection of this
situation. Out of the 80 instances of participant structure in which the daughter is
involved, a great amount of her participation (90%) is devoted to the D-X dyads and
only 6% to the P-X dyads.

Table 3: The distribution of the daughter’s participation

D-X dyads P-X dyads D-X-P triads total
72 (90%) 5 (6%) 3 (4%) 80 (100%)

In my third step, I identify the initiator of the D-X dyads and P-X dyads. By initiator
of a dyad, I mean the person who initiates a shift of participant structure. For
example, in excerpt 4, the daughter addresses the doctor with the question "what is
‘retaining water’" (5). Her utterance changes the D-P dyads (1-4) into D-X dyads.
 p.13

This shift of participant structure is coded as an "other-initiated shift" in Rosenfeld's

term. I will refer to the role of the daughter in line 5 as the initiator of the D-X dyad.

Excerpt 4: Indent Test

D-P P D X D-X Patient (P) Doctor (D) Daughter (X)
episode episode
1 [ ------> =Yeah, (I) just don’t
[ understand why (it)
[ turned out like this for no
[ reason? This one is fine
[ but this one looks puffy
2 [ <------ (it) looks a little bit.. like
[ (its) retaining water=
3 [ -------> =how come that turns out
[ like this?=
4 [ <------ =like retaining water,
5 <------| ] …”retaining water”?
] what is
]
6X <------ ] [that means something is [“retaining water”?
6D ------>
] swollen.
]
7D ------> ] [(it) swelled a little bit, [right,
7X <------
] (it) swelled, (it) swelled
]
8 [ |-----> (it) itches
[
9 [ <------ (it) itches,that’s a
10 \------>
] sign of dermatistis, you
] see..there’s an indent /?/
] this is
]
11D ------> ] [since (it) happened since [this is, this is. this
11P |------>
] a couple of days ago, I is…….second degree
] was not aware of it, I edema
] I ….for example at that
] time, there was a spot
]
12 <------ ] Really?=
]
13 ------> ] =yeah, second degree
] edema, you see,( it) does
] not happen to healthy
] people, you see, just press
] (it), you see
]
14D ------> ] [why . why does it [(it’s) all swollen [Oh my God!
14X <------
14P |------>
] happen?
]
15D ------> ] [(it) doesn’t happen to [/?/
] you, you see, does (it)
] happen to you?
16D ------> ] [Does(it) happen on the [if (it) happens to you,
16P |------>
] other side? right?…
]
17D ------> ] [no, (it) won’t, right? [I don’t know, maybe I
17X <------
] Does it occur to . to you? didn’t press (it) hard
] enough
18D ------> ] =[Does (it) happen to this =[no, (it) doesn’t, you
18P |------>
side? see, this indent is still
there
 p.14

Excerpt 4: Indent Test (Chinese)

D-P P D X D-X Patient (P) Doctor (D) Daughter (X)
episode episode
1 [ ------> =hio, 啊是講無歹無歹誌
[ 慨按內啊?這邊攏 ting
[ kok kok (硬邦邦). 啊攏
[ 像加足大 kho 咧這隻
[
2 [ <------ 小可 hang . hang . hang 水
[ 欸=
3 [ -------> =彼是按吶 hai 按內?=
[
4 [ <------ =hang 水欸

5 <------| ] …hang 水?什麼叫

]
6X <------ ] [彼就是有腫腫的啦, [hang 水?
6D ------>
]
7D ------> ] [/?/ [有一點腫,水腫水腫 [henn
7X <------
]
8 [ |-----> 啊會癢啦
[
9 [ <------ 癢啦,彼
10 \------>
] 皮膚炎欸現象,你看..有
] 個洞,/?/這是

11D ------> ] [自…….自迄兩日仔按吶 [這是,這個就是.這個就

11P |------>
] 我 m 知影講, 我我…..啊 是 …..二度水腫
] 像講彼陣一 gia (某個部
] 位)
]
12 <------ ] 真欸喔?=
]
13 ------> ] =henn二度水腫, 你看正
] 常人不會啊,你看,隨便壓
] 一下,你看
]
14D ------> ] [這 . 這是按吶欸? [都腫起來 [噯唷!
14X <------
14P |------>
]
]
15D ------> ] [你不會嘛,你看你會嗎? [/?/
]
16D ------> ] [啊這邊敢會? [你會的話, 對不對? …
16P |------>
]
]
17D ------> ] [不會嘛,你.你會嗎?= [我啊知,我 teng 了無夠
17X <------
] 力
]
18D ------> ] =[啊這邊敢會? =[不會啦,你看看,這個洞
18P |------>
到現在還在這裡

In line 10, the doctor shifts his addressee from the patient to the daughter, as indicated
by his code-switching. It changes the D-P dyads (8-9) into D-X dyads (10-17). This
shift of participant structure is coded as a "participant-initiated shift" in Rosenfeld's
 p.15

term. I will refer to the role of the doctor in line 10 as the initiator of the D-X
dyad 12 .

Based on my previous coding of dyads, lines 5-7X are coded as 5 instances of D-X
dyads and lines 8-9 as 2 instances of D-P dyads. To enhance my analysis, I will refer
from now on any series of exchanges of the same dyad as an episode. For example,
the 5 instances of D-X dyads in lines 5-7X form a D-X episode which is indicated by
the continuous brackets “ ] ”, and those in lines 8-9 form a D-P episode which is
indicated by the continuous brackets “ [ ”. Those single D-P dyads in lines 11P, 14P,
16P, and 18P do not form an episode. In other words, this indent excerpt is composed
of two D-P episodes (lines 1-4, lines 8-9) and two D-X episodes (lines 5-7X, lines
10-18D).

Table 4 is the resulting numbers of D-X and P-X episodes and the initiators of each of
them. It shows that there are 22 D-X episodes composed of the 72 instances of D-X
dyads in this medical encounter. While 19 of the D-X episodes (86%) are initiated by
the daughter, only 14 % of them are initiated by the doctor. Also, there are 2 P-X
episodes composed of the 5 instances of P-X dyads, and both of them (100%) are
initiated by the daughter.

Table-4: Numbers of D-X and P-X episodes and their initiators

D-X dyads (72) = D-X episodes (22) P-X dyads (5) =P-X episodes (2)
initiated by D initiated by X initiated by P initiated by X
3 (14%) 19 (86%) 0 2 (100%)

I have presented earlier that the D-P dyads are the dominating interaction of this
encounter and the patient is the primary addressee of the doctor’s utterance. Neither
the doctor nor the patient frequently address the daughter. Only 14% of the D-X
episodes are initiated by the doctor, and none of the P-X episodes are initiated by the

12
That is to say, the term "initiator" of a current dyad does not distinguish whether the initiator is a
participant or a non-participant of the previous dyad. For one reason, this distinction is not necessary in
this paper. Almost all of the dyads in the whole interaction are either doctor-patient dyads or
doctor-daughter dyads. The doctor is the center participant in these two types of dyads. Thus, the
 p.16

patient. In other words, for the daughter to get herself involved in the interaction, she
needs to break the dominating D-P dyads and initiate the D-X dyads (86%) and P-X
(100%) for herself. With respect to this high frequency of self-initiation, I conclude
that the daughter actively involves herself in the interaction, instead of passively
waiting for the doctor or her mother to give her the floor.

2.5 Summary

First, based on the amount of dyads (Table 1) and the amount of participation (Table
2) that the three interactants contribute to this medical visit, I conclude that the D-P
dyads are the primary participant structure. That is to say, the third person in this
encounter, i.e. the daughter, plays a minor role. Second, given the fact that most of the
episodes in which the daughter is involved is initiated by herself (Table 4), I conclude
that she is an active participant.

3. The Functions of the Daughter

In section 3.1, I will briefly review the conceptual model of the roles of the third
person, proposed by Adelman et al. From sections 3.2 to 3.4, linguistics and discourse
evidence will be presented to argue that the daughter plays a multi-functional role of
doctor facilitator, mediator between doctor and patient, and patient advocate.

3.1 Functions of the Third Person

In their observation of physician-elderly patient interaction, Adelman et al (1991: 130)

notice that about 60% of the elderly patients are accompanied by a third person, such
as caregivers, adult children, or spouse, on their visit to a physician. Also, in their
discussion of the triadic interactions among physicians, elderly patients, and

doctor-daughter dyads initiated by him is always a participant-initiated one, those initiated by the
daughter are always other-initiated.
 p.17

patient-companions, they propose a conceptual framework of the roles of the patient

companion, whom I will refer to as "the third person".

Roles of the third person, proposed by Adelman et al. (1987:731)

1. Advocate
-patient promoter/activist
-patient extender
-patient-doctor mediator
2. Passive participant
3. Antagonist
-Saboteur/underminer
-Opportunist

Under this framework, there are three possible roles that the third person can play:
advocator, passive participant, and antagonist. An advocate is a third person who
shows support for the patient. There are three subtypes of advocates. They are patient
promoter or activist, patient extender, and patient-doctor mediator. The patient
promoters are "the most supportive of the patient's agenda for the visit."(p731). They
actively and assertively encourage and empower the patients. Patient extenders act "as
the voice of the patient." For example, they may act as a translator when the patients
are not able to express themselves. The mediators support and encourage an effective
patient-physician relationship. They bridge the gap between the doctor and the patient.
In that sense, the mediators serve both the doctor and the patient. A passive
participant is a third person who is present in a medical encounter but contributes
very little to the conversation. An antagonist works against the patient, e.g. showing
hostility toward the patient, ignoring the patient's concern, or taking advantage of the
patient. There are two subtypes under this category. A saboteur or underminer works
against the patient with overt or covert manner. An opportunist takes advantage on
both the doctor and the patient.

To measure the role and effect of the third person in geriatric medical encounters,
Adelman et al. adopt the system of Multidimensional Interaction Analysis (MDIA).
With the MDIA system, they identify some global discourse patterns of the third
person. For example, they found that patient promoters, compared to patient extenders,
 p.18

pose more questions to physicians and show less abrupt changes of topics. Patient
promoters do not refer to that patient as 'she' or 'him'. They correct physician's
misattribution of symptoms to the aging process. (p733)

There are five potential deficiencies of Adelman’s (et al.) model. First, as noted by
Adelman et al. themselves, the three roles of the third person are defined from the
patients' perspective.(p731) The following is my example to illustrate this weakness.
An adult child who shows support of the doctor's proposed treatment may be seen as a
patient advocate from the doctor's view, but seen as a patient antagonist by the elderly
patient whose refusal to accept the treatment is a strategy to gain the child's attention.
Secondly, the roles of the third person in the duration of an encounter may be multiple
since the interaction is dynamic. Thirdly, the distinction between a patient promoter
and patient extender is rather vague. What degree of support paid to the patient
qualifies a third person as a patient promoter or extender? Additionally, the
quantitative results from MDIA can be strengthened if collaborated with a qualitative
approach, such as the evaluation of speech acts involved in the third person's
questions. Finally, as Adelman et al have emphasized, this hypothetical model has not
been empirically validated. They require verification in clinical settings (p731). Thus,
it is my attempt in this section to apply Adelman’s (et al) definition of the roles of the
third person to my Taiwanese data.

As you would recall, the results in Tables 1-2 suggest a high level of autonomy of the
patient. She can handle the medical interview with the doctor in an effective way. She
never feels the need to address her daughter during this interview. That is to say, her
daughter’s presence is not required at all. Given this autonomy that the patient
possesses, it would be interesting to see why the daughter’s presence sometimes
supplants the patient’s chance of participation (Tables 3-4). Why does the doctor
address the daughter instead of the patient? Why does the daughter actively volunteer
herself in this encounter?

As the following analysis will reveal, the three functions that the daughter plays are
similar to the advocate category in Adelman’s et al. framework. I will redefine the
 p.19

roles of the daughter in terms of three aspects: the initiator of her participation, the
speech acts achieved in her participation, and the party who benefits from her
participation. The three roles are: 1)doctor-facilitator, whose participation serves
mainly the doctor, 2) mediator between the doctor and the patient, who serves both
the doctor and the patient, 3) patient advocate, who serves mainly the patient.

3.2 The Daughter as a Doctor Facilitator

The third person who plays a doctor facilitator mainly serves the doctor alone. This
role is not discussed by Adelman et al. I single out this function since it serves mainly
the doctor, which is in contrast to the function of a mediator, who serves both the
doctor and the patient. I will present two excerpts to show that the daughter functions
as a doctor facilitator.

As mentioned in excerpt 4, the doctor conducts an indent test. During this test, the
doctor first presses the patient's leg and it results in an indent on her leg. Based on this
test, he diagnoses the patient with second degree edema ”that’s a sign of dermatistis,
you see .. there’s an indent /?/ this is this is . this is …second degree edema”(9-11D).
At the same time, the daughter presses her own leg and it does not result in an indent.
In line 13 the doctor directs the daughter’s attention (“you see”) to his comment "(the
indent) does not happen to healthy people, you see, just press it, you see." Here, the
doctor refers to the daughter as "healthy people". By presenting the contrasting
phenomenon between the unhealthy status of the patient and the healthy status of her
daughter, the patient’s intimate partner whom she can trust, the doctor achieves an
expository speech act. He strengthens his diagnosis and makes it more persuasive.
The doctor's reference to the daughter as healthy people reflects how he perceives her
role in this encounter. She functions as a healthy example. Since this function is
invoked by the doctor to facilitate his presentation of evidence, this role serves only
the doctor. Thus, the daughter plays the role of doctor facilitator.

The doctor's perception of the daughter as a doctor facilitator is also evident in the
 p.20

following excerpt. In line 1, the daughter initiates a D-X episode. She reminds the
doctor that, besides, her mother’s swelling legs, her face looks puffy as well (1). The
daughter’s statement prompts the doctor to give an extended monologue explanation
of the chain reaction which starts with cardiomegalia and poor blood circulation and
results in puffy legs and face. (This excerpt will be referred to as "chain-reaction"
from now on.) To make this complicated medical knowledge more accessible to the
daughter and the patient, the doctor uses an analogy. A swollen heart wall requires
more energy to operate, just as a thick metal requires more energy to shape (5). Then
he makes another contrast between a healthy heart and an unhealthy one, by
addressing the daughter : "for healthy people (the thickness of the heart) is like
this..and your mom's is like this" (5). Then he switches the addressee to the patient by
saying: "your daughter's heart/?/her heart is like this big, and yours is like this big"
(7) and "compare to the heart walls of healthy people, (they) are thin, and your heart
wall is like this thick." (11) As observed in the previous excerpt, the doctor tries to
explain what an unhealthy heart wall looks like in comparison to that of a healthy
person. Again, the daughter’s role as healthy example is invoked by the doctor to
facilitate his presentation of medical knowledge.
 p.21

Excerpt 5: Chain-reaction
P D X Patient (P) Doctor (D) Daughter (X)

1P ------> =[if (I) eat /?/ =what if, did you see my
1X <------|
] mom’s face, it looks like .
] now . now my mom’s face
] looks looks puffy=
]
2 ------> ] =(it) looks puffy because
] the heart is swollen .. if the
] heart swelled .. (it) will
]
3D ------> ] [it’s not that (I) really gain [influence some other part ..
3P |------>
] weight, right? other part, when your heart
] swells it can’t work, the wall
] of the heart wall is thick and
] heavy=
4 <------ ] =m-hng
]
5 ------> ] if it gets thick and heavy,
] like. if the metal is thick it
] requires more energy to
] shape it … the heart will ..
] (the heart wall) for healthy
] people (the thickness of the
] heart) is like this .. and your
] mom’s is like this
]
]
6D ------> ] [the heart will . will swell, [the heart will /?/
6X <------
] ok?=
]
7D ------> ] =[yeah, sometimes (I) =[yeah, /?/ your daughter’s
7P |------>
] sometimes I feel breathless, heart wall /?/ her heart is
] sometimes I feel breathless like this thick, and yours is
] like this thick, yeah, and you
] this .. the .. this is very .
] very .. thick yeah=
]
]
8 <------ ] =m-hng=
]
9 ------> ] =very thick, very thick=
]
10 <------ ] =m-hng
]
11 ------> ] =compared to the heart
] walls of healthy people of,
] they’re) thin thin thin thin,
] and your ? is like this ..
] (your) heart ? is like this
]
]
 p.22

Excerpt 5: Chain-reaction (Chinese)

P D X Patient (P) Doctor (D) Daughter (X)

1P ------> =[食/?/ =無, 汝看我媽媽欸臉敢有

1X <------|
] 卡 . hio 我媽媽欸臉即嘛即
] 嘛像卡卡澎按吶=
]
]
2 ------> ] =卡澎是這心臟放大 .. 心
] 臟放大會 .. 影響
]
]
3D ------> ] [彼 m 是正經肥喔 honn [局部 .. 局部化的影響,汝
3P |------>
] 心臟放大著心臟無法度,心
] 臟 . 心臟肥厚,
]
]
4 <------ ] =henn
]
5 ------> ] 肥厚那打鐵都很用力嘛,心
] 臟就 .. 正常人就這樣 …
] 啊你媽媽是這樣
]
]
6D ------> ] [心臟就 . 放大啦, honn= [心臟咧//?
6X <------
]
7D ------> ] =[henn,有當時仔足 gau 喘 =[honn, /?/ 汝查某子/?/一
7P |------>
] 著啦,有當時仔足 gau 喘 欸心是按吶大,啊汝欸心是
] 按吶大, henn 啊汝這 ..這壁
] honn 攏 . 蓋 .. 蓋厚按吶=
]
]
8 <------ ] =henn=
]
9 ------> ] =很厚啦, 肥厚啦=
]
10 <------ ] =henn=
]
11 ------> ] =跟正常人的壁是薄薄薄薄
] 欸,啊汝欸壁是按吶 .. 心
] 臟欸壁是按吶
]

3.3 The Daughter as the Mediator between the Doctor and the Patient

Mediators refer to the third person whose role serve both the doctor and patient, and
bridge the gap between them. In the following, I will argue that the daughter functions
as a mediator both from the doctor's perspective (3.3.1) and the daughter's own
perspective (3.3.2).

3.3.1 The Daughter as the Mediator: from the Doctor’s Perspective

 p.23

My first evidence is, again, from the indent test (repeated after this paragraph). As I
mentioned earlier, right after the doctor presses the patient’s leg and it results in an
indent staying on her leg (9), he immediately code-switches to the daughter all the
way down (from lines 10-18D). Here, the daughter plays two roles simultaneously.
She is the sole recipient of the doctor’s verbal information “that’s a sign of dermatistis,
you see..there’s an indent /?/ this is. this is, this is. this is…….second degree edema” (9-11D).
She is also the taker of the indent test at the request of the doctor: “you see, (the indent)
does not happen to healthy people, you see, just press (it), you see” (13) “you see,
does (it) happen to you?” (15D) “no, (it) doesn’t, you see” (18D).

Excerpt 4: Indent Test (Chinese transcription on p.13)

P D X Patient (P) Doctor (D) Daughter (X)

8 [ |------> (it) itches

9 [ <------ (it) itches, that’s a
\------>
10 ] sign of dermatistis, you
] see..there’s an indent /?/ this
] is
]
11D ------> ] [since (it) happened since a [this is, this is. this
|------>
11P ] couple of days ago, I was is…….second degree edema
] not aware of it, I I ….for
] example at that time, there
] was a spot
12 <------ ] Really?=
]
13 ------> ] =yeah, second degree
] edema, you see,( it) does not
] happen to healthy people,
] you see, just press (it), you
] see
]
14D ------> ] [why . why does it happen? [(it’s) all swollen [Oh my God!
<------
14X |------>
]
14P ]
15D ------> ] [(it) doesn’t happen to you, [/?/
] you see, does (it) happen to
] you?
]
16D ------> ] [Does(it) happen on the [if (it) happens to you,
|------>
16P ] other side? right?…
]
17D ------> ] [no, (it) won’t, right? Does [I don’t know, maybe I
<------
17X ] it occur to . to you? didn’t press (it) hard enough
]
18D ------> ] =[Does (it) happen to this =[no, (it) doesn’t, you see,
|------>
18P side? this indent is still there

In the previous discussion, I state that the doctor recruits the daughter as sample of
 p.24

healthy status to make his argument more convincing. However, all these arguments
are presented in Mandarin which the patient does understand at all. If the doctor’s
purpose of this indent test is to convince the patient what she has suffered, why does
he bother to present his evidence exclusively to the patient’s daughter instead of to
the patient? I will argue that by addressing the daughter alone, the doctor expects her
to explain the indent test to the patient should the patient have any concerns about it.
According to Adelman et al., the third person, who functions to facilitate an effective
patient-physician communication, is defined as a mediator. Thus, the doctor’s
expectation that the daughter will communicate with her mother reflects his
perception of seeing her as a mediator.

Such an expectation from the doctor is more evident in the following example.
Excerpt 6 is from the second visit in which the patient takes the X-ray examination
and the doctor informs her of the result 13 . During this interaction, the doctor asks the
patient if she feels any abnormality when she urinates (1). When the patient replies
that she sometimes feels a burning sensation, the doctor explains that it might be a
symptom of urinary passage infection, which could be caused by an inadequate way
of cleaning the anus. He then suggests a more adequate way of cleaning. Here, the
doctor is giving an explanation which may threaten the patient's face because the
topic concerns a very personal issue. Also, as a male doctor, it is uncomfortable for
him to advise his female patient on how to maintain her personal hygiene.

Excerpt 6 (from the second visit)

P D X Patient (P) Doctor (D) Daughter (X)

1 [ <------ when you urinate, do you

[ feel any stinging.. or
[ burning? do you feel
[ stinging?
[
2 [ ------> ..sometimes, if the weather is
[ hot, (I) feel like burning
[ sensation

13
My analysis does not include the interaction of the second visit. I quote this example since it clearly
demonstrate how the doctor sees the daughter as a mediator.
 p.25

3 [ <------ yeah that sometimes might

\------>
] ..because that
] girls..women’s urinary
] passage=
]
4D ------> ] =[and somtimes like, like, =[ get easily infected, when
4P |------>
] for example excreting, most people tend
] to wipe back to front, it
] happens to a lot of
] people..haha..it’s easy to get
] infected that way..haha
]
5D ------> ] [it’s like. like it doesn’t [it’s just a matter of
5P |------>
] come out quickly changing your habit, yeah,
] because the passage is
] really short
]
6 <------ ] it got to be front to back
]
7 ------> ] yeah, it got be front to back,
] you probably do it back to
] front..haha….you tell your
] mom, yeah you tell your
] mom it got to be front to
] back
]
8 |------->-------> I have no idea at all of what
are you two are talking
about.

Excerpt 6 (Chinese)
P D X Patient (P) Doctor (D) Daughter (X)

1 [ <------ 啊放尿欸時陣會感覺刮刮.
[ 燒燒..刮刮..啊放欸時陣會
[ 感覺刮刮?
2 [ ------> ..有當時仔若講熱著按吶
[
3 [ <------ henn 彼是有欸時陣
\------>
] ..因為女孩子的..女人的尿
] 道=
]
4D ------> ] =[啊彼像講 honn, 像講.攏 =[很容易感染，擦大便的
4P |------>
] 像講 時候,很多人從後面往前擦
] 的,那個都有.哈哈.很容易
] 感染..哈哈
]
5D ------> ] [禁,像 tsuann 啊禁未著按吶 [習慣性的問題,henn啦,因
5P |------>
] 啦 為尿道很短
]
6 <------ ] [啊卜放放無啥 [愛向後
]
7 ------> ] hann愛向後擦啦, 我看你
] 也向前擦啦,很多人都向前
] 擦啦..哈哈……..你跟你媽
] 媽講,henn你跟你媽媽講,擦
]
大便是從前面往後擦,
]
8 |------->-------> 恁講那我攏聽無啦
 p.26

The doctor purposefully avoids these face threatening effects and uncomfortable
feelings with four strategies: 1) He attributes the problem of inadequate cleaning to
most females. 2) He makes a joke of this phenomenon to reduce the embarrassment,
as indicated by his laughing in line 4. 3) He excludes the patient by speaking
Mandarin to the daughter when he comes to the embarrassing explanation in line
3:“yeah that sometimes might ..because that girls..women’s urinary passage get easily
infected.” These explanations are totally missed by the patient, as indicated by her
complaint in line 8 ("I have no idea at all of what you two are talking about.") At the
end of his explanation, the doctor explicitly ask the daughter to tell her mother his
advice on how to maintain personal hygiene ("you tell your mother, yeah you tell your
mom") (7).

It is obvious that the doctor's intention of initiating the D-X episode (3-7) is to have
the daughter as the mediator. He explicitly asks her to deliver a sensitive but
important issue with which he does not feel comfortable to inform the patient. In their
hypothesis of the effect of a third person’s presence, Adelman et al. suggest that
"issues concerning sexuality and other intimate personal and medical subjects (e.g.
urinary or fecal incontinence) are unlikely to be discussed with the presence of a third
person" (1991: 131). This instance presents a counterexample of this hypothesis. The
presence of the third person, who is the female patient’s daughter in this case, helps
the male doctor to handle a touchy issue which in turn benefits the patient as well.

In the above discussions (3.2, and 3.3.1), I argue that the doctor perceives the
daughter as a doctor facilitator and a mediator. The discourse evidences for the basis
of my argument are referential expression (e.g. healthy people), code-switching, and
speech acts (e.g. expository ) achieved in the D-X episodes which he initiates. I have
shown earlier that among the 22 D-X episodes, only 3 of them (14%) are initiated by
the doctor (Table 4). Among the three, the indent episode discussed earlier is the only
one extended in length by the doctor, which is evident by the discourse lines it takes
up. This tiny amount of 14% reflects that the doctor is reluctant to shift his focus to
the daughter. He sees the patient as the center of this encounter. He does not see the
daughter as a required participant in this encounter. However, if it is necessary to get
 p.27

her involved, the two roles in which she can best enhance this medical visit are doctor
facilitator and mediator between himself and the patient.

In the following, I will shift the focus from the doctor’s perspective to the daughter’s:
how does she perceive herself in this medical encounter.

3.3.2 The Daughter as a Mediator -- from her Perspective

I will argue that the daughter perceives herself as a mediator between the doctor and
the patient with three pieces of evidence. As I mentioned during the indent episode
(excerpt 4), the doctor uses Mandarin through lines 10 to 18D in addressing the
daughter. However, the daughter, though a native Mandarin speaker, does not
code-switch into Mandarin, which her mother neither speaks nor understands. The
daughter’s refusal to use Mandarin can be interpreted as her intention to keep the
patient partially informed of what is going on. By her insistence of using Taiwanese,
she functions as a language mediator -- she receives the Mandarin input from the
doctor and expresses her reaction in Taiwanese which will be in turn received by the
patient as well.

The daughter's perception of herself as a mediator can be further supported with the
only two P-X episodes that ever occurred in the whole interaction. Right after the
indent excerpt, the doctor addresses the daughter with the information that the patient
is now in the stage of second degree edema. Then he shifts to the patient by asking
her if she has a hard time breathing while climbing upstairs (1). The patient does not
reply immediately, as indicated by her repeating of the doctor's question and her
pause (2P). At the same time, the daughter repeats the doctor's question to the mother
(2X). The daughter hears the doctor's question, then addresses it to her mother as if
she herself is the doctor. By doing so, the daughter establishes herself as a mediator
between the doctor and the patient.

Excerpt 7
P D X Patient (P) Doctor (D) Daughter (X)
 p.28

1 ------> So, you are in the stage of

second degree edema, I’ll
tell you what
<------/ ..when you climb upstairs,
[ do you have hard time
[ breathing?
[
2P [ ------> [climbing upstairs .. Yeah, I [hard time breathing, while
2X <---------------|
[ had hard time breathing climbing upstairs?
[ while climbing upstairs=
[
3 [ <------ =yeah, that means (your)
[ heart is not strong enough
[ /?/ this is cardiomegalia,
[ yeah=
[

Excerpt 7 (Chinese)
P D X Patient (P) Doctor (D) Daughter (X)

1 ------> 所以你這已經是二度水腫
了,我跟你講
<------/ . 汝平平常時汝爬樓梯爬
[ 樓梯會喘無?
[
2P [ ------> [爬樓梯 . 爬樓梯是攏會喘 [爬樓梯敢會喘?
<---------------|
2X [ 對啦=
3 [ <------ =henn 彼心臟無 kiau 好/?/
[ 這心臟放大欸.按吶啦=
[

Upon receiving the patient's confirmation, the doctor states that her heart is not strong
enough. He then relates her heart problem to second degree edema. The patient told
the doctor about a terrible experience she had with her heart. Based on the patient's
story of her heart problem and the fact that she had a hard time breathing, he
diagnoses that she suffers from cardiomegalia. Then he goes on to give advice: the
patient needs to lose weight. After several exchanges, the daughter initiates a question
to which the doctor gives an extended but complicated explanation of the relation
among edema, cardiomegalia, puffy faces, and losing weight (i.e. excerpt 5:
chain-reaction). Then he receives a call on his cellular phone (line 1 in excerpt 8).

Excerpt 8
P D X Patient (P) Doctor (D) Daughter (X)

1 <---------------- ] [yeah speaking..umm Big [Mom, he is saying..now if

] Brother I will be there you get fat, and your heart
] tomorrow.. yeah yeah yeah will be um.. not strong
 p.29

] I’m sorry, I meant to, I enough

] meant to give you a call,
] huhuh
]
2 ----------------- ] not strong enough to /?/
>
]
3 ] (I’m) sorry..right=
4 <---------------- ] =yeah, so, for example,
-
] when climbing upstairs=
]
5 ] =[oh, OK, thank you =[(you) will have hard time
] breathing=
]
6 ----------------- ] =[yeah, sometimes (I) had =[thanks..thanks,
>
] hard time breathing, yeah thanks….OK, thanks, thanks
] right. (hang up the phone)
]

Excerpt 8 (Chinese)
P D X Patient (P) Doctor (D) Daughter (X)

1 <---------------- ] [是..enn大哥我明天會 [媽,伊是講..汝即嘛人若大

] 去,henn henn henn, 會去 koo 啊汝心臟著 honn 著
] ..henn 不好意思,我本來我 heir..無無無夠力啦
] 打給你的,哈哈哈
2 ----------------- ] 無夠力通/?/
>
3 ] [不好意思..對=
4 <---------------- ] =啊所以講汝譬如爬樓梯=
-
5 ] =[喔,好,謝謝 =[著會足喘=
]
6 ----------------- ] =[henn 有當時仔足喘,對啦 =[謝謝..謝謝,謝謝…..好,謝
>
] 謝,謝謝 （掛斷電話）=

While the doctor is speaking on the phone, the daughter initiates a P-X episode (1).
She addresses her mother by paraphrasing the doctor's statements: “Mom, he is
saying..now if you get fat, and your heart will be um.. not strong enough yeah, so, for
example, when climbing upstairs (you) will have hard time breathing”(lines 1, 4, and
5). The daughter's paraphrase not only recapitulates the doctor's previous points, but
also simplifies the logic of the doctor's statements in the chain-reaction excerpt. What
the daughter is doing here fulfills the doctor's expectations, that I have interpreted
earlier in the indent excerpt, as to why he recruits the daughter as his information
recipient – the doctor expects her to explain to her mother what he has said.

3.4 The Daughter as a Patient Advocate

 p.30

A patient advocate refers to the active supporter of the patient’s agenda, thus his/her
function is to mainly serve the patient 14 . I will illustrate this function of the daughter
with three excerpts.

In line 1 of excerpt 9, the doctor advises the patient that she should not work too hard
otherwise her heart can not take it. The patient admits that she always works too hard.
At that point, the daughter interrupts the conversation and initiates a D-X episode.
She volunteers the information: "did you see my mom’s face?..now my mother's face
looks looks puffy"(3X). The doctor interprets her statement as a request for an
explanation because he goes on to provide the extended explanation of the
chain-reaction (4-8).

Excerpt 9
P D X Patient (P) Doctor (D) Daughter (X)

1 [ <------ (you) can’t work too hard, if

[ (you) keep working hard,
[ (it )will…there’s no way to
[ save=
[
2P [ ------> [I was thinking .. I was [m-hng
2D <------
[ thinking mm=
[
3P [ ------> =[if (I) eat /?/ =what if, did you see my
3X <------|
] mom’s face, it looks like .
] now . now my mom’s face
] looks looks puffy =
]
4 ------> ] =(it) looks puffy because
] the heart is swollen .. if the
] heart swelled .. (it) will
]
5D ------> ] [it’s not that (I) really gain [influence some other part ..
5P |------>
] weight, right? other part, when your heart
] swells it can’t work, the wall
] of the heart wall is thick and
] heavy=
]
6 <------ ] =m-hng
]

7 ------> ] if it gets thick and heavy,

] like. if the metal is thick it
] requires more energy to
] shape it … the heart will ..
] (the heart wall) for healthy
] people (the thickness of the

14
Unlike Adelman et al., I will not distinguish the role of patient promoter from that of extender,
because of the vague boundaries between the two.
 p.31

] heart) is like this .. and your

] mom’s is like this

(Lines 8-23 are deleted)

24 [ <------ =[yeah, if you don’t pay =[/?/

[ attention to these
[ syndromes, (it) will get
[ worse and there’s no way,
[ yeah
[
25P [ ------> [oh really= [OK?
25D <------
[
26 [ <------| [if that’s the case, what if=
[
27 [ <------ [to save (your) life should be
[ the top priority, otherwise,
[ you earned money but for
[ what?=
[
28P [ ------> =[yeah, so.what can be =[once( you) die, you got
28D <------
[ done? nothing, how can you make
[ more money?
[
29D [ <------ =[OK? =[what.what if the heart, the
29X <------|
] heart, for example, you talk
] about losing weight, what if,
] if (it) gets worse, what will
] happen? what if=
]
30 ------> ] =if (it) gets worse.you meet
] your maker, /?/, little by
] little, the heart can not make
] it=

Excerpt 9 (Chinese)
P D X Patient (P) Doctor (D) Daughter (X)

1 [ <------ 足thiam未使啦,閣做thiam
[ 著.…就沒法=
[
2P [ ------> [啊是講 .. 是講 honn= [m-hng
2D <------
[
3P [ ------> =[食/?/ =無, 汝看我媽媽欸臉敢有
3X <------|
] 卡 . hio 我媽媽欸臉即嘛即
] 嘛像卡卡澎按吶=
]
4 ------> ] =卡澎是這心臟放大 .. 心
] 臟放大會 .. 影響
]
5D ------> ] [彼 m 是正經肥喔 honn [局部 .. 局部化的影響,汝
5P |------>
] 心臟放大著心臟無法度,心
] 臟 . 心臟肥厚,
]
6 <------ ] =henn
]
7 ------> ] 肥厚那打鐵都很用力嘛,心
] 臟就 .. 正常人就這樣 …
] 啊你媽媽是這樣
]
(Lines 8-23 are deleted)
24 [ <------ =[henn, 汝症頭閣無注意著 =[/?/
 p.32

[ 愈來著無法度啊, henn
[
25P [ ------> [按吶呢啊= [好無?
25D <------
[
26 [ <------| [按吶若=
[
27 [ <------ [愛顧命第一啦,汝賺錢嘛無
[ 啥麼錄用啊=
[
28P [ ------> =[hio,按吶.按吶卜按若? =[著無命啊卜閣按吶賺
28D <------
[ 錢?=
[
29D [ <------ =[honn =[啊這若講心臟 . 若講:
29X <------|
] hier . 若講 . 譬如講汝講
] 愛減肥,啊若講無 . 若講愈
] 來愈嚴重欸按吶?若講=
]
30 ------> ] =愈來愈嚴重著 . 烏彌陀
] 佛啊/?/慢慢啊心臟著無法
] 度=

After several exchanges, he conveys strong advice by directly addressing the patient:
"to save (your) life should be the top priority, otherwise, you earned money but for
what?" (27). At this point, the daughter initiates another D-X episode by raising her
second concern in the form of a conditional statement: if losing weight does not
improve the problem, what is going to happen ? (29X)

Both the daughter's utterances in these two D-X episodes achieves the speech act of
seeking information which is related to the health problem of the patient: she points
out the problem which the doctor should have noticed (the puffy face) and the
concern which the patient should have anticipated (if losing weight does not improve
the situation). In that sense, the daughter perceives herself as the advocate of the
patient.

The daughter’s role as patient advocate is clearly illustrated by her use of deictic
expressions "my mother" and "we" in the following two D-X episodes. As you would
recall the main point of the doctor's advice is that the patient should lose weight.
However, this advice does not sound reasonable based on the daughter's judgment.
Her argument is that since her mother always works hard, instead of sitting around
and doing nothing, why does she gain weight in the first place? ("but my mother is
always . always busy with work” ) (lines 31-32 in excerpt 10) .
 p.33

Excerpt 10 (a continuation of excerpt 9)

P D X Patient (P) Doctor (D) Daughter (X)

31 <------ ] and the um . but

]
32D ------> ] [m-hng [my mother is always.always
32X <------
] busy with work, instead of ..
] (she) is not just sitting at
] home oranything like that,
] why why um (she’s) getting
] fatter and fatter?
33 ------> ] getting fatter?=
34 <------ ] =yeah, why?
35 ------> ] =getting fatter, now, say
] after you reach 30 or 40 the
] adulthood,
36 <------ ] hng
37 ------> ] (you) eat the same stuff
] every day
38X <------ ] [yeah [yeah=
38P |------>
]
39P ------> ] =[when (I) eat when (I) eat, =when you eat, um not
39D ------>
] (it) will mentioning you’re getting
] old, say,you’re not eating
] like people of age 20=
] (pager rings at the same
] time)
40 <------ ] =m-hng
41 ------> ] whatever they eat..whatever
] they eat they don’t care=
(lines 42-53 are deleted)
54 <------| ] =and and my my mother, (I)
] felt that my mother has a
] very normal diet, because
] we we are farmers, and=
55 ------> ] =yeah=
56 <------ ] =being farmers, and so (we)
] need to eat a lot=
57 ------> ] =yeah=
58 |------> ] =yeah, (I) was wondering
]
59P ------> ] =[(It) used to come to me, =[but (it) digests at the same
59X <------
] sometimes when (I) was time, but (it’s) strange, why
] hungry, yeah, (I) ate a lot, (it) turn out like this?
] yeah right=
]
 p.34

Excerpt 10 (Chinese)
P D X Patient (P) Doctor (D) Daughter (X)

31 <------ ] 啊 hier . 啊 m 過
]
32D ------> ] [henn [guan 媽媽攏嘛攏.攏常咧做
32X <------
] 工作,啊無講..啊 m 是講足
] 閒啊是按若,奈會奈會 hier
] 愈大 koo 欸?
]
33 ------> ] 大 koo 喔?=
]
34 <------ ] =henn 啊,奈會按吶?=
]
35 ------> ] =愈來愈大koo,汝即嘛人.
] 汝.中年三四十.十歲以後
]
36 <------ ] hng
]
37 ------> ] 逐天食飯攏食同款欸食飯
]
38X <------ ] [henn [henn=
38P |------>
]
39P ------> ] =[攏食飯攏食會 =[汝食飯,enn 汝 m 講汝年
39D ------>
] 歲到啊,若是講汝.二十幾歲
] 欸=
] 人(畢畢同時扣響起…)
]
40 <------ ] =henn=
41 ------> ] 食啥麼物件攏..食什麼物件
] 攏 m 免驚嘛=
]
(lines 41-54 are deleted)
54 <------| ] =啊啊 guan guan 媽媽,感覺
] guan 媽媽食飯嘛攏足.足正
] 常,因為 guan.guan 佇作田,
] 啊=
]
55 ------> ] =對啦=
]
56 <------ ] =作庶啊,啊所以愛食飯食
] 卡濟欸啊=
]
57 ------> ] =對啊=
]
58 |------> ] =hio 啦,想講=
]
59P ------> ] =[捌食飯 honn,有當時仔腹 =[啊嘛是有咧消化,啊奇怪
59X <------
] 肚 honn,夭像嘛是攏食真濟, 奈會?
] 對啦=
]

The doctor responds to her argument by attributing her mother's weight-gain as a

natural process of aging -- people, who are reaching 30 or 40 and eat whatever they
want as if they were as young as 20, will gain weight (lines 35-41). At this point, the
doctor stops his statement to answer a phone call. Right after the doctor finishes the
phone conversation, the daughter poses the same argument and strengthens it with
 p.35

more details. Since her mother works on the farm, she does eat a lot in each meal;
however, her diet should not cause her to gain any weight since the farm tasks
consume all her energy ("and and my my mother, (I) felt that my mother has a very
normal diet, because we we are farmers, and being farmers, and so (we) need to eat a
lot"(54-56). The daughter concludes her argument with the question: why does her
mother gain weight in the first place (59X).

Both the daughter's arguments begin with "my mother (always)". Her choice of the
possessive form "my" and the relationship term "mother", reveals her perception of
seeing the patient among her personal relations. The daughter’s use of the plural
pronoun "we" indicates that she aligns herself with the mother as being farmers. Her
choice of the word "always" indicates that she is such an intimate partner of the
patient that she knows all of the details of the patient’s life world. Given this intimacy
that the daughter and the patient share and the daughter’s perceiving of the patient as
part of herself, it is justifiable to say that the daughter is speaking for the patient. Thus,
she functions as the patient advocate.

Also, the proposition of the daughter’s argument is a pursuit of a logical reason for
the cause-effect of the patient's suffering -- are the patient's puffy face and legs the
result or the cause of cardiomegalia? If the patient's gaining weight is the result of
cardiomegalia, it does not make sense for her to lose weight 15 . Regardless of whether
the daughter’s argument is medically correct or not, her argument is motivated by the
benefit for the patient -- the patient needs to take the right action to save her life. In
that sense, the daughter functions as the patient advocate who tries to pursue the best
interests of the patient.

4. Conclusion

15
I do not intend to say that the daughter's argument is a correct reasoning. However, since most
patients or third persons are concerned of the causes of diseases, and they tend to interpret the
cause-effect relationship in terms of their life-world knowledge. Thus it is a challenge for physicians to
persuade their patients to follow their advice or recommendation.
 p.36

In quantifying the participant structures in which the daughter is involved, I find that
even though the daughter contributes a minor portion of participation in this
encounter, she actively involves herself in the interaction. By a qualitative
examination of discourse elements, such as referential term, deixis, code-switching,
and speech acts, three roles of the daughter are identified. These three roles are doctor
facilitator, mediator between the doctor and the patient, and patient advocate.

The above analysis contributes to the field of discourse analysis in three ways. First, it
supports Rosenfeld’s statement that triadic interaction is primarily composed of a
series of exchanges of dyads, instead of triads. Also, the use of personal deixis as an
identifier of participant structure is not applicable in a pro-drop language such as
Taiwanese and Mandarin. Code-switching, instead, serves as a better identifier in a
bilingual speech community as Taiwan. Finally, relying on Rosenfeld’s original
framework, this study establishes a quantifying approach in measuring the third
person’s participation.

This study contributes to the field of doctor-patient communication in three ways as

well. First, it refines the definition of the third’s person’s roles with three specific
aspects: who initiates the third person’s participation, what speech act is achieved by
his/her participation, and who benefits from his/her participation. Second, the good
use of the third person as doctor facilitator or mediator can actually enhance
doctor-patient communication. For example, the doctor recruits the daughter, the
intimate partner that the patient trusts, to present his medical arguments and to give a
face-threatening advice such as the maintenance of personal hygiene. Also, a
well-informed third person helps the patient comply the doctor’s advice in the life
world, such as keeping a diet.

Besides the quantitative and qualitative framework that this single case study achieves,
it also serves as a preliminary foundation for future study. Some issues to be extended
from this study are: 1) How is the participation of the third person related to different
stages of a medical encounter, such as history taking, diagnosis, and the scheduling of
 p.37

the next visit? 2) How does code-switching play a role in a bilingual medical visit
where most Taiwanese elderly speak only the local dialect in which the medical terms
find no place? How does the role of the third person as interpreter between doctors
and patients influence the interaction? 3) In this study, only three roles of the third
person are identified. How would other categories, such as passive participant and
antagonist, be identified with linguistic and discourse evidence? How would these
roles interplay with each other? For example, can a third person play as a patient
advocate and antagonist at the same time? These issues call for more data-based
studies in the future.

References

Adelman, Ronald D; Greene, Michele G., Charon, Rita. 1987. The Physician-elderly
patient -companion Triad in the medical encounter: The development of a
conceptual framework and research agenda. The Gerontologist, 27.6: 729-734.

Adelman, Ronald D; Greene, Michele G., Charon, Rita. 1991. Issues in

physician-elderly patient interaction. Ageing and Society, 11: 127-148.

Rosenfeld, Elif T. Participant structures in therapeutic discourse: an analysis of

dyadic discourse in marital therapy. Ph.D. Dissertation in Georgetown
University.
 p.38

scheduling the next visit. This doctor-centered analysis is motivated by the general