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The Discursive

Construal of Trust
in the Dynamics of
Knowledge Diffusion
The Discursive
Construal of Trust
in the Dynamics of
Knowledge Diffusion
Edited by

Rita Salvi and Judith Turnbull

The Discursive Construal of Trust in the Dynamics of Knowledge

Edited by Rita Salvi and Judith Turnbull

This book first published 2017

Cambridge Scholars Publishing

Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Copyright 2017 by Rita Salvi, Judith Turnbull and contributors

All rights for this book reserved. No part of this book may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without
the prior permission of the copyright owner.

ISBN (10): 1-4438-4315-6

ISBN (13): 978-1-4438-4315-7

List of Tables ............................................................................................ viii

List of Figures.............................................................................................. x

Preface ........................................................................................................ xi
Marina Bondi

Introduction .............................................................................................. xiv

Rita Salvi and Judith Turnbull

Part I: Building Trust

Chapter One ................................................................................................. 2

The Discursive Construction of Trust in European Political
Rita Salvi

Chapter Two .............................................................................................. 26

The PhD Thesis Report: Building Trust in an Emerging Genre
Sara Gesuato

Chapter Three ............................................................................................ 46

The Appeal of Travel Blogs: The Image of Italy through American Eyes
Giuliana Diani

Chapter Four .............................................................................................. 62

Repositioning Museums on Childrens Agenda
Federico Sabatini
vi Table of Contents

Part II: A Corporate Culture of Trust

Chapter Five .............................................................................................. 88

Markers of Trust: Epistemic Adverbs of Certainty and Restrictive
Adverbs in CSR Reports
Paola Catenaccio

Chapter Six .............................................................................................. 108

Conveying Trust in a Globalized Era
Franca Poppi

Chapter Seven.......................................................................................... 131

Building Trust through Corporate Identity: An Analysis of CSR Reports
and Webpages
Donatella Malavasi

Chapter Eight ........................................................................................... 154

Organizational Trust Creation in Peer Coaching Events:
Multimodal Means and Representations
Janet Bowker

Part III: Maintaining and Repairing Trust

Chapter Nine............................................................................................ 184

A Digital Meeting Place? A Socio-semiotic and Multimodal Analysis
of the Social Hub
Ilaria Moschini

Chapter Ten ............................................................................................. 206

Knowledge Transfer, Ideologies and Trust in Public Financial Reporting
Chiara Prosperi Porta

Chapter Eleven ........................................................................................ 229

Past in Present: Disseminating Credible Heritage Knowledge Online
Christina Samson

Chapter Twelve ....................................................................................... 249

Repairing Trust: A Case Study of the Volkswagen Gas Emissions Scandal
Judith Turnbull
The Discursive Construal of Trust in the Dynamics vii
of Knowledge Diffusion

Part IV: Trust in Medical Communication

Chapter Thirteen ...................................................................................... 272

The Construal of Trust through Relevance: Patterns of Evaluative
Language in Medical Writing
Renzo Mocini

Chapter Fourteen ..................................................................................... 293

Medical Knowledge Dissemination and Doctor-Patient Trust:
A Multi-modal Analysis
Daniele Franceschi

Chapter Fifteen ........................................................................................ 316

Spin in Health News: Levels of Trust in Knowledge Diffusion
Ersilia Incelli

Chapter Sixteen ....................................................................................... 339

Informational, Promotional and Trust Building Strategies in the Web
Genre of Clinical Negligence Case Studies
Girolamo Tessuto

Afterword on Trust .................................................................................. 362

Giuseppina Cortese

Contributors ............................................................................................. 372

Index ........................................................................................................ 379





1. Introduction
Spoken medical English has been investigated from three main
perspectives so far (Salager-Meyer 2014 and references therein). One
avenue of research has dealt with the analysis and development of oral
skills in non-native health professionals working or intending to work in
an English-speaking context. This approach is pedagogical in nature in
that it aims at improving competences as well as ESP teaching
methodologies and materials. A second line of research, which also has an
applied component to it, has focused on a less interactive type of spoken
discourse, i.e. the language of medical conference presentations, investigating
a number of different aspects, such as the juxtaposition of the verbal with
the visual (e.g. slides), the question-answer phase following the speech,
the differences between oral and poster presentations, etc. A third research
strand has specifically studied doctor-patient interactions, as well as
communication between patients and a range of other health professionals
including nurses, physiotherapists, alternative practitioners etc. (references
in Adolphs et al. 2004), mainly from a socio-linguistic perspective, taking
into consideration, among other aspects, how cultural and status
differences or gender diversity may result in conflictive encounters (also
Gotti et al. 2015).
The present paper examines doctor-patient conflict in an English L1
context and how it may be resolved through the adoption of certain
strategies by the doctor himself/herself, which, on the one hand, facilitate
comprehension of medical information and, on the other hand, manage to
294 Chapter Fourteen

create empathy and rapport between the parties. The latter elements have
been shown to play a fundamental role in improving the patients health
and medical care in a broad sense (Duffy et al. 2004). The analysis is
based on what can be regarded as representative examples of appropriate
and successful doctor-patient communication.
The paper is structured as follows. Section 2 presents the data and the
methodology used. Although the dynamics of doctor-patient interaction
have been widely investigated in the literature, research has traditionally
followed a mono-semiotic (verbal) approach, neglecting the bigger picture
of how meaning and trust are built in context (Candlin and Crichton 2013
for a thorough illustration of the concept of trust). Hence, the multi-modal
perspective of analysis adopted here. Section 3 describes those linguistic
elements in the dialogues under investigation, which appear to enhance the
effectiveness of the exchange between doctor and patient. Interestingly,
the three dialogues examined, albeit different in a number of ways, present
some common features at the lexical-semantic and pragmatic level,
resulting from deliberate decisions on the part of the doctor to ease
communication on important issues. Section 4 considers the non-verbal,
i.e. extra-linguistic, factors that also play a significant role for a better
understanding of medical information and, eventually, for the construal of
trust. The approach followed is thus multi-semiotic, since not only
language but also facial expressions, hand gestures and body movements
are observed and considered as contributing to meaning. Section 5 briefly
summarizes the results of the study and suggests possible future research

2. Data and methodology

Before plunging into the study, let us consider more in detail the type
of data analysed and the methodology used for its transcription/annotation.
The three doctor-patient dialogues examined were chosen from a pre-
collected database available on-line,1 consisting of video-recorded
conversations aimed at improving patients knowledge about the various

The database was prepared by Caring Ambassadors Program Inc., Oregon City,
OR (, to give hepatitis C patients free access to doctor-
patient interviews with useful information about screening, diagnosis, treatment
and disease management. Many thanks to Lorren Sandt, Executive Director of
Caring Ambassadors Program Inc., for allowing me to use the interviews and some
images for my research.
Medical Knowledge Dissemination and Doctor-Patient Trust 295

options available to treat their medical conditions.2 The reason why these
three conversations in particular were chosen is because they appeared as
the ones that best fit my research goal, i.e. showing how the adoption of
certain communicative strategies may improve doctors counselling skills
and consequently have a positive impact on the outcome of their
consultations with patients (Fong Ha and Longnecker 2010 for a review of
the literature on doctor-patient communication). To address this specific
research objective, a very small specialized spoken corpus consisting of
approximately 6,650 words was created by manually transcribing and
annotating the conversations between three different doctors and one
patient who is initially refusing to start therapy for hepatitis C. Although
the data only makes up a mini-corpus,3 it provides interesting evidence of
what works for effective medical communication and patient
engagement. Both the doctors and the patient in the videos are native
speakers of American English.
The conversations were studied in minute detail from a multimodal
perspective. First, they were digitized into computer-readable form and
printed out in order to get a general feel for the data and to start
developing the analysis. At a purely linguistic level, the most interesting
features of discourse are the lexical-semantic and pragmatic choices that
the doctors make to gear conversation to the patients needs, while at the
same time maintaining their firmness and consistency of purpose.
Therefore, all the relevant words, phrases and expressions used by the
doctors to achieve this aim were assigned tags in order to mark their
functions. Since the analysis brought to light both hypothesised
phenomena as well as a number of unforeseen items, especially with
respect to extra-linguistic usages, the study may be considered as both
corpus-based and corpus-driven (Tognini-Bonelli 2001). As for the non-
verbal elements that accompany and reinforce speech, they were also
included in the transcription of the data, following the technique proposed
by Baldry (2000), Thibault (2000) and Baldry and Thibault (2006), which
brings together verbal text and visual image in addition to a description of

I personally contacted one of the doctors involved in the project, Dr. Lyn Patrick
(Medical Director at Progressive Medical Education, Irvine, CA,, to know whether the conversations had
been prepared before filming them and whether the patients appearing in the
videos are really affected by the condition(s) described. I was assured that the
interviews were spontaneously conducted and that the interviewees are all patient
advocates who have (or had in the recent past) hepatitis C.
For reasons of space, it has not been possible to include the full dialogues here,
which are, however, freely accessible on-line at
296 Chapter Fourteen

the function of non-verbal behaviour (see Tables 14-1, 14-2 and 14-3 in
Paragraph 4).
The mark-up of the transcripts includes punctuation in order to make
the conversations easier to read and analyse, and those paralinguistic
elements, e.g. stress, pace and tone of voice, as well as extra-linguistic
factors, e.g. hesitations, pauses, smiling, etc., which are considered to be
relevant for the study.4
Finally, the decision to limit the observation and the analysis to a small
corpus was not just motivated by the need to examine the three chosen
conversations in the greatest detail possible. It was also dictated by the
nature of the transcription task itself, which is extremely labour-intensive
and time-consuming. It has been estimated that an hour of recording may
take up to ten or even twenty hours to transcribe (McCarthy 1998; Creer
and Thompson 2004). As a matter of fact, for the transcription, manual
inspection and annotation of 36 minutes of video-recorded conversations I
required approximately 12 hours. More time was then needed for the
analysis of the results.

3. Speaking to the patient: the verbal mode

This section examines those verbal elements used by the three doctors
in the dialogues, which have proved as particularly effective for successful
communication and good patient management. The two latter elements are
directly related and consequent to the doctors ability to build trust
between themselves and their patients. Trust, however, must be regarded
as a discursive practice that needs to be continually negotiated. In other
words, it is not constructed all at once, but rather through the use of
conscious and strategic communication practices in interaction.
Most of the linguistic strategies used to facilitate comprehension and to
build rapport are of a lexical-semantic and pragmatic nature. Syntactic and
prosodic structure appears to play a less important role, instead. The three
doctors appear to have a similar communicative style with respect to a set
of features discussed in the following sections.

The transcripts, however, are not completely objective, because there is other
information that may potentially be annotated, but which in fact is not because it is
not pertinent to my particular research aim. Transcripts are never complete and, to
a certain extent, may be viewed as an interpretation of the communicative
exchange (Bucholtz, 2000). Contact the author (
for samples of the annotated transcriptions.
Medical Knowledge Dissemination and Doctor-Patient Trust 297

3.1. Simplification, reformulation and informality

A lot of medical terminology in English has Latin origins, because
Latin was the language of science until the beginning of the 1700s. Most,
if not all, medical texts during the 18th century continued to be written in
Latin. Under the influence of Andreas Vesaliuss work on human
anatomy,5 many technical words referring to the human body and to
clinical conditions remain in Latin even today, with no changes in the
original (e.g. abdomen, apparatus, fistula, etc.), or are derived from Latin
(e.g. cerebrovascular, hepatic, jaundice, etc.). Latin is also very influential
at the level of word formation processes, as can be observed in the use of
prefixes, combining forms and suffixes (Ten Hacken and Panacov 2015).
Words of Latin origin, however, are considered as formal or technical
and are not always easy to understand for the layperson. Therefore, in the
three dialogues examined they often tend to be replaced by their Anglo-
Saxon counterparts, which come across as clearer and more natural. There
are several instances of such a process of simplification or reformulation
(Glich 2003). Let us take a look at some examples of how the doctors try
to avoid medicalese with their patient:6

(1) We have not seen the remission, in other words the getting rid of the
virus, just with alternative medicine.

(2) And Im wondering if you know anybody that has gone through
standard of care treatment with the, we call it adjunctive, meaning in
addition to standard of care, these adjunctive treatments.

(3) The fluid in the abdomen is called ascites.

(4) What our therapies can do is help minimize the toxicity or side effects
of standard of care therapy.

(5) There are some good studies that show that with weight loss and
exercise that can be reversed. [] there are good studies that show that
that can be turned around.

Andreas Vesalius (1543), De humani corpori fabrica.
The Latin-based terms are in bold, while their Anglo Saxon versions have been
underlined. It is also interesting to note that these reformulations are often
introduced by a word or phrase signalling that we are faced with a paraphrase,
transposing technical expressions into more popularized/ordinary ones. These
words or phrases have been italicized.
298 Chapter Fourteen

The doctors either use technical terms immediately followed or

preceded by the explanation of their meaning, as in the examples above, or
completely avoid medical jargon and resort to plain language that their
patient can quickly understand:7

(6) And the things that can happen with cirrhosis include turning yellow.

(7) The whites of your eyes turning yellow.

(8) Another thing that can happen is you start accumulating fluid all over
your body.

What is being talked about in (6) is a condition known as jaundice,

while in (7) the doctor obviously refers to the scleras of the eyes and in
(8) to a complication of cirrhosis, i.e. ascites. When the need for clarity
is strong as when trying to educate the patient about a surgical procedure,
which may scare him, the style of the conversation becomes particularly
informal. In (9), for instance, all the verbs used by the doctor are
phrasal/prepositional verbs describing in a very direct and simplified way
how a liver biopsy is performed. Such style is supposed to soften the
perception of fear and danger associated with the procedure in question:

(9) Your liver is up here under the ribs. We numb up the area of the skin
and we put the needle directly into the liver, we suck up a little piece of
liver and take it back out. [] And the piece of liver that we take out, its
about as thick as the lead in the lead pencil, not the pencil itself, just the

This is a good example of recipient-tailored language use (Brown

and Fraser 1979), aimed at reaching doctor-patient alignment and,
ultimately, patients compliance.
The style of the dialogues is often rather chatty and characterised by
colloquialisms (10), onomatopoeic phrases (11) and even slang
expressions (12)8 that have the effect of reducing, or even cancelling at
times, the patients feeling of asymmetry with the doctors. This is
because through the adoption of such speaking style they put themselves
on an equal footing with him:

Since the patient uses primarily a colloquial register and informal words, e.g.
docs for doctors, bellies for abdomens, the doctors may feel the need to adapt
to his speaking style in order to avoid comprehension failure.
They have been put in bold in the examples provided.
Medical Knowledge Dissemination and Doctor-Patient Trust 299

(10) Well, turns out, if you get rid of the hepatitis C with treatment,
theres a good chance that your risk of cancer is gonna go way down.

(11) The biopsy itself, the needle is in there less than a second. Boom
boom, its done!

(12) Why the heck would you want treatment?

As a consequence, the patient feels at ease and sometimes even decides

to start ironic exchanges leading to laughter:

(13) Terry: Alright. Well, I wanna think about these things.

Doc: I, I would expect you would and I would definitely talk to your wife
about it. And I would
Terry: [laughing] Youll talk to my wife or I talk to my wife?
Doc: Well, I cant talk to her unless you give me permission. But Id be
happy to talk to her.
Terry: No, I wont give you permission to do that [laughing].

The ability on the part of the doctor to tune in with the patient, also at
the language level, appears to play a fundamental role in gaining the
patients trust and in stimulating his willingness to undergo treatment,
which culminates in his decision to accept the doctors advice (see
Paragraph 3.7 below).

3.2. Repetition
All the three doctors have a marked tendency to rely on the use of
synonyms and paraphrases in order to explain a certain concept in the best
way possible and to make sure that the patient understands what they are
talking about. This often results in the use of doublets (14) as well as of
lists of several items (15) that essentially express the same idea:

(14) Some patients with genotype two can even take fewer weeks of
therapy, but because you have significant fibrosis and scarring [].

(15) You know, working out in the farm, where you get injuries and sores
and cuts and bruises and scrapes, thats ways of again transmitting blood
between people that would be minor and nothing that you would pay
attention to, but potentially could have occurred [].
300 Chapter Fourteen

Repetition often takes the form of extended descriptions,9 in order for

the patient to understand what behaviours are to be avoided (16) and what
justifies treatment (17):

(16) [] when you have underlying, active sores, if you will, the hepatitis,
then the alcohol is much more damaging than it would be to a normal liver.

(17) Some of them already have very advanced disease, cirrhosis, which
would be at the one extreme of severe scarring damage to the liver.

The patient needs to be informed of the fact that hepatitis presupposes

that there are sores in the liver tissue and that drinking for a person with
hepatitis is like pouring alcohol on an open wound (16), i.e. it causes
inflammation and makes the wound worse. Similarly, the doctor in (17) is
indirectly warning the patient about the possible risks of refusing therapy.
The message here is delivered in a rigorous yet courteous and professional
manner, but there is a constant swing between this style and a more
sympathetic and less straightforward mode.

3.3. Hedging
Doctors often need to attenuate the full semantic load of a certain
expression or the force of a speech act. This rhetorical strategy, known as
hedging (Lakoff 1972), may be used to mitigate the emotional impact of
a diagnosis, to make suggestions in a tentative manner so as not to be
perceived as too invasive, to communicate that there is no full
commitment to what is said, and so on (Frazer 2010 and references
In the conversations examined, the doctors are trying to convince the
patient that standard of care therapy is the best option for his present
condition, despite the possibility of a number of side effects that he may
experience while on treatment. The patient fears, for instance, that the use
of medication for hepatitis C will aggravate his PTSD and depression, for
which he is also being treated. Therefore, the doctors have to find a way of
encouraging this reluctant patient to follow their advice, while at the same
time dealing with his worries and taking his requests into consideration.
This results in what may be described as cautious communication, i.e.
characterised by a number of features aimed at softening the impact of
what is being said:

These descriptions have been underlined, while the conditions they refer to are in
Medical Knowledge Dissemination and Doctor-Patient Trust 301

(18) Well, the interferon side effects make you feel like you have [pause]
the flu, to some extent. Erm, you may have some loss of appetite, may
lose a little weight on treatment. Erm, the ribavirin might give you, oh,
sometimes a little funny taste in the mouth, sometimes a little soreness,
maybe some rash.

This answer to the patients question about whether he will be sick,

should he decide to do therapy, presents different types of hedges.
Although the initial well suggests that there is indeed a likelihood of side
effects, such verbally unexpressed message is mitigated by the use of the
two modal verbs may and might, the adverbs sometimes and maybe, and
the expression a little. The interjections (erm, oh) and the pause also seem
to attenuate the bluntness of the reply, because they give the doctor time to
think and to present his thoughts on the matter in a less direct way. The
modal items in particular introduce optionality and help to minimise the
threat inherent in the doctors statements.
There are also several instances of a subtype of hedge phrases in the
dialogues, known as shields (Prince et al. 1982), which enable the
doctors to protect themselves while presenting objective data reflecting
the truth about the patients condition. Through the use of these shields
the doctor acquires more freedom in conversation and avoids being held
fully responsible for the statements he/she makes:

(19) It also looks like being stage three, which youve seen the model of
the liver and how the next stage is cirrhosis, which is the worst, you know,
stage that you can get to, kind of the final stage with hepatitis C, that your
condition which it sounds like you have had for a while, you know, that
case scenario was non-A non-B was hepatitis C from what we can tell.

(20) [] there was a recent study with acupuncture that actually just
showed that this is the case in people with hepatitis C.

Hedges do not just have an impact at the propositional level by

affecting the truth-value of what is said. Some of them also contribute to
the production of a performative effect:

(21) Now, I think its time for you to consider [pause] getting the hep C
treated and trying to get rid of that infection.

(22) [] Im strongly recommending that you consider the treatment.

302 Chapter Fourteen

I think and Im strongly recommending that, for instance, support the

doctors commitment to the patients health and serve the function of
reinforcing the act of convincing and advising him, respectively.

3.4. Speech acts

The analysis of the data shows that the three doctors use verbal
elements to perform acts going beyond the communicative level (Austin
1962; Searle 1975). Doctors primary aim is usually that of advising
patients about what is best to do. It is interesting to observe, however,
that in the conversations examined there is also a constant attempt at
achieving goals other than those associated with the final act of convincing
and advising the patient, as we have seen with examples (21) and (22)
above. It might be argued that there are a series of pre-speech acts working
towards convincing the patient to get treatment, but which are per se not
directly associated with this function.
The first step on the road to convincing the patient that he should
commence treatment is praising him about all the good things he has
already done for his health:

(23) Youve done some great things to control the other aspects, the
mental health, the alcohol.

This appears to be an important step for different reasons. First of all, it

acknowledges the patients efforts and increases the likelihood of such
behaviour occurring again. Secondly, being praised is a flattering feeling
that may consolidate relationships. In a medical context praising
potentially strengthens rapport between doctors and patients. And this is
exactly what happens in the case under scrutiny here.
Another speech function identified in the conversations is that of
encouraging and giving hope:

(24) I think youre gonna do well.

(25) Doing that will definitely help your liver.

(26) So thats something that is in your control for the most part in terms
of [].

Similarly, the doctors pay a lot of attention to reassuring the patient

that his condition is something they are familiar with and thus able to
address or that the testing procedures are painless and easy to perform:
Medical Knowledge Dissemination and Doctor-Patient Trust 303

(27) [] thats again quite typical of the patients we see.

(28) [] thats simple blood test, like youve had many times before.

However, there is an alternation between praising/encouraging and

warning/scaring, as if the doctors carefully mixed the right dose of
confidence and frustration in order to get the patient started with

(29) Hepatitis C can cause cirrhosis. And once you get to that stage
[pause] then you start having many problems. Right now you feel well.
But when you develop cirrhosis youll be well for a while, but as the
cirrhosis worsens [pause] theres many things that can happen to you
and your body. It can take away your life. And the things that can
happen with cirrhosis include [pause] turning yellow.

(30) [] the amount of scar tissue in your liver is substantial.

The ultimate goal of the three conversations, therefore, is that of

empowering the patient to have control over his condition.

3.5. Figurative language

Speaking figuratively, i.e. by means of metaphors, metonymies and
similes,10 is another recurrent strategy used in the dialogues to increase
message clarity.
The instances of figurative language use identified in the data,
however, are limited to the conversations between the patient and the male
doctors. The following example is an interesting case of mens talk
(Coates 2003), in which the doctor compares viruses with different types
of cars:

A metaphor is a rhetorical device based on a cognitive operation consisting in
making an implicit comparison between two unrelated domains, so that one
domain (source) allows us to understand and reason about the other (target)
(Lakoff and Johnson 1980, 1999 and Lakoff 1987, 1993). A metonymy, by
contrast, relies on a domain internal mapping, whereby the source domain is used
to provide access to the target, for which it stands (Kvecses and Radden 1998;
Ruiz de Mendoza 2000). A simile requires the explicit use of a comparative
particle, such as like or as, but is inherently a metaphor.
304 Chapter Fourteen

(31) Cos hepatitis C is more than one virus, if you will. There are different
subtypes, just like Ford has different kinds of cars, they are all Fords, but
ones a truck and ones an SUV etc. Hepatitis C has different subtypes.

Hepatitis C is then associated with a fire and drinking alcohol is

considered to be as dangerous for the liver of a person with hepatitis C as
pouring gasoline on fire (32). The hepatitis C virus is also metaphorically
referred to as a friend when it remains dormant and does not cause any
complications (33). This meaning is activated by the phrasal expression to
get along alright together, which is normally used to refer to people who
are on good, friendly terms:

(32) The combination of alcohol with active hepatitis, I look this as kind
of putting alcohol on a fire or putting gasoline on a fire, it just makes
the fire worse.

(33) [] and their disease never progressed anywhere very seriously. So

for some reason their body and the virus are kind of getting along alright
together, without major damage occurring.

Metonymies are also productively exploited for reasons of conciseness,

since information in them is compressed, thus allowing the doctor to evoke
a certain frame by naming it only partially:

(34) The normal liver, it doesnt really like alcohol [].

This is a part-for-whole metonymy thanks to which the NP normal

liver economically encapsulates the idea of a person with a normal liver.
It is the verb like here that works as a cue for conceptual connectedness.

3.6. Empathy, trust and convergence

By empathy we mean the ability of a person to identify with the
feelings, thoughts and attitudes of another. In a medical setting, when a
doctor manages to understand his/her patients condition and the emotions
associated with it, without being overwhelmed by them, there is a good
chance that he/she will then be able to adopt a suitable communicative
style to address such condition and try to resolve it. This is exactly the
case in the three conversations analysed, in which the language that the
doctors use always shows respect, attention and care for their patient.
The first step towards building trust involves attentive listening, so as
to gain an insight into the patients concerns and sources of distress. There
Medical Knowledge Dissemination and Doctor-Patient Trust 305

are several expressions in the dialogues signalling that the doctors are
indeed on the patients wavelength:

(35) Terry: Thats myone of the biggest concerns I have.

Doc: I hear you. I think that Im not gonna take your alcohol away from
you right this minute, but []. And so, I hear you, I hear that this is
really important for you and that youre not ready to give it up, but if you
are willing to talk about alternatives I can certainly help you in that, in that

(36) But right now Im concerned about you.

The next step is that of tentatively trying to help the patient to shift the
focus of his attention to possible alternatives, while at the same time
reminding him about the facts:

(37) And so what Im talking about is you, if you ever choose to do this,
this is completely up to you, standard of care therapy with a combination
of traditional Chinese medicine [].

(38) Is this something that youre willing to entertain or be educated


(39) We have not seen the remission, in other words the getting rid of the
virus, just with alternative medicine.

(40) [] what I tell my patients is if there was an alternative to standard

of treatment I would suggest it, believe me, because it is like

The three doctors try to make their advice authoritative through

depersonalisation, i.e. they anchor what they say to external sources
supporting their opinions. Published medical literature is typically
regarded as the main source of authority that gives credibility to their

(41) [] I think that all the published information in the medical literature
will bear that out.

This is a recurrent technique that the doctors use to seek their patients
compliance. What they are implicitly saying is that their positions are
officially recognized and accepted in the scientific community and are
therefore trustworthy.
306 Chapter Fourteen

There is then a constant invitation to convergence on the part of the

doctors, i.e. they actively encourage the patient to agree with and perform
the course of action they recommend:

(42) I dont want you to continue progressing and getting to a situation

where [].

(43) I mean, youre stage three now. We dont want you to get cirrhosis
or any of those complications.

(44) You and I can work together in terms of addressing dietary factors
and get you on a very specific exercise programme that can help reverse

This is a laborious process, because the patient is not leaning towards

treatment for his hepatitis C at all, fearing the possibility of side effects.
But, finally, after a detailed and pondered description of what he may
experience while on interferon, the patient finally decides to be treated:

(45) Doc: But I think youre gonna do well, because youve done some
great things. One is youre taking care of yourself, with the mental health
and the counselling youre getting there and the second thing is youve
made a decision to control that alcohol. So I think, I think youre ready. I
think you should consider
Terry: So is there anything we have to do before I start or and when can we

The construal of trust in the case under scrutiny must thus be seen as a
complex and dynamic process, which involves the development of faith on
the part of the patient both in the single doctors and in the medical
profession as a whole. Put differently, it is a micro-macro phenomenon
that eventually leads to the establishment of different but interrelated
orders of trust.

4. Non-verbal behaviour in doctor-patient interaction

This Section presents a microanalysis of non-verbal communication by
focusing on a video fragment of the interaction between Dr. Lyn Patrick,
who uses the most pronounced gesturing, facial expressions and body
movements of all the three doctors, and Terry, the patient referred to in
this paper. Because this minute analysis is extremely time-consuming, it
could not be extended to the whole conversation or to other segments of
the dialogues involving the other two doctors. For this reason, the findings
Medical Knowleddge Disseminattion and Doctorr-Patient Trust 307

are clearly llimited and onnly indicativee of how non--verbal behav viour may
both replicatte semantic coontent and sommetimes even carry key ind dependent
In the ffirst part of the
t video fraagment analyssed (Table 14-1), Dr.
Patrick remmains mostly silent while Terry is pressenting his problem.
After askingg him why hee came to con nsultation, thee doctor simp
ply listens
and shows hhim both verbbally and with h her attentivee gaze as welll as with
her noddingg that she is following wiith interest w what he is say ying. The
verbal compponent is redduced to a minimum
m heree and comm munication
develops maainly through the non-verbaal cues that thee doctor uses.

Image frrame Verb

bal text Nonn-verbal behav viour &
1 So, teell me Sligghtly shaking head
why you (doeesnt know wh hy
are here
h pati ent is there), slightly
worrried gaze (waaits for
pressentation of
symmptoms), holdiing open
handds together wiith
finggers intertwineed
(we lcoming attitu ude)

2 Ok Noddding (shows
undderstanding), lo ooking
straiight into patieents eyes
(shoows attention and
interrest), slightly worried
gazee, holding han nds
togeether with fing gers
interrtwined (show ws
willlingness to waait and

I have inccorporated imaage frames intto the multimoodal transcriptiion of the
exchange, foollowing Baldryy (2000), Thib bault (2000) an
and Baldry and d Thibault
(2006), but I have not incluuded the patients turns, sincee the focus heree is on the
strategies useed by the doctorr to enhance com
mmunication annd rapport.
308 Chapter Fo

3 Ok Noddding, smiling
g (shows
undderstanding and

4 Smiiling (shows
conffidence) and looking
straiight into patieents eyes
(shoows interest) holding
handds together wiith
finggers intertwineed
(shoows willingness to
waitt and listen)

5 So, Can,
C Steeepling (as if beegging
Let me
m for aan answer), sqquinting
Theres a (loooking for an annswer
y thatt may not be easy to
impoortant findd for the patien
nt), head
piecee of slighhtly turned to the right
I need your
help with.

Table 14-1. A multimoddal transcription of a doctoor-patient intteraction

segment L
Listening to the patient.

Her faciaal expressionss and hand gesstures are iconnic and metaphoric and
may well suubstitute wordds at this initiaal stage. She iis obviously worried
w at
the very begginning (imagge 1). The no odding later suuggests that she
s either
understands the patients point of view or agrees witth him (image 2 and 3).
The fact thaat her gaze iss fixed on hiis face and iss never distraacted also
Medical Knowleddge Disseminattion and Doctorr-Patient Trust 309

shows the ppatient that hiis narration iss worth listenning to. Holdiing hands
together witth fingers inteertwined (imaage 2 and 4) iis iconic for thet act of
waiting, so the patient gets
g the message that it iss his turn to speak. In
addition, thee doctors sm
miles communiicate that she is feeling com mfortable
in the patiennts presence and her upright position eexpresses streength and
confidence iin dealing witth a potentiallly difficult sittuation that th
he patient
may be in.
The use of metaphorric/iconic pictographs and kinetographs becomes
more systemmatic as the coonversation prrogresses (see Tables 14-2 and a 14-3)
and the docctor starts askiing questions and explainiing medical isssues and
options to tthe patient. Steepling (fingger tips touchhing each oth her as the
hands are pplaced out in front formin ng a church ssteeple-like structure),
which resembles the act a of prayin ng, appears to have a question
reinforcemeent effect. At the same tim me, she is carrefully lookin ng for the
right wordss to frame thhe question, as a is suggesteed by her looking up
(image 6).

Image frrame Verrbal Nonn-verbal behav viour &

textt inteerpretation
6 Can n you Firsst steepling theen
tell me movving both hands
whaats togeether vertically (as if
gonne into beggging for an an nswer),
youur lookking up (as if looking
deccision for tthe right way of
not to do phraasing the quesstion)

7 Wh hats ft hand separatting from

happpened righht hand along
to you
y or horiizontal line (supports
whaat conncept of otherr
youuve peoople), body slightly
seenn movving forwardss
happpen to (preepared to take answer
otheer on bboard)
310 Chapter Fo

8 th hats Movving left handd

mad de you verttically (supporrts
deccide conncept of not wanting)
youu do
not wanna

Table 14-2. A multimod

dal transcription of a doctoor-patient intteraction
segment R
Requesting in

The horiizontal movem ment of the do octors left hannd, instead, strresses the
concept of other people and is perforrmed exactly w while those twwo words
are being utttered. She alsso moves forw wards as to suuggest that shee is ready
and open too get the answ wer from her patient (imagge 7). Finally y, her left
hand starts moving up and down vertically, som mehow mimiccking the
behaviour of cutting something,
s which
w has tto be metap phorically
understood here as makinng a clear-cu ut decision. TThis gesture is indeed
performed w while using the
t verb deciide (image 8)). It looks ass if body
language woorked as a meeta-discourse hereh to emphaasize the impo ortance of
what is beinng said.
As the conversation moves
m on and the doctor neeeds to explain n medical
information and terminollogy to the paatient (Table 14-3), the usee of non-
verbal elem
ments is more frequent and d consistent. H Hand gesturess become
very importtant vehicles of expression. They tendd to accompaany those
words that are particularrly salient in the context oof the utterance or the
ones that thhe doctor beliieves require additional claarification. In n order to
give credit to the truth of the statem ments she maakes, for instaance, she
emphasises the word puublished by suddenly s opeening her han nds, thus
metaphoricaally illustratingg the concept of being avaiilable (image 9). 9 Iconic
pictographs are often useed to remind the t patient of anatomical feeatures as
well (imagee 10 and 11)), while kinetographs seem m to complement the
meaning of lexical items through a mo ore detailed ddescription off a certain
concept. Thhe idea of makking gradual progress
p in reesearch (imagee 12), for
example, is better exppressed with h the movem ments of th he hand,
metaphoricaally standing for the steps made, than with the phrasal verb
come up witth alone. Sim milarly, the terrm adjunctive is best explaained also
Medical Knowleddge Disseminattion and Doctorr-Patient Trust 311

by reproduccing the act off putting someething inside a container (im mage 13).
Perhaps we should then speaks of parad
discourse to reefer to the usee of these
non-verbal eelements, sincce their charaacteristic is thhat of actuallyy running
parallel to annd highlightinng the verbal meaning
m compponent.

Image frame Verb

bal text Nonn-verbal behav viour &
9 [] I think Sudddenly opening both
that all
a the hannds (reinforcess the
publiished conncept of publiished)
in the
will bear
that out

10 It alsso Movving hands ass if

lookss like holdding somethin ng (she
being g stage prettends she is ho
threee, the model of the liver)
seen the
modeel of
the liiver

11 an nd how Hannds in the samme

the next
n posiition but move to the
stagee is righht, body leans right
hosis (em
mphasizing thee concept
[] of nnext)
312 Chapter Fo

12 The best
b ft hand moving
Left g to the
that we
w left,, then back,
havee been reprroducing the idea
i of
able to the steps made (ssupports
comee up notiion of coming g up
with in withh)
terms of
13 [] Liftting left hand and
dard of prettending to putt
care sommething insidee a
ment conntainer (stressees the
with the, conncept of adjun nctive or
we call it in aaddition to)
mean ning
dard of
care,, these

Table 14-3. A multimod

dal transcription of a doctoor-patient intteraction
segment E

5. Conclusions
This chaapter has attem
mpted to show w the potentiall offered bothh by some
verbal strateegies and nonn-verbal behaaviours in hellping to build d rapport
with difficuult patients who
w are relucctant to follow w their doctorrs advice
and recomm mendations. Inn the case ex xamined, the ppatient is unw willing to
consider meedical therapyy for his cond dition, but is eventually convinced
that the bestt thing to do for him is to be treated ussing a standarrd of care
approach, deespite all the possible side effects that hhe fears. Such h decision
appears to hhave been faciilitated by a cllear understannding on the part
p of the
patient of thhe nature of hiis disease and of the possibble solutions to
o manage
it, in order to potentiallyy get into rem mission. Thiss process has required
Medical Knowledge Dissemination and Doctor-Patient Trust 313

skillful discussions and dialogue, aimed first of all at making sure that the
patient understood all the medical information and technical terminology
used to talk about his condition. This increased awareness seems to have
empowered him to be involved in decisions regarding his care, thus
viewing doctors in a less asymmetric way. The feeling of being on the
same level with the doctors has then led to increased trust and to the
resolution of the initial conflict.
Given the limited amount of the data analysed, it is not possible to
generalise the findings of this study, which however seem to show that a
certain communicative style potentially has a significant impact on the
level of patients adherence to the advice or treatment regime recommended
by the doctors. For this reason, future research should focus on the
development of more fine-grained guidelines for best communication
practice in the medical context, taking into consideration both the verbal
and the non-verbal dimension. It would be interesting, for instance, to
compare the scenarios examined here with similar ones in which the
doctors do not adopt strategies for effective and affective communication
and see whether or not, or to what extent, this impinges on the quality of
the doctor-patient relationship and, ultimately, medical care. My
impression is that the narrower the gap between doctors and their patients,
the greater are the chances of achieving the desired therapeutic outcomes.
The possibility for the doctor to master conflictive situations may arise
from his/her ability to use specific verbal and non-verbal techniques, some
of which have been presented above.
It is my persuasion that doctor-patient communication can be improved
through instructed attention to certain features of both spoken and body
language and to how their use is essential if a consultation is to go

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