Doctor-patient communication in medicine and dental medicine

Doctor-patient communication is a type of institutional communication which
 distinct linguistic features can significantly affect patient satisfaction
 and treatment outcome. A medical encounter has a clearly defined structure
 that has been shifting from clinician-centred to patient-centred. Therefore,
 it is of utter importance for prospective doctors and dentists to be aware
 of the role of language when communicating with their patients. Given the
 fact that working in a medical/dental practice has become increasingly
 international, the paper focuses on the role of the English language. New
 communicative models and environments such as Computer-Mediated Medical
 Communication (CMMC) and Video Interaction Guidance (VIG) are also
 presented.


INTRODUCTION
Doctor-patient communication as a type of institutional communication has been analysed within various disciplines over the past few decades -conversation analysis, critical discourse analysis, sociology, sociolinguistics, psychology, anthropology, and medicine itself. Research results from this field of communication are considered to be highly applicable in medical practice as they can improve interactions between doctors and patients and contribute to better treatment outcomes. It has been reported that the communicative style a doctor adopts highly affects both patient satisfaction and treatment outcome [1]. Besides, patients who have good communication with their doctors and are adequately informed of their condition seem to recover faster and more successfully after complex surgical procedures and are rarely depressed in comparison with other patients [2]. Studying doctor-patient interaction also reveals potential problems in this type of communication, helps solving these problems and results in better informed patients who can follow doctors' advice more precisely. Research results from this field are also valuable for teaching English for medical (academic) purposes (EMAP) as they provide practical examples and illustrate important characteristics of doctor-patient communication that can help prospective doctors/dentist communicate efficiently with foreign patients in an era of medical/dental tourism expansion.
This paper provides an insight into doctor-patient communication and its characteristics through the prism of medical encounters and encounters in dental medicine.
First, institutional communication is briefly presented and contrasted to ordinary communication. The characteristics of a medical encounter, as a typical representative of institutional communication, are given. Finally, the importance of contemporary communication in dentistry is emphasised, including computer-mediated communication (CMC).

Institutional talk
This type of communication is usually accomplished through the exchange of talk between professionals (i.e. institutional representatives) and lay people (i.e. institutional clients) and it takes place in an institution such as a school, a police station, a courtroom or a hospital/examination room [3]. Such interaction: (1) involves participants in specific goal orientations which are connected with their institution-relevant identities (e.g. doctor-patient), (2) it includes specific constraints on what will be taken as allowable contributions to a particular business, and (3) it is associated with inferential frameworks and procedures that are specific for institutional contexts at hand [3,4,5].
Institutional talk is distinct from ordinary conversation in several different ways: turn-taking organization, word choice, and asymmetry being the most important ones [3,6]. Turn-taking procedure is rather similar to that in ordinary conversation except that participants could be sanctioned for their contributions, e.g. if they answer when they are not supposed to, when they are expected to answer a question and they do not do it or when they talk when somebody else is talking [6]. Besides, turn-taking organization can differ considerably in various institutions.
Institutional representatives can sometimes organize their turns in such a way that they achieve a particular goal in communication with their clients. For example, in order to prepare their patient for a piece of bad news they are about to receive, a doctor might ask the patient for their own opinion of that problem and by doing this they prepare the patient for the information by changing their perspective of the problem, which makes it easier for the patient to understand the information [3]. In another example, a paediatrician asks parents how they see their child and only then presents the intended information partly relying on parents' own impressions [7].
Unlike ordinary conversation, which is fluid and prone to variations, institutional communication has a specific structural organization [3]. In institutional talk, participants usually choose more formal lexis than in ordinary conversations. They more often opt for descriptive terms [6] and it has also been noticed that institutional representatives frequently choose the first person plural (we) instead of the first person singular (I) with the aim of presenting themselves as institutional representatives rather than individuals [4]. Institutional euphemisms are also frequently used in order to downplay potentially problematic issues [6]. For example, references to pain are often euphemistic in a way that the words pain and painful are often avoided and replaced by something softer (e.g. sore) [8].
Asymmetry is one of the main characteristics of institutional talk and according to Heritage it is visible on different levels: (1) participation, (2) interactional and institutional knowhow, (3) epistemological caution and asymmetry of knowledge, and (4) rights of access to knowledge [6]. When it comes to asymmetry in participation, it can be illustrated by the fact that institutional representatives usually hold initiative throughout the conversation and they thus have greater power than their clients. However, Sinadinović and Polovina's research showed that the patient's initiative was very often accepted, which is contrary to some previous findings [9]. This means that patients do possess some power although doctors undoubtedly dominate the entire communication.
Institutional knowhow implies different attitudes that participants have towards the problem because of which a client has come to the institution; in other words, what is extremely important to the client may be just another routine case for the institutional representative. Asymmetry of knowledge can take two different forms -institutional representative may be cautious in expressing their opinion on something or they might openly show their superiority (this is often the case in doctor-patient interaction where doctors emphasize the possession of knowledge in a particular field). On the other hand, patients might miss asking important questions just because they do not have knowledge in the field and for the same reason, they might misunderstand doctor's agenda [6,10]. Finally, rights of access to knowledge manifest themselves in the fact that institutional clients have no right to have the same knowledge that institutional representative possess owing to their position, education and profession. In doctor-patient interaction, this would mean that a patient should not reveal to their doctor if they have previously informed themselves on their problem on Internet websites or elsewhere. Similarly, it has been reported that doctors who take their children to paediatricians try not to behave like doctors in such situations, but like parents who know nothing and they try to hide what they know in order not to offend their colleague [6,11].

Medical encounter
A medical encounter is considered to be a typical representative of the institutional communication being a "tightly organized event" which is almost completely ritualized [12,13]. Authors in both discourse literature and praxis literature 1 agree that there are several phases of a medical encounter, but the number of phases and their content vary considerably. Byrne and Long were the first linguists to research the six-phase model known as the biomedical model containing the following steps: (1) establishing a relationship with a patient, (2) discovering the reason for the patient's visit, (3) conducting a verbal and/or physical examination of the patient, (4) considering the patient's condition with the help of the patient if necessary, (5) discussing further treatment or suggesting further investigation, and (6) ending the conversation (this is usually done by the doctor) [14]. Heritage and Maynard accepted these six phases, elaborating further on their content. They recommended that the first phase should be cordial and relaxing for the patient and they also insisted that in the fifth phase the patient's condition should not be discussed only by the doctor but that the patient should be involved as well and that their opinion on any further steps should be respected [15]. Almost identical models are found with Heath and also with Gill and Roberts [16,17], whereas Mishler insisted on a three-part model -(1) doctor's question, (2) patient's answer to the question, and (3) doctor's assessment of patient's answer (e.g. a-ha, mhm, etc.) or another question [18].
A medical encounter organized according to one of these classical models is clinician-centred and mostly follows the structure of an interview where patients are expected to answer doctors' questions. However, praxis literature has insisted on introducing a more patient-centred model that would help doctors reach more precise diagnoses, treat their patients more successfully and achieve better overall results [13]. Nowadays, patient-centredness is recognized as one of the essential constituents of continuous quality improvement (CQI) [19]. Fortin et al. suggested the socalled biopsychosociological model that respects patients' needs and promotes changing of some important health and lifestyle habits [20]. This is an 11-phase model -(1) setting the stage for the interview (putting the patient at ease), (2) eliciting the main concern and setting the agenda (deciding what is going to be covered during the interview), (3) asking an open-ended question (in order to let the patient express her/himself), (4) eliciting symptoms, the personal and emotional context, (5) summarizing previous conversation, checking accuracy and preparing the patient for the next step, (6) obtaining a chronological description of the complaint(s), (7) obtaining past medical history, (8) obtaining social history, (9) obtaining family history, (10) physical examination, and (11) terminating the interview. Fortin et. al insist on integrated interviewing that promotes using patient-centred skills in the first and the final part of the interview, whereas the central part of the interview is dedicated to physician-centred skills. This is the basic difference between this novel model and the biomedical model, which always favours doctors over patients and give doctors much more space [20].
Having conducted a thorough contrastive research where she compared doctor-patient communication in Serbian and English corpora, Sinadinović came to a conclusion that Serbian doctors still follow the biomedical model, but that there are certain steps which resemble some phases of the biopsychosociological model [21]. This is not surprising if we have in mind that medical encounters in Serbian are much shorter than those in English and they cannot be expected to cover all the recommended steps.
Classical physician-centred medical encounters are similar to interviews with precisely defined roles. In patient-centred interviewing narratives prevail over interviews as patients are allowed to present the problem in their own words and in the way they find most appropriate, while doctors should pay attention to some signals that are usually unobserved in typical doctor-patient communication [1]. Ainsworth-Vaughn believes that telling a story can considerably contribute to a more precise diagnosis [22]. Ainsworth-Vaughn, Davis and Young report that patients usually tell stories in order to bridge the gap between them and their doctor and to fight for their own voice in institutional communication [22,23,24]. According to Ainsworth-Vaughn, patients use narratives in order to explain why they have come or who have convinced them to (finally) come as well as to describe their symptoms or details of their lifestyle [22]. On the other hand, when doctors use narratives, they either do it in order to explain the diagnosis and prescribed therapy or to explain how human organism functions in a particular situation and how the prescribed therapy works. Sinadinović showed that narratives in the Serbian corpus were not as numerous as in the English corpus and that there were considerably more narratives told by doctors than those told by patients [21]. The very presence of narratives in medical encounters determines the genre of medical encounter -it possesses elements of both an interview and ordinary conversation. Mishler believes that a medical encounter is more humane when there are narratives in it as they enable patients to present their case in their own way, emotionally and subjectively [18]. This way, the voice of lifeworld interferes with the sterile and objective voice of medicine [18].
Interruption is an important characteristic of institutional communication in general and doctor-patient interaction in particular. Although both interruptions and overlaps are regularly found in the discourse of medical encounters, interruptions are explored more thoroughly as they are a sign of unequal distribution of power. Beckman and Frankel report that there is an interval of only 18 seconds between doctor's first question and the moment when patient's answer to that question is interrupted [25]. Fairclough offers several reasons for interrupting a patient -by doing this, doctors can direct their patients towards a desired answer and prevent patients from repeating information or sharing irrelevant information [26]. According to Mishler, doctors interrupt their patients in several different ways: (1) by not paying attention to what the patient is saying (interruption by inattention), (2) by introducing a new topic and (3) by signalling the patient to stop talking, usually by using a particle ok (active interruption) [18]. Sinadinović noticed that the doctor interrupted the patient mostly by asking questions and ignoring what the patient was trying to say as it had nothing to do with his agenda [27]. West concluded that doctors interrupted their patients much more frequently than the other way around [28]. Interestingly enough, she discovered that female doctors interrupted patients more rarely than their male colleagues and that patients in comparison with their male colleagues more often interrupted them. Moreover, female doctors were more frequently interrupted by male patients than by female patients [28]. According to Klikovac, patients do interrupt doctors, although not that frequently, and they do it for one of the following reasons: to give a negative answer to the doctor's question, to introduce a new topic, to oppose the doctor's statement or to refuse the doctor's suggestion [29]. Sinadinović discovered that female patients interrupted both male and female doctors more often than male patients, whereas male doctors interrupted patients twice as much as their female doctors [21].
Finally, the choice of lexis doctors use when communicating with patients could be an important obstacle in their relationship. This is the reason why in praxis literature doctors are often advised to avoid technical terms and check if and to what extent their patient has understood them [2]. Doctors tend to use technical terms in order to support knowledge asymmetry and demonstration of power, but very few patients are capable of taking part in such communication. Consequently, patients are confused, and they do not fully understand what is expected of them, so they will possibly fail to adhere to the prescribed therapy or follow doctor's advice. Not all the doctors necessarily use technical terms, but a plethora of research in this field has proved that is frequently the case [27]. Apart from using technical terms, doctors tend to opt for formal lexis and to "translate" patient's words to the language of medicine in order to emphasise their superiority concerning medical knowledge [29]. Sinadinović showed that both oral and written doctor-patient communication in Serbian is characterized by a large number of terms borrowed from English, even when there are adequate Serbian terms [30].

Communication in Dental Medicine
The study of communication is increasingly interdisciplinary and extends across disciplinary boundaries [31]. Thus, the role of communication skills in dentistry has been recognised and investigated as one of key prerequisites for managing and treating patients [32, 33,34]. Therefore, communication has been incorporated in the curricula of dental schools worldwide [33]. This comes as no surprise taking into account the fact that the Code of Ethics for Dentists in the European Union has stressed the role of communication by describing it as "fundamental to the dentist-patient relationship" [35,36]. A model that is widely used by dental school to teach communication in health care is the Calgary-Cambridge model as it offers step-bystep descriptions of different stages of clinician-patient encounter [33]. However, in recent years an innovative method called Video Interaction Guidance (VIG) has proved to be effective in teaching communication in clinical settings [33]. Quinn et al. conducted a study to investigate dentists' perceptions of the video review technique used to foster dentists' communication skills in complex clinical situations 2 [33]. Their findings indicate that dentists find this technique beneficial as it helps them become aware of their verbal and non-verbal communication, including the communication strategies they had been applying that turned out to be ineffective [33].
Furthermore, communication represents an integral part of quality health care. There has been a necessity to assess the quality of communication in dental settings. This is carried out by patient satisfaction surveys which role is to measure and monitor patient satisfaction with dental services in primary care institutions, which was first introduced in Serbia in 2010 by distributing a questionnaire that evaluates whether a dentist provides clear explanations of procedures, among other factors contributing to providing quality health care [19]. This is in accordance with the fact that being able to provide proper and comprehensive information is of utter importance in doctor/ dentist-patient relationship [35].
Two other studies have emphasised the importance of effective communication in dental practice. One of them was concerned with restorative treatments and understanding patients' expectations related to aesthetics and concluded that any misunderstandings should be prevented by applying effective communication techniques "prior to initiation of irreversible therapy" [37], while the other was concerned with dental anxiety and concluded that being able to discuss dental anxiety with dentist before undergoing dental treatment contributed to alleviating patient anxiety [32].
Yet, the question is -what happens in multilingual settings where linguistic differences may pose a barrier to providing high-quality dental care? This kind of dentist-patient encounter has been described as "exceptionally challenging" [38]. For example, the decision-making process can be significantly affected by linguistic differences, i.e. the fact that a dentist and a patient do not share the same language [35,38]. Thus, English language has taken on the role of a lingua franca of the global health care. Owing to globalisation, medical/dental tourism has been prolifer-ating and English language has become a dominant and an indispensable factor when it comes to communicating with foreign patients and providing quality health care. A study conducted in Australia in order to explore and analyse dentists' perceptions related to providing dental care to patients whose English was limited revealed that on average dentists experienced communication barriers with patients on a weekly or monthly basis as a consequence of patients' inadequate English [38]. Finally, the participants pointed out that it was particularly demanding to provide explanations in the fields of endodontics and periodontics -28 and 19 per cent, respectively [38].

Doctor/Dentist-Patient Communication 2.0
In today's world, telecommunication and technological advances are developing at a very fast rate enveloping in its wake many other areas of life including science and medicine. Telehealth and telemedicine are steadily gaining applicability and seeping into everyday medical practice. Today, with the rise of internet and particularly Web 2.0, there are many different options at hand for a patient to communicate to a doctor or other medical professionals. These include apps, online forums and Q&A types of platforms, private email consultations, video consultations, and even social media. This type of communication via networked computers or other digital devices is called computer-mediated communication (CMC) [39]. CMC is a wider interdisciplinary field that includes psychology, sociology, linguistics, etc. The branch of CMC focused on language and language use which applies the methods of discourse analysis is called computer-mediated discourse (CMD) [40]. CMD covers a variety of genres or as Crystal [41] calls them internet situations that include email, chatrooms, discussion groups, MUDs (multi-user dungeons), and many other emerging genres.
One type of these genres includes sites where patients can communicate with doctors/dentists and seek medical advice, support, and online consultation and it falls under the label of computer-mediated medical communication (CMMC) [42]. CMMC in this form is considered asynchronous, where a message is sent and stored somewhere until read, which also makes it more lasting [40,41]. This type of d-p communication differs from the traditional face-to-face communication in many ways. The patient initiates the communication which is established through messages/emails, turn-taking is typically limited (question and answer) and some questions even stay unanswered. This and the medium considerably influence the communication itself. Namely, textual messages typically cannot convey extra-linguistic information such as intonation, prosody, and other auditory information as well as any type of visual information that could be crucial in a medical consultation. Furthermore, patients typically use pseudonyms, which in turn allows for more disclosure, while at the same time any personal information that could lead to identification is anonymized by page administrators. Other medical information such as tests, findings, and patients' photos are sent directly to the administrators or the corresponding doctor.
The communicative purpose of this online communicative event can vary. Zummo [42] has identified four categories: asking for opinion, asking for a second opinion, explanation or clarification of a term, procedure, etc., therapy, and diagnosis. Doctors, on the other hand, seem to provide a different service than that expected from users. Where possible, they will provide the patient with an answer, but in case of diagnosis they tend to solicit a proper visit, as they cannot make any conclusions without direct evidence [43].
Technological advances are influencing and will continue to influence not only medicine, but also the way medical professionals communicate with patients. The implications of this technological progress also include the way communication is taught to students of medicine and dentistry.

CONCLUSION
Doctor-patient communication is an important cross-sectionally researched subtype of institutional communication that is held essential in the outcomes of medical treatments and patients' general adherence to therapy and doctors' recommendations. There are numerous differences between institutional communication and ordinary conversation with turn-taking organization, word choice and asymmetry being most conspicuous.
Medical encounters have been explored from various aspects, both by linguists (discourse literature) and medical doctors (praxis literature). The classical six-phase biomedical model has been explored and further developed since 1976. In the meantime, experience from practice has shown that a more patient-centred approach is necessary, so a novel biopsychosociological model was suggested in 2012. According to research results, in the context of Serbia, the biomedical model still seems to be more applied.
Doctor-patient communication seems to have elements of both an interview and a narrative. However, researchers report narratives' valuable contribution to more precise diagnoses and strengthening patients' voice in institutional communication. The choice of lexis seems to be one of the main reasons for misunderstandings and poor doctor-patient relationship. Consequently, praxis literature advises doctors to avoid technical terms and too formal lexis when communicating with their patients.
When it comes to dentistry, communication skills are believed to be essential for managing and treating patients. The Calgary-Cambridge model is traditionally used to teach communication, but an innovative model has recently been introduced -Video Interaction Guidance, which is found to be effective in teaching communicative strategies. Effective communication in dental practice has been investigated from different perspectives including dentist-patient relationship in primary care institutions (Serbia), dental tourism, understanding patients' expectations concerning restorative treatments, dental anxiety, dentist-patient communication in a multilingual setting (Australia), etc.
Finally, apart from face-to-face communication with a doctor/dentist, there is another option -computer-mediated