論文提要
傳統醫師與病人在互動過程中使用不同的認知及思路在說話，醫師掌握著大部分的主控權，醫師的知識來源來自於學校的課程以及臨床的經驗，而病人的知識則來自於過去健康的經驗，以及通俗性的醫學雜誌期刊之中，不同的醫學認知模式，導致醫病溝通常會產生成效不良的情況，隨著資訊的發達、消費意識抬頭以及健保制度的變更，醫病之間溝通的品質更顯重要。
本研究以個案研究的方式進行，收集醫師與病人對話的的方式來進行，選擇以小兒科門診醫師病人診間溝通為例，蒐集醫師與病人的對話內容，涵蓋三個不同的醫療層級，六位資深主治醫師的30位病患為研究對象。並以Brown和Levinson的禮貌理論(politeness theory)為分析架構，Grice的交談會話的四個準則（maxim），以及Roter的診間醫病溝通行為的分析系統為構面，分析醫病診間溝通對話時所採用的禮貌策略，以及常見的溝通模式。
研究結果發現兒科診間的禮貌策略，以最直接的赤裸紀錄內（Bald on record）的策略為最多，顯示著對於溝通效率上的共識。針對醫師的專業知識部分，病患絕大部分還是以較具禮貌的策略來因應。而幾種常見的禮貌策略對話模式，可以提供醫師病人進一步的自我察覺。記錄外的（Off record）禮貌策略，則同時出現在醫師與家屬的語句中，期待對醫療資源的節省以及醫病溝通的效率，能有所助益。

關鍵字：醫病溝通、禮貌理論、醫療行為、兒科門診

Abstract
Traditionally, doctors and patients are based on different cognitions and ways of thinking to communicate with each other. Doctors are often holding dominated role in the process. The knowledge of doctors is coming from the curricula that they have learned at medical school and their clinical experience, whereas the knowledge of patients is coming from their health experience and the information which was reported in the common medical magazines and journals. Because of the different cognitive modes of medicine between doctors and patients, the efficiency of doctor-patient communication is usually unsatisfied. With the popularity of medical information, the rise of consumers’ consciousness, and the change of health insurance system, patients are asking better quality of medical treatment now. Thus, the quality of doctor-patient communication seems to be more important.
This research was employed by case study. The doctors and outpatients of the pediatrics department were selected as the research sample. Totally, the sample included six senior doctors with three different levels of hospital and 30 outpatients. The dialogs of interrogation enquiry between these doctors and patients were collected. The analytic framework was derived from Brown and Levinson’s politeness theory, Grice’s conversational maxims, and Roter’s analytical system of doctor-patient communication behavior. This study analyzed the politeness strategies used during doctor-patient communication, and also found the communication modes that were frequently emerging in the diagnostic processes.
The research results show that the maximum politeness strategies used in pediatrics clinics is the bald on record. This reveals a kind of consensus on the importance of communication efficiency for doctors and patients. Most of patients adopt more polite strategies to communicate with doctors for medical knowledge. The results also suggest several commonly-seen dialog modes providing the further self-awareness and self-observation for doctors and patients. Indirect communication, the off-record politeness strategies are also appeared in the dialogues of doctors and patients. This study contributed toward gaining the efficiency of doctor-patient communication, thus may be helpful in the saving of medical resources.

Keywords: doctor-patient communication, politeness theory, therapeutic behavior,
pediatrics clinics

目錄
第一章 緒論……………………………………………………………1
第一節 研究動機與目的………………………………………………… 1
第二節 研究範圍 ……………………………………………………… 2
第三節 研究流程 ……………………………………………………… 3
第二章 文獻探討………………………………………………………4
第一節 醫病對話的型態………………………………………………… 4
2.1.1 醫病的認知模…………………………………………… 4
2.1.2 醫病診間互動的模式………………………………………5
第二節 面子之定義與探討……………………………………………… 6
2.2.1 語言與禮貌的產生 ………………………………………6
2.2.2 面子與面子功夫（face work） ……………………………7
第三節 Brown和Levinson禮貌理論的探討 ………………………………8
2.3.1 禮貌理論的發展 ………………………………………… 8
2.3.2 積極的面子與消極的面子………………………………… 8
2.3.3 人際間禮貌的決定因素 ………………………………… 9
2.3.4 Brown和Levinson的禮貌細則……………………………10
2.3.5 Grice的交談準則……………………………………… 12
第四節 Brown和Levinson的禮貌細則探討…………………………… 12
2.4.1 紀錄外（Off-Record）禮貌………………………………12
2.4.2 積極的禮貌 ……………………………………………14
2.4.3 消極的禮貌 ……………………………………………15
2.4.4 赤裸紀錄內（blad on record）……………………………17
2.4.5 細則的有禮程度的排序 …………………………………18
第五節 亞洲國家關於禮貌理論的探討………………………………… 19
第六節 禮貌理論在醫病關係上的探討 …………………………………20
第三章 研究方法 ……………………………………………………22
第一節 研究設計與流程 ………………………………………………22
第二節 資料蒐集方式………………………………………………… 22
第三節 個案選擇與資料分析 …………………………………………22
第四章 資料分析與討論 ……………………………………………25
第一節 禮貌策略之分布圖分析…………………………………………25
4.1.1醫師的禮貌策略分布圖之分析……………………………25
4.1.2 家屬的禮貌策略分布圖之分析……………………………26
4.1.3病童的禮貌策略分布圖之分析……………………………26
4.1.4 综合分析……………………………………………… 27
第二節 門診各流程常見之對話策略之分析…………………………… 28
4.2.1 門診起始的禮貌策略之分析…………………………… 29
4.2.2 醫師問診時策略之分析………………………………… 30
4.2.3 病患家屬提問時策略之分析 …………………………… 34
4.2.4 醫師解釋病情及衛教時策略之分析……………………… 36
4.2.5 結束道別時策略之分析………………………………… 39
4.2.6兒科的特殊狀況………………………………………… 41
第三節 策略分析對醫療效率的影響…………………………………… 43
4.3.1 策略分布對溝通效率之影響之分析……………………… 43
4.3.2 紀錄外策略之分析……………………………………… 44
第四節 醫師對此研究反應之分析 …………………………………… 52
第五章 結論與建議 ………………………………………………… 53
第一節 研究發現與貢獻 ……………………………………………… 54
第二節 研究限制……………………………………………………… 54
第三節 未來研究方向 ………………………………………………… 54
參考文獻 ……………………………………………………………… 55
中文部份 ……………………………………………………………… 55
英文部分 ……………………………………………………………… 55



表目錄
表2.1、威脅面子行為的類型………………………………………… 9
表2.2、總結Brown and Levinson的禮貌策略與細則……………… 11
表2.3、消極禮貌細則的舉例…………………………………………15
表2.4、積極禮貌策略的舉例…………………………………………16
表3.1、研究取樣醫師之基本資料 ……………………………………23
表4.1、 門診各流程常見之對話策略…………………………………40
表4.2、紀錄外【Off】策略之分析………………………………………51

圖目錄
圖2.1禮貌對策的流程表，以面子的威脅程度排序…………………19
圖4.1 醫師使用禮貌策略之分布圖 …………………………………26
圖4.2 家屬使用禮貌策略之分布圖 …………………………………26
圖4.3 病童使用禮貌策略之分布圖 …………………………………27
圖4.4 醫師與家屬使用禮貌策略之比較圖 …………………………28

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