Patients as Problem Solvers: Toward a Rhetoric of Agency in Healthcare

Author: Amanda Young
Degree: Ph.D. in Rhetoric, Carnegie Mellon University, 2000

This dissertation presents two components of my work: developing a model of healthcare communication focusing on agency and then building and testing an interactive computer program based on that model, which I call collaborative interpretation (or CI). CI is a rhetorical practice that situates patients as partners in a reciprocal relationship and as joint problem solvers and decision makers. My development of this model began with analyzing patient/provider interactions in an emergency department. I argue that the communication problems I observed are rooted in mismatched expectations and the lack of explicit comparison and negotiation of expectations - or, a failure to see patient/provider interactions as rhetorical, knowledge-building events. CI helps patients represent their medical problems in the context of their lives and share the logic behind their healthcare decisions. It helps patients and providers identify expectations, obstacles, and options.

The second part of the dissertation focuses on What's Your Plan?, an interactive program built on the principles of CI and designed to support girls as they make decisions about abstinence and contraceptive use. The program was built in collaboration with teenagers in four sites in Pittsburgh. Then, with Planned Parenthood, I conducted a study with 7 girls at Wilkinsburg High School as they worked through the program with a mentor. I wanted to learn how the girls use language to construct agency in making decisions and plans about their health. Analyses of the girls' texts show them making a series of cognitive, rhetorical, and linguistic moves that signify a high degree of agency. These moves fall into two categories: analyzing the decision making process and manipulating knowledge. The first includes considering emotional and psychological well being; recognizing the possible results of a decision; and thinking critically about the decision-making process. Knowledge manipulation includes identifying internal and external sources of expertise, evaluating and combining knowledge sources, and extricating embedded knowledge. The data also show girls reaching a critical decision point where residual conflicts and competing belief systems emerge to threaten their agency. In addition to relevance for adolescent counseling, these findings have concrete and specific implications for support systems for chronically ill patients.