Changing the structure of medical discourse: implications of cross-national comparisons

In the discourse of medical encounters, social problems arise frequently. Such problems typically derive from work and economic insecurity, family life and gender roles, aging, and conditions that foster substance use or other self-destructive behavior. The structure of medical discourse tends to marginalize the social issues that generate personal troubles in everyday life. Long-range strategies to alter medical discourse aim toward basic modifications of power and finance in the larger society of which medicine is a part; such strategies seek to change the contextual issues that create personal troubles on the individual level. As shown by the examples of the Soviet Union, eastern Europe, and China, social revolution does not necessarily resolve the micro-level contradictions of the doctor-patient relationship. In contrast, the Cuban revolution apparently has succeeded in transforming both the context and the structure of medical encounters. Short-range strategies in countries such as the United States involve more direct ways in which patients and doctors can alter their communication. These alterations involve reducing devices of language that maintain professional dominance, avoiding the medicalization of nonmedical problems, attempting not to marginalize contextual issues, and encouraging active attempts to change social conditions that generate personal troubles.