在集結眾多專科及重大儀器設備的現代醫療複合體系日益龐雜的情況下，醫病關係無可避免地正經歷重大的改變，然而相關研究卻十分有限。另外，在網路發達的當代，網路健康論壇提供病友一個可於線上群聚並分享個人經驗的重要社交平臺，而病患於平台上分享的故事（patient stories）提供我們另一種從病方角度探討醫療人員角色的管道。
本文便以臺灣國內著名的社交網路討論區－電子佈告欄(BBS)為語料來源，蒐集61個抗癌看板中癌症版友描述自身罹癌確診的自介貼文（本文稱其為「確診敘事(diagnosis narratives)」），以言談分析 (discourse analysis)的角度檢視文中提及的三種「醫療事件(medical events)」：（1）「信息性醫療事件(informative events)」：係指醫療信息的傳遞，如醫方針對病徵或檢驗結果所給予的解釋，以及針對後續診察方向所給予的建議（例如“葉醫生建議我去教學醫院＂）；（2）「操作性醫療事件(operational events)」：係指以治療或回復健康為目的所進行的一切檢查及檢驗工作（例如“馬偕的醫生幫我做了徹底的檢查＂）；（3）「確診性醫療事件(diagnostic events)」：係指對於檢查結果予以判定的醫療動作，通常具有宣告診斷結果的功能（例如“醫生證實是惡性腫瘤＂）。接著，我們聚焦於觀察這些醫療事件中指涉醫方時的用詞（我們稱其為「醫方指稱詞(reference terms for medical parties)」），針對這些詞彙對照真實世界的受指者之明確性或鑑別性高低又分為三類：（1）高揭露度（例如“葉醫生＂或“詹啟傑醫師(化名)＂)；（2）中揭露度（例如“馬偕的醫生＂）；（3）低揭露度（例如“醫師＂）。
在真實世界中(real world)，我們合理認為醫療事件的執事者(agent)理當為具專科背景的醫療專業人員，然而，我們想知道在病患的敘述世界(narrative world)中，醫療人員被提及的方式，其揭露度是否能明確對應至真實世界中的身分，因此本文將從以下三個研究問題來探討：

1. 在癌友的罹癌確診敘事中(cancer diagnosis narratives)，三種醫療事件(medical events)中所呈現的醫方指稱詞(reference terms for medical parties)為何?
2. 這些醫方指稱詞出現的言談模式為何？
3. 這些模式反映醫方在癌友描述的確診過程中扮演的角色功能為何？

針對研究問題一與研究問題二，我們有以下五點發現。
（1）在醫療事件中的醫方指稱詞可分為以下三類：「醫療人員」（47%，出現184次），接著是「醫療工具」（17%，出現67次）及「醫療地點」（15%，出現63次），另外還有省略無執事者的情況（21%，79 次）。與我們先前的假設相反的是，只有47%的醫療事件是以「醫療人員」出現於含醫療事件子句的主題位置作為執事者；而有超過半數的情況是沒有任何執事者（21%），或是為「醫療工具」（17%）或「醫療地點」（15%）取代，例如“病理檢查證實是惡性腫瘤”或“醫院幫我做了徹底的檢查＂)。
（2）在操作性醫療事件中，以「醫療地點」出現於主題位置做為執事者的比例最高（36%，例如另一間大型醫院就幫我做腹部超音波”）。我們稱此現象為「操作機構化(the institutionalization of medical procedures)」。
（3）在確診性醫療事件中，以「醫療工具」出現於主題位置做為執事者的比例最高（47%，例如“病理檢查證實是惡性腫瘤”）。我們稱此現象為「確診器械化(the technoscientifization of diagnosis)」。
　而針對揭露度分析，我們又發現以下兩個模式。（4）「醫療人員」揭露度分析結果，以「低揭露」所佔比例最高（132次，73%）；（5）「醫療地點」揭露度分析結果，以「高揭露」所佔比例最高（32次，52%）。也就是說，當提及醫療人員時，其姓或名鮮少被提及（僅14%），反而是指涉範圍十分廣泛的詞彙（例如“醫生”）之使用比例最高（73%，例如“醫生說：你是內膜癌一期＂）；然而，當提及醫療機構時的情況則相反，反而有半數以上的詞彙會明確指出醫療機構之全稱，屬於高揭露度（52%，例如“台安醫院門診診斷為良性”）。
　　根據以上五點關於醫療事件中之醫方執事者呈現模式的研究發現，我們推論出兩個論點來回應研究問題三，以反映在臺醫療人員於癌友描述的確診過程中扮演的角色功能：（1）重症診斷標準化與團隊化；（2）醫療人員顯要性降低。
　　論點一，腫瘤相關專科行醫模式漸趨標準化及團隊化：像癌症這樣的重症，一旦經確診，不但對癌友生活有相當衝擊，也會影響到公私立醫療資源的分配，因此其確診的客觀性便至關重要。而為了提升客觀性並降低醫療的不確定性，便需要有病理解剖或MRI造影等高科技醫療工具所提供的客觀數據報告來為專科醫師之主觀評估背書。然而，唯有具備足夠規模及財力的醫療機構才較有可能擁有這樣的專科人員以及專業器材，重症診斷便因此漸趨團隊化及標準化，這也解釋了我們於癌友確診敘事中觀察到之「確診器械化」及「操作機構化」現象。
　　論點二，醫療人員之顯要性降低：先前提過，技術上來說，執行醫療事件的執事者理應為「人」，舉例來說，實際執行人體組織分析以及撰寫實驗報告以證實腫瘤科醫師之初步判斷的人就是「病理科醫師」。然而，在現今以團隊化醫療為趨勢的醫療體系裡，反而因為癌友確診過程中將遇見多位醫療人員，而使得醫師個人之姓名及身分的重要性在癌友的敘事中相對減少；相反地，當提及醫療地點時，半數以上的情況會完整明確提及機構名稱，如同這些機構才是宣判病患罹癌的關鍵人物一樣，這樣的現象解釋了醫療人員揭露度偏低，但醫療地點揭露度卻相當高的現象。
　　在操作性醫療事件裡，癌友傾向於提及醫療地點作為主事者，表達在罹癌確診過程中為其檢驗的施行者；在確診性醫療事件裡，則傾向於提及醫療工具作為最後的得病宣判者。總結來說，在癌症確診敘事裡，我們發現醫療人員顯著及重要的程度不再被彰顯，取而代之的是醫療地點以及工具。
　　從癌友確診敘事中針對醫方指稱詞的語言表現及其所呈現模式，我們認為腫瘤相關的專科人員其顯要性及個人性正逐漸降低。然而，本研究發現僅根基於在網路社交平臺所分享的病人罹癌故事。當代醫師去個人化的現象要如何進一步推論及應用解釋至其他醫病溝通領域或語料範圍，將是值得後續深入探討的議題。

As the operation of modern health care systems has developed into a vast complex involving multiple specialties and advanced high-tech equipment, this inevitably has impact on conventional physician-patient relationship. This change, however, has received little attention in the literature. While internet health forums have becomes an important social media platform where patient groups gather, their online discourse, such as patient narratives, provides an alternative window to explore the roles of medical specialists from the patients’ perspectives. Using discourse analysis, the current study examines 61 patients’ narratives of their cancer diagnosis (‘diagnosis narratives’) collected from a popular online bulletin board system in Taiwan. We targeted narrative clauses which describe any of the following three types of medical events: (1) informative events in which messages about certain medical events, behaviors, or practice are delivered (such as ‘葉醫生建議我去教學醫院/ Doctor Yeh suggested that I go to a teaching hospital’), (2) operational events in which the operation of a medical procedure or intervention was performed (such as ‘馬偕的醫生幫我做了徹底的檢查/ The doctor at the MacKay Hospital did a thorough examination for me’), and (3) diagnostic events in which news related to diagnosis or health check results were delivered (such as ‘醫生證實是惡性腫瘤/ (The doctor verified it as a malignant tumor’).
We further classified the reference terms identified in this study into the following three levels of discernibility—the likelihood that the referent in the narrative clauses can be identified with its corresponding one in the real world: high-discernibility (‘葉醫生/ Doctor Yeh’ or ‘詹啟傑醫師/ Doctor Qi-Xian Zhan’, a pseudonym example), mid-discernibility (‘馬偕的醫生/ The doctor at the MacKay Hospital’) , and low-discernibility (‘醫生/ the doctor’). While in the real world we would normally assume that these medical events would be performed by a medical professional with a discernable presentation of their name or specialty title (e.g., name tag or official chop on lab reports), we wonder, in the patients’ narrative world, whether they retain the same agency with their identity presented in the same discernible manner. Specifically, we focused on the following three research questions:
（1）How are the medical parties linguistically referred to in the three medical event types in the cancer patients’ diagnosis narratives?
（2）What are the discourse patterns of the use of the reference terms?
（3）What are roles of modern medical professionals in Taiwan, as reflected in the above discourse patterns?
Our findings to research questions (1) and (2) are as follows.
(1) The agents who perform the three medical events are referred to in three noun phrase groups (‘NP’): medical professional NP (47%, 184 instances), medical equipment NP (17%, 67 instances), medical institution NP (15%, 63 instances), and zero NP (i.e., not mentioned at all, 21%, 79 instances). Against our assumption, only 47% of the time is a medical professional referred to with regard to what they did by an NP of their family name and professional title (e.g. ‘葉醫生建議我去教學醫院/ Dr. Yeh suggested that I go to the teaching hospital’). Most of the time, they are either not mentioned (21%), or replaced by a medical equipment NP (17%, e.g. ‘病理檢查證實是惡性腫瘤/ The pathological examination verified it as a malignant tumor’) or a medical institution NP (15%, ‘醫院幫我做了徹底的檢查/ The hospital did a thorough examination for me’).
(2) In the narrative clauses which describe medical operational events, the most frequently used NP in referring to the agent is medical institution NP (36%, e.g. ‘另一間大型醫院就幫我做腹部超音波/ Another big hospital did an abdominal ultrasound for me”. We termed this phenomenon ‘the institutionalization of medical procedures’.
(3) In the narrative clauses which report diagnostic events, the most frequently used NP in referring to the agent is the medical equipment NP (47%, e.g.“病理檢查證實是惡性腫瘤/ The pathological examination verified it as a malignant tumor”. We termed this phenomenon ‘the technoscientifization of diagnosis’.
With regard to the discernibility of the reference terms, we also observed the following two patterns. (4) While the discernibility of the medical professional NP is generally low (73%), (5) that of the medical institution NP is high (52%). That is, when a medical professional is mentioned as the agent of a medical event, his/her (family) name is hardly mentioned (14%); instead he/she is very likely to be generalized as any or some doctor (73%), such as ‘醫生說:你是內膜癌一期/ the doctor said: You are a case of stage I endometrial cancer’. However, when an institution is described as the agent of a medical event, its name tends to be fully spelled out (52%), so that one has no trouble in identifying it in the real world (such ‘台安醫院門診診斷為良性/ the out-patient department at Tai-an Hospital gave a diagnosis of benign status’).
The above five discourse patterns of how the agents, i.e., the medical parties, of three medical event types are referred to answered our research questions (1) and (2). They also led to our following two arguments in response to our third question regarding the roles of modern medical professionals in Taiwan: ‘team-based and standardized diagnosis of severe disease’ and ‘the disappearance of medical professionals’ visibility and individuality’.
Argument (1): ‘team-based and standardized diagnosis of severe disease’: A diagnosis of a critical disease, such as cancer, has a great impact on patients’ life course and their rights to public or private medical resources. To minimize medical uncertainty, the subjective evaluations of specialists must be confirmed with a series of objective reports by high-tech medical equipment, such as pathology exams or MRI images. Access to these specialists and equipment is only possible in a tertiary care center. Such a team-and-institution-based practice of oncology-related specialists accounts for the discourse patterns of “the institutionalization of medical procedure” and “the technoscientifization of diagnosis” we observed from cancer patients’ diagnosis narratives.
Argument (2): ‘the disappearance of medical professionals’ visibility and individuality’: Technically speaking, all the medical procedures or interventions have to be operated by a human agent; for example, the pathologist is the one who analyzes the body tissue and gives the lab report to confirm an oncologist’s initial impression. In the patient’s journey of completing all the required procedures in this team-and-institution-based medical system, the names or identities of the specialist they have physically encountered became less relevant in their diagnosis narratives. Instead, it is the medical procedures or interventions (i.e., the technoscientifization) they have received that confirm their status as cancer patients, further endorsed by the title of the institution who owns these equipment. This accounts for the low-discernibility of medical professional NP and the high-discernibility of medical institutions.
When patients describe the agent who performs the medical procedures on them, they tend to construct this individual by the institution name he/she affiliates to, and when patients report the agent who gives the final word on their diagnosis it is often the medical procedures that receive the credit. In conclusion, the medical professional’s agency in cancer diagnosis, as observed in patients’ online narratives, is becoming invisible or gradually yields to that of institutions and equipment.
Based on the linguistic expressions which refer to the agent of medical events that cancer patients had gone through till they received the diagnosis, we observed discourse patterns that suggest the loss of the visibility and individuality of oncology-related specialists involved in the diagnosis process. This linguistic construction, however, is solely based on the online social media where patients share their diagnosis stories. How this de-individualization phenomenon is applicable in other contexts or how it reflects physician roles in other health care contexts are important questions for further studies.

Burke, Kenneth. (1969). A grammar of motives: University of California Press.
Chang, Yu-hsiu. (1998). The study of personal pronouns in Mandarin political discourse. Unpublished MA thesis. Graduate Institute of English, National Taiwan Normal University, Taipei, Taiwan.
Chao, Y. R. (1968). A Grammar of Spoken Chinese: University of California Press.
Charon, Rita. (2005). Narrative medicine: Attention, representation, affiliation. Narrative, 13(3), 261-270.
Chou, Wen-Ying Sylvia, Hunt, Yvonne, Folkers, Anna, & Augustson, Erik. (2011). Cancer survivorship in the age of YouTube and social media: a narrative analysis. Journal of medical Internet research, 13(1).
Clarke, Adele E, Shim, Janet K, Mamo, Laura, Fosket, Jennifer Ruth, & Fishman, Jennifer R. (2003). Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine. American Sociological Review, 68(2), 161-194.
Du Bois, Inke. (2010). Wir bleiben Kanzlerin—We are Pregnant?: On grammatical, semantic and pragmatic usages of the" we" pronoun. SWPL, 3, 21-34.
Estes, Carroll L, Harrington, Charlene, & Pellow, David N. (2000). The medical industrial complex. The encyclopedia of sociology, 1818-1832.
Fan, Yanping. (2013). The Lexical Features of English Advertisement. Paper presented at the 2013 International Conference on the Modern Development of Humanities and Social Science.
Gawande, Atul. (2003). Complications: A surgeon's notes on an imperfect science: Profile Books.
Hafferty, Frederic William. (2015). 2015 "Hidden Curriculum" Faculty Development Workshop.
Hampton, JR, Harrison, MJ, Mitchell, JR, Prichard, JS, & Seymour, Carol. (1975). Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. BMJ, 2(5969), 486-489.
Huang, CT James. (1989). Pro-drop in Chinese: A generalized control theory The null subject parameter (pp. 185-214): Springer.
Jewson, Nicholas D. (1976). The disappearance of the sick-man from medical cosmology, 1770-1870. Sociology, 10(2), 225-244.
Klemm, Paula, Reppert, Karla, & Visich, Lori. (1997). A nontraditional cancer support group. The Internet. Computers in nursing, 16(1), 31-36.
Kreuter, Matthew W, Green, Melanie C, Cappella, Joseph N, Slater, Michael D, Wise, Meg E, Storey, Doug, . . . Holmes, Kathleen. (2007). Narrative communication in cancer prevention and control: a framework to guide research and application. Annals of Behavioral Medicine, 33(3), 221-235.
Kuo, Chih-Hua. (1999). The use of personal pronouns: Role relationships in scientific journal articles. English for specific purposes, 18(2), 121-138.
Labov, William. (1972). The transformation of experience in narrative syntax. Language in the inner city, 354, 96.
Li, Charles N, & Thompson, Sandra A. (1981). A functional reference grammar of Mandarin Chinese: University of California Press.
McKinlay, John, & Marceau, Lisa. (2008). When there is no doctor: reasons for the disappearance of primary care physicians in the US during the early 21st century. Social science & medicine, 67(10), 1481-1491.
Osler, William, & Silverman, Mark E. (2008). The Quotable Osler: ACP Press.
Parsons, Talcott. (1951). The Social System.
Sackett, David L, Rosenberg, William M, Gray, JA, Haynes, R Brian, & Richardson, W Scott. (1996). Evidence based medicine: what it is and what it isn't. BMJ: British Medical Journal, 312(7023), 71.
Sanders, Lisa. (2010). Every patient tells a story: medical mysteries and the art of diagnosis: Random House LLC.
Sekhar, M Sonal, & Vyas, Navya. (2013). Defensive medicine: A bane to healthcare. Annals of medical and health sciences research, 3(2), 295.
Studdert, D. M., Mello, M. M., Sage, W. M., DesRoches, C. M., Peugh, J., Zapert, K., & Brennan, T. A. (2005). Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA, 293(21), 2609-2617.
吕叔湘. (1979). 汉语语法分析问题: 商务印书馆.
朱秀鳳. (2008). 從組織圖探討醫院管理部門之位階演變型態. 國立中山大學.
李秉穎. (2006). 醫學的機率與藝術. Retrieved August 21, 2015, from http://olddoc.tmu.edu.tw/pinging/MED/MED18.HTM
周碧香. (1999). 漢語親屬稱謂詞的文化內涵. 語文教育通訊, 17, 21-32.
屈承熹. (1983). 語言學論集: 理論, 應用及漢語語法 (Linguistics: Theory, Application and Chinese Syntax). 文鶴出版社.
侯英泠. (2002). 良性醫病關係之建立. 應用倫理研究通訊(21), 36-40.
胡光夏. (2005). 廣告與戰爭: 走避或共舞? 以兩次波斯灣戰爭為例. 復興崗學報(85), 115-136.
范國棟. (2002). 是醫療專業者？還是雇傭勞動者！-初探歐美醫師角色的轉變與分析醫療專業的學說. 台灣醫界, 45(10).
張苙雲. (1998). 從不穩定的口碑到主要的求醫場所: 台灣西醫的制度信任建構. Social Sciences, 8(1), 161-183.
曹逢甫. (2005). 漢語的句子與子句結構. 北京: 北京語言文化.
許達夫. (2012). 誤診誤醫: 許達夫為你揭開現代醫療真相: 時報出版社.
郭吉助. (2008). 論醫事法律上之醫療行為-由法制面談起.
陳杰峰, 蔡宛真, & 邱文達. (2004). 實證醫學於健康照護之應用. 臺灣醫學, 8(2), 235-240.
陳進明. (2004). 防禦性醫療. 台灣醫界, 47(8).
储泽祥. (2004). 小句是汉语语法基本的动态单位. 汉语学报(2), 48-55.
程俊源. (2011). 台, 華語 [稱代系統] 與閩, 客語 [親屬稱謂] 研究. 臺灣師範大學國文學系學位論文, 1-312.
黃莉萍. (2010). 臺灣美濃地區客語親屬稱謂詞之研究. 國立屏東教育大學.
楊心儀. (2011). 以語用觀點論現代漢英人稱代詞之非典型用法. 暨南大學.
廖真慧. (2015). 閩南語第一人稱複數包含式代名詞 ‘咱’於電台賣藥廣告語用功能之言談分析. 國立成功大學.
廖真慧、蔡美慧. (2015). 閩南語第一人稱複數包含式代名詞於電臺賣藥廣告之語用功能與應用分析. 靜宜語文論叢, 8(2), 66-105.
劉仲冬. (2000). 教育大辭書. Retrieved July 11, 2014, from　　　　　　　　　　　　　　　　http://terms.naer.edu.tw/detail/1315232/
劉育志. (2013). 臺灣的病人最幸福：有圖有真相: 臺灣商務.
鄭盈盈. (2014). 人稱代詞在政治語境中的應用--以俄漢人稱代詞" 我" 和" 我們" 為例. 人文資源研究學報(15), 175-189.
蕭淑惠. (1996). 從文化角度看臺灣親屬稱謂之演變. 雲漢學刊, 151-164.
戴玉慈, 呂淑華, & 徐銘玉. (2000). 醫療人員如何稱呼病患? 醫學教育, 4(3), 307-314.
謝啟瑞. (1994). 醫療糾紛風險與防禦性醫療行為. 人文及社會科學集刊, 6, 199-230.
韓良誠. (2011). 2011 年成大醫學院 101 級宣誓典禮致詞. 當代醫學(454), 612-615.