問診中的結尾階段是醫生與病人最後溝通的時機，互動的觀點從著重於解決過去與現在的問題轉換至未來安排，即達到結束互動的目的 (White et al, 1997)。結尾階段不僅是醫生與病人建立良好關係的重要時刻，更是尋求問題解答的最後時機。然而，在互動中未解決的問題 (unresolved concerns) 經常因為醫生與病人掌握資訊的不平衡、時間壓力等種種因素無法獲得解決。與西方醫療環境不同，台灣的醫療環境中，病人無論於問診的前後都屬客人，也就是，病人進出診間，醫生則固定留在診間中接待每位病人。因此，醫生在環境設定中，已經具有環境的優勢。這樣的環境因素凸顯醫病關係不對等的本質。尤其，醫療問診的主要目的即是幫助病人解決問題以達到良好的健康結果；因此，如何在資訊與關係不對等的自然環境下善加利用問診每分每秒的同時，也能夠提供病人更友善的醫療環境 (Patient-centered) 成為了一個值得探討的議題。過去醫療溝通相關領域的研究探討多專注問診中較為著重資訊需求的階段，如資訊蒐集階段(information seeking stage)等等。相較之下，一般被視為建立互動關係 (building rapport) 的結尾階段之相關研究相對較少。然而如醫療問診這樣結構與語意皆較為限制的語境中，本文研究目標在指出(1)台灣醫療問診中的結尾階段有哪些語言成份以及其出現的時機? 又什麼語言結構構成台灣醫療問診的結尾階段? 以及(2)什麼語言成份能夠延展話題並可能促成醫生重新開啟前面的資訊蒐集階段? (3)在受制的語境下溝通，什麼語言成份表示溝通已達到相同的觀點並對互動結束的接受?
本文研究重心在分析台灣醫療問診之結尾階段的語言結構並點出於結尾階段中醫病是如何達到共識並結束互動。根據Schegloff & Sacks (1973)與White et al (1997) 對於日常對話中結尾的分析方法，本文分析從30個問診案例中，歸納與分析一適合台灣醫療結尾階段之基本模型。語料收集於台灣南部某一教學醫院之研究結果發現台灣醫病對話中的結尾階段分別由前段結尾 (pre-closing sequence) 與後段結尾 (closing sequence) 組合而成；其中在前段結尾中可見的語言成份為: (a)預備 (preparation) (b) 最後通知 (final-notification)，組成後段結尾的語言成份為: (c) 共同接受 (mutual acceptance)。由此可一覽台灣問診中結尾階段的模型。研究中發現，前段結尾中的主要發言者與首先開啟結尾階段的角色有97%的案例都是醫生。而有43%的案例中，醫生主動以最後通知 (final notification) 主導結尾。病人在結尾階段中的發言亦屬於較為被動之角色，此發現反映了醫病關係的不對等。本文亦發現在醫生提出預備(preparation) 之後，病人若有未解決的問題則會在這個言談位置上提出，本文中將此時機出現之尚未解決的問題稱為結尾抗拒 (closing resistance)，該尚未解決的問題有時會使得醫生需要重新開啟前面的資訊蒐集階段，而後再一次的提出結束互動的邀請。結尾抗拒亦可視為病人獲得言談主導並延展話題的時機，然後研究中發現九個(30%)帶有結尾抗拒的案例中僅有一例延展話題並促使醫生重新開啟前面的問診階段，病人言談主導的比例仍然相對較低。另外，後段結尾中 “再見” (20%) 與 “謝謝” (80%) 被視為對結尾溝通的共同接受，亦是共同接受互動的結束。其中，有80%的案例中，謝謝可作為對結尾溝通的共識與接受，亦反映醫病關係在語言環境(施惠與受惠的語境) 的限制下亦呈現其關係之不對等。
最後，研究結果呈現在結尾過程中，醫療人員為主導結尾流程的主要角色，病人在結尾互動中能夠藉由提出結尾抗拒 (closing resistance) 延展話題的比例低顯現醫病關係的不對等仍可清楚在結尾階段中看見。並且，研究結果更反映台灣醫療環境仍然傾向著重滿足病人的資訊需求而較容易忽略病人的情感需求。

The closing stage in medical encounters is the final stage for doctors and patients to negotiate the perspective from present events to a future orientation (White et al, 1997). Closing stages are not only a crucial stage for both doctors and patients to build up a positive relationship but also the last chance to solve problems. Often, due to the agenda of patients’ and the authorized higher power status of the doctor, sometimes these additional concerns, along with the chief complaint are difficult to follow. Additionally, unlike western medical environment in which the doctor will leave the examining room before the patient does, in Taiwanese medical encounters, patient comes and goes while the doctor is in the examining room preparing for the next patient’s visit. The doctor has the home court advantage in medical encounters. Therefore, the nature of power asymmetry may become the patient’s agenda thus makes the patient fail to reveal all the concerns. Patients’ agenda and the asymmetric power relationship may cause concerns unresolved. Since the essential purpose of medical encounters is to resolve the concerns from patients and to contribute to a good health outcome, successfully resolving concerns through communication skills in medical encounters is a crucial issue worth following. However, clear linguistic elements and discourse positions which signal the closing stages still remain unclear. For improving diagnosis and achieving a patient-centered medical environment, the study follows previous studies to examine the interactions between doctors and patients in the closing stages in medical encounters because every second in an encounter is important. The aim of this study is indicating the linguistic elements reflect the interaction between doctors and patient parties in closing stages and how the participants achieve the mutual acceptance of closing. In order to demonstrate it, the first description of closing stages needed to be pinned down in advance. Hence, the first focus of the current study is (1) how the closing stages in Taiwanese medical encounters are structured? (2) what linguistic elements may cause the doctor to reopen the previous seeking stage to solicit the unresolved concern? Third, (3) in institutional settings, in a way to negotiate the closing of the encounter, what are the linguistic elements that signal the confirmation for participants that they are in the same perspective and ready to leave? An observation of the interaction in closing stages of Taiwanese medical encounters is presented in this study based on the analyzing approaches proposed by Schegloff & Sacks (1973) and White et al (1997). By analyzing 30 cases that were collected in the department of family medicine at a medical teaching hospital in southern Taiwan, the finding shows that closing stages in medical conversations is constituted by pre-closing and closing sequences jointly in Taiwanese medical closing stages. Linguistic elements that are used as materials to warrant a closing are as following: (1) pre-closing sequences: (a) preparation (b) final-notification; (2) closing sequences: (c) mutual acceptance. Moreover, the first finding shows the main initiator of preparation in the negotiation of closing is mostly the doctor (97%). And doctors actively take the leading position in current interaction by using final notification (43%). The finding provides us an overview of pre-closing sequences in the closing stages in Taiwanese medical encounters. Second finding shows that the unresolved concerns which are brought up after a preparation are closing resistance. When it occurs (30%), it may cause the doctor an effort to reopen the information seeking stage. We concluded closing resistance represents an approach for the patient parties to take control of the turn of talking hence to extend the interaction and resolve their concerns. Third, closing sequence occurs after pre-closing sequence and before the actual end point in an encounter. We found linguistic elements such as goodbye phrase (20%) and thanking (80%) are used as mutual acceptance in closing sequences in Taiwanese medical encounters. Goodbye phrase and thanking demonstrate a unit of closing sequence and signal a completion of the current interaction. The findings indicate that linguistic elements (pre-closing and closing sequences) found in closing stages are mostly used by medical staffs; in terms of that dominators in closing stages are still medical staffs. Further, the opportunity for patient parties to extend and control the interaction is rare (30%). In which the asymmetrical power status between doctors and patients seems easily seen in closing stages. Since to detect and assist the patient parties to fully express their concerns is important, acknowledging patient parties’ approach to express their concerns is a crucial issue in present study. The study also indicates that a task-oriented approach is still the mainstream even in the final phase in Taiwanese medical encounters. Moreover, the unrevealing agendas of participants may decrease the effectiveness of medical encounters, or cause the psychological pressure of the patient. Hence, problem resolving and rapport building are both worth achieving in every stage in medical encounters.

Ainsworth-Vaughn, N. 1995. Claiming power in the medical encounter: the whirlpool discourse. Qualitative Health Research 5.270.
Ainsworth-Vaughn, Nancy. 1992. Topic Transitions in Physician-Patient Interviews: Power, Gender, and Discourse Change. Language in Society 21.409-26.
Baker, L.H., D. O'Connell & F.W. Platt. 2005. “What Else?” Setting the Agenda for the Clinical Interview. Annals of Internal Medicine 143.766.
Bardovi-Harling, K, BAS Hartford, R Mahan-Taylor, MJ Morgan & DW Reynolds. 1991. Developing pragmatic awareness: Closing the conversation. ELT journal 45.4.
Barr, D.A. & S.F. Wanat. 2005. Listening to patients: cultural and linguistic barriers to health care access. Fam Med 37.199-204.
Beach, W.A. 1995. Conversation Analysis:'Okay'as a Clue for Understanding Consequentiality. The consequentiality of communication.121-62.
Beckman, HB & RM Frankel. 1984. The effect of physician behavior on the collection of data. Annals of Internal Medicine 101.692.
Bou-Franch, Patricia. 2010. Openings and closings in Spanish email conversations. Journal of Pragmatics In Press, Corrected Proof.
Button, G & JRE Lee. 1987. Talk and social organisation: Multilingual Matters Ltd.
Byrne, PS, BEL Long & G Britain. 1984. Doctors talking to patients: A study of the verbal behaviour of general practitioners consulting in their surgeries: Royal College of General Practitioners.
Cheng, S. 2008. Doctor's Eye Contact and Patient's Response in Geriatric Triadic Encounters: A Study on Verbal and Nonverbal Interaction.
Coupland, J, N Coupland & JD Robinson. 1992. "How are you?": Negotiating phatic communion. Language in Society 21.207-30.
Coupland, J., J.D. Robinson & N. Coupland. 1994. Frame negotiation in doctor-elderly patient consultations. Discourse & Society 5.89.
Drew, P. & J. Heritage. 1992. Talk at work: Interaction in institutional settings: Cambridge Univ Pr.
Dutton, WH & F Nainoa. 2002. Say Goodbye: Let's Roll: The Social Dynamics of Wireless Networks on September 11. Prometheus 20.237-45.
Dyche, L. & D. Swiderski. 2005. The effect of physician solicitation approaches on ability to identify patient concerns. Journal of general internal medicine 20.267-70.
Epstein, R.M., L. Mauksch, J. Carroll & C.R. Jaén. 2008. Have you really addressed your patient's concerns? Family Practice Management 15.35.
Eyal, K. & J. Cohen. 2006. When good friends say goodbye: A parasocial breakup study. Journal of Broadcasting & Electronic Media 50.502-23.
Feinberg, M.R., G. Feinberg & J.J. Tarrant. 1978. Leavetaking: When and how to say goodbye: Simon and Schuster New York.
Fisher, S. 1984. Institutional authority and the structure of discourse. Discourse Processes 7.201-24.
Fitch, K. 1990. A ritual for attempting leave‐taking in Colombia. Research on Language & Social Interaction 24.209-24.
Fitzpatrick, M.A., T. Edgar & V. Freimuth. 1992. Communication, language and health: An overview. Journal of Language and Social Psychology 11.1-8.
Frankel, R. 1990. Talking in interviews: A dispreference for patient-initiated questions in physician-patient encounters. Interaction competence.231-62.
Goffman, E. 1981. Forms of talk: Univ of Pennsylvania Pr.
Greene, M.G., R.D. Adelman & S.D. Majerovitz. 1996. Physician and older patient support in the medical encounter. Health Communication 8.263-79.
Greif, E.B. & J.B. Gleason. 1980. Hi, thanks, and goodbye: More routine information. Language in Society 9.156-66.
Hamilton, W. & N. Britten. 2006. Patient agendas in primary care. Bmj 332.1225-26.
Heritage, J. & J.D. Robinson. 2006. The structure of patients' presenting concerns: physicians' opening questions. Health Communication 19.89-102.
Heritage, J., J.D. Robinson, M.N. Elliott, M. Beckett & M. Wilkes. 2007. Reducing patients’ unmet concerns in primary care: the difference one word can make. Journal of general internal medicine 22.1429-33.
Huang, S. 2008. Laughter in Doctor-Elderly Patient Communication Effects on Patient Participation.
Huang, Yu Ting. 2009. Failure to close the interaction-when doctors and patients have the disagreement. Paper presented at the NCL2009, Yuan Ze University.
Humphreys, J. 2002. The Role of Questions and Answers in Doctor-Patient Interaction: Online:< http://www. ling. lancs. ac. uk/staff/florencia/201/res/diss/humphreys. pdf> Retrieved.
Irish, J.T. & J.A. Hall. 1995. Interruptive patterns in medical visits: the effects of role, status and gender. Social Science & Medicine 41.873-81.
Jefferson, G. & J.R.E. Lee. 1981. The rejection of advice: Managing the problematic convergence of a troubles-telling'and a service encounter'. Journal of Pragmatics 5.399-422.
Kaplan, C.B., B. Siegel, J.M. Madill & R.M. Epstein. 1997. Communication and the medical interview. Journal of general internal medicine 12.49-55.
Laver, J. 1981. Linguistic routines and politeness in greeting and parting. Conversational routine.289-304.
LeBaron, C.D. & S.E. Jones. 2002. Closing up closings: Showing the relevance of the social and material surround to the completion of interaction. Journal of Communication 52.542-65.
Levinson, W, R Gorawara-Bhat, R Dueck, B Egener, A Kao, C Kerr, B Lo, D Perry, K Pollitz & S Reifsteck. 1999. Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care. JAMA 282.1477.
Levinson, W., W.B. Stiles, T.S. Inui & R. Engle. 1993. Physician frustration in communicating with patients. Medical Care.
Lipkin, M. 1996. Patient education and counseling in the context of modern patient-physician-family communication. Patient Education and Counseling 27.5-11.
Lutton, M.E. 2004. Sticking the landing: How to create a clean end to a medical visit. Family Practice Management 11.51-53.
Magolda, PM. 2003. Saying good-bye: An anthropological examination of a commencement ritual. Journal of College Student Development 44.779-96.
Martin, D. 2003. Martin's Map: a conceptual framework for teaching and learning the medical interview using a patient‐centred approach. Medical Education 37.1145-53.
Marvel, M.K., R.M. Epstein, K. Flowers & H.B. Beckman. 1999. Soliciting the patient's agenda. JAMA: The Journal of the American Medical Association 281.283.
Mauksch, L.B., D.C. Dugdale, S. Dodson & R. Epstein. 2008. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Archives of internal medicine 168.1387.
Maynard, D.W. & J. Heritage. 2005. Conversation analysis, doctor–patient interaction and medical communication. Medical Education 39.428-35.
Mishler, E.G. 1984. The discourse of medicine: Dialectics of medical interviews: Ablex Publishing Corporation.
Pilnick, A., J. Hindmarsh & V.T. Gill. 2009. Beyond ‘doctor and patient’: developments in the study of healthcare interactions. Sociology of health & illness 31.787-802.
Pilnick, Alison. 2001. The interactional organization of pharmacist consultations in a hospital setting: a putative structure. Journal of Pragmatics 33.1927-45.
Pinzon, J.L., K. Jacobson & J. Reiss. 2004. Say goodbye and say hello: the transition from pediatric to adult gastroenterology. Canadian journal of gastroenterology= Journal canadien de gastroenterologie 18.735.
Placencia, M.E. 2004. Rapport‐building activities in corner shop interactions. Journal of Sociolinguistics 8.215-45.
Putnam, S.M. 2002. Changing health behaviors through the medical interview. Epidemiologia e Psichiatria Sociale 11.218-25.
Raclaw, J. 2008. Two patterns for conversational closings in instant message discourse. Colorado Research in Linguistics 21.
Realini, T., A. Kalet & J. Sparling. 1995. Interruption in the medical interaction. Archives of Family Medicine 4.1028.
Rhodes, DR, K.F. McFarland, W.H. Finch & A.O. Johnson. 2001. Speaking and interruptions during primary care office visits. FAMILY MEDICINE-KANSAS CITY- 33.528-32.
Robinson, D. & T. Stivers. 2001. Achieving activity transitions in physician‐patient encounters. Human Communication Research 27.253-98.
Robinson, J.D. 2001a. Asymmetry in action: Sequential resources in the negotiation of a prescription request. Text-Interdisciplinary Journal for the Study of Discourse 21.19-54.
—. 2001b. Closing medical encounters: two physician practices and their implications for the expression of patients' unstated concerns. Social Science & Medicine 53.639-56.
—. 2003. An interactional structure of medical activities during acute visits and its implications for patients' participation. Health Communication 15.27-59.
—. 2006. Soliciting patients' presenting concerns. STUDIES IN INTERACTIONAL SOCIOLINGUISTICS 20.22.
Rodondi, P.Y., J. Maillefer, F. Suardi, N. Rodondi, J. Cornuz & M. Vannotti. 2009. Physician Response to “By-the-Way” Syndrome in Primary Care. Journal of general internal medicine 24.739-41.
Roter, D. & K.S. McNeilis. 2003. The nature of the therapeutic relationship and the assessment of its discourse in routine medical visits. Handbook of health communication.121-40.
Ruiz-Moral, R., JM Parras-Rejano, JA Alcalá-Partera, E. Castro-Martín & L.A.P. de Torres. 2005. Welcome and I’ll See You Again or Hello and Goodbye?: Communicative Behaviour of Medical Residents in the First and Last Moments of Consultations. Aten Primaria 36.537-44.
Schegloff, E.A. & H. Sacks. 1973. Opening up closings. Semiotica 8.289-327.
Shapiro, J., R. Yu & M.K. White. 2000. Reconciling doctor and patient agendas: a case illustration, 2000.
Sherwood, A. 1983. Exit interviews: don't just say goodbye. The Personnel journal 62.744.
Silverman, J. & J. Draper. 1995. Identifying the agenda in the consultation. The British Journal of General Practice 45.52.
Silverman, J., S.M. Kurtz, J. Draper, J. van Dalen & F.W. Platt. 1998. Skills for communicating with patients.
Suchman, A.L. 2003. Research on Patient‐clinician Relationships. Journal of general internal medicine 18.677-78.
Sun, H. 2004. Opening moves in informal Chinese telephone conversations . Journal of Pragmatics 36.1429-65.
Tai-Seale, M., R. Bramson & X. Bao. 2007. Decision or No Decision: How Do Patient–Physician Interactions End and What Matters? Journal of general internal medicine 22.297-302.
Tannen, D. 1993. What's in a frame? Surface evidence for underlying expectations. Framing in discourse 14.56.
Ten Have, P. 1989. The consultation as a genre. Text and talk as social practice.115-35.
Ten Have, P. 1991. Talk and institution: A reconsideration of the" asymmetry" of doctor-patient interaction. Talk and social structure.138-63.
Tsai, MH. 2005. Opening stages in triadic medical encounters in Taiwan. Communication & Medicine 2.53-68.
—. 2007. Who gets to talk? An alternative framework evaluating companion effect in geriatric triads. Communication and Medicine 4.37-49.
van Dulmen, A. M. 2002. Different perspectives of doctor and patient in communication. International Congress Series 1241.243-48.
West, C. 1983. Ask me no questions...": An analysis of queries and replies in physician-patient dialogues. The social organization of doctor-patient communication 2.127-57.
—. 1984. Medical misfires: Mishearings, misgivings, and misunderstandings in physician‐patient dialogues. Discourse Processes 7.107-34.
White, J., W. Levinson & D. Roter. 1994. Oh, by the way…. Journal of general internal medicine 9.24-28.
White, JC, C Rosson, J Christensen, R Hart & W Levinson. 1997. Wrapping things up: A qualitative analysis of the closing moments of the medical visit. Patient Education and Counseling 30.155-65.
Williams, S, J Weinman & J Dale. 1998. Doctor-patient communication and patient satisfaction: a review. Family Practice 15.480.
Žegarac, V. & B. Clark. 1999. Phatic interpretations and phatic communication. Journal of Linguistics.321-46.
Zimmermann, C, L Del Piccolo & A Finset. 2007. Cues and concerns by patients in medical consultations: a literature review. Psychological bulletin 133.438.
Zoppi, K. 1997. Interviewing as clinical conversation. Introduction to Clinical Skills.41-57.
蔡美慧, 曹逢甫 & 盧豐華. 2004. 揭開病人面具─ 從傾聽病人開始. 醫學教育 8.336-49.
蔡美慧 & 盧豐華. 2001. 適當的回應病人—從言談技巧改善醫病關係. 醫學教育 5.245-52.