Perlocutionary Speech Act of Conveying Bad News in Medical Communication

Abstract


Introduction
In the realm of healthcare services, proficient communication plays a pivotal role because the messages must be effectively conveyed (Curtis, Tzannes, & Rudge, 2011).For instance, the language barrier and different cultures between medical professionals and patients can become an obstacle to getting the message across.Such situations can significantly influence the efficacy of patient care, leading to instances of misdiagnosis, improper treatment, and irrelevant recommendations for the health issues at hand.Hence, the competence in communication displayed by healthcare professionals holds significant importance, underlining the need for communication training for healthcare workers (Wittenberg, Alabere, Beltran, Goldsmith, & Moledina, 2022;Moore, Rivera, Bravo-Soto, Olivares, & Lawrie, 2018).
In addition to honing communication skills, another challenge faced by healthcare professionals is acquiring expertise in pragmatic competence.This competency refers to the capacity to employ language functions effectively within a social context, facilitating the comprehension of the conveyed meaning by the conversational partner (Salgado, 2011).Many of these capabilities prove valuable for medical practitioners when delivering healthcare services, particularly in areas that demand sensitivity, such as delivering distressing news, managing patients with severe illnesses, offering palliative care (Tietbohl & White, 2022;Rayan, Hussni Al-Ghabeesh, & Qarallah, 2022), and providing end-of-life support (Anderson, Bloch, Armstrong, Stone, & Low, 2019).
Conveying adverse information within professional communication is frequently a significant consideration because it requires a particular approach.The consideration underlying this concern is the potential negative impact that could arise because of disclosing unfavorable news (Thoms, Degenhart, & Wohlgemuth, 2020).The strategies for conveying bad news are direct and indirect approaches (Jansen & Janssen, 2011).However, no definitive empirical evidence unequivocally recommends a better approach based on the information recipient's responses.
An alternative that can be taken to foster the pragmatic competence of health or nursing students is to expose them to authentic social interactions.One media that contains images of natural socio-cultural interactions is movies, so it can be used as learning media (McCutcheon, O'Halloran, & Lohan, 2018).Moreover, the interactions in films can offer insights into the context and linguistic features employed, facilitating their integration into language learning, particularly for foreign languages.Movies provide a more genuine portrayal of language usage in contrast to artificially crafted examples typically found in textbooks (Seferoğlu, 2008).In this context, The Resident movie series stands out as a medical-themed film with the potential to serve as a resource for learning a foreign language.Students can gain insights into medical-themed interactions and the values associated with the healthcare profession, encompassing doctors and nurses, by engaging with The Resident movie series (Quick, 2009).
Pragmatic competence can be developed by understanding speech acts (Glaser, 2009).This perspective is rooted in the components of speech, encompassing both the words utilized and the underlying actions.The speech act theory originated with Austin, who delineated three categories of speech acts: locutionary, illocutionary, and perlocutionary; this was later expanded upon by Searle (Wallace, et al., 2013).Searle classifies illocutionary speech acts into five distinct types: assertive, directive, commissive, and declarative (Hayugraha, Nababan, & Marmanto, 2019).The concept of speech acts emphasizes that in someone's speech there is an action.The actions contained in illocutionary speech acts can be identified by considering the context accompanied (speaker and listener, time, and place).
In the domain of daily communication, the three categories of speech acts are interlinked-locutionary, illocutionary, and perlocutionary.As outlined in Austin's speech act theory (as cited in Kissine, 2012), locution involves the fundamental action of articulating sounds, words, or phrases to convey literal meaning; illocutionary pertains to the intention or communicative force inherent in speech, specifically what the speaker aims to accomplish through their utterance; and perlocution concerns the influence or response elicited by speech on the listener or the recipient of the message.Examples of these three types of speech acts in medical communication are illustrated as follows.When the doctor informs the patient, "You have advanced cancer," it constitutes a locutionary speech act as it involves conveying the diagnosis.On the other hand, when the doctor suggests, "I recommend starting intensive cancer therapy immediately," it represents an illocutionary speech act, indicating a communicative purpose where the doctor expresses a recommendation for specific actions based on the diagnosis.In response to the doctor's illocutionary speech, the patient reacts by crying and expressing concerns about their future.Hence, this illocutionary expression can have a perlocutionary impact, involving the influence or reaction induced by the doctor's speech on the patient, eliciting an emotional response and apprehension.This research will specifically explore perlocutionary speech acts, as the focal point in medical communication is to impact the recipient, specifically the patient.This influence may take the form of actions or perceptions aimed at promoting an improvement in health status.For instance, a scenario where a doctor seeks to persuade a patient to undergo surgery for the treatment of a condition, but the patient harbors fears about the procedure.In this situation, the doctor employs a perlocutionary speech act, demonstrating the action of persuading the patient that the surgery poses minimal threats to their life safety, reassuring them.As a consequence of this perlocutionary speech act, the patient becomes prepared to participate in the surgical procedure.In essence, the doctor's perlocutionary speech act exerts an impact on the patient, shaping their readiness to undergo the surgical intervention.
One of the pragmatic skills that health professionals must acquire is the ability to communicate unfavorable information to patients and their families (Skelton, Murray, & Hobbs, 1999).This notion is supported by the findings of Laranjeira, Afonso, and Querido (2021), who highlight that proficiency in delivering unwelcome news constitutes a vital aspect of professional competence within healthcare provision.
Several studies in the field of linguistics have been dedicated to examining speech acts.Observations regarding speech acts lead to the conclusion that speech acts are used to discover doctor-patient communication patterns withing various cultures (Ohtaki, Ohtaki, & Fetters, 2003).These findings suggest that cultural disparities may influence certain aspects of communication, yet shared professional imperatives contribute to similarities, emphasizing the importance of cultural awareness in guiding clinicians toward effective approaches when interacting with patients from diverse cultural backgrounds.Furthermore, the examination of speech acts proves valuable for understanding communication dynamics within the medical profession, encompassing the evaluation of interventions through speech acts (Wallace, et al., 2013); Wallace et al.'s (2013) communication model not only outperformed current methods but also faithfully replicated analyses of randomized control trials assessing interventions to modify communication habits among physicians, showcasing its high fidelity and robust performance in capturing both topical content and various types of speech acts in conversations.Next research is about identification of unique characteristics within doctors' employment of speech acts during patient interactions (Černý, 2007).This study offers valuable perspectives on the structured arrangement of speech acts, further enhanced by contextual descriptions of interactions within institutional settings.Then, the study investigated The other study investigated the assessment of speech acts in doctor-patient interactions alongside the data they analyze, thereby serving as pedagogical material for foreign language instruction (Martínez-Flor, 2005;Liu, Zhang, & Zhu, 2015), generating language learning models for foreign languages based on a comprehension of speech acts.The next research observed the scrutiny of speech acts within the film "The Good Doctor" reveals instances of assertive, directive, expressive, and commissive speech acts (Hayugraha, Nababan, & Marmanto, 2019).
Based on the explanation of several previous studies regarding speech acts, an examination of the types of speech acts that have a perlocutionary impact produced by medical personnel when interacting with patients to convey bad news in films has not yet been widely explored.Therefore, this research aims to present an overview of perlocutionary speech act to convey bad news in The Resident movie.Examining perlocutionary speech acts when delivering unfavorable information offers advantages to the field of pragmatics.This includes enhancing a more profound comprehension of the context within medical communication, particularly in delicate scenarios like conveying bad news to patients.It aids in formulating messages that display greater sensitivity while considerinng the psychological aspects of the patient.Additionally, it contributes to the development of efficient communication strategies and serves as a valuable resource for creating ethical guidelines pertaining to medical communication.

Methodology
This study employs a pragmatic approach.This approach is apt for researching perlocutionary speech acts in delivering bad news in a medical context due to its emphasis on understanding language use in specific contexts, providing insights into the nuanced and context-dependent nature of doctorpatient communication.The selection of the research design aligns with the study's objective, which is to depict social phenomena in the form of speech that generates perlocutionary impacts within interactions between medical professionals and patients during the communication of unfavorable news.
Human respondents are not featured in this study, as the data observed pertains to the discourse of physicians in the series "The Resident," specifically in Season 6.This season's selection stems from its status as the final season, rendering it relatively close to the year of the research, thus enabling the data to reflect contemporary conditions.As this study employs a pragmatic perspective to analyze speech act data, the examination is intricately linked to the surrounding context (Siemund, 2018).In this study, contextual elements considered for interpreting perlocutionary expressions include the interpersonal connection between speakers, the setting or location, the emotional ambiance, and the speakers' experience.The data encompass medical personnel's speech during interactions with patients and/or their companions as they convey negative news within the series, spanning 11 identified delivering bad news contexts.
The process of selecting this data involves several steps.Initially, the entire episodes are observed, with a focus on identifying the context surrounding the delivery of bad news.During this phase, the researcher also examined the contextual factors for the purpose of analyzing the data.Subsequently, relevant segments containing this context are revisited, and the footage is recorded using the screen record feature in the PowerPoint application for data documentation, then the data stored at cloud and computer drive.The recorded data is then transcribed, and the speech containing perlocutionary speech acts is determined.Additionally, the study extends its analysis beyond verbal expressions to encompass non-verbal elements such as facial expressions and gestures, aiming to identify the impact of perlocutionary speech acts.

Results and Discussion
The objective of this study is to scrutinize perlocutionary speech acts and the responses within the context of health professionals delivering bad news in the movie "The Resident."This section presents several utterances, including perlocutionary speech acts that occur in the context of delivering bad news.The examples presented in this section come from the footage of the movie The Residents.Before presenting examples of perlocutionary utterances, the contexts involved in giving bad news will be discussed.The context included in bad news in the medical field is news that contains the following things.
The context of delivering bad news found are an abnormal condition in fetal development, the fetus in the womb experiencing TTT (Twin to Twin Transfusion) syndrome, the risk of surgery performed on the fetus, the risk of delaying the surgery schedule, the possibility of a cancer diagnosis in a lump on the head, the risk of dangerous surgery, the cancer prognosis worsening (cannot be treated with surgery), delay in Csection surgery, abnormalities in the baby's spine due to lack of folic acid during pregnancy, possible misdiagnosis, and conditions that require the baby to be sent to an orphanage temporarily.
The doctors' perlocutionary speech acts delivered to patients and/or the patient's family in the context of conveying bad news will be described below.The perlocutionary acts revealed are asking for confirmation, calming, explaining, informing, suggesting, and convincing.The parts of the conversation that are included in perlocutionary speech acts are printed in bold.

Asking for Confirmation
The perlocutionary act employed in the context of delivering bad news involves seeking confirmation.In this scenario, the doctor aims to elicit a response from the patient, seeking information about the patient's activities.An illustrative instance of this act occurred in the obstetric examination room, involving four doctors (the patient's obstetrician/dr.Gabbi, the father of the twin fetuses/dr.Austinn, the patient's twin sister/dr.Leela, and the patient's sister's fiancé/dr.Pravesh), along with the pregnant patient (Padma) expecting twin fetuses.In this situation, the patient experiences anxiety as the obstetrician raises concerns about potential abnormalities in the development of the twin fetuses.It is noteworthy that this pregnancy, resulting from an IVF program, represents the patient's initial pregnancy, with egg cells sourced from her twin sister and sperm donated by the patient's boyfriend.The doctor shows the action of asking for confirmation through the statement "Uh, I see you missed your last prenatal appointment".This utterance represents a locutionary speech act, manifesting as a statement conveying the doctor's assessment that the patient failed to attend the obstetric examination.Within this statement lies a perlocutionary speech act, as the doctor aims to elicit confirmation from the patient due to suspicions about the development of the twin fetuses.The speech holds perlocutionary force, intending to prompt a reaction of surprise and irritation from the baby's father toward the patient.This reaction is articulated through interrogative statements directed at the patient in a heightened tone, indicating annoyance.In this context, the perlocutionary speech acts employed in delivering negative medical information in this research were communicated indirectly.An instance of this linguistic pattern is evident in the doctor's statement highlighting an irregularity in the fetus's development, "Uh, I see you missed your last prenatal appointment."Rather than directly presenting the diagnosis, the doctor is, in fact, seeking confirmation from the patient, initiating a more profound conversation.This underscores the importance of considering moral elements when articulating speech that anticipates a response in delicate contexts (Garsten, 2009, as cited in Slotta, 2015).

Calming
The subsequent perlocutionary speech act involves the act of calming.In this instance, the doctor endeavors to soothe the patient, expecting a composed response from the patient.An illustrative example occurred in the obstetric examination room, attended by four doctors (the patient's obstetrician/dr.Gabbi, the father of the twin fetuses/dr.Austin, the patient's twin sister/dr.Leela, and the patient's sister's fiancé/dr.Pravesh), and the pregnant patient (Padma) expecting twin fetuses.In this scenario, the patient is concerned that the ultrasound machine may adversely affect the developing fetus.The obstetrician responds using speech acts to reassure the patient that the ultrasound machine will not harm the fetus.Dr. Leela's statement, "Dr.Sullivan is an expert in exactly what the twins need," communicates to the patient that the assigned doctor is highly proficient in addressing the specific needs of the twins.This expression encapsulates a perlocutionary speech act aimed at reassuring the patient who harbors concerns about the well-being of her twin fetuses.The speech carries perlocutionary power as evidenced by the patient's response, manifesting through a calming breathing gesture in an attempt to soothe herself.Analyzing Dr. Leela's statement may show the act of reassurance.This act is pragmatic in addressing the patient's concerns and fostering a supportive doctor-patient relationship (Riedl & Schüßler, 2017).This action can enhance a patient's trust, which is a fundamental aspect of any successful relationship, including the one between a doctor and a patient.Patients are more likely to follow medical advice and adhere to treatment plans when they trust their healthcare providers (Deledda, Moretti, Rimondini, & Zimmermann, 2013).

Explaining
The subsequent perlocutionary speech act involves the act of providing explanations.This endeavor is geared towards fostering comprehension, with the anticipated response being the manifestation of understanding in the speaker (patient).An illustration of the speech act of explaining is evident in the dialogue provided below.This exchange transpired in the treatment room, with two doctors (dr.Sutton and dr.Conrad) engaging in conversation with a female patient who serves as a chef at the hospital.Both doctors are familiar with the patient.During this conversation, the doctors elucidate the potential risks associated with the surgery, emphasizing the potential threat to the patient's safety.The surgical procedure is deemed necessary to investigate the cause of the lump that has appeared on the patient's skull.
Patient : "A mass in my brain.My aunt's husband, uh, died  Dr. Suton's statement, "The surgery is dangerous with many possible complications.We need to go over them," serves as a communication to apprise the patient of the high-risk nature of the impending operation, which poses potential threats to the patient's life.This expression embodies an illocutionary speech act, functioning as an explanatory action regarding the hazards associated with the surgical procedure.Illocutionary acts involve the speaker performing an action through the utterance, such as asserting, questioning, commanding, or explaining (Hidayat, 2016).In this context, dr.Suton's illocutionary act is explanatory, as she is providing information about the risks.Additionally, this statement holds perlocutionary force, as the patient comprehends the surgical risks, leading to the patient expressing agreement to undergo the head surgery despite the acknowledged high risks.The perlocutionary act highlights the effectiveness of dr.Sutton's communication, as the patient not only comprehends the risks (perlocutionary impact) but also responds with agreement, indicating the successful communication of the intended message.

Informing
The subsequent perlocutionary speech act involves the act of imparting information.This endeavor is directed towards the provision of information, with the anticipated response being that the conversation partner comprehends the information and can offer a contextual response.An example of a speech containing this perlocutionary speech act is evident in the dialogue below.This conversation unfolded in the treatment room while the patient awaited a scheduled cesarean section.The participants engaged in this conversation were one doctor, Dr. Pravesh, who is the fiancé of the patient's sister, and the patient, Padma.During this exchange, the doctor informed the patient that her scheduled cesarean section was deferred by one hour due to an emergency situation.Padma (patient) : "Oh, so just... half an hour to go." dr.Pravesh : "Uh, no, actually, your Csection has been pushed back by an hour."Padma : "An hour?Why?" dr.Pravesh : "There's a backup in the OR due to a gunshot victim."Padma : (sighs) Dr. Pravesh's statement regarding the postponement of cesarean operations conveys information about the rescheduling.This expression constitutes an illocutionary utterance, serving as an act of informing the patient about the delay in the surgical schedule.Illocutionary acts represent the speaker's intended action through the utterance, such as informing, requesting, and commanding (Sadock, 2006, in Rett, 2011).In this case, Dr. Pravesh's illocutionary act is characterized by the act of informing the patient about the postponement of the cesarean operation.Furthermore, this statement possesses perlocutionary force, evident in the patient's surprised response with the question, "An hour?Why?" and the patient's deep breath as a reaction.The perlocutionary act highlights the effectiveness of dr.Pravesh's communication, as the patient's response demonstrates the impact of the information on their emotional state, leading to surprise and curiosity.

Suggesting
The subsequent perlocutionary speech act involves the act of suggesting to do something.The purpose of this action is to encourage the patient to take a particular course of action, with the expected response being the patient complying with the speaker's request.Instances of speeches containing suggesting speech acts can be identified in the dialogue provided below.This conversation took place between a doctor, dr.Pravesh, and a patient, Marty, in the patient's wardroom.During this exchange, the doctor expresses concern about the patient potentially receiving an incorrect diagnosis.Consequently, the doctor extends a suggestion to the patient, urging them to undergo a series of tests for a more accurate diagnosis.Dr. Pravesh's statement, "What I mean is, have you ever considered that your original diagnosis could be flawed?" is a questioning statement directed at the patient regarding the initial disease diagnosis.This expression functions as an illocutionary speech act as the doctor encourages the patient to undergo a reevaluation to explore the potential of a misdiagnosis.Illocutionary acts represent the speaker's intended action through the utterance, such as questioning, asserting, suggesting, etc. (Stiles, 1981, in Zaefferer, 2001).Here, dr.Pravesh's illocutionary act is characterized by the act of questioning, encouraging the patient to reconsider the possibility of a flawed diagnosis.Additionally, this speech carries perlocutionary force, as it has the ability to influence the listener.This influence is evident in the patient's response, as they inquire once again about the disease diagnosis and express readiness to undergo a series of tests to arrive at the correct diagnosis.

Convincing
The subsequent perlocutionary speech act involves the act of persuasion.This speech act is intended to instill belief in the speech partner, with the expected response being the partner becoming persuaded by the speaker's viewpoint.Instances of speeches containing persuasive actions can be observed in the dialogue below.This conversation unfolded in the examination room, involving two doctors (dr.Voss and dr.Pravesh), an elderly patient grappling with Multiple Sclerosis (MS), and the patient's child.The patient, a former athlete now paralyzed due to the illness, harbors a strong desire to regain the ability to walk.During this exchange, the doctor informs the patient that the upcoming operation cannot guarantee restored mobility, yet emphasizes that the procedure will be conducted by a skilled expert to minimize risks.Dr. Voss's statement conveys information about the preparedness of the medical team for the upcoming surgery on the patient.This expression constitutes an illocutionary speech act, acting as a persuasive effort to encourage the patient to consider undergoing the surgical procedure.
The statement possesses perlocutionary power, as evidenced by the patient's response, indicating agreement to proceed with the spine surgery.Perlocutionary effects focus on the impact or response generated in the listener as a result of the speaker's utterance (Czerwionka, 2012).In this case, the perlocutionary effect is the patient's response, indicating agreement to proceed with the spine surgery.The perlocutionary effect highlights the persuasive impact of Dr. Voss's statement.The patient's agreement to undergo the surgery demonstrates the success of the persuasive illocutionary act in influencing the listener.
Perlocutionary speech acts can be defined as verbal expressions that hold the power to impact the recipient of the speech.Aligned with this notion, the spoken utterances involved in delivering bad news possess the capacity to exert an influence on those who hear them.This impact will be elaborated below.
Ideally, speakers possess a comprehensive understanding when delivering influential speeches, enabling them to effectively address any ensuing impacts on the recipients.As stated by Alexander and Klein (2000), the effects of bad news on recipients can encompass emotions such as shock, denial, despondency, frustration, guilt, feelings of hurt, and withdrawal.A number of these responses should be handled by the giver of bad news, namely health workers, in the context of this study.Based on this reason, conveying bad news becomes challenging because it is feared that negative (unexpected) responses cannot be handled (Rayan et al., 2022).
The effects of conveying bad news in this study will be categorized into two kinds, namely expected response (positive) and unexpected response (negative), which are explained as follows.The positive responses found in the recipients of bad news in this study were the patient provided an explanation, willingness to undergo an ultrasound examination by showing a lying down gesture, achieved a sense of calmness through deep breathing, displayed composure while attentively listening, comprehended the explanations provided, the patient is willing to undergo surgery to save her twin fetuses, showed willingness to undergo surgical procedures for addressing the cranial lump, exhibited self-motivation, demonstrated acceptance of her condition through a composed sigh, and expressed a willingness to participate in a series of diagnostic tests for disease identification.
Conversely, the negative reactions included the patient's relatives feeling shocked, the patient's relatives angry, the patient showing panicked gestures, the patient blaming himself, the patient and his family crying, the patient felt confused about his condition, the patient refused, patient shows emotional distress, and patient experiences fainting.
Moreover, the efforts made by health workers in dealing with unexpected responses as an effect of delivering bad news will be described as follows.A number of these efforts include providing explanations that can reduce anxiety, asking for relaxation techniques, providing explanations so that patients do not blame themselves, giving time, and preparing security officers and medical teams.

Conclusion
The objective of this study is to examine perlocutionary speech acts and the effects within the context of conveying bbad news.The findings of this investigation reveal that health workers express their actions through perlocutionary utterances when conveying bad news.These actions encompass asking for confirmation, calming, explaining, informing, suggesting, and convincing.The perlocutionary speech acts in this context can elicit both expected and unexpected responses.As a manifestation of professional ethics, healthcare professionals are expected to adeptly handle any responses elicited by recipients of bad news.
The examination of perlocutionary speech acts in the delivery of bad news holds significance by yielding research outcomes applicable for enhancing communication strategies between doctors and patients, thereby contributing to the overall enhancement of medical communication quality.It can serve as a foundation for refining ethical guidelines in medical communication, guiding doctors to approach the delivery of bad news with care and sensitivity.Additionally, it offers valuable insights for refining the professional training of doctors and healthcare personnel, ensuring their proficiency in communication skills during challenging situations.Furthermore, it aids in cultivating a supportive communication environment for patients, assisting them in navigating such challenging circumstances.It is important to acknowledge that this study has limitations in terms of data sources as it is not derived from authentic societal communication.Consequently, there is an expectation that future researchers will explore more natural data sources.

I see you missed your last prenatal appointment." dr
. Austin : "You did what?Padma."

chief surgeon here at Chastain is a top-notch neurosurgeon. Dr. Sutton and I will be operating together, so it's an ideal team going into
dr. Pravesh : "However, I would..." dr.Voss: "And our