Doctor-patient Communication and Preferred Terms of Address: Respect and Kinship System (a Pragmatic Study)

The concept of face, face work and politeness model in the doctor-patient communication which is based on English for Academic Purposes: medical relied on the face as a social construct. This study investigates greeting in the form of second person pronoun based on the kinship system in terms of address to show respect as preferred by patients in Indonesia. There were twenty-six (26) male out-patients and forty (40) female patients. Data from the questionnaire consist of patients’ gender, age, education, marital status and preferred second person pronoun in terms of address. They were analyzed using the ‘interaction model’. The research showed on the importance of the use of greetings in the form of second person pronoun based on kinship system to show respect preferred as follows: Father/ Bapak, Elder Brother/Mas, Younger Brother/Dik, Mother/Ibu, Elder Sister/Mbak, and Younger Sister/Adek. The married female patients prefer Mother/Ibu rather than Older Sister/Mbak and the married male patients prefer Father/Bapak rather than Older Brother/Mas. Thus, the patients’ choices on terms of address were based not only on age but marital status. These findings were different from the previous research as it was based on age to show respect.  


Introduction
Colonial Health Care in Indonesia can be dated back as early as in the 1900's during the Dutch colonial government not only by building hospitals but also opening up schools (Hal Sekolah Dokter Djawa, 1901) to train the Indonesian paramedical cadres called Doktor Djawa (Hal Dokter Djawa, 1900;Hull & Iskandar, 1996). The Doktor Djawa program brought medical care to the villages based on approach that relied heavily on the paramedicals view of the health system and not on the patients' view of the world (Mishler, 1984).
The use of Dutch is then changed to English after the Indonesian proclamation on August 17, 1945 as the medical world is referring to the English language community of medical world. In the early of the proclamated country, the Indonesian government opened up Medical Schools or STOVIA but with a different approach as the English is the media for communication in the society where English is used as a foreign language. The Family Doctor system in the 2000's for medical doctors in Indonesia initiated the importance on a more humane approach to the patient (Iragiliati, 2008;Claramita & Majoor, 2006). Medical schools were then opening up laboratory skills in the Medical Faculty to train the medical students' communication ability in a doctor-patient interaction in using English and Indonesian.
One's communicative competence and how to use it effectively is an important factor in a doctor-patient interaction in a western context. In 1984, Mishler stated on the importance of a more humane approach in the doctor-patient interaction. The approach was based on the view of how important it was to shift more to the patients' need. Patients' need was stated as the patients' voice or "view of the world" and this need was sometimes not felt by some of the medical doctors. Thus, Mishler pointer out that a medical doctor should not only rely on his medical expertise but also paid attention to the patients' voice or patients' "view of the world" as well. The shift of approach was not an easy task as some of the medical doctors were not ready for the "new" situation. In another research based on two medical interactions, Mishler et al. (1989) offered a different approach to promote one's communication skill in doctor-patient communication activities. It involved both a skilled medical doctor in communication skills and a more humane doctor approach to the patient. The result was that it supported on the importance of a more humane approach to the patient. The importance of acquiring skilled communication skills during the doctor-patient intertaction was also carried in Maguire and Pitceathly (2002) research. It was reported that a medical doctor needed communication skills to interact and one of the ways was to practice them was not only for their benefit but also for the patients' benefit. The medical students' competence in English (EAP: Medical) as in a western context was considered acceptable as in the Morning Report sessions (Claramita, 2009).
In real life situation, the difference of a western and a non-western context in the doctor-patient interaction was very apparent. A doctor is not only skilled in his medical expertise but is also expected to be sufficient enough for his non-medical expertise as well. Iragiliati (2008) investigated how during doctor-patient education, medical doctors should greet their Southeast Asian patients properly and how medical doctors should act as if they were a member of the patients' family. This condition was also mentioned by Claramita (2009) during a personal interview with her. Claramita mentioned that Iragiliati's research (2008) was the research in Indonesia dealing with the issue of considering patients' as one of the family member in a society. Iragiliati (2008) further reported that in the medical discourse carried out in the interaction, it was the imprtance of respect in terms of politeness seen in the use of second person pronoun. She stated further that the kinship system preferred was that of the local culture. Local culture in this case was the Javanese culture of East Java, Indonesia.
Awareness on the importance of a more humane approach and the use of language of attentive care as mentioned by Mishler was also discussed by Claramita. Claramita and Majoor (2006) stated that undergraduates at the Medical School of Gajah Mada University, Yogyakarta, Indonesia that were trained in the communication skills training were more aware of communication behavior skills as being preferred by the patients. In a community of a densely populated country, as in Indonesia, the question was whether there was a possibility of carrying the desired condition would arise conflicts between the two parties. In another study, Claramita et. al (2011a) stated that as Indonesia is one of the four top densed populated countries, where in the teaching hospitals the primary, secondary and tertiary care is provided resulted in a rather complex environment. It arised conflicts of interest between observed and ideal communication styles of communication. However, it turned out that patients' educational level and communication style showed no significant relationship. Results showed that patients' expressed preference and reality differed markedly which was related to the patients' background (Claramita et al., 2011b). The need of a more humane approach in a densely populated communited where conflicts of interests arised, there was another point to be considered. Related to the condition stated, Claramita et al. (2012) found out that the influence of culture in the doctor patient communication in terms on what is polite in a western context is different on what is considered polite in a non-western context. In the Southeast Asian culture, "social distance" and "closeness of relationship" and to characteristics as "specific clinical context" should also be considered. Thus, this condition that supports the importance of communication skills in a doctor-patient interaction in a non-western context showed that a more humane approach is thus felt by both sides and culture plays an important role.
In English for Academic Purposes: Medical, it is also true in a nurse-patient communication as stated by Spiers (1998) that analysis of specific communication based on universal but culturally mediated face needs may provide other views on verbal conversation. However, as Face work is universal, it is also important for the medical students to be familiar with conditions of English for Academic Purposes: Medical in a nonwestern context which is actually based on the English for Academic Purposes: Medical. The approach as bilingual medical specialists of English and Indonesian, where the medical education is based on the English for Academic Purposes: medical approach to medical, the medical students are expected to be competent in English and Indonesian as well. In the English for Academic Purposes: Medical, the use of terms of address is related to the use of Mr. and name such as Mr. Richardson (Lloyd & Bor, 2004) in the beginning of the interview for out-patients. However, the meaning of Mr. in this sense is tuan in Indonesian and is followed by the second person pronoun of "you" during the whole process. The use of "you" is also stated in the interaction of during the taking history of the patient which was initiated with the use of Mr., Mrs., or Miss and name at beginning of the interaction (Glendinning & Holmstrom, 2005). As a bilingual person, the medical students has to be educated in the politeness approach of English for Academic Purposes: medical and also the use of terms of address in a non-western context to show respect.
In a non-western context where the terms of address used the second person pronoun to show respect (Helmbrecht, 2003), and maintenance of positive face required achievement of closeness and common identity, greetings in the use of second person pronoun were based on the local kinship system (Sukarni, 2007). The second person pronoun mentioned are as follows Bapak/Father, Ibu/Mother, Mas/Elder Brother, Mbak/Elder Sister, Oom/Uncle, and using the last syllable in the name Mad for Ahmad. The use of second person pronoun is potentially positive politeness, an ingroup marker that indicated intimacy of being a member of one big family and when an inappropriate choice of the terms of address would certainly threatened the speaker's and listener's face.
The approach on using qualitative research methods are able to encompass complexity of interaction (Spiers, 1998;Iragiliati, 2008) seen in face needs, face threats and contextuality of power, culture, and social distance. To understand the context of communication, Spiers (1998) stated that both nurses and patients are culturally grounded in and constrained in social conventions, institutional norms and procedures, and medical discourse. In a doctor-patient communication, it is thus important that both doctors and patients are culturally grounded in, constrained in social conventions, institutional norms and procedures and medical discouse (Iragiliati, 2008;Spiers, 1998). Furthermore, Spiers also mentioned that if talk is not concerned with face (face needs) then there is no need to protect one's self or other and there would be no need to praise, be polite, or soften the impact of information. Communication is more of a social action based on interpersonal considerations and involves delicate introduction and negotiation of a topic as in the greetings in an anamnese session. There are also strategies in using greetings of second person pronoun to show respect in the beginning, middle and ending of the anamnese in a nonwestern context (Iragiliati, 2008).
In this research, the contextuality of the patients' gender, age, education, marital status and preferred terms of address are seen in the doctor-patient communication. It is concerned with the importance of terms of address in a doctor patient communication which is intertwined with a broader development of doctor-patient communication: doctor-patient communication skills model on patients' preferred terms of address suitable for a non-western context. To illustrate the above approach, we shall discuss the following doctor-patient interaction between a male medical student and a female patient based on face needs, face threats and contextuality of age, education, power, culture, and preferred terms of address by the patient as in social distance of both sides.
In the example of a doctor-patient communication seen in the laboratory skill of Gadjah Mada Medical School, between a male medical student (MS) of twenty-five (25) years old and a female patient (FM) of thirty-five (35) years old where the male medical student used the second person pronoun based on the kinship system to show respect (Kartomiharjo, 1979;Helmbrecht, 2003;Iragiliati, 2008). During the anamnese session or patient history taking sessions, he chose the word Ibu/Mother to greet the female patient as there was a difference of 10 years between them. However, the female patient refused to be greeted as Ibu/Mother and preferred to be greeted as Mbak/Older Sister. The use of forms of address as expression of politeness is needed in order to fulfill face needs, decrease face threats in the interaction (Brown & Levinson, 1987) and related it to the contextuality of age, education, power, culture, and preferred terms of address by the patient. In the embarrassment model of Spiers (1998), effective interaction depends on the social context of both parties. In the example below, the embarrassment model only poise and improper identity and strategies to overcome it. The young medical student feels "understood" when he chose the terms of address Ibu/Mother to the patient as he is a professional medical person and talking to a female patient older than he was. It turned out that the female patient was not happy and made the medical student lose of poice and feel embarassed (Spiers, 1998). It is then assumed that competent medical student in communication skills would be able to overcome his or her embarrassment by using certain strategies. These politeness strategies are used to restore a disconfirmed identity following embarrassment in loss of poise and improper identity. It is a complementary model to expand the understanding about the impact of communication need in situation where request and orders (the basis of the politeness model) and embarrassment are both important in a doctor-patient communication.
( In the first line, the medical student opened up a doctorpatient communication by asking the patient's illness and greeted her by using the word Ibu/Mother. But his opening sentence has threatened the patient's face which is seen in the second line. The patient then choses the strategy to state her mind and recovered her poise and embarrassment by stating that she was young enoung to be considered as an late teenager stage. Her answers are in line four and five, where she indicated a change of greetings in the terms of address made the medical student's face threatened in return. The medical student's strategies were to overcome the embarrassment by apologizing by using the word "sorry". In doing the action, the medical student has saved his own face and the patient's face by agreeing the proposed action by the patient. In line six, after apologizing and made the condition neutral where no loss of poise and embarrassment for both sides, the medical student then began his or her anamnese process but using the agreed terms of address. The use of a local kinship system in a family seen in the second person pronoun to show politeness and preferred by patients has gone beyond the family and is used in the society as well. Implication of this strategy is then considering the society in a doctor-patient community as one big family. The concept of face, face work and politeness model in the doctor-patient communication relied on the face as a social construct. As a medical professional, the medical student used the face work strategies in terms of face needs, the specific aspect which is important in that cultural and social context of a non-western context (Iragiliati, 2008). It was reported that the medical students use a negative face strategy as in the desire to have the freedom of action as he or she is the one who has the medical expertise over the patient. However, when the medical student started the communication, he or she used the positive politeness strategy as considered to be understood or appreciated by using the second person pronoun in terms of address based on the kinship system towards the patient in the beginning of the anamnese process. This approach or strategy was then repeated in the middle and the end of the anamnese process by the medical student in order not to threaten the patient's face. Politeness strategies seen in expression on the medical expertise were usually direct which include order, requests, suggestions, advice, etc and could result in an opposition or a threat to the medical student's face as well. Iragiliati (2008) mentioned that during the anamnese proses of medical discourse, terms of address was found at the beginning of the anamnese or greeting stage, at the middle or eliciting stage one (1) and at the end of the anamnese proces. It was in this respect, that the medical student used the combination strategies of positive and negative politeness in order to simultaneously minimize the threat to negative face (autonomy) and, at the same time the medical student, promote positive face through expression of respect by using the desired terms of address. The terms of address was based on kinship system as proposed by the patient as seen in the example above. However, as stated above, the kinship system based on local context applies in this situation is then seen also as a potential aspect in the communication.
In line with the description above, the main objective of this research is: what are the patterns of second person pronoun in terms of address based on kinship system to show respect and preferred by patients in a non-western context.

Methods
The method in this research is qualitative ethnographic descriptive. Qualitative research was chosen as a fundamental approach in discussing on face work or the communication strategies used to protect, maintain, and enhance face, to satisfy face needs and to mitigate face threats. It is different with the check-list approach as this approach will record all the interactions using the deep interview model. Data of twenty-six (26) male outpatients and forty (40) female out-patients answers in the deep interview based on the guidelines in the questionnaire were taken. The questionnaire questions consist of patients' gender, age, education, marital status and preferred second person pronoun in terms of address based on kinship system. Information of the out-patients of the teaching hospital of dr. Saiful Anwar (RSSA), Malang, Indonesia preferred terms of address were taken directly on-site and described on the spot.
The data in the structured interview consist of the outpatients' sex, age, education, marital status and second person pronoun preferred terms of address based on the kinship system. The data was analyzed using the "interactive model" of Miles & Huberman (1994 (30) female.
The second data was taken on August 16, 2010 until September 7, 2010. The data were on seventeen (17) out-patients of the Polyclinic at the dr. Saiful Anwar Teaching Hospital Malang, East Java, Indonesia, who were not being given medication while the data were taken. There were seven (7) male patients and ten (10) female patients. Thus, there were sixty six (66) patients.

Results and Discussion
Male Out-Patients' Preferred Terms of Address suitable for a non-western context. The use of secondperson pronoun based on the kinship system that shows respect and prefered by male out-patient at their earlyadolescent age below seventeen (17) years old and lateadolescent age -adolescent age of seventeen (17) to twenty three (23) years old. The discussion will cover the context of sex, age, education, marital status, and prefered term of address related to the male or female medical students' condition.
The pattern of the early-adolescent age group consisted of male out-patients who are younger than the medical students and between twelve (12) till seventeen (17) years old. Their education is lower than the medical students and not yet married. This group prefers the term of address of Mas/elder brother or Adek/younger brother if they are greeted by the medical students. The reason for this preference was that the patient feels that his face was not threatened as he is at ease where he was considered as to talking to a member of his family and not to a stranger. However, nobody wanted to be greeted with Bapak/Pak/Father as this would threaten their face as they consider themselves as teenagers and not a married man. In a society where age is an important factor and related to responsibility in life, the appropriate terms of address is connected to age and marital status which conotes that even though you are young but already married, then the implications would be that you have a responsibilty towards your family and also to the society. It is then understood, that if you are a grown-up and married then the responsibility of a family lies on yourself, while on the other hand, if you are not married yet, the responsibilities of your doings would be the responsibility of your parents as in this Javanese society. This concept is different from the concept of a family in the western society where a person who is already 17, her or she is responsible for his or her own doings.
The following pattern is late adolescent male outpatients who are younger than the medical students, between seventeen (17) till twenty four (24) years old, with education lower than the medical students and not yet married. This group preferred the term of address Mas/Elder Brother which shows respect and the reason stated was this term of address suits their age although they are not yet married. The use of Brother/Mas shows respect and also makes them feel close to others as in a family. The feeling of comfort here means that the medical students respect the male out-patients and not treat them as children. Context in an institutional setting as mentioned by Spiers (1998) is important and when you are sick, being comfortable plays an important part in the healing process. It is carried out by providing facilities connected to the medication for the sickness and in the communication process as well. For example, the late adolescent male out-patients felt that their face were threatened if they were greeted by using the word Bapak/Father as it connote that they are very old and not young. To minimize the threat, the medical student should choose the word Mas/Elder brother.
The second pattern is male-patient with is the same age as the medical students, education lower than the medical students and not yet married. Patients preferred Brother/Mas as it fulfilled the face needs of ingroupness as seen in the reason for the choice of the terms of address: we are young or of the same age/karena sama-sama muda and a proof of an ingroupness of young people/karena mas-mas.
The third pattern is male out-patients who are older than the the medical students with education higher than medical students and married. In this group, there are male out-patients of thirty-one (31) till forty (40) years old, forty-one (41) till fifty (50) years old, fifty-one (51) till sixty (60) years old, and sixty-one (61) till seventy (70) years old. The thirty-one (31) till forty (40) years old group of male out-patient who is older than the medical students with education lower than the medical students and married prefer the term of address Father/Bapak or Elder Brother/Mas. The male outpatient who prefers the second-person pronoun terms of address such as Elder Brother/Mas stated that they are still in the young age and are not old enough to be responsible of their own well being. This concept was based on face needs or face wants of the male outpatient. As a young person, your face would be threatened if you are expected to be someone older or with responsibility that is actually too big for your age with the usage of Father/Bapak. It is then understood, the reason for the male out-patients who prefer Father/Bapak as a polite term of address stated that even though they are between 31-40 years old but they are married and have children. The word Father/Bapak conotes that the choice was not only based on the age of a mature man but also a responsible person for his own and his family's life. Male out-patients in the age fourty one (41) till fifty (50) with the variety of education prefer the term of address Father/Bapak or Father/Pak (the truncated form) because they are old enough and have a family or married. Kartomihardjo (1979) stated that in East Java elders have been traditionally accorded with respect and this everywhere overtly stated. He also explained that a young person of superior rank (in this case, the medical student) will treat an older inferior (the village elderly person) with more respect than his younger inferior. This condition was also supported by the elder pheasant seen in his comments on his preferred terms of address: Nggeh tiang deso, ngoten iku eco (yes, we are from the village, that word sounds nice).Beside age which affects the male out-patients preferance of the second-person pronoun based on kinship system for the preferance of the term of address which shows respect, marital status is another factor. Marital status has big effect because in a society, someone became a whole person if they have already been a father. This is based on Javanese and Islam culture which emphasizes on the importance of having a family and descendant. By choosing the appropriate terms of address, the medical student saves the patient's face and himself/herself as well. It is then important to respect or feel respected by others (Kartomihardjo, 1979;Helmbrecht, 2003;Sukarni, 2007). In the next group of male out-patients with education lower than the medical students, married, and belong to adolescent group with the age fifty one (51) to sixty (60) years old, the condition was similar. Preferrence Father/Bapak as the choice of the terms of address was based on several things such as based on age and marriage: old enough to have children, suitable age, and appropriateness. Male out-patients, age sixty-one (61) till seventy (70) years old, prefer the same use of second-person pronoun that is in the form of Father/Bapak or Father/Pak (the truncated form) and their reason was that it suits the patient's age while on the other hand, the medical student shows respect to the elders who are married as well.
The use of second-person pronoun based on kinship system in term of address which shows respect and preferred by male out-patients shows the importance of intimacy like in a family and respected by the medical student who is younger but of higher same or higher status (Table 1). Thus, the application on the concept of face, face work and politeness model in the doctorpatient communication is also related to the social construct in institutional setting that was seen in the choice of terms of address.
Pattern of the use of second-person pronoun by female out-patients in a doctor-patient communication. Iragiliati (2008) mentioned that the concept of face, face work and politeness model in medical discourse showed that during the doctor-patient communication when instrumental goal (on medical expertise) takes over social goals (terms of address of second person pronoun based on kinship system) then face work will be reduced. The medical student will use less face work when he or she talks about the medication of the patient however face work increase when he or she talks about the cultura aspects in life other than the medical conversation. The switch from medical terms to social terms happened several times during the doctor-patient interaction at the beginning, middle and closing stage of the anamnese. Magnis-Suseno (1999) also mentioned that to overcome the gap between strangers, in this case the patient and the medical student, the use of terms of address in the second person pronoun is the choice. Face needs as the specific aspect which is important in that cultural and social context of a non-western context is seen in the reason of the patient that her face is not threated as there is a secured feeling to be taken care of (medically) by a "member" of the family. This feeling of being accepted as a human being is believed to give the positive effect as an important factor in the healing process on the female out-patients. The first group (1) early-adolescent (12-17 years) and late-adolescent (17-23 years) male out-patients, with lower education than the medical students and not married. The female outpatients of the adolescent group consist of earlyadolescent female out-patients that are between twelve (12) till seventeen (17) years old and late-adolescent age group consists of seventeen (17) till twenty three (23) years old female out-patients. In this group, the first pattern is the early adolescent with education lower than the medical student and not yet married. This group prefer the term of address Younger Sister/Adek which is the same word for Younger Brother/Adek but with a different meaning. The reason stated was that it makes you feel close to each other as if the medical student is a member of the family and approximately of the same age as you are. On the medical student's side, the choice of decreasing the social distance will benefit in the decrease of the face threat between the two parties. In return, face needs will promote one's poise and belongingness to one another while still being respected. The second pattern in this group is female out-patient who is older than the medical student and the age range is between seventeen (17) till twenty four (24) years old. The patient's education is lower than the medical student

Tabel 1. Doctor-Patient Communication Skills Model on Male Patients' Preferred Terms of Address Suitable for Non-Western Context
Age Bapak/Mas Note: 1. The medical students' age is around twenty five years old and is in the internship program at the Teaching Hospital of dr. Saiful Anwar Malang. 2. The first group (1) early-adolescent (12-17 years) and late-adolescent (17-23 years )male out-patients, with lower education than the medical students and not married; (2) the second group, male out-patients with approximately the same age (23-25 years) as the medical students, lower education than the medical students and not married; (3) the third group, adult male out-patients (26-30 years; 30-40 years; 41-50 years; 51-60 years, and 61-70 years, older than the medical students, whose education is higher or lower than the medical students, and married. 3. Mas= Older Brother; Dek= Younger Brother; Bapak/Pak= Father. not yet married. This group prefers the term of address Elder Sister/Mbak or Younger Sister/Adek which shows respect. The reason stated was this term of address suits their age as they are not yet married. Usage of the terms of address preferred will not threatened the patient's face as it would be an acknowledgement that she will feel comfortable and not lose her poise. Feeling of ingroup with the medical student is important to assure that the proses of anamnese runs well. The position of a woman who is not married in the Javanese society is still the parents' responsibility to pay for her life, safety, education etc. until she gets married and then the responsibility shifts to the husband who is the head of the family. The second group, female out-patients with approximately the same age, twenty-three (23) till twenty-five (25) years old, as the medical students, lower education than the medical students and not married Elder Sister/Mbak as they are not married yet. It is a proof that the reason was not only age for the choice of terms of address but also the marital status. Feeling matured but not yet married was also stated by another female out-patient and she was against using first names as it threatened her face. The use of first names (jambal) is considered impolite in the Javanese spoken communication as politeness is something one directs to another so as the equilibrium condition of no one loses face is conditioned.
The issue on how to act properly based on Javanese etiquette is already raised by the young female outpatients. Appropriateness (kepatutan, pantes) in the way you interact with another is also based on the phylosophy of harmony (andap asor). Spiers (1998) mentioned that face needs of people of different ages, or of different cultural or social affiliation are likely to differ in terms of importance, but universal face needs do not dissappear. Related to the fact that communication skills are important for any health professionals, Spiers (1998) also stated quoting Iwasiw & Olson (1995 that as inappropriateness communication can dehumanize, depersonalize, ignore, or discount the needs of the client, in this case the patient. The condition is different from the male out-patient, where the issue of how to act properly is raised by the male out-patient who is married and older than the medical doctor. The question then arises why do women who are relatively young have already a strong sense of good and bad. Women in a Javanese society is being educated as the future mother of her children who is responsible for the success of her children in life which includes their proper attitude in interacting with other people as mentioned by Geertz (1976) in the Javanese etiquette. People will blame the mother who cannot educate her childre well and not blaming the father. It is then concluded that as the burden is bigger on the woman's side to educate the children, the question of appropriateness also arises with the younger female outpatient and not yet married.
The third pattern of adult female out-patients group of twenty-six (26) till thirty (30) year old years; thirty (30) till forty (40) years old; forty-one (41) till fifty (50) years old; fifty-one (51) till sixty (60) years old; and sixty-one (61) till seventy (70) years old, older than the medical students, whose education is higher or lower than the medical students, and married. The group of female out-patient group of twenty-six (26) till thirty (30) year old years whose education is lower or higher, and married preferred the second person pronoun terms of address Mother/Ibu. The reason stated was that the female out-patients are married and have children. They will be considered as respectable people in the society as they have fulfilled the concept of obtaining one's rounded education in life. The demand on being appropriate is a must that can be seen from comment of the patients that if you do not follow the social construct,

Tabel 2. Doctor-Patient Communication Skills Model on Female Patients' Preferred Terms of Address Suitable for a Non-Western Context
Female Adek/Mbak 2 Mbak 3 Ibu/Buk Note: 1. The medical students' age is around twenty five years old and is in the internship program at the Teaching Hospital of Dr. Saiful Anwar Malang; 2. The first group (1) early-adolescent (12-17 years) and late-adolescent (17-23 years) female out-patients, with lower education than the medical students and not married; (2) the second group, fe male out-patients with approximately the same age (23-25 years) as the medical students, lower education than the medical students and not married; (3) the third group, adult female out-patients (26-30 years; 30-40 years; 41-50 years; 51-60 years, and 61-70 years, older than the medical students, whose education is higher or lower than the medical students, and married; 3. Younger Sister = Adek; Mbak = Older Sister ; Mother = Ibu/ Buk (truncated form) it would threat both parties as it is not accepted/Ndak lumrah or not appropriate/Ndak patut. The reason of not being appropriate if you are not using the correct terms of address is also true for the thirty (30) till forty (40) years old group. In doing that her face would be threatened if you violate the Javanese etiquette and in return disturb the stability of her inner life (batin) as she respond with an equal politeness (Geertz, 1976). Preferrance on choosing the Mother/Ibu as the terms of address was also seen in the forty-one (41) till fifty (50) years old. They old and have grandchildren and prefer not to be called on first names/dijambal. The face threat is related with the social function of being a grandmother that conotes a respectable woman by her children, grandchildren and the society. The condition is also true with the fifty-one (51) till sixty (60) years old preferred the terms of address of Mother/Ibu. The reason of the choice was that they are comfortable with the term of address. Feeling comfortable will promote the female out-patient condition. The sixty-one (61) till seventy (70) years old group with lower or higher education and married said that if they are greeted with the Mother/Ibu, they will feel weird as they are already that old. In order not to hurt the medical student's face and feelings, the elderly out-patient female is trying to build a wall within herself and the medical student so as to keep the situation comfortable for both sides.
No one's face should be threatened as it is based on the Javanese philosophy andhap asor (be humble) would be an important factor (Table 2). Based on above explanation, we can conclude that female out-patients group also needs intimacy, kinship, appropriateness, consideration, equity in interaction between doctorpatients. There are three patterns of the female outpatients want the term of address based on kinship system which is affected by local culture especially Javanese value and culture so that they want to be called as Younger Sister = Adek, Older Sister = Mbak, and Mother/Ibu or Buk (truncated form). Beside age and appropriateness, this research is different from the previous research because the patients emphasize the importance of marital status as well.

Conclusions
The research showed on the importance of strengthening the use of terms of address in the form of a second person pronoun based on kinship system to show respect preferred by patients. The second person pronoun are as follows: Father/Bapak, Older Brother/Mas, Younger Brother/Adek or Dik (truncated form) and Mother/Ibu, Older Sister/Mbak, and Younger Sister/Adek. The condition differs if the male and female patients are married and younger or older than the medical students. The married female patients prefer to be called Mother/Ibu rather than Older Sister/Mbak and the married male patients prefer to be called Father/Bapak rather than Older Brother/Mas. It is different from previous research, this research showed that preferrence of terms of address was not based on difference of age but also the mraital status.
Previous actual teaching and practice of a doctor-patient communication was based on a "checklist" type and it has the impact that the research and practice is not intergrated well. The notion of face is universal and has the advantage of intricately connecting face need (the desire to mantain a sense of competency, liking, appretiation, self esteem) with specific speech acts or ways of saying something. Understanding the patient's condition by the use of the appropriate terms of address which will not threaten the client's social identity (seen as face threat or violations of identity, poise or respect) will have a different outcome and complexity of positive interaction. In order to maintain the process of anamnese to be carried out smoothly, the medical doctor Thus, doctor-patient communication which is a specific communication based on universal but culturally mediated face needs will give a broader view on the social phenomenon of institutional talk within the social construction of verbal conversation. In other words, the training of doctor-patient communication which is based on the English for Academic Purposes: medical is also added with specific communication skills which is culturally bound and can mediate the face needs while following the guidelines for conducting an interview in English and Indonesian as well.
It is suggested that in the teaching of politeness and appropriateness in a social phenomenon of a doctorpatient communication which is related with face work and politeness theory seen in the use of second person pronoun in terms of address will be useful to interpret the framework in English for Academic Purposes: Medical and in a non-westem context. This approach will also support the understanding of the structure, process, perceptions of interactions from a different point of view. For other researcher, it is suggested to analyze the values in English for Academic Purposes: Medical and other local values of client's response to health and illness which influence the choice of patients. Patinetns' preferred terms of address based on face work and politeness theory will then provide a deeper understanding of the possible shift in cultural values.

Declaration of Conflicting Interests
The author declared no potential conflicts of interest.

Ethical Approval
This study has been approved by The Committee of

Funding
The author disclosed the financial support of the Research Center of State University Malang, Indonesia for individual research.