Q J Med 2003; 96: 615-616
© 2003 Association of Physicians
Coda |
Uniqueness and conformity
If you observe medical consultations closely, you will nearly always observe some kind of struggle going on between medical and lay styles of conversation. Patients mostly display a style that is best described as a narrative one, while doctors pursue one that is more normative. (The distinction is my own, but it closely follows the psychologist Jerome Bruner, who talks of ‘narrative’ and ‘paradigmatic’ modes of speech.)Patients, by and large, have a story to tell. This story-telling has a primeval drive behind it, a drive that is universal and probably far older even than medicine. If you want to find out how powerful the story-telling drive is, you have only to interrupt patients prematurely in their narratives—as we all sometimes do—and to notice how they generally carry on from exactly where they stopped.
Doctors, by contrast, generally approach conversations with patients in quite a different way. Our utterances are largely aimed at matching patients’ words against known patterns of description, or norms. These may be norms of diagnosis (‘Is this angina?’) but they may also be norms of degree (‘How much has her breathing deteriorated at night?), norms of behaviour (‘Does she smoke?’) or norms of treatability (‘I wonder if this warrants a trial of an antispasmodic’). So while patients may try to carry on delineating the uniqueness of their experiences—and to take as much time as they need in order to do so—probably our own commonest concern is to find out the common denominators in these stories, and then to move our conversations to a close as rapidly as possible. Although patients are sometimes in a hurry and only want their doctors to get on with the task, and conversely doctors can be possessed by curiosity about someone’s story and forget about time constraints, this discordance between the two styles is probably present during most of our encounters with patients.
Doctors seem to vary greatly in their awareness of this discordance. Some exert their professional power unthinkingly and as a matter of routine, ensuring that the normative style dominates every consultation. Effectively, they screen the patients’ words for whatever corresponds to their own conceptual framework, (‘blood’, ‘pain’, ‘smoking’, ‘pills’) and conveniently tune out anything that does not. Most doctors are probably rather more tolerant of patients’ narratives than this, at least in the opening part of the consultation, but they may still be waiting to pounce on any opportunity to bring the normative style into play, certainly as soon as they think it polite enough to do so.
One of the most difficult tasks in the whole of medicine may to be manage each consultation so that it continually meets both narrative and normative requirements. This goes far beyond so-called ‘patient-centred’ medicine. It means recognizing the equal legitimacy of the patient’s need for self-expression and one’s own need as a doctor to achieve pattern recognition, action and closure. It means finding ways to satisfy both needs at every moment in the consultation.
To do this effectively involves careful conversational micro-skills. In practical terms, the doctor has to try and interpolate normative questions or statements into the conversation only at moments that exactly fit in with the natural flow of the patient’s story as well. Some doctors appear to do this intuitively. Others seem able to learn over time how to rearrange the strands of their conventional history-taking and advice-giving, so that these interweave seamlessly with the fabric of the patient’s story. The most skilful can manage the conversations so well that they often achieve both normative and narrative closure at the same time.
In spite of the crucial importance of such conversational micro-skills, there is remarkably little teaching available for either medical students or doctors that is directly focused on developing these, and probably even less research on how some doctors manage to operate such micro-skills in practice. One outstanding exception is an article written by a team at Harvard Medical School.1 The article includes transcripts from two contrasting consultations. In the first of these, the doctor does indeed seem able to pay attention to the patient’s narrative in such a way as to find exactly the right cues for each normative question that needs to be asked. Here is an example:
Patient: ...my boss hadn’t got all the parts for it, so I started working on another car, ya-know? That’s when I ended up having the seizure.
Doctor: Okay...So did your boss or someone else see the seizure happen?
The doctor in the second consultation, by contrast, seems incapable of listening to anything except the deafening drumbeat of medical imperatives pounding inside his own head.
Patient: It’s one spot right here. It’s real sore. But then there’s like pains in it. Ya-know how...I don’t know what it is.
Doctor: Okay...Fevers or chills?
Patient: No
Doctor: Okay. Have you been sick to your stomach, or anything like that?
Patient: [Sniffles, crying] I don’t know what’s going on.
Many of us will recognize an aspect of ourselves in the doctor’s clumsy interventions. The patient’s heartfelt exclamation—‘I don’t know what’s going on’—speaks to us poignantly as readers. What is going on is only too obvious. It is, of course, the institutionalized disqualification of the narrative.
References
1. Mishler E, Clark JA, Ingelfinger J, Simon P. The language of attentive patient care: a comparison of two medical interviews. J Gen Int Med 1989; 4:325–35.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||