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A QC is a 3-4 page (single spaced) summary, commentary, and question(s) of the assigned readings for the class period/topic. You should summarize each reading for that class period/topic (you do not need to summarize any popular press readings). Each article summary should be approximately 1 paragraph (be concise). This is your chance to demonstrate that not only did you do the readings, but you can cull out the major elements of the readings and make connections between readings. After the summaries, you should write a brief commentary that includes reactions to the readings, connections you see between the readings, and/or concerns you have about the readings (arguments against, etc.). This section will be 1-2 pages. Finally, you should pose questions—questions you still have after completing the readings, questions about connections, theoretical questions, etc. This section is incredibly important as I will use your comments to guide our discussions.

Other important information for the assignment:

1. You need to complete 12 QCs. Each is worth 10 points.

4 points for summary

5 points for commentary

1 point for questions

2. Each QC should be typed and proofread. Also, don’t forget to put your name and the class topic at the top of the QC (just to make sure that you didn’t post to the wrong assignment post).

3. You do not need a title page or reference page (unless you are citing material not covered in class).

4. Make sure to follow APA format rules—12 point font, Times New Roman, 1” margins on each side.

**You should always bring copies of your QCs to class as I will call on students to share thoughts, questions, etc. from their QCs.**

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HEALTH COMMUNICATION, 14(3), 339–360 Copyright © 2002, Lawrence Erlbaum Associates, Inc. Physician–Patient Co-Construction of Illness Narratives in the Medical Interview Susan Eggly Department of Medicine Wayne State University Researchers and medical educators in the area of physician–patient communication encourage physicians to elicit patient narratives during medical encounters to facilitate data collection, rapport building, and patient satisfaction. These scholars, however, provide little information about the nature of the narrative, especially in the context of the medical interview. This article reviews the multidisciplinary literature on narrative and reports the results of a narrative analysis of 21 physician–patient interviews. A set of criteria for defining narrative is derived from the literature and applied to these interviews, demonstrating the limitations of previous conceptions of narrative and suggesting an expanded definition. This expansion emphasizes the notion that narratives are co-constructed through the interaction of both participants in the conversation in which they occur. Application of the expanded definition to the same interviews reveals 3 new narrative forms: narratives that emerge through the co-constructed chronology of key events, the co-constructed repetition and elaboration of key events, and the coconstructed interpretation of the meaning of key events. The medical interview is essential to the task of diagnosing and treating medical patients. On average, practitioners conduct 150,000 interviews during their career—an extraordinary number for any task (Lipkin, 1995). Effective communication during the medical interview plays an essential role in determining doctor–patient rapport; patient and physician satisfaction; patient adherence to the treatment plan; and, frequently, the course of the illness itself. Alternatively, ineffective communication is associated with poor health outcomes, doctor shopping, and malpractice suits (Co- Requests for reprints should be sent to Susan Eggly, 2E University Health Center, Department of Medicine, Wayne State University, 4201 St. Antoine, Detroit, MI 48201. E-mail: seggly@intmed.wayne.edu 340 EGGLY hen-Cole & Bird, 2000; Coulehan & Block, 1997; Cali & Estrada, 1999; Kurtz, Silverman, & Draper, 1998; Stewart et al., 1999). In response to abundant empirical and theoretical evidence supporting the significance of effective communication skills during the medical interview, many medical schools currently include interviewing skills in their curricula (Coulehan & Block, 1997). Traditionally, physicians were trained in the biomedical, disease-centered model of health and illness and instructed to “extract a history” from their patients, using lists of questions about symptoms and past illnesses. Patients who were unable to answer these questions efficiently were labeled poor historians; physicians who requested instruction in communicating with patients were told that it was an intuitive skill, gained through experience (Coulehan & Block, 1997). Today, however, many medical schools have moved away from a biomedical approach in favor of a patient-centered, biopsychosocial model of health and illness. According to this model, Every patient has a story that demonstrates the interaction among the biologic, psychologic, and social components of his or her life … The physician’s task is to elicit and understand this story, for it provides an introduction to who the person is and why he or she is seeing the physician. The story also provides clues to diagnostic and therapeutic issues relevant to the patient’s problem. The primary means for eliciting the story is clinical interviewing, the core skill of the clinician and a skill that has long been central to the clinical method. (Smith & Hoppe, 1991, p. 470) In keeping with this patient-centered approach, physicians today are trained to facilitate good communication during the medical interview through the elicitation of the patient’s story. Instruction in eliciting the patients’ story is abundant throughout recent textbooks devoted to the medical interview. One recent textbook, for example, consists of two sections—the titles of which are an obvious clue to the patient-centered medical model on which the book is based: “Part I: Basic Skills: Understanding the Patient’s Story” and “Part II: Basic Skills in Practice: Applying the Patient’s Story” (Coulehan & Block, 1997). In another well-respected text devoted to the medical interview, Mack Lipkin, Jr., one of the foremost researchers and theorists in the field of doctor–patient communication, suggested that The most efficient approach [to eliciting the necessary information about the present illness] is to allow the patient to tell the story in his or her own words, while gently and behaviorally shaping the storytelling toward the necessary clarity, completeness, and brevity. (Lipkin, 1995, p. 71) Despite the fact that many textbooks instruct medical students and physicians to elicit the patient’s story as an efficient method of achieving the goals of the inter- CO-CONSTRUCTION OF ILLNESS NARRATIVES 341 view, a clear explanation of the nature of narrative is often lacking. Although there are examples of stories, explanations of the importance of listening to patients’ stories, and instruction in the art of eliciting the story, a precise definition of the words “story” or “narrative” is frequently left open to interpretation. Because the elicitation of narratives has been shown to be essential as a method of gathering data about illness, a clearly articulated definition of narrative would serve two important functions: (a) providing a foundation for further analysis of narratives in a medical context as well as in other contexts, and (b) providing physicians and other health care providers with insights as to the nature of narratives in the medical encounter, as well as ways to elicit, understand, and use them as an essential tool to achieving the goal of the interaction. In this article, I review the literature on the nature of narrative from a variety of disciplines; following this, I apply a set of criteria for defining narrative adapted from the foundational work of two scholars to 21 medical encounters between resident physicians and elderly patients to identify and characterize narratives in the encounters. Based on the results of this application, I suggest that this context provides evidence for an expansion of our previous conception of the nature of narrative—one that encompasses the constructivist notion that the illness narrative is created by both participants in the interview rather than by the patient or by an objective truth. Finally, I describe three previously unrecognized narrative forms that emerge in these medical encounters based on the expanded definition. REVIEW OF THE LITERATURE This section begins with an overview of the multidisciplinary literature on the nature of narrative and continues with a focus on the study of narrative in the context of medicine and, in particular, in physician–patient interactions. This section concludes with a review of the literature on narrative analysis, leading to an explanation of the method of analysis of this study. The Nature of Narrative Scholars from a broad spectrum of disciplines (Langellier, 1989) have argued that people are universally motivated by a need to make sense of deviations from the ordinary. When we see something we do not understand, we try to understand it. We do this by creating an explanation for extraordinary events, stringing them together into a logical plot. We communicate these explanations to others, adjusting the plot to fit with our understanding of the events and the context in which we are telling. Our explanations take the form of stories, or narratives. Narrative, therefore, is the method we use to mediate between the world of the unexplained and the sensible 342 EGGLY (Bruner, 1990; Fisher, 1987; Hunter, 1991; Mishler, 1984; Reisman, 1993; Waitzkin, 1990). The study of narrative, therefore, offers the opportunity to understand both what is perceived as normal or ordinary as well as extraordinary or abnormal. Once the province of literary study, researchers in many fields now use narrative as an analytical tool in seeking to understand the interpretation of experience (Reisman, 1993). In the field of communication, Fisher (1987) argued that people are essentially storytellers, and that the study of narrative brings us closer to understanding human communication and action because it allows us to understand the reasons humans use for selecting certain narratives over others in explaining their world. Brockmeier and Harre (1997) looked to a narrative approach to bring us closer to accounting for the dynamic patterns of human behavior, citing two special qualities of narrative that make it important as a focus of study: first, “an open and flexible structure that allows us to examine precisely these fundamental aspects of human experience, its openness and flexibility, traditionally neglected by the human sciences” (p. 278), and second, “narrative mediates between the self and the world, functioning as a model or analogy of each … in this way, narrative helps us construct ourselves as part of the world” (p. 279). In psychology, Bruner (1990) referred to narrative as the “biology of meaning,” arguing that people naturally organize experience in a narrative form. The way in which narrative organizes experience is through framing, which “provides a means of ‘constructing’ a world, of characterizing its flow, of segmenting events within that world, and so on” (p. 64). In other words, the narrative construction of meaning organizes seemingly meaningless events into larger, meaningful structures that are symbolically represented as stories. From a multidisciplinary perspective, narrative is explained as an activity undertaken by people as a way of organizing and interpreting their world. This perspective is critical to the study of narrative in physician–patient interactions in that the explicit goal of these interactions is to organize and interpret the patient’s illness experience to explain and resolve the illness. The next section reviews the literature on narrative in the context of medicine, and more specifically, in the context of the physician–patient interaction. Narrative in the Context of Medicine Researchers have used a narrative approach to examine many aspects of health and illness. Some examples are the study of cross-cultural psychiatry (Kleinman, 1988), health concerns specific to women (Borges & Waitzkin, 1995) and the elderly (Waitzkin, 1990), agoraphobia (Capps & Ochs, 1995), and the use of narrative by physicians themselves (Hunter, 1991). Narrative analysis in a medical context frequently focuses on the conflicting rhetorical agendas in medical interviews, CO-CONSTRUCTION OF ILLNESS NARRATIVES 343 described by Mishler (1984) as two voices: “the voice of medicine,” which involves the technical details of illness and disease, and “the voice of the lifeworld,” which includes the social and emotional concerns that patients often express in explaining their experience (Kleinman, 1988; Mishler, 1984; Sharf, 1990). An example of the flexible, interpretive nature of a narrative approach to the study of doctor–patient interactions is Waitzkin’s (1990) analysis of two interactions between physicians and elderly patients. This discourse analysis of narratives in the interactions reveals themes of the socioemotional context of aging such as social isolation, limited resources to preserve independent function, financial insecurity, and physical deterioration associated with the process of dying, as well as ideologic assumptions of the doctor. In one of the interactions, the doctor listens supportively and explores these themes with the patient, but tension rises in the encounter when the doctor faces the inability of medicine to address these socioemotional issues. The doctor manages the patient’s problems through encouraging her to maintain her ability to function independently, revealing ideologic assumptions that value individualism and stoicism, rather than exploring options for her to enhance her social support (Waitzkin, 1990). Waitzkin’s work illustrates the unique power of narrative analysis in exploring themes of health and illness from the perspective of the storytellers. Sharf (1990) supported the use of narrative analysis as a promising rhetorical approach to the analysis of medical encounters. She viewed the clinician’s attempt to persuade the patient to take action as inherently rhetorical, following the Aristotelian notion of rhetoric as persuasive speech. Her work provided “a rationale for and application of narrative rhetorical theory to the medical encounter and discusses how this methodology can contribute to a broader understanding of the clinical interview as interpersonal rhetoric” (p. 218). Sharf illustrated her views through the analysis of a medical interview in which the patient and the doctor reveal their rhetorical objective through the use of narrative. The patient tells his story by enumerating his problems as well as using anecdotes, examples, and personal beliefs. The style as well as the content are unacceptable to the doctor, who tells his story in an accounting style, offering medical explanations and reprimands. Although both participants address the same topics, their stories conflict in many ways, leaving little room for agreement about the nature of the patient’s problem or its resolution. Research on narrative in the medical context demonstrates the key role of narrative analysis in understanding how physicians and patients organize and interpret the patient’s illness experience. This research reveals conflicts in the interpretation of the patient’s experience, but more important to this study, it demonstrates the way in which the interactive process of narrative allows the participants in the interaction to influence each other, shaping their interpretation of the illness. In the next section, I review the literature on the method of analysis known as narrative analysis. 344 EGGLY Narrative Analysis Narrative analysis seeks to reveal the underlying meaning of a story. Through an examination of the discourse as well as the content, narrative analysts attempt to understand how storytellers interpret their experience—specifically, the social and cultural norms that they draw on to make sense of their world. Narrative analysts tend to take as their point of departure a specific definition of narrative. The most widely cited and current linguistic model of personal narrative stems from the work of William Labov. Labov (1972) defined narrative as “one method of recapitulating past experience by matching a verbal sequence of clauses to the sequence of events which [it is inferred] actually occurred” (359–360). Labov specified that stories have both a referential function, in that they describe a specific past event, and an evaluative function, in that they reflect the point of view of the narrator. To meet the criteria of a narrative, according to this model, stories have to contain, minimally, one temporal juncture that refers to the past event. To be more complete, the narrative must have an internal structure of the following six components: (a) abstract, which tells what the story is about through a short summary; (b) orientation, identifying the time, place, and people; (c) complicating action, in which the clauses relate the temporal sequence of the event; (d) evaluation, in which the narrator describes the significance of the event or point of the story; (e) result, which concludes the story; and (f) a coda, which brings the perspective back to the present moment (Labov, 1972; Langellier, 1989). Labov’s (1972) method of narrative analysis has been widely accepted and built on, especially in the fields of sociolinguistics, communication, and narrative analysis (Langellier, 1989; Polanyi, 1985; Reisman, 1993). It is an extremely useful tool in examining the personal narratives of the patients in this study, not only because of its broad, interdisciplinary acceptance, but more important because it provides a clear structure and method. This method is limited, however, in that it detaches the narrative from the linguistic and social context in which it occurs. Langellier pointed out a major disadvantage of this analytical method: There are two separate but related points to be made here. The first focuses on audience and concerns the Labovian assumption that narrative is a relation among clauses rather than an interaction among participants. The second interrogates what constitutes context beyond the interview setting, especially what social and cultural assumptions are implied and masked in viewing narrative as a text of clauses. In other words, what are the consequences of viewing the personal narrative as a text autonomous from its context of performance by the participants, its position within social and political discourses, and its interpretation by researchers? (p. 248) Other researchers have solved the problem of social context by looking at the role of narrative as a part of the natural flow of conversation. Discourse analysts CO-CONSTRUCTION OF ILLNESS NARRATIVES 345 have viewed conversation as interaction, mutually constructed by the interactants, adhering to the cultural and social norms of turn-taking (Langellier, 1989). In particular, Polanyi (1985) built on the Labovian model of narrative by expanding the unit of analysis to the interactional sequence. According to Polanyi, the purpose of telling a story is “to make a point, to transmit a message—often some sort of moral evaluation or implied critical judgment—about the world the teller shares with other people” (p. 21). In Polanyi’s (1985) model, the point is negotiated by the speakers and the context of the interaction, and constraints are therefore placed on both the speaker and the recipient. It is the responsibility of the teller to (a) tell a topically coherent story in which an event produces a meaningful change, (b) tell a story on a narratable topic worth building a prolonged telling around, (c) introduce the story so that it connects with the conversation, (d) structure the story so that it appropriately distinguishes between states and events, (e) start at the beginning of the story and move forward, and (f) evaluate states and events so that the point is made clear. At the same time, the recipient must (a) agree to listen or provide a reason not to listen, (b) refrain from taking a turn that does not support the telling of the story, and (c) demonstrate understanding of the point (Langellier, 1989, p. 258). The set of criteria for defining narrative adopted for this study is an adaptation of the structural model described by Labov (1972) and the suggestion by Polanyi (1985) that narratives are constructed by all members of the conversation in which the narrative occurs. This adaptation seems particularly appropriate for physician–patient interactions for two reasons. First, the Labovian model provides a clearly identifiable linguistic structure that can be applied to interactions, such as the medical encounter, that would on the surface, appear not to have any of the characteristics of a narrative. Second, the Polanyi model adds the advantage of the consideration of social context. This adaptation furthers previous research by characterizing the linguistic structure of narratives in the context of the medical interview. In addition, this study is significant in that it explicitly acknowledges the critical role of both the doctor and patient in the construction of the narrative, and therefore, in the construction of the perception of the illness itself. This contribution stands in contrast to the literature that tends to portray the patient as the relatively passive recipient of a physician who consistently controls the conversation, and thus, the outcome of the interview (Beckman & Frankel, 1984; West, 1984). STUDY DESIGN This study uses a qualitative methodological approach known as conversation analysis with the assistance of QSR NUD*IST 4® (1997), a qualitative research software package. Conversation analysis, a method widely used by linguists and anthropologists, assumes that analysis of naturally occurring conversation provides 346 EGGLY the researcher with stable, organized patterns that reflect and construct the social organization of society (Silverman, 1993). The setting for the study is an outpatient medicine clinic at a major urban teaching hospital. The majority of the patients who attend this clinic are elderly, poor, and African American. The physicians are trainees in a general internal medicine residency training program. The majority are international medical graduates, indicating that they were born and received their medical training outside the United States and Canada. The large number of international medical graduate residents is typical not only of this training program, but of general internal medicine residency programs nationwide (Dunn, Miller, & Richter, 1998). Data for this project consist of transcripts taken from a larger corpus of videotapes (n = 45) of physician–patient encounters recorded previously as part of the communication skills curriculum of the medical residency training program. The university’s institutional review board granted permission to use the videotapes for this project. Twenty-one videotaped interviews were included in the project because they met the following criteria: First, the physician was currently in the training program, in case questions arose about the interview that he or she might be able to answer; and second, the patient was between the ages of 70 and 85. This age group was chosen because it reflects a growing population of patients seen by internists, and in part to respond to other research questions that are a part of a larger project in which these data are used. A third criterion was that no additional person was in the room during the interview. Among the 21 physicians in videotaped medical encounters, 8 were women and 13 were men; 15 received their medical training outside the United States, and the other 6 were trained in the United States. Among the 21 patients, 14 were women and 7 men. The mean age of the patients was 72 (range = 70–85). There were four new patient visits, eight return visits, and nine transition, meaning that the doctor was new but the patient was returning to the clinic for a follow-up visit. Transcripts of the 21 videotaped interviews were made according to guidelines from Tracy (1997). The time of the segments of the interviews that were transcribed ranged from 5 to 23 min. Only the history was transcribed, that is, from the beginning of the interaction until the moment when the physician asks the patient to step onto the exam table for a physical exam. RESULTS: FORMAT OF THE NARRATIVES The narratives that emerged from the interviews fell into two general categories: narratives that are easily identified as narrative in format, and those that, at first glance, seem to be randomly organized and lacking in narrative structure. In the following section, I describe these two categories, demonstrating that despite their differences in format, both categories share two important characteristics—they tell a CO-CONSTRUCTION OF ILLNESS NARRATIVES 347 story, and the story they tell is coconstructed by both participants in the interaction. The following description of these two categories of narrative demonstrates the need to expand our previous conception that narratives must exhibit the linguistic structure of narrative. Furthermore, it suggests an expanded definition of narrative to address this need. Category 1: Narratives that Exhibit Labov–Polanyi Structural Format A working set of criteria for identifying narratives in the interviews was initially created by adapting criteria derived from Labov (1972) and Polanyi (1985): The patient must (a) tell a story that has at least one temporal juncture, (b) tell a story that is topically coherent and relevant to the context of the medical interview, (c) introduce the story so that it connects with the conversation, (d) adhere to the chronology of the events, and (e) evaluate the events so that the point is made clear. The physician must participate by (a) agreeing to listen, (b) refraining from taking a turn that does not support the telling of the story, and (c) demonstrating understanding of the point of the story. Among the 21 videotaped interviews, a total of 30 exchanges meet the previous criteria for narrative form, and are referred to here as exhibiting Labov–Polanyi (L–P) format. Some of them are very brief, providing sparse recitations of events in chronological sequence; others describe the events in great detail. Tapes 9 and 19 provide examples of minimal narratives, consisting of a small number of sequential events that construct the patient’s (Pt) experience. Tape 9 Pt: And I need ah, my nephew went to the doctor and they wouldn’t pull his teeth because he had, they say have to have stuff from his doctor. But I went one time and they called my doctor and they gave me a bridge. I lost the whole thing. But I got three teeth that got to be pulled. Dr: Uh-hm. Pt: And do I have to have a slip to let my doctor know what kind of medicines I’m takin’ ((coughs)) to get my teeth pulled? Tape 19 Dr: How you doing? Pt: Well uh I’m doin’ alright., till uh a hernia got in my stomach, and I went to that doctor, through Emergency. Dr: OK. Pt: So he told me it was a hernia. He said I have to wait for my doctor, to get it operated on and come back. Next week. Dr: OK. 348 EGGLY Tapes 1 and 4 illustrate narratives that exhibit L–P format, but with greater elaboration of the key events. Tape 1 Pt: I haven’t smoked a cigar since January, when my baby passed. My daughter, she was the baby. Dr: What happened? Pt: I don’t know! Dr: How old was she? Pt: 41. She worked in that computer place, I forget the name. She got a cold, and she couldn’t stop coughing. She’d cough, cough, cough. Sometimes her EYES would just get red, she coughed so much. So she went to the hospital, and they would give her some tests. They told her to “come back next Friday morning,” they was gonna take a, a biopsy of the ((pause)) lung, I think, somewhere, anyway, they were gonna take a biopsy. At [name of hospital] I told her don’t go, go to [name of different hospital]. She went in there Friday morning, Saturday morning, she deceased! Dr: Just like that? Was there any reason? Pt: Don’t nobody know nothing. They said they don’t know. Dr: I’m sorry to hear that. Tape 4 Dr: So, how have you been doing since last time you were here? Pt: Well, doin’ pretty good. The only thing is that he took my potassium away from me and I got kind of weak, like, you know. Dr: OK. Pt: That’s all I need prescriptions for. I got refills on all the other medicines. I get five. And I just got them refilled. Dr: OK. OK. So, when you say you’re feeling weak, are you feeling dizzy or short of breath? Pt: Kind of dizzy, like, you know. See I fell out I was in the hospital for four days, went home, and came back and they gave me a CAT scan. My head was hurtin’. It hurt all that day on one side. When I got a little easy I went out and flagged me a cab, about a half a block, came back and they kept me ’till about 3 in the morning. They worked on me, and discharged me I ain’t had no trouble with that anymore. These stories exhibit the L–P format with a more elaborate description of the events that construct the experience than the previous two illustrations. In fact, some narratives among these data meet the rigorous criteria laid out by Labov (1972) for a complete narrative: They contain an abstract, which briefly summa- CO-CONSTRUCTION OF ILLNESS NARRATIVES 349 rizes the story; an orientation, identifying the time, place, and people involved; a complicating action, in which the clauses relate the temporal sequence of the event; an evaluation, in which the narrator describes the significance of the event or point of the story; a result, which concludes the story; and a coda, which brings the perspective back to the present moment (Labov, 1972; Langellier, 1989). The story in Tape 3 exhibits these six components. Tape 3 Dr: Yeah, I guess. OK, so how are you feeling today? What brought you here? Pt: Ah, pretty good. I say not too bad.. I have, what I want to come today.. I have a navel infection. (abstract) Dr: Uh hmm. Pt: And ah the 20th, which was on the Sunday before last, or was it Saturday? … Whatever, day the 20th was (orientation) Dr: Uh hmm. Pt: My daughter works at the hospital (orientation) and when she came home I discovered my stomach was kinda burning and it was red (complicating action) Dr: Uh hmm. Pt: So, she took me back up there to the doctor. She gave me some cream to put on it (complicating action) and I thought I’d better come back (evaluation). Because, I had surgery in ah 19, 77. Dr: Uh hmm. Pt: at [name of hospital] and I had a hysterectomy and this is what she gave me to put on it. And, it is somewhat better, (result) but it’s still, if I be bendin’, you know, it be a little red around there. (coda) The previous narratives, from the most minimal to the most complete, illustrate the L–P format of narrative that most physicians would likely agree on as reflective of the narrative form they are encouraged to elicit as part of the patient’s history: The patients participate by reporting a chronology of events that led them to seek medical attention, while the doctors participate by asking open-ended questions, listening, and refraining from interrupting or redirecting the flow of the narrative. A narrative analysis of these and other narratives that emerge from doctor–patient interviews is extremely instructive in that it provides the opportunity to consider the perspective of both participants, the doctor and the patient. This narrative analysis is incomplete, however, because it excludes many stories that do not exhibit the L–P format. This study furthers the analysis by looking deeper at the transcripts to discover a second category of narratives, those that do not exhibit the L–P format, nevertheless telling a story. The identification and illustration of this second category of narrative forms lays new ground in our understanding of narrative form. 350 EGGLY Category 2: Narratives That Do Not Exhibit Labov–Polanyi Format The identification of the second category of narratives—those that tell a story yet do not exhibit L–P format—demonstrates the need for a definition of narrative that departs significantly from our previous understanding of narrative by explicitly addressing the constructivist notion that meaning emerges from social interaction. Narrative is not simply the telling of a chronological sequence of events by one speaker with the support or facilitation of a listener; instead, the story is cocreated through the social interaction of the participants. The expanded definition suggested by these data is that a narrative is the discursive co-construction of a chronology of events that describe a meaningful experience. The three forms of narrative that suggest this expanded definition of narrative form can be characterized as follows: co-constructed chronology of key events, co-constructed repetition of key events, and co-constructed interpretation of key events. Co-constructed Chronology of Key Events In the following two examples, the chronology of the events evolves through the interaction between the doctor and the patient. The patient describes the key events in a random rather than a chronological sequence, and the doctor facilitates the chronological ordering of the events by asking questions that elicit the chronological relationbetweentheseevents.Ultimately,achronologicallyorderednarrativeemerges. Tape 6 Dr: OK, I got the idea. So we talked about two things, first the cold, second the calf problem, let’s talk about the third one which is the arthritis you told me. Pt: Yeah, I had it once before and you gave me some kind of medication Dr: Um-hm. Pt: to use. It throbs in there. Hurts ((touches wrist and jumps back)). Dr: I will examine you. I know it’s swollen, since when it’s swollen like this? Pt: It started hurting this last week. Dr: Just last week. Is it the same, or it’s going worse? Pt: It’s the same, but just right in there, it just hurts. Dr: Did you feel hot over it when it start, or just like now? Pt: It just feel like that ((touching wrist)). Dr: So it started one week ago. Just hurts when you move your hand? Pt: Just hurts. Dr: Just hurts. All the time. Pt: Right in there. Just kind of throbbing in there. Goes on up into the thumb ((tracing hand to thumb)). Dr: ((touching hand)) Goes to the thumb. Any numbness? CO-CONSTRUCTION OF ILLNESS NARRATIVES 351 Pt: No. Dr: No. Did this happen to you before? Pt: Yeah. One year or so back, you took some x-rays but it wasn’t showin’ nothing. But since that arthritis is in there that hurts. Dr: Yeah. Pt: You give me some kind of medication or something for it. And that helped, and it lasted for a week, and it eventually went on out. But it ain’t swollen quite as big as it was last time. Dr: OK. We will take care of this. This interaction does not exhibit the L–P format for a narrative; however, the interaction between the doctor and patient constructs a chronological sequence of events. The patient’s first statement (lines 2–4) describes three events, with an implied relation between them: 1. I had this once before. 2. You gave me some kind of medication to use. 3. It throbs in there. The doctor’s questions that follow this statement create the chronological relation between the events, as well as a more detailed description of the quality of the symptoms. These questions clarify the time of onset of this episode of pain, the quality of the pain, and the relation between this episode and previous episodes. The patient participates in the development of the chronology by providing the answers to the questions. At the conclusion of the entire exchange (line 21), the participants have coconstructed the following chronology of events, which now exhibits the L–P format. 1. 2. 3. 4. 5. 6. 7. 8. A year ago, I had a pain. You took an x-ray, but it didn’t show anything. You gave me some medicine, which helped. It lasted for a week. It eventually went on out. Since then, the arthritis in there has continued to hurt. A week ago, the same pain started to hurt again, all the time. It throbs, but it’s not as swollen as it was last time. In the next example, the patient’s description of her medical problem is somewhat vague, but is elaborated through her interaction with the doctor. Together, they construct a narrative that is agreeable to the patient and at the same time provides the doctor with the chronological sequence as well as the description of symptoms that he requires to initiate the diagnostic process. 352 EGGLY Tape 18 Dr: OK. Has it been troubling you in any way, like giving you any chest pain, headache… Pt: No…but um sometimes … I don’t know if it’s the medicine or not, but it seems like sometimes, something makes me very uncomfortable, like it’s squeezing in my heart. Feels like a depressed feeling. Sometimes. Not all the time, just sometimes. Dr: How often it comes to you? Pt: Oh, maybe if it’s something I eat, or different times when I take my medicine, sometime I can’t take it real early in the morning, cause I forget it, or if I’m going somewhere, I don’t want to be goin’ to the bathroom, maybe I’ll take it bout 12:00, maybe sometimes later, and then sometimes at night. Dr: So how often in a week you get like that? Pt: Maybe about once or twice. Dr: OK, and it is there in the center of your chest? Pt: Mm-mm. Right along here—just feels like something, just a depressed feeling. Dr: And does that pain shoot anywhere? Pt: No, I don’t have no pain, unless I have gas. Dr: Oh, OK. So it’s not pain, some sort of discomfort you have. Pt: Yeah, uh-huh. Dr: OK. And it goes away by itself? Pt: M-hm. Dr: And does it bother you at sleep? Pt: No. Dr: So what do you do when it happens? Pt: I just sit still, and, sometimes I drink water. Sometime I just take—breathe in and out like that ((demonstrates)) about three or four times and it go away. In Tape 18 the patient provides core information regarding a recurrent physical feeling of discomfort that might be related to either the medication or food (line 2). This core information is jointly developed into a narrative through the doctor’s questions and patient’s answers regarding the chronological sequence and details of the events that describe the experience. This process results in the following L–P format. 1. About once or twice per week, I eat something or I take my medicine. 2. I get an uncomfortable feeling, like a squeezing or a depressed feeling in my heart. 3. I just sit still or drink water or take a few breaths. 4. It goes away. CO-CONSTRUCTION OF ILLNESS NARRATIVES 353 Although these conversational exchanges do not initially exhibit L–P format in that they do not adhere to the chronology of events, they demonstrate that the chronology emerges through the social interaction, and thereby support the definition of narrative as the co-construction of a chronological sequence of events that describe a meaningful experience. This expansion of the definition of narrative is significant in furthering our understanding of narrative form to include discourse in which two participants collaborate in the construction of the chronological sequence required for narrative. Co-constructed Repetition of Key Events The following example illustrates a second discourse strategy that patients and physicians use to co-construct narratives. In this example, physician questions elicit the patient’srepetitionofthekeyevents,andthenarrativeemergesoutoftherepetition. Tape 4: Initial Report of Events Dr: So, how have you been doing since last time you were here? Pt: Well, doin’ pretty good. The only thing is that he took my potassium away from me and I got kind of weak, like, you know. Dr: OK. Pt: That’s all I need prescriptions for. I got refills on all the other medicines. I get five. And I just got them refilled. Dr: OK. OK. So, when you say you’re feeling weak, are you feeling dizzy or short of breath? Pt: Kind of dizzy, like, you know. See I fell out I was in the hospital for four days, went home, and came back and they gave me a CAT scan. My head was hurtin’. It hurt all that day on one side. When I got a little easy I went out and flagged me a cab, about a half a block, came back and they kept me ’till about 3 in the morning. They worked on me, and discharged me I ain’t had no trouble with that anymore. The second report occurs after several exchanges and changes of topic, when the physician raises new questions about the events referred to earlier in the interview. Tape 4: Second Report Dr: So, you were admitted over here to [name of a different hospital]? Pt: Yeah, four days straight. I was in pretty bad shape. ’Cause I couldn’t even go and cash my checks, when I got home, I fell with both of my checks on me. Dr: Hm! Pt: Um-hm, I got out in the street and I came home and I hit that head hard, ( ) I came back ’bout two days, they discharged me, I was feeling fine, I ain’t 354 EGGLY had no more trouble. They kept me from early that evening till about 3 in the morning, so my sisters got me and they discharged me, and I’m doin’ pretty good. Just when my potassium gets low, I gets kinda weak, they took it away from me because I was doin’ pretty good ’bout two months ago. Dr: Um-hum. Pt: But it looks like I need some. I try eatin’ bananas, try to drink orange juice, but it don’t give me enough to keep my potassium on the level. The third report occurs after a discussion of a different topic, pain medication for chest pain. In relation to the discussion of pain, the patient again refers to her low potassium level, which in this case, is causing pain in her knees. When the physician indicates he understands her desire to have him check her potassium, she repeats the initial story, and the doctor responds once again with questions about the event. Tape 4: Third Report Dr: We’ll check your potassium level here again. Pt: OK, I wish you would. You see, that’s why I fell out! My blood was low and my potassium. Real low. Dr: Did they say where you were bleeding? Pt: Hmm? No, I just passed a lot of water. Dr: Were you Pt: I fell twice. I fell once going to the post office to get my check and when I got almost home and I had to sit down and rest. It’s a park there. I live on [name of street], downtown. Then I said, oh, I can get make it upstairs, and I made it upstairs I was going to the bedroom, my head going like this, rolling my head, and I was down! I hit my head. (My shoulder…) I took a pain pill. Dr: So the room started spinning and you Pt: Um hm, I went down. And that’s the reason I had to come back to the hospital. I told them about that, but they got me stable, I was all right, walked out of the hospital, went on home and everything, my sister came and got me and I was doin’ alright, and all of a sudden. And I had a headache about 2 days later. And they didn’t bother when I was in the hospital, they did something about it while I was here. ’Cause they got me stable, back to normal, before they discharge me. They kept me in emergency and worked on me real good, two nights, put me on three machines, I think it was the heart machine, and, the IV, whatever that is they put in my arm, and up my nose, what is that? Dr: The oxygen? Pt: Yeah, all day and all night for 2 days, in the basement. And then they brought me upstairs on four, and I was doin’ all right I think, so they discharged me. CO-CONSTRUCTION OF ILLNESS NARRATIVES 355 Dr: All right. Pt: What I came back for in 2 days was that head. They wanted to do a CAT scan, and I was afraid of it, and he said it was just like an x-ray. Dr: So did you have that done? Pt: Yeah, I had that, and they kept me from about 4:00 in the evening till about 3:00 the next morning. My sister came, but I haven’t had no trouble since. Dr: You haven’t had any trouble since? Pt: That’s why I fell. I thought something, cause I hit hard when I fell. I tried my best to make it to my bed, but I went down. I’m heavy too, I weigh nearly 200! I FELL, uh! Dr: OK, Ma’am. In this interview, the patient and physician co-construct the events three times. The physician indicates clearly that he understands the point, but encourages the repetition, responding to each telling with questions and other indications of interest. In this way, deliberately or not, he participates in the construction of the ever-more detailed report of the patient’s experience. Co-constructed Interpretation of Key Events In the next two examples, the doctors express skepticism that the events occurred as the patients relate. The doctors and patients then proceed to negotiate the interpretation of events, ultimately creating a story that allows them to proceed with the interaction. If the disagreement over the key events continues, it is not expressed in a way that provides an obstacle to the construction of the story. In the long run, however, this type of co-construction may be an early indication of patient or physician dissatisfaction with the encounter. Tape 17 Pt: My sugar was up last week, but see it went down, 100 over 30. Dr: When you say your sugar’s up, are you talking about testing it at home? Pt: No, uh, my cousin got one, so she take it last Wednesday, 250, but it went down. Dr: So now your cousin’s taking your sugar? Pt: No. Dr: Oh, it was just a one-time thing. Pt: No, see she got one. Dr: Oh, your blood pressure! Pt: No, my sugar. That blood pressure’s better since you had me take it at bedtime. Dr: Yeah. Oh, so with your cousin’s machine, she’s poking your finger? 356 EGGLY Pt: Dr: Pt: Dr: Pt: Dr: Yeah. And you said over 200 or something. It WAS, last Wednesday. But And what was it recently? She took it a while ago, it was 100 over 30. Let’s see how your blood pressure’s doing ((looking at chart)). Oh, it’s sorta better! Pt: ((laughing)) it’s sorta better! Dr: I’ll take it again myself, OK? Pt: OK. This patient attempts to relate the story, but when her doctor expresses skepticism through interruptions, she slowly abandons the telling and allows her doctor to take over. In the next story, disagreement over the report of key events occurs when the doctor inserts her agenda directly into the story, contradicting the patient’s perception of the events. Tape 1 Pt: Everything’s going along fine. Just one thing, every once in a while I wake up and my hands feel numb, you know what I mean. I woke up last night they were like that, so I got me some alcohol, and I rubbed it real good ((demonstrates rubbing hands)). And then it goes away. Why is that, do you know? Dr: With alcohol? Pt: Hm? Dr: With alcohol? You said you rub some alcohol and it’s going away? Pt: Well I think so ((pause)). You think that’s it? Dr: ((laughs)) Pt: Oh, now you’re gonna stop me from that. Dr: Uh-huh! ((nods)) When this patient provides a narrative to request an explanation for his numb hands, his doctor quickly jumps in to raise the question, however irrelevant, of alcohol abuse. Later in the interview, when the doctor raises the issue of the numbness again, the patient has revised his story, and is no longer looking for an explanation from his doctor. His doctor continues to be more interested in the alcohol abuse than the numbness. Dr: So, you came to see me today because you’ve got some cramps in your arms. Pt: No, I came because I had an appointment! Dr: So it’s not that your arm is bothering you. CO-CONSTRUCTION OF ILLNESS NARRATIVES 357 Pt: No. Dr: Oh! Pt: ((looks for something in wallet)) See, today is the day I was supposed to come back ((pulls out appt sheet)). Someone called my house Friday to remind me that today was my appointment, but I knew it anyway. I haven’t forgotten. Dr: OK, ((pause)) So your arm is not really bothering you then? Pt: No, my arm’s not bothering me. Just sometime you know you feel like your hand be numb, or your feet or something. Just my hand. Just this hand. Dr: OK, tell me something about your arm. When it actually started, how it started, what happened. Pt: I don’t know, when I wake up it’s like that sometimes. Dr: OK. Pt: I wake up every night about 4, 4:30, 5:00 and turn the TV on ((pause)). And this morning it happened, it felt like it was numb when I woke up. I might have been sleeping on it, I don’t know. If you be layin’ on it or something, come to think about it I was. And I guess that probably cut some of the circulation off, or slowed it down or something. Dr: So you know why you are getting that then ((smiles)). Are you taking alcohol before going to sleep? These narratives illustrate ways in which the doctors and patients construct a mutually agreeable interpretation of the key events that constitute the story, despite initial disagreement over the truthfulness of the key events. They contribute to our understanding of the discourse strategies physicians and patients use to construct the patients’ illness narratives. CONCLUSIONS AND IMPLICATIONS The purpose of this study is to contribute to medical education and effective physician–patient communication through a description and analysis of narrative form in the context of the medical interview. An initial set of criteria for narrative format is derived from the literature and applied to 21 medical interviews between residents and elderly patients in an outpatient clinic. Although this set of criteria appropriately describes some of the narratives that occur in the interviews, other narratives emerge that suggest that this set of criteria, and in fact our previous conception of narrative, is inadequate to the task of characterizing narratives in this context. An expanded definition is suggested, emphasizing the notion that the narrative is cocreated through the interaction of both participants in the interview. When this expanded definition is applied to the 21 interviews, three new narrative forms are revealed: Narratives emerge through the co-constructed chronology of key events, 358 EGGLY the co-constructed repetition and elaboration of key events, and the co-constructed interpretation of the meaning of key events. Through understanding the nature of illness narratives within the medical interview, medical educators can further the goal of encouraging the elicitation of the patient’s story as a primary history-taking tool. This study promotes this objective in two significant ways. First, this study demonstrates the essential role of both physician and patient in the construction of the illness narrative. Medical educators can clearly demonstrate to future physicians that illness is not an objective phenomenon over which physicians have unique ownership or expertise; instead, illness is demonstrated to be an interpretive phenomenon constructed through the active participation of both doctor and patient during their interactions. Second, through these data, medical educators can demonstrate to current and future physicians that when they elicit patient illness narratives in the medical interview, they can expect the narratives to emerge in a variety of formats. Physicians must be cognizant of the fact that all patients have a story that is essential to the diagnostic process, and the format of the story may differ from that expected by the physician. Examples from the data of this study illustrate some of the formats that may emerge. Once aware that narratives can emerge in an unlimited number of ways, physicians can be instructed to tailor their interaction style to their patients’ to facilitate the emergence of the story in the most effective way. One limitation of this study that deserves mention is the sample. The sample size is appropriate and typical of conversation analysis and results are not generalizable to a larger population of physician–patient interactions. This study focuses on only one type of patient and physician; further research might investigate the co-construction of narratives by patients of different ethnic groups, social class or age, or physicians of different types of training. Results of this study suggest further research in many directions. A logical next step is to compare various narrative formats and medical contexts to explore their efficiency in achieving the goals of doctors and patients. With this information, medical educators can educate physicians not simply to elicit a narrative, but to develop communication strategies of narrative elicitation that lead to the greatest outcome in terms of satisfaction, health, and other measures. Another important direction for research is to explore interactions in which the patient’s illness narrative does not emerge in the interview. This study is limited in that it does not explore interactions in which there is no narrative; for example, because the patient is physically unable to communicate or because the interview is so heavily controlled by the physician that the patient has no opportunity to relate the story. This suggests future research into either a further expansion of the definition of narrative to include all interactions, or an exploration of the interactions that fall outside the limits of narrative. Having identified and characterized the forms of the narratives, another suggestion for further research is to continue the narrative analysis to explore the perspec- CO-CONSTRUCTION OF ILLNESS NARRATIVES 359 tives of the participants in the interactions that are revealed within the narratives. These perspectives could be explored through a theme analysis. Some suggestions of themes that might emerge from the narratives and provide insight into perspectives of the participants are the perception of the social identity of elderly patients, the nature of the illness, and the roles that physicians and patients play in relation to the illness. Finally, another area for further study is to explore the co-construction of physician-centered narratives in physician–patient or physician–physician interactions; for example, during explanations to patients of test results, diagnosis, or treatment. 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Communication Quarterly Vol. 65, No. 4, 2017, pp. 419–435 Mobilizing a Narrative of Generosity: Patient Experiences on an Urban Mobile Health Clinic Heather J. Carmack, Zoey Bouchelle, Yasmin Rawlins, Jennifer Bennet, Caterina Hill, & Nancy E. Oriol Mobile health clinics address the health needs of underserved populations by bringing healthcare to patients’ communities. Mobile health clinics find unique ways to treat patients and empower them to take control of their health. In this article, we examine how patients who use an urban mobile health clinic narrate their experiences on the clinic and what they see as the impact of the clinic on the community. A narrative of generosity emerged from the interviews, where patients believe the mobile health clinic creates a sense of welcome, encourages patients to become active participants in their health, and fosters a “pay it forward” attitude among community members. Keywords: Health Communication; Health Disparities; Mobile Health Clinic; Narrative; Patient Experiences Heather J. Carmack (Ph.D., Ohio University, 2008) is an Associate Professor in the School of Communication Studies at James Madison University. Zoey Bouchelle (B.A., The Pennsylvania State University, 2008) is a medical student at Harvard Medical School. Yasmin Rawlins (B.A., Harvard University, 2015) is a medical student at Columbia University College of Physicians and Surgeons. Jennifer Bennet (B.A., Williams Smith Colleges, 1983) is the Executive Director of the The Family Van at Harvard Medical School. Caterina Hill (MSc, London School of Hygiene and Tropical Medicine, 2003) is a Senior Researcher at Commonwealth Care Alliance and a Teaching Associate in the Global Health and Social Medicine Department at Harvard Medical School. Nancy E. Oriol (M.D., Harvard Medical School, 1979) is the Dean of Students and Research Associate in the Global Health and Social Medicine Department at Harvard Medical School and Associate Professor at Beth Israel Deaconess Medical Center. Correspondence: Heather J. Carmack, James Madison University, The School of Communication Studies, Harrison Hall, MSC 2106, Harrisonburg, VA 22807; E-mail: carmachj@jmu.edu A version of this article was awarded Top Paper in the Health Communication Interest Group at the 2016 meeting of the Eastern Communication Association annual meeting in Baltimore, MD. ISSN 0146-3373 print/1746-4102 online © 2017 Eastern Communication Association DOI: 10.1080/01463373.2017.1279677 420 H. J. Carmack et al. For more than a quarter of a century, mobile health clinics (clinics operating out of vans, buses, and mobile units) have traveled the American landscape, providing healthcare to underserved and vulnerable populations. Mobile health clinics offer a variety of care options, ranging from identifying and treating high blood pressure (Song, Hill, Bennet, Vavasis, & Oriol, 2013), osteoporosis (Newman et al., 2004), and tooth decay (Mulligan, Seirawan, Faust, & Habibian, 2010) to administering vaccines (Carmack, 2010) and diagnosing sexually transmitted infections (Lieberman, Lamberti, & Altice, 2002; Zabos & Trinh, 2001). Mobile health clinics often target communities who have the poorest access to healthcare, including children, people without homes, people with lacking or no health insurance, racial and ethnicity minorities, and people with low incomes (Hill et al., 2014). Traveling to urban centers or rural towns, mobile health clinics are alternative forms of health organizing designed to bring healthcare to individuals who lack the ability, transportation, or funds to visit providers for care (de Jesus Diaz-Perez, Farley, & Cabanis, 2004; Dulin, Olive, Florence, & Sliger, 2006; Hill et al., 2014). The estimated 2,000 mobile health clinics in the United States create an alternative health space, bringing care to patients’ front doors and neighborhood street corners (Carmack, 2010; Harter, Deardorff, Kenniston, Carmack, & Rattine-Flaherty, 2008). The movable, flexible, and resilient nature of mobile health clinics marks them as an emergent form of health organizing. Emergent forms of organizing negotiate organizational tensions by positioning the organizations as discourse communities that problematize the role of power and participation in the organization (Harter, 2004). These forms of organizing are committed to understanding how organizations privilege marginalized voices and experiences in order to re-imagine the world (Buzzanell, 1994). Emergent or alternative forms of organizing are often born from disenchantment with traditional structures, and tensions manifest because of the embracing of cooperative organizing (Stohl & Cheney, 2001). This mobile nature of the clinic serves as a challenge to the traditional, hierarchical arrangement of healthcare, by turning healthcare into a participatory event (Resnick, 2016). Creating and maintaining a space “is a deliberate means of representing a place and the people who live in it” (Mattingly, 2001, p. 448). Alternative forms of organizing reframe the other, discrediting the traditional role of otherness and situating the other as the center of the communicative process, thus giving vulnerable groups a voice. The mobile health clinic serves as a way to recognize the importance of underserved and marginalized peoples, groups whose voices and needs are not always heard and who are often left out of the patient narrative. By taking healthcare out of the hospital or doctor’s office and bringing care to the people, the mobile health clinic acts as a vehicle for inclusion and platform for unheard voices. In some form, alternative forms of organizing emphasize mutual caring and empowerment of the other and view the work of organizing as social rather than technical (Mumby, 1996). These organizations serve a greater purpose than to simply make money; organizations that organize in an alternative fashion function as a challenge to traditional bureaucracy, focusing on a greater communal goal. Staff working on mobile health clinics must find ways to treat patients in alternative physical spaces while maintaining the standards of healthcare (Carmack, 2010). By offering curbside care in the primary settings of people’s lives, the presence of mobile health clinics challenges patient expectations and larger health narratives. Communication Quarterly 421 Although health scholars and practitioners have explored design and implementation considerations for mobile health clinics (e.g., Cummings, Whetstone, Earp, & Mayne, 2002; Hayward, 2005; Heller & Goldwater, 2004; Hugo, Smout, & Bannister, 2002; Lieberman et al., 2002; Murphy, Klinghoffer, Fernandez-Wilson, & Rosenberg, 2000), health communication scholars and practitioners have only recently begun to explore the communicative acts of the mobile health clinic and the transformative power of this form of alternative health organizing. As an important setting for patient health experiences, how patients narrate their interactions with mobile health clinics is important to understanding their purpose and continued need. Communication scholars have previously examined the ways that the material and discursive spaces of mobile health clinics impact continuity of care (Harter et al., 2008) and the negotiation of privacy and disclosure of health information (Carmack, 2010); however, these examinations have been from mobile health clinic practitioner perspective. The experiences of patients reveal the ways they see mobile health clinics impacting their health and lives. In this article, we examine how patients narrate their experiences using an urban mobile health clinic and how patients make sense of the mobile health clinic’s impact on their communities. Literature Review Mobile health clinics have positive health outcome impacts on the communities they serve. As cost-effective healthcare centers, they have high returns on investment, saving patients and facilities money typically spent on unneeded trips to the emergency department and hospitalizations (Bollinger, Morphew, & Mullins, 2010; Oriol et al., 2009). Just as important, mobile health clinics create warm and inviting spaces for patients, where they feel comfortable disclosing private information and developing trusting relationships with clinic staff (Guruge, Hunter, Barker, McNally, & Maghalhães, 2010; Rodriguez, Appelt, Young, & Fox, 2007). Mobile health clinic staff work to challenge stigmas associated with underserved populations and address material constraints while working to create empowered spaces for patients to become invested in their healthcare (Harter et al., 2008). The physical space of mobile health clinics helps with this; it brings healthcare to people, sets up clinics in familiar community spaces, and develops unique communication strategies to encourage dialogue (Carmack, 2010). These relationships are crucial for the success of mobile health clinics, and as we argue in this article, contribute in empowering patients’ involvement in their health and the health of the community. Although mobile health clinics offer a number of benefits to underserved and vulnerable communities, these clinics are not without limits. Mobile health clinic providers have identified a number of challenges to this model of care. Confidentiality issues are a constant concern for clinic staff (Carmack, 2010; Guruge et al., 2010). The layout and design of mobile health clinics make it difficult to keep information private. The fact that patients know each other and might overhear or determine the reason for a clinic visit has led staff to create unique strategies to disrupt these violations, but they are still ever-present. Another challenge is the fragmentation of care (Guruge et al., 2010; McDaniel & Strauss, 2006). Most mobile health clinics are limited in the types of care they can offer, often only being able to 422 H. J. Carmack et al. provide initial screenings and referrals (Hill et al., 2012). This creates fragmentation in patient care because patients are not able to see the same provider to address one health issue. Unfortunately, clinic staff are not always able to successfully track patient referrals (Edgerley, El-Sayed, Druzin, Kiernan, & Daniels, 2007; Hill et al., 2012), so there is not a clear way to determine if patients’ health issues are addressed. Narrative Theorizing Individuals draw on a variety of narrative strategies to understand and define the important relationships and events in their lives (Fisher, 1984, 1985). Stories are the ways through which “we come to know, understand, and make sense of the social world” (Somers, 1994, p. 606). Narrating our lived experiences serve as a way for people to communicate knowledge, feelings, values, and beliefs on a particular subject (Burke, 1969). The narration of lived experiences is situated in time and space (Polkinghorne, 1988), meaning that to understand a story, listeners have to also understand the circumstances which impact and frame the story. For example, stories about health interactions have changed drastically over the past 50 years, with patients moving from being passive subjects to empowered advocates (Passalaqua, 2014). This concern for time and space creates “episodes” for narrators to use as a way to communicate with others. A focus on storying experiences centers on two key elements: narrativity and emplotment. Narrativity, which positions individuals in the disruptions of lived moments, calls on individuals to address these disruptions in order to get back to a sense of normalcy. Essentially, narrativity requires individuals to become aware of the stories of their lives and how to use those stories to communicate with others. This awareness is emplotment. Mattingly (1998) argued that emplotment makes us more thoughtful and purposeful in the stories that we tell as representative of our lived experiences. Emplotment also helps narrators make connections across narratives, identifying points of difference and similarity. As mentioned earlier, time and space are important to consider in the storying of an experience. This consideration, narrating as emplotting, refers to how we must find ways to move ourselves and others forward in the story (Harter, Japp, & Beck, 2005). For patients, this may mean focusing on different (and perhaps separate) episodes that, when combines, weave a health narrative. Patients pull not only from their personal stories but also from the stories of others, including providers. Because narrative theorizing generally draws our attention to relationships between people, actions, and the places where these actions take place (Burke, 1969), it provides a rich perspective for understanding how space can influence those relationships. Moreover, the space of the narrative experience is also essential to how individuals tell and make sense of stories. In this case, the actual physical space in which experiences take place (i.e., the narrative scene) influences what is emphasized in the story as well as the language used to communicate the story (Burke, 1969). The space of the narrative acts as a container that situates the act, making those telling the narrative ask, “What kind of scene did he say it was, that called for such an act” (Burke, 1969, p. 12)? Although mobile health Communication Quarterly 423 clinics are spaces that motivate health actions, they are more than just the space; they are the catalyst for the events of the narrative (Harter et al., 2008). Narrative provides a sensibility to examine how mobile health clinics shape and are shaped by communicative interactions (Harter, 2005). Scholars see narrative theorizing as a way to make sense of and advance health and health communication research and praxis (Harter et al., 2005). From a narrative perspective, mobile health clinics are not merely the repositories or settings of stories but generate stories themselves. Material elements, corporeal practices, and environmental conditions interweave and shape our communication experiences (McKerrow, 1999). This is especially important when considering alternative forms of organizing, which challenge discursive and material communicative practices (Ashcraft & Mumby, 2004). For mobile health clinics this includes the discursive, such as communication and symbols, and the material, such as transportation and cost, which impact communication about and within the clinic (Harter et al., 2008). Carmack (2010) found that the physical space and flimsy accordion doors of a rural mobile health clinic required the clinic staff to adapt their communication in order to maintain health privacy standards. The unique nature of how mobile health clinics use space, be it in a 40-foot van or setting up in a local church parking lot, challenges contemporary understandings of American healthcare spaces. The space transforms communication for patients and providers and creates a number of opportunities to help patients approach health using different lens. Guided by narrative sensibilities, we asked the following research question: How do patients narrate their experiences with a mobile health clinic? Method Research Setting and Participants This article is part of a larger project examining mobile health clinic patient decision making, expectations, and recommendations for care. We used individual interviews to examine patients’ storied experiences of the mobile health clinic. Data collection began after receiving university IRB approval. The Family Van,1 a program of Harvard Medical School, was created in 1992 as a way to address health disparities among underserved populations in the greater Boston, Massachusetts area. The Family Van provides a variety of services, including blood pressure, glucose, and cholesterol screenings, vision exams, HIV and STI testing, educational counseling services, and referrals for low-cost dental services, food services, mental health assistance, and other local health and social services. Operating out of a 40-foot van, The Family Van sets up on busy street corners. The primary staff consists of eight members: an executive director, care supervisor, clinical dietitian, program coordinator, community health workers, research and evaluation manager, grants manager, and research assistant. Many of the staff speak multiple languages and are licensed healthcare providers. Students from Harvard Medical School, local colleges and universities, and healthcare professionals volunteer for clinical observation and practice experience. 424 H. J. Carmack et al. Twenty-five patients were interviewed after a mobile health clinic visit during summer 2014. Ten participants identified as female (40%) and 15 participants identified as male (60%). Ages ranged from 19 to 72 (M = 52.64). Participants’ ethnic backgrounds represented a variety of nationalities, including Black (n = 7), Cape Verdean (n = 3), Hispanic (n = 6), White (n = 3), Asian (n = 1), Jamaican (n = 2), Black/Native American (n = 2), and Other (n = 1). Participants primarily spoke English at home (n = 17), although some participants did speak both Spanish and English or multiple languages at home (n = 7). Fifteen participants were visiting The Family Van for the first time and 10 participants were returnees. The returning participants had been using The Family Van for a number of years, including less than one year (n = 2), one year (n = 2), more than one year (n = 2), two years (n = 3), three years (n = 2), four years (n = 1), and five or more years (n = 3). Data Collection Two of the authors (YR and ZB) conducted individual interviews with patients. Patients were interviewed in an unused area on The Family Van after completing their visit. The authors used semi-structured protocols to ask a variety of questions about experiences on the mobile health clinic, benefits of the mobile health clinic, experiences with other healthcare facilities in the city, and recommendations for mobile health clinic care improvement. The semi-structured nature of the protocols, however, allowed participants and the researchers to deviate from the protocols to talk about other issues the participants deemed important (Heyl, 2001). Interviews lasted between seven and 50 minutes and all interviews were audio recorded with participants’ consent. All interviews were transcribed verbatim without participants’ names to maintain confidentiality (Poland, 1995). Transcription resulted in a total of 236 single-spaced pages of data. Data Analysis We conducted an emergent thematic analysis using a constant comparative method. The authors began the process by reading the transcripts several times to gain a full understanding of patients’ experiences. Data were analyzed interpretively, focusing on major ideas and meaning (Lindlof & Taylor, 2011). We open-coded the data to identify potential themes and to ensure that any potential themes were grounded in the data; these categories were integrated until theoretical saturation was reached and we identified common, overarching themes. Narrative theory provided the authors a vocabulary to make sense of the data while still keeping the emergent themes grounded in the participants’ experiences. A narrative of generosity emerged during the analysis process as a way to make sense of the common themes and was used to show the connections between the themes. We noted themes based on recurrence (similar meaning was communicated but different words were used), repetition (the reiteration of key words and phrases), and forcefulness (indicated by vocal features such as inflection, volume, or pausing that set off certain portions of an account from others) of participant comments (Owen, 1984). Communication Quarterly 425 Quotations from participants are used to illustrate themes. The authors relied on a variety of quotations and interpretation of those quotations as a way to demonstrate rigor, validity, and theoretical depth (Tracy, 2010). In this article, we chose to present participants’ comments verbatim rather than edit for grammar or word choice. Mobile Health Clinics and a Narrative of Generosity The Family Van has been a fixture in Boston neighborhoods for 25 years. Its constant presence, providing free healthcare services to underserved patients, created a narrative of generosity, which calls for mobile health clinic patients, providers, and communities to work together to improve the health of community members. A narrative of generosity is centered on the discursive impact of giving to others without expecting something in return, or as Frank (2004) explained, “the grace to welcome those who suffer” (p. 1). The storying of generosity is concerned with dialogue (spaces to come together), alterity (kinship and questioning where our stories intertwine), justice (doing good to help those in need), and joy (pleasure and happiness in helping others; Frank, 2004). As one participant explained, This is an area where a lot of people do need to get tested because as you look around, this is a harsh area. There’s a lot of drugs, a lot of prostitution, a lot of that type of stuff. And some people don’t feel comfortable going to the doctor’s or, don’t have the insurance to go to the doctor’s. So with this Van being there, they can go right there… . I think that’s really nice because, like I said, we are in the ghetto. A lot of people around here don’t have money, a lot of people around here are struggling. So with it being free, it’s accessible for everybody who wants it. A narrative of generosity is concerned with justice and helping those in need; the narrative should invite “the ill to feel less stigmatized and isolated” (Frank, 2004, p. 3). The Family Van specifically targets underserved populations that need healthcare the most. Patients crafted a mobile health clinic narrative of generosity by talking about how The Family Van (a) created a sense of welcoming on the van, (b) activated patient interest in their health, and (c) empowered a “pay it forward” attitude. Creating a Sense of Welcome For Family Van participants, generosity began with creating a sense of hospitality and invitation. “Generosity begins in welcome: a hospitality that offers whatever the host has that would meet the need of the guest” (Frank, 2004, p. 2). Participants were quick to point out that The Family Van staff was friendly, inviting, and caring. This hospitality begins before patients even board The Family Van; staff stands outside, inviting patients into the Van for care. When patients board the Van, the staff makes sure to welcome everyone and make them feel safe. As one participant explained, Well, they are good at how they receive, how they welcome people, because I see how they welcome in there. And with all the other, since I’m there I see the other people go there and they go in the door and “Come, Come!” They are very happy to receive people and do their job. 426 H. J. Carmack et al. This narrative of generosity begins with creating a communicative space where staff and patients feel comfortable talking about health. As one participant expressed, “It’s a friendship thing, with mutual respect towards each other.” A key component of a sense of welcome is how the Van staff communicated with patients. The warm welcoming atmosphere has to continue beyond the waiting room; the Van staff must communicatively build relationships which reduce the uncertainty and intimidation of healthcare. As one participant explained, I thought it was a very friendly atmosphere, because the lady, I first came in, we sat down and I was talking to her and she was very friendly. That helps people listen up some and not be intimidated to come in. So that makes a big difference if people are welcoming like that. And slowly people started coming in and I think it’s an open atmosphere that’s gonna help a lot of people in the community. Building relationships is difficult for healthcare providers, as there is often a power difference between patients and providers. The Family Van staff spend time breaking down some of those power differences through simple communication strategies such as calling providers by their first names, finding out personal, non-health related information about patients, and being honest with patients about their healthcare needs. Staff members even speak multiple languages common in the areas they serve in order to find the best ways to communicate with their patients. As one participant stated, “For me, it was very easy to establish a relationship with them. Very communicative. Very helpful people. For me, the more open you are, you’re just going to get honest feedback and that’s how it was.” One of the reasons patients return to The Family Van was because they take the time to learn about and remember patients. Although The Family Van’s purpose is to provide care, this care is successful because the staff spend time talking with patients about their families and lives and remember that information when patients return. Participants appreciated that Van staff remembered them and treated them like family or close friends. As one participant stated, “When they see me they give me a hug or when they don’t see me, ‘Where you been? Oh I miss you, I love you.’” This warm, caring communication is simple, but effective, in helping to build and maintain relationships with patients. It made participants feel as if the care they received is personal. One participant summed up the importance of remembering and asking about family: You know, you come back to The Family Van after, you know, everything’s said and done and it’s, “How’s everything?” They always ask me how my kids are and I’ve been going to them since I had my daughter who is now 5. It’s just when you build up that, just like I’m going to The Family Van, make sure everything’s straight, and go on my way. Patients saw this sense of welcome as a way to overcome the fear or stigma which might prevent them from seeking care. As one participant explained, Anyone could just walk in, you know. Just walk off the street, if you’re sick or you need a little help or something. You might as well just come in and ask. They was telling me about spare diapers and things like that. And formula if you need it—if Communication Quarterly 427 you’re running low. Even as an emergency. Don’t be embarrassed, just come in, and see what they have. The Family Van staff created a sense of welcome by seeking to bring healthcare to those who need it. By doing so, patients saw how The Family Van cared about their and the community’s health. Activating Patient Health Behaviors The primary purpose of The Family Van is to provide healthcare for community members. Although the Van’s staff does this, their presence also activates patients to be interested in their own health. The narrative of generosity created by the Van empowers patients to take an active role in their health. Be it because the Van triggered a desire to get checked or because its presence helps community members to seek out healthcare, patients believed the simple sight of the 40-foot van sitting on busy street corners made people want to engage in positive health behaviors. As one participant succinctly said about getting tested for HIV, “As soon as I saw the Van though, I wanted to do it. Because I really wanted to be tested.… I’m just trying to change.” For many participants, patient empowerment began with a simple question: “Why not?” Participants saw The Family Van, often walking past it several times before deciding to step inside. One participant nervously laughed as she explained why she was only now using the Van for the first time: “Um. (laughs) I don’t know, at first I was kinda skeptical about doin’ it. But I’m like, ‘Hey, you know, why not get tested for diabetes or high blood pressure, because it all runs in my family?’” Although hesitant, the idea that it “can’t hurt” to get her diabetes and blood pressure checked is the starting point for that patient to take control of her health. Knowing her family history helped in this situation, but she became more of an active patient by stepping onto the Van. For other patients, the “why not” was triggered by feelings of illness. When patients feel ill but do not want to go to the hospital or other local clinics, the Van’s presence served as a reminder that there are free services to help them take control of their health. One patient recalled his reason for visiting the Van: The day before I was feeling, like, a little dizzy and I said, “I will not lose anything if they do some check-ups for blood pressure, stuff like that for medical help.” I said, “I might as well. I’m here. Let’s see. I don’t lose anything. Let’s give it a shot.” Although this patient was originally motivated to visit the Van because he reported feeling light-headed the previous day, it would have been easy for him to not seek care because he was feeling fine the next day. The underlying logic of “it can’t hurt” activates patients to take control and take action. As one participant stated, “Best to be safe than sorry.” The free services provided by The Family Van also helped patients engage in positive health behaviors. The high cost of healthcare services and co-pays offered by hospitals and private clinics often deter patients from seeking care. One participant explained the simple dynamics which encourage patients to be active in their healthcare: Because it’s free. That was amazing because this is the number one reason why people don’t get tested, because they have to pay money and they have to, like, fill 428 H. J. Carmack et al. out a lot of forms. But here literally all you do is walk in, sit down, they ask you about 5 questions and you’re good to go. Many participants commented on the fast, efficient, and easy care provided by the Van staff. The fact that the care was free and easy encouraged patients to continue to seek care; it is difficult for patients to ignore their health when some of the barriers preventing them from seeking care are removed. Whatever the reason for visiting the Van, the narrative of generosity crafted by the staff raised patients’ awareness of their own health. The Van provides an alternative health space for patients and providers to come together and dialogue about health, which in turn, sparked awareness and interest in patients. As one participant indicated, “I am more aware now of stuff I didn’t know. So next time I’m going be more careful of what I’m going to do and what I’m not going to do.” The Van’s staff encouraged patients to become health knowledge seekers and users. Patients began to see their health as not something to just take care of when they get sick but as illness prevention and well-being maintenance. A participant who regularly visits The Family Van explained how the staff generate awareness: It made me be more aware of my health and start taking steps to prevent things before they become problems. To me the doctor’s office, they don’t tell you about preventative things. They tell you about treating things. And I want prevention, I don’t want to treat a problem. I want to prevent a problem from becoming more of a problem. ‘Cause my high blood pressure, my doctor wanted to put me on pills and I refused. They’re not trying to prevent it, they’re trying to treat it. To me that’s the backwards way. Many participants noted they did not like to visit hospitals or other health clinics because of a variety of reasons and only do so when they have to go to treat an illness. The Family Van showed patients how to be proactive with their health through pamphlets, testing, and caring conversations. The staff helped patients identify successful health strategies and how to implement them. As one participant explained, The Van helped me set the right benchmarks to make sure I’m active, I’m physical. What I need to do right, what I’m doing correctly, what I’m not doing correctly. It always showed me a path to attain better medical services that would be more catered towards my needs. The simple act of setting health benchmarks empowered the patient to become active in his health on a more long-term basis. The Van staff does not just treat patients in the moment but shows them how to take control after they pull away from the curb. The activating of long-term healthcare empowerment requires more than setting benchmarks. The constant presence of The Family Van in local communities served as a reminder that individuals do not need to postpone seeking care; the Van’s staff is always there to offer care to patients. As one participant explained, “Because they don’t know what’s wrong with them. The majority of the people here do not know what’s wrong with them.” Rather than just treat patients and send them home, the Van staff has the added responsibility of helping patients learn about their health. This is another way the staff helped them; they tell patients what they need to do, providing recommendations, Communication Quarterly 429 directions, and referrals. One vocal advocate of the Van told her story of breast cancer and the way the care from The Family Van encouraged her to take action: Right, they’re very honest. They’ll say, “I think you need to do this, I think you need to do that. I can’t make you, but I suggest that you do this and you do that.” And that’s how it happened. That’s how I originally found out that I had cancer. They said, “Take this to your clinic”, which was the Boston Medical Center, and I did. Here I am! Still a survivor! Still living! For this participant, the Van’s staff served as the catalyst to empowering her longterm healthcare. If the Van’s staff did not push her to get checked, her cancer may not have been caught in time to successfully treat. Participants reported how staff helped them to identify and triage their healthcare, and encouraged them to take control. Empowering a “Pay it Forward” Attitude Part of the mission of The Family Van is to help community members strengthen and protect their minds and bodies, which will strengthen and protect the community. By creating a sense of welcome and encouraging patients to be active in their health, patients’ mobile health clinic narrative of generosity also showed how patients felt empowered to give back to their communities. This desire to give back because they see the Van giving back helped to strengthen and protect their communities. As one participant explained, “So for them, all those resources just on that one Van it’s like, you’re like, damn, I wish I could, like, help, I wish I could, like, donate money, like, get rich and just donate money to the Van.” A narrative of generosity is ultimately designed to empower others to become generous. As Frank (2004) argued, this giving domino-effect will create feelings of joy. This joy is infectious, and patients developed a desire to give back to their communities, too. In some cases, patients wanted to give back to The Family Van because they see the benefit of having a mobile health clinic in their neighborhood. One participant talked about her desire to give back to the Van: And I actually, when my son got off of formula, he was on a specialty and that’s hard for parents, especially coming from one who’s low income like myself…. It was Enfamil but it was AR so it’s not something that WIC typically covers and I just, I had like 2 months of a shipment from Mass Health. I said, “I’m just going to give it to The Family Van. I know they give out formula. If they’re not gonna carry 2 months on the Van, but you know, they know they’re clients by now. If I have this and it helps somebody else. This seemingly simple act, bring some canisters of formula to The Family Van, showcased how some patients develop a “pay it forward” attitude. This participant knew that the formula would go to help someone in the community. Rather than let the formula go to waste, she turned to the Van to use its generosity to help others. The ability to “pay it forward” is somewhat difficult for individuals who visit The Family Van because of socioeconomic disparities; however, they did find ways to give back. Patients typically used the resources of The Family Van as a way to give back. As one male participant admitted, 430 H. J. Carmack et al. Once in a while, I will get a bag of condoms, which I give out to people I know. I don’t use them myself, but I know people who use them so I’ve managed to help a couple of people out who use them. This patient knew of an important service offered by The Family Van, and although he did not need the service himself, he felt it was important to share that service with others. Many participants stated that it is difficult to get others to visit The Family Van or other clinics because of distrust of providers, lack of access, or fear of healthcare. This patient found a way to give back by making the healthcare seem like it was coming from a trusted friend. Additionally, patients’ narrative of generosity communicated the joy they felt in giving back to others in the community. The easiest way for patients to give back to their communities was by encouraging others to become active participants in their health. “I’ve talked to a lot of people out there and say, ‘I just got off the Van. It’s a nice idea. If you happen to come in the neighborhood and go in there.’ I take my friend there.” The Family Van helped patients become empowered, and many participants decided to “pay it forward” to others by talking to them about why they should start engaging in proactive health behaviors. As one participant stated, You know, we talk as friends and we get to know some people they may feel or they may have some symptoms. So you know, I tell them, “Why you don’t check your high blood pressure or you don’t check your sugar level?” Or if anything else—like condoms or Pampers or things like that. So I just tell them to go to the Van—that they can probably help them out with that or something else that they can be needing. The simplicity of these conversations, showing concern for family and friends and recommending care, subtlety encouraged others to take control of their health. This participant’s comment also highlights how participants “give back” to the Family Van by recommending family and friends visit. The ways patients approached others about their health is important because, in order for the communication to be genuine and generous, it has to be about their health. Even me, if I see someone that shouldn’t be drinking or shouldn’t be doing this, I say, “You need to get on that Van. Whether you take my advice or not. Because if it was you, saying that to me, I would take your advice, because I’d know you knew what you were talking about.” The participant’s casual conversation shows how she use her own active participation as a catalyst for others. Now, everyone is working together toward better health, which speaks to the heart of a narrative of generosity. “The renewal of generosity requires envisioning this vast enterprise of care for suffering as one in which we all participate together, each doing his or her part that would be impossible without others doing their parts” (Frank, 2004, p. 10). Ultimately, by feeling empowered to help others in the community, patients contributed to the clinic’s mission of strengthening and protecting the community. Communication Quarterly 431 Discussion In this article, we examined how The Family Van patients narrate their experiences on the mobile health clinic. As an emergent form of health organizing, The Family Van is a unique healthcare space for patients to use to meet their healthcare needs. Patients believed that the Van staff generated a sense of welcome in the community through genuine, honest communication and empowered them to address community health inequities. The presence of The Family Van staff helped patients to take an interest in their own health by offering them the care and skills necessary to engage in positive health behaviors. Finally, patients were empowered by the Van’s presence to find ways to give back to others in the community. Whether it is through donations or encouraging others to seek healthcare, this narrative of generosity showed how everyone can work together to create a healthier community. There are several implications related to this narrative. First, patients’ narrative of generosity underscores the importance of health activism in healthcare delivery and scholarship. At the heart of narratives of generosity is a call for justice and activism. At the individual level, health activism is a form of social health justice because it frames activism as a form of health citizenship, a citizenship which we all should have access to (Zoller, 2005). This individual-level health activism focuses on how individuals take responsibility for their own health, how they work to improve the health conditions for a group or community, and how they make an effort to change health policy to benefit the community (Geist-Martin, Ray, & Sharf, 2003). The narrative of generosity crafted by patients easily addresses the first components. Patients not only have access to tools to help them be active in their own health, but they also use their “pay it forward” attitude to help others in the community. What is missing, however, is how patients find ways to change health policy. This may be difficult for patients to do because of social and economic disparities. For many of the participants, economic disparities were a driving force for why The Family Van was needed. The communities The Family Van serves are located in a large urban city, where there are multiple pockets of poverty, food deserts, and lack of healthcare facilities. It may fall to mobile health clinic staff to find ways to change health policy, which raises the question: How can mobile health clinic staff change health policy using a narrative of generosity? The answer may be in the emergent form of health organizing utilized by mobile health clinics. One of the foundations of emergent and alternative forms of organizing is how members in the organization are able to challenge the status quo. Zoller (2005) argued that this is also critical for health activism; individuals must challenge the existing order and power relationships. Mobile health clinics begin to challenge the existing organizational order for how to deliver healthcare by bringing healthcare to people (Carmack, 2010; Harter et al., 200...
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Summary, Commentary and Questions
First Article
Physician–Patient Co-Construction of Illness Narratives in the Medical Interview
Summary
It is important for physicians to stimulate narratives when interacting with patients. These
narratives enhance the collection of data, building of good relationships between the physicians
and the patient and meeting and satisfying the needs of the patients. According to Eggly (2002),
medical interview is the most crucial diagnostic as well as a therapeutic tool in the course of
treating patients. Therefore, physicians must ensure that they communicate effectively with the
patients during the medical interviews, since efficient communication is a critical determinant of
whether patients are satisfied, whether the patients will adhere to the treatment plan and the
resurgence of the illness. In most of the instances, when physicians do not effectively
communicate with their patients, it is normally linked to poor health outcomes as well as legal
actions against doctors. Consequently, doctors must be careful when getting history of the
patients. For instance, it is important to be specific when asking questions concerning symptoms
and previous illnesses. This is enhanced with the use of a patient-centred model where doctors
are encouraged in addition to training to facilitate efficient communication when interviewing
patients. The physicians are trained to give the patients room to explain themselves and let them
tell their story in their own words without influencing the patient story telling approach. This
way, physicians promote the completeness, clarity and brevity of the patients in explaining
themselves.
Commentary
It is clear that physicians have a privilege in the medical setup. This is because physicians are
entrusted by patients with the most intimate details concerning their lives. Therefore, such a
privilege does not come without responsibility. When patients share their stories to physicians,
they expect them to be understanding, offer explanation and ensure that they get relief from their
ailments. Physicians are thus expected to act in the best interest of the patients and subordinate
their interests using a patient-centred model.
Physicians must learn to use the patient-centred model in interviewing patients so as to
systematically and effectively gather information. Consequently, physicians are not supposed to
use closed-ended questions in making a diagnosis, rather, they should allow the patient to give
their version of their story in whatever manner they feel like. Shaping the behavior of answering
questions is detrimental to effective diagnosis and might imply collecting inaccurate information.
In order to increase the ability of the physician to establish rapport with the patients, the
physician must encourage the patient to spontaneously explain their symptoms in their personal
and emotional context. Efficient establishment of a relationship with the patient must ensure that
the physician focuses on both the emotional state and the concerns of the patients. This way, the
physicians obtain a more accurate and complete biopsychosocial story.

Consequently, it is clear that encouraging patients to freely talk about their concerns results in
more valid data, which is key to enhancing patient satisfaction, compliance and recall. They are
also crucial in decreasing legal actions against doctors when the patients do not yield good health
outcomes.
Furthermore, the medical history of the patient offers important information just as both physical
examination and laboratory investigations. Diagnosis can normally be made from the patients
explaining their medical history. This implies that having an accurate history helps the physician
to choose the type of physical examination, thus making it time efficient. Medical interviews
provide a diagn...


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