The Narrative

Novice interviewers are often worried about remembering the patient's history. However, it is poor form to write extensive notes during the interview. Attention should be focused more on what the person is saying and less on the written word. In addition, by taking notes, the interviewer cannot observe the facial expressions and body language that are so important to the patient's story. A pad of paper may be used to jot down important dates or names during the session.

After the introductory question, the interviewer should proceed to questions related to the chief complaint. These should naturally evolve into questions related to the other formal parts of the medical history, such as the present illness, past illnesses, social and family history, and review of body systems. Patients should largely be allowed to conduct the narrative in their own way. The interviewer must select certain aspects that require further details and guide the patient toward them. Overdirection is to be avoided, because this stifles the interview and prevents important points from being clarified.

Small talk is a useful method of enhancing the narrative. Small talk is neither random nor pointless, and studies in conversation analysis indicate that it is actually useful in communication. It has been shown that during conversations, the individual who tells a humorous anecdote is the one who is in control. For example, if an interviewer interjects a humorous remark during an interview and the patient laughs, the interviewer is in control of the conversation. If the patient does not laugh, the patient may take control.

Be alert when a patient says, ''Let me ask you a hypothetical question'' or ''I have a friend with ...; what do you think about ...?'' In each case, the question is probably related to the patient's own concerns.

A patient often uses utterances such as ''uh,'' ''ah,'' and ''well'' to avoid unpleasant topics. It is natural for a patient to delay talking about an unpleasant situation or condition.

Pauses between words, as well as the use of these words, provide a means for the patient to put off discussing a painful subject.

When patients use vague terms such as ''often,'' ''somewhat,'' ''a little,'' ''fair,'' ''reasonably well,'' ''sometimes,'' ''rarely,'' or ''average,'' the interviewer must always ask for clarification: ''What does sometimes mean?'' ''How often is often?'' Even terms such as ''dizzy,'' ''weak,'' ''diarrhea,'' and ''tired'' necessitate explanation. Precise communication is always desirable, and these terms, among others, have significant variations in meaning.

The interviewer should be alert for subtle clues from the patient to guide the interview further. There are a variety of techniques to encourage and sustain the narrative. These guidelines consist of verbal and nonverbal facilitation, reflection, confrontation, interpretation, and directed questioning. These techniques are discussed later in this chapter.

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