Storytelling in extended answers
Patients often change topics in medical interviews by telling stories. Storytelling is an important part of conversation analysis because many conversations consist of the exchanging of stories between speakers. Stories are “extraordinarily complex speech events” that either “report a sequence of events” or they are an evaluation of those events by the speaker (Goodwin, 1990, p. 230). Patients tell stories in medical interviews in two different forms. They tell stories through preemptive telling and narrative responses.
Preemptive telling is not triggered by a question and does not expand on the patient’s answer (Stivers & Heritage, 2001). Instead, preemptive telling is triggered by the patient’s response to a question. These extended answers “raise a matter that is apparently on the patient’s mind” (Stivers & Heritage, 2001, p. 165).
Below Example 1: “If only the world was that simple” demonstrates preemptive telling in a medical interview:
Example 1: “If only the world was that simple”
1 Doctor: So they don’t really uh. Oh oh okay so you had 10 10
2 biopsies all together. Is that right. It says 5 on the right and
3 5 on the left.
4 Patient: Umm I guess. I thought it was 8 but it could have been 10.
5 Doctor: Right.
6 Patient: And he said it was in one little section.
7 Doctor: Right.
8 Patient: And the doctor over there actually made a comment that
9 was kind of strange to me. Its just bed side manner he said
10 that you know you you’re in a very early stages and uh you
11 have lots of options and if you didn’t do anything for 10
12 years you’d be fine.
13 Doctor: Yeah.
The excerpt starts with the doctor asking about the number of biopsies and the sides they were performed on in lines one, two and three. The patient responds with it could have been eight or ten biopsies in line four. Then the doctor responds with “right” in line seven indicating he agrees with the patient. The patient comments on the biopsies again by saying it was all in “one little section” in line six. The doctor confirms his response with a “right” in line seven. Line eight is the beginning of the preemptive telling. The patient was thinking about the things his last doctor said when he had his last biopsy in line six. This triggered the patient to think about what the previous doctor had said about his cancer status. The purpose of this whole medical interview if to find out the status of his cancer and make a plan to deal with it. Clearly, the status of his cancer is on his mind and therefore he brings up what the previous doctor said about it in line eight through twelve. The doctor concludes the patients story in line thirteen with saying “yeah” agreeing that he understands what the previous doctor said, but not necessarily agreeing with the statement made by the previous doctor.
Narrative responses show three things. First, these answers “embody a shift in the interactional organization of history taking”, which consist of the patient becoming a story teller (Stivers & Heritage, 2001, p. 167). The patient’s role is often lost and it becomes unclear to the doctor when the comprehensive medical history answers will resume (Stivers & Heritage, 2001). Second, these responses are an introduction to new material “that departs from the agenda of a prior question” (Stivers & Heritage, 2001, p. 167). Third, these answers “involve a volunteering of information that more overtly attends to the patient’s agenda of concerns” (Stivers & Heritage, 2001, p. 167).
Example 2: “If only the world was that simple” demonstrates a narrative response in a medical interview:
Example 2: “If only the world was that simple”
1 Doctor: Oh okay. ( ) Any trouble with um cancer in the family that
2 you’re aware of. ( ) Brothers. sisters.
3 Patient: Well I I can’t. My my one cousin who is down in uh
4 actually he just had his ((sp.)) down but his jumped his
5 escaladed pretty highly so I’m not sure if there is something
6 in the family or not because his brother who is ( ) one of the
7 chief research guys at Georgia tech um in um neurology he
8 basically uh he has to go in for a biopsy. And skip is about
9 six skip the one who just has the ((sp.)) done had it done
10 down at either runway or Georgia tech, down in that area
11 cuz Dick knows all the doctors down there. Um I think he
12 is about 60 probably 65. I just turned 62, Dick is 61, Dick
13 told me in July he went for a biopsy.
14 Doctor: Yeah but but you know [immediate family. ]
15 Patient: [But my immediate ] family no.
First in lines one and two the doctor asks if the patient has “any trouble with um cancer in the family” such as brothers or sisters. The doctor is looking for the short yes or no answer from the patient. Instead in line three the patient begins to think if he has any cancer in the family and starts to tell story about his cousin. The shift in interactional organization of history changes at the beginning of line four when the patient starts to explain the medical experiences his cousin had. The agenda of the prior question is lost when the story begins as well in line four. The intense detail and length of this story indicates the patient fears what happened to his cousin may happen to him. Therefore his story addresses his concerns and not the concerns of the doctors.
Responses to storytelling
Sacks (1974), Jefferson (1978) and Mandelbaum (1987) have discussed in their research that “storytelling invites some form of response in the form of assessment or a second story” (as cited in Stivers & Heritage, 2001, p. 176). Doctors often respond to patient story telling in one of two ways. First they may not comment and treat the story as a complete answer. Secondly they may use the word “okay” to treat the narrative answer as an “extended response” rather than a narrative (Stivers & Heritage, 2001, p. 176). In some cases, the doctor treats the story as an ”elaboration of an answer” that has no important significance on its own (Stivers & Heritage, 2001, p. 176). The word “okay” can then be used as a topic shift onto the next question.