Intended for healthcare professionals

Education And Debate Narrative based medicine

Stories we hear and stories we tell: analysing talk in clinical practice

BMJ 1999; 318 doi: (Published 16 January 1999) Cite this as: BMJ 1999;318:186
  1. Glyn Elwyn (, senior lecturera,
  2. Richard Gwyn, research coordinator.b
  1. aUniversity of Wales College of Medicine, Cardiff CF4 4XN,
  2. bCentre for Language and Communication Research, University of Wales, Cardiff CF1 3XB
  1. Correspondence to: Dr Elwyn

    This is the third in a series of five articles on narrative based medicine

    Even at its scientific best, medicine is always a social act.1

    For all the science that underpins clinical practice, practitioners and patients make sense of the world by way of stories. 2 3 Even the most evidence crazed doctors have to translate their perception of “biostatistical truths” into accounts that make sense to others. Studies of the consultation process, which have largely taken place in primary care, have focused on the structure of the meeting from greeting to closure. 4 5 The concepts of doctor centredness or patient centredness are described6 and measured7; these concepts undoubtedly have a profound influence on professional practice.8 These observations have led to an ongoing exploration of the effect that communication styles have on both patient satisfaction and clinical outcome.9

    But there is much more depth to be explored in the process of communication, and the tools normally used are insufficient to examine the layers of meaning that lie within the text of exchanges.10 The microanalysis of talk can inform the essence of medical practice, define principles for effective communication, attach meanings to a patient's story, as well as help doctors share ideas about fears and hopes for the future—in medical speak: communicate risks and benefits.11 By deconstructing a piece of dialogue in this paper, we hope to illustrate the value of learning to listen carefully to the stories we hear.

    Summary points

    • Conventional studies of the doctor-patient consultation tend to focus on structure rather than content and are therefore relatively superficial

    • The different interactional perspectives within the clinical encounter can be exposed using techniques of microanalysis that take account of text, tone, pauses, interruptions, and non-verbal communication

    • Through the detailed study of discourse in …

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