Seeking Narrative Coherence: Doctors' Elicitations and Patients' Narratives in Medical Encounters

<p>This thesis presents research on how doctors and patients negotiate meaning through interaction, focusing on the role of narrative in the medical encounter. Within sociolinguistics, most previous studies using discourse analysis to analyze patients’ narratives have adopted the canonical (Labovian) framework. This thesis adds more recent approaches to narrative analysis, within an interactional sociolinguistics (IS) framework in order to examine the relationship between doctor elicitations and patient narratives. The analysis also explores the clinical approach of Narrative Medicine (NM), which offers patients “space” in which to construct their narratives, to create an interdisciplinary lens for exploring data. The data comprised 69 videotaped medical interviews, amounting to 18 hours of naturally occurring medical interactions, plus evaluative feedback from questionnaires and interviews with 12 doctors. All interactions were initially analyzed for canonical narrative components. Twelve interactions were then selected for more detailed analysis on the basis of the frequency of doctors’ elicitations, which represent medical interview approaches. The analysis of these interactions demonstrates how and to what extent participant roles and identities frame the co-construction of patient narratives. Evaluations of three of the interactions by 12 doctors provided information on how aspects of patient narratives are perceived by clinicians, particularly with respect to the types and amounts of patient information considered necessary for making diagnostic decisions. Key findings demonstrate that both patients and doctors seek to construct narrative coherence. The analysis shows how the frame of developing narrative coherence offers insights on the interactional narratives as they are co-constructed by participants. Patients living with chronic illness may have difficulty constructing coherent narratives, and thus, strategies for developing narrative coherence are important for both patients and doctors when managing patients’ chronic illnesses. Additionally, in constructing narrative coherence, patients present important aspects of their identities potentially offering important information related to their illness and intervention. Evaluating doctors’ also engaged in using this frame which offers insight into one way doctors develop their professional identities and perhaps indicates the strength of the role of narrative in our lives. This research represents a first attempt to use both interactional sociolinguistics and NM to contribute to the understanding of doctor-patient interaction. Overall, the research indicates that narrative plays an important part in constructing relevant meanings in medical interactions between doctor and patient. Patients strive to create a coherent narrative as they present their medical problem to their doctor. Although this analysis provides further evidence of the relevance of the power asymmetry in medical interviews, it also suggests ways in which patients can shape their narratives to construct themselves as active agents to their benefit in medical interactions.</p>

Seeking Narrative Coherence: Doctors' Elicitations and Patients' Narratives in Medical Encounters

<p>This thesis presents research on how doctors and patients negotiate meaning through interaction, focusing on the role of narrative in the medical encounter. Within sociolinguistics, most previous studies using discourse analysis to analyze patients’ narratives have adopted the canonical (Labovian) framework. This thesis adds more recent approaches to narrative analysis, within an interactional sociolinguistics (IS) framework in order to examine the relationship between doctor elicitations and patient narratives. The analysis also explores the clinical approach of Narrative Medicine (NM), which offers patients “space” in which to construct their narratives, to create an interdisciplinary lens for exploring data. The data comprised 69 videotaped medical interviews, amounting to 18 hours of naturally occurring medical interactions, plus evaluative feedback from questionnaires and interviews with 12 doctors. All interactions were initially analyzed for canonical narrative components. Twelve interactions were then selected for more detailed analysis on the basis of the frequency of doctors’ elicitations, which represent medical interview approaches. The analysis of these interactions demonstrates how and to what extent participant roles and identities frame the co-construction of patient narratives. Evaluations of three of the interactions by 12 doctors provided information on how aspects of patient narratives are perceived by clinicians, particularly with respect to the types and amounts of patient information considered necessary for making diagnostic decisions. Key findings demonstrate that both patients and doctors seek to construct narrative coherence. The analysis shows how the frame of developing narrative coherence offers insights on the interactional narratives as they are co-constructed by participants. Patients living with chronic illness may have difficulty constructing coherent narratives, and thus, strategies for developing narrative coherence are important for both patients and doctors when managing patients’ chronic illnesses. Additionally, in constructing narrative coherence, patients present important aspects of their identities potentially offering important information related to their illness and intervention. Evaluating doctors’ also engaged in using this frame which offers insight into one way doctors develop their professional identities and perhaps indicates the strength of the role of narrative in our lives. This research represents a first attempt to use both interactional sociolinguistics and NM to contribute to the understanding of doctor-patient interaction. Overall, the research indicates that narrative plays an important part in constructing relevant meanings in medical interactions between doctor and patient. Patients strive to create a coherent narrative as they present their medical problem to their doctor. Although this analysis provides further evidence of the relevance of the power asymmetry in medical interviews, it also suggests ways in which patients can shape their narratives to construct themselves as active agents to their benefit in medical interactions.</p>

Coherence in Legal Evidence

This chapter discusses the concept of coherence and its role in evidential reasoning in law. It examines three main approaches to coherence, namely, structural coherence, narrative coherence, and coherence as constraint satisfaction, and argues that coherence as constraint satisfaction provides an account of the kind of coherence that is relevant to legal fact-finding that is both descriptively adequate and normatively appealing. Next, it addresses some problems concerning the relation between coherence and inference, coherence and virtue, and coherence and truth in the context of legal factfinding. More specifically, it examines three main objections facing a coherentist account of inference, i.e., conservatism, circularity and unfeasibility, and conceptualizes it as an explanatory kind of inference. Then, it articulates a problem that has not been traditionally discussed in the coherentist literature, to wit, the coherence bias, and argues that virtue coherentism has the resources to effectively counteract it. Last, it defends the coherentist approach to evidence and legal proof against three objections that put into question the truth-conduciveness of coherence, namely, the isolation or input objection, the alternative coherent systems objection, and the truth objection. The chapter concludes by suggesting some avenues for further research on coherence, evidence, and legal proof.

Narrative Abilities and Episodic Memory in School-Aged Children Followed by Child Protective Services

The ability to narrate routine familiar events develops gradually during middle childhood, in increasingly higher levels of coherence and temporal cohesion. Improvements in episodic memory are also observed, reflecting children’s increasing ability to recall specific circumstances of past events and personal experiences. Even though several studies have evaluated children’s narrative abilities and episodic memory, little information is available regarding the children exposed to risks that justify their referral to Child Protective Services (CPS). The current study analysed children’s narrative abilities and episodic memory performance, according to the circumstances related to the referral to CPS. Event schema representation, narrative coherence, narrative temporal cohesion, and episodic memory concerning routine and specific personal events in family context were analysed in a sample of 56 school-aged children followed by the CPS in Portugal. Children referred to CPS due to disruptive behaviour presented higher episodic memory performance, compared to those exposed to domestic violence, neglect, and abuse. No significant differences were found between groups regarding narrative abilities related to familiar routine events. Results highlight the relevance of evaluating the adverse circumstances that lead to CPS referral, considering the levels of risk and danger involved, given its differential effects on children’s episodic memory development.

‘Not at all afraid’: Queer Temporality and the School Detective Story

Kate Haffey has recently argued that if queer time can be seen as a turning away from narrative coherence, it suggests new possibilities for considering narrative structures more generally. Combining the narratively rigid structures of the school story and the detective novel, the four novels discussed in this article – Gladys Mitchell’s Laurels are Poison (1942), Josephine Tey’s Miss Pym Disposes (1946), Shirley Jackson’s Hangsaman (1951), and Joan Lindsay’s Picnic at Hanging Rock (1967) – disrupt conventional understandings of linear time. Depicting not only queer, or potentially queer, characters, but a queer phenomenological perspective, they challenge reader expectations with a focus on aporias and gaps, whether in terms of trauma (Jackson), the blurring of fact and fiction (Lindsay), or the prolonged delay of both crime and resolution (Tey). These novels draw attention to the insufficiency of texts to capture experience, and the inadequacy of textual authority. As such, they reveal the extent to which mid-twentieth-century women’s fiction was able to challenge the genres and narrative structures with which it was most closely associated.