Opening Up History-Taking: From Problem Presentation to Shared Understanding

• In Event: Research in Ethnomethodology and Conversation Analysis: Interactions in Institutional Settings I

Abstract

As Robinson (2003) showed, medical encounters are structurally organized into phases (problem presentation, history-taking, diagnosis, treatment, and closing), yet the precise boundary between them, as well as the particular resources used to transition between them, remain understudied. In this paper, we focus on the transition between problem presentation and the question that initiates history taking. We argue that through the initial history-taking question, physicians orient to a problem presentation as having a normative structure.
Relying on 198 video-recorded primary-care consultations addressing acute complaints, where the problem is presented by the patient, we identified four main types of initial history-taking questions: (1) temporality (onset and duration of symptoms), (2) the presence or absence of symptoms, (3) the quality of symptoms, and (4) prior treatment used to deal with those symptoms. In analyzing these different types of initial history-taking questions relative to which elements were included in the problem presentation, we find that physicians treat an optimal problem presentation as one that includes temporal positioning, symptomatic information, and a minimally coherent narrative trajectory.
As evidence for this claim, we rely on a mixture of distributional evidence as well as participant orientation evidence. When these elements are not included in the presentation, physicians commonly initiate history taking with establishment questions that address the missing information; in contrast, when they are produced, physicians more commonly initiate with deepening questions, treating baseline informational work as already accomplished. Statistical analysis confirms this pattern: duration questions constitute 50% of first history-taking questions when temporal information is absent, but only 15% when it is present (p < 0.001). In this way, the first history-taking question is a consequential moment in which the physician publicly displays what they take the patient to have already accomplished, and what still remains clinically necessary before the visit can progress. Additionally, we consider whether patient demographic characteristics shape this pattern across different patient populations.

Author

• Mikhail Belov, University of California-Los Angeles