Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care.

This study asked how patients and doctors process self-destructive behaviors that warrant preventive action, such as smoking, substance use, and sexual practices. Although many suggestions have appeared about how physicians should encourage health promotion and disease prevention by counseling patients about self-destructive personal habits, few studies have examined actual encounters to assess how patients and doctors communicate about these matters, and prior research rarely has considered the social context of self-destructive habits. The present research has been influenced by a growing recognition of narratives, embedded in the sociocultural context of medical encounters, as an important analytic focus in the study of patient-doctor communication. Our conceptual work extended perspectives from literary criticism, critical theory, and narrative analysis in the humanities and social sciences to focus on elements of sociocultural context, ideology, social control, underlying structure, and superficially marginal features of discourse in medical encounters. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by two illustrative encounters, the discourse of health care reinforces ideologic principles of professional surveillance and individual control in dealing with patients' self-destructive tendencies. Contextual issues remain largely marginal features of the discourse, despite their pertinence to the goal of prevention. Narrative analysis provides a useful method to study the processing of self-destructive behavior in medical encounters. Future studies should continue to assess the variability of discourse in dealing with self-destructive behavior and should begin interventions to test the efficacy of differing discourse styles. Meaningful improvements in health-care discourse depend partly on difficult changes in the social context of medicine, including policies that address social conditions contributing to substance abuse and other forms of self-destructive behavior.