Medical residents' use of narrative templates in storytelling and diagnosis

This paper examines the diagnostic storytelling that medical residents perform in order to situate patients in a story trajectory with an imputed past and future. It is a study of "ordinary" expertise, as practiced by a family practice medical team in a small urban community hospital in the United States. Narrative storytelling--an activity that is at once cognitive and practical--allows residents to identify the sort of disease, the kind of patient, and the likely outcome for this patient, based on what the resident knows about patients like these. Residents acquire a set of narrative templates, or rough outlines, that they deploy when they encounter a new patient or his or her information. Going into an admissions interview, a resident already has a set of "facts" about the patient and his or her complaint. In a process that is routine, habitual, and iterative, a resident starts from this set of facts and draws on his or her repertoire of narrative templates to pursue a line of questioning that starts to define relevance for this patient, a relevance that is revised as the physician begins to settle on a story. These templates make a first organizing pass at answering, "What's going on with this patient?" They provide the preliminary structure, the warp and weft, for building a patient story that holds together long enough to diagnose, treat, and discharge the patient. Diagnostic stories are shaped by what residents think they can do for the patient, practically speaking, and by habitual hospital activity.