Throughout the past two weeks we have been discovering the meaning within these words that were shared with us one night over dinner with a physician from the New River Health System. “Within the clinical encounter,” Dr. Doyle said,” the meaning emerges from the interaction.” We have been taught a certain approach to patient interaction. When a patient presents to a clinic visit, we poke and prod with questions, seeking specific information. But, even with the intended good will behind our approach, something is still not working. What would happen if we handed over the control? If we stepped out of the driver’s seat and let the patient steer the conversation. What if we let go of our expectations, the drive for answers, and simply listened? William Osler, father of modern medicine, is quoted as saying, “Listen to your patients. Listen and they will tell you what is wrong with them. Listen long enough, and they will even tell you what will make them well.” Maybe what we need is a return to his philosophy; a return to oral history.
During the last few days of our stay in the West Virginian mountains, we put our final touches on the project we had been given to do. I say “our” final touches, because the work we have done is merely the foundation of an approach or tool that the Cabin Creek Health Systems (CCHS) may use to increase the effectiveness of their communication with patients. In the hopes of increasing our understanding of the Oral History approach, we split into pairs and went on home visits throughout the communities surrounding Cabin Creek. Patrick Krueger and I visited three different homes, and came away with three very different experiences. As a group we created this list of “lessons” learned and tips to conducting an effective oral history interview:
- The goal of the interaction is to establish the relationship and foundation
- The emphasis should always be listening
- Learn to be comfortable with silence
- Digressions do not exist; affirm the participants’ stories
- Utilize neutral facial expressions/avoid nodding/verbalizations
- Avoid the urge to use “teachable moments”; mentally note the statement for later follow-up or motivational interviewing
- Keep follow-up questions or statements succinct and open
- Be present; focus on the client
- Respect time limitations
I would like to emphasize three of these points, one through a story, and two for their poignancy. At the first home Patrick and I visited, we spent 30 minutes listening to this woman share her struggles with diabetes and weight loss. She haltingly shared her story. But, as soon as we thanked her for her time and turned off the recorder, our true education began. In talking about her home and her hobbies, she casually mentioned her frequent use of the tanning bed in her back room. Unable to control my surprise, my mouth fell open. That, of course, raised her defenses, and we ended up doing a little risk-factor education. This was a departure from the true nature of our visit, which was to hear her story, not judge it. Utilizing neutral facial expressions is paramount. When someone is sharing their story, judgmental expressions, such as raised eyebrows, and a jaw dropped in disbelief, can effectively close the book of their lives they had so graciously opened for you to read.
We presented our findings to CCHS as a tool for their Health Coaches to use in forging a strong relationship with their clients. The aim is for the Oral History approach to be utilized on the first visit, in order to lay the foundation for more effective motivational interviewing on subsequent visits. In receiving someone’s oral history, you are being given a window into their lives. It is a beautiful way to come to truly know someone. What a better way to start a therapeutic relationship. But, in order to foster this type of openness, the interviewer needs to avoid the urge to capitalize on any and all “teachable moments.” As nurses, we have been taught to never let a opportunity for education slip by. However, in this setting especially, imparting knowledge or advice through education, however well intended, creates a power differential. So, it is imperative to hold back on those urges. Make mental notes only. And simply continue to listen, opening yourself to truly hearing their story.
Lastly – probably the hardest part of this approach – is silence. Silence is a powerful force. And under its power we saw individuals blossom. By our silence we them gave the gift of time to construct and relive their stories, and we conveyed our genuine interest in their lives. I know I have yet to reach the point where I am comfortable with silence. But, I have seen the beauty that comes out of letting that silence stretch a few moments longer than normal. Fears are confessed, joys are shared, truth emerges.
For two weeks, our team of 7 persevered through long days; hours and hours of commuting on curing country roads between the clinics, the communities, and our beautiful forest cabin. We also spent countless hours researching, conversing, and compiling our plan to present to CCHS. (If you would like to view the fruits of our labor, please visit www.oralhistorytrainingmodule.com ). We also cooked delicious meals every nights, wandered through the forested hills surrounding New River, and even spent an afternoon rafting down its turbulent waters. All in all, I believe that we came away from West Virginia changed. This experience has reshaped the way we will approach communication with our clients; to focus less on searching for the right questions to ask, and more on the relationship built, and the words that are spoken. For it is true – the meaning we are searching for emerges from the interaction we foster with being open.