Many clinicians are aware that it is an effective diagnostic strategy to give the patient the space to tell the story of their illness and injury. After all, patients are the most valuable source of information about themselves. However, less confident (often more junior) clinicians can sometimes deny the patient this valuable communicative opportunity. While we acknowledge that clinicians are under pressure to set the agenda in the emergency department, our data indicate that allowing patients a greater opportunity to contribute to building shared knowledge may be a way of making the patient journey more efficient, because patients more often than not provide crucial medical information themselves. At the same time, patients have the satisfaction of knowing that they have been given the opportunity to discuss their concerns and anxieties and explain what they think may be wrong with them.

Indicators of whether the patient has been given sufficient space to tell their story are the use of particular types of questions, the type and number of initiating utterances made by the patient, the type and number of clarifications and queries, both by the patient and the clinician, and the length of patient turns during talking. An additional indication is to what degree the clinician expands on and enhances the information the patient provides and picks up on the patient cues.

Here is an example of a triage nurse starting her assessment by asking the patient an open question (‘Um, so what’s happened today?). She then gives the patient the space to provide a detailed narrative, using minimal acknowledgements (such as ‘yeah’ and ‘mm’) and asks more specific questions when she needs further clarification:

In the next extract, the doctor gives the patient space to provide the information he needs. He offers the patient space to provide an alternative in his first question and then uses assumptive questions to show he is listening and to probe for further clarification:

In contrast, in the excerpt below, the nurse begins with two open questions, but then does not allow space for the patient to tell his story, as many of the questions she asks are closed (requiring a yes/no answer):

Table 5.2 gives examples from triage conversations with Jean (review suture for leg injury) and Graydon (cardiology admission) and discusses why we believe one interaction is more effective than the other.

In Graydon’s case, the nurse asked only five questions during triage . Four of these related to the patient’s medical condition and one to the hospital system. Graydon asked only one question about his medical condition. His main contribution to the interview was to respond to the questions he was asked. Although one of Graydon’s responses as well as one of his wife’s were more lengthy because they had been through the same process the day before and they were now more familiar with the system, they were constrained in terms of the space they were allowed. Having been told that Graydon was in heart failure, the triage nurse responded with ‘Mmhm’ and proceeded to ask another two questions about his age and allergies.

The triage nurse explained the reason she needed to reassess the presenting illness herself, and the patient and his wife responded by sharing what they knew. Once the presenting condition was established, the triage nurse returned to the triage protocol, even though this information would have been recorded in the patient’s notes. This is a demonstration of the fact that all clinicians are accountable for their own practice and must stick to protocols—but it is frequently mystifying to patients who assume clinicians have access to prior information.

At the conclusion of the triage interview, the triage nurse told the patient that he was to be placed in the acute section of the emergency department, and then took him to the bed and began the admission stage herself. She then double-checked the patient’s personal details, and reaffirmed her own responsibility for this when the patient appeared bemused:

Some doctors in our consultations opened space for patients to tell their stories very effectively in the initial medical consultation stage . In the example below, the doctor gives space to Jean to outline her condition.

In this example, the doctor initially engaged the patient by asking an open, neutral question. She then limited her own contributions so that Jean could describe the sequence of events uninterrupted. The doctor’s response at the end of the narrative was positive but non-committal, ‘Mm, OK, good’.

In Chap. 4, we quoted from the case of Fahime (dizziness, feeling stressed), the Middle Eastern patient who was examined by two junior doctors, neither of whom picked up on clues to her depression . In fact, in the 3 hrs Fahime spent in the emergency department, she was asked 149 questions, most of which were closed (requiring only yes/no answers). By contrast, Fahime and her family asked a total of four questions, suggesting a striking lack of collaboration in the patient–clinician relationship.

Our data repeatedly indicate that allowing patients a greater opportunity to contribute to shared-knowledge building may be a way of making the patient journey more efficient. Patients may well be able to provide crucial medical information. This is particularly the case in the initial medical consultation stage . If clinicians allow patients room to tell their stories, by encouraging longer turns at talking, patients may provide crucial medical information themselves. At the same time, patients have the satisfaction of knowing that they have been given the opportunity to express themselves. However, given the time and clinical pressures on senior doctors, they must find out efficiently what they need to know from patients.

Some doctors—mainly senior doctors—displayed considerable skill in allowing the patient time to talk while also narrowing in to clarify essential medical information. For example, the two senior doctors involved in the diagnosis stage for Nola (per-rectal (PR) bleeding) and Graydon (cardiology admission) used the same strategy that other clinicians in our data have employed, and began the final history-taking process by asking an open, neutral question, i.e. ‘What were you doing at the time?’ (Nola); ‘Can you tell me what it was like?’ (Graydon) This offers the patient communication space. They then made use of a range of question types based on the information they needed to establish a plausible diagnosis/hypothesis.

The surgical registrar who took responsibility for care of Nola during the diagnosis, treatment and disposition stage of her consultation invited Nola to tell her story:

The doctor checked that some of the information Nola had given in the initial medical consultation was still the case, by asking a series of assumptive questions. This less direct style of questioning appeared to place a positive value on Nola’s earlier contribution. The re-questioning process gave Nola an opportunity to explain the reason why she did not have a scheduled colonoscopy, and time to accept the inevitable need for another one in the future:

When the surgical registrar required more specific information, he asked a series of closed questions, often repeating what Nola said out loud, gradually building up a clearer picture of the problem for himself and for her: