The art of conversation
The art of conversation
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谈话的艺术
DOI：
10.1016/s0140-6736(18)30264-2
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发表时间：
2018
期刊：
影响因子：
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通讯作者：
R. Kneebone
中科院分区：
文献类型：
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作者：
R. Kneebone
像所有医学院的学生一样，我被教导要“学习”一门历史。我背了一长串，一套标准的问题——“哪里疼，什么时候开始疼的，疼到哪里去了，家里有什么疾病吗？”他们的假设是，除了获取已经存在的信息外，我不会在这个过程中发挥任何实际作用。直到很久以后，当我做了几年的全科医生之后，我才开始认为咨询是一个双向的过程，我是其中的参与者，而不仅仅是一个背诵提示列表的密码。我意识到，人们往往不知道自己的问题是什么，直到他们通过对话把问题说清楚。“我从来不知道自己在想什么”，他们可能会告诉我，“直到我听到自己说出来”。尽管有明显的相似之处，但谈话不同于记录历史、采访或非正式的聊天。谈话是一个深思熟虑的建构过程，既依赖于给予，也依赖于索取。它是临床实践的核心。在过去，谈话被认为是一门艺术，需要练习和关注。从蒙田（Michel de Montaigne）到现在，无数作家都在讨论社会对话的乐趣和挑战。他们经常哀叹它的衰落，并提供指导。然而，谈话的技巧不能只从书本中获得。谈话是一次性的现场表演，永远不能重复。它的本质是它的消逝，试图在写作中捕捉它就像阅读剧本或电影一样薄。当然，总是有炫耀的余地，可以大胆地展示自己的博学或智慧，也可以通过闪耀的光芒使他人黯然失色——但真正的谈话更谦虚。这不是一个展示自己知识的机会，也不是一个支配或过度塑造遭遇的机会。对话取决于共同所有权；它在人与人之间的空间中出现并形成。患者与临床医生之间的对话具有特殊的特点。最重要的是，这样的对话需要仔细倾听和慷慨地关注另一个人，以及他们在说什么或没说什么。正如全科医生和家庭治疗师约翰•劳纳（John Launer）所说，“两次沉默也可以构成一次对话”。这是一种微妙的平衡。在一个方向上走得太远，交流就变成了一系列问题；在另一个方向上走得太远，它就变成了统治，霸权。在临床实践中，在对话的过程和结果之间也经常存在紧张关系。虽然其中一些结果会以电脑记录、手写笔记、推荐信、给同事的电子邮件或电话的形式被记录下来，但谈话本身很快就会消失，其中的细微差别也会消失。如果过于狭隘地关注结果，对话本身的价值就会被掩盖。
Like all medical students, I was taught to “take” a history. I memorised a litany, a standard set of questions—“where’s the pain, when did it start, where does it go to, are there any diseases in the family?” The assumption was that I would play no real part in the process apart from eliciting information that was already there. It wasn’t until much later, when I’d been a general practitioner (GP) for several years, that I started to think of the consultation as a two-way process in which I was a participant, not just a cipher reciting a list of prompts. I realised that people often do not know what their problem is until they give it shape through conversation.“I never knew what I thought”, they might tell me,“until I heard myself say it”. Despite apparent similarities, conversation is different from history-taking, interviewing, or an informal chat. Conversation is a deliberate process of construction that depends on giving as well as taking. It is the heart of clinical practice.In former times conversation was acknowledged as an art, requiring practice and attention in its own right. Countless writers, from Michel de Montaigne to the present day, discuss the delights and challenges of conversation in society. Often they lament its decline and offer guidance. Yet the skills of conversation cannot be gained from books alone. A conversation is a one-off live performance that can never be repeated. Its essence is its evanescence, and attempts to capture it in writing are as thin as reading the script of a play or a film. Of course there has always been scope for showing off, for bravura displays of erudition or wit, or for eclipsing others through coruscating brilliance—but true conversation is more modest. It is not an opportunity to display one’s own knowledge, to dominate or over-shape an encounter. Conversation depends on joint ownership; it emerges and takes shape in a space between people. Conversations between patients and clinicians have particular characteristics. Above all, such conversations require close listening and a generous-minded attention to another person and what they are saying—or not saying. As the GP and family therapist John Launer puts it,“two silences can also constitute a conversation”. This is a delicate balance. Too far in one direction and the interchange turns into a list of questions; too far in the other direction and it becomes a domination, a hegemony. In clinical practice there is often also a tension between the process of conversation and its outcomes. Although some of these outcomes are captured as computer records, handwritten notes, referral letters, and emails or telephone calls to colleagues, the conversation itself soon evaporates and its nuances are lost. By focusing too narrowly on the outcome, the value of the conversation itself can be eclipsed.