When patients portray their conduct as normal and healthy: an interactional challenge for thorough substance use history taking.

Researchers and medical practitioners have argued that routine substance use histories are performed less frequently and less thoroughly than they should be. Previous research has identified a range of structural, attitudinal, and socio-cultural barriers that help to explain this pattern. Using conversation analytic (CA) methods, this paper complements previous work by exploring a potential interactional barrier to thorough substance use history taking in the USA. In response to routine substance use queries (e.g. "Do you drink alcohol?"), patients often do more than just providing information. They also convey normative stances toward their conduct, essentially making a case for how it should be understood by the physician. One stance that patients may take is that their conduct is normal and healthy. This paper describes three interactional practices that patients used to enact such a stance: 1) employing marked lexical, intonational, or interactional features when indicating no use of a substance; 2) volunteering normalizing details about the type, quantity, frequency, or circumstances of substance use; 3) providing minimizing characterizations of substance use. The paper explores some reasons why physicians treated these as appropriate and sufficient responses and did not seek additional details even when the information provided was quite superficial. Two social functions of patients' "normal/healthy" stances are discussed: 1) redirecting the physician's history taking to other topics and 2) presenting oneself as a health-conscious patient. "Normal/healthy" stances can represent an expression of patient agency, but can also present a dilemma for physicians, who must balance a concern for thoroughness with a concern for rapport. Recommendations for navigating this dilemma are discussed.