Many arise each day with a scenario of expectations to be achieved. For those individuals of working age, some of these expectations revolve around our jobs, put into place by our employers over which we have little to no control. But what about those narratives, those stories, that we tell ourselves in the middle of the night or the ones that pop into our heads in the middle of the day when we stare out into space and wonder does any of this really matter?
What about the wife who comes into her doctor’s appointment complaining about headaches and an occasional racing heart but is hesitant to mention little more? Maybe she’s told to try to catch an extra nap and take an aspirin. If she had the opportunity to tell her “narrative,” it might have been disclosed that her husband is abusive and that she is under constant stress and anxiety which is now affecting her health.
What about the blonde-haired 3-year-old boy who is brought into his pediatrician’s annual appointment? At the exam, the physician notes bruises on the child’s arms. When questioned, the mom quickly answers, “Johnny falls a lot … boys will be boys.” If the full narrative was spoken, it would come out that the mom is a “single mom” and occasionally loses her temper when her son misbehaves. But there was “no time” to allow the narrative to unfold … as a result, the situation is left to fester a while longer.
What about the 80-year-old woman who comes to her family med appointment? The doctor notes that this kindly elderly woman has been losing weight over the last few appointments she has had. When asked, she simply states she isn’t all that hungry anymore but is feeling fine. If her narrative was allowed to unfold, it might be disclosed that she lives alone, cooks for herself, and has a difficult time paying for rent, medications, and groceries. So she tries to save where she can … and that means tapering back on the grocery bill.
These narratives may change when there is a trusting relationship established between the patient and the physician and when there is sufficient time placed into the schedule to allow for an honest discussion to take place. With careful, guided questions, the truth is allowed to bubble up to the surface and resolution has the potential to take place. The physician has the opportunity to get to know his patient on a more caring, intimate level rather than the stark and cold summary on the computer screen.
The narratives of our lives … the struggle between truths and falsehoods. What has happened to our health care systems when a physician feels pressured to process a patient in and out of an exam room as quickly as possible … when he receives a “scolding” for not having met his patient quota within a pre-conceived timeframe? There is more to the truth than what is visible on an EHR, and quite frankly, often it is more relevant to a patient’s well-being.
The ability to listen, to empathize, to build trust – this is the basis of narrative medicine. Developed by Rita Charon, MD, a professor at Columbia University College of Physicians and Surgeons, narrative medicine is a model of enhancing patient-physician relationships through empathy, reflection, and enhancing trust. It uses the skills of recognizing, absorbing, interpreting, and being moved by the stories of illness.
Research reveals that most clinicians interrupt a patient within 18 seconds after the interview begins. Dr. Charon suggests we begin with “Tell me what you think I should know about your situation.”
After that simple question, Dr. Charon does her best “not to say a word, not to write, but to absorb all that the patient emits about himself – about his health concerns, his family, his work, his fears, and his hopes.
Dr. Charon describes the effect this has on patients. “After a few moments, the patient stops talking and begins to weep. I ask him why he cries, and he says, ‘No one ever let me do this before.”
If our patients do not feel like we have heard them, we may not gain acceptance of the care plan we offer.
In the telling and listening to a patient’s story, there becomes clarity, and a more concise diagnosis may be formulated by the physician. Time wasted … I think not. The patient feels that he has been acknowledged, validated and has been able to share with his doctor those concerns which are deemed most important. He and his physician form a bond of trust and travel on the path of healing together. When a physician applies the tenets of narrative medicine to his interaction with a patient. a stronger and more durable connection is fused between the two. The patient feels that he can depend on his doctor to be with him during trying times and to be a partner with him in formulating a course of action. At its best, the practice of narrative medicine rekindles the close and sacred trust between patient and physician, which during these times of corporate medicine, often appears disjointed, rushed, or simply altogether lacking.
So how does the narrative, the story, apply to the physician? What are the stories that a physician tells to himself, colleagues, and family members? Each day a physician is the receiver of a multitude of complicated life stories from his/her patients … some of which do not have “happy endings.” The burdens are heavy as the physician compassionately supports his patient on this journey of illness. A physician may derive a feeling of elevated satisfaction from knowing that he has put forth the effort to “know” his patient, instead of simply viewing the patient as a collection of data in a chart.
By applying the concepts of narrative medicine, a physician may, similarly, support his colleagues during emotionally trying times … to “walk beside them” and hopefully lessen the feeling of aloneness. This ability was very important during the time of the COVID pandemic to help ease the exhaustion and sadness that was so prevalent. The ability to “talk it out” with a colleague may mean the difference between surviving an emotional crisis or succumbing to it. It may also help to lessen the emotional effect of the ever-increasing burdens placed upon the physician which eventually may lead to burnout.
Lastly, as a physician be truthful to yourself and your family. If you have had a “rough” day, share as best as you can with your significant other. You might also try writing your feelings down on paper … somehow the act of putting the words down on paper reduces the level of burden somewhat.
Finally, it is an injustice to our system of health care if the ability to tell one’s story and have it acknowledged is thought to be a trivial act. The world around us seems so at odds, to the point of appearing heartless. Let us restore the act of compassion and empathy in our interactions with our fellow human beings and most importantly, within the healing profession.
Michele Luckenbaugh is a patient advocate.