the time it takes...the trouble it saves

 

 

 Training in the practice of narrative medicine focuses on motivating and enabling health care providers to uncover the real story behind the patient’s illness…not just his symptoms, but his attitudes toward health and healing, how his illness affects his life and the lives of people around him, and his fears and hopes for the future.

 

“It can be argued that the largest

yet most neglected health care resource

worldwide is the patient.”

~Dr. Warner Slack~

 

Let’s say a woman presents with a complaint of palpitations…the sensation that her heart has been beating rapidly and/or irregularly, off and on, for a couple of weeks. It scares her because her father died suddenly following a heart attack at the age of 54. She limits her caffeine intake, exercises regularly, and is otherwise healthy. When you see her in the office, her cardiac exam is normal…her pulse is 80 and regular. Her blood pressure is normal. So, you schedule her for a stress test and a cardiac event recorder. The only thing that shows up is an occasional episode of sinus tachycardia. You have now run up several thousand dollars in bills and you still have no diagnosis.

 

Had you taken time to ask about recent stresses in her life, she might have told you about the cigarette burn she recently found on her twelve-year old’s shirt sleeve. And how poorly he’s doing in school. And how worried she is about him because if he’s smoking already, what’s next? And how hard it is as a single mother because she has to work two jobs and she can’t keep her eye on him the way she should.

 

“We know that stress is perhaps

the most underrated of all  

our heart disease risk factors.”

~Michael Miller~

 

It’s no wonder her heart is acting up. But her cardiac condition is not the problem. Stress is. And stress can be a whole lot harder to treat than a cardiac arrhythmia. You could run every test known to mankind in an effort to convince your patient that her heart is fine…but until you identify and address the real issue, she will continue to have symptoms. Her problems will only get worse.

 

Narrative medicine encourages us to take time to elicit the patient’s whole story, and to consider the context of his illness. To touch the sensitive spot. To probe the wound. Not only to make an accurate diagnosis but to explore the patient’s fears, expectations, and beliefs about his condition…anything that might delay healing.

 

Or promote it.

 

“The good physician treats the disease;

the great physician treats the patient

who has the disease.”

~William Osler~

 

jan

 

 

 

 

 

 

 

 

 

 

 





i smell smoke

 

 

 

 

Another random rant:

 

It’s no wonder we have been hearing more and more about the problem of “burn out” among health care professionals as we witness the premature exodus of capable, dedicated physicians and nurses from a system that defies excellence in patient care by virtue of its unspoken battle cry: Bigger. Faster. Greedier.

Burn out is defined as:

 

“…a state of physical, emotional, or mental

exhaustion accompanied by

doubts about one’s competence

and the value of one’s work.”

~https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642~

 

But it doesn’t have as much to do with fatigue as it does with frustration. The problem isn’t about keeping up with technology or advances in diagnostic and treatment modalities. We can do that. The problem is that we are forced to compromise thoroughness in favor of efficiency. Connection in exchange for productivity. Compassion in lieu of profit.

Dedication, fulfillment, and integrity are no longer part of the equation.

When I gave up after thirty years in Family Medicine I told my patients and colleagues I was retiring…when I meant I was quitting. I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over the decision for years.

I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue or forgetfulness or ill-health.

No. What finally got to me was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. When I started out in medicine the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in research. A health insurance industry whose number one priority is corporate profit…which translates into seeing more patients faster regardless of the complexity of the presenting problem. I worried I would miss something, and I feared for my patients because of it. It scared me. I had to leave.

 

“The very concept,

I would say ministerial function of being a physician,

is to be attentive, is to be present,

is to listen to that story,

is to locate the symptoms on the person

of that patient,

not on some screen,

not on some lab result,

but on them."
~Rosmarie Voegth~

 

It's no wonder we worry about competence given the constraints imposed on our ability to deliver excellent care to our patients. It's no surprise we question the value of our work when we measure it in terms of quality and compassion while the system is busy tallying the receipts. 

Physicians are encouraged to manage their stress…when they are helpless against it. To get outdoors more. To meditate. To eat better and to get more sleep…when, some days, we don’t have time to eat at all. When we can’t break away long enough to poop on the pot. When we don’t have the strength to blink at the end of the day…not because the work has gotten any harder, but because the hoops we have to jump through have multiplied…and somebody in a fancy office is holding them higher.

 

“America’s healthcare system is neither

healthy, caring, nor a system.”

~Walter Kronkite~

 

 Looking back on thirty years of practice in the American medical system, I can only say, "It weren't broke." But it sure needs fixin' now.

For more on professional burnout, check out  https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072470/

jan





 



this week's challenge

 

 

 

I just registered for the third annual conference on narrative medicine to be held at Kripalu Center for Yoga and Health in July. The title of this conference is "Narrative Medicine--A Cutting-Edge Approach to Healthcare."

*

Narrative Medicine A Cutting-Edge Approach to Healthcare

·                     July 8–13, 2018

·                     Sunday–Friday: 5 nights

·                     Presenter: Natalie Goldberg

·                     Presenter: Nancy Slonim Aronie

·                     moderator: Lisa Weinert

·                     and more…

For caregivers, doctors, nurses, yoga teachers, writers, and anyone interested in personal narrative as a healing path to recovery.

*

Now, I don’t know about you, but when I think of cutting edge approaches to health care I think of things like new and more effective antibiotics, high tech scans and digital something-or-others, and robotic microsurgical techniques. But storytelling?? Not so much.

Advances in medicine, whether having to do with the development of new drugs, tests, or methodologies, have to pass rigorous tests of their efficacy and safety before they are introduced into mainstream practice. This requires large scale randomized, double-blind, placebo-controlled studies…which are notoriously difficult to design. Once you have demonstrated the safety and efficacy of, let’s say, a new drug, you still have to consider its cost effectiveness, applicability and acceptance rate. It’s surprising anything makes it through the process. But storytelling??

 

“I love storytelling.

It’s endlessly healing.”

~Ben Vereen~

 

For the sake of this discussion, let’s assume that the techniques taught in narrative medicine programs represent an advance in the practice of clinical medicine…that this method improves patient satisfaction, shortens hospital stays, decreases the number of readmissions, and in the long run, saves time and money. The numbers that prove these claims may be hard to get at. How can we measure the effect of patient satisfaction on healing? How would we code and bill for the time it takes to listen to the patient’s real (aka “whole”) story? Won’t it wreak havoc on our schedules to engage with our patients on their terms?

 

There is one way to find out:

 

Try it.

 

See if it works for you. Other people have. Other healthcare providers have reported not only improved patient satisfaction, but an improved sense of personal and professional fulfillment, a greater sense of dedication to and connection with their patients, better insight into the cause and clinical course of the patient’s illness and recovery. More accurate diagnosis. Fewer unnecessary tests. More effective interventions. All of which add up to better health care.

 

“Each time I told my story,

I lost a bit,

the smallest drop of pain.”

~Alice Sebold~

 

This is my challenge: look over your patient schedule for the week. Find a day when you have a little built in leeway. Pick a patient who is coming in for the first time. Or for a new problem. Ask this question:

 

“What do you think I should know

about your situation?”

 

Then just listen. Try not to interrupt, or redirect, or clarify what the patient says. There will be time for that later. He will tell you everything you need to know…what has happened, how it affects him, how he feels about it, and what he thinks about it. Bam!

 

This is the technique employed by Rita Charon, director of the Program in Narrative Medicine at Columbia University and chief contributor to the landmark text, The Principles and Practice of Narrative Medicine.

 

If the concept behind narrative medicine interests you, you might consider ordering a copy. Or…attending this year’s conference!

jan