The art of storytelling is as old as the spoken word, and it's just as powerful. It entertains, informs, and connects mankind across culture, race, and creed. It has the power to heal, and in medicine, it can be a life-saving skill.
Most people enjoy reading or listening to stories at their leisure. The health care provider, on the other hand, listens to stories all day long because it's part of his job. This is how he obtains the "history of the present illness," perhaps better described as the "story of the present illness." It forms the basis of all that follows: performing the physical examination, tracking down the diagnosis, and formulating a treatment plan.
The clinical encounter begins when the health care provider takes the patient's history. He listens for specific details that lead him to the diagnosis. If the problem is pain, the provider wants to know where it's located, and whether it's sharp or dull, steady or throbbing, constant or intermittent. He wants to know how long the patient has had the pain--for a day? For a month? For years? What makes it better? What makes it worse? These details guide him through a maze of possibilities.
The problem is that patients don't know what the provider needs to hear. They don't arrive at the office prepared to rattle off a list of relevant signs and symptoms. It's the provider's job to ask about them, but he only has so much time to get to the bottom of the patient's problem. Nowadays, the written or dictated clinical note has been largely replaced by the electronic medical record (EMR), so rather than listen to the patient's history, the provider navigates his medical record with a series of clicks that pull up an array of bulleted lists, complicated charts, and sketchy details. This is intended to expedite what has been ruthlessly abridged to a ten-minute office visit.
Because time is limited, doctors often redirect the patient who appears to be getting off track or is slow coming up with answers. In fact, one frequently quoted study found that physicians interrupt and redirect the patient when they are as few as 18 seconds into the interview. Frequent redirection leads the patient to believe that what he wants to say isn't important or relevant, so details go missing.
This is a problem. Healing, or failing to heal, occurs in the context of a person's relationships with his family and friends, his surroundings, expectations, and perceptions, as well as his emotional, psychological, and spiritual life. If the patient is denied the opportunity to tell his whole story, part of him may never heal.
Let's say, for example, that the patient presents with abdominal pain. He answers all of his doctor's questions. The pain has been present for four days. He describes it as constant. It started in his upper abdomen, but now it radiates into his back. Eating makes it worse. In fact, the patient says he hasn't been able to keep anything down for the past twenty-four hours. After a focused physical exam and a few tests, the physician correctly diagnoses the problem as acute pancreatitis. But that doesn't explain why the patient develops a headache, has trouble keeping his balance, and becomes confused the day after he is admitted to the hospital.
What the doctor doesn't know is that the patient has been drinking heavily because his wife walked out on him recently. In fact, he blacked out a couple of days ago and woke up on the floor next to his bed. He didn't mention it because he was busy answering the doctor's questions about his abdominal pain. So, the doctor missed the small subdural bleed his patient sustained in the fall until days later when he had his first seizure.
This scenario highlights an important problem. Obtaining an accurate and thorough medical history takes time. Given the imperative to see more patients faster, the provider may have little time to explore the details of the medical history with every patient. Perhaps he's running behind schedule, or an emergency interrupts him. In some cases, the patient can't bear to disclose the sorrow, or fear, or shame that underlies his symptoms, so he doesn't mention it. It takes time to invite, enable, and encourage some patients to share the story that brings them to the office in the first place.
When the patient is constantly redirected in order to satisfy the provider's agenda, important parts of the story may be overlooked. This reinforces the importance of hearing the patient's full narrative. When we reach into their cholesterol laden hearts to understand why they are poisoning themselves with food, we need to know more than what they are putting into their mouths. When a patient is noncompliant, we need to consider what he is afraid of, or angry about, or grieving over. When we allow the patient to speak, we may discover that the reason for this one's fatigue, or that one's intractable headache is end-stage disappointment, or anger, or shame that has festered for years.
Only then can we help them heal.
.JPG)
