can you hear me now?

If you are interested in, or for that matter, even if you're a bit skeptical about the concept of narrative as an instrument of healing, you should run right out and pick up a copy of “What Patients Say, What Doctors Hear” by Danielle Ofri, M.D. If you harbor any cynicism about the relevance of narrative medicine as a healing practice, you should read this book. Then, lend it to a friend, or two, or three.

Among the topics she tackles are:

• Obstacles to effective communication including time constraints, over-booked schedules, and individual productivity quotients that have nothing to do with improving patient care.
• The importance of listening patiently when obtaining the patient’s medical history, and how our body language and facial expression can intimidate or discourage the patient from sharing important parts of his story.
• The role our own back story plays, and how it affects our expectations and interactions with patients.
• How the use of jargon reflects our attitudes towards patients, for example, referring to the disease rather than the person who has the disease (the diabetic, the epileptic, the asthmatic) or labelling the patient who fails to respond to treatment as a “difficult” or “noncompliant”.
• The influence of gender identity, race, culture, socioeconomics, and religion on communication.
• How to break bad news to the patient and his family.
• The correlation between poor communication skills and malpractice claims, and the pros and cons of disclosing medical errors.
• How effective communication influences the perception of pain, and how this affects healing. 

I often hear from people about the fragmented and impersonal relationship they have with their healthcare provider. They feel as though they aren’t being heard or understood. Issues that are important to them are dismissed or left untouched by physicians who appear hurried, distracted, or disinterested in their problem.

“Listen. People start to heal

the moment they feel heard.”

~Cheryl Richardson~ 

The physician can hardly help himself. He is forced to practice in a health care system whose number one priority is corporate profit. His schedule is overbooked. He struggles with an electronic medical record that doesn’t work for him. He has to navigate a baffling coding and reimbursement system, and he is tethered to his very own productivity quotient, a.k.a. how much income he is expected to generate.

These stresses drive a wedge between the patient and his provider, disrupting the fundamental patient-doctor relationship. The patient is disappointed in his care, and the physician is disappointed in himself.

On the other hand, physicians who are trained to practice narrative medicine learn skills that help them elicit and interpret the patient’s history, to seek missing details, and to understand the patient’s illness in the context of his life and his community. As a result, patients under their care feel as if someone is finally listening to them. That someone cares. When they feel heard, they do better. They cope better. They are more receptive to therapeutic intervention.

Do they heal because of it?

That, of course, depends upon how you define healing.

“You are so brave and quiet

I forget you are suffering.”

~Ernest Hemingway~

It might take a stretch of the imagination to say that a narrative approach to patient care speeds wound closure (although some studies have demonstrated this phenomenon), or that it prevents the spread of cancer. Antibiotics would be a better choice for pneumonia. You need surgery if you have appendicitis. Nevertheless, the empathetic resonance that develops between the physician and the patient when the patient is heard in a caring, receptive, and nonjudgmental manner can improve his prognosis.

No illness is free of emotional fallout. Fear. Anger. Shame. Heartache. None of which the patient may want to admit or be able to express. These feelings may, however, be the most amenable to the healing power of storytelling in the clinical setting. Only if the patient is encouraged to express his frustration, fear, and sense of loss can we know what kind of support he needs. Perhaps he just needs facts to help him understand and embrace his treatment plan. Maybe he needs constant reassurance and encouragement. A glimmer of hope. Maybe she needs assistance arranging for help at home. Some patients may welcome prayer at the bedside. All of which can help the patient heal.

For those of us involved in patient care, the operative word is “care”. This involves more than tending to the tasks required to treat our patients. It implies caring about them. Caring enough to explore the impact of their illness on their emotional and psychological well-being, and its impact on their family and friends. On their future. On their souls. All the hidden places pain lingers.

"The healing that can grow

out of the simple act of telling our stories

is often quite remarkable."

~Susan Wittig Albert~

Training in narrative medicine empowers the physician to elicit, interpret, and respond to the stories that patients tell us about their illnesses. In addition to exploring the occurrence and progression of their symptoms, it encourages the physician to consider the nature and course of suffering, attitudes about healing and recovery, and the ways family members, community, and circumstances influence these attitudes, all of which affect patient outcomes.

The overwhelmed health care provider may suggest that this is what we have nurses, social workers, pastors, and family and friends for. But by disengaging himself from the patient’s psychological, emotional, and spiritual life, the physician sacrifices his connection with his patient, and with it, his sense of empathy. With loss of empathy, morale suffers, and when morale suffers, physicians tend to burn out.

Storytelling is one of the many art forms that enables people to explore and to process the full scope of illness and recovery. It is built into the clinical encounter under labels like “the history (or story) of the present illness”, “the past medical history (or story)”, “the social history (or story)”, and “the family history (or story)”, as though an epic novel is about to unfold.

Storytelling is a useful tool for the patient himself as a means of exploring the cause, effect, and meaning of his own illness. He needs more than a diagnosis, a referral, or a prescription. For healing to proceed, he needs to know that his provider cares about what he has to say, understands him, and addresses all the ways he is suffering.

“The most precious gift

we can offer anyone

is our attention.”

~Thich Nhat Hanh~

jan