how to save time and money

 

"Why, certainly. Help yourself..."

 

This summer, I enjoyed a brief writing hiatus that included a week away at Kripalu Center for Yoga & Health for the third annual conference on Narrative Medicine. Of course, I came back ready to share what I learned about compassionate listening, cognitive coupling and dissonance, and the interpersonal neurobiology of storytelling...and how all of that relates to patient care and healing. No small task.

 

But it wasn't until I got home and was enjoying a cup of coffee with an old friend, a nurse practitioner, that the point was driven home. She presented me with this photo of a patient's foot and dared me to make the diagnosis:

 



 

This was the patient's history: She'd been seen in the emergency room several days earlier with an injury to the foot. She said she'd twisted it. X-rays were negative for fracture and she was discharged with instructions to elevate the foot and apply ice for pain and swelling. A few days later she saw my friend for follow-up because her foot had gotten so much worse. This is a picture of the foot at follow-up.

 

What do you think was going on?

 

"There is need of a method

for finding out the truth."

~Descartes~

 

I ran through a quick differential in my mind. Was it a crush injury? No. Necrotizing fasciitis from "flesh-eating bacteria"? No. Disseminated intravascular coagulation? No.

 

My friend, too, had been puzzled because the history did not fit the findings. So she'd gone back to the patient and asked again what had happened. If she hadn't taken the time and made the effort to uncover the whole story, she never would have made the correct diagnosis. The patient would have undergone expensive and unnecessary testing, and misguided attempts at treatment.

 

This is a case of frostbite.

 

To ice her foot, the patient had purchased an icing boot. It numbed her foot to the point that she left it on for 48 hours and didn't realize what was happening until she took it off. With this bit of additional history, the diagnosis presented itself. The patient underwent extensive treatment and rehab, and eventually recovered.

 

 "Listening constitutes the very

heart and soul of the

clinical encounter."

~Mary T. Shannon~

 

This is a perfect example of the importance of narrative in medicine. Taking the time to hear the patient's whole story promotes accurate, efficient, and effective evaluation and treatment. And, for all the CEOs and CFOs out there...that saves time and money.

jan