obstacles to storytelling in medicine

 

"Obstacles to the Application of Narrative Medicine

in Clinical Practice"

 

The impetus behind the use of narrative in patient care has to do with understanding the patient's whole story. Not just the time line along which his illness developed, or the severity of his symptoms, but the root causes of the problem, how it affects his quality of life, and how it impacts the people around him...all of which affect his ability to heal. The problem is that not many providers practice narrative medicine, and not all patients are good storytellers.

 

One issue involves the time constraints that health care providers confront daily. There simply is not enough time in the schedule to invite every patient to elaborate on the details of his medical history or symptoms. The provider gets the basics down, but then he is left to jump to conclusions or to dismiss further input that might otherwise affect the patient's treatment and prognosis. For example, it's bad enough when a patient presents with a broken arm after falling off a ladder at work...but it gets complicated if the patient fell because he was drinking on the job. That's a whole different problem.

 

The provider is also tethered to a coding and reimbursement system that doesn't reward him for the time he takes with his patients. The EMR does not reflect psychosocial, emotional, or relational complications of illness or injury. In addition, the practice of narrative medicine requires certain skills that are not traditionally covered in medical school and training. "Deep listening" and "close reading" are foreign concepts to most health care providers. Most providers are unfamiliar with the importance of neurocognitive resonance and dissonance when caring for patients. Expertise in technology is valued over connection with the patient.

 

"Patients don't care how much you know

until they know how much

you care."

~unknown~

 

While numerous studies have demonstrated the healing power of storytelling, the system is stacked against it. People are busy. They're in a hurry. They may have to squeeze in a quick visit to the doctor between meetings or other commitments. To save time, they may minimize or dismiss their symptoms. For example, the patient may not want to stick around while you run an EKG for what he wants to believe is a case of indigestion. But, if you take the time to explore the symptom, you may suspect angina...it gets worse when the patient climbs a flight of stairs, he sometimes feels it in his jaw, it makes him a little dizzy. It's not just a little heartburn.

 

Another problem is the fact that the patient may not have the language to describe his symptoms. To a doctor, there is a difference between lightheadedness and dizziness, throbbing pain and steady pain, fatigue and weakness. They mean different things and imply different conditions, and that may take some sorting out.

 

"It can be argued that

the largest yet most neglected

health care resource, worldwide,

is the patient."

~WV Slack~

 

Patients may also withhold information out of shame, fear, or guilt. Alcohol, tobacco, and drug abuse are prime examples. Rape is another. Shame can shut a patient down. Any behavior or practice or habit that contributed to their illness or heartbreak or regret is part of the story that needs to be addressed before healing can begin.

 

It can be as much of a challenge for patients to tell their whole story as it is for physicians to sort it all out.

 

"People will forget what you said.

People will forget what you did.

But people will never forget

how you made them feel."

~Maya Angelou~

jan