Keeping the narrative going

Holistic Health: Why settle for role of tragic victim when you could have that of courageous survivor?

NARRATIVE MEDICINE is the new buzz term in medical circles. Defined by American doctor Rita Charon as the physician’s ability to practise “medicine with empathy, reflection, professionalism and trustworthiness”, narrative medicine may be what we all naturally expect from a doctor but, for many reasons, don’t always get.

According to Charon, patients need doctors who not only understand their disease and treat their medical problems but who can accompany them through their illnesses. Her research on the subject has become the benchmark for doctors keen to re-engage with their patients.

"The value of the patient's story must be re-emphasised in this age of technological medicine," says Dr Muiris Houston, Healthpluscolumnist and the author of an Arts Council funded study on narrative medicine.

In his study, Houston draws attention to how patients’ anecdotes show how well they understand or misunderstand their illness. “An attentive doctor will pick up on such anecdotes and build on them to create a shared understanding of the illness and future priorities as defined by the patient,” he writes.

Patients’ anecdotes also help doctors understand that every patient’s experience of a particular disease is different. Studies have found that if a narrative- based approach (in which the patient’s agenda is prominent) to the consultation is followed, a patient is more likely to reveal their fears and concerns. One particular study has shown it takes a patient, on average, only 28 seconds to tell their story but, remarkably, doctors often interrupt after only 18 seconds.

Dr Iona Heath, a London-based GP, has written a lot on the importance of stories of endurance in chronic illness. “Stories can accommodate suffering and give a meaning to experiences but if the story is allowed to become fixed, the patient can become trapped within the narrative,” she says.

“Sometimes, doctors can offer the patient a different story which could enable them to see a way forward. The patient may have settled for the role of tragic victim and yet be capable of a shift to that of courageous survivor which can offer much more scope for renewed self-determination, dignity and self-respect,” she says.

Prof Des O’Neill, geriatrician at the Adelaide, Meath and National Children’s Hospital, suggests that narrative medicine is much more than improved doctor/patient relationship. “It’s about new forms of dialogue. The doctor’s dialogue with his/her peers and doctors’ dialogues with themselves and with wider society. It’s an issue of insight,” he says.

According to O’Neill, bringing narrative medicine to the fore is not about creating a dichotomy between technological medicine and a more humane approach to illness but acknowledging the need for both.

“There is a strong interest in narrative medicine among senior clinicians and many journals dedicate a significant amount of space to the medical humanities [courses in music, film, literature taken by medical students] and the patients’ experience,” he says.

At Trinity College Dublin, medical students are taking medical humanities courses for the first time this year. According to O’Neill, the arts offer medical students opportunities to understand illness from a wider perspective. “Some students get it immediately but about one-third of medical students who start university have a technocratic approach to medicine so this area of study helps them build a life-long engagement with the narrative of medicine.”

Houston also points to a vocational training scheme for general practice in Britain in which GP trainees are shown feature films. “The films are selected so that the themes might help future family doctors reflect on the human situation and become more empathetic with their patients,” he explains.

Dr Rita Charon goes one step further. She says that if the doctor can’t engage with the patient’s personal story, the patient won’t tell the whole story or ask the most frightening questions and, therefore, will not feel heard. She suggests that incorrect diagnoses might be made followed by poor compliance from the patient, the search for a second opinion and a shallow and ineffective therapeutic relationship.

She says that doctors will benefit from richer relationships with their patients as they reflect on their roles and the wider place of medicine within the society.

She even suggests that narrative medicine has the power to help doctors regain some of the public trust in medicine that has recently been called into question.