The Role of Narrative in Doctor and Patient Education and Doctor-Patient Communication   5 comments

Thus far, my research relates to how narrative in its various forms (i.e. written, spoken, interactive) conditions, shapes and transforms our thoughts, notions of self, actions and worldviews, both consciously and unconsciously. Narrative permeates every aspect of our society and our identities, whether individually or collectively. Doctors appear to be no exception. Though much of this week’s reading takes the form of narrative (as opposed to expository text) in that the author recounts in detail her daughter’s battle with breast cancer, I only realized that I could wrap the narrative angle (as it relates to medical practice and communication) into our discussion in Chapter 3, when Kathryn Montgomery really begins to explore how narrative is integral to proper diagnosis and treatment of illness. Indeed, when the doctor asks the opening question, “What brings you here today?” and the various secondary questions that follow (Ch. 4), what the doctor really wants (and I daresay, needs) to hear, is a story.

I was first intrigued by the idea of narrative in medicine when I read (though the reference is lost) that first-year Harvard medical students take a course where they simply read narratives designed to condition their inner sense of compassion, ethics, and even spirituality, as it relates to the role of healer and relating to patients on a human level – sort of a “Chicken Soup for the Future Doctor’s Soul” if you will. After doing some research, I believe I have found this course, taught by none other than Jerome Groopman (see reading list and course summary below).

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A Reading List for Future Doctors

*Freshman Seminar 23k. Insights from Narratives of Illness
Catalog Number: 1904 Enrollment: Limited to 12.
Jerome E. Groopman (Medical School)
Half course (spring term). Th., 1–3.
A physician occupies a unique perch, regularly witnessing life’s great mysteries; it is no wonder that narratives of illness have been of interest to both physician and non-physician writers. Examines and interrogates both literary and journalistic dimensions of medical writing from Tolstoy to Anne Fadiman as well as newspapers and periodicals. Studies not only mainstream medical journalists, but so called alternative medical writers such as Andrew Weil also. Work with different forms of medical writing.
Note: Open to Freshmen only.

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It is only with engagement in our discussion and readings that I begin to consider other ways that narrative becomes the indispensable vehicle for reaching a sense of effective communication, understanding and recovery in patient treatment. It was fitting that early in her discussion of narrative, Montgomery references famed constructivist theorist, Jerome Bruner (pg. 44-45), author of “Narrative Construction of Reality (1991).” In this article, one of the characteristics of narrative that Bruner discusses is his notion of “Canonicity and Breach.” In short, what makes a story worth telling is not what is normal about the circumstances or activities of the story, but what deviates from the normal – the breach. From Montgomery’s discussion, it would seem this is really what gets the cognitive wheels turning in the doctor’s mind and starts the intrinsic constructivist process of bouncing new data off the doctor’s “knowledge base” (pg. 45). In constructivist language, this ‘organized knowledge base’ is called one’s “schema,” against which new data is either assimilated or accommodated. In either case, it is a natural process of learning and reformulating how we think about things. Other narrative and memory theorists emphasize how interactive conversational story-telling gets people’s thinking ‘on the same page’ and can potentially reframe one or more of the participants’ understanding of the situation (Nelson, 2003; Sutton, 2002).

Considering what Groopman says about ‘how doctors think,’ it is evident that problems in doctor-patient communication and subsequent diagnosis, may arise as much or more from the doctor’s manner than from the patient’s. Groopman notes that “on average, physicians interrupt patients within eighteen seconds of when they begin telling their story” (Pg. 17). Later, Groopman states, “an expert clinician typically forms a notion of what is wrong with the patient within twenty seconds” (pg. 34). If we subscribe to what Malcolm Gladwell says in his book Blink, all experts do this in one way or another, intuitively, heuristically, and with great accuracy. But, Groopman might say differently, at least as it pertains to doctors. The question then that I pose related to narrative and doctor-patient communication is:

What mediums and methods might best serve to augment traditional doctor-patient interviews in helping patients tell their stories in such a way as to get doctors to rethink their heuristic intuitions, and/or what might be in the patient’s existing medical records, while preserving confidentiality? – perhaps, as a supplement to the new regional electronic medical records system?

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Bruner, J. S. (1991). The Narrative Construction of Reality. Critical Inquiry, 18, 1-21.

Nelson, K. (2003). Self and Social Functions: Individual Autobiographical Memory and
           Collectve Narrative. Memory, 11(2), 125-136.

Sutton, J. (2002). Cognitive Conceptions of Language and The Development of
           Autobiographical Memory. Language & Communication, 22, 375-390.

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Posted August 30, 2010 by jardaneh in Uncategorized

5 responses to “The Role of Narrative in Doctor and Patient Education and Doctor-Patient Communication

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  1. Kevin –

    I thought of you and your research interests through most of this reading. The significance placed on the critical importance of narrative on what I’ve always considered a more-or-less investigative hard science surprised me, to say the least.

    Additionally, I was thinking often of our service-learning projects, and the difficult implications that narrative presents. If we’re working with a digitization of records, most of our class had thought of test results, simple measurements, instructions from the doctor to a specialist, or imagery. Nothing was said about the stories told by and about patients. We all seemed to have this assumption that a patient needed a list of conditions and symptoms included in the medical records…and nothing else. Now I’m wondering whether a digital patient record will need to look more and more like a collection of essays.

    What form would a DMR database need to take, and how could it increase the efficiency and accuracy of patient care? We’re no longer talking about the storage of objective figures like blood pressure. Now it’s “a contingent, multivariant narrative” (69). Just like modern patients need to be told the story behind the treatment of mycoplasma pneumonia, in which the patient can stop taking medicine when the symptoms go away, contrary to our socialized training to take antibiotics through a full course (66), doctors need to have the full story of what brings a patient in, rather than a simple list of ‘facts’.

    To me, the “How does any system capture this?” dilemma came to a head on page 72: “Narrative captures the subtle, tenuous, vaguely interlocking but cleanly temporal relationships among possible secondary or ancillary causes.” There isn’t a word in that sentence that represents a concept easily stored in, generated by, or retrieved from a database. On the other hand, a searchable, automatically indexed database of a patient’s narrative could come in handy, particularly with zebras. “Medicine differs from the physical and social sciences, disciplines that may discard oddities and statistical outliers. For physicians the anomalous case is still a patient in need of care” (88). If a doctor could compare narrative notes of his patient to those of others, I wonder whether today’s disparate and random-seeming symptoms could be tomorrow’s rare-but-recognized condition.

    The value of narrative can’t be overstated, but the challenges of using narrative (which takes time to compose and absorb) in spite of the pressures of time and cost are significant. I’m reminded of work I did at the Apple retail store helping repair computers or train customers. It’s common for a customer to say something to the effect of, “I pressed this button on my keyboard, and the whole thing blew up.” That sort of comment is usually a cue to settle in for an interesting tale, but the solution is always the same: have the customer tell the whole story from the beginning to see what small detail locks events into place. Without narrative, doctors can’t do their jobs. I know what I plan to emphasize in the curriculum unit.

    Likewise, I suspect most patients have had the experience of simply wishing the doctor listened better—perhaps just more patiently, as in the case with Will’s mother being treated dismissively. I believe it was Groopman (because I can’t find it in Montgomery) who claimed that the patient usually tells the doctor the correct diagnosis if the doctor listens carefully enough. (A brief discussion of this, though stated in less-concrete terms, is on page 108.) Perhaps the ability to store all the narratives of a patient’s case in one comprehensive database itself could be a strong argument made in favor of the kind of DMR system we’ll be exploring. I’m hearing a deep, movie-preview voice talking over shots of exasperated mothers and bewildered children trying desperately to explain one more time what the trouble is: “Imagine a world…where you tell your doctor only once what brings you in.”

    “In this world, prescriptions are typed, so you can actually read them.”

    I’m sold.

    • I think the patient narrative is incredibly crucial, but I think it’s imperative that the patient document it ahead of time, prior to doctor visit.

      Over the years I’ve realized as a patient that I must type up a narrative of illness, detailed year by year, opposed to one long run-on story of illness, and also attach a thorough family tree history of illnesses. On the top page I just list my diagnoses (yes, there’s much more than one!) and all medications I take and all the ones I’m allergic to.

      This is great because my illness history is so long and detailed, there would not be enough time in a single doctor visit to cover even a quarter of it. Also, as a patient I tend to forget important details, or have trouble recalling the tale linearly.

      It makes the job easier for the doctor and thus he/she can concentrate on me the patient in the here and now during that visit as opposed to reviewing my history.

      Usually a typed up medical history is happily welcomed from doctors I encounter, though there have been a couple of times I believe it has come across as an actual ‘turn-off’. It’s as if they are threatened by me compiling the information. Perhaps doing their job for them??? Perhaps seeing it printed out is intimidating??? (“Hey buddy, try LIVING that medical history!” I feel like saying) I never understand the attitude. There are some that won’t bother to read the damn thing. Which, again, I don’t understand that.

      Bottomline though: A patient’s narrative, no matter spoken or typed, will only be useful and truly informative if the doctor is not trained to ‘think inside the box’ or is there just for a paycheck because their parents wanted them to be doctors. With Postural Orthostatic Tachycardia Syndrome (POTS), neurocardiogenic syncope, Fibromyalgia, being the first documented case of Betaine deficiency in the world, etc, etc— I don’t fit into any box. My medical history is going to be damn complicated. But because of its length, weightiness, seriousness, and seemingly dramatic symptomology— Telling my narrative to a new doctor sometimes feels like if I were to go on a first date and spill my entire life story and blabber about my ex-boyfriend to the blind date infront of me. I can see the new guy’s eyes glancing more and more at the door, his closest escape.

      I’ve concluded, somehow doctors need to be trained to understand where the patient is coming from, because only then will they be willing to listen to a patient’s narrative. I would recommend more readings like Groopman from last week, and also seminar classes in which med students get to sit and just listen to patients’ stories. Instead of looking at patients in hospital rooms like zoo animals on display, they need to sit in a close circle with patients and hear their stories.

      —Genevieve

  2. Some fantastic ideas for curricular units in this thread of responses!

    Thanks for the additional resources, Kevin. I’m counting on you to help lead tonight’s discussion.

  3. Genevieve–I think you’re absolutely right. I often bring notes when I go to the doctor.

  4. Thank you all for your responses to this thread. I was thinking about some of these same concerns and look forward to talking more about them in class. I actually found a few more articles that I think are very relevant. Here are the links, but if they don’t work, they can be downloaded in pdf on Google Scholar if anyone is interested:

    Narrative Medicine: A Model of Empathy, Reflection, Profession and Trust (and more articles!)

    http://jama.ama-assn.org/cgi/content/full/286/15/1897
    http://jama.ama-assn.org/cgi/content/abstract/286/15/1897

    and,

    Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care

    http://www.bmj.com/content/329/7473/1013.full?referer=www.clickfind.com.au

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