by Carolyn Thomas ♥ @HeartSisters
I’ve been reading lately about something called the patient’s narrative in medicine. Although it’s basically defined as patients telling the story of what originally brought them to see the doctor, it’s actually much more.
Doctors, for example, all too often may see “the story” as an unnecessarily lengthy distraction from getting swiftly to diagnosis and treatment.
But as U.K. physician Dr. Jeff Clark describes it, connecting with and understanding the patient requires a doctor to appreciate each person’s unique perspective. In the December 2008 issue of The British Journal of General Practice, he asked other doctors to consider how not listening to a patient’s story can be compared to his colleague’s golf game:
“He had hit a hole-in-one, but was on his own. The ball sank into the hole – leaving him feeling rather empty. If only someone had witnessed it!
“The patients’ narrative is rather like that hole-in-one. The story needs to be witnessed to give it meaning.
“Telling your story to the doctor means it is witnessed and validated.”
I’ve previously mentioned (here and here) the work of Dr. Jack Coulehan, a physician, award-winning poet, and editor of the 5th edition of The Medical Interview: Mastering Skills for Clinical Practice, a best-selling textbook on doctor-patient communication.
He believes that when doctors don’t listen to, or don’t even ask about a patient’s unique story, it’s called narrative incompetence.
In his article called Metaphor and Medicine: Narrative in Clinical Practice, he writes: *
“Patients understand their illnesses in a narrative way whether their physicians realize it or not.
“If this is so, and if physicians ignore or devalue narrative, then health care is bound to suffer. From the patients’ perspective, narrative incompetence causes widespread dissatisfaction, distrust, and failed expectations.”
Physicians, of course, have their own unique ways of responding to the patient who starts telling their story in response to the initial question:
“Why are you here today?”
Many doctors, Dr. Coulehan explains, have been taught to objectify their patients and to remain emotionally detached, warning:
“In so doing, they may not only diminish their ability to heal, they may also harm themselves by developing chronic stress, emotional numbness, and burnout.
“Within the profession, this leads to the persistent belief that something valuable is lost – for example, the old days were better.“
One theory is that doctors may tune out a patient’s story when seeking a diagnosis and simply zero in on specific symptoms, which may actually lead them to over-test and over-treat.
I’ve also written previously here about London physician Dr. Iona Heath, who wrote this in the journal Medical Humanities:**
“Patients come to doctors to tell their stories; to give an account of when they first became aware of things being not quite right with their body or mind, of how it all seemed to begin, and how it developed to the point when they felt they must seek the attention of their doctor.
“But how much of these stories do we hear? The evidence suggests that the patient’s whole story is seldom heard. On average, the doctor interrupts after only 18 seconds of the patient’s narrative.
“Yet, if the patient is allowed to proceed, the full story lasts, on average, only 28.6 seconds, which seems not much to ask of the listener.”
So how can you help your doctor to become a better listener while you’re telling that story?
Here are five good tips from the book, When Doctors Don’t Listen by Brigham and Women’s Hospital Emergency Department physicians Dr. Leana Wen and Dr. Joshua Kosowsky:
1. Tell a good story. Start at the beginning and proceed chronologically, highlighting the most important parts in five minutes or less, if possible. If your doctor tries to interrupt your tale with questions, take a breath and ask to continue before the questioning.
2. Always provide context. What was happening in your life when the symptoms started? If they’ve recently gotten worse, explain what you think may have made them worse. This will help your doctor to think beyond the set diagnostic protocol and see you more as an individual person.
3. Describe symptoms as specifically as possible during a physical exam. If you feel the pain in only one spot, make that known. Let your doctor know if it’s sharp or dull, intermittent or constant.
4. Get a differential diagnosis. Usually, a doctor will strongly suspect one particular condition while considering a few others. Be wary if your doctor seems to focus on one particular disease to rule out.
5. Ask for the reasons behind every medical test. Your doctor should be able to explain what the test is looking for, how likely you are to have that diagnosis, and whether your treatment plan will change based on that diagnosis. Every test, even a simple blood draw, has risks so they all should be done for a reason.
* Coulehan J. “Metaphor and Medicine: Narrative In Clinical Practice”. Perspectives in Biology and Medicine, volume 52, number 4 (autumn 2009):585–603 © 2009 The Johns Hopkins University Press
** Heath, I. “A Fragment of the Explanation: the Use and Abuse of Words”. Medical Humanities 2001;27:64-69 doi:10.1136/mh.27.2.64
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9 thoughts on “Just not listening – or “narrative incompetence”?”
This is so true and we have experienced it so many times. It is yet more dangerous when accompanied by arrogance and narcissism, which is almost as common as narrative incompetence. The doctor’s faith in his own opinion is favoured over the narrative he is being given, even if the evidence he is being presented should tell him otherwise. So the narrative isn’t heard. See my open letter to doctors on the subject.
Thank you for an excellent article.
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Thanks Matt – you and your wife Ann have been to hell and back in search of accurate diagnoses and treatment for her. Your open letter is graphic and compelling, yet sadly unlikely to be read by most physicians (realistically, it’s far too long for the average doctor to tackle).
One question I had while reading it was this: why use just a letter designation to list the six physicians who really helped Ann (Dr. A, Dr. B., Dr. C.) instead of writing out their full names/affiliations to properly and publicly acknowledge them? It’s prudent to disguise names of those doctors whose care has been lacking, but why not openly thank the good ones as role models on how it should be done?
I hope Ann is on her way to full recovery.
This is an excellent piece. I’ve had doctors who had narrative incompetence. I did the only thing I could do — I fired them. I’m pleased that today, my doctors care about my story, and I love them. But I guess one has to kiss a lot of frogs before getting the prince(ss).
Hello Beth and thanks for your perspective. Is there anything more reassuring to a patient than having a prince(ss) of a doctor? Thanks also for introducing me to your wonderful blog. And your book Calling The Shots sounds intriguing – when will it be out? I can tell already that you are a woman after my own heart. So nice to meet you here… ♡
This is a terrific piece underscoring the fact that both patient and doctor have a responsibility here. Doctors simply must be good listeners and patients must at least try to tell their story in a coherent manner.
However, doctors need to always keep in mind that patients are often in a vulnerable state when ill or injured. I just wrote a post on how doctors often seem to be dismissive. Calling not listening “narrative incompetence” takes it a step further. Thanks for the post. Great tips.
Nancy, I love your new blog post. You perfectly captured that sense of vulnerability and embarrassment that accompanies feeling dismissed by one’s health care team. Well done and thank you.
LOLOL Ain’t that callin’ the kettle its real color! I went to get my 2nd opinion with a female cardiologist in Chattanooga, TN. She said that since I’m prone to going into v-tach a lot, that my heart is getting just as much damage to my heart as a mild heart attack would do. As far as she can see without having my scans, that I have had a heart attack just because of me being ignored and not getting the deep & true evaluation that I should have been getting all along especially since I called 911 believing that I had one. BUT….they concentrated more on the seizure I had in the ambulance from my heart attack to begin with!!
Thanks Kimberley – there’s nothing like a seizure to distract your medical team from what else might be going on.