Just not listening – or “narrative incompetence”?

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.

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* 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

See also:

• Empathy 101: how to sound like you give a damn
• “She’s a fighter!” and other metaphors in medicine
• Six rules for navigating your next doctor’s appointment
• The lost art of common courtesy in medicine
• How to communicate your heart symptoms to your doctor
• My lowly beginnings as an empowered patient
• Would it kill you to treat your patients with respect?