The gift of stories
Reflection on Charon, R. (2001). Narrative Medicine – A Model for Empathy, Reflection, Profession and Trust. JAMA, 286(15), 1897–1902.
The patient’s narrative is a gift to the person who is willing to listen. The patient wants, needs to tell the story of what happened, and it is the provider who cuts it short with questions which may be well intentioned, but in most cases interrupt and deflect from the patient’s narrative. I chose psychiatry after trying GP, because I realised the 8 minutes per GP consultation were never going to be enough for me. I am reluctant to type during the appointment; I know there are charting coaches who model efficient charting so that the doctor can finish on time, and that in the reimbursement system, writing notes after the patient has left the room is not compensated, but I cannot rush my assessments. I want to develop therapeutic alliance. That includes asking open-ended questions, including ICE (ideas, concerns and expectations); listening attentively, observing movements, facial expressions or gestures. I want to look at the patient, try to get into their minds, imagine a small part of their lives. I am hoping that this attention will increase the likelihood the patient will trust me and also empower him or her to ask follow-on questions. I like to make a list of goals for the appointment, saying “I have some questions to ask you, but what do you want to ask me?” I jot them down, as well as some phrases, to capture their own voice and so I can write their response to the MSE questions word by word.
Even though I did not know the term “narrative competence” before I read Rita Charon’s article “Narrative medicine- a model for Empathy, Reflection, Profession and Trust,” I believe that the practice that I have described above represents the “patient-physician: empathic engagement.” To illustrate this, I give an example of a patient who came in for a shared care mental health consult. This was not the reason for the referral for consult. Yet, to her, this was more important than the reason her GP had referred her. So I addressed the pressing issue first. Once the patient was satisfied, we looked at the reason for the referral.
The second, “physician-self: reflection in practice” relationship involves self-reflection, which is the foundation of personal growth. This can be in different forms: in journalling, in therapy, in creative writing, in taking a walk in nature, in meditation, in listening to music; in short wherever we allow our mind to wander freely.
The third “physician-colleagues: profession” relationship refers to what occurs in a supportive peer group of colleagues who are open about certain difficult encounters. An ideal format is Balint groups which provide structure to discuss cases in a safe environment.
The fourth, “physician-society: the public trust” relationship is one that views the physician as having a small role to play within a bigger system. The physician can usually only do advocacy (with a small “a”), rather than capital “A.” If there is enough consensus, there may be a possibility for improvement of the health system as a whole. There are an increasing number of books on the topic, including one I have recently purchased: “Unheard” and plan to read soon.