As a GP I am in the privileged position to be paid to listen to people’s stories and it has taken me a long time to appreciate that really listening, without interruption, can be the most valuable therapeutic tool available to me. I recently listened to a podcast on Life Matters about the power of narrative medicine where doctors are taught to hear the patient’s experience as a story. It is excellent and well worth listening to.
Unfortunately, a standard medical consultation is only fifteen minutes and there is pressure to make a diagnosis, to examine a patient, arrange appropriate investigations and to initiate a management plan during this brief period. With most surgeries now forced to charge a gap fee, patients are reluctant to attend for several sessions so there is a limited time frame in which to learn about each patient as a person and to provide good, comprehensive care.
What I have learnt after working in general practice as well as emergency departments for three decades is that you can do a lot of listening in a short space of time. Letting the patient speak without interruption when they first tell you why they have come in provides a valuable insight into what is most important to them and what their expectation is from the consultation.
At medical school we are trained to look for red flags, to exclude serious conditions. When someone begins to tell us their symptoms, we are scanning for clues that will lead to a diagnosis. While this is important, after all we don’t want to miss the early signs of a cancer or serious illness, it means that we can easily miss patients’ underlying worries and they leave a consultation unsatisfied. It has taken me many years to read between the lines, to learn why the patient has presented and to try to address their issues while not missing a serious diagnosis. It is a carefully calibrated interaction which relies on me really listening and checking in to ensure that I have understood the real reason they have presented.
Story is the essential building block of the human experience. It is how we convey information, learn about others, and make sense of the world. Using story as the foundation of a consultation makes my work so much more enjoyable. Every patient becomes a person with a family, a history, and a story to tell, not just a diagnosis to be made.
The concept of narrative therapy is a relatively recent one coined by Dr Rita Charon who launched a programme in narrative medicine at Columbia University in 1996. Australia’s first narrative medicine course was launched at Melbourne University by Dr Fiona Reilly and Dr Mariam Tokhi. While medicine is considered a science, the application of our knowledge as doctors is an art, with every person’s experience of illness, pain, and trauma unique. When a patient is encouraged to tell their story, it places them in a context and moves the consultation away from what is wrong with this patient and how can I treat it, to what does this patient need right now? And the more I listen, the more I learn that often what is needed is support and time and being understood.
The demands on doctors have changed with increasingly sophisticated technologies to make diagnoses and high demands for documentation. These factors encroach on the time spent with a patient and have a negative impact on the doctor patient relationship. Medical schools who teach narrative medicine have found it improves empathy with graduating doctors more skilful at history taking and health advocacy for their patients.
Here are three scenarios from my own practice where the patient has shared a story, giving me an insight into their experience so that I am better able to address their worries.
'A consultation is about so much more than symptoms and diagnosis, it is about context. It is helpful to think about the consultation with your doctor as an interface between two different stories. Your symptoms in the context of your personal experience coming together with the GP’s professional knowledge.'
I have had bloating and tummy pain for a few weeks now. I’m worried because my good friend was diagnosed with ovarian cancer. Am I being silly?
I have a sniffle and am feeling unwell. I know it’s probably just a cold but I’m worried that I might get worse. I’ve only just started a new job and can’t take time off. I visit my elderly mother in a nursing home and don’t want to make her sick.
I know I haven’t been in for a while. I stopped taking my blood pressure medications, gained weight and know my diabetes control is poor. I was worried you would get angry. My wife died after a long battle with cancer, and I just can’t get motivated.
When I know that my patient’s greatest concern is ovarian cancer or a fear of losing their job or passing an infection onto an elderly parent, the consultation shifts to address these concerns and avoids unnecessary and costly investigations. The relationship becomes a more human one and the patient leaves satisfied that their concerns have been heard. When I learn that my patient has lost of their wife, my focus shifts from just managing diabetes and high blood pressure, to acknowledging their grief. In the words of Dr Rita Charon, narrative medicine is, ‘a commitment to understanding patients’ lives, caring for the caregivers and giving voice to the suffering.’
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A consultation is about so much more than symptoms and diagnosis, it is about context. It is helpful to think about the consultation with your doctor as an interface between two different stories. Your symptoms in the context of your personal experience coming together with the GP’s professional knowledge. If the GP knows that you are anxious about cancer, losing your job or that you are grieving, they can tailor questions and investigations appropriately to address the things that concern you the most, meaning that you leave satisfied that your fears have been addressed. Don’t be afraid to tell your story. It is central to understanding not only your medical issues, but who you are.
Jo Skinner is a Brisbane-based GP, women’s fiction author, freelance health writer and distance runner.
Main image: (Getty Images)