One of principle tenets of narrative medicine is listening with the patient’s story, not to the patient’s story.
Listening medically (To) is about identifying the signs, symptoms and information to make the differential
Listening narratively (With) is about hearing the patient’s ‘history of present illness’ as a story not driven by the physician’s agenda.
I read this blog on Scientific American about practicing Narrative Medicine from a fourth year student at Harvard Medical School.
By: Samyukta Mullangi
Since the first day of medical school, I was in breathless anticipation of my third year. I came to Harvard with a background in creative writing and the big draw of medicine for me lay in its compendium of human stories.
In college, I volunteered at local hospitals where my primary responsibility was to go knock on patients’ doors and keep them company for a little while. This was awesome. Few things delighted me as much as entering a patient’s room, seating myself in the armchair by her bed, and over the next hour, unearthing those unfrequented histories that made up her life. Hospitalized for what seemed like interminable, lonely days, patients appreciated the close attention of an interested stranger, even for a little while. In turn, their stories made me appreciate the breadth of human experience—their joys, tragedies, relationships and transformations that co-exist in society.
Still, as only a volunteer, I felt that I was a voyeur. I waited for the day that I could marry the privilege of being privy to their narratives with the ability to intervene in their lives in such a way that would markedly alter and perhaps improve the course of those stories.
Third year, the year that students leave their paper cases and prep books behind in favor of white coats and real patients, however, was full of surprises. I quickly realized that my vision of spending long unadulterated periods of time just chatting with my patients was neither feasible nor helpful to anyone. In fact, between morning rounds, work rounds, attending rounds, afternoon rounds, and sign out, I thought it was a good day if I could at least spend 20 minutes actually face-to-face with each patient. The important speech-act then was not the conversation with the patient, but rather the case presentation to my professional peers.
If the first two years of medical school are about seeing and understanding pathological processes, the latter two are about speaking and communicating those findings to others. At the heart of those communications were the patient notes. The clarity and cohesiveness of a standard history of present illness was beautiful in its straightforward logic, but it forced me to template the lives of patients in a bland summative formulation. I had to approach my patients, not with idly open-ended questions, but through an interpretive lens that required a constant modification of my questions based on previous answers or findings. I began to think in terms of buckets—was this patient an endocrine patient, traumatic, vascular, or surgical? When patients’ stories proved to be too ambiguous or complex to neatly fit my templates, I felt pressured to distort them in a way that would make them fit these nice patterns.
When preceptors and residents heard of my interest in narrative medicine, they’d always smile. You certainly picked the right profession then, they’d say, which I hungered to hear. But then, I bet you have a fantastic time with those patient notes.
I frequently heard about Michael Crichton and how he got his start as another medical student writing flourishing notes at Mass General. This inevitably made me panicky, as guilt would rush and flood my senses.
Didn’t I gently interrupt my patient the other day as he went off on a tangent about his love for bird watching? Didn’t I only half listen to the elderly gentleman who spoke at length about losing his fiancée to cancer in her thirties? Didn’t I surreptitiously look at my watch as the old veteran told me his sixth story about faking courage in Vietnam?
My interactions with my patients as a medical student were so markedly different from those when I was a volunteer, the latter being a role that was marked by a complete absence of responsibility. Now I had a product to produce. A document. I had to investigate and probe this person’s life and circumstances in a targeted fashion, because they were mine now. I had to take ownership of their story, interpret and organize it in a way that drew out the obvious conclusion, and then present it during rounds to my attending physicians, residents and fellow medical students. If I got lucky and the story proved to be exceptionally interesting, I might get the opportunity to get fancy and present it at the noon conference, or if sufficiently tragic, perhaps at the monthly morbidity and mortality rounds. In this way, my patient’s story became a commodity that I had to process and present.
Case presentations represented a genre of storytelling that was vividly new to my cohort and me. I grew up an avid reader, digesting everything from historical dramas to travelogues. But I had no experience with the oral tradition, with performance art. Case presentations come in stereotyped formats from the 10-minute stories I might deliver during formal rounds to the 2-minute bullets I’d offer during afternoon updates. During teaching experiences, I’d proffer more illustrative stories, rich in detail and the occasional red herring.
As a fourth year medical student now, I have enough experience with speaking to patients, and representing them fairly to my superiors, that I can divert from the script every now and then with comfort. But never too much. I realize that my naïve pre-medical view on medicine was laughably distorted. Real medicine, real doctoring is not primarily about making friends out of strangers, and drawing out a patient’s entire life-world within the course of a single meeting. At the end of the day, our objective is to be a good doctor first and to discern the details that matter in saving that person’s life.
But there’s a part of me that struggles to accept this, even yet. I don’t think I should ever become comfortable with treating the patient not as a multidimensional person, but rather as the site of a disease process. It brings me no small amount of guilt to know that through my disinterest in the facts of their lives that truly matter to them, I am seeking to replace them as the narrative agent of their own lives.
I’m promising myself now that I will honor my patients by hearing them out, by paying attention to their complex personhood even if I am not getting a clear outcome out of it. I think that there are tremendous consequences to making this a conscious decision. I believe that this reminder to myself is absolutely necessary if I want to remain aboveboard with the patient presentation, depicting reality rather than constructing it.