Thursday, October 16, 2003

Every Patient Has a Story (Blogs as Narrative Medicine?)

My wife (who is also a physician) emailed me a recent article from the New York Times titled, "Diagnosis Goes Low Tech". Interestingly enough, it was in the Arts and Science section, not the Health section.

Endoscopy. Sigmoidoscopy. Electromyography. M.R.I. These days, the main interaction between doctor and patient is often technological, with doctors relying on complex diagnostic tests that make use of the latest advances in medicine.

This technology has become a religion within the medical community," said Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine. "It is easy to lose sight of the fact that still, in the 21st century, it is believed that 80 to 85 percent of the diagnosis is in the patient's story."

Yet medical educators say that doctors are insufficiently trained to listen to those stories. After all, there is no reimbursement category on insurance forms for it.

It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: narrative medicine.

I think this is part of what I am trying to achieve with my solo practice. A focus on the patient not just a physical body, but as a person with a past made up of memories and secrets; a present filled with family, friends, work, play, pleasure and pain; a future built of hopes and dreams. All culminating in a story that is somebody's life.

Plus, you need to have enough time for the person to tell their story. (I suppose it's possible to write a great short story in 15 minutes, but it's not likely.) My practice will give patients the time to let their stories unfold. This is what we try to teach the 1st year medical students at UCLA, where I am one of the volunteer faculty, as part of their Doctoring Program.

One of the articles we have the medical students read brings home this point. First published in JAMA (Journal of American Medical Association), an attending physician is trying to impress upon a group of medical students how every patient, no matter how ordinary they seem, has a story to tell. He directs them to find the most boring, uninteresting patient is the hospital wards and he will demonstrate his point. The students find a little old lady, originally from Europe. The attending proceeds to interview her and despite quetioning her for a long time finds that she has had a very ordinary life. Just as the attending is about to give up, he notices that her past medical history mentions a broken arm. How did you break your arm? A suitcase fell on it. How did a suitcase fall on it? It happened because the boat was sinking. When did the boat sink? When I was a little girl coming to America. What was the name of the boat? The Titanic.

It turns out she was one of the few remaining survivors from the last voyage of the Titanic. After that, she received a lot more attention and newspaper articles were even written up about her. This is a rather dramatic example, but you get the idea.

But the narrative medicine movement is part of an ongoing trend in exposing medical students to the humanities. It is needed, educators say, to teach aspiring doctors to pay close attention to what their patients are saying and to understand the way their own emotions affect their perceptions, and ultimately their clinical practice.

The basic teaching method is to have medical students read literary texts and then write about themselves and their patients in ordinary language, rather than in the technological lexicon of the traditional patient chart.

Hey! Isn't that what these medical blogs are all about? Can I get CME credits for this?

Countdown: 80 days until target start date