What Is Narrative Medicine
Narrative medicine is “a fundamental tool to acquire, comprehend, and integrate the different points of view of all the participants having a role in the illness experience.”
Narrative medicine is one of the most important concepts I have come across in my learning. After all, it is through stories that we make sense of the world, ourselves, and ultimately our experience. It is through story that we attempt to communicate what matters to us – and what matters to us shapes our experience of illness.
This is well recognised by psychology and the social sciences but, until recently, entirely ignored by medicine.
Like patient-centred care, it was developed in reaction to the inadequacies and limitations of the biomedical model. Narrative-based medicine emerged out of several different schools of thought:
- The medical humanities (such as philosophy and ethics).
- Primary care and patient-centred care.
- Biopsychosocial medicine and holistic care.
One well-known advocate of narrative-based medicine, Rita Charon, says that it is medicine practised with narrative competence “to recognise, absorb, interpret, and be moved by the stories of illness.”
Another frequently cited definition of narrative-based medicine, formulated by a committee of international experts in 2014, is “a fundamental tool to acquire, comprehend and integrate the different points of view of all the participants having a role in the illness experience.” (source)
So, the fundamental belief of narrative medicine is that meaning is derived from the stories that we tell.
And many stories are told by many different people in each and every person’s experience of illness.
Patients tell a story about a symptom or a concern, its context, how it is affecting them, and why they came to the doctor/health practitioner. This is a story with infinite variations in content, the person telling it, the language used, and how it is told. It reflects the uniqueness of the patient and their experience.
Doctors obviously have their own stories that they bring to the consultation, too. These stories might revolve around what they think is occurring for the patient, the diagnosis, and ideas about the cause and management of the condition. This all has to be communicated to the patient, and here we see the story again – the way all of this information is relayed back to the patient reflects the doctor’s personality, experiences, beliefs, and practice. (source)
A fundamental question the patient should ask their health practitioner is…..” what are your beliefs around dis-ease and healing?”
“When we cannot find a way of telling our story, our story tells us—we dream these stories, we develop symptoms, or we find ourselves acting in ways we don’t understand.” Stephen Grosz
This quote is highly relevant when we consider the term alexithymia and its role in conditions such as irritable bowel syndrome and chronic fatigue syndrome.
Why Narrative Medicine Matters
“Wouldn’t you want someone to tell your story? Ultimately, it’s the best proof there is that we mattered. And what else is life from the time you were born but a struggle to matter, at least to someone?” Elliot Perlman
We are really starting to appreciate the importance in understanding the illness experience. We have been partly informed by trauma studies, which have demonstrated to us the importance of the survivor of trauma telling their story and the listener acknowledging that their suffering is real.
Narrative medicine, at a minimum, gives permission to patients to unburden themselves, and attentive listening is intrinsically therapeutic. We have all felt the benefits of a deep initiate conversation with our best friend, for example (as a very simple one!).
“In palliative care, when medical science has nothing more to offer, it is comfort and understanding that patients seek to carry them through until their last breath.”
We need only ask patients about their experience, as well as doctors who have experienced illness, to know the importance of allowing a patient to share their story.
Medical students and GP trainees are taught the importance of good communication skills, patient-centredness, the biopsychosocial and “holistic” paradigms, and addressing the patient’s ideas, concerns, and expectations. Despite this, patients frequently complain that doctors do not listen, they appear disinterested, they interrupt, they make assumptions, and they do not address patient concerns. Doctors defend themselves by complaining about difficult patients, the pressures of patient numbers and time, and the travesties of consumer medicine. Nevertheless, from a patient’s perspective, doctors have lost sight of what matters. Narrative-based medicine seeks to redress that imbalance. (source)
The 4 Divides
Rita Charon, who we mentioned earlier, is an advocate of narrative-based medicine, has discussed that while doctors might be very knowledgeable about disease, they do not always fully appreciate that illness often changes everything for the patient.
Rita says that there are “four divides” that contribute to the disconnection that might occur between doctor and patient.
- The relation to mortality: Illness is often a completely unexpected event that evokes many emotions, especially the fear of death. Our attitudes to illness and mortality are influenced by previous experiences, while doctors often have a differing perspective because of their training.
- The context of illness: Doctors often, understandably, view illness as a biological event that requires medical intervention (and sometimes nothing else). Patients experience their illness within the paradigm of their entire lives, and often have alternative explanations as to why they are ill. This is also influenced by things like culture.
- Beliefs about disease causality: Patients’ understanding of illness, including its causes, can naturally differ from that of their doctors because they don’t have the medical training. When patients and doctors conflict on the true cause of the condition, care is always going to be compromised as the therapeutic relationship is compromised.
- Shame, blame, and fear: Patients are embarrassed, revealing intimate aspects of themselves. Illness can make people vulnerable and fearful. They might blame themselves, and if they don’t get the outcome they’re after, they might blame the doctor. Doctors might get embarrassed asking certain questions. These emotions, on both sides, affect the illness experience considerably. These issues ideally need to be addressed; if they are not, they might damage the therapeutic relationship irrevocably. This final point reminds me that doctors are just human too – they have their ‘stuff,’ which is part of the relationship. What we really need is an honest and open conversation that can only happen when there is enough time and safety created. This safety might only develop through the relationship, so time is needed to even create the safety. (source)
Therefore, as Rita Charon states, deeply listening, acknowledging, and exploring the four divides are part of understanding the illness experience and what it means for the patient.
Questions and prompts useful in narrative-based medicine
Questions and prompts inviting change
- How else might you explain …?
- Are there any other possibilities?
- Suppose …
- What would happen if …?
- If you had a magic wand, what would you do?
- What needs to happen for the situation to change?
- If the situation did change, what would happen then?
- What will happen if nothing changes? (source)
The 7 C’s
To find ourselves at a shared understanding of someone’s story, good communication skills are essential. Launer discusses the 7 Cs and talks about “conversations inviting change,” which underpin his approach to narrative medicine. (source)
Conversations: The doctor allows the patient to express their story adequately and in their own words, while at the same time “exploring connections, differences, new options, and new possibilities, probing and guiding the conversation in a deliberate way that facilitates and enhances understanding without being controlling or interfering.” Once the story is understood, any recommendations for what the patient needs to do/change are mutually agreed upon rather than something that is imposed by the health professional. As a result, the conversation flows naturally and will often continue throughout several consultations.
Curiosity: The health professional needs to have a genuine interest in their patients and a desire to know more about them and their circumstances. This curiosity must extend into their own life and experience – exploring their own feelings, emotions, and reactions to the patient.
Context: The context might include considerations around family, work, community, spirituality, finances, beliefs, values, time constraints, and expectations. It is often useful to ask, “Why has this patient presented at this moment with this problem?”. This is so relevant within the context of nutritional therapy and functional medicine. For example, we (nutritional therapists) might discuss dietary changes that sometimes need to be made within the context of the wider family unit. But we can get really reflective and ask why has this client/patient entered my life right now? What teaching are they offering me?
Complexity: Things are rarely straightforward in health, partly because when something changes, a ripple effect is created. A sense of complexity, and an awareness of the interconnectedness of things, is essential to overcome some common challenges we see – “fixed notions of cause and effect, beliefs around the ability to change” (or more importantly, not change) and the “concrete solutions with which patients burden themselves”.
Challenge: It is sometimes important to challenge the patient as well as one’s self to consider new ideas and alternative explanations.
Caution: It is simultaneously important to have an awareness of one’s limitations and be sensitive to the patient’s needs, including willingness to go into unexplored areas and readiness for change.
Care: Care requires being nonjudgmental and accepting patients for who they are. Nothing can be achieved if the health professional does not genuinely care about their patient/client.
Benefits of narrative-based medicine
Narrative-based medicine …
- Is intrinsically therapeutic for the patient (in the telling and in being listened to), prevents the disconnect that might otherwise occur between doctor and patient
- promotes …
- deeper understanding of the patient and
- improves rapport and strengthens the doctor-patient relationship
- enhances the doctor’s powers of reflection
- increases awareness
- facilitates the potential for considerable change (source)
It’s Doesn’t Just Benefit The Patient
“Narrative medicine provides healthcare professionals with practical wisdom in comprehending what patients endure in illness and what physicians themselves undergo in the care of the sick.” (Rita Charon) (source)
However, imagination to see things from the patient’s perspective and to consider different viewpoints is not the only thing that is gained. By reflecting on the encounter, the doctor always reflects on their own role, thereby enhancing their self-awareness.
As many nutritional therapists can testify to (most of us do this work because we suffered from chronic health issues), it is also valuable for health practitioners to reflect on their own personal illness or vulnerability. (source)
Criticisms Of Narrative Based Medicine
The first criticism is easy…..not all presentations call for a narrative exploration. This, I actually think, is important for health practitioners to appreciate. We can be so passionate about narrative medicine that we might ‘put it on our client’ when it simply isn’t needed.
Second, there might be resistance. These could be from either the patient or the health professional. For example, some patients might prefer the skilled technique of a doctor over a bedside manner, while others might not want to share their feelings or life story. And there are doctors who may prefer to work purely through the biomedical model – and they might be the perfect doctor for some patients. These are just some of the examples that might create resistance. (source)
Additionally, narrative medicine can be time-consuming, which, depending on how you work, comes with problems. (source)
Bringing Narrative Medicine Into Your Practice
For the GP who is new to narrative medicine, the first step in practising it is, invariably, listening to and exploring the narrative and empathising with the patient.
Narrative skills will evolve from here because, as more complex narratives present, the need will arise to make sense of these stories and to uncover hidden meanings.
Reflection on the consultation and discussion will assist with deciphering the stories, deepening the understanding of the patient, and developing insight into the dynamics of the interaction.
This is where the GP will need to learn new skills and might therefore consider undertaking courses in advanced communication skills, counselling skills, or psychodynamic principles for GPs.
Listening, exploring, deciphering, and reflecting are tasks with the common aim of understanding, ultimately leading to the creation of a new narrative that enables and facilitates management.
Practical strategies for the novice in narrative-based medicine
The following are some practical approaches to getting started:
- Show interest in the patient. Find out about him or her.
- Listen deeply.
- Do not interrupt, especially at the beginning of the consultation.
- Ask open-ended questions.
- Silences are good. Resist the impulse to ask a question. Wait for the patient to break the silence. Whatever he or she has to say will probably have more value than the response to any intended question.
- Listen for cues and follow them.
- Observe body language.
- If, for whatever reason, the narrative must be stopped, ensure that it is continued at the next opportunity.
- View noncompliance as a blocked narrative, not as the product of a difficult patient.
- Do not make assumptions.
- Do not be judgmental.
- Do not be in a hurry to manage the problem.
- Be mindful of the “4 divides”.
- When it is not very clear why the patient has presented, ask yourself, “Why has this patient presented at this moment with this problem?” Reflect this question back to the patient. Ask for the patient’s opinion. (source)
“What makes narrative-based medicine stand out is the fact that it is a collaborative and mutually beneficial process, having the power to create a new narrative—a narrative that heals and transforms the patient and the doctor.” (source)
By viewing the patient’s story as central to the healing process, narrative medicine shifts the health professionals focus from the need to solve a problem, to the need to understand. This strengthens the patient-doctor relationship, and the patient’s needs and concerns are addressed more fully. All of this will result in improved health outcomes. (source)
Research has actually demonstrated that when practitioners use narrative skills, not only do we see an increase in patient well-being, but also we see a reduction in things like cancer pain, reduced disease activity in rheumatoid arthritis, improved lung function in asthma, and improved immune response following hepatitis B immunisation. (source)