Medicine, like so many things in life, is about stories. In a simplified form, one can posit that a story exists in the real world, namely, the story of how a seemingly healthy human being came to feel (or look or sound or smell) sick enough to seek your help. But this story, intriguingly, isn’t accessible in any of the acceptable formats, be they books or audio books or documentaries.
Rather, it exists in fragments in a patients mind, and the minds of his or her friends and family. The doctor-patient interaction represents a joint attempt at recreating the narrative from these fragments. The implication of course being that, in all the years of medical school, and through endless nights of sleep-reading through textbooks and journal articles, the physician has built up a literary knowledge sufficient enough to recognize the genre, plot elements and structure of this story and relate it to a well described and studied narrative. In doing so, one can predict where this story is heading, and since it is being written in real time, one can attempt to direct it towards a happy ending.
So, we as physicians want to create an environment where the patient’s story emerges. Through the appropriate prompts and questions, we help the narrative along, whilst all the while taking note of the flow of the events, of the main players, of the likely ending. It should come as no surprise that this process is less than perfect. The analogy also makes explicit the artistic side of medicine. Narratives have twists and turns, the catch us off guard, they leave us speechless. And sometimes, the good guys don’t win, the ending doesn’t make sense, the work is left unfinished.
In a moving example, Elwyn and Gwyn report the findings of a recorded patient consultation. Please note that the key to the transcript appears below the text:
And the doctors response? He correctly allowed the patient to relate her story, with minimal interruption, but upon reflection afterwards, one learns that this might have been unintentional:
“I hadn’t expected this: three deaths and a request to withdraw from antidepressants during a routine repeat prescription. Would that be all right? To participate in a shared decision about the end of grief, about a symbolic farewell to a son, killed five years ago. I attempted to give her autonomy over her decision, hoping not to abandon her. But it wasn’t enough. How could I tell her that I didn’t know. That if I had lost a son I can’t imagine surviving at all, never mind coming off tablets.”
Sometimes a story is too much to take, sometimes the narrative is haunting. And sometimes the fact that a story isn’t a story at all, but rather a woman relating the suffering that has been her life for the past five years. Then, more than ever, medicine is more art than science…
_______
The article is worth reading in full – it is one of my favorites:
Elwyn, G. & Gwyn, R., 1999. Narrative based medicine: stories we hear and stories we tell: analysing talk in clinical practice. BMJ Clinical Research Ed, 318(7177), p.186-188.