Practicing patient-centred care brings many benefits for the patient. It enables them to be heard and their ideas, concerns, and expectations addressed. For the doctor it is less clear. Registrars sometimes tell me they feel they ‘have given in to the patient’, or ‘the consultation didn't achieve what they had hoped.’ Of course with experience we realise that a consultation needs to involve negotiation if we are to connect with the patient and reach agreement. We also realise that things often take more than one consultation and following patients is a real strength of our general practice. If, during a consultation, we achieve a new understanding which empowers the patient, we all feel satisfied. Furthermore, when that great consultation happens I suspect we all know we have connected on a deeper level with emotions and maybe even in a spiritual dimension. This is my great reward as a doctor.
Watching newly qualified doctors early in their training I don't feel many achieve that ‘great consultation’. This is mainly because they need to make sure that they are not missing serious treatable physical illness. They rely on using questions and answers to work towards a truth, a dialectic method. This method is encouraged in medicine and of course it has an important part to play, but connecting with and understanding a patient requires the doctor to appreciate their unique perspective. This unique perspective is expressed through the patients' narrative, which doctors all too often see as a distraction from, ‘getting to the bottom of things’. Conversations with registrars about their consultations confirm this when they say: ‘they wouldn't let me ask what I wanted’, or ‘they were only interested in telling me their story’. Trying to help registrars appreciate the value of the patient's story is difficult when the focus is on black and white truths.
At the last South Bristol trainer's workshop I was strolling along the soft Saunton sands and sharing stories when we stumbled on a metaphorical insight into narrative. One of the trainers was talking about golf and said he had hit a hole-in-one but was on his own. The ball sank into the hole leaving him feeling rather empty. If only someone had witnessed it! The patients' narrative is rather like a hole-in-one, it needs to be witnessed to give it meaning and increase its value. Telling it to the doctor means it is witnessed and validates it. Rita Charon talks about the narrative as a singularity, ‘what distinguishes narrative knowledge from universal or scientific knowledge is its ability to capture the singular, irreplicable, or incommensurable.’.1
Witnessing the patients' narrative is an important part of a good patient-centred consultation; their narrative is unique and it connects us with their way of seeing the world. This is an important idea because patients and doctors see the world in differing ways. Immanuel Kant understood this.2 Before Kant it was thought that we were all passive receivers of information about our world and therefore we all see the same things in the same way. Kant however said that the world we live in and perceive depends on our individual experience and the qualities of the perceiver's mind rather than it existing independently. As a result we all perceive things differently and reason alone will not give us the nature of someone else's reality. We can tell one patient that they have irritable bowel syndrome but this same advice might mean something very different to another patient (or even another doctor!). The patient's understanding is built from their knowledge but also requires their sensory experience and concepts which means we must listen to the patient's story if we wish to help them.
Therefore it follows that reason, logic, and direct questions cannot be the only guide in a consultation. Doctors need to weave knowledge into the narrative if the patient's understanding is to be appreciated and changed. Understanding on a philosophical level is not simply reconstruction but a mediation of the truth.3 Negotiating this truth could involve using our own narrative, using rhetoric ourselves; the patient has a narrative but so does the doctor and we could enlist this in our tool box to explain things to the patient. Involve the patient in a story. Playwrights have known this forever! Shakespeare didn't just write; ‘Romeo loves Juliet who is from a different feuding family. In a moment of confusion when he thinks she is dead, he accidentally takes a lethal poison and she is heartbroken.’ Instead he wove a tale and took us on a journey. Our message would have much more impact if we entertained the patient with a story. This way our information is memorable. We are, after all, educators and as BF Skinner says ‘Education is what survives when what has been learnt has been forgotten.’4 Saying to the patient ‘you must stop smoking’ might work but how about using a little tale and fixing it into their narrative; ‘you were telling me earlier what happened to your dad because of smoking? It would be a shame to give your kids the same memories,’
The consultation is better for narrative; it is greater than a direct questioning approach alone. Consider this; think about going to a film of your favourite book. The film is never as good. The film tells the facts but the book is the real narrative, emotion and imagination. In a similar fashion, clinical medicine tells the facts but the narrative contains the emotion, opportunity to use imagination and real unique meaning for the patient. We would all like our doctors to have ‘seen the film’ and know the facts. But I think we would all like them to listen, ‘read the book’ and engage with our story.
- © British Journal of General Practice, 2008.
