Narrative-Based Primary Care

A Practical Guide

John Launer

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315347974
• Edition: 1
• Topic: Medizin
• Subtopic: Medizinische Theorie, Praxis & Referenz

This book provides an important contribution to the new and growing field of 'narrative-based medicine'. It specifically addresses the largest area of medical activity, primary care. It provides both a theoretical framework and practical skills for dealing with individual consultations, family work, clinical supervision and teamwork, and offers a comprehensive approach to the whole range of work in primary care. Using a wide range of clinical examples, it shows how professionals in primary care can help clarify patients' existing stories, and elucidate new stories. It can be used as a training resource and includes exercises and summaries of key points to consider. It is based on, and describes, an established evaluated training method, and is of immediate and significant practical use to readers. It is essential reading for general practitioners, practice nurses and others in the primary care team, psychologists, family therapists, counsellors and other professionals attached to primary care. GP trainers, tutors and course organisers will find it a valuable educational tool. Professionals elsewhere in primary care such as pharmacists, dentists and optometrists, and academics in medical sociology and medical anthropology will also find it very useful.

PART ONE

Practice

CHAPTER 1

The narrative practitioner at work

‘My story is broken, can you help me fix it?’
Howard Brody (1994)

The purpose of this chapter is to give an overview of a narrative-based approach so that readers can gain a quick impression of what is on offer, and to consider what new ideas they are likely to discover from it. The overview is based on a description of one consultation between a man and his doctor. The doctor is attempting to work as a narrative practitioner.

The consultation is a compilation, drawn from several real ones to illustrate the approach. The description is interspersed with some commentary drawing attention to important themes. Many of these themes are discussed in more detail later in the book.

Key ideas in this chapter

• Narrative-based practitioners see their main task as helping the patient to develop a new story.
• This involves paying close attention to the patient’s language and to the contexts that make sense of it.
• It also involves offering the patient choices about how to make use of the practitioner, and about how to proceed at each juncture in the consultation.
• Narrative-based practice does not need to be time-consuming. It can even save time by being focused and connected with the patient’s needs.

Points to consider

• What are the distinctive features of this approach compared with other common approaches?
• How is it similar to what you already do and how is it different?
• What appeals to you, and what reservations or questions do you have?

The consultation

A patient walks into his GP’s consulting room and starts to describe five different problems. It is a familiar moment, one that any GP or practice nurse would recognise as typical. As the patient goes through his list, the GP feels a mounting sense of stress. In her mind, she runs through a range of options she has learned from her former trainer, her colleagues and her years of experience.

Should she point out her own time pressures and say something about the limits of GP consultations? Would it be fair to ask the patient to choose just one problem to concentrate on? Perhaps it would help to comment on how overwhelmed she feels by the list and ask the patient if he too feels overwhelmed. Or is it best to let the patient speak without interruption, accepting the emotional burden and the delay to other patients?

Instead, she chooses a quite different strategy and asks: ‘Do you think all these problems are separate ones or is there something that connects them?’

Generally, patients do not come into surgeries and clinics with stories that are well-formed and clearly articulated. Their initial narratives are much more likely to be hesitant, disjointed, fragmented, complicated or full of things that puzzle them. Whatever a new narrative does, it must provide a better kind of explanation and some coherence for what is happening to the patient. There may need to be a technical solution, but there will also need to be a story where some of the confusion is lessened, some of the fragments are united and some of the puzzles are solved. The patient who has been well treated in technical terms but cannot speak (or think) of a new story has not experienced any healing. In the particular consultation illustrated here, what chiefly guides the GP is the wish to help the patient towards a more coherent story.

The patient with five problems says: ‘I don’t think my problems are connected. I’ve just saved them up because it’s hard to get to see you.’

The GP wonders for a moment if she should challenge the patient’s explanation, perhaps with an inquiry about stress or an explanation about the appointment system. However, she decides it is better to accept his words at face value. She says: ‘Is it all right if we start with the problem that’s most important to you? Depending on how that goes, we may need to think later on about finding enough time for the other problems.’

Health professionals come to consultations with a rich set of prepared narratives in mind. These come from all kinds of sources, including the rules and regulations of the practice, their professional knowledge and training, personal experiences and beliefs. In any one encounter, the narrative in the clinician’s mind may include such elements as ‘I must keep good time’, ‘I must appear interested’, ‘I must be as good a GP as my trainer was’, ‘I must practise good evidence-based medicine’, and so on.

The professional’s narrative may be so dominant that it takes over the consultation completely. Patients then lose any chance to develop their own stories. Alternatively, practitioners can be aware of their own narratives, but hold these in abeyance. This is not to say they have to suppress or abolish them. There may well be occasions when they have to assert them: for example, when someone has serious symptoms or when a consultation has badly overrun. However, clinicians can use their own narratives with transparency, as the GP is trying to do here.

From his five problems, the patient identifies tiredness as his most important problem. Having covered the routine ground of history taking (working pattern, sleeping habits and an enquiry about physical systems) the GP widens her scope of enquiry: ‘Apart from yourself, who in your family do you think is most aware of your tiredness?’

Narratives never exist in isolation. They are forged in relationships with friends and families, contacts and acquaintances, colleagues and communities. To make sense of any narrative, and to provide an opportunity for it to change, we have to make some enquiry into the densely populated background of what is being said. Pursuing a narrative in primary care inevitably means pursuing an interest in the family. This is not because families in any sense ‘cause’ problems, or because it is the family’s responsibility to solve them. It is because most people create their stories largely in family conversations. In addition, illness nearly always has an impact on the family - whether this means having someone at home with flu, or the huge disruption that occurs when a parent or a child is seriously ill or disabled (Altschuler 1997; Altschuler and Dale 1999).

Professionals have families too, in both a literal and a metaphorical sense. The literal family may be present in all sorts of subtle ways in the consultation: in memories, habits, assumptions, expectations or as photos on the desk. The metaphorical family consists of the partnership, the practice, the profession, and all the present and past systems that have contributed to the stories in practitioners’ minds, and to their preferences in the way they like stories to go. Thus, it may be helpful to regard every consultation as an intersection of two families - the practitioner’s and the patient’s - as represented in the minds and narratives of both. While both may often need to be discussed, it is nearly always the patient’s family that needs to be brought into the conversation.

After a few more minutes the patient and GP have established that the tiredness dates from the death of the patient’s father-in-law. His wife has been sunk in grief and he has had to take on most of the domestic duties. The GP suggests that his wife should attend for a consultation, either by herself or with her husband. The patient says he has already suggested this but his wife is adamant she will get through her bereavement on her own. She has evidently had previous encounters with a counsellor but found these intrusive and upsetting. She generally has no truck with ‘talking things through’.

The GP toys with a number of possible interventions, including a sympathetic phone call to the wife or sending a reassuring message of invitation through the husband. Rejecting either of these courses, she asks: ‘If your wife doesn’t change her mind about coming herself, what’s the most helpful thing I can do in relation to your own tiredness?’

At almost any moment in a consultation, the practitioner has the option of taking charge: for example by ‘spelling out the rules’, by taking unilateral action, by deciding what is best for the patient or by foreclosing the encounter. However, there is nearly always an alternative. It is to hand over the threads of the story, or the narrative lead, to the patient. The GP here has done exactly that. Rather than challenging the realities of the patient’s life, she acknowledges them. Instead of deciding ‘the best way forward’, she asks what use the patient wants to make of her. In effect, she continually asks not just ‘How are you today?’butalso‘Who am I today - for you?’

In response to his GP’s question, the patient says he can largely deal with his own tiredness but he would be reassured by a checkup. He says he has found it helpful today just to have an opportunity to talk about his wife’s bereavement and how much he has had to support her. He feels certain that he can see her through this difficult phase in her life if the doctor can lay to rest his own anxieties about his health. He wonders if the doctor can also address the other four problems that have been bothering him (a skin blemish, a painful wrist, ear wax and a toenail problem) during the checkup. The GP accepts his judgement. She suggests a further appointment for the following week.

Reviewing this consultation, one thing is perhaps worth noticing above all others. It is the doctor’s attentiveness to language. Wherever possible, she follows the exact words of her patient rather than her own speculations about those words. When he says his five problems are unconnected, she accepts this. When he says his wife would not consider coming, the doctor pursues alternatives rather than challenging him. She treats language not as a mere starting point for her own chain of associations but as an utterly authoritative guide for the conduct of the interview. Her consulting style is not driven by the attempt to make one single decision - or five separate ones - in order to solve the patient’s problems. It is driven by language, and by a series of micro-decisions about how to proceed in the conversation itself. Each of these micro-decisions is shared with the patient. The doctor’s main focus is not on producing diagnoses or treatments (although these may play a part in the next consultation). It is on producing a shared new narrative.

As a result, in a short space of time, she and the patient are able to put together a story that is an improvement on the opening one, satisfies the patient for the time being, and fits with her own understanding of her role and its limitations.

At the end of her consultation with the tired man, the GP reflects that the outcome is perhaps not very different to what it might have been if she had conducted it more conventionally. But she has a sense that the man has participated more fully in the way the consultation was constructed. She hopes he may have experienced it as therapeutic, and makes a mental note to ask him next time if anything that happened in this consultation was particularly helpful. She feels less stressed than she expected, and she has almost kept to time.

Suggested exercises

• After a consultation, compare the final story with the initial one that the patient brought. How was it different? How far was it a medical one and what other elements did it have?
• After a consultation, try to recall how many people or organisations were mentioned in it.
• After a consultation, recall how you managed limitations of time or resources, or indicated them.
• In any consultation, pay attention to the first juncture when you asked a question. Afterwards, think about why you chose that juncture. What then happened? What other questions could you have asked? What might have happened if you had?
• In another consultation, try to pay attention to the first two or three questions in the same way.

An extract from the sources

We may consider narration to be a reciprocal exercise, consisting both of the act of telling the story and the act of responding to it. In this mutual, interactive approach, the physician does not simplistically ‘take a history’ but is also prepared to see the patient narrative grow and change over time, and to participate in that process. In this interpretation, the act of co-creation of patient narrative must be mutually negotiated between physician and patient. Such an approach assumes the intrinsic value of patient narrative, although it does not conform to biomedical rules and formats, and does not attempt to dismiss this narrative once the essential ‘biomedical’ aspects have been extracted . . .

The physician also has a responsibility to challenge automatic or conventional elements of the patient’s story, in effect, to say to the patient, ‘it seems to me there is much more to tell here’. In this guise, the physician’s responsibility is to help the patient’s tale gain momentum and depth, to draw out the story in hiding. In a similar vein, the physician commits to scrutinising the patient’s story in order to find new meanings that may more accurately reflect the reality of the storyteller and, in doing so, help the storyteller see where the story wants to go . . .

The physician can also attempt to recognise and/or encourage conditions that facilitate the creation of meaning during the process of patient narrative. In eliciting a patient narrative, the physician must encourage the patient to be emotionally engaged in his or her story, in other words to acknowledge fears, hopes, and expectations . . . Finally, to facilitate a meaningful patient story, the physician must help patients take the risk of confessing those aspects of their story that are confusing and full of gaps. When we demand certainty, patients oblige with fictive information that conforms to our logico-scientific criteria, but distorts the patient’s reality. When we allow ambiguity and mystery their place in the treatment room, patients have permission to offer narratives with those qualities as well.

Joanna Shapiro (1993)

References

Altschuler J. (1997) Working with Chronic Illness and Disability. With contributio...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• Acknowledgements
• Introduction: narrative and primary care
• Part I Practice
• Part II Teaching
• Part III Theory
• Appendix: the initial research
• Index