Damian Sendler: Skeptics of narrative medicine have a good point. In the beginning, it is important to remember that not all presentations need a narrative investigation. The second reason is that both patients and physicians may be reluctant to use NBM. It’s possible that some patients, for example, might choose a doctor who is proficient in his or her craft over one who has a good bedside manner. 9 The biomedical paradigm and evidence-based approaches are also preferred by certain clinicians. 8 Furthermore, some physicians are overcome by the emotions elicited by specific narratives,10 while others have special behaviors that inhibit the flow of story.
Among other things, NBM has been criticized for being time-consuming8 and for opening the door to a wide range of issues.
Damian Jacob Sendler: When working under tight deadlines, balancing narrative and normative requirements may be a challenge. 4 In contrast, studies have shown that it does not take a lot of time to enable a story to flow. 9 Understanding is time well spent, and drawing out the underlying concerns is always preferable since there is frequently where the true troubles are. NBM has also been criticized for focusing primarily on the psychological and social requirements of patients11 and ignoring the biological components of sickness. In this regard, the literature on NBM is ineffective when the stated case studies are mostly psychological in nature. Remember that from an NBM viewpoint, the biological is equally as significant as the psychosocial story.
Dr. Sendler: Being swept away by tales and not recognizing one’s limits are both common pitfalls for NBM practitioners. Genuine individuals with real difficulties share their tales in order to help other people in the same situation. When pursuing a story just for the purpose of telling a story, extreme care should be exercised.
Damian Sendler
As a practitioner of NBM, you must learn how to tell a story.
However, as Launer points out in his book Narrative-based primary care, they are not beyond the reach of GPs. A step-by-step manual. 4 In fact, doctors with a lot of expertise and strong interpersonal skills have found that getting to know their patients better and better over time makes managing their patients much simpler. They have introduced an NBM approach into their consultations without having been trained narrative skills since they have learned that listening to the patient has substantial advantages for both the doctor and the patient.
NBM requires good communication abilities.
A successful consultation relies heavily on the ability to effectively convey information to all parties involved.
Damian Jacob Markiewicz Sendler: It is essential to provide the patient the freedom to express themselves by allowing them to use storytelling. Genuine concern for the patient and a desire to listen are implied. When working with a patient, it’s important to listen carefully to what he or she has to say about their illness experience, their thoughts, worries, hopes, and fears, as well as their bodily cues and reactions. It’s also important to look for connections and patterns in the story, as well as ways to help the patient understand the illness better. 4 Launer’s 7 Cs,4,13, which were introduced in the first piece of this series and included examples of appropriate inquiries, cover many of these fundamental communication abilities. 14
Narrative abilities may be used in a variety of ways in the consultation.
Damien Sendler: Doctor’s manner and talents, as well as the context, determine how much of a story the doctor tells. Management of the presentation in an emergency would obviously take priority over a story-based approach. 4 Box 1 presents the case of Nerida, a patient with what seems to be a straightforward biological condition who was treated using an NBM approach and communication skills. Dr. Nerida preferred to focus on Nerida’s physical issues first rather than her emotional concerns. The doctor would not have gone into such length about Nerida’s past if her condition necessitated it. Despite this, the doctor would have taken into account Nerida’s worries and the potential consequences of her condition for her and her family. From an NBM standpoint, Nerida has been given the freedom to tell her story in her own time and in her own manner, without any interference. It is true that the consultation has taken longer than intended, but the patient’s ailment has been put in a more full perspective. Emotional load has been lightened, worries addressed (physical symptoms and repercussions of continuing to be poorly), her “stress-related” hypothesis has been substantiated, and empathy has been communicated to Nerida. Every doctor’s communication talents have been used in this endeavor.
Narrative medicine draws its particular abilities from the 7 Cs4,13, which also include family therapy, but other talking treatments aren’t without them (eg, psychotherapy, counseling). Neutrality, circular questioning, and hypothesizing are all examples of these.15
When it comes to problem-solving,15 many GPs have a hard time being neutral. Focusing on the work at hand without getting caught up in the end result is what neutrality is all about, as is being open to other people’s points of view and accepting of them. Most general practitioners are aware with the basic concepts of motivational interviewing, which include educating the patient, assuring them that change is possible, exploring choices, and never pressuring them to make a decision against their will.
Following the patient’s mental process and eliciting their story is made easier with the use of circular questions 15. Reflecting back to the patient or utilizing them in some manner to explain or encourage replies are some of the ways in which this may be done. As a result, a question-response-question cycle is created, which keeps the story moving forward. Listening well and picking up on subtle clues are two prerequisites for circularity. It also necessitates that the listener be at ease with following rather than attempting to steer the tale.
The GP will create impressions about the patient throughout a talk. However, it would be a mistake to presume that the patient’s reality is exactly the same as that depicted in these reports. This is what Hypothesizing15 is all about: asking “How do you explain…?” “Suppose…,” and “What if…?” inquiries. To help patients contemplate realistic options for change and the mechanisms by which they may occur, hypothesizing in combination with circularity is an effective tool.
Damian Jacob Sendler
NBM is comprised of two key components. One of the advantages of having a deeper understanding of complexity is that it allows you to make better decisions. 4,12 Everything from how individuals connect to the various results of their interactions and how one event may have several effects is included in this. In addition, it is crucial to have an open mind to all kinds of possibilities15, which may be fostered by interactions with significant persons in the past and current relationships. Relationship patterns reveal why some patterns persist and why certain errors are made again and time again, proving that life events do not occur at random or in isolation. It is not necessary for the GP to have a working grasp of psychological theory to be able to investigate these issues.
The GP avoided the desire to address Nerida’s biological issue early in the conversation. To better understand Nerida’s sickness, a new viewpoint was obtained, one that was confirmed in the mind-body connection or what may better defined as mind-body oneness. 16 The GP is not trying to assume the job of a counselor or psychiatrist when he or she employs these specialist talents. The GP, on the other hand, is looking for new interpretations and deeper understandings of the patient via a more in-depth examination of the story.
Narrative medicine and the doctor.
Reflection on the consultation, according to Schön17 and others18, is an effective way to improve consultative abilities, and they recommend that this reflection be focused on the consultant, the patient, and the interaction. Similarly, the Balint method19–21 encourages the patient to focus on his or her own thoughts, behaviors, and potential reasons for what he or she is experiencing. Reflection on oneself and the role that one performs in the consultation are also encouraged by this technique. 19 There’s nothing unique about storytelling in this regard. For Charon, it’s clear that introspective abilities are a priority, but they develop as story experience rises for Launer.
As a doctor, it is important to think on moments when you have been sick or vulnerable. Using the self as a point of reference to acquire insight into another’s perspective is known as “reflexivity,” a sort of reflective thinking. 22 As a consequence of being more in tune with one’s own emotions and experiences, it enhances one’s ability to empathize with others9,23–25. An increased awareness of one’s own needs and a desire to take better care of oneself can only lead to an increase in resilience. It’s also possible to assist patients and colleagues “examine, reconsider, and transform their own narratives” with the use of “narrative concepts.” 4
The doctor-patient connection deepens when the patient learns more about the doctor as a person, rather than just a professional. Patients may even teach the doctor things about their disease and how to treat it that the doctor hadn’t considered before.
Doctors are regularly chastised for their lack of compassion and for failing to address patients’ concerns in the era of consumer care.
There has been a downward spiral in the relevance of the patient narrative due to the expansion of hospital medicine, technological advancements in health care, government and insurance company meddling, and evidence-based medicine (EBM). 28 It is becoming more challenging for general practitioners to deal with patients who are more complex,29–31 more knowledgeable, and more demanding than in the past. Comorbidity is on the rise, posing a slew of new problems. When it comes to patient care, it’s not uncommon for it to be fragmented, and PCC, shared decision-making, and EBM don’t function well together for patients with many illnesses. 29
In addition to PCC, NBM has been considered as “particularly useful” for treating comorbidity.32 PCC4 benefits from narrative skills (Box 2) because they place an emphasis on the patient’s disease experience and the things that are important to him or her, as well as the perspectives of the patient’s loved ones and caregivers. Evidence-based practice isn’t compromised by storytelling skills. 9,33 Because the doctor’s story includes evidence-based practice, there is a strong case that the two are compatible. 8,9,34
Narrative-based medicine, PCC, and EBM can work together, and a doctor’s style of practice reflects what he or she has been taught, as well as who he or she is. The literature, on the other hand, emphasizes the significance of the patient’s story and the need to comprehend the disease as a whole. In NBM, patients and doctors work together to build a new narrative—a story that heals and changes both parties. This is what sets NBM apart.
Dr. Damian Jacob Sendler and his media team provided the content for this article.