part0009

Stories capture us and take us on a journey. Sometimes they take us to a place that is familiar, resonates with our experience and hence reaffirms what we know and value. Other stories reveal experiences that are unknown to us and as such, may challenge our belief systems, beseeching us to wonder and reflect. Narratives about patients and their physicians continue to enrapture us, because at some time and point we will all be a patient. For physicians, narratives provide insight and illumination of what it truly means to be patient-centered. They also help clinicians to examine, in a reflective manner, what it means to be a healer.

Listening to stories, collecting stories, sharing stories and writing stories has been, in recent years, an important jewel in the practice and teaching of medicine. Authors from varied disciplines in medicine have passionately embraced the role of narratives, as they exquisitely detail the profound experiences of patients as well as the experiences of clinicians caring for those patients (Borkan etal. 1999; Brown et al. 2002; Cameron 2011; Charon 2004, 2006, 2007; Frank 1995, 2004; Greenhalgh and Hurwitz 1998; Groopman 2008; Nuland 2010; Ofri 2005).

For example, Rita Charon, an internationally renowned author on the power of narrative in medicine, explains: “More and more health care professionals and patients are recognizing the importance of stories they tell one another of illness.„ Charon contends that “only in the telling is the suffering made evident,„ and thus we must “accept our obligations to learn how to receive these stories„ (NEJM 2004, p. 862).

Ian Cameron, a well-respected family physician and eloquent raconteur, asks: “Are narrative plot, words, the importance of listening, the importance of stories, and their values in the effective relationship between patients and doctors vital in the practice of medicine?„ He then tells the following story: “I had a patient who, in his mid-50s, had a crisis of identity and purpose. I asked him to return in a week and tell me about his very first memories. He chronologically moved forward with his memories in 15-minute weekly sessions. By the sixth session, he had reconnected with his story and rediscovered himself„ (CFP 2011, p. 67).

Jerome E. Groopman, in his forward to the book Soul of a Doctor, writes, “It has been said that all of literature can be divided into two themes: the first, a person goes on a journey; the second, a stranger comes to town. This is, of course, terribly simplistic, but there is a core of truth in it. And it is also true that narratives of medicine meld both these themes. A person goes on a journey: that person is the patient, but accompanying him on the voyage is the doctor. A stranger comes to town: that stranger is illness, the uninvited guest who disrupts the equilibrium of quotidian life. Where the journey leads, how the two voyagers change, and whether the stranger is ultimately expelled or in some way subdued give each narrative its unique drama„ (Pories, Jain and Harper 2006, p. xi–xii).

Collectively, these authors value the place of narratives in medicine. Indeed, they would argue that narratives, or the patients’ stories, are central to patient care. These stories are the essence of what we receive. We are privileged to bear witness to these stories and to sometimes be a part of them – from the beginning to the end.

This book presents examples of the many challenges encountered in patient-doctor interactions and provides some ideas for dealing with these problems more effectively. It does not address every concern, but it does highlight those common in day-to-day practice. What makes these narratives important and useful is that they are based on real situations – ones that we have all encountered and wondered how to handle. We hope to challenge you, to stimulate you to think, and most of all, to listen in a new and fruitful manner.

For 30 years, the Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario has been developing and testing a method of practice that integrates the traditional medical model with a patient-centered approach endeavoring to understand the patient’s unique experience of illness. A program of education, research and conceptual development led to a body of work represented in Patient-Centered Medicine: transforming the clinical method (2nd ed.), which described the six components (Stewart et al. 2003). The new and revised patient-centered clinical method is outlined below and consists of four interactive components to be considered in every patient-physician interaction.

The first component involves exploring the patient’s perceptions of health, disease and the illness experience. Primarily, health perceptions are the person’s sense of his or her own health and the benefits and barriers to that health. In addition to assessing the disease process by history and physical examination, the doctor explores the patient’s illness experience. Specifically, the doctor considers how the patient feels about being ill, what the patient’s ideas are about the illness, what impact the illness is having on the patient’s functioning, and what he or she expects from the physician.

The second component integrates the concepts of health, disease and illness with an understanding of the whole person. This includes an awareness of the patient’s position in the life cycle and their proximal and distal contexts.

The third component of the method is the process of finding common ground between the patient and the doctor. This consists of reaching a mutual understanding and a mutual agreement with regard to: defining the problem(s), examining the goals and priorities of treatment, and identifying the roles to be assumed by both the patient and the doctor.

The fourth component takes into consideration that each encounter with the patient should be used to develop the patient-doctor relationship. The trust and respect that evolves in the relationship will have an impact on other components of the method.

There is strong evidence supporting the efficacy of patient-centered care, which has been associated with: higher patient satisfaction (Fossum and Arborelius 2004; Krupat et al. 2000; Stewart et al. 1999), better patient adherence (Golin et al . 1996; Stewart et al. 1999), better patient health outcomes such as reduction of concern and discomfort (Stewart et al. 2000), better self-reported health (Stewart et al. 2000; Stewart et al. 2007), improved physiological status, e.g. blood pressure, metabolic control for patients with diabetes, (Golin et al. 1996; Greenfield et al. 1988; Griffin et al. 2004; Kaplan et al. 1989; Krupat et al. 2000; Rao et al . 2007; Stewart et al. 1999); and lower costs of care (Epstein et al. 2005; Stewart et al. 2011). Furthermore, the patient-centered component of finding common ground has been associated with lower utilization of medical services (Stewart et al . 2000).

The patient-centered method is valuable to physicians for several reasons. First, the clinical method is a reasonable representation of the realities of medical practice. By providing a useful framework, the patient-centered clinical method guides physicians in their complex work of caring for patients. Because the method grew out of medical practice, it has immediate applicability by both novice as well as experienced physicians.

Second, the patient-centered method applies to the majority of interactions between patients and doctors. It is not geared only towards counseling or interviewing, but can be employed with patients of all ages with a variety of health issues and concerns.

Third, it describes what doctors do when they are functioning well with their patients; thus it supplies a conceptual framework for physicians in their daily practice. The patient-centered clinical method is more than an exhortation to be more caring; it describes specific behaviors that need to be learned, and it explains when and how to use them with patients. Because this clinical method is explicit about the behavior of an effective clinician, it also provides a vocabulary and a focus for teaching and learning.

The narratives presented in the first four sections of this book highlight each of the four components of the patient-centered clinical method. The stories in the fifth and final section illustrate how the enactment of patient-centered care requires attending to many, if not all, of the components that comprise the patient-centered clinical method. This reflects the interactive and dynamic nature of the patient-centered clinical method and emphasizes how clinicians must shift from one component of the method to another as they follow patients’ cues. The analogy is to a dance: as one partner responds to the tempo and nuance of the music, the other follows, and then vice versa. The mutual rhythm that is created is influenced by the environment or context in which the “dance„ or interaction transpires.

Several of the stories illustrated in this book reflect our aging population. This is not unexpected, as the care of this group of individuals may be our greatest clinical challenge in the future. Hopefully, these stories provide some guidance as to how we can best address the ever-growing demands for patient-centered care of this most valued cohort of patients. Another group of patients to which we extend a special focus are those who are disadvantaged and vulnerable. They are now desperately in need of our care.

While most of these narratives have been written from the perspective of family physicians, the basic tenets of patient-centered care are transferrable to all health care professionals who are committed to providing exemplary health care.

The names and many identifying characteristics of the individuals portrayed in the narratives have been changed to protect confidentiality. All of these stories are based on real experiences, most often described by physicians. In some instances, the stories have originated from patients’, or family members’, own personal experiences. From our perspective, these stories have tremendous validity and value; they exemplify the human qualities of suffering, conflict and perseverance. On many occasions, we are privileged to witness the patient’s triumph over tragic and troubled circumstances. Time and time again, we see the critical role of communication in these triumphs. When we take time to listen – to give value to people’s stories, their fears, their angst and their sorrow – we gain a deeper and more thorough appreciation of their suffering, and the listening ultimately provides direction in the process of healing .