Does your doctor really listen to you?
Think back to your last checkup. After you slipped on that crinkly paper gown, a nurse took your temperature, checked your blood pressure and asked you why you came. Then you sat and you waited.
Minutes, probably many of them, passed as you thought of all the things you could be doing instead of staring at your toes. Maybe you made a call or checked messages on your phone, but you didn’t linger on those tasks. You wanted to be ready to launch into what ailed you as soon as the doctor came through the door. Then your physician arrived, a brief discussion of symptoms and possible causes ensued, a physical exam occurred — "Quiet, now; let me listen to your breathing" — and it was time to get dressed and go on your way. As soon as your doctor left, though, you had the feeling that something important was left unsaid.
You were probably right.
Americans seek care in some 1 billion medical visits a year. But the average appointment lasts just 19 minutes, according to the National Center for Health Statistics, and within that narrow window, doctors are trained to focus on a patient's immediate clinical issues, not his or her life story. Now a different approach, known as narrative medicine, is emerging, in which doctors are taught to "receive" a patient’s story about illness, and the clues it may contain for the issue at hand, so they can get a more complete picture — one that is crucial to diagnosis and correct treatment.
Your Story Matters
“When a patient comes in, it’s because 'something doesn’t feel right,' and people struggle with words to express the problem,” says Dr. Rita Charon, executive director of the first-of-its-kind master of science program in narrative medicine at the Columbia University College of Physicians and Surgeons. “Predictably, a doctor is more likely to focus on the organ systems, and do a test or ask questions like, 'Are you having trouble with your bowel movements?' Right away, we’re missing the first floor of the edifice. Life, love, dreams, hopes, fears — all that gets bypassed, in the rush to find out what’s wrong and fix it."
Charon, a primary-care physician and professor of clinical medicine at Columbia, launched the program because she felt doctors, including herself, needed to listen to patients more actively. As someone schooled in paying close attention to stories — she earned a Ph.D. in English after becoming a doctor — Charon realized that while medical schools successfully taught the science of medicine, they needed to put a stronger focus on training students to see the whole patient, not just a collection of test results. Her goal is to help doctors improve their clinical encounters so patients are more at ease and more open to sharing information that could aid their treatment.
Multiple studies have established that many people feel intimidated by their doctors. Narrative medicine seeks to alter that power dynamic, shifting the doctor from an all-knowing authority to a participant in a story, told by the patient, that needs resolution.
Columbia's program grants M.S. degrees to practicing doctors and other health-care professionals, as well as academics, writers and others with an interest in the field. The degree can be completed in one year of full-time study, although many health professionals take classes part-time and complete the program in two or three years. It is the only degree-granting program of its kind, although other schools offer similar individual courses as electives within their med-school curricula.
Teaching Doctors to Be Listeners
For doctors trained in narrative medicine, listening is as important a diagnostic tool as the stethoscope. "It’s not about finding out what their hobbies are," Charon says. "It’s finding out what needs to be asked.”
She cites the case of a middle-aged woman who came to her with multiple, vague health complaints, including substantial recent weight gain. The woman had seen a number of specialists, but no one could identify the problem. Charon greeted her the same way she greets every patient, by asking, "Tell me what you think I should know about your situation.” What the woman eventually revealed in their conversation was that she had started gaining weight around the time her daughter died from cancer. Recognizing that connection, Charon says, was crucial to discovering the behavioral patterns that needed attention and finding a way to address them.
“All things come from the story,” says Dana Gage, a primary care physician at the Bedford Hills Correctional Facility in New York and a narrative medicine advocate. “If you listen carefully the patient will give you the diagnosis 90 percent of the time. I rarely order a test without knowing the outcome.”
Listening to patients' stories can be essential for determining treatment, but like any other clinical skill, it needs to be learned. “Stories are complicated,” says Dr. Susan C. Ball, associate professor of medicine at New York-Presbyterian Hospital, who recently completed the narrative medicine program. “Learning narrative techniques has taught me to listen and hear in ways that allow me to do a close reading of patients' stories, the same way a student in a poetry class 'reads' a text for symbols, metaphors, clues to meaning. It helps me get to where and what I need to know to plan treatment.”
Get Your Story Out
And what about you, sitting on that table in your thin, scratchy gown, awaiting your checkup? Can you make your story heard in an age of electronic records, when physicians are torn between patient care and administrative demands? Narrative medicine practitioners say you can, and that the conversation you launch with a doctor who knows how to listen can only benefit your care.
"There is the mistaken belief that there just isn’t time for this work because doctors are forced to see the maximum number of patients during the day," says Craig Irvine, academic director of the Columbia program. “But when doctors aren’t allowed to elicit stories from their patients, it increases the cost of medical care, because they miss aspects of those problems and end up doing more tests. Patients have to return again and again for treatment, because their doctors aren’t really addressing the problem.”
Donna Bulseco, the assistant managing editor at InStyle magazine, has also worked at Women’s Wear Daily, W, and Good Housekeeping. She is a part-time student in her third year of the master of science program in narrative medicine.