Typical case scenario in a busy family practice setting
Mrs. Smith is an 82 year old senior living alone who is here today for a renewal of her blood pressure medications. Mrs. Smith has type 2 diabetes, coronary artery disease, hypertension and COPD. You are running behind and welcome the opportunity for a quick visit to renew her BP medications. Mrs. Smith has been your patient for a long time and you know that Mrs. Smith has a long list of about 10 medications. When you enter the exam room you find Mrs. Smith and her daughter Dale.
Dale is hoping to have a few minutes of your time to discuss her concerns about the number of medications her mother is taking, particularly in light of her mom’s failing memory. Dale is hoping you could take a closer look at her mom’s medication list and considering stopping a few. She is also really hoping you have time to do a “quick memory test”. Mrs. Smith is having increasing difficulty remembering when to take her pills. In fact, last week Dale learned just how much difficulty her mom is having when she found a bunch of her mom’s pills hidden in her dresser drawers. Mrs. Smith, too embarrassed to admit that she needed help with her medication, started hiding her missed doses.
Looking at your watch you realize this is not going to be a quick appointment. Dale senses your frustration and suggests they come back another time to discuss her mom’s medications and memory issues when you have more time. You quickly write the prescription and move on to your next patient feeling equally frustrated as Dale and Mrs. Smith with the whole situation.
Frustration and dissatisfaction when dealing with the complexity of patients like Mrs. Smith
The scenario above describes an all-too-common situation with many older adults who have multimorbidity. Although we can sense the patient’s frustration, recent qualitative research suggests that many primary care clinicians (family physicians) are equally frustrated(1;2). One study(1) that interviewed family physicians showed that most felt professionally inadequate when dealing with multimorbidity. These family physicians did not feel they could adequately prioritize the patients’ needs and enable shared decision-making. This concern stemmed from:
- perceived lack of time, competence;
- lack of a holistic view;
- lack of appropriate guidelines and;
- inadequate payment for dealing with complex patients.
A recent systematic review(2) summarized findings from studies describing primary care clinicians’ perceptions when dealing with patients like Mrs. Smith. The review identified four main challenges and one of these concerns is related to shared decision-making. Making decisions with older adults with multiple chronic conditions was perceived as difficult especially when attempting to elicit patient preferences.
How do we make these complicated encounters better and increase our satisfaction in dealing with complex patients with multiple chronic health conditions? And how do we enhance meaningful dialogue between the doctor and the patient or patient’s family? One approach would be to consider how the “narrative” or story of these patients provides important evidence necessary to providing evidence-based care. This blog post describes the significant benefits of narrative-based medicine (NBM) for both the doctor and the patient, and how this complements management of complex patients such as Mrs. Smith.
Why is narrative-based medicine important to your clinical practice?
There are two important reasons why this will help your practice:
1. Forcing the patient’s story into our biomedical perspective misses important information needed to manage their chronic illnesses
The patient’s story (or narrative) has always been an important and vital part of medicine. However, modern medicine today has become less reliant on the patient’s narrative and more reliant on scientific evidence and technology. While “facts and findings” are essential in the practice of medicine we run the risk of replacing the patient’s story of illness with the doctor’s story of disease. It is essential to allow the telling of the illness narrative from the patient’s perspective rather than forcing the narrative to fit into the biomedical perspective. The physician armed only with evidence-based medicine (EBM) cannot help the patient grapple with the loss of health or find meaning in their suffering. The evidence-based physician who is able to listen to the patient’s story and understand the significance of the patient’s suffering is both scientifically and narratively competent.
2. Narrative as evidence
From the medical perspective reaching the diagnosis is often the end of story, a place where we often stop inquiring; but Illness continues to unfold over time. In other words the patient’s history is provisional and continuously changes. This is of particular importance as we provide care to the elderly, many of whom have complex, chronic health problems. The patient’s narrative provides meaning, context, and an understanding of the patient’s experience of illness. In other words, the narrative builds the bridge connecting the evidence of large clinical trials to the individual patient. The complete story from the perspective of both the doctor and the patient increases diagnostic accuracy, and better informs us as to whether an evidence-based intervention applies to the patient before you. The fear often expressed by physicians is not having enough time to hear the patient’s story. However, allowing for the narrative to unfold does NOT always require more time. In a study in which patients were given the opportunity to recount their symptoms and concerns uninterrupted, 80% of the patients were able to tell their story in only two minutes and many of the patients had complicated co-morbidities(3)! The other important aspect of this study was that the physicians were trained in active listening skills. In other words, the physicians were trained to listen to all the patient had to say THEN reflect back to the patient what they heard. Keeping in mind that illness unfolds in stories, both Frank(4) and Charon(5) remind us of the importance of letting the patient tell their own stories and observe how their description of their symptoms fits into the larger story of their lives. Now, armed with the complete story, the likelihood of adherence to complex drug regimens or treatment plans, increases. As our population ages considering a NBM approach in the context of optimal aging and disease prevention will be paramount.
Clinicians incorrectly perceive conflict with EBM and NBM use
It is well known that physicians who practice with both scientific and narrative competence are more empathetic, more resilient, find greater meaning in their work and are less likely to burn out. It also leads to greater patient satisfaction(6).
The “art of medicine” lies in the ability to apply both types knowledge to a single case. EBM and NBM must be understood as complementary methodologies and cannot be pursued separately; they are intricately intertwined.
It is important to remind ourselves of the original components of EBM as originally conceptualized by Dr. Sackett(7). The three components are: individual expertise, best external evidence, and patient values and expectations - all weighted equally.
A truly EBM approach means integrating all three elements. Over the past 20 years the “evidence” circle is now over-represented and overshadows the importance of the other two. We must remember the risk we take when the analysis of evidence is limited to either quantitative or qualitative data. In the complicated world of medicine using just one form of evidence will be ineffective in all cases(8).
What are some important things to know about narrative-based medicine?
Complex, chronic health problems increase with age. Many people over the age of 65 have at least three chronic conditions. If we applied individual, EBM guidelines to a patient with five chronic health problems this would result in the need for 12 different medications, at five different times each day. This significantly increases the risk of an adverse drug interaction as well as creating significant challenges with medication/treatment adherence(9). Care by EBM standards would be considered excellent but significantly challenging for the individual patient. In addition, it is very important to keep in mind that many of the clinical practice guidelines were developed using much younger patients, many of whom did not have co-morbidities(10). As our population ages over the next few years and with growing social, economic, and institutional constraints, it will be increasingly important that medicine is practiced in a way that is effective and efficient for the doctor, patient and society. NBM provides efficiency in capturing both clinical and patient preference information.
How can we increase our narrative skills or competency?
Increasing NBM competency requires a combination of empathetic presence and mindful listening. Instead of being distracted by our computer screens and being tempted to look up the patient’s last results we must learn to listen to all the patient is telling us in both words and silences. Charon(5) has written extensively about how reading and interpreting literature teaches us how stories are built and told and how this translates to listening to and better understanding patients and how they described their symptoms. Writing reflectively about our experience of caring for patients we gain a deeper understanding of the impact that caring has on us as well as deepening our understanding of the impact of illness on the patient (11).
Where can we go to hone these skills of empathetic presence and mindfulness?
There are many programs available in most medical faculties. In my own, the Program for Faculty Development at McMaster University offers workshops in Narrative Healthcare as well as a number of courses in Mindfulness training in the context of healthcare. Search for these and you will find one in your area.
What is the bottom line about this topic?
Primary care physicians are increasingly frustrated with current approaches to dealing with complex patients who are aging and have multiple chronic health conditions. NBM competency is one solution to helping with these complex clinical encounters. It also balances the over-emphasis on the external evidence in EBM in daily practice.