LC 9/18/15: Patient Narratives

Every story needs a villain

From a Learning Communities discussion on September 18, 2015

On patient narratives and patient perspective

Communication is complicated. What we mean and what others hear sometimes have as much similarity as two ends of a game of “telephone.” We have different perspectives, emotions, and knowledge. Most of us are novices at the subtleties of non-verbal communication. Words themselves may have different meanings and associations in different brains. “Chronic” to a medical student means long-term, but I have watched it echo around a patient’s mind with a ring of terminal illness and mortality.

One way we deal with all these differences is to provide context and embed our words in narratives. Our brains are stellar at rationalizing cause and effect, at finding patterns, at remembering stories. Therefore, as a physician I should really pay attention to my patients’ narratives, for I will then have the best chance of understanding their illnesses. As William Osler famously said, “Listen to your patient, he is telling you the diagnosis.”

What else can we derive from the narrative’s centrality? Every story needs a villain. Thus patients (and doctors) are often anxious to find it, and can go through even greater anxiety if they are told that the villain is not what they thought it was! Even worse is the occasion when we must tell a patient the diagnosis they have held is false, but we do not yet know the true culprit. As any horror story shows, we fear the unknown evil far more than the known villain. Worse still is when patients hear that they themselves are the problem, even if that is not what we meant to say. This crops up far more often than we would like, when diagnosing psychiatric disorders and suggesting lifestyle changes. Such situations require great care to navigate successfully.

What if the patient thinks the health care system or the doctor is the villain of the story? How can we break that narrative? The most direct, and perhaps best, way is explicit reiteration of my commitment and desire to help them. Even if my patient does not see me as a villain, it is still useful to know what role I play in my patient’s mental story. If I know that I am a confidant, an advisor, or an educator, I can act accordingly, or if necessary try to change it. And what about my story? I think that if we have a chance to truly empathize or connect with a patient, we should snatch the chance to build rapport. Perhaps if I tell some of my stories, my patients will feel more free to share theirs.

Cognitive Heuristics in Patient Narratives

In preparation for a Learning Communities discussion on September 18, 2015

The peak-end rule: people judge experiences by their peak (i.e. the most intense point) and their end, rather than the sum or average of every moment of the experiences.

Duration neglect: people's judgments of the pleasantness or unpleasantness of experiences depend little on their duration.

 

Barring conscious self-monitoring, the peak-end rule and duration neglect are powerful and often non-intuitive biases governing most people's thoughts about narratives most of the time. This applies to both patients and their families as well as ourselves and our colleagues. How can we use this knowledge of psychology to enhance our practice of medicine? Such a question can be applied when listening to and assessing medical narratives or when communicating with patients and the rest of our team. It can be asked short-term to a single visit or long-term over the course of months and years.

Some applications may be generally intuitive. When comparing a high-pain, short-duration treatment with a low-pain, longer-duration treatment, the latter is typically preferable, all else equal. Likewise, acutely painful conditions evoke more sympathy than chronic diseases with marginal effects on quality of life. When asking a patient for the severity of pain on a 1-10 scale, we understand that the patient's response will lie closer to the peak than to the average and act appropriately. We are much more likely to receive a fuller description of pain severity ("sometimes it hurts a little, but every now and then it's a 5 out of 10") as part of the patient's narrative in response to an open-ended question, rather than a closed-ended 1-10 inquiry.

On an optimistic note, patient memories of doctor appointments are biased by the peak-end rule and duration neglect. This means that even if visit times decline from 45 to 30 to 15 minutes, maintaining the same high level of engagement, compassion, and interest (especially toward the end of the visit) may have an equally therapeutic effect on the patient. Even a few crucial moments of excellent rapport and empathy can dramatically affect perception of an otherwise uneventful or even troubling appointment. However, moments of poor professionalism or severe neglect in the course of a typical visit may conversely affect patient's memories more than one might expect.

Another important area where these rules may come into play is end-of-life and palliative care. What implications do they have for patient and physician decisions in such situations, and how might we address them? Or should we address them at all? At the very least, we must identify them to answer this question.

Lessons from our VMSI Wellness Retreat

From September 11, 2015

1. To thrive and not just survive, I must consider what health, balance, and success mean to me and prioritize that. However, the work-life scale is dynamic and is naturally heavier on either side sometimes. I must also remember to re-assess all of this periodically, because those meanings can shift as I change over my life.
   
2. Acknowledging the inevitability of imperfection can help me deal proactively with failure. Even better is non-judgmental self-assessment of the causes of that failure, followed by gap analysis and goal-setting to improve in the future.
3. After I fail in some way, I will feel way worse for longer if I used a shortcut or did not do my best before failing. Note that this is true even if my shortcut or lapse didn’t cause the failure. If I did my best in preparation and execution, then my mind will not be so plagued after failure with regrets and self-doubt.
4. Recognizing that life has highs and lows (and medicine has high highs and low lows) can reduce the pain of failure and let me have a more temperate temperament. Great achievements and dismal failures will inevitably happen, and they will both pass.
5. Talking with other people, experiencing their empathy, and hearing their stories of mistakes can alleviate the severity and duration of the crippling pain of failure. If I am lucky (or proactively ask), I might even get ideas about how to avoid such mistakes myself. I don’t have time to experience every failure, so I must experience most vicariously. By extension, I should latch on to people who have experience and know what they’re doing to absorb as many delicious life lessons, tips, and tricks as I can.
6. I have so many resources for support and advice. (And I probably will wherever I go.) I must not wait to go use these resources if I'm struggling. Honest self-assessment of weakness is itself my greatest strength as a learner and doctor, and so I should act on it quickly and efficiently.