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| Every story needs a villain |
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.
