Perspectives

Narrative Medicine: A Re-emerging Philosophy of Patient Care

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The movement toward a scientific focus on data in health care was intended to reduce errors and improve care. But it also took the patient out of his or her own story. What have we lost in the process? Here’s why we need to restore patients to the narrative.


 

References

Narrative medicine (NM) centers on understanding patients’ lives, caring for the caregivers (including the clinicians), and giving voice to the suffering.1 It is an antidote for medical “progress,” which often stresses technology and pharmacologic interventions, leaving the patient out of his/her own medical story—with negative consequences.

This missing patient narrative goes beyond the template information solicited and recorded in the history of present illness (HPI) and review of systems (ROS). It is well expressed by Francis W. Peabody, MD, (1881-1927) in a published lecture for Harvard Medical School students: “One of the essential qualities of the clinician is an interest in humanity, for the secret of the care of the patient is in caring for the patient.”2

This article serves as an introduction to NM, its evolution, and its power to improve medical diagnoses and reduce clinician burnout. While its roots are in palliative and chronic care, NM has a place in the day-to-day care of patients in acute settings as well.

VIGNETTE

It’s been a busy day in clinic; the clock ticks toward closing. Scanning the monitor, you permit a brief moment of relief as you spy the perfect end-of-shift, quickie patient case: “Sore throat x 2 days,” with a rapid strep test under way. You quickly check lab coat pockets for examination tools and hasten down the hall noting age 22, white female, self-pay. Vitals reveal a low-grade fever. Maybe this sore throat will be bacterial; all the easier as there will be no need to do the “antibiotics don’t work for viruses” sermon.

You knock briefly, enter the exam room, place the laptop on the counter, and immediately recognize the patient from multiple visits over the past 2 years, mostly for gynecologic issues. You recall treating her for gonorrhea and discussing her worry about HIV. She told you that she’s a graduate student, although she is overdressed for a week night, wearing a silk blouse, short skirt, and high heels. She offers a winning smile and tells you with her pleasant accent that she is running late for an appointment.

The patient describes her symptoms: unrelenting sore throat for 2 days and pain with swallowing. She complains of feeling feverish and fatigued, with no appetite and “swollen glands.” She denies cough and runny nose; she looks and sounds exhausted. She denies smoking and excessive alcohol intake. You vaguely hone in on the accent, thinking it might be South African. Her HPI and ROS completed, you record her physical findings of pharyngeal erythema, no exudates, and moderate anterior lymphadenopathy.

You have a nagging thought about her “story.” As an urgent care clinician, you know you are likely her only health care provider and you feel some connection. It is late, and the patient is in a rush, so you promise yourself to delve deeper the next time she presents.

Continue to: You confirm the negative strep test results...

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