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Narrative medicine empowers patients, improves care
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“Health care has gotten away from a focus on caring for patients and has moved towards a more limited goal of curing patients,” Kirsten Roberts, MD, MS, told Primary Care Optometry News. “This is partly because of many wonderful modern medical advances, but has been detrimental to patient care, especially for patients for whom there is no cure.”
However, some clinicians are discovering that the practice of narrative medicine is putting more of an emphasis back on patient care.
Roberts, assistant professor of pediatrics at Albert Einstein College of Medicine, said, “Generations ago, when technological advances weren’t as great, physicians did a better job of being there for their patients during health, illness and even death. Narrative medicine is nothing new; it’s a return to how medicine was practiced in the past.”
In one of the few papers on narrative medicine in vision care, 69% of optometrists and ophthalmologists reported experiencing trouble communicating with patients, and 89% of providers reported interest in learning new communication techniques, according to Michelle Glass, OD, now a private practitioner in Fairfield, Ohio, who completed the research prior to graduating from Southern College of Optometry.
Image: Bence BG
A definition
Narrative medicine is a model for humane and effective medical practice involving the ability to acknowledge, absorb, interpret and act on the stories and plights of others, according to a study from Rita Charon, MD, PhD, executive director at Columbia University’s Program in Narrative Medicine.
“With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals and inaugurate consequential discourse with the public about health care,” Charon wrote in a study in the Journal of the American Medical Association.
“A style of narrative medicine was the norm in early medicine, when being present was sometimes all doctors had to offer their patients,” Roberts told PCON. “As medicine became more technologically advanced, the patient got pushed back. We forgot to take care of the patient along the way. We lost the big picture.”
Glass noted that patient interaction is not often taught in medical school.
Brett G. Bence, OD, FAAO, president of the American Academy of Optometry, told PCON, “I think people aren’t aware of this medical emphasis. In the profession’s conscious, it’s just not broadly discussed.”
However, he feels aging Baby Boomers will shift this, as demand for care will increase.
The American Medical Association has yet to release any guidelines or best practices on this type of care, which affects implementation, Kellie Gergoudis, coeditor, Journal of Narrative Visions (JNV), and second-year medical student at the Icahn School of Medicine at Mount Sinai, said in an interview. JNV is an online literary journal for health care professionals to submit narrative medicine pieces on ophthalmology and optometry topics such as low vision/blindness, diabetic retinopathy and other diseases pertinent to vision care.
“There are bad outcomes if you practice too far to either side: If you’re too robotic and not empathetic with patients, they won’t feel comfortable talking to you,” Gergoudis said in an interview. “On the other hand, if the doctor is too emotionally involved...your judgment can be clouded.”
Barriers
According to several of the experts interviewed, the barriers to narrative medicine often revolve around physician time and the money involved in expending needed resources. If a current practice model is working, a clinician may see no need for change. Many providers have a tight appointment schedule and feel they lack the time to learn a patient’s entire story, Roberts explained.
She noted that some doctors may concentrate more on the diagnosis than listening to the patient and “have become famous for cutting people off.”
Glass added, “The best care won’t be effective if you don’t deliver it properly. I can know everything in the world about a condition and how to treat it, but if the patient doesn’t understand me, it doesn’t mean anything.”
Bence added: “Doctors are faced with having to cover overhead, with only 20 to 30 minutes to diagnose and treat a patient. There is a definite time crunch.”
Glass reported that with tuition costs up and reimbursements down significantly, optometrists need to see a larger volume of patients to pay the bills. In addition, with constantly changing vision plans, patient loyalty has gone down.
“But if we can show our patients a caring perspective and deliver the highest quality of care,” she said, “in this current environment, we may be able to keep more patients when their insurance plans continue to change.”
Narrative medicine in practice
Bence suggests intently listening about how a condition will impact a patient’s life.
He told the story of a female patient he saw early in his career who developed bilateral blindness from arteritic anterior ischemic optic neuropathy. She presented with instant monocular vision loss, and even with immediate intervention with corticosteroid therapy, her second eye went blind within 1 week, he said.
“Remarkably, even with no line perception vision in both eyes, she was able to navigate the first floor of her home from visual memory,” Bence said. “Her bravery and ability to overcome her disability was inspiring, so much so that I decided one morning to take a shower and shave in the dark, to fully experience these tasks without vision.
“It may seem unnecessary to some clinicians,” he continued, “but to me it gave meaning to what we do. To experience blindness gave me a better understanding of the patient’s perspective. It was a lesson learned and a tipping point in my career.”
Glass also shared a story of putting herself in her patient’s shoes.
Her patient presented with dense cataracts in each eye, and other optometrists had recommended surgery. The patient had strong religious beliefs and told Glass she wanted God to heal her; she wanted a miracle to happen.
Glass told her, “Maybe God sent you to us to make you better,” approaching the patient from her standpoint rather than dismissing her religious beliefs. As a result, the patient felt more comfortable with a surgical option.
“Narrative medicine involves a shift, with the patient being more involved in their health care and being a part of the team to make their own decisions,” Kalla Gervasio, founder of JNV and a third-year medical student at the Icahn School of Medicine at Mount Sinai, told PCON. “They want to be presented with options, whether it’s treatment or none at all. Having a sensitive discussion can help empower patients.”
Empathy, listening and trust are important cornerstones to narrative medicine, Roberts said.
“If you have a better sense of the difficulties a patient is facing,” she said, “you’ll have more empathy for the way their life has gone and how it is that they find themselves in their current situation.”
Roberts said humility is another important aspect to narrative medicine, to realize you have your own perspective on a patient’s medical issues and that the patient has another that is equally valid. She believes attention to patient narrative gives patients the sense that providers are there with them, listening to them and experiencing the situation with them. – by Abigail Sutton
- References:
- Charon R. JAMA. 2001;286(15):1897-1902. doi:10.1001/jama.286.15.1897.
- Columbia University Medical Center. Program in Narrative Medicine. www.narrativemedicine.org.
- Glass M, Bennett H. Optometry & Visual Performance. 2013;1(5):175-184.
- For more information
- Brett G. Bence, OD, FAAO, can be reached at bbence@nweyes.com.
- Kellie Gergoudis can be reached at kellie.gergoudis@icahn.mssm.edu and www.narrativevisions.org.
- Kalla Gervasio can be reached at kalla.gervasio@icahn.mssm.edu and www.narrativevisions.org.
- Michelle Glass, OD, can be reached at mglassod@gmail.com.
- Kirsten Roberts, MD, MS, can be reached at kirsten.roberts@nbhn.net.
Disclosures: No products or services were mentioned that would require financial disclosure.