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THE PATIENT’S NARRATIVE
The two ways of Data Gathering - the narrative vs the tick-box approach
There are two ways to gather data (i.e. take a history) from a patient in the consultation:
- In a tick-box way or
- In a narrative way.
THE TICK BOX APPROACH – the doctor-centred approach
In the tick box approach (sometimes called the ‘question-answer’ method) what the patient says is controlled by you – the doctor. You guide (and essentially conrol) the patient. This is the method taught by a lot of medical schools. The aim is to reduce the ‘waffle’ and irrelevant information that patient’s tell you and get straight to the information that really matters (or information that you think that matters).
So, a patient might go on about how we was really scared about his chest pain and you might cut him short and say
- “Sorry to cut you short, but can you tell me what the pain was like – was it sharp, dull or tight?”…
- “And where was this pain, show me on your chest?”..
- “And was the pain bought on by exertion or did it happen at rest too??”
- “And did the pain go anywhere like down your arm or up your neck?”
THE NARRATIVE APPROACH – the patient-centred approach
Narrative is basically another word for ‘the story’. The narrative approach is sometimes called the ‘story-telling’ approach. And in the GP consultation – the story is the spoken account of connected events. Allowing this oral story telling to happen enables both the story teller (the patient) and the reciever (the doctor) to get a full picture of what really went on. In other words, it provides a more accurate picture of the event(s) itself compared to tick-box approach. And that means that you’re less likely to get the wrong end of the stick, less likely to make a mistake, and more likely to get the right diagnosis and do the right thing (=management plan).
Going back to the chest pain example above, in the narrative the patient would be allowed to talk freely and in so doing may say something like “I don’t know if this is important or not, but my aunt died of a clot in the lung and she had a funny blood disorder thing. So that’s got me a bit worked up.” Can you see how this extra information moves you over to a new clinical track of enquiry to follow up (the PE route) as well as doing the obvious the cardiac route?
This doesn’t mean you let patient talk without interruption or guidance. Of course, if something looks like its going off track, you may gently want to reign the patient in and other moments, you might want to actually take the patient back and explore something they said. The whole point is to be CURIOUS and INTERACT with the patient. Yes, allow the patient to talk, but actually LISTEN and be CURIOUS in what they are saying and INTERACT with patient to either clarify or explore things deeper in a natural story-telling way.
I once saw a patient who had already seen three other doctors about being a little ‘off his feet’ and he wondered whether it was due to an injury he had at work several months before. The others doctors got pulled in by this and agreed with him and told him things would get better and time the healer needed to do its thing. But months had passed and his wife was getting frustrated, so she made him come and see the doctor again – this time me.
I simply allowed the patient to tell his narrative. Again, he said it had been going on for 8 months and again he said ‘I suppose it takes time for things to settle after the injury I had”. I think he basically wanted me to agree with him and probably did the same to the previous doctors. The events around the injury he sustatined went something like this: a heavy pallette nearly fell on him at work and he quickly and abruptly jumped out of the way and landed with a heavy fall. Luckily the pallette missed him.
But what made me sit up and listen was that he said that over the last 6 months he sometimes had to be guided by his wife in which direction to walk. Again, he said ‘I suppose these things take time to heal’. And I asked him to explain more and simply gave him space. He said ‘sometimes, I can’t walk directly somewhere and I start veering off. It’s not too bad though – my wife just needs to hold me and then I’m okay.’ This was the second or third time that he was belittling his problems. It crossed my mind whether he was scared and whether he actually knew this spelt out something more sinister. From that moment on, the wise voice inside my head was telling me to SLOWWWWW down in my history taking and data gathering.
The thoughts running through my mind at the time were
- “this doesn’t sound like a result of the fall”,
- “why should it affect his gait?”,
- “I better examine him good and proper”,
- “I hope it isn’t anything neurological – I better do that examination too”.
He ended up with Motor Neurone Disease but the thing I want to point out is that it was HIS NARRATIVE that stopped me from saying “Yeah, injuries take a while to recover from”. It was his narrative that made me stop and worry a bit more. It was his narrative that made me refer him. It was his narrative that made me do something different to the other doctors. It was his narrative that made me do the right thing.
Did you know subsequently, this patient came to see me again. Not because I got the right diagnosis. He said it was because he felt he could be at ease and talk freely. This told me we had built rapport – but that rapport building was effortless because of my natural curiosity and my geuinine desire to want to understand the psycho-social impact of this problem on the patient’s life. And the thing that helped me do ALL of this, was simply employing the narrative approach. The narrative was the thing that triggered an emotional spark within me which in turn triggered my internal voice to tell me to slow down.
TED talks on the narrative
Rita Charan shows you how she does narrative medicine. I absolutely love her two examples at 7:40 and 10:20.
Sayantani DasGuptas makes a great case for why we should think about narrative competence and not just clinical competence. I couldn’t agree any more.
The benefits of the narrative
The narrative (or story telling) is one of the most powerfully motivating human forces. That’s why film-makers are so amazingly skilled at using them in films. In the GP consultation (and in the CSA) these emotional forces help us in several ways.
- The patient feels listened to.When that happens, the patient will open up and tell us more. As a result we get more ‘jigsaw pieces’ to help them with their puzzle.
- When patients open up like this, it is therapeutic in itself – being allowed to talk and vent is a bit like an emotional steam valve – where they get things off their chest and feel better as a result of all the released anxiety and stress. This is called ‘the patient’s lament’. The story telling allows ventilation of feelings and thoughts. In doing so, story telling is a form of therapy: it helps patient’s feel better through their lamenting and this can be a way of coping with things like illness and death.
- The story telling also helps ground the patient and keep them more centred – and they end up becoming a little more resilient and a bit better in terms of emotional health and happiness.
- It also helps build rapport effortlessly AND it provides a more accurate picture of what is going on.
- The story helps the patient construct meaninig and make sense of what is going on (the experiences). And it helps them come to terms with sensitive or traumatic times (divorce, violence etc).
- In this way, the story helps the patient help them reflect on themselves and their self/identity. Patients discover more about themselves through the stories they tell. Who am I? What kind of person am I?
- It helps patients understand their relationship with other people involved in the story.
- When we get an accurate picture of what is going on, we then ask questions that are more relevant and help clarify the picture even further. In the case of a doctor-patient consultation, this helps us determine more accurately how serious something is or not.
- The more accurate the picture, the more accurate the diagnosis.
- The more accurate the diagnosis the better the subsequent management plan.
- Stories tell us more about the patient in front of us – their self-identity unveils as they reveal more about themselves. A sense of who they are.
- The narrative (or storytelling) can be an incredible force to bridge gaps between opposing beliefs and ideas between you and the patient and their families.
- Good stories stick in your mind. They stay with you forever. They help transform you. In doing so they help you with your learning. You learn and remember things effortlessly. Just like I can tell you all the signs and symptoms of MND because all i have to do is remember that patient and not try and recall what I read in some book as a medical student x number of years ago!
- And finally, the narrative propels us to give the time to things that matter and to do the right thing. It help us to appreciate the patient’s perspective. In fact, by doing this, the narrative protects us from making mistakes (i.e. doing the wrong thing). Protecting us from making mistakes is both good for the patient and ourselves in this litiginous age.
What relevance does the narrative have for the CSA?
If you approach the CSA by simply using a question-answer approach (i.e. being doctor-centred and asking the patient a question, waiting for an answer, then asking another question and then waiting for another answer and so on) – you are likely to kill the consultation narrative. If you kill the narrative, you also kill the accuracy of events around the presenting complaint and the impact on the patient’s and their family’s lives.
Trainees who follow this ‘tick-box’ approach to data gathering during the consultation do so because they have firmly fixed their minds to ask a rigid set of questions which they feel must ask. These candidates fail because they end up asking questions that are not relevant to the patient scenario and also end up NOT asking questions that are. For example, let’s say a patient comes in with a mild bit of bruising and is worried that they might be a carrier of the haemophilia gene. You’ll be surprised at the number of trainees who I see who rigidly ask about smoking and alcohol at the expense of more important information like – whether there are any haemophiliacs in the family and what made them think of it in the first place.
What is without a doubt a better approach is the narrative approach – where you the let story come out naturally and that if you need to ask questions, you ask them at natural points in the flow of the conversation where possible. This is a narrative approach – both the patient and doctor build a picture of what’s been happening together – through dialogue and discourse. And CSA examiners love it when they see this in action.
Of course you may have a mental picture of some of the things you want to ask – and I am not saying don’t ask them. What I am saying is see if you can ‘park’ them in your mind and allow the patient to tell their story and at some point, weave those questions in. You will always find a place where it seems natural and seamless to ask one or more of those questions. Asking questions in a natural way helps the story unfold naturally. If you interrupt the story (as in the tick-box doctor-centred approach), you end up with a fragemented story with many bits missing. And if the data gathering stage has many bits missing, you’re more likely to end up making the wrong diagnosis. With a wrong diagnosis then comes a wrong management plan and so on.
Surely we all want to truly help our patients and to do this, we need an accurate picture of events. I hope you can see that a narrative based approach really allows this to come out. And the CSA examiners love it. Remember, the CSA is not an OSCE. And it is NOT marked as a tick list – the marking is more complex and sophisticated than that – each examiner makes a synthesis of your performance in each of the three domains across the totality of the case.
One final point – the narrative based approach is a skill in itself. So discuss it with your trainer. Of course – you cannot acquire a skill without repeated practise. So practise, practise and practise some more. And especially with real patients.
Won't using a CSA framework hinder the narrative approach?
Question: Wont using a CSA framework result in me doing a question-answer/tick-box type approach? And yet you want me to do a narrative consultation. So should I ditch the frameworks.
Answer: No, not at all. There is nothing wrong with using a CSA framework. A framework is simply a structure to guide you. So, most CSA frameworks out there look something like this…
- Open question/golden minute
- Psychosocial (work, home life, mood)
- Confirm drug hx and PMH based on patient information given
- Closed questions, Red flags
- Relate to ICE
- Discuss diagnosis
- Options for treatment
- Follow up +- safety net
And this looks like a good ‘guide-map’ for your CSA consultations. Remember that word – guide – in other words, to gently provide a direction for you in the consultation. It’s not there to force you into doing something in a rigid and strict fashion. If it was, it would have called it a protocol! Therefore, use the consultation frameworks as they are intended to be used – as a guide – gently follow their direction – but allow for flexibility. If the patient goes off in another interesting and relevant direction, then be curious and follow them, and when that line of enquiry is over, gently come back to the framework, see where you are, and continue.
But the problem is that in the CSA, trainees end up following their favourite CSA framework in a rigid and inflexible manner. And what that results in is a whole series of ‘doctor question – patient answer’ interactions. The interaction is more like a survey, questionnaire or even interrogation – no actual story develops. If the patient decides to say something sensitive, they are quickly shut down by such doctors simply because it would mess up the sequence in their favourite consutlation framework. Such doctors say something like ‘we’ll come back to that’ just because they want to carry on rigidly in the sequence of the framework rather than the story. Remember, the story provides the accurate picture. If the patient’s story could be likened to a big jigsaw puzzle, the narrative results in lots of jigsaw pieces being given to you whereas the tick box approach results in you getting a few. Thus you’ll end up with less clear a final picture
So, what I am saying is YES use a CSA framework to help structure your CSA consultations. But don’t use them so rigidly. Allow a bit of flexiblity depending on the patient, their problem and the context. Yes, explore the ICE and psychosocial. But in some cases you might do the ICE first and others the psychosocial first – it depends on what the patient tells you – i.e. there story. If they’re telling you about their pyscho-social and you interrupt because you have only just finished section 1 above (open question/golden minute) and want to move onto section 2 (ICE), then you will have damaged the flow. The patient may have been all geared up into telling you something senstive and delicate in their psychosocial but now is less likely to do so.
So, a patient whose husband has just died, yes – be flexible, go gentle, see where the patient takes you, and follow the patient (keeping the CSA framework parked in your mind to come back to when it is a more appropriate time to do so). Yet with the patient who rambles on and on and on about this that and the other, then you might want to follow a CSA framework with less flexibility in order to ensure a comprehensive enquiry in a structured way. Follow your heart as well as your mind. Be curious. Be interested. Be open. Show compassion and empathy. Be flexible. Be relaxed. Be you.
I hope that makes sense. If not, post a comment below.
The theory behind the narrative approach
In this video, Graham Gibbs from the University of Huddersfield talks about the use of narratives in speech and research analysis. At first, I thought “what has my job as a GP got to do with data analysis of the narrative?” but then I came to realise, that is exactly what GPs do! Okay, so Graham in this video is talking about the analysis of the narrative for his students studying ‘Qualitative Data Analysis’, but the fact is – we as GPs do the same on a daily basis – except in a less formal and less research sort of way. What he has to say in this lecture is extremely thought provoking. To us GPs, it gives some idea of the different ways we can analyse the story the patient is telling us. For example, Gibbs advises his students that if a person repeats part of a story, then that person is trying to emphasise that part of the story and the students should take note. The same is true of our patients. I hope, when listening to this video, you will learn a lot of things that you can transfer to your daily GP practice which will hopefully transform your practice to a completely new and wonderful level.
If I had to summarise what Graham Gibbs says about the narrative, I would pick the following bits from his slides…
The narrative is the story conveyed by patients which represents and contextualises their expereince and personal knowledge. It helps them to make sense of what happened. Norman Denzin (1989) says the story is a sequence of events with significance for the narrator and audience (in our case, the patient and us). The story has a beggining, a middle and an end. They are connected through logic. Narratives are temporal – in other words they have a causal sequence where one thing leads to the development of the next thing that leads to the development of the next thing and so on.
HOW DO PATIENTS TELL THEIR STORIES – The Cortazzi Model (1993)
This is the Cortazzi model (1993) of how people tell their stories as applied to patients. Cortazzi says a story goes through the following 6 optional phases. The abstract and coda bits are sometimes missing.
- Abstract (optional part) – what was this about? Initiates the narrative. Summarises the point or gives a general proposition which the narrative will exemplify. Sometimes, the doctor may ask a question which will help clarify the abstract.
- Orientation – Who, what, when and how. The patient elaborates about themselves, others in the story (the cast), the setting, the time period and so on.
- Complication – Then what happened? This is where the major account of the story and it’s central events are told; the bones of what happened; the meaty part of the story. Often in past tense. Involves a description at some point of problems, crises and turning points. But also an account of what the patient thinks about these (how they made sense of it all).
- Evaluation – So what? This is where the patient evaluates the narrative told so far.
- Result – What finally happened? The patient details the outcome of events or the resolution of the problem. “So, hence I did…” or “And that’s why…”
- Coda (optional part) – Have we finished? Marks the end. A return of speech to the present tense. The patient leaves the consulting room.
- Patient: “Doctor, can I talk to you about these headaches I’ve been getting for a while. I can’t cope with them any more…”
- (Patient tells doctor more about the headaches)
- Doctor asks some medical questions (e.g. red flags) about the headaches – by the way, there are none.
- Then doctor asks – “How’s things are home? You seem a bit on edge”.
- Patient breaks down and cries. “Well where do I start? My life is a mess at the moment and I really feel like I don’t know whether I’m coming or going. Everyone is stressing me out and I dont think I’m coping very well.” (THE ABSTRACT)
- Doctor says “Sounds like you’re in a very difficult place right now. Are you able to tell me more?”.
- Patient says “Well, first of all there’s my husband. I ended up with a sexually transmitted infection about 6 months ago. And I know I haven’t been sleeping around. But I found out he was. That hurt so much”. (THE ORIENTATION)
- Doctor says “I am sorry to hear that”
- Patient says: “Well anyway, the infection and thing is all sorted know. But it was embarassing going to the sexual health clinic at my age. I mean I’m 55 and every one in there was like in their 20s. They way they were looking at me. And then me and him just had arguments all the time. He kept apologising but I’m not sure I can forgive him. I want to but I am finding it so hard. And you wouldn’t think things could get any worse. But then after that my daughter announced that she’s taking her family and emigrating to Australia. And that was a severe shock. I love seeing my grandchildren and I look after them three times a week. They’re going in 2 months time and after that I’ll see them like once every 2 years or something. It’s awful. Absolutely awful (patient cries)”. (THE COMPLICATION).
- Doctor says: “So where are you up to with things now?”
- Patient says: “Well, I’m still very sore at my husband. But the biggest thing troubling me is the daughter. I don’t know what to do.”
- Doctor: “Coming back to these headaches, have they been getting worse of late because of all of this?”
- Patient: “Yes, come to think of it – yes definately. In fact they only started about the time I found out about my husband”.
- Doctor: “So, what do you think needs to happen to make your life a bit more stable again?”
- Patient: “Well, I suppose the first priority is the daughter thing. The husband thing can wait – but she’s going in 2 months and I don’t know what to do”. (EVALUATION)
- Doctor “Why don’t you talk to her about the way you feel. Truly express what you are thinking and feeling to help her understand things from your point of view?”
- Patient: “I suppose you’re right. I don’t know though. What will come of it? But I suppose it’s better than keeping it all in. Doctor, do you you think that’s why these headaches are happening? [doctor nods]. So, I really do need to get a hold of the situation don’t I rather than just ignoring it? [doctor nods again]. Okay, I think it will make me feel better even if nothing can be done but she at least understands my point of view.” (RESULT)
- Doctor says: “Sounds like you have a plan. Why don’t you come and see me again in a couple of weeks and let me know how things are going? We can also see if these headaches are improving, which I have a feeling they will.”
- Patient: “Thank you so much for listening doctor. I’m going to give it a bash. It’s better than doing nothing. Thanks again.” (CODA)
HOW TO ANALYSE THE PATIENT’S NARRATIVE AS A DOCTOR
- How the person (in our case, the patient) is using their time to tell their story.
- How the story is organised – the romance, the tragedy, the up and down movement of the story etc (more on this below)
- How the tale is developed – what events are, where other people come in and out.
- Where and how the narrative begins and ends. Why does it end.
- How they give shape to events.
- How they make a point. (PS making a point suggests there is something they want to bring out).
- How they ‘package’ the narrated events.
- Their reaction to events.
- How they articulate their narratives with you (and bear in mind that the narrative might have been mentally rehearsed before it is told to you).
More specifically, you can explore patient’s narrative in several ways (modified from Leiblich et al, 1998)
- The Content of the Narrative
Focus on the meaningful content of the story. What themes are being talked about? Allow the patient to express their ideas, concerns and expectations. Gently allow the exploration of the psycho-social-occupational story to unfold. Does the story make sense? If not, explore the gaps or inconsistences. Are there big chunks of a story being left out? If so, gently expore why they were left out (there’s often a reason!).
- The Plot, Form or Structure
Explore the plot of the life story. The plot generally falls into one of four categories: romance, comedy, tragedy and (rarely) satire. Romance – the patient faces a serious of challenges en route to their goal (and hence eventual victory). For example, patient overcomes some disruptive life event (the fight against a serious illness for instance) and then the patient gets back into life. Comedy – where there is social disorder of some form and the goal is the restoration of the social order. For example, where there is massive changes at work and the patient then overcomes all of that and order is restored again. Another example is a massive disruption to the family structure and dynamics (e.g. new children, husband leaving, sister does this that or the other etc). Tragedy – the patient is defeated by the “forces of evil” and is ostracised from society (metaphorically speaking). By ostracised we mean they are excluded some way and society might be the work place family, the family, a community, or that they simply don’t get the benefits that are due to them and so on. Satire – a cynical perpsective on a social hegemony/heirarchy/leadership/organisation. Where a patient may step out of a community, society or group and negatively comment from the outside – like how ridiculous people are and/or a criticism of the social norms they are following.
- Linguistics & Style
Focus on the discrete linguistic or stylistic characteristics of the way the patient tells the story. For example, what metaphors are used. Whether the tense is passive or active. These discrete linguistic or stylistic characteristics usually help us to decipher the inner meaning of events to the patient. So – listen carefully to what the patient is saying, the words they are using, and the structure of what is being said.
– Adverbials like suddenly may indicate how expected or unexpected events were.
– Mental verbs like I thought, I understood, and I noticed, may indicate the extent to which an experience is in consciousness and can be remembered.
– Denotations of time and place may indicate attempts to distance an event or bring it closer.
– Past, present and future tense in verbs and transition between them, may indicate the patient’s sense of identification within the events described. Past tense indicates a story is being told and perhaps to distance things.. The comparison between past and present may be used to emphasise progression or ascension or to distance things again.
– Transitions between first-person, second-person and third-person voice may indicate difficulty of re-encountering a difficult experience. Is it being done to me or is it being done by them?
– Passive and active verbs may indicate the patient’s perception of agency. Again, do I achieve or is it things being done to me.
– Breaking chonological or causal flow with disgressions, regressions, leaps in time etc may indicate attempts to avoid discussion of a difficult experience. Why are they moving away or digressing? Is the new thing more important or are finding it difficult to continue talking about something?
– Repetition may indicate thta the subject of discussion elicits an emotional charge for the patient. Repetiton emphasises something important; there must be a reason why patients repeat themselves – it may have high significance for the patient.
– Detailed descriptons may indicate a reluctance to describe difficult emotions (hence the focus on the descriptive rather than feelings).
- Holistic vs Categorical
What is being told – the whole story (holistic) or just part of the story (categorical)? If the story is being told in segments or parts, remember to book follow-up consultations to allow the whole story to develop. In both cases look at the progression of the story. What’s happening? Ascension or Advance – where a story moves to better things. There may be a turning point – an epiphany and so on. Descension or Regression – the story moves to worse things. Stable – where the plot is steady. Neither worsening or getting better; just the same. A combination of the above – a story might ascend to a climax and then fall. This is often the case in Romance stories, where an awful illness brings a person down (descension) and once they go through the journey, they recover and end up in a better place and possibly even with an epiphany in the end (ascension).
The science behind the narrative approach
The Science of Story Telling
A narrative approach triggers the angel’s cocktails of blood chemicals. All stories do this – not just those with suspense! And what the patient experiences with their difficult is in its simplest form their story.
The Angel’s Cocktail
- Dopamine – alert and focused. Your attention is increased. And you create thoughts in your mind. And so, in the consultation – you’re more alert, focused, and form relevant and good clinical thoughts about further enquiry.
- Oxytocin – makes you feel more human, more relaxed and more bonded to the patient. And in turn the patient will see, feel and hear this and will be more bonded and trusted in you.
- Endorphins – make you relaxed, creative and focused. Mild laughter and bounce in the consultation does this.
Quick non-narrative approaches like the Question-Answer and Tick-Box type methods result in the devil’s cocktail being produced in your blood.
The Devil’s Cocktail
- Both of these also make you more focused and concentrated (which you might at first think was a good thing), but they also narrow your focus and lead you to missing things. High concentrations of these make you intolerable, irritable, uncreative, and overly critical. This results in impairing your memory and thinking resulting in bad and unsafe decision making. Is this something you want? Would you agree that this is something that you cannot afford to do with people’s lives?