I use a three phase cycle when teaching medical students and doctors.
Phase one is the story.
Phase two, making sense of the story.
Phase three, a therapeutic action.
All doctors have been trained to start with the patient’s story. Sounds simple, and at one level it is, but what makes it complicated is that in every story there is an author and a reader. The patient is the author, and the doctor is a reader. But neither of these roles exist in isolation and the consultation in this phase is a process of co-creation. Both the patient and the doctor bring their stories into the room and, together, they co-author a new story.
Most of these narratives are very, very short stories. Typically less than ten minutes. I remember being very struck by a study which measured how long into a consultation before the doctor first interrupts the patient’s story – 18 seconds. In such short consultations the doctor is seeking to focus and direct the story right from the outset. He or she will decide which story lines to close off, and which to open up. The goal is to quickly move on to phases two and three.
What sense can I make of this patient’s story? Another way to think of this making sense phase is to see that it is about achieving an understanding. The doctor is trying to understand the patient, and the patient is trying to understand their experience. In fact the declared aim of medical undergraduate education is to teach doctors how to make a diagnosis (diagnosis means an understanding). Sadly, the biophysical model and short consultation approach to medicine means that diagnosis is reduced to discovering the presence or absence of a lesion. It’s not about understanding a person in the context of their life, nor about understanding their “illness” in a whole of life context.
The reduction of the understanding phase to the declaration of a clinical label which is then called a diagnosis sets the limits of the third phase – treatment.
The therapeutic interventions are intended to reduce or contain the diagnosed lesions. If no lesions are found, the intention becomes one of reducing the symptoms.
At every stage of this cycle there is a narrowing of vision, which reduces the story to a data set which will be judged as either normal or abnormal. Treatment is then either a surgical procedure or the prescription of drugs to try to alter the data.
What’s the alternative?
Broadening the focus at all stages.
Expand the story from a biophysical one to at least a biopsychosocial one and a story of a person replaces the story of a disorder.
Expand understanding from diagnosis of a lesion to understanding the emergence of an illness in the context of an individual’s life and a person can make sense of their experience.
Expand the interventions on offer beyond surgery and drugs to methods which increase vitality and resilience and a person can experience greater health.
Recommended reading –
Read Arthur Frank’s The Wounded Healer, Kleinman’s Illness Narratives or Cassell’s The Healer’s Art, to better understand the importance of narrative in the shift from biophysical to biopsychosocial.
Read Balint’s The Doctor, the patient and his Illness, Leader and Corfield’s Why do People Get Ill? Or Broom’s Meaning-full Disease to better understand the shift from a disease to an illness agenda.
Read Dan Siegel’s Mindsight, Doc Childre’s The Heartmath Solution or David Servan-Schreiber’s Healing without Freud or Prozac to understand the potential for interventions which don’t involve surgery or drugs.
