A few articles about the practice of medicine echo each other in significant ways, but I share them here as a reminder that all of our work that increasingly relies on technology (e.g., developing digital products) will suffer terribly if we fail to engage the human who thinks, talks, listens and tells stories.
With Electronic Medical Records, Doctors Read When They Should Talk
Even if all the redundant clinical information sitting on hospital servers everywhere were error-free, and even if excellent software made it all reasonably accessible, doctors and nurses still shouldn’t be spending their time reading. The first thing medical students learn is the value of a full history taken directly from the patient. The process takes them hours. Experience whittles that time down by a bit, but it always remains a substantial chunk that some feel is best devoted to more lucrative activities.
Enter various efficiency-promoting endeavors. One of the most durable has been the multipage health questionnaire for patients to complete on a clipboard before most outpatient visits. Why should the doctor expensively scribble down information when the patient can do a little free secretarial work instead? Alas, beware the doctor who does not review that questionnaire with you very carefully, taking an active interest in every little check mark. It turns out that the pathway into the medical brain, like most brains, is far more reliable when it runs from the hand than from the eye. Force the doctor to take notes, and the doctor will usually remember. Ask the doctor to read, and the doctor will scan, skip, elide, omit and often forget.
Like good police work, good medicine depends on deliberate, inefficient, plodding, expensive repetition. No system of data management will ever replace it.
Why Doctors Need Stories
I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: “Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of ‘big picture.’ ”
Beyond its roles as illustration, affirmation, hypothesis-builder and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence. Thoughtful doctors consider data, accompanying narrative, plausibility and, yes, clinical anecdote in their decision making. To put the same matter differently, evidence-based medicine, properly enacted, is judgment-based medicine in which randomized trials, carefully assessed, are given their due.
I don’t think that psychiatry — or, again, medicine in general — need be apologetic about this state of affairs. Our substantial formal findings require integration. The danger is in pretending otherwise. It would be unfortunate if psychiatry moved fully — prematurely — to squeeze the art out of its science. And it would be unfortunate if we marginalized the case vignette. We need storytelling, to set us in the clinical moment, remind us of the variety of human experience and enrich our judgment.
From October 2003, Diagnosis Goes Low Tech
“This technology has become a religion within the medical community,” said Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine. “It is easy to lose sight of the fact that still, in the 21st century, it is believed that 80 to 85 percent of the diagnosis is in the patient’s story.”
Yet medical educators say that doctors are insufficiently trained to listen to those stories. After all, there is no reimbursement category on insurance forms for it. It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: narrative medicine.
The idea that medical students need an academic discipline to teach them how to listen may strike some as farfetched. After all, what should be more natural — or uncomplicated — than having a conversation?
But the narrative medicine movement is part of an ongoing trend in exposing medical students to the humanities. It is needed, educators say, to teach aspiring doctors to pay close attention to what their patients are saying and to understand the way their own emotions affect their perceptions, and ultimately their clinical practice.
The basic teaching method is to have medical students read literary texts and then write about themselves and their patients in ordinary language, rather than in the technological lexicon of the traditional patient chart.
Venerable medical journals like The Journal of the American Medical Association and Annals of Internal Medicine are increasingly publishing reflective writing by doctors, their editors say. And now some medical schools even have their own literary journals. At Columbia University College of Physicians and Surgeons, there is Reflexions; Pennsylvania State University College of Medicine publishes Wild Onions; at the University of New Mexico’s Health Sciences Center, there is The Medical Muse.
Columbia also publishes a semiannual scholarly journal devoted solely to narrative medicine, titled Literature and Medicine, which is edited by Maura Spiegel, a literary scholar, and Dr. Rita Charon, a professor at the medical school and a founder of the narrative medicine movement.