The importance of listening to the patient in the consultation: What is narrative medicine?

"The patient comes into the office. I look at my watch. I'm already behind. I'm going to have to speed up if I want to see everyone waiting outside. We greet each other, he sits down, and he begins to tell me about his health problems. I notice he's rambling, jumping from one topic to another, and most of his story is fluff that doesn't interest me. After half a minute, I can't take it anymore and decide to interrupt him with a direct question, since I need to save time and get the interview back on track."

This scene is repeated today in almost every doctor's office around the world and is a reflection of modern medicine. There is an ever-increasing demand for care from citizens, and healthcare system resources are limited (and becoming insufficient). This is the result of a welfare society in which life expectancy is increasing, but in which chronic diseases and hospitalizations for health problems associated with old age are on the rise .

At the same time, modern medicine has changed over the last twenty-five years. Previously, priority was given to patient questioning and a thorough examination of their body. Today, professionals rely on ultramodern diagnostic tests that produce reports of unquestionable rigor and on increasingly accurate artificial intelligence tools that learn as they are used. It is no longer necessary to talk to the patient to find out what is wrong. This is the result of today's lifestyle, where promptness and the immediate gratification of our desires predominate .

The demand for care will become overwhelming for society within a few years, as healthcare management experts predict. In this context, one of the potential maneuvers to avoid healthcare collapse would be to diagnose and treat diseases as quickly as possible thanks to emerging technology . Consultations would reduce time spent with patients, thus increasing the number of patients seen per specialist per day. However, this philosophy, which is gradually permeating our healthcare system, is leading to the loss of dialogue with the patient . The abandonment of the narrative of the illness told by the true protagonist. We are witnessing the depersonalization of the doctor-patient relationship caused by the loss of narrative medicine .

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What is narrative medicine ? It is defined as " medicine practiced so that the physician can recognize , absorb , interpret, and be moved by the patient's story of the illness ." The term is taken from the book Medicinanarrativa. Honoring Illness Stories by Dr. Rita Charón , who is convinced that "while it must be acknowledged that the task of listening on the part of the doctor in a consultation is very demanding, that of recounting one's own illness is even more so, because pain , suffering , worry , anguish, and the feeling that something is not right are conditions that are very difficult to express in words."

Narrative medicine is currently being lost. The tight schedules of appointments are a problem for any doctor who consults, and this causes them to unconsciously (or not) interrupt the patient when they are speaking and steer their conversation back to practical matters. Often, the doctor has done a mental calculation before starting the day and estimates an average time for each of the twenty or fifty patients scheduled to be seen that morning. If at any point they need to elaborate on any of them, they know they will have to cut back on the interview with someone who will follow later. This is the sad reality of a healthcare system that is beginning to suffer from the problems I have outlined above.

But the lack of narrative is not only a consequence of limited consultation time . Sometimes the physician may have it available, but other circumstances prevent him from applying narrative medicine, such as a self-protective mechanism in the face of the sadness caused by the patient's story. It may also be because he believes that narrative can undermine his clinical objectivity or even be a consequence of an irrational fear of a possible future request from the patient (what is called defensive medicine ). Experts are convinced that medicine practiced without understanding and awareness of the tragedy the patient is suffering is an insufficient therapeutic maneuver , even when the technical and therapeutic objectives established for the cure are met. This lack of empathy or depersonalization seems to increase as the physician's professional career progresses, since they tend to harden as they gain experience.

Another situation that alters the doctor's perception of the story is often their lack of understanding of the ordeal the sufferer is going through (generally, the physician doesn't understand this until they themselves become ill). I've always thought it's due to the false sense of immortality that accompanies those who are accustomed to dealing with illnesses that affect others. We doctors often have no idea of the rage and fear that comes with suffering from an illness, or we don't want to know so it doesn't affect us. I remember how, as a first-year resident, a patient died in the operating room. That affected me profoundly, so much so that when I got home, I wondered if this was what I really wanted to be. Not only because of the death of a fellow patient, which is a very difficult situation for a doctor, but because of the attitude of the two surgeons who had performed the operation: once the patient died, they had left the operating table and started talking (in my opinion, in a nonchalant manner) about other cases that needed to be treated the next day. At the time, it seemed like an inhuman and undignified attitude to me, until years later I realized that it had been just a defense mechanism against misfortune, and that the bitterness of the event (which, without a doubt, was deep within both of them) gnawed at them as if they had ingested acid.

Listening to the patient's story of their illness has healing properties for them. It doesn't eliminate microorganisms, nor does it fix an intestinal or coronary obstruction, nor does it shrink or eliminate a malignant tumor, but it helps provide comfort to the patient during the terrible process they are immersed in. Suddenly, from having an orderly life, with established routines, someone has told them they need surgery or a major treatment, and their world as they know it comes to a standstill. Doubt, fear, and rage overwhelm them, and they demand understanding of their personal drama from their loved ones, but also from their doctor. Psychiatrist George Engel emphasizes this theory and calls it the " biopsychosocial framework ," defining it as "that branch of medicine that takes into account not only the biological changes of the disease [extremely important, of course], but also its familial , community, and social consequences."

In consultations, in addition to time, which is always scarce, there are other variables that increase the distance between doctor and patient and hinder the narrative (and which could be easily resolved with a willingness on the part of both). The first is shame. There are topics that are difficult for the patient, such as revealing their sexual practices , bowel habits , the use of certain substances, or certain emotional problems . These are also uncomfortable topics for the doctor to ask and hear, and he or she may omit the questions to avoid discomfort. Often, both doctor and patient may modify the story (intentionally or not) to avoid the embarrassment of the situation.

The second is the feeling of guilt . The patient may be aware that they have done something wrong and regret it. For example, they smoked and have been diagnosed with lung cancer. They knew about the association between smoking and cancer (everyone knows this nowadays), but they have continued smoking despite the recommendations. And now they regret it. This patient will suffer even more than the one who also has lung cancer but did not smoke (the latter will be overwhelmed by a feeling of rage at the injustice). On the other hand, the specialist may be tempted to blame the patient by stating that "they brought it on themselves; they shouldn't have smoked two packs a day," or "they're not following their treatment properly and that's why they're not getting better." In all these cases, the doctor-patient relationship becomes strained and the patient's prognosis for treatment may worsen.

The third variable is the fear of dying . The patient asks about the risks of treatment or surgery , and the doctor may not understand the patient's fear if he or she hasn't experienced a similar situation before. This feeling impairs communication between the two. The topic of death must be managed with caution, patience, and... time.

In short, the importance of narrative medicine and its daily use by all healthcare personnel seems logical and proven. Because the transmission of the patient's story, and its acceptance and understanding by their caregivers, is not limited to physicians but also to all other groups: technicians, nurses, assistants, etc. Listening to the patient, allowing them to express themselves and tell us how they feel, is also effective in eradicating diseases, healing wounds, and eliminating tumors.

Get well soon .