Last April we celebrated the first Narrative Healthcare Network Meetup. We were excited to welcome Dr. Danielle Ofri, author and practicing internist from New York City, in the Chassé Theater in Breda, the Netherlands.
In her new book ‘What patients say, what doctors hear’, she shares several stories that show that the gulf between what patients say and what doctors hear can be very wide. We believe that her message goes beyond just the patient-doctor relationship and can be valuable for anyone who wants to become a better listener.
“Communication, empathy, and connection are not things doctors typically learn in medical school. Med schools are beginning to pay attention to these skills but they are usually still seen as add-ons.” […] “Yet the simple verbal exchange between patient and doctor is the cornerstone of medical diagnosis”.
In her journey of studying the verbal exchange between patients and doctors, dr. Ofri found an important reflection tool in writing.
We had a brief moment to talk to her after her reading and this is what she shared with us:
How did writing books change your live as a physician?
Medicine is so fast. There is no time to stop and reflect, whether that’s in the hospital or the clinic – there is always another patient. Writing was the first time that there was a chance for me to reflect. To just sit and enjoy the slowness of writing, it was such a different pace. Each word takes time, each sentence and that gives you space think about them and then to revise. In real life you can’t revise but in writing you can. Not that I’m changing the facts, but it can change how I think about them and where the story will ultimately sit. I have to put it somewhere so I can move forward. Writing gave me the chance that I don’t have in my daily practice. To really think about what I do – to turn it over, look at it from a different angle. Without that, there is just too much emotion going on to really function.
So writing was sort of an outlet for you…
Yes, it is. And so is music, but writing specifically lets me dig around and dissect into the story of what I was feeling, what the patient was feeling, the people around, how society might look at this etc. Like in the time of AIDS, there was so much emotion and no time to think about that. It was a trauma. It was a terrible epidemic and no one stopped to think about it and it was just this daily slog of death. You have to give that a moment, give it some air.
The patient-doctor relationship is the most important medical tool and I believe this is my strongest message.
You write that you feel like there is no space for this air in the medical practice…
Well I think we don’t see this space as being a valid part of the medical practice. You come to the doctor, I give you the prescription and we are done. I have one part in the book where a patient and a doctor come together and speak in front of an audience to share both their experiences and have a discussion about their relationship. There is almost no place to do that, but it is so important because the patient and the doctor have different agenda’s and that was depleting the care. So wouldn’t it be great if we had a chance to talk about how we interact with each other. The patient-doctor relationship is the most important medical tool and I believe this is my strongest message.
You mentioned in your book “The more technological advanced medicine becomes, the more we are reminded of the crucial role of story”, could you talk a little more about this?
Often the technological conversations overtakes the other conversation: “Oh let’s get a CAT scan and we will see everything”, but we skip the part about what is really going on with the patient. The CAT scan is not going to help if the underlying cause of the illness is domestic violence. We rush to technology because it’s easy, we can just check the box. But taking the time to uncover the story of what’s going on at a patients home takes much longer and it’s not something you get paid for at the moment. We need to start recognising that this is important. We don’t exchange technology for the conversation; it’s a supplement.
How does this affect medical education?
We need to start at the beginning of medical school and we need to demonstrate it in real life. We can’t do a PowerPoint with a checklist anymore that says: Talk to your patients, be nice, connect etc. That doesn’t work. We need to demonstrate to the students what an effective conversation looks like. For example, when I’m on the ward, I like to ask my students: “Who is the most difficult patient here? Let’s talk to them!” and then to demonstrate in real time how you can help a difficult situation become easier. That will have a lasting effect on students.
We don’t like ambiguity and uncertainty, but we have to recognise that this is the human condition.
This also means that you, as a supervisor, have to be able to embrace uncertainty and vulnerability…
Yes, you have to live with ambiguity. That is very real. We don’t like ambiguity and uncertainty, but we have to recognise that this is the human condition. And that we still dive into a situation even though it’s not clear what we can expect. We go with the messy part because that is the human part.
Narrative skills are…
Narrative skills are the ability to tell the story and to hear the story. This sounds really simple but there are many skills that go into this. Understanding the layers of the story, the meaning for each part of the story, the role of the characters and how this all fits in the overall medical care.
It is the ability to be in someone’ shoes and to also communicate that. I might understand in my head how you feel but if I don’t let you know that, empathy doesn’t work.
Healthcare needs many things but if I have to pick one, it would be time. We need enough time to do effective medical care; the conversation, the physical exam and time to sit and think about the patient. All these things take time. We try to rush and be ‘efficient’ by pushing more things into less time but it all ends up being inefficient; we make more errors.
“Human connection is a seedling that needs to be cultivated, and good communication is the loam in which it is nurtured. I cannot promise I’ll never have any miscommunication in the future. But I could promise that I will pay more attention to how I listen and how I speak.”