Category: Clinical Decision Making

Narrative medicine? Listening to the patient’s story and emotional response: Anne the ‘anorexic’.

Listening to the patient’s story and emotional response: Anne the ‘anorexic’.

In this brief paper, I discuss the importance of the patient’s story and having the space to listen to it.

The way doctors come to their diagnoses, how they listen to patient’s stories, how they decide what to treat, is not a straight forward process though it might seem so. Take a history-perform a physical examination-order tests-analyse results-diagnose-treat-evaluate treatment. It looks linear. It is supposed that the hypothetico-deductive method accurately describes this thinking. However, the objective gathering of data, the analysis of that data to produce a hypothesis, the testing and revision of that hypothesis and subsequent diagnosis could be more an objective academic description of a process rather than an accurate description of what happens in actuality.

 

In addition, medical (and nursing) students are taught increasingly using algorithms, protocols and preset guidelines and decision trees. Evidence based practice in addition supports decisions based on statistically proven data which, while providing sound data regarding populations, cannot account for the idiosyncratic individual patient. Bayesian analysis underpins this type of approach (gather data – hypothesise – assign statistical probabilities – calculate likely diagnosis).

 

Now that nurses are beginning to undertake clinical consultations and diagnosis, the errors in thinking, the ‘cognitive biases’ that doctors are open to, equally apply.

 

Therefore it may be useful to think about our ‘ways of thinking’ in addition to our ‘ways of knowing’. That is to say that in or empirical, aesthetic, ethical, intuitive and social domains of knowledge we may engage in disordered thinking in order to come to empirical, aesthetic, ethical, intuitive and social decisions.

 

According to Groopman (2008) Medical errors result more as a result of ways of thinking rather than technical errors (prescribing the wrong dose of drug for example).

 

One good way to get a grip on this is examining actual cases. The following is from Jerome Groopman’s (2008) ‘How doctors Think’:

Anne Dodge.

Over a 15 year period Anne had seen many doctors. Her problems started with food, experiencing a twisting pain in her stomach after a meal. A visit to the family doctor, resulted in a visit to the psychiatrist with a diagnosis of anorexia nervosa.  Following that Anne had seen:

 

  1. A GP specialising in eating disorders.
  2. Endocrinologists
  3. Orthopaedists
  4. Haematologists
  5. Infectious disease specialists
  6. Psychologists
  7. Psychiatrists

 

Treatment had included four different antidepressants, weekly talking therapy and nutritional assessment monitoring calorific intake.

 

Osteoporosis developed, a hairline fracture of a metatarsal, and a failing immune system resulting in a series of infections including meningitis. Anne was hospitalised 4 times in 2004 in an attempt to gain weight under supervision. However the more she ate the worse she felt. Finally her doctor decided she had Irritable Bowel Syndrome (nausea, vomiting, intestinal cramps, diarrorhea). Despite eating 3000 calories per day she lost weight, which the psychiatrist interpreted as her not telling the truth about intake, consistent with psychological stress and anorexia.

 

The past 12 months saw a deterioration. Red blood cells and platelets dropped dangerously, she felt ill, bone marrow biopsy showed few developing cells. Haematologists put this down to nutritional insufficiency.

 

Finally she was seeing Dr Falchuk, a gastroenterologist.

 

Would he be any different confronted with a very long history, diagnosis and symptoms consistent with IBS, deteriorating mental health and anorexia? The referring doctor implied that he should examine (again) her abdomen and confirm IBS and its treatment.

 

However, his first approach was to question, listen, observe and to think differently. It was Anne’s words which led to the correct diagnosis, not the tests, procedures and scans, language being the bedrock of clinical practice.

Falchuk first noticed body language and observed in Anne:

 

  1. She looked emaciated and haggard, faced creased with fatigue, hands clasped together – he thought how timid she looked.
  2. Beaten down by suffering, she needed a gentle approach that would draw herself out.

 

In the consultation, Falchuk put aside the pile of case notes and simply asked Anne to go back to the beginning, to tell him about when she first felt ill. He asked for her own story in her own words. Anne told her long story all the while encouraged to continue by Falchuk. Then he asked for specifics about her recent attempts to gain weight and what happens after each meal. Anne had felt she had already explained this before to her doctors but now had the time to express her experience. In this encounter the emotional response by Falchuck was instrumental in the unfolding of her story. Falchuk undertook a physical exam but not just of her abdomen; following her story he looked for clues in her mouth and nails,  and her loose stool that remained in her rectum.

 

Not convinced her symptoms were down to IBS or anorexia he ordered bloods and an endoscopy. He believed that indeed she was taking in 3000 calories but that something prevented digestion, hence the weight loss.

 

Falchuk’s consultation and tests revealed coeliac disease. Anne soon gained 12 pounds, the IBS symptoms disappeared. Anne did have an eating disorder but she also had coeliac disease commonly thought to begin in childhood.

Falchuk explained that a maxim he used was that:

“ if you listen to the patient, he is telling you the diagnosis”

 Technology he argues can take you away from the patient’s story. He argued that the “picture didn’t fit”, Anne’s story did not fit the known facts about her medical condition.

 

Debra Roter and Judith Hall have researched doctors’ communication and point out that doctors need to ‘wake the patient up, so that they feel free to seek and enter into dialogue’. If the patient is inhibited or cut off or constrained down one path something vital could be missed. It has been noted that doctors interrupt within 18 seconds of the patient’s story. Falchuk gave Anne more than 18 seconds.

Falchuk began with Anne with open ended questions, responding to the emotions of his patient. Without attending to her emotional state her story would not have emerged. If one is sure of a diagnosis then closed questions can get you to your end point quickly. This was not the case with Anne. We need to reflect that in our initial encounters with patients presenting with minor illness and injury that the sure diagnosis may lead us into closed questions, non attendance to the emotional state of the patient and the potential for missing a vital clue that indicated something important for the patient. Hall argues that patients can easily pick up how doctors are feeling about them and in consultations those feelings can negatively impact on how the patient expresses themselves.

 

The cognitive error was to put Anne into a narrow frame (IBS, Anorexia) and information that did not fit that frame was ignored or not even elicited due to consultation style and over reliance on known facts.

 

Conclusion.

 

Although we do not see complex cases like Anne every day, we still need to listen to the patient, as they will pick up on how you are feeling toward them. This will influence the direction of the consultation and the sort of questions asked and the answers given. The manner of the consultation will direct the result. The technology and investigations are adjuncts. A sure diagnosis may mislead. The fact that we see many ‘minor cases’ may militate against developing this consultation style at all and prevent us  recognising this error in thinking when we may need it most.

Reference

Groopman, J. (2008) How Doctors Think. Mariner. Boston.

See also: http://www.happinessinthisworld.com/2009/04/26/when-doctors-dont-know-whats-wrong/#.VLPE1yusV8E

 

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