Every day my Twitter timeline is full of ‘listening to the patient’, in some cases to the ‘patient’s narrative’. You need to listen, you must listen, it’s good to listen, I listen, they listen, you listen. You could think the medics just about only listen. And so, today I want to write about the opposite, about not listening or ignoring the patient’s narrative.
Over the last few months I have seen more doctors in more consultations than over the last 5, perhaps 10 years. I have written about repeating the same narrative over and over and over again, wishing I could simply shut up. Every time this narrative is ignored. And it has recently struck me that there are two ways in which doctors do it.
The first way is the seemingly nice way. The doctor makes a ‘listening face’, it’s a mixture of pained concern and dramatic interest, with the body tilted, almost holding my hand. Every time I see it, I wonder whether to weep or laugh. And then I start, I talk, and talk, and talk, sick of hearing myself say the same things over and over again. And then I hear
And all of a sudden everything is clear. I have just wasted my breath for a couple of minutes. My narrative, the centre of ‘patient-centredness’, is irrelevant, as my doctor looks at the computer screen on which they see ‘the evidence’, usefully colour-coded in green and red. Oh yes, the ‘objective evidence’, so aptly technologised by the computer and the internet delivery.
This is ignoring the narrative by stealth. The interest, the concern, the body tilt is like a sleight of hand, you’re lured into the narrative mode only to be thwarted by the ‘real’ evidence!
The other way of ignoring the narrative is much more straightforward. You sit down as the doctor is reading the bloods. They are not even remotely interested in what I say, occasionally nodding their head, not paying attention to a single word I say. Mercifully – I start thinking after a while. At least I don’t have to repeat everything again.
Here are two ways of ignoring what I say – one clandestine, by pretence (I could go on here, after all, I used to write about deception), the other direct, honest not caring. Which one wins? Surprisingly and at the same time obviously, the latter, hands down. Why? Well, for two reasons. First, at least we (well, it’s hardly ‘we’, but let’s pretend) have introduced some honesty into our relationship. You don’t care, I don’t need to babble. But the second reason is more important. Even though the doctor doesn’t give two hoots about my narrative, they still acknowledge the fact that I have it. They reject it as evidence, but they accept it as the trigger for looking for ‘real evidence’.
The first consultation model I described, looks like focusing on the patient’s narrative. Except it doesn’t. It’s about paying lip service to ‘patient-centredness’ and all other new things doctors are supposed to do. What’s quite fascinating is that introducing the narrative mode into the consultation results in rejecting it.
Here is another example of rejection. I was recently challenged by a doctor who decided that it was the clinical notes (inevitably typed as I talk) that tell them what I ‘really’ said. I protested, the doctor, with a polite and patronising smile, accepted my protest, yet, really, the notes trumped everything I could possibly say. Incidentally, I might even understand why a particular part of my story was not picked up on and not recorded as such, but simply saying: “Hang on, you didn’t say this before.” is, quite frankly, unacceptable. But, yes, every time I am soooo invited to ‘share’. The ‘listening face’, the body tilt, the concern, every time.
So what of the other kind of narrative-ignoring? Well, at least it’s honest. As the doctor doesn’t give a damn about what I say, at least they are not pretending, barely listening out of politeness. What matters is the ‘real evidence’. But, as I already mentioned, apart from honesty, there is the ‘narrative-as-trigger’ bit.
The narrative is not evidence, it is used to point the doctor in the ‘right’ direction and then the doctor-turned-detective is looking for her/his evidence. The trigger sets the doctor off on her/his way to find our what is wrong with me. The quest for evidence does not end, after all, I keep saying that I am feeling ill. I have ‘a complaint’, a mystery which the medical model must solve.
It’s a paradox, isn’t it? The model of consultation in which I am encouraged to talk, ultimately results in rejection of the narrative and my frustration. The model in which the narrative – my experience, really – is irrelevant, leads to paternalistically given help, but at least there is help, and without undermining what I say. You cannot undermine what doesn’t matter. I am a patient and the powerful doctor is telling what is wrong with me.
But I don’t want to end with praise for the powerful medic, I understand well the pitfalls of the doctor-universe-master telling me what reality is all about. Still, I am yet to meet a doctor who engages with me, well, meaningfully engages with me, rather than simply asks me to do my bit, after which they will theirs. I want to point out some consequences of asking me to ‘tell my story’. For if you ask me to share my pain with you, you cannot simply reject it, saying that there is the real stuff which is more important.
Or let me put it like that. If you really want to focus on the narrative-as-evidence, you must know what nature of evidence the narrative provides you with and what relationship it has with the ‘real evidence’. And this is a job for you, the medic, not for me, the linguist. But the linguist has one more point to make. Instead of repeating, stressing, reinforcing the need to ‘listen to my story’, I would start with wondering about how you ignore it, because you do, my ‘personal’ experience tells me you do it ‘all the time’. And I would like an answer as to why you do it. Have you got it?