Posted by: First 521 March 2017
We are all defined by the stories we tell. Stories are used to tell others how we have got to where we are, and when listened to teach us people’s narratives. On a daily basis – nay, a 10-minute basis – we are exposed to stories. Many stories we hear so commonly we barely register them consciously before making our own conclusion. 'My left ear was really hurting, then there was a sharp pain which quickly got better before lots of muck came out of it' is a short story which tells us, somewhat remarkably if you think about it, that a patient has suffered from a burst eardrum secondary to an ear infection and allows us to alter the ending by prescribing appropriately.
The way forward is to try and change the patient’s story they tell themselves
Other stores are more nuanced, and our conclusions are reached even more subtly and often with a ‘feel’ for what is the correct conclusion. Chest pain might be a suitable example.
'It felt really tight in the middle of my chest, went right up into my arm and my back. I was sick and sweaty and maybe it was a bit worse moving around but made be breathe harder,' feels more ominous than the slightly different: 'It feels a bit tight in my chest, my arms and back ache and I feel a bit sick and hot and sweaty especially when I try and move. My breathing has never been so hard.' To a layman or perhaps early-year medical student (and most certainly a 111 call-operator), both tales contain enough breathless and tight-chestedness to raise alarm (or an ambulance) whereas to experienced GPs the latter is probably no more than the flu.
Where these stories fit our experience, deducing the ending is fairly simple. Problems arise when illness and pain is less organic, and therefore the story becomes clouded by the patient’s perceptions. Chronic pain is but one example of this. The story of lower back pain in a 30-year-old man who goes to the gym thrice weekly is vastly different from the 30-year-old who hasn’t worked since an accident three years prior and subsequently lost his job, house and self-respect. These stories are harder to align ourselves with, and cannot fit in our framework in which we can truly imagine. Empathy might allow us to recognise this conundrum, but 'I know what you must be going through' usually means we really do not.
When we are faced with these stories, the temptation is to try and end them within our framework of medicalisation and attempting rational changes. As you are probably aware, this is rarely successful. The way forward then, is to try and change the patient’s story they tell themselves. Cognitive behavioural therapy and motivation interviewing techniques are two tried-and-tested if time-consuming methods for facilitating this change. Personally, in these situations I find consciously avoiding medicalisation and the temptation to treat or investigate ‘medically’ encourages the patient to find another solution, which more often than not comes from changing their tale.
Sometimes though, it is important to recognise we cannot change people’s stories ourselves; rather to try and offer them alternative chapters with which to move forward. In these cases, as always in general practice, listening and reflecting are more important than trying to write our own version pf an ending. And when this is realised, the story we tell ourselves of how influential we really are becomes more humble.
Dr Danny Chapman is a locum GP in east and south Devon