New thinking mirrors old wisdom: to understand this manifestation of disease, understand this patient.
Storytelling in medicine
Storytelling in medicine can sound like a nebulous affair. Even if we acknowledge the importance of a person’s self-perception of a disease, the idea that a doctor should sit at the bedside and elicit this–amid unending pages about coffee-ground emesis and uncontrolled pain–might strike the busy clinician as over-ambitious (if not ill-advised). After all, once you open yourself to the hopes and fears of a patient, where will that inexhaustible exploration end?
Tell me about yourself
These theoretical qualms make it all the more striking that most clinicians I talk to find it vital to grasp a patient’s story and personality as well as the chronicity of symptoms. An active hospitalist told me recently how she improved both the quality of her history taking and her efficiency when she stopped asking people, “tell me about your cough,” or the even-more-open-ended, “tell me what brought you to the hospital,” and started instead with a request: “tell me about yourself.”
A person’s experience of a disease
This focus on a person’s experience of disease is typified by the rising interest in narrative medicine. Why are we returning to this most unquantifiable aspect of patient care at the very moment of expanding analytic capacities in diagnostics, data processing, and evidence-based treatment? I think part of the answer is that the more objective data we gather, and the more treatment options we have available to us, the more often we find that our finely-crafted management plan is on a collision course with patient preferences.
Not what, or how, but who
Whether we are recommending medical management of stable angina or chemotherapy in stage IV non-small cell lung cancer, the clinical question is often not “what is the pathophysiologic process underlying this symptomatology?” but “how does the recommended treatment plan for this disease process map onto the personal values and social realities of this patient?” The key concern becomes not what or how, but who.
The metaphor in my mind comes from the dawn of particle physics, when Rutherford, Geiger, and their colleagues bombarded thin sheets of gold foil with alpha particles. It was expected that this heavy particle would pass uneventfully through the diffuse positive charge of the material, interacting only with a puny electron here and there. They found instead that once in every so-many-thousand events, the alpha particle is thrown back the way it came. Rutherford described his astonishment at this finding as similar to what he would feel if they had fired artillery at a piece of tissue and observed the bullet bounced back.
Understand this patient
Similarly, in contemporary medicine, as our ever-expanding clinical knowledge encounters people facing disease, we are forced to acknowledge the inadequacy of that model of the patient as a vague container for diseases and their treatment. Instead, we are coming to re-acknowledge the patient as a solid center, a dense nucleus of aversions and commitments and relationships and values, under whose distinctive influence a disease will chart its path. As is so often the case, new thinking mirrors old wisdom: to understand this manifestation of disease, understand this patient.