Attending to the Story

I reviewed my patient’s chart before I went into her room. Her chief complaint was “headaches for two weeks” and she had a history of PTSD. I researched possible differential diagnoses for headaches and wrote down critical questions to ask.

I introduced myself to my patient and her infant son and asked what was going on. She looked at her baby while describing waking up in pain, feeling torn between staying alone in a dark and quiet room or playing her son, and hoping every night that the pain would be gone in the morning.

She quickly wrapped up her concise story and looked at me. I felt certain there was more to her story. I asked her how work was going. She talked about her new job, the stress of leaving her son at daycare, trying to succeed at work, and rushing home each night. She said she was sure stress was the reason for her headaches. She handed me her solution: new job + new baby = stress headaches. It made sense given all of the pressures in her life, but I wanted to find out more.

I reflected on the diagnosis of PTSD on her chart and on my experiences shadowing attendings, how even people I respected and admired sometimes ignored or dismissed patients with mental health complaints. I considered how my patient’s diagnosis might color her interactions with clinicians. Might professionals diminish or dismiss her symptoms as less real than those of patients without mental health diagnoses? What were her expectations of the healthcare system? Through failing to take her needs seriously, had we taught her to expect less from us? To assume that she didn’t need or deserve as much as other patients? That her pain was somehow less real than someone else’s pain? That it could be more easily dismissed?

I paused for a moment and said, “Stress can definitely cause headaches, but it also might be something else. If we decide now that it’s stress and don’t think about other possibilities, I’m worried we might miss something. If we don’t figure out the actual cause, then we won’t be treating the right thing.”

Relief flooded her face and tears welled in her eyes. I returned to my questions about her headaches, and she told me stories about changes in her sleep, neck and shoulder pain from staring at the computer all day, and an unsupportive family. I listened.

I spent so much time listening that my attending came in. I briefly shared my patient’s story and watched as the attending wrapped up the visit. I was happy when the final diagnosis wasn’t stress, but eye strain. Ultimately, new glasses resolved the headaches. I saw for myself the impact of dismissing or ignoring symptoms because of internalized biases linked to a prior diagnosis.

Here are four ways to create space for your patient’s story:

1. Examine and address your biases and assumptions.

We all have biases that show up with us in the room. Examine them critically and continually. Once you identify  your biases, address them. Recognize the assumptions you bring from reading the chart or hearing a brief description from a colleague. Don’t let assumptions erase, replace, or diminish the patient’s story.

2. Attend to your patient’s story.

Hear all parts of the story, both spoken and silent. Try not to rush, make time to listen.

3. Ground yourself in the moment.

Often we feel rushed and communicate this feeling either verbally or through body language. Center yourself by pausing before you walk into your patient’s room.

4. Be trauma-informed.

Don’t assume that the experience of trauma is responsible for what brought your patient to see you today.

We must value our patients’ stories and attend to the way the stories are told. We need to recognize what’s both said and unsaid. We must create space for someone to speak who no longer expects anyone to listen.