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Hearing the Stories – a Holistic Approach
Up until writing these first words I have a memorised narrative, as we all do. We call this our Life Story and we define ourselves by this and the stories we tell about the major chapters of our history. Of course, our stories and our actual history do not always correspond as we build our narrative, evolve it, exaggerate it and conveniently forget some parts of it. We have to remember that patients have been known to do the same with their histories too.
Our day to day working life involves inviting people into our surgeries and asking them to share the narrative of their clinical problems, quite often associated and coloured by their personal life and circumstances. When patients bring their problem to a clinic, they quite often narrate the story as though it is a separate entity, divorced from themselves. They tell the story about their tooth, as in “my tooth hurts”, not “I hurt”. It is as though they are distancing themselves from pain and also from the responsibility for the problem. We, as practitioners, need to employ skills to analyse this story and to reach into it to extract information relevant to a possible clinical problem whilst listening to them holistically and trying to understand what is important to them and how it relates to their universe. As the philosopher Michel Foucault describes in his work, The Birth of the Clinic - “The task lay with this language of things, and perhaps with it alone, to authorise a knowledge of the individual that was not simply of a historic or aesthetic order”. However, just by being the listener, we are altering the way the story might be told.
Give patients a voice
Despite this need to enable patients to feel `heard` and despite the need to weave their stories into our clinical answers, patients quite often complain that their doctors and dentists do not listen. In order to be more effective, clinically, and practice Person-Centred Care, we have to learn to deploy some degree of `narrative analysis`. Our need is their need, and that is to give patients a voice.
We then have to reframe their narrative in clinical terms and feedback the story to help them understand the rationale of any clinical problem. The really difficult stage comes next, when we have to define options and choices of treatments in a way which fits in to their personal needs, or at least resonates with their personal understanding of their problem. In other words, we become story tellers. “Within any healing art, whatever else we do, we treat by telling a story” - Lewis Mehl-Madrona (2007)
There is an amazing synchronicity in the work that we do, because teeth do have another function other than eating. Teeth are required for the function of communication too. Through non-verbal communication such as smiling or growling and in the forming of intelligible words when sounds are made by the exact position of the tongue at the back of the front teeth. Our work involves both listening to narrative and enabling the telling of narrative.
A definition of narrative is “a sequence of events in time”. So this could be any sequential telling or writing that involves “This happened, then this happened, then we did this”. However, we can add in another element of `causal narrative` as defined by “This happened because this happened”. These are the foundations of taking a history from patients. However, both dentists and patients can actually put two and two together and make eleven, as their understanding of illness is coloured by cultural, ethnographic and personal influences. We need to be very aware of this.
The conflicts and difficulties of engaging patients in their own health/illness narratives are varied too. This is quite often complicated by the fact that even the health provider has their own history of being a patient. We can help by defining the `plot` in this story, which is defined as “How has this illness affected me?” or “How has my story changed?”. In other words, a version of the causal narrative described earlier. The way to use this plot, once understood, is to continue the story with chapters on how characters (such as the dentist) will help in achieving good health. However, do we see ourselves or the patient as the “hero” in this story?
A man in his fifties came to me with a problem of loose teeth not so long ago. The story he unfolded started with a playground accident as a kid. He fell and bumped his front teeth and needed to lose one as a result. Not an uncommon story even now. However, he described the gradual loosening and loss of several more teeth over the years which he said was “not through gum disease”. In his mind this was just a “domino” effect from the original bump over which he had no control. After listening to his story, I needed to unpick the constituent parts of the narrative and explain that he had gum disease after all and this was confirmed by other signs and symptoms he had described over the period. These conflicting beliefs are cognitive maps, anchored in strong emotions. These maps are difficult to change, but understanding them in the first place is helpful.
Dentists also involve themselves in a “visual narrative” when we study X-rays. An x-ray is an image capturing a fleeting instance in time, however, it tells a story of its own which meets the definition of “narrative” as I described previously. The number and position of missing teeth, the shape and thicknesses of bone, the drift and position of anatomical landmarks all tell a story of activity over time, of disease history and of cause and effect. As clinicians, we need to read this story, analyse the plot and make up our own conclusion. How this visual text is read depends on the training, background and experience of the “taker”. In my position as an Expert Witness, I am continually investigating the skills and motivations of other practitioners and the x-ray images are one aspect of this work. Even the decision to take an image and the particular angle and choice of view tells me as much about the practitioner as his work.
There is a case for narrative training in developing “narrative competence”, through which health care professionals can become more attentive to patients, more attuned to patient`s experience and more reflective in their practice. Of course this also means more accuracy in diagnosis and increased clinical effectiveness. I am hoping that some practitioners will study Narrative Research in order to enhance active listening and increase engagement of the patient with their care – enabling a better understanding of individual stories within the clinical environment, or through the study of collective stories and a greater understanding of the effect of poor (and good) health on those individuals.
Dr John Shapter – QCS Expert Dental Contributor