the story (2 voices) BK50249

Immediately his story was thrust upon me. Before we’d even sat. Like a stove kettle whistling and bubbling over only stopping once boiling point was reached. “Dismissed” by the GP in 5mins as a rotator cuff strain, seen by private physio for 9 sessions of soft tissue massage with no benefit. They’d recommended a scan as they couldn’t help any more, the referral to us had been delayed and he’d had to chase the GP surgery multiple times before it was sent. Pissed off doesn’t come close! The doctor and reception staff “incompetent”. The physio “competent” but unable to help. He “knew” it couldn’t be “muscular” as there was no injury, and he was worried about the effect it was having on his paragliding and driving. His story was over and he’d come off the boil.

My wife loves a good story shared over a cup of tea. In narrative therapy our story is our identity. If we share in their story then we connect on a personal level not just as a professional. This requires a conversation. Conversation requires at least 2 voices. Two voices give balance, perspective and understanding that monologue cannot. “As iron sharpens iron so one person sharpens another” so the old proverb goes.

I get worried if I feel like I’ve been talking too much but equally if I can’t get a word in. I’m happy with interjection. It allows detail to be garnered, instills a sense of really listening and that they’re being taken seriously. But briefly and allowing flow to the story. Essentially they are telling us what is wrong with them. Often desperate to give us clues if we’d only listen and allow them time and permission. In reality a dichotomy of subjective and objective data exists simultaneously within this conversation. Incomplete history may skew red flag risk profile, objective assessment, and patient specific treatment priorities.

oslerquote

Each story has its past, present and future. If we don’t allow their story to unfold we may not know where they have been, are currently or even are going. Very often re-living this is emotional whether happy, sad, funny, painful, or angry. People often open up deep wells. Stuff they haven’t told others and sometimes can’t believe they have told you. There can be unexpected tears. This is not to be avoided. In fact narrative therapy encourages exposure to these events to allow processing. Here the worst type of therapist is the avoidant. Allow space. Don’t ask questions you don’t want to discuss. Now is not a time for pretense.

buzzard quote

The start of a healthcare visit is an important moment of amazing potential. Normally I’ll start by asking if its their first time. This often provides interesting insights. Maybe I’m their first impression, maybe they’re coming with baggage. Once that conversation has ended I’ll start with something simple like “so what’s been going on?”. The way we introduce the conversation is vital in developing and contextualising the healthcare experience. It is not the start of their health journey nor is it the only journey that they are on. Remember this. You are joining part way through THEIR story. This is a privilege. Are they fitting into our schedule and expectations or are we fitting into their story?? I can recall countless patients put off by their doctor (usually surgeon!) by their dour bedside manner, and conversely enthused by those who are simply courteous or engaging. Likewise there are countless who complain that they weren’t even looked at/touched (often due to time restraints). They feel fobbed off, disengaged, and not taken seriously.

As this subjective unfolded my heart sunk as he proceeded to explain rotator cuff type symptoms in his story. By this time he was coming off the boil and it felt like my point in the conversation. I approached the rotator cuff symptoms, explained massage was unlikely to make it stronger and told him what I’d expect from his objective assessment if I was right. The fact I write this you may guess that the objective was clear and he marveled at his lack of strength on what he considered his dominant side. (3 sessions later and he had returned to paragliding- and wanted to implement a preventative rotator cuff program to his paragliding club!). Coming in he was an emotional wreck, he left a new man. Not from anything fancy; I just listened, talked, explained and re-assured. You know, like humans do. (Try that robot).

Every life has a story. Everyone is on a journey. So what’s your story? And what is your patients? How have they got to here? What were the milestones?

Have a cup of tea with your patient. A little MORE conversation a little LESS action. Or at least a little more conversation before getting to the action!

Be more human. Be less robot.

Thanks for getting this far.

Neil

Further reading:

Please please read this if you get the chance, an excellent piece in BMJ (slightly longer but worth it!) Lehman 2015 http://bit.ly/bmjrealebp

Brilliant new blog from Alan Taylor + great case study of why we should listen for alternative diagnosis http://bit.ly/altaylorTHINK

The above case study was relatively simple. For an insight into more complex cases this from Bronnie Thompson gives practical advice on developing a shared plan http://bit.ly/bronniesharedplan

Featured content:

Wiki. https://en.wikipedia.org/wiki/Narrative_therapy (includes criticism)
Proverbs (700 BC). The Bible. https://www.biblegateway.com/passage/?search=Proverbs%2027:17
Red Hot Chili Peppers (2006). Tell me baby. https://youtu.be/tX72ZEWlWQY
Presley (1968). A little less conversation. https://youtu.be/d0vXxH1IEmQ

4 thoughts on “the story (2 voices) BK50249”

  1. Morning Neil,

    Anyone who writes passionately and logically like this deserves a reply to their blog. Especially when they are a Dirty Leeds fan. 1971 under Revie was my start.
    You are absolutely right in what you say. We need the biomedical model to spot the potentially nasty stuff and help our reasoning, but this is easily integrated into what you are advocating.
    A bit of compassion, reassurance and telling of the truth regarding MSK injuries goes a long way.

    Kind regards

    PS. Top kettle

    Like

    1. Great comments! I am a long suffering Leeds fan which affects my outlook on life!

      This chap certainly had a very biological component to his condition. Any individual system needs to be contextualised in them as a person. Feelings of weakness, pain, disability can be profoundly different between individuals.

      I’m writing in the context of my career which was very much quick subj tick box to get major relevant data before cracking on to the important bits. This has reversed over time.

      Really appreciate you taking time to feedback it certainly fuels my passion for writing and gives ideas for future blogs.

      Super Leeds!

      Like

  2. Great stuff Neil. Ive just started a new job at a private clinic and the amount of handovers im getting that says analysis: rotator cuff tendinopathy then Rx: acupuncture with no exercises given is literally a joke! I query if healthcare needs an Ofsted equivalent because there are so many charlatans genuinely making patients worse not better!

    Congrats again

    Paul

    Liked by 1 person

    1. Thanks for the feedback Paul. I share your frustrations!

      I would add that I’ve had similar experience from NHS care. It (seems) relatively simple doesn’t it.

      I agree bench mark quality is hit + miss in physio so an OFSTED like body may help that. But as a caution would this send us down an increasingly objective route, paperwork, targets, stats (all good in the right dose) but I’m aware of plenty of teachers who feel the children are coming 2nd in education. A tricky balance to achieve. Needs a lot of careful consideration.

      It should also be said in both out experiences physics who have some clinical reasoning + knowledge of evidence would help daramtically!

      Thanks again for engaging!

      Like

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