Dear John,

You are approaching the coal face that is primary health care, health
visiting and a pain clinic. The hand-over of narratives is achieved after
establishing a rapport with the patient and then a tacit understanding of
the problem. The paradox is that the consultation is not a fairly short
time. I consult in 7 and 1/2 minutes, but this reflects the high morbidity
levels in a elderly community! The key to providing care is to improve
access. We have just, some what sceptically, provided 48 hour access to a
consultation. This is the first week, but it is working and seems to have
worked where other practices have piloted the idea.

The great aspect of my work with patients is that I see them several times.
I can switch from not missing a transcendable medical illness (e.g.
Polymyalgia Rheumatica would be an example) to listening to an illness
narrative. The latter achieved over several consultations, but each
consultation contains a mix of the physical, psychological and social. The
problem with my job is that the opportunity to be a therapist is limited by
the very need of patients to have access. So I have to triage, If I can not
get to a point where I can explore emotional problems sufficiently deeply, I
have to know a counsellor who can.  My therapeutic relationship is
undermined by the patients request for a magic medical solution to  their
problems. In a sense the style of doctoring where practitioners like to open
a can of worms is restricted by the time available at coal face and the need
to come to the surface for clean air. There is not sufficient room to delve
deeply and the doctors may feel that their need to be a therapist is not
being acknowledged by the fat controllers (sorry Mr Milburn et al)

The use the time between consultation is crucial. The aim must surely be to
give patients the opportunity to write down their experiences or conversly,
the use of medical handout literature can better inform the subject as to
the medical narrative. So is the skill to give to GPVTS scheme doctors one
of exploiting the time between consultations? I am anxious to keep the
Registrars in the context of a general practice coal face. I feel that the
patient has to make there own journey, the consultation proceeds at a pace
where disclosure may be forced.

Well time to mix my metaphors,

Yours sincerely,

Nigel
----- Original Message -----
From: "C&F John Launer" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, November 08, 2001 9:38 AM
Subject: Narratives


Hello everyone

Some thoughts arising from the very interesting exchange of ideas that
followed Nigel's request:

1.      Doctors and nurses aren't anthropologists. We need to know
something about
the way that that social scientists listen to narratives but if we
diverge too far from our own social role we will (a) freak patients out
and (b) get struck off. One conceptual framework I use in order to deal
with this, is to see the encounter with patients as a cross-cultural
exploration involving two narratives: the biomedical one and the
personal one. In effect, I am offering the patient a particular kind of
cultural narrative that I am paid to know, and I am asking the question:
can any of this be usefully incorporated into your personal story? Very
often the answer is yes (e.g. 'Yes I do find it useful to be told this
is tennis elbow'). Sometimes it is no. ('e.g. No I don't think the label
of depression is of any use at all for the complex experiences I am
having') And then there are all kinds of other situations where the two
narratives seem dissonant and one has to work very hard to interweave
them (e.g. a patient with a sky high TSH who thinks they shouldn't take
thyroxine, or someone who insists their child has ADHD when I think this
is a very simplistic way of describing a whole matrix of difficulties)

2.      Social science interviews can take one or two hours, but our
narrative encounters are usually about ten minutes, twenty if we're
lucky or run late. So the overriding question for me always is: what is
the part of the narrative that most urgently invites inquiry or
development? Often I think we have no choice but to make a unilateral
decision about this (hopefully an informed and benign one). But I am
also interested in how to share this decision with patients, by making
the context transparent (e.g. 'We've only got a fairy short time -
what's the most important aspect of this problem that we need to
address?') I think that if we avoid this transparency, it builds up
false expectations of what we can offer therapeutically, and also
puts us at risk of exhaustion and burnout.

I am talking here about doctors and nurses working in typical NHS
circumstances - obviously there are some therapeutic settings where they
may be able to take a much more flexible stance far more akin to social
science ones.
John