Typical case scenario in a busy pharmacy setting
Mrs. Jones is an 82 year old widow living alone who is here today for a renewal of her blood pressure medications. She has type 2 diabetes, coronary artery disease, hypertension and COPD. Your pharmacy technician informs you that Mrs Jones is wants to speak to the pharmacist and is waiting in the consultation room. Mrs Jones has been your patient for a long time and you know that she has a long list of about 10 medications. When you enter the exam room you find her and her daughter Chris.
Chris is hoping to have a few minutes of your time to discuss her concerns about the number of medications her mother is taking, particularly in light of her Mum’s failing memory. Chris is hoping you could take a closer look at her Mum’s medication list and review them to see if any of them could be contributing to her memory loss. Mrs Jones is having increasing difficulty remembering when to take her tablets. In fact, last week Chris learned just how much difficulty her Mum is having when she found a bunch of her Mum's pills hidden in the drawer of her bedside locker. Too embarrassed to admit that she needed help with her medication, she started hiding her missed doses.
Looking at your watch you realise this is not going to be a quick appointment. Chris senses your distraction and suggests they come back another time to discuss her Mum’s medications when you have more time. You quickly dispense the prescription and move on to your next customer feeling as frustrated as Chris and Mrs. Jones with the whole situation.
Frustration and dissatisfaction when dealing with the complexity of patients like Mrs. Jones
The scenario above describes an all-too-common situation with many patients who have complex healthcare challenges. Although we can sense the patient’s frustration, many healthcare professionals are equally frustrated. How do you adequately prioritise the patients’ needs and enable shared decision-making? There are challenges.
- perceived lack of time,
- lack of confidence and competence in eliciting the patient's perspective
- lack of a holistic view
- lack of appropriate guidelines and
- inadequate payment for dealing with complex patients.
A recent systematic review(2) summarised findings from studies describing healthcare professionals perceptions when dealing with patients like Mrs. Jones. The review identified four main challenges and one of these concerns is related to shared decision-making. Making decisions with patients with multiple chronic conditions was perceived as difficult especially when attempting to elicit patient preferences.
How do we make these complicated encounters better and increase our satisfaction in dealing with complex patients with multiple chronic health conditions? And how do we enhance meaningful dialogue between the healthcare professional and the patient or patient’s family? One approach would be to consider how the“narrative” or story of these patients provides important evidence necessary to providing evidence-based care. This blog post describes the significant benefits of narrative-based methodologies (NBM) for both the healthcare professional and the patient, and how this complements management of complex patients such as Mrs. Jones.
Why are narrative-based methodologies important to your delivery of healthcare?
There are two important reasons why this will help your practice:
1. Forcing the patient’s story into our biomedical perspective misses important information needed to help them to manage their chronic illnesses
The patient’s story (or narrative) has always been an important and vital part of healthcare. However, modern healthcare today has become less reliant on the patient’s narrative and more reliant on scientific evidence and technology. While “facts and findings” are essential in the practice of healthcare we run the risk of replacing the patient’s story of illness with the healthcare professional’s story of disease. It is essential to allow the telling of the illness narrative from the patient’s perspective rather than forcing the narrative to fit into the biomedical perspective. The healthcare professional, armed only with evidence-based medicine (EBM) cannot help the patient grapple with the loss of health or find meaning in their suffering. The evidence-based healthcare professional who is able to listen to the patient’s story and understand the significance of the patient’s suffering is both scientifically and narratively competent.
2. Narrative as evidence
From the medical perspective reaching the diagnosis is often the end of story, a place where we often stop inquiring; but Illness continues to unfold over time. In other words the patient’s history is provisional and continuously changes. This is of particular importance as we provide care to patients, many of whom have complex, chronic health problems. The patient’s narrative provides meaning, context, and an understanding of the patient’s experience of illness. In other words, the narrative builds the bridge connecting the evidence of large clinical trials to the individual patient. The complete story from the perspective of both the healthcare professional and the patient increases diagnostic accuracy, and better informs us as to whether an evidence-based intervention applies to the patient before you.
The fear often expressed by healthcare professionals is not having enough time to hear the patient’s story. However, allowing for the narrative to unfold does NOT always require more time. In a study in which patients were given the opportunity to recount their symptoms and concerns uninterrupted, 80% of the patients were able to tell their story in only two minutes and many of the patients had complicated co-morbidities(3)! The other important aspect of this study was that the healthcare professionals were trained in Active Listening Skills. Now, armed with the complete story, the likelihood of adherence to complex drug regimens or treatment plans, increases.
Is there a conflict between Evidence Based Medicine (EBM) and Narrative Based Methodologies (NBM)?
It is well known that healthcare professionals who practice with both scientific and narrative competence are more empathetic, more resilient, find greater meaning in their work and are less likely to burn out. It also leads to greater patient satisfaction(6).
The “art of science” lies in the ability to apply both types knowledge to a single case. EBM and NBM are methodologies that complement (not compete) with one another.
It is useful to consider the original components of EBM as originally conceptualised by Dr. Sackett(7). The three components are: individual professional expertise, best external evidence, and patient values and expectations - all weighted equally.
A truly EBM approach means integrating all three elements. Over the past 20 years the “evidence” circle is now over-represented and overshadows the importance of the other two. We must remember the risk we take when the analysis of evidence is limited to either quantitative or qualitative data. In the complicated world of medicine using just one form of evidence adversely affects patient safety.
What are some important things to know about narrative-based methodologies?
Complex, chronic health problems increase with age. Many people over the age of 65 have at least three chronic conditions. If we applied individual, EBM guidelines to a patient with five chronic health problems this could result in the need for 12 different medications, at five different times each day. This significantly increases the risk of an adverse drug interaction as well as creating significant challenges with medication/treatment adherence(9). Care by EBM standards would be considered excellent but significantly challenging for the individual patient. In addition, it is very important to keep in mind that many of the clinical practice guidelines were developed using much younger patients, many of whom did not have co-morbidities(10). As our population ages over the next few years and with growing social, economic, and institutional constraints, it will be increasingly important that healthcare is practiced in a way that is effective and efficient for the healthcare professional, patient and society. NBM provide efficiency in capturing both clinical and patient preference information.
How can we increase our narrative based skills or competency?
Increasing NBM competency requires a combination of robust methodologies, empathetic presence and mindful listening. Instead of being distracted by our computer screens, phones and other demands, we must learn to focus on listening to all the patient is telling us in both words and silences. Writing reflectively (e.g. in our CPD e-Portfolios), participating in professional mastermind groups or undergoing reflective supervision about our experience of caring for patients, we gain a deeper understanding of the impact that caring has on us as well as deepening our understanding of the impact of illness on the patient (11).
Where can we go to hone these narrative based methodologies and skills?
There are a number of programmes associated with 4Front which teach you to deepen your understanding of the context of the patient's life.
CLICK HERE to learn more about the LEAD Online Mastermind Programme, which has an 'Engagement of Others' Module, which focuses on active listening skills, resolving conflict, motivating others and demonstrating empathy.
CLICK HERE to learn more about Medical Coaching, a comprehensive professional training in all the mental and emotional aspects of supporting patients living with a medical condition - beginning 26th Jan 2017 in Ireland.
CLICK HERE or scroll down to learn more about the Medical Coaching Learning Community,