Sunday, November 27

The big idea: why modern medicine can’t work without stories | Health & wellness

MMost of us over the age of 30 can remember the family doctor we had when we were kids. They met us as babies and watched us grow up. They knew our stories, those of our siblings, our parents and often our grandparents, too. These stories were fundamental to the bond of trust between doctors and their patients. We are now learning that this deep, accumulated knowledge was also palpably beneficial in medical terms.

The stories came in fragments, of course. Any GP will tell you this: that alongside the medical history, there are glimpses of the life that accompanies it: a past trauma, a triumph, a family crisis, a morbid fear or a reason to hope. Reducing any patient to their affliction, the tumorous breast or lazy pancreas, is akin to regarding a book as nothing more than paper and ink.

This focus on the whole person, while valuable in all medical disciplines, is bread-and-butter work for GPs. Their role as the keeper of patients’ stories is what most of them love about their job, or what they used to. Because the world has turned, and with it the dynamics of primary care. Few of us attending the doctors’ surgery these days expect to see the same GP twice. We don’t know our doctors like we used to, and they don’t know us, a situation only compounded by Covid and the default to remote consultation. Shared stories have, in many cases, given way to medical transactions.

Even before the pandemic, doctor-patient relationships were in serious trouble. A mobile population, a shortage of doctors, overwhelming workloads, the move towards part-time working (for many GPs, the only way to endure the pressures of the job), bigger practices, larger teams: all of this gnawed away at the humanity of primary care. Meanwhile, the rise of evidence-based medicine has been seen to shift towards the management of health risk via a playbook of standardized interventions. While this has driven progress in the treatment of many illnesses, it’s had unintended consequences for the relationship between GPs and their patients. Precisely because the value of those relationships is difficult to render in cold, hard figures, performance metrics are skewed towards outcomes that are easier to quantify. The emphasis, and indeed the measure of success, has shifted from the individual patient to the disease.

As patient numbers have risen, speed of access to a doctor – any doctor – has become the overriding priority, the policy goal to eclipse all others. Continuity is still nominally the gold standard, but the system is no longer designed to support it. It doesn’t even feature in the framework of payment incentives for GPs. Care based on narrative, relational principles is increasingly regarded as a luxury, a throwback to the days of Dr Finlay’s Casebook; in other words, ill-suited to 21st-century healthcare, a video rental store “in the age of Netflix”, as the former health secretary put it in June.

I know this not because I am a doctor myself, but because I’ve spent the last two years studying one. Over many months, I observed a remarkable female GP at work in the same rural practice portrayed in A Fortunate Man, John Berger’s classic account of a country GP in the mid 1960s. In the course of around 130,000 patient encounters over more than 20 years, she has built something that many doctors no longer enjoy: high-quality, longstanding relationships with her patients.

A compelling storyteller in her own right, she told me during our first interview: “Yes, it’s important to examine people, but you work out what’s going on from the stories. And if people know you and trust you, and you give them time to talk, they give you gems of critically important medical information.”

Because of course the relationship between doctor and patient is not simply a nice-to-have. It saves lives. A growing body of research links seeing the same doctor over time to a number of significant benefits: greater patient satisfaction, closer adherence to medical advice and medication, better uptake of vaccines, reduced use of out-of-hours services, lower referral rates, better job satisfaction and retention of doctors, fewer A&E admissions, even, according to a large -scale study from Norway published last year, a reduction of up to 25% in mortality among patients for whom there was long‑term continuity of care. As Professor Martin Marshall, chair of the Royal College of General Practitioners, told me: “If relationships were a drug, guideline developers would mandate their use.”

In May, the Commons Health and Social Care Committee held an evidence session on continuity of care. They heard from Dr Jacob Lee about what it’s like to see someone in a practice that doesn’t have personal lists. “You are trying to read their notes and get a feeling for what has been happening in the past. It makes the consultation really challenging when you are looking at blood test results and letters for patients you do not know because they are split between the different GPs who are in that day. It is so inefficient and difficult to try to do a good job for that individual.”

This will have an impact on all of us at some point. But without more widespread recognition of the problem, we might not even notice what we are missing out on. to longitudinal study of continuity of primary care in England published in 2021 showed that not only were fewer patients able to see their preferred GP, but fewer even had a preferred GP in the first place. We have, it seems, forgotten to expect, or even to want, a doctor who knows our stories. That experience of a doctor-patient relationship that’s more than transactional is slipping from collective memory. And if it’s something you have never known, why on earth would you cherish it, or fight for it?

Polly Morland is the author of A Fortunate Woman: A Country Doctor’s Story (Chopper, £16.99)

further reading

A Fortunate Man – The Story of a Country Doctor by John Berger & Jean Mohr (Canongate 2016, £9.99)

Narrative Medicine: Honoring the Stories of Illness by Dr Rita Charon (Oxford, £26.99)

With the End in Mind: Dying, Death and Wisdom in an Age of Denial by Kathryn Mannix (William Collins, £16.99)

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