Medical History, constructed or compiled?

“I explained that we all had accumulated stories in our lives, that each of us had a history of such stories, that no one's stories are quite like anyone else's, and that we could, after a fashion, become our own appreciative and comprehending critics by learning to pull together the various incidents in our lives in such a way that they do, in fact, become an old-fashioned story.” (Coles, 11)

On whose account is “history” told? On whose account do we rely? This is something that comes into play on a daily basis and impacts everyone. We learn history on a regular basis, but many things are learned on individual accounts of them. Shield's made his position clear on with many quotes; one of the most striking being, “You wonder how I could lie so fluently to you. That's because at some level, I believed everything I was telling you.” (Shields, 32) To me, as a future nurse, this brings up the validity of medical histories,since for the most part they are stories constructed by the patients. This constructedness of stories does not seem robust enough to base medical diagnoses' on.

“Telling stories and constructing a narrative about experiences can empower individuals by helping them to reclaim control over chaotic events and to build a positive sense of self.” (Pearce, 2010) While I am in support of individuals trying to build a positive sense of self I am against the idea that while doing so they might mislead the medical staff assisting them. The issue seems to be that the patients do not know what may be of interest to the staff and therefore feel that fudging where or how they received an injury or illness is not critical information. Especially if you are embarrassed or feel that you cannot confide in your doctor. For example, when I was about fifteen I went to a specialist for a medical issue. They asked me some basic questions like have you ever smoked, had sex or done drugs. They asked me this in front of my mother though, so I am sure you can see the dilemma I was put in. I wanted to let them know that yes, I had smoked before just in case it was pertinent to my illness, but in the sense of self preservation I told them that no, I had never done any of those things.

“Narratives are constructions that present the 'displays' and 'doings' of identity, and are used strategically to portray one's self in a certain light.” (Pearce from Riessman 1990,1993)
 

“... Our patients all too often come to us with preconceived notions of what matters, what doesn't matter, what should be stressed, what should be overlooked, just as we come with our own lines of inquiry.” (Coles, 14) This reminds me of a hypothesis I have held that there are two types of people in the world, those who tell you too much and those who do not tell you enough. How is it that doctors and nurses manage sift through all the information, or lack of it, and pull out what is important and relevant to helping their patient? The sad fact is that many of them do not. This has become such an issue that Columbia has started a “Narrative Medicine” program which “fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness.” (Columbia University, The Program in Narrative Medicine) This relatively new program is used to address the issue and gap that seems to form between the patient and care-giver.

Rita Charon, the director of this new and innovative technique describes it as “knowing what to do with stories.” (Sandy, 2010) When discussing the impact of narrative medicine Charon goes on to say a lot about how it makes the patient and doctor more connected and the patient tends to have a better understanding of the treatment and is more likely to go along with the treatments specified by the doctor. While this seems to be a good general model for smaller facilities it does not seem practical or even feasible in larger, bustling hospitals. This program also teaches the physicians to have a “parallel chart” in which they write the care given regarding the patient that does not belong in their medical histories, such as observations on their disposition. Two examples Charon listed were “This woman makes me sad” and “I'm angry at this guy.” The issues I had with that was that those reflections have nothing to do with how the patient is treated and brings a personal feeling into a professional setting and that it seems like a process that will take more time than is available. I think in theory that this program would be beneficial in interpreting stories and getting the most accurate depiction of what really occurred, but in practice may crash and burn.

“Memory is selective; storytelling itself insists on it. There is nothing in my story that did not happen. In its essence it is true, or a shade of true.” (Shields, 33)

“The people who come to see us bring us their stories. They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly.” (Coles, 7) Coles goes on to talk about how instead of listening to the stories a lot of psychiatrists, and most doctors I presume, are focused on diagnosing and “fixing” the person in a timely manner. Too often individuals are diagnosed on snap decisions because they fit some preconceived notion. As I stated before I do not think it is possible to give every patient the time to tell you their life story and every bump and bruise they have had for the last five years but it is possible to listen to what they are saying rather than latch onto a single thought and stick to it. That is one of the major gaps between psychiatrists and medical doctors; they both want to diagnose you and keep the flow moving but one is supposed to listen to your life story, while the other focuses on your physical story.

Everyone constructs their story based on their present circumstances and emotions, it is up to the health care provider to delve into that and focus on the issues related to what they are doing. While it may seem odd that individuals “construct” a medical story it is a circumstance that occurs frequently. Most, if not all, people have had the experience of finding a bruise or cut that they did not even feel or notice, but remember cramps, a sprain, headache, etc. that was particularly painful. Is it not feasible that we may exaggerate its pain or duration when discussing it? Of course it is. How many times have we had a blinding headache that lasted all day that in reality was a headache that lasted the afternoon because you forgot to eat? The issue with this constructedness is not something that would be called into account when you are recounting a story, but has serious implications when trying to relate your medical woes. Though the implications are far reaching there are not many new ideas to try and address this. The work that Columbia is doing with their Narrative Medicine program is one of the first to even recognize, let alone address, this divide. Realistically what else could be done though?

“... acknowledging that the individual 'embodied' remembering is always 'embedded' in social context.” (Pearce from Mitzal, 2003)

Works Cited

Coles, R. The Call of Stories: Teaching and the Moral Imagination. Boston: Houghton Mifflin. 1989.

Columbia University, The Program of Narrative Medicine: College of Physicians and Surgeons. http://narrativemedicine.org/about/news_about.html

Mitzal, B. (2003). Theories of Social Remembering. Milton Keynes, UK: Open University.

Pearce, C. (2010). The crises and freedoms of researching your own life. Journal of Research Practice, 6(1), Article M2. Retrieved September 14, 2010, from http://jrp.icaap.org/index.php/jrp/article/view/219/184

Reissman, C.K. (1990) Strategic uses of narrative in the presentation of self and illness: A research note. Social Science and Medicine, (30) (11), 1195-1200.

Reissman, C.K. (1993) Narrative Analysis. Newbury Park, CA: Sage.

Sandy, M.P. (2010). Rita Charon: The Literary Physician. ProtoMag.com. Retrieved September 15, 2010, from http://protomag.com/assets/rita-charon-the-literary-physician