Our Memorable Patients

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Our Memorable Patients
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Our Memorable Patients

• Aims
• Enrich the experience of daily practice
• Improve the accuracy of our diagnoses
• Improve the workability and possibilities of
  outcomes for patients
• Reduce our chances of burn-out and increase
  efficiency and enjoyment of medicine.

• Objectives
• Learn to really listen to some good stories
• Practice reflection in the cycle of learning
• Reconsider the vital interface between the
  science and art of medicine
• Add to my understanding of what it means to
  practice holistically

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Our Memorable Patients

• Somewhere between the first year and the
  final year of medical education, undergraduate
  students exchange a native facility for eliciting
  and appreciating patients' narratives for the
  learned expertise of constructing a medical
  history.
• (Trish Greenhalgh)

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Professionalism (Attitude)
Approach to tasks (Knowledge/ Attitude)
Performance of tasks (skills/ behaviours)
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Our Memorable Patients

• A hunch
• I got a call from the Hollys mum who said her
  little girl with the tonsillitis I had seen
  earlier that morning was much worse. I knew the
  family well, and was sufficiently concerned to
  break off
• my lunch-time meeting and visit immediately.
• We cannot commit ourselves completely and
  immediately to all patients who seek our help
• If meningitis is suspected the doctor must act
  urgently and make the patient a priority
• Tonsillitis in previously well children is
  generally viral and self limiting
• Meningococcal meningitis produces a
  characteristic rash and neck stiffness
• Meningococcal meningitis presents
  nonspecifically in primary care

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Our Memorable Patients

• Was it 007 or just another episode in both the
  Hollys family soap opera?
• Have a listen to this patients story
• In pairs.

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Our Memorable Patients

• clinical medicine shares its methods of
  knowing with history, law, economics,
  anthropology, and other human sciences less
  certain and more concerned with meaning than the
  physical sciences. But unlike those disciplines,
  it does not explicitly recognise its interpretive
  character or the rules it uses to negotiate
  meaning.
• K. M. Hunter, (Professor of literature)

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Our Memorable Patients

• So if you really want to be a better doctor but
  know you are not a genius..

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Our Memorable Patients

• ..dangerous tendency of clinicians to see the
  expected and unconsciously to dismiss the
  anomalous
• At its most arid, modern medicine lacks a metric
  for existential qualities such as the inner hurt,
  despair, hope, grief, and moral pain that
  frequently accompany, and often indeed
  constitute, the illnesses from which people
  suffer.

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Our Memorable Patients

• Lifelong learning means daily learning
• Reflection assisted by discussion OK in teams/
  COTs/ CBDs/ SEA but what about at other times?
  And what about after these?
• In our education ( and our patients), narratives
  are often memorable, grounded in experience and
  encourage reflection.

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Our Memorable Patients
4 (i) Power of the Narrative..

• Encourages us to think of longitudinal aspects of
  care
• And reminds us that we are unwittingly part of
  our patients narrative as well as they of ours.

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Our Memorable Patients
4 (ii) Power of the Narrative..

• Contextualises this problem
• Encourages a fuller and more meaningful view of
  the patients presentation
• Why now?
• Why present like this?
• Helps us to really understand the I. C. E.
• Allows building of relationship/ understanding
• Enables us to live through the experience with
  a patient rather than have knowledge about the
  patient empathy
• Helps patients gain self-insight and make more
  realistic planning

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4 (iii) Power of the Narrative..
Our Memorable Patients

• Allows us to pace our care for better concordance
• Allows us to use time a tool on occasions
• Vastly enhances and sometimes dictates the range
  options available to a patient from this point on
• Makes us more holistic in our care
• Restores the balance between the art and the
  science of medicine

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Our Memorable Patients
4 (iv) Power of the Narrative..

• Help to set a patient centred agenda
• May challenge received wisdom and generate new
  hypotheses and so change our practice
• 5 Keeps the daily excitement of General
  Practice

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Our Memorable Patients

• Integrated diagnostic judgments
• Appreciating the narrative nature of illness
  experience
• Use intuitive and subjective aspects of clinical
  method
• Do not reject the principles of evidence based
  medicine
• Rather it enables us to seek for real evidence
  within an interpreted story

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To Finish

• Listen again to patients story
• Reflect
• How does it make you feel about her
• How would you now proceed?
• How might this change your current clinical
  practice?
• How might this influence your learning

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To Finish

• Now reconsider your case
• Look at all the info you have
• Imagine the current social situation
• Imagine the impact of previous life events
• What sort of personality is this patient?
• How does this change
• your consultation style,
• management plans/ options
• Concordance
• Ideas for follow up