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Dynamic Chiropractic – October 21, 2009, Vol. 27, Issue 22

Patient Stories: Negotiating Shared Clinical Reality to Improve Outcomes

By Shelley Simon, RN, DC, MPH, EdD

In Woody Allen's movie, "Hannah and Her Sisters," there is a scene in which Allen's character, Nick, goes to the doctor seeking reassurance about a stomach pain.

He mentions as an aside that he has some hearing loss in his right ear ("or is it my left ear?"). His doctor reassures him that it's "nothing," but tells Nick he should be tested to rule out the one-in-a-million chance that he has a brain tumor. If you've ever seen a Woody Allen movie, you can easily imagine the story that begins to take shape inside Nick's mind in reaction to the doctor's comment.

When we offer patients chiropractic explanations for their presenting problems or challenges, they track what we're saying while simultaneously filtering competing thoughts, concerns, feelings and goals, and selectively weaving new information into their already existing story about their health. The meaning that is interpreted by Nick or any of our patients is dependent less on what we mean to convey than on what patients are concerned about and the stories they hold dear. Can we learn to more effectively communicate so that we share a similar clinical reality and assist our patients in constructing a healthier narrative or story about their health? Yes, we can.

We Are Our Stories

As Daniel Pink says in his most recent book, A Whole New Mind, "We are our stories. We compress years of experience, thought and emotion into a few compact narratives that we convey to others and tell to ourselves." Studying narrative helps a practitioner relate better and assess a patient's current condition or challenge in the context of that person's full life story, personal meaning ascribed to the story and their desired goals. "Story represents a pathway to understanding that doesn't run through the left side of the brain," says Pink.

Stories shape our experiences, reshape our past and inform our future. Stories give meaning, coherence, structure, and explain cause and effect in our lives. And perhaps most important is the fact that stories tap into emotions and feelings, facilitate a sense of partnership, and help build trust between narrator and listener. Just as you tell stories to help your patients better comprehend how chiropractic care can enhance well-being, patients tell you stories to illustrate their health challenges and what those challenges mean to them. At some point in your career, you've probably heard a story that goes something like this: "I was in a car accident five years ago and that's the cause of my neck pain. I've been told I'll always have neck pain unless I have surgery. I've tried acupuncture, massage, and two other chiropractors. I'm just about ready to go back to the neurosurgeon to schedule an operation. I'm really here because my friend insisted, but I'm not sure you can help me."

Negotiating Shared Reality

Lack of a shared clinical reality and discrepancies in perceptions and expectations can have a negative impact on patient satisfaction, treatment plan adherence and clinical outcomes. The stories patients believe about their health challenges give us clues into how they make meaning of experiences in their lives and what they want moving forward. Individuals construct meaning about health (or lack thereof) based on past experience, cultural indoctrination, age, gender, values, and a variety of other factors. It is up to practitioners to recognize and participate in these stories if we hope to create shared meaning that will result in positive clinical outcomes.

Unfortunately, many practitioners find disagreement with their patients' stories and instead of trying to negotiate shared meaning for the benefit of the patient, end up pushing them away by forcing their own agenda or trying to control the story. Understanding the power of story and how to more effectively help patients craft wellness-based stories is crucial to improving outcomes and having successful practices.

How do we join our patients in their stories and then help them construct more empowering narratives that lead to better health outcomes? When there is conflict or simply different interpretations about the "facts" of a story, who wins? There is an all-too-common struggle between the chiropractor who wants to speak about wellness or nervous system function and the patient who is preoccupied with pain. How do you negotiate and find meaning with these stories playing out simultaneously?

Who Owns the Narrative?

When you engage with a patient around their story, you are entering into a negotiation, but it's not about "winning" an argument. Patients always - without exception - own their stories. A patient's core health narrative is based upon a host of variables and a patchwork of experiences and biases related to health and well-being that they have collected over a lifetime. Perhaps they grew up hearing from a parent that "too much exercise is bad for your joints," "the human body was designed to eat red meat, so clean your plate," or "arthritis runs in our family." Or maybe during a particular health challenge the patient visited a variety of practitioners, including a chiropractor, neurologist, endocrinologist, naturopath, acupuncturist, and energy healer and now they have a whole host of sometimes overlapping but often competing explanatory models for what's wrong with them and what they should do about it.

It matters not if a patient's story is rational or makes sense to you. The patient owns the story. Our job is to help patients make sense of deeply embedded and/or conflicting stories and craft a new story that will motivate them toward more positive outcomes.

For example, at the urging of a spouse or family physician, a patient sees an orthopedic surgeon who recommends surgery and physical therapy. Although the patient had been making steady progress under your care, he abruptly discontinues treatment in favor of following the new story line. What do you do in a situation like this? You could call the orthopedic surgeon, challenge the patient's story, or reignite your existing story about conventional medicine. Or you could calmly work with the patient to co-create yet another story, one that might actually include chiropractic care for a mutually agreed-upon time frame to determine if surgery could be avoided.

For decades, the allopathic narrative has been dominant with its story of disease, diagnosis, and pharmaceutical and surgical cures. While this story has been tarnished somewhat in recent years, it is still the reigning belief system or story told in Western culture. The chiropractic story is powerful and an empowering alternative explanation for the body, health, and the healing process. And yet, it is not the dominant story, cultural narrative or paradigm for the public - much to the collective frustration of chiropractors and their patients. How do we work with this frustration toward a better outcome for our patients and our profession?

Working With Patients' Stories

When faced with a patient who is deeply connected to their own narrative about health, it's ineffective and confusing for the patient if you tell them to release their story and try to indoctrinate them with a story that is in sync with the diagnosis and treatment plan you wish to offer. Instead, support the patient by helping them synthesize and integrate their story with what you have to share. As you develop the narrative competence to hear stories and engage patients in talking about the underlying meaning of their stories, you will be in a much stronger position to positively influence patients toward healthy outcomes.

When you are face-to-face with a patient who has a story like the one above about the patient who was in an accident and has chronic neck pain, how can you honor that patient's narrative, find shared meaning within the story, and gently guide the patient toward a story that is based on health and hope, rather than on pain, illness and the default surgical remedy? The process requires patience and skill, but the reward of seeing a patient's light bulb go on as a new story develops is well worth the effort. Here are a few ways to facilitate shared meaning and create a healthier narrative:

Listen to the entire story. Most doctors interrupt patients after 22 to 25 seconds and then use closed, probing questions to create a diagnostic narrative to fit the story into their own explanatory model. Yet if you let patients speak without interrupting, they generally will not go on for longer than a minute or two. Then you can redirect the conversation and ask questions as necessary to understand and negotiate for meaning and thus for care. When we don't let patients speak openly about their pain and interrupt them to explain the cause or recommend a treatment plan too quickly, we risk alienating the patient and miss the opportunity to more effectively evaluate their health status and their motivation to improve. Determine if there are pieces of the patient's story that are valid in terms of influencing the course of care (e.g., perhaps chiropractic combined with massage and dietary changes are appropriate; perhaps the patient will always have some degree of pain and the new story is about reducing it and helping the patient manage it to improve function).

Don't try to control the story. One of the most common mistakes chiropractors make is that in their enthusiasm, they try to take over the patient's story. They discount what the patient says and what other practitioners have advised, begin educating before the patient is prepared to learn, try to indoctrinate toward a chiropractic model of care before the patient understands the benefit to them, and rush too quickly into suggesting a comprehensive treatment plan before they have buy-in from the patient. Bottom line: Notice these tendencies and resist the temptation.

Draw the patient out to get even more of the story. By being genuinely curious and asking questions, you will be better able to understand the impact of the patient's condition. Avoid the typical "closed probe" questions and instead inquire in a way that will make the patient think about the meaning they've placed on their own story and become open to new interpretations. Only then will you be able to shed light on a different future for the patient and help them feel less hopeless or helpless. Listen also for what is not being said. This requires using your intuition and paying attention to the patient's body language. When you sense you're not getting the whole story, say something like, "Tell me more about that." When you sense the patient is holding back an entire chapter in their story, say, "I get the sense there's more to this. Can you go a little deeper along those lines?"

Work with the patient to reframe the story. Guide the patient to put a different spin on their current story and help them move away from an "illness" plot line to one that is based on a future of wellness. Questions such as, "Try to envision having complete range of motion again and tell me how that would make you feel" and "What kinds of results or outcomes would make a true difference for you?" are useful. Try not to rush the patient at this point. Let them use their imagination and tap into their emotions to come up with a new draft of their story.

Educate and offer care. Once you have the original version of a patient's story and the potentially revised version on the table, you can look at the gap between the stories, help them see themselves in the healthy story, and begin to educate the patient about how chiropractic care might positively impact their situation (i.e., less pain, improved function, a brighter future). Because the patient now has a somewhat clearer picture of what a better tomorrow might look like, they may be open to learning a new way of managing themselves and allowing for the possibility that you should play a transformative role in their current drama.

Narrative Competence Improves Outcomes

The benefits to chiropractors and their patients of taking the time to work with stories are significant. When patients feel heard, they are more likely to trust you and bring you into their story as a key character. Having done so, they will feel like a partner in their own care and be motivated to follow through with a treatment plan and achieve a positive outcome. As you hone your narrative competence - listening to stories as well as telling them - you will develop a stronger connection with patients and a more satisfying practice.

Click here for previous articles by Shelley Simon, RN, DC, MPH, EdD.

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