Thursday, February 22, 2007

Change of Shift, and Rita Charon

The new Change of Shift is up over at Protect the Airway, and I'm delighted to be included. AC has done a splendid job with this edition, which is clearly organized and provides an excellent sense of what each post's about.

I just have to kvetch, though: does anybody else hate black blog backgrounds? For me, it makes the text very difficult to read, and my middle-aged eyes have enough trouble already!

And for our next topic: Rita Charon and Narrative Medicine.

Charon's a family practitioner in Manhattan, serving mostly poor patients, who runs the Narrative Medicine Program at Columbia (the only one of its kind in the country). This program teaches medical students to be better listeners to patient stories, and to use writing as a way to reflect on their practice and form closer bonds with patients. Charon's also a literary critic and scholar with a PhD in English Lit from Columbia; impressive lady!

On Tuesday, she gave a series of talks at UNR. I was only able to attend one, but it was excellent. Charon's an eloquent and compelling speaker; listening to her, you can tell that she must be a wonderful teacher and doctor.

What struck me most about her talk was her description of how she takes patient histories. The traditional way of doing this is to ask about history of the current illness or condition and then about broader medical history, followed by a review of systems. While Charon gets to all of that in the course of a first visit, it's not where she starts.

She starts, she says, with two sentences; she's trained herself not to say more than that. "I'll be your doctor, and that means that I have to know as much about you as I can. Please tell me what you think it's most important for me to know about you." (I may have the precise wording of that wrong, but that's the gist of it.) While the patient talks, Charon just listens; it took her a while to train herself not to write notes. ("At the beginning, I literally had to sit on my hands.") She said that patients will start all over the place: with family history, with what's happening at home right now, with their fears about their current condition.

She told us how moved many patients are by being asked to do this. One man started crying, because Charon was the first doctor who'd ever asked him what he thought was important.

While the patients are changing for the physical examination, Charon will type up as close to a verbatim transcript of what they said as she can remember. At the end of the visit, she'll give them the transcript and say, "Is this everything?" Sometimes she'll have forgotten something, and sometimes the patients will read the report and say, "Well, we left something out, and we should put it in." Charon told her audience: "You can imagine the things that get left out at first. The traumas, the stillbirths, the losses, the abuse."

Charon gives the patient a copy of this document to take home, as well as putting it in the chart. Her patients get copies of everything that goes in their chart; she encourages what she calls a "co-authored record of care."

Charon's patients must love her. I've certainly never had a doctor take my history that way, and I've had some excellent doctors (as well as some lousy ones). Obviously there are some specialties, like emergency medicine, where this approach would be impractical for time reasons. But I think the state of American medicine would be vastly improved if more physicians listened to their patients' priorities.

And hearing Charon has made me rethink how I introduce myself to hospital patients. I usually say, "I'm a volunteer chaplain, and I visit everyone in the ER to see if anyone needs to talk or would like a prayer." Many patients hear this, correctly, as an invitation to tell their stories, but some patients still seem to view chaplains as people who talk at them. (One recent patient responded to my little intro by glaring and snarling, "I wouldn't call you if I were dying!")

So I think I'm going to try a slightly different intro, something along the lines of, "I'm here to listen to anything you want you tell me." I won't have time to write down what I hear and show it to the patient, but in my work, reflecting what I've heard in how I pray with that patient (if the patient requests a prayer) often serves the same function. A well-worded prayer lets people know that they really have been heard.

At last night's Ash Wednesday service at church, we sang a Taize chant that reinforced the theological importance of listening:

O, Lord hear my prayer,
O Lord hear my prayer;
when I call, answer me.

O, Lord hear my prayer,
O Lord hear my prayer.
Come and listen to me.

When people pray, they want a sense that they're praying to someone, that a living entity has heard them. The same is true when they talk to chaplains, or doctors.

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