Understand your veterinary clients narrative

Photo: Shutterstock.comDo you enjoy reading? Do you follow the lives of characters in a favorite TV series? Have you ever kept a journal? It may not have occurred to you that these activities could contribute positively to your work, but according to proponents of narrative medicine, they can. Narrative medicine is a young but growing field in human medicine. Columbia University's medical school offers a master's degree program in narrative medicine, and several other medical schools have created narrative medicine programs for their students. Nursing programs are beginning to teach this concept as well. There's even a narrative medicine journal.

What is narrative medicine?

Narrative medicine is a term coined by physician Dr. Rita Charon in 2000. In a groundbreaking 2001 JAMA article, she wrote that “the effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret and act on the stories and plights of others.” Rather than viewing a patient as a collection of symptoms or just another example of a disease like diabetes or cancer, narrative medicine helps you place the symptoms and illness into the context of the patient's larger story.

I recently stumbled across the concept of narrative medicine online, and something immediately clicked for me. I've owned a small house call practice for more than 20 years, and I also work in a clinic part-time. In addition to conventional veterinary medicine, I use acupuncture. I'm accustomed to seeing my patient's home environment, and I've been trained to seek a holistic, wide-angle view of my patient's life, rather than to focus on a presenting symptom.

In the clinic's exam room, if I'm with an unfamiliar client and patient, I sometimes find myself struggling to get a “read” on the clients. How concerned are they about the pet? How does the animal fit into their household? Until I heard about narrative medicine, I didn't realize that I was searching for information to help interpret my medical findings. At times, the scientific part of veterinary medicine-the medical history, physical exam, a list of rule-outs-can seem like the easy part. To have the highest confidence in my treatment plan I look for the bigger picture, which is not always easy to find.

NARRATIVE MEDICINE: GET STARTED

> Think about a patient you saw recently with other team members. Can you pull pieces of the pet's story together to form a narrative? Do other team members have the same or a different perspective than you do? 

> Consider a regular client who's been challenging to interact with. Does it help to consider what his or her story might be? 

> After a challenging shift, think about writing a few things down in an informal journaling session. Were you surprised by what you wrote?

This is the reason I dread drop-offs. The patient's history feels incomplete when it is reduced to a short, scrawled message. And unless I know the client well, I find it more difficult to get a summary over the phone than in person. Pet and person are a family unit; it seems unnatural to examine the pet without having seen it with the owner. Thus, I typically seek out the team member who admitted the pet to get their impression before speaking with the owner. My team members' insights are invaluable. For example, a team member might say, “Those pet owners seemed very frustrated, because their cat keeps vomiting on their brand-new sofa.” Or I might hear: “Oh, that woman is my neighbor. She's super sweet. But she's had a tough time lately. She just got divorced, and her mother is in the hospital. She adores that dog. I hope he's OK.” While the information may not change my medical recommendations, a full understanding of the situation can be critical to effectively communicate with the client and help the patient.

Recently, I saw a new patient at the clinic for a holistic consult. The dog, Nala, was a sweet 9-year-old boxer mix owned by a young couple. She was non-weight-bearing on her left front leg, and she'd just been diagnosed with osteosarcoma at another veterinary clinic. Nala's female owner was very pleasant, but her male owner was a different story. He sat on the bench in the exam room, his arms folded, exuding anger. He didn't make eye contact as he threw out his questions. Why can't they just remove the tumor? Why would they have to amputate the whole leg? His wife calmly explained that they couldn't afford surgery. The couple's two young daughters played with a phone as I examined Nala and carefully answered the man's questions, explaining the nature of the disease.

“Have you had Nala since she was a puppy?” I asked casually, as my hands palpated her lymph nodes.

“He has,” responded the female owner, tilting her head towards her husband.

Ah.

I thought back to my first dog, Trudy, and how she'd been my buddy when I was single. We'd done everything together, and we had made a great team. She had been a constant presence through many changes in my life. Perhaps this man felt the same way about Nala.

The remainder of the appointment was still sad and painful, yet I felt that I had gained a greater understanding of this angry man. It helped me communicate with him and avoid overreacting to his strong emotions.

When I later discussed the visit with a colleague, she said, “So, for that man, the dog may have represented his youth and freedom.” The lives of our pets span certain time periods of our lives, and the death of a pet may seem like the end of an era. Understanding what a pet may represent to a person, in addition to the human-animal bond they share, can be helpful. This is especially the case in situations where a pet previously belonged to a deceased family member and the pet represents a living link to that person.

Could narrative medicine help us heal?

The veterinary clinic is a uniquely stressful environment, and many of us have experienced some degree of compassion fatigue or burnout. The high rate of suicide and depression among veterinarians has led many to call for a focus on wellness within the profession. What could narrative medicine do for us?

TEAM TIPS

> Share your insights about a patient or a client with other team members 

> Make a note in the file if a client is a friend or family member of a team member 

> If you know the pet previously belonged to the client's deceased family member, note this in the patient's record.

I believe that narrative medicine could be an effective tool to promote wellness among the veterinary team. If we can reflect upon the stories of the people we serve and the animals we treat, we may better be able to appreciate our own role in those stories. After treating a family's beloved pet throughout a lengthy illness or performing an emotional euthanasia, it could be helpful to remind ourselves that the story we may have found ourselves entangled in is not our own. We may have played a significant role in another's story, and that's an important thing to realize. Yet the interactions have also become part of our own personal story, and that's something we may wish to share, through journaling or talking with team members, family members or friends or a professional therapist.

Narrative medicine as a field is a new concept in human medicine, and it's even newer in veterinary medicine. In a sense, our situation is more complicated than that of human medicine, as we must consider not only the patient but the client, as well as the human-animal bond itself.

This gives us the opportunity to help define what it could mean for us as a profession.

Karen Fine, DVM, CVA, owns Fine Veterinary House Calls, based in Worcester, Massachusetts.