Narrative-based medicine, communication skills, and client-centered care

“The ill person who turns illness into a story transforms fate into experience … [that] which sets the body apart from others becomes, in the story, the common bond of suffering that joins bodies in their shared vulnerability.”

 — Arthur Frank1


Lesley Jones, PhD, is the senior lecturer in social science at Hull York Medical School, University of York, North Yorkshire, UK.

There has been an increasing emphasis on communication skills in medical and allied professional courses in the West over the last 10 years. The evidence shows that this not only improves the relationship between client and practitioner but also improves concordance.

This seems particularly appropriate in a profession such as hearing health care, which relies on patient compliance with regimens (eg, hearing aid use following the initial consultation), in order for the relationship to continue on a proper footing. For this reason, it’s appropriate to examine the communication and consultation skills used in the teaching and practice of medicine, then adapt appropriate behaviors for the field of hearing care.

Understanding the clients’ perspective about their hearing impairment and their use of assistive devices is vital to any joint attempt to introduce change into their lives. In order to understand that perspective, narrative-based medicine has some useful insights to offer as well. This article addresses the fear often expressed by clinicians that there is no time to listen to the client’s story during the consultation by looking at the similarity between the clinical encounters relying on physical examinations. These three things—narrative-based medicine, communication skills, and client-centered hearing care—are the focus of this article.

Letting the Client Tell the Story

Clients need to be able to express their concerns and know that they have been understood by the clinician. They also need to reach a shared understanding with the practitioner about the nature of their impairment and what is proposed for resolving it.

Hearing care professionals, on the other hand, need to know why a client has come to see them at this particular time. This goes beyond the initial reason that may be given. If it is because a partner has “nagged them” into coming and they have no real desire to change their circumstances, then the professional should work on finding out what they do feel able to change, rather than what they feel that their partner wants them to change. If, for example, they are mostly concerned about concealing their hearing loss at work because of fears of losing their job, then that is a starting point for exploring how to address these issues.

In both examples, the clinician will be interpreting what is said using his or her physical and psychosocial knowledge in relation to the client’s background, expectations, and beliefs. In just the same way, the clinician is bringing his/her own beliefs to the exchange. For a hearing care professional, this may influence how he/she responds to a perceived lack of interest by the client in what is being offered (eg, a hearing aid). Bringing together these two views is essential to the negotiation and agreement about any management plan.

Quest, Chaos, and Restitution

Narrative-based medicine has made use of the idea of allowing people to tell their own stories about what is happening to them and their bodies as a more effective way of treating illness. Arthur Frank’s work in The Wounded Storyteller: Body, Illness, and Ethics1 maintains that people are more than victims of disease or patients of medicine; they are wounded storytellers. Frank highlights the power of using the sense that people make of their own experience of illness—turning their suffering into stories—to help them find healing. He characterizes this process as the quest, the chaos, and the restitution narratives of illness.

These three ways of interpreting illness illustrate how significant it is to understand the client’s perspective. Jones and Bunton2 have developed this in relation to hearing impairment with the idea of the Wounded or the Warrior view of being—or becoming—hearing impaired. For some people, hearing loss is seen as a devastating “end of the world as they know it”; for others, it is a given fact to be absorbed into life.

How people see hearing loss influences how they respond to professional recommendations. Passivity and despair may result from a wounded view, but an active fighting response might arise from a warrior view. The wounded might see hearing care professionals as saviors; the warriors might see them as opponents.

Understanding how clients perceive their hearing impairment seems to be an important component in any process of engagement about changing behavior. Hearing care professionals equipped with the skills needed to absorb and interpret illness narratives may be better able to arrive at joint planning for the future with their clients, as well as being able to “honor what has befallen them.”3

This is why developing the tools to understand the patient’s story and to learn how to listen and use the results is a useful addition to the clinician’s skills.

Client-Centered Hearing Care
ADDITIONAL INFORMATION

Bringing Relevancy to the Appointment, by Jay B. McSpaden, PhD, and Von Hansen. September 2004 HR. Available at: www.hearingreview.com/issues/articles/2004-09_04.asp.

Allowing clients to tell the story in their own words also gives them the chance to structure it according to their own Ideas, Concerns, and Expectations (ICE). ICE is one of the acronyms used in the Calgary Cambridge4-6 framework for communication skills and can be used as a basis for creating a new method for audiologists and dispensing professionals. It is useful because it provides a structure for the clinical encounter and for the learning and teaching of the skills required. One inhibitor to the use of these skills is the fear that the clinician simply does not have time to listen to people’s stories because they have an agenda and tasks to complete, such as producing an audiogram, impression-taking, hearing aid programming, etc. The benefit of the Calgary Cambridge method is that it is an Integrated Clinical Method, which allows for physical examination during the course of the consultation and also takes account of the physiological elements of the consultation.

The Integrated Clinical Method outlines the consultation process and provides a checklist for clinicians to ensure that they have covered all of the options. These include initiating a session by establishing rapport and identifying why the client is there. An agenda is then set for the consultation based on these findings. The structure continues with the gathering of information, negotiation, creating a shared understanding, and joint planning.

The method adapted for use in Hull York Medical School allows for explanation and planning to be crucial parts of this process. The process skills include the use of attentive listening, open- and closed-cone questioning, picking up cues, acknowledgement, clarification to gather information, and summarizing of the information given in order to reach a shared understanding of how to proceed. The structure of the consultation and the problem solving is a part of this process and provides a framework both for training and for practice.


CORRESPONDENCE can be addressed to:

References
  1. Frank AW. The Wounded Storyteller: Body, Illness, and Ethics. Chicago: University of Chicago Press; 1995.
  2. Jones L, Bunton R. Wounded or warrior? Stories of being or becoming deaf. In: Hurwitz B, Greenhalgh T, Skultans V, eds. Narrative Research in Health and Illness. Malden, Mass: Blackwell Publishing Ltd; 2008.
  3. Charon R. The ethicality of narrative medicine. In: Hurwitz B, Greenhalgh T, Skultans V, eds. Narrative Research in Health and Illness. Malden, Mass: Blackwell Publishing Ltd; 2008.
  4. Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Oxford, UK: Radcliffe Medical Press Oxford; 2005.
  5. Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge Guides. Academic Med. 2003;78(8):802-809.
  6. Calgary Cambridge: Teaching and learning communication skills in medicine. Available at: www.gp-training.net/training/communication_skills/calgary/index.htm