Pain management in cancer patients is a good opportunity to examine how medicine can be both
humane and effective,1 writes Giovanni Rosti.
Rosti constantly balances medicine’s outcomes with its humanity. A medical outcome can easily skew towards numbers and raw data. That emphasis can quickly become efficacy to the point of ruthlessness. Medicine’s humanity constantly reminds us that
individuals are being treated, and not just patients.
Published in Supportive Care in Cancer, the article is framed in terms of the practice of Narrative Medicine. Narrative Medicine is not restricted to mental health professionals, or end-of-life caregivers, Rosti writes.
Rosti argues that both evidence-based approaches and narrative techniques deliver the best quality of care for the patient. He quotes Rita Charon calling this
the art of medicine.2
Narrative Medicine comes alongside Evidence-Based Medicine and compliments it.
Evidence-based medicine, Rosti writes,
dictates what therapies the clinician will offer in a given circumstance, ideally supported by (evidence-based) guidelines. The word “dictates” is a powerful one, as if
meta-analyses and randomized, controlled, and blinded clinical trials alone can make decisions.
Both narrative information about the patient’s life and evidence based data are needed together. Much like Donnelly talking about suffering, Rosti points to narrative giving a broader scope of information. Narrative information about the patient is labeled “low-context”, or we might call it “broad context”. Medical data
such as questionnaires and assessment tools Rosti calls “high-context approaches.”3
Thinking these approaches together is
fact finding with empathy, which mirrors Rosti’s call that medicine should be effective and humane.
Rosti turns to a thought experiment to demonstrate his point:
Consider, for example, a retired man with metastatic prostate cancer who when asked by his physician rates his pain as 3. For the physician, this would be considered mild pain, and therapy would be continued with no changes. However, the physician could, for example, query the man about the impact that this mild pain has on his quality of life. Being retired, he might say that even if the pain is mild, he is no longer able to carry out daily activities that he would otherwise have a strong desire to continue. … Obviously, this has a large impact on his social and daily life. Better communication with patients, and trying to understand the individual issues that affect them, and how they perceive and deal with even mild pain, as in this case, could help the physician to understand that a pain score of 3 may be considered as a relative score that actually merits better treatment.
The author also includes a clinical study by Cepeda, et al. on cancer pain.4 The study divided several hundred patients into three groups:
- patients who wrote a story about their pain,
- patients who filled out a standardized pain questionnaire, and
- a control group, given
As evidence that narrative alone can’t improve care,
pain intensity was similar between groups both before and after treatment. The only group who showed reduced pain were the
patients whose narratives had high emotional impact.
Put bluntly, the only way to reduce pain is to make your suffering understood.
One of the objections to narrative approaches is that healthcare professionals don’t have time to listen to patients. This way of thinking is problematic, and also untrue. Rosti includes data from a 2002 study:
…physicians were trained in active listening techniques, and were asked to not interrupt patients during the initial phase of the consultation. In this context, [patients’] mean spontaneous talking time was only 92 s, and 78% of patients concluded their initial statement within 2 min. From that study, the authors concluded thateven in a busy practice driven by time constraints and financial pressure, 2 min of listening should be possible and will be sufficient for nearly 80% of patients.5
Rosti mentions that the 92 seconds of time the average patient spends talking might include some things traditionally viewed as irrelevant. After a diagnosis of leukemia in her early 20s, the writer Souleika Jaouad wanted to know about
issues of sexuality and infertility related to her disease. Anyone battling cancer might want to know the same thing. She wrote that
to my surprise, sex is not at the center of the conversation in the oncology unit — far from it.
Talking about sex and reproductive health might not be a part of leukemia treatment itself, but it certainly matters to the patient and the rest of their life.
The article reviewed: Rosti, Giovanni. “Role of Narrative-Based Medicine in Proper Patient Assessment.” Supportive Care in Cancer 25, no. Suppl. 1 (2017): 3–6. https://doi.org/10.1007/s00520-017-3637-4.
1 Charon, Rita. “The Patient-Physician Relationship. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust.” JAMA 286, no. 15 (October 17, 2001): 1897–1902. https://doi.org/10.1001/jama.286.15.1897. ↑
2 Charon, Rita. “Narrative Medicine: Caring for the Sick Is a Work of Art.” JAAPA: Official Journal of the American Academy of Physician Assistants 26, no. 12 (December 2013): 8. https://doi.org/10.1097/01.JAA.0000437751.53994.94. ↑
3 Moore, Rhonda J., and James Hallenbeck. “Narrative Empathy and How Dealing with Stories Helps: Creating a Space for Empathy in Culturally Diverse Care Settings.” Journal of Pain and Symptom Management 40, no. 3 (September 1, 2010): 471–76. https://doi.org/10.1016/j.jpainsymman.2010.03.013. ↑
4 Cepeda, M. Soledad, C. Richard Chapman, Nelcy Miranda, Ricardo Sanchez, Carlos H. Rodriguez, Andres E. Restrepo, Lina M. Ferrer, Rene A. Linares, and Daniel B. Carr. “Emotional Disclosure through Patient Narrative May Improve Pain and Well-Being: Results of a Randomized Controlled Trial in Patients with Cancer Pain.” Journal of Pain and Symptom Management 35, no. 6 (June 1, 2008): 623–31. https://doi.org/10.1016/j.jpainsymman.2007.08.011. ↑
5 Langewitz, Wolf, Martin Denz, Anne Keller, Alexander Kiss, Sigmund Rüttimann, and Brigitta Wössmer. “Spontaneous Talking Time at Start of Consultation in Outpatient Clinic: Cohort Study.” BMJ 325, no. 7366 (2002): 682–83. https://doi.org/10.1136/bmj.325.7366.682. ↑