Understanding Current Physician Perspectives

Interview with Dr. Priya Raju

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When did you start noticing a lack of emphasis on storytelling and narratives in your practice?

I probably noticed in residency. I will tell you it's harder in training because you don't get as much continuity of care then as you do when you are out of that world. When you're in training, you meet a patient for an instance of time and then you don't follow up with them later. Working in a private practice is better because you learn to have some patience. I started asking maybe two or three times, in different ways, about underlying feelings behind pregnancy and that's when I started hearing a lot about this where there was normal delivery on paper and in the patient’s experience, the birth was very traumatizing.

 

Have you sort of implemented an approach where you focus on the patient's journey and experience as opposed to necessarily fixating on the outcome?

I think that there are so many nuances to managing a way you go through the birthing process and that's okay. I would say now after hearing some of the experiences that women have, some of them you know they have actually had a bad outcome and even though it's explanation is not medically indicated for the visit or you know they want to have an extra ultrasound in the beginning even though it's not technically evidence-based care for them, sometimes delivering this type of care is necessary for the patient to feel more comfortable. Sometimes they might be delivering in a very different setting or sometimes they've had a bad experience with a bad doctor. We try to have a discussion together about all the risks and benefits early and even if they're not an educated person who I think has a good understanding of pregnancy, then I'm willing to kind of wait to try and get them to experience what they want. 

 

Have you noticed an increased sense of comfort and women who were able to share their stories with you?

Definitely 100%. So many patients have said to me “I feel like you actually hear me or I feel like this is the first time someone is actually listening. This is extremely sad to me. This has really created space for long lasting conversations about every aspect of health in my patients that is even just tangentially related to birth and pregnancy. 

 

How has your personal experience with birth impacted the way you deliver care to patients? 

So a few things I will say is that the whole expectation of people being worried is very real. Before I was pregnant myself, I had very little understanding of the fear of loss - like you don't realize how much you care about this little person who's not there until you're actually pregnant. I realized that this is what I really want so it was after that when I realized how difficult it was to cope with the idea of loss. Of course, I was lucky because what I would do was I could take a peek and do an ultrasound myself whenever I wanted to and it made me feel better so little things like that definitely showed how my experience may be more comfortable. I will tell you the biggest thing is no matter how good it goes, the worry is always there. My delivery was also different because the people in my room were my co-workers and I really trusted them. A nurse in my office was actually just telling me how she felt a lot of the things that women say during labor. She felt very rushed and pressured to finish quickly since the healthcare workers were trying to get to each room. 

 

Reflection

The aspect of this interview that stood out to me most was Dr. Raju’s comments on continuity of care. In medical school, they do not give you experience with care continuity. Even if they teach students about the principles of narrative medicine, the practice isn't available to students based on structural limitations of rotations. Clinical rotations in medical school are assigned shifts at an affiliated clinical center. Once assigned to a site, students deliver supervised care individually and as a team. However, the purpose of clinical rotations is often to see a lot of cases and patients, as opposed to taking deep dives in every case. Storytelling and narrative medicine cannot be implemented in one visit or one interaction. Being able to actually use someone’s narrative in their care means understanding the fundamentals of who they are on a timeline. It is surprising to me that most doctors do not have adequate experience in this realm of medicine until they start practicing on their own. 

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As a future physician, this interview got me thinking about how I would try to incorporate this framework into my practice. I think even if the structural nature of medicine is not conducive to practicing narrative medicine in medical school, there are certain things I can do. I am not naive and I know that by the time I matriculate into medical school, narrative medicine will not be an emphasis. However, I do believe in the power of thinking through a narrative lens. 

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I currently work as a medical assistant in a cardiology office where I am trained to ask patients about their symptoms, medications, take vitals, take EKG’s, etc. Although we are trained to be efficient and run through each of these tasks as a checklist, I found it very difficult to find meaning in this work. I started to take the time to get to know my patient - what their favorite foods are, where their children go to school, where they grew up, etc. I have started spending upwards of 30 minutes in each room, despite being told that 10 minutes was sufficient. While the short term benefit is sometimes hard to see, I have had patients open up the second or third time they see me. After I saw the same patients a couple of times, I started to understand that the constant shortness of breath in one of my patients was because she grew up in a household of smokers and has had terrible asthma ever since and the palpitations in another patient were from her undiagnosed anxiety. I’ve learned that the current nature of medicine lies in yes/no responses, and actively combatting this means asking “why?” for every word that comes out of a patient’s mouth. If a patient says they are short of breath, I ask “how long has this been happening,” “does it get worse when you exert yourself,” “does it worsen when you are stressed,” “have you had any major or minor lifestyle changes recently,” etc. There should be no checklist or structure for seeing a patient, as it boxes them into a category of their diagnosis without examining the root causes, and this is a mindset I see myself carrying throughout my journey in medicine.