April 18, 2021

The patient's first-person narrative


The original first-person patient narrative forms the foundation of clinical medicine, yet it can rapidly become contaminated and evolve once the patient enters the medical system.

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The patient's first-hand narrative is the foundation of clinical medicine.

In general, a patient encounter starts with them telling the physician a narrative of their health concern

In this way, it is correct to say that the patient is the primary author of the clinical narrative. To be specific, this is a first-person narrative.

In their narrative, the patient describes their health, highlighting those aspects that they perceive as of concern, and they skip over those areas they perceive as unimportant. The expressions used and the pacing is that of their imagination.

The expert clinician uses the first-hand patient narrative to drive diagnosis.

When interpreting a patient's story, the physician pays attention to all aspects of the patient's first-hand narrative. Who is the narrator, where do they live, what are the social circumstances that they live in. What particular keywords, expression, and pacing does the patient present in their story. All of this is considered.

It is not uncommon for patients to present their own unique narrative but to overlap with classic patterns that hundreds of patients before them have used when telling a story of the same condition.

My impression from having observed expert clinicians is that they sit and listen to the patient tell their story from start to end. They do not interject to ask questions, as this may bias the story. They do not put as much weight in the clinical notes of other clinicians who may have written down their own copy of the patient's story. For them, listening to the patient tell their medical story, in their own words, is one of they most important parts of arriving at the differential diagnosis.

It seems that it is the narrative whole of the patient's story which is valuable. The story the patient presents is often 'flawed' from a medical perspective. It may leave out key details or include superfluous details. However, this does not matter, as quite often, these trends are similar among other patients. And in this way, the narrative the patient presents is the most original form of data.

Interestingly, it also seems that expert clinicians are often able to assemble a better understanding of the patient's condition and diagnosis (especially if it is a tricky diagnosis) from a rambling first-hand narrative that a patient presents, rather than from a series of answers to discrete specific questions posed to the patient. This is an extremely important point and the subject of future posts.

One extremely experienced physician that I was working with once told the patient who had a complex and undiagnosed presentation that he "had not heard of another patient in his career tell a story like their's before." I believe this strongly reflected this master diagnostician's approach in his diagnostic reasoning. Having listened carefully to what the patient had to say, he compared it with over a half-century of stories that he heard from patients to assess for overlap.

Contamination of the patient narrative occurs almost immediately upon entering the medical system.

However, the patient's first-hand narrative rapidly becomes contaminated. This is not necessarily, good or bad; it just how medicine is.

The patient may discuss their condition with family or friends. They may spend time researching on Gooogle. The physician, or other clinicians, start to ask probing questions of the patient. We begin to ask the patient to clarify certain parts of their story.

Each time the patient tells the narrative, it morphs and changes. The patient's choice of words slowly morphs away from their natural lexicon into medical terms. The patient starts to emphasize parts of the story that were initially of no concern or interest to them, but that came up as repeated probing questions, giving the patient the impression that particular detail may be important.

Although second reflections upon an event and narrative may uncover details that were forgotten initially, it is also equally possible for aspects of the patient narrative to morph, embellish, and change with each subsequent retelling.

This evaluation of the patient's original raw narrative is just the nature of medicine. Physicians are typically skilled enough to understand if they are listening to an original raw narrative patient story or a story that may have changed over time.

This is not to suggest that physicians don't believe patient narratives that are retold, but that we weigh the word choice used (and not used) by patients differently depending on how unadulterated the narrative is. This process of adapting our interpretations of the first-hand narrative to the situation is a rather opaque part of medical diagnostic reasoning and extremely difficult to quantify within a coded diagnostic algorithm or computer system.

To conclude

And so, to conclude part one, the start of the patient encounter (generally) involves the very words used by the patient to tell their first-hand narrative of their health.

This original first-hand narrative is both invaluable and generally unreproducible.

The start of the patient narrative involves the very words that the patient uses to tell their story for the first time. However, it rapidly becomes influenced by previous Google searches, subsequent questions the clinician asks, and slightly changes upon each retelling. This all potentially influences the patient story and are potential areas of bias and error to enter the narrative.

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