Narrative medicine, fears and investment in health care

Maria Giulia Marini co-edited with Alessandra Cosso


 metaThomas Hobbes was born  prematurely on April 5, 1588, when his mother heard of the coming invasion of the Spanish Armada. Thomas Hobbes later reported that “my mother gave birth to twins: myself and fear.” His father, also named Thomas Hobbes, was the vicar of Westport in Gloucestershire, England. After being involved in a fight with another clergyman outside his own church, the elder Thomas Hobbes was forced to flee to London, England, leaving his wife, two boys and a girl behind.

http://www.notablebiographies.com/He-Ho/Hobbes-Thomas.html#b#ixzz2eIHgGivn

Sometimes I wonder whether it is useless that we propose Plato’s and  Aristotle’s idea of a common welfare, a shared sense of good, such as Plato describes very well in his Politeia, inaccurately translated as The Republic, whereas the philosopher is writing about the city and the citizenship, the polis, ruled by philosophers, or in Aristotle’s Nichomachean Ethics, the ethics explained to the young scholar.And in these days I feel it particularly useless while we are here witnessing the failure of the G20,  the financial economy prevailing on the real economy, and the continuous disinvestment in culture and services, not only by the public but also by the private sector. And, unfortunately, Italy is the country with the lowest level of investment in continuous education in Europe. I’ve been always avoided studying Hobbes who became famous for endorsing the concept of Homo Homini Lupus, a man is a wolf to another man, in other words Mors Tua, Vita Mea, your death is my life. Hobbes clearly explained, through this lupitudo concept why law has to exist: to control the huge egoism and and to prevent evil  which might happen to each others.  By the way, Homo Homini Lupus is not a concept invented by Hobbes but it comes from the classic Latin tradition, cited in satirical comedy. Romans sometimes had this mind set, whereas the Greek Aristotle and Plato were dreaming of an evolved society. Not all Greeks, to be precise, otherwise Socrates would not have been condemned to death. However even Thomas Hobbes is still confident that something good may happen, so that a metamorphosis is possible, somehow, to human nature: Hobbes enunciates also that among people who know themselves well reciprocally (so that they are not external to the society), man to man is God, so Homo Hominis Deus. Of course reciprocal knowledge is mandatory.

What has to do this preface with narrative medicine and wellbeing? Do we want to get rid of old automatisms and leave behind us old useless timemoney consuming habits? Do we want to get rid of laws which ends up in defensive medicine in health care with a proven economic waste of around 30% of the total current health care expenditure? Then we should consider that the trigger behind all this is  such  Homo Hominis Lupus concept.

Why most physicians instead of listening to the story of their patients and family -according both to 20-year old and recent studies- interrupt them after an average time of 18 seconds[1], starting to prescribe lab tests and pills, therefore not listening to a human being with a possible illness but just treating the patient like a broken machine? Because, they reply, we don’t have time.

Why don’t doctors rebel to time of visit imposed by their managers if  they are too short to ensure the good outcome of the visit? And why nurses, who are very well prepared and stay very much closer to patients in hospitals, monitoring and controlling them, are not allowed – in Italy, the situation is different in favour of nurses in Canada and UK – to suggest a change of therapy and they do not react to patients’ request, while the doctor has to understand in an independent way whether the therapy has worked or not? Because of fear, the Homo Homini Lupus terror, the ghost that something unwarranted can happen, for instance, angry patients running to a court complaint, the anxiety of losing the job, of being despised by the scientific community and by its own  enclave. The terror of losing some supposed privileged which could be fake. If in the very far 1966 Donabedian[2] based his concept of quality of excellence of care, on structure, process and outcome, understanding outcome as wellbeing, caring and healing,  today rules are mainly there to enhance efficiency, productivity, so that they endanger excellence of care: wise rules should be measurement of performance based on quality of given care, as witnessed by the patients’ experience, and this is written on paper, but the economic  bonuses and incentives are mainly given for linear cuts of human resources, shorter time for visits, saving on drugs. This while poorly measuring whether the appropriateness concept is kept as valid or neglected, a part some specific countries and regions in which this is starting to be applied.The expenditure for defensive medicine is still growing, the budget of hospital structures and trusts are over almost at the beginning of fall, so it is not wise to get ill in this period of time.

And in which sector money is invested in health care? Opera magna, refurbishment or building of new hospitals and intermediate care structures: in other words, bricks.

And what about the intangible? Narrative medicine is shown and proved to produce better outcomes of care, to reduce errors and to improve team affiliation, in other words, to improve  happiness, which is a very desirable state also for reaching a better job climate.  It is a  somewhat radical change of ways of taking care of the patients, not only through technology but also through listening and understanding and understanding the person who is behind the potential feared wolf which might bring you to Court, or in the best condition might tell that the cures that you have prescribed have not worked at all. Listening might show that there is a human being behind who is sacred and that the taking care of  this person can be sacred as well. Narrative medicine is a wonderful method against our proneness to have fear for making mistakes and to hurry up beyond safety. And now please stop and go back to re-read the sentence of Hobbes. “my mother gave birth to twins: myself and fear”. Imagine for a while the childhood of Hobbes: shouldn’t have been it must have not been very pleasant.  As a general rule, if we want to have some glances of the mind set of whom we are talking, when she/he  is referring to particular concept, go back to the biography of the person: everybody is free to ask questions for a short survey to better understand how was the personal life. In my view, the past is not a private owning of the psychoanalyst  and psychotherapist, it is something that shared with others can provide wonderful information to help each other.

Narrative medicine collects biographies of patients and physicians and nurses and all other professionals: this is why it is so powerful in healing and cure, because through the listening it touches the heart of the experience of all the involved people. And childhood is important to impact the framework of reference, the Weltanschaung: poor Thomas Hobbes has always been breasted milk and fears and therefore we are not surprised that he developed the system of thought which made him so famous.Researchers who are studying human cognitive behaviours at the MIT, are very clear when they say that most of our automatism on basic reactions are formed during our childhood: and the childhood, apart from our magical remembering can be a dangerous realm: our body is so exposed: to the to the fear of being hungry, to the touch of the adult people which can be strong or delicate, to the continuous falling when learning to walk and to achievements of different objects when trying to say some words but eventually end up in being misunderstood. We can deem  the outside realm as a magnificent world where to live and play or as a very hostile environment from which we have to defend; or both. And when fear is dominating us in our adulthood, we have to remember that according to the Berne Transactional Analysis we are always going back to our childhood[3]; and the ancient patterns, the frame of reference which has dominated our first years is again ruling our adult life.Adult people who work in health care have to deal with fears every day, since health care can be a realm full of dangers: fears of the patients, since their body “has fallen again”, fears of  providers who can make mistakes, since there is no wonder drug  to take away pain and sufferance, especially existential pain: fears of not finding the right resources, fears, masked by the daily habit, to be powerless before not curable disease. So, embarrassed, they adopt an avoiding behaviour.Moving forward, given the fact that hopefully after Plautus and Hobbes later,  the poor wolves have been re-established in the much more politically correct community by the movie “Dance with the wolves“, and so they now are protected since they are an endangered species, we can now see them as much more affective and capable of boundaries. And, having searched a little on the childhood of Hobbes to understand  how much the childhood impacted on his mind-set, we now have to make the change and to face our automatism and our fears of changing in health care.

Health care has to go through a metamorphosis re-uptaking the natural vocation to care, re-considering the human being behind, being able to see the importance of the intangible words, and not only pushing sales on technology and bricks. Private and public should invest not only on drug research for inducing serotonin, the queen of mediators of happiness[4], but also  on continuous education to the words and  behaviours that are shown to stimulate the production of serotonin, the producer of happiness even in very difficult situation of illness and in very restricted time of crisis. Hostile behaviour is depletory of serotonin and therefore of happiness.

Private and public sector should invest money  in re-humanising the care process which is becoming day by day sadder and more bureaucratic and technologic: educational programs should be phased very early and continuously, inspiring all providers of care to choose not only management course on balance sheet so that they can rule department, but also the ability to cure by caring. This is what narrative medicine stands for: Arthur Frank says “to give a style”,  and I add: reaching an own style means reaching a little bit of happiness even in a very difficult environment.

Metamorphosis is a must: Though there was land and sea and air, it was unstable land, un swimmable water, air needing light. Nothing retained its shape, one thing obstructed another, because in the one body, cold fought with heat, moist with dry, soft with hard, and weight with weightless things.  This conflict was ended by a god and a greater order of nature, since he split off the earth from the sky, and the sea from the land, and divided the transparent heavens from the dense air. When he had disentangled the elements, and freed them from the obscure mass, he fixed them in separate spaces in harmonious peace “dissociata locis concordi pace ligavit”.[5]

 

[1] ] Why Doctors Interrupt, by Juliet Mavromatis, the health care blog, June, 2012

[2] Donabedian, A. (2003). An introduction to quality assurance in health care. (1st ed., Vol. 1). New York, NY: Oxford University Press.

[3] The basic script of transactional analysis, Games people play, Eric Berne, 1962

[4] Psychiatry Neurosci. 2007 November; 32(6): 394–399, How to increase serotonin in the human brain without drugs, Simon N. Young

[5] Metamorhosis, Ovidio

Maria Giulia Marini

Epidemiologa e counselor - Direttore Scientifico e dell'Innovazione dell'Area Sanità e Salute di Fondazione Istud. 30 anni di esperienza professionale nel settore Health Care. Studi classici e Art Therapist Coach, specialità in Farmacologia, laurea in Chimica e Tecnologie Farmaceutiche. Ha sviluppato i primi anni della sua carriera presso aziende multinazionali in contesti internazionali, ha lavorato nella ricerca medica e successivamente si è occupata di consulenza organizzativa e sociale e formazione nell’Health Care. Fa parte del Board della Società Italiana di Medicina Narrativa, Insegna all'Università La Sapienza a Roma, Medicina narrativa e insegna Medical Humanities in diverse università nazionali e internazionali. Ha messo a punto una metodologia innovativa e scientifica per effettuare la medicina narrativa. Nel 2016 è Revisore per la World Health Organization per i metodi narrativi nella Sanità Pubblica. E’ autore del volume “Narrative medicine: Bridging the gap between Evidence Based care and Medical Humanities” per Springer, di "The languages of care in narrative medicine" nel 2018 e di pubblicazioni internazionali sulla Medicina Narrativa. Ha pubblicato nel 2020 la voce Medicina Narrativa per l'Enciclopedia Treccani e la voce Empatia nel capitolo Neuroscienze per la Treccani. E' presidente dal 2020 di EUNAMES- European Narrative Medicine Society. E’ conferenziere in diversi contesti nazionali e internazionali accademici e istituzionali.

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