Narrative Medicine is democratic: it belongs to every individual, it is transversal and crosses all roles and specialities; it requires a systemic approach to attain a multiple stakeholder consensus, uniting the listening and collection of stories from patients, caregivers, friends, employers, and teachers.
If governance is a word born from the synthesis of two terms – government, with a so-called top down approach, and alliance, with an acknowledged bottom-up direction – Narrative Medicine can be defined as a governance tool, with a bidirectional flow between the healthcare system and the patients, and vice versa. Governance is, in fact, an establishment of policies, and a continuous monitoring of their proper implementation by the members of the governing body of an organization: it includes the mechanisms required to balance the powers of the members, and their primary dutyr of enhancing the prosperity and viability of the organization.
Thinking about implementation of Narrative Medicine into medical practice, we automatically acknowledge a possible clinical benefit of a therapeutic alignment with patients, but we rarely envision this as a potential tool for building an eco-friendly sustainable healthcare system. Sustainability in healthcare is composed by different features which should be all embraced with complexity management: the road to sustainable wellbeing must consider the overall impact/benefit of environment, resiliency, patient education, and cost and payment of value health care activities.
Among these, resiliency is a quite interesting issue. As David Pencheon states, “the health and care system is increasingly aware of the benefit of helping to develop resilient communities: resiliency that is fundamental to health and wellbeing, both in times of relative stability, and in times of crisis”. Indeed, narrative practice is widely applied to booster resiliency, following traumatic issues both in patients and in care providers who need to be prepared to support the person they assist.
As Pencheon continues: “The health and care system can take every opportunity to work with people to prevent the preventable and manage the manageable. This means helping us all improve our understanding and control over our own health, illnesses, and life chances, within our homes and communities. The traditional model of us being well, then ill, then treated, then better, is increasingly outdated. Most of us will live with multiple conditions that we will largely manage ourselves with the support and guidance of the health and care system using improved information, integration, collaboration and technology”.
Since Narrative Medicine encompasses the patient from a global point of view, the being chronically ill with multiple conditions will better probed through patients, who, by writing, will develop a leap of awareness and will foster the coping ability, by reflections on their situation. Pencheon continues: “This […] plank requires a cultural shift for public, patients and particularly professionals. We may need more diverse business models for providers of care. We could reward care providers for the amount they reduce death rates or health inequalities or survival times or for simply improving the experiences of patients. Those who commission healthcare are increasingly choosing to pay for outcomes”.
Pencheon refers to macro-economic elements and dynamics, but eco-friendly and sustainable practices could begin even in everyday-life contexts. In such perspective, works such as Langewitz and colleagues’ study can be seen as an example of a totally eco-friendly sustainable and feasible practice to carry on in our Western healthcare services improving the diagnostic process and reducing time and money wastefulness.
Outcomes should represent value for patients and providers: as Michael Porter points out, “value should be the preeminent goal in the healthcare system, because it is what ultimately matters for customers (patients) and unites the interests of all system actors. If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health care system improves. Value encompasses many of the other goals already embraced in health care, such as quality, safety, patient centeredness, and cost containment, and integrates them. It is also fundamental to achieving other important goals such as improving equity and expanding access at reasonable cost”. Governance here is strongly taken into account: since value for patients is what matters, the patients have the main power to decide which type of health care system they wish.
This transition toward a truly sustainable healthcare service, based on governance practice will only happen through honesty, collaboration, public involvement and the innovative use of business models and technology widely used in society to deliver a safer, fairer future. It is remarkable that Pencheon’s and Porter’s visions, both fully engaged in designing sustainability concepts, are similar in terms of a moral code which empowers patients voice and that of providers of care, and lastly to money makers: “a sustainable, system-wide approach avoids the trap of false choices, thinking, for example, that a growing economy is more important than a lively community for our children”.
A key factor that has strongly limited the development of a sustainable health care system is the use and abuse of defensive medicine. Studies show that the distorted behaviour of defensive medicine can sum up to 34% of unneeded medical visits. According to a recent USA physicians’ survey by Jackson Healthcare, the 75% of doctors say that they order more tests, procedures and medicines than are medically necessary in an attempt to avoid lawsuits. Gallup reports that one in four healthcare dollars spent in healthcare can be attributed to defensive medicine – about $650 billion annually. These costs are passed along to everyone, significantly driving up health insurance premiums, taxes to cover public health insurance programs, co-pays and out of pocket costs. In Italy, according to the last report of Healthcare Authorities, the habits of defensive medicine is practiced at least once a month by 80% of the physicians: drugs, visits tests and hospital in stay that are not necessary, cost to the Italian population 1% of the GDP. In the mainframe of governance, since the citizens are the payers of the health care service, it turns out clear that their “money” is not being spent wisely when defensive medicine is applied, and irremediably wasted. It’s a useless expenditure of money, which contributes to maintain a corrupted, unsustainable system very far from echo- friendly services.
One of the dilemmas that narrative rises concerns the shift from the single individual case – the personalization of a therapy, to a general level, when large scale decisions are needed. While highlighting governance and sustainability concepts, we can state that the scope of Narrative Medicine has come to include two other main stakeholders: health economists and decision-makers. These experts have to make difficult decisions on the basis of data on populations, epidemiological forecasting and response to treatment: at a first glance, apparently leaving no room for personalization of care. Decision-makers need figures and numbers and heavily rely on robust Evidence Based findings, but do not see the potential in other kind of evidence: Evidence-Based Medicine comes short in many aspects which have proven to be critical to optimal patient management, whereas Narrative Medicine again presents to be an alternative way of thinking outside the box for finding new solutions.
