Extract from the book “Bridging the Gap between Evidence-Based Medicine and Medical Humanities” by Maria Giulia Marini
Narrative Medicine is democratic. It does not belong to, or side with, anybody or a specific role but belongs to all individuals, and at least once in a lifetime, each human being has to deal with the patterns of balance/imbalance of health and illness. It is transversal and crosses all roles and specialties and requires a systemic approach to attain a multiple stakeholder consensus uniting the 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, indeed, as a governance tool, with a bidirectional flow between the health care 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 (with the associated accountability), and their primary duty of enhancing the prosperity and viability of the organization. [the Business dictionary.com]
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 echo-friendly sustainable health care system, that can deliver accessible quality care without impacting our future generations. Sustainability in health care 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, perhaps a scarcely considered aspect, is a quite interesting issue and concept that is recently gaining some attention. As stated by Dr David Pencheon, director of the Sustainable Development Unit (SDU), and consultant for NHS England and Public Health England, claims “the health and care system is increasingly aware of the benefit of helping to develop resilient communities: resilience 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 (or better antifragility skills) following traumatic issues both in patients and in care providers who need to be prepared to support the person they assist [Porter, 2010].
Pencheon declares: “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. After reflective writing they will become active, informing themselves, sharing their stories of care through the digital network. Continues Pencheon: “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 these perspective, some interesting data come from the work of Langewitz and colleague, who offers a starting point for reflecting on the moment of doctor-patient communication. Often is assumed that letting the patient talking could only mess-up the medical encounter: on the contrary, this study’s results point out that the 80% of patients need just two minutes of not interrupted talking (and of active listening by professionals) to narrate their illness stories, meanwhile revealing elements useful for the diagnosis. So, this study can be seen as an example of a totally eco-friendly sustainable and feasible practice to carry on in our Western healthcare services to improve the diagnostic process and to reduce time and money wastefulness.
Outcomes should represent value for patients and providers, to water the garden of an eco-friendly health care system: as Michael Porter, Harvard Business School Professor and Institute for Strategy and Competitiveness Director, points out, “value should be the preeminent goal in the health care 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.” [Porter 2010]. 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, and not only to faintly influence from very far away the decision makers.
This transition toward a truly sustainable health care service and based on governance practice will only happen through honesty, collaboration, public involvement and the innovative use of business models and technology widely used elsewhere in society to deliver a safer, fairer future. It is remarkable that both Pencheon’s and Porter’s visions, both fully engaged in designing sustainability concepts, respectively from UK and USA, are similar in terms of a moral code which empowers patients voice and then 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 so far is the use and abuse of defensive medicine, the practice of recommending a diagnostic tests or treatments which may not be necessary or the best option for a specific patient, but are prescribed against any liabilities or malpractice claims. Studies show that the distorted behaviour of defensive medicine can sum up to 34% [Sherz, 2013] of unneeded medical visits, According to a recent USA physicians’ survey by Jackson Healthcare, the nation’s third largest healthcare staffing agency, 75 percent 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. As to the Europan setting, in particular to UK, a recent survey addressed to hospital doctors found that up to 78% (n = 159) was practicing —in one way or another— defensive medicine [Otashi, 2013]. In Italy, from the last report of Health Care Authorities, published in March 2015, the habits of defensive medicine is practiced at least once a month by 80% of the physicians. The fear of being sued hits 80% of the Italian physicians; drugs, visits tests and hospital in stay that are not necessary cost to the Italian population 1% of the GDP [Ministry of health, 2015]. In the mainframe of governance, since the citizens are the payers of the health care service (public or private,) 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, non sustainable system very far from echo- friendly services.