Anna Beug is a general practitioner and medical educator in Dublin, Ireland. From a clinical perspective, she has worked for over 20 years in a deprived area of Dublin’s south inner city. She has been involved in medical education since the beginning of her career. She teaches undergraduates at Trinity College Dublin, but most of her teaching now takes place at the postgraduate level. She works with GP trainees both individually and in groups, and also collaborates nationally with experienced GPs in the areas of mental health, communication skills, and persistent pain. Recently, she joined the faculty of the Master’s Program in Applied Narrative Medicine at Fondazione ISTUD.
- Anna, how has narrative practice affected your work?
I first became aware of Narrative practice about 10 years ago when I encountered CIC (conversations Inviting Change) – The work of Dr John Launer (see resources). Already quite established as a clinician and teacher, the principles of narrative practice seemed to be something I had long searched for. In the last decade, narrative ideas, and CIC in particular, have profoundly influenced my clinical practice and teaching. I am an accredited CIC facilitator, I regularly teach CIC workshops both online and in person, and I have started to introduce narrative practice in GP training here in Dublin.
CIC is based on ideas from narrative studies, systemic thinking, communication theory and educational theory. It is an approach that promotes precise attentiveness to language and the idea that the goals of any conversation should not be predetermined. It offers the learner precise skills for giving patient’s stories ‘room to breathe’, and a closely choreographed and disciplined training methodology for helping clinicians to acquire these skills.
From a personal perspective my encounter with narrative practice has significantly changed my stance in the consultation. I have learned something crucial about curiosity, a vital skill in terms of being able to elicit narrative. I have learned to be more tolerant of a position of ‘not knowing’. I have made some headway in uncoupling listening from fixing. I am fascinated by ‘the art of asking questions’ and understand something about their enormous power. I know that I cannot forget my obligations as a doctor and must learn to combine the narrative with the normative.
Narrative skills are something I have had to learn to use flexibly. I am always battling with time, but even small moments of listening can be highly impactful. My work in mental health and persistent pain has taught me that stories of seemingly intractable suffering are often the hardest to hear. They confront me with my failures as a healer and having a technique to guide my listening in these moments has been containing and rewarding. I have learned that if I can find a way to give these stories space, it can make a huge difference to my patients.
In the beginning I feared that being more open to patient’s stories would slow me down and overwhelm me, but as I have become more skilled in narrative techniques the opposite has occurred. I speak less, I explain less, and I ask shorter, more responsive and more creative questions. Another unexpected effect of a narrative stance is the joy that I experience in hearing the amazing and unexpected details of patient’s stories that would otherwise be lost. In an increasingly stressful, bureaucratic medical world, paying attention to narratives reminds me of the humanity in the work, of the art of medicine.
- What have you learned from teaching narrative methods – What are the main challenges?
Teaching narrative practice has been both challenging and hugely rewarding for me and I am fortunate to have received very detailed feedback from my trainees. They have articulated to me the challenges they face in exploring these methods and in trying to apply them to everyday practice. Their honesty in sharing their struggles has guided me in adapting my teaching over many years.
One of the most pressing concerns of doctors in response to being asked to adopt a more curious stance relates to time. They understandably feel that eliciting stories better equates to eliciting longer stories. While this can sometimes be the case, the opposite often occurs. My work as an educator seems to lie in giving them the encouragement, support and techniques to try. Very quickly they discover, that when given space, patients not only get to the heart of the matter much more quickly but may also offer very helpful ideas about how to manage their own problems. I have sometimes said to trainees – ‘If we can get out of the way, our patients will do much of the work for us’. This kind of stance requires a willingness to relinquish control, to share power much more equally with our patients, and to understand that fixing is only sometimes an option in medicine. I find it important to remind learners that narrative skills can be used flexibly. In medical emergencies the doctor needs to be focused and decisive. In very straightforward consultations involving simple minor illnesses, narrative skills are not so critical. It is in the most complex consultations that I believe these skills matter most, and certainly in primary care, it has been my experience that narrative practices can transform these encounters for both the doctor and the patient.
I have encountered a huge range of reactions to my attempts to teach narrative practice to doctors. The resistances are varied and personal. I have also reflected closely on my own resistances which still arise every day. One of the great strengths of the CIC method for me is that it is taught in a supervision structure. Techniques are practiced by asking learners to ‘supervise’ each other as they speak about professional dilemmas. This provides a safe place where narrative skills can be practiced. It also provides doctors with a first-hand experience of having their own stories heard and allows them to become more reflective about their interactions with each other and with patients. Formal supervision, a requirement for many mental health professionals, is almost entirely absent from medicine. CIC in my experience, can go some way towards mitigating this.
A narrative stance asks the doctor to step back, to give power to the patient and space to the patient’s story. It asks the doctor to imagine that they are not responsible for fixing everything they hear and to trust that when all else fails, listening still matters. The level of resistance to these ideas is closely related to the individual doctor’s relationship with knowing, with power and with needing to fix. Medical education and the prevailing culture in western society re-enforce these values which often have deeply personal roots. I do not believe that narrative practices can be widely adopted by doctors unless real attention is paid to working conditions and support for the clinicians themselves. We want doctors to be caring, curious and compassionate under often impossible circumstances. I think we need to conder who is being caring, compassionate and curious towards the doctors.
- Why should we listen to patients Narratives?
I would approach this question by considering the consequences of not listening to patients’ narratives in the hope that this might help us to see narrative skills not as the icing on the cake, but as part of the cake itself. I have come to believe that unheard stories are one of the greatest causes of difficulty and risk in medical encounters. When stories are not heard, vital diagnoses are missed, and patients’ individual concerns ignored. I believe that when patients feel unheard, they tend to consult more often, are understandably more dissatisfied and may even be more motivated to complain or initiate legal proceedings. I believe that combining narrative skills into structured medical consultations is not only possible but critical at a time of real crisis in the medical profession.
At a time where high rates of burnout represent a huge threat to the medical workforce, I will mention again the joy that can come from making even small amounts of space for stories in clinical encounters. It can remind us of our shared humanity and well as adding depth, and humor to our work. It can help us to be moved by our interactions without being overwhelmed and it can help our patients to see us as a human and finite resource. I believe that with the correct support, introducing narrative ideas into mainstream medical education seems possible as long as we remain mindful of the immense pressures and expectations placed on young doctors.
I wish to briefly address a view I have often encountered which is that doctors don’t want to listen. In my opinion this is rare. I have encountered doctors who don’t know how to listen and doctors who are so burnt out that they can’t listen. I have no doubt that many people who enter the medical profession are motivated not only by ideals of healing but are also drawn to the status and power that the profession might seem to offer. I see that listening and more specifically narrative enquiry are not highly valued in medical education, but I believe that change is possible and needs to be introduced with the reality of the work in mind.
I am aware that there are a wide variety of narrative methods, many of which seek to work on the relationship between doctors and stories. I have been curious to learn about as many of them as possible. CIC has been important to me as I have found it practical and teachable, and I appreciate the way it explicitly occupies itself with the real world of medical practice.
I have spent my whole working life surrounded by the stories of others. Having now cared for three generations in the same community, I am continually reminded that stories are always moving and changing. These stories challenge me, they exhaust me, they excite me, they move me, and I am grateful for what they have taught me. By engaging with narrative practice, I have also learned something about the need to engage with my own story and the story of my relationship with medicine. There is no other way to get out of the way and let my patients’ stories be heard.
Resources:
- https://www.conversationsinvitingchange.com
- Launer, J. (2018) Narrative-Based Practice in Health and Social Care, Conversations Inviting Change. Second edition. Routledge.
Contact:
anna.beug@icgp.ie