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Parallel chart in General Practice

We are pleased to publish an excerpt from the project work of Ingrid Windisch, General Practitioner who participated in the last edition of the Master in Applied Narrative Medicine of ISTUD Foundation. You can consult the complete presentation in Italian.

Introduction

Listening to the stories of our patients and our patients and in turn, telling the stories we live in the workplace to colleagues and colleagues or loved ones is such an obvious daily occurrence that it hardly deserves to be mentioned. These stories do not always have positive implications: they do not help us to understand something better, they are not a source of wisdom and often not even funny; most of the time they are tragic, chaotic, whining, they make us nervous, they fill our heads without leaving us time to untangle the different threads, they confuse our ideas. Communication is always full of unexpected traps. But it is still also relationship and contact. Narration creates a bridge between the listener and the narrator, and if we go deeper into this subject, we realize the complexity and infinite nuances of telling each other.

This also applies to the medical profession. Reflection on communication in care relationships becomes indispensable if one wants to understand oneself, one’s patients and the complicated life situations with which every one of us has to deal with, sooner or later.

Methodology

For my project work in Narrative Medicine, I chose to focus on the use of the so-called “parallel chart”, experimenting it on myself. A parallel chart is a tool that was introduced by internist and literature scholar Rita Charon in 1993 to integrate patients’ stories into clinical practice.

As a sample, I chose the group of patients from my home visits PHC and IHC (Programmable Home Care and Integrated Home Care) [6] in June of this year, 2020. In all, I have compiled 17 parallel charts.

In June, I performed 9 PHC visits to people who cannot leave home, and I completed 8 IHC visits to a person with a rare disease, for complex medications and general medical care.

After each visit, I wrote a parallel chart, in which I reported what I thought, what happened, in short: everything that I do not write in the regular medical chart.

To better focus on the meaning of my work, I formulated three questions to be answered at the end of the path:

Can the parallel chart be a support tool for the General Practitioner / General Practitioner?

What changes in everyday work when writing a parallel chart?

How can personal experience be integrated into the culture/science/research of Narrative Medicine?

Personal experience

I enjoyed writing the parallel folders: describing situations, telling a piece of reality, grasping a shred of truth, sticking to the facts.

Faced with violent experiences, destructive events, profound suffering, sometimes language fails, voice is missing, language is insufficient. And that is where my interest in finding an incipit, a first word, a word that can become an anchor of salvation, a point of crystallization that transforms a world without words into a shared story.

Analyzing the stories I wrote was not easy. I did not know which lenses to use. In the end, I chose four recurring themes that somehow emerged in many of the stories: closed eyes, carers, machines, colours. And a metaphor: the boat.

Reflections

I was writing the parallel chart after home visits required discipline, consistency and time.

Every time I went back to the clinic or home, I wrote down what was coming to my mind, without overthinking. Only afterwards did I dedicate to a thousand daily tasks to do. It was a moment of pause that I had to take to reflect on what I had seen, heard, thought and experienced.

Then, I transcribed the texts written by hand in a computer file. Writing with pen and paper is different, more sensual, more carnal, closer, more profound.

Mrs Narrative Medicine was my physical and mental companion in June 2020. An invisible presence, more prominent than me. A wise being, who put her good-natured hands on my shoulders. I realized that they had a perfect size, these hands, these very hands, just for my shoulders. I am not sure where this experience will take me, but I trust my companion, I trust her knowledge, I let myself be guided by her expertise and the affection she shows me.

Language/Language

I wrote the parallel folders in Italian, a language that is not my first language. I liked this experience, even if sometimes it was frustrating because I didn’t have the exact word, I didn’t have the linguistic security that guides me in my first language. However, I dared to “throw myself”, even making mistakes, facing insecurities and with vocabulary beside me. Sometimes I didn’t know if what I was writing was understandable. And even less could I use any rhetorical embellishment, because words were enough for me to express the fundamental things.

Once, in a moment of intense emotion, I changed language in the middle of the text, because I was no longer able to write in Italian what I wanted to say. I continued writing in German, and I saw that then the story became more detailed and full of elements.

Then there is the question of dialect: now and then it happened to write a sentence in dialect. Sometimes it is not possible to express in any other way. The dialect is so close to people and their context, it’s like a talking dress that a person wears to tell something that belongs to them, something of themselves. And it is untranslatable.

I have also chosen to write using a language that is attentive to the female gender since I am a woman and most of the people I assist are women; so are most people in the medical and nursing professions, who somehow have to deal with “loved ones”.

Answers to initial questions

Can the parallel chart be a support tool for the General Practitioner?

Yes, it can be. It is a tool for reflection, an opportunity to deepen the relationship with one or a patient, discovering maybe a piece of a bigger puzzle, the missing piece that you have to put right there. In this way, even in a hopeless situation, one feels able to offer/do something that relieves the burden of the illness, which burdens both the sick person and the caregiver. It can also be an opportunity to get to know yourself, your strong and weak sides better.

What changes in everyday work, writing a parallel chart?

I would say that you learn. New ideas come in, different perspectives are created, a clearer view of how to do the job is achieved. You can better understand personal and professional needs, for example, the usefulness of participating in training courses, supervising or trying to share experiences with others.

How can personal experience be integrated into the culture/science/research of Narrative Medicine?

This is why a reference group, sharing with other people and contact with experts in the field is indispensable.

Conclusions

For me, the project work was exciting, and I felt very involved. I learned to pay attention to moments of tiredness, frustration, heaviness. It is as if writing helped me to find small ways out where the road became a dead end. It helped me to find new possibilities to assist patients even in cases where I thought nothing could be done. I understood the value and richness that comes from accepting that a path also has deviations.

It was challenging to be alone, and I understood that it is necessary to have reference people, a group or team with whom to share the experience. A coherent, convincing and complete story has more and more points of view. 

Narrative Medicine is an approach that through this experience, I have been able to know better, and that will surely, in one way or another, accompany me in my future professional life.

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