When we met Carmen, a woman in her fifties, she was sitting on the bed with her
legs crossed. She smiled when she saw us. She had smart brown eyes and short
brown hair; she looked very alert. Dr. J. let Carmen talk without interruption for
about 21s. Carmen related that she had flu-like symptoms and a mild fever and
that she had been in pain for several days, having missed her regular doctor’s
appointment—“not because of negligence or forgetfulness,” she emphasized, but
due to her family situation. Dr. J. did not interrupt the narrative to ask her about
it, but Carmen oriented her narrative to her personal situation: her
“nervousness” at leaving her mother with Alzheimer’s under the care of another
less skillful person in order to come to the hospital. She also introduced another
theme: the recent passing of a family member.
Carmen was able to clearly articulate her symptoms and demonstrated that she
was familiar with some medical jargon about medical procedures, which Dr. J.
approvingly acknowledged by saying, “You even know the terms.” Dr. J. did not
ask her about any psychiatric symptoms . He asked some concise questions,
such as her mother’s age. What Carmen said was, “I had to come to the hospital
because I thought I had the flu, but I have had a transplant, you know?” we can
say that this information was not given to the physician by virtue of his
elicitations or questions, but given off by the patient—that is, it leaked into the
interaction- the surprise factor.
Dr. J. maintained eye contact with her and back-channeled what she was saying
with interjections that showed attention to, interest in, and coordination
with the narrative. The clearest manifestation of attention was displayed in two
subtle and interrelated ways: first, by suspending judgment, Dr. J. seemed to
adopt a phenomenological approach (Heidegger, 1962; Husserl, 1931/2002) that
required him to bracket his prior assumptions of a “psychiatric patient” in order
to listen to the patient’s own narrative orientation (Sacks, 1992). That is, he
observed how her discursive orientations made her history relevant, what had
happened to her, and what had led her to seek assistance in the ER. Dr. J.’s
second manifestation of attention was demonstrated by restraining and
downplaying his own voice to avoid interrupting the patient to further explore his
own initial hypothesis. He allowed the patient to speak for herself and raise her
own hypothesis of what might be wrong. In that manner, we see a form of
“emptying oneself” that is not passive but rather active, as mentioned above.
This type of listening practice allows the patient’s voice to rise above the voice of
the medical record. In this process, not only has the patient gained agency but
also the doctor has preserved his own agency. Representation and affiliation
were also put into practice. Without the doctor’s self-monitoring skill in
determining whether or not his diagnostic hypothesis is in alignment with the
patient’s explanatory system, there is no representation or affiliation.
Representation allows us to imagine that given Carmen’s family situation, she
had more than enough reasons to suffer “from anxiety”—without medicalizing
her condition. And affiliation comes from the capacity to recognize that similar
situations would have overwhelmed us as well. By allowing the patient to present
herself, Dr. J. momentarily downplayed the voice of medicine, represented in the
impersonal form of the EMR, to instead highlight and honor the voice of the
patient. This practice is, as it is argued, the result of putting into practice the
narrative medicine skills that empower the clinician (and thus the patient) to
listen to
