All of us have a life story to tell, whether we are President or pauper. Such a story pulls together fragments of experience in ways which are meaningful both to the teller and to the trained listener.
When I make my first medical house call to a new patient, I try to listen and to write down the other person's story, using the visual device of the family tree. Circles represent females and squares represent males. This technique conveys that the story is important to me, the doctor. It also helps me understand the caregiver situation in the present. By the time I am invited into someone's home the hourglass is nearly empty, the story is long, and the maladies multiple. (A typical patient has about twelve medical problems on their list.) I am not in a big hurry, so I allow the patient and/or the adult child to wander within a subtly rigorous framework.
"I was born in Turkey… My father was a high government official… My childhood was wonderful… It was a mistake for me to move to America."
"I was a semipro baseball player who soon became married and a family man. Then I worked in the engine room of a FDNY fireboat for 27 years, which is why I am so hard of hearing nowadays."
I can picture many deceased patients through their stories even if I can't as often remember their specific medical conditions. Lots of people have high blood pressure, but the stories make them unique and alive.
So we go through a life, asking a few questions here and there. Most people are eager to tell their stories, and grateful that the doctor will listen. "So your husband was alcoholic but a good provider so you stayed at home and raised five children?" I might reflect, and the patient responds "but he never hit me or hurt me. He just drank on the weekends." Then I might say "You have been a widow now for about 30 years, what has that been like?" "It may surprise you for me to say this, but I do miss him."
Then and only then, do I start to weave in more obviously medical content such as "It sounds like you got very sick about three years ago, is that right?" "Yes, it was really bad after my stroke I couldn't do anything for myself. I like to keep a tidy house but was unable to do that. I had to ask my kids to clean and bathe me. Can you imagine? I am a burden now."
By this time, hopefully, the tension and anxiety that usually greet a first visit has given way to an understanding that the doctor accepts the patient, however they may be. It's unconditional. It is okay with Dr. S. to say and be whatever you are. If a beloved cat has just died, it is unlikely that the patient will have much interest in blood pressure medication before kitty has been put to rest, at least in our conversation.
One of my patients has what is sometimes called complex grief. The ten years older woman, with whom this never-married man shared a life for sixteen years, died two years ago and he still needs to talk about it. So that is where every visit starts. It appears that the grief will never leave him, but he is doing other things in his life now, and he knows the doctor will listen to the same story, month after month. With this knowledge, the grief story becomes a little less intense each visit, maybe a little less frightening; he knows the doctor will listen and not judge or lose interest. It has been said that the main purpose of the first visit is to make possible the second visit. And the third, the fourth and so on.
With this approach, the medical facts are not difficult for either doctor or patient to sort out, list, and understand. The doctor must first be trusted before the patient will accept more, less, or different medication. (The doctor's presence is actually the most effective drug in some situations.) Maybe those stiff shoulders would benefit from some Aleve and a few sessions of physical therapy. “I’ll be back next month, OK?” “Sure, doc, see you then.”