The Patient’s Narrative Is a Part of Medicine Patients’ stories may be as important as their diagnoses, and there’s room for both in treatment. On the Pulse
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On the Pulse  |   April 01, 2017
The Patient’s Narrative Is a Part of Medicine
Author Notes
  • Carly Bergey, MA, CCC-SLP, is a clinician with Bethlehem Ear, Nose and Throat Associates in Bethlehem, Pennsylvania. She specializes in treating voice, paradoxical vocal fold movement/vocal cord dysfunction, chronic cough and swallowing disorders. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. cthebergey@gmail.com
    Carly Bergey, MA, CCC-SLP, is a clinician with Bethlehem Ear, Nose and Throat Associates in Bethlehem, Pennsylvania. She specializes in treating voice, paradoxical vocal fold movement/vocal cord dysfunction, chronic cough and swallowing disorders. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. cthebergey@gmail.com×
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / Practice Management / Professional Issues & Training / Speech, Voice & Prosody / On the Pulse
On the Pulse   |   April 01, 2017
The Patient’s Narrative Is a Part of Medicine
The ASHA Leader, April 2017, Vol. 22, 38-39. doi:10.1044/leader.OTP.22042017.38
The ASHA Leader, April 2017, Vol. 22, 38-39. doi:10.1044/leader.OTP.22042017.38
Jill, a patient I was seeing for voice treatment, got a phone call during a session. As she listened to the caller, I watched her demeanor change. She hung up and shared her news with me: The results of her thyroid biopsy were abnormal.
Jill then motioned that she wanted to continue her vocal warm-up, waving her hands to indicate “let’s-get-this-over-with.” I could have pressed on—after all, evidence-based practice tells us that repeated motor trials are essential to muscle memory. And we fear that discussing a phone call like this is out of our scope of practice. But I paused, because something had just changed—dramatically.
There is a great deal of research surrounding the concept of an “illness narrative.” We know that when a person experiences a health problem, they often experience an interruption in their sense of self, and that perception of who they are gets put on hold while they seek to understand their illness.
I am a student and teacher of narrative-based medicine (NBM). This framework, while certainly not new, is becoming more relevant in communication sciences and disorders, as audiologists and speech-language pathologists seek to provide care in a more holistic manner. NBM seeks to narrow the gap between the indispensable medical and behavioral management of pathology and the ever-changing therapeutic landscape that occurs when a patient and caregiver come together. It looks to give patients ownership of their place in their own narrative as they manage illness. The patient’s story has primacy. There is a shared power—and with it a shared story—that has the potential to change everyone involved.

Narrative-based medicine is becoming more relevant in communication sciences and disorders, as speech-language pathologists and audiologists seek to provide care in a more holistic manner.

Incorporating the patient’s story
Let’s look a little deeper. How can we incorporate NBM with evidence-based practice? As every audiologist and SLP knows, time is short and reimbursement is low.
A logical place to begin is how we approach the intake of medical history. The use of open-ended questions and inclusive language helps serve the greater structure of the illness narrative.
For example, I may say, “I’ve read your records, so I have an understanding of the medical aspects of your story. But I’d like to hear in your own words about your experience with your voice.”
This statement gives the patient the option to unravel their story in whatever manner feels natural. As a clinician, I listen for medically and therapeutically relevant information, while simultaneously listening for details that have meaning for a patient. This approach also lends itself to patients setting their own goals alongside measurable goals set by the clinician.
For example, during voice treatment I may want a patient to “produce a resonant voice in functional, spontaneous speech without cueing across three consecutive sessions as perceptually judged by clinician.” In a complementary goal, the patient may want to “sound like myself again when reading to my preschool students.” The patient and clinician share and understand both goals, which therefore become collaborative and cooperative.
How does NBM affect treatment? Evidence-based practice still guides a clinician in selecting appropriate modalities and up-to-date practices in treatment options for patients. And we were all taught to “build rapport” with patients, a concept we can expand in treatment as we bring our own perspective and experiences to the clinical relationship over time. We are so often consumed with achieving measurable goals that we may not reciprocate a patient’s vulnerabilities in our sessions. Without crossing ethical boundaries, the clinician is invited to engage in the patient’s experience with mutual storytelling as part of the greater illness narrative.

We are not psychotherapists, and using a narrative framework does not mean that we lose sight of our scope of practice and offer advice or instruction outside of our expertise.

Some caution
There are, however, pitfalls to avoid. We are not psychotherapists, and using a narrative framework does not mean that we lose sight of our scope of practice and offer advice or instruction outside of our expertise. Instead, in voice treatment for example, we want to instruct patients to use good vocal production while they reflect on their therapeutic experience relevant to the session and course of treatment.
I might say, for example, “Tell me what you are thinking about our voice treatment sessions, and as you do so, I want you listening and feeling for airflow as you speak.” This direction gives the patient a chance to reflect on the therapeutic process alongside other treatment goals.
In a situation like my session with Jill, NBM calls for an adjustment in the session plan. After her “let’s-get-this-over-with” motion, I gently made the hand signal for “time out” and said, “You just received bad news, and even as we finish these last few voice exercises, I want to acknowledge the bigger picture of what’s just happened. Would it be interesting to use your voice in an easy or neutral way, while you process that news? Can we do both?”
Jill dropped her shoulders. She resumed the humming exercises we had been practicing just a minute before. She was invited to become aware of vocal production while thinking about a difficult situation, and in doing so, voice treatment was integrated into her story. Simple humming became an acknowledgment of something bigger going on.
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FROM THIS ISSUE
April 2017
Volume 22, Issue 4