Muiris Houston

How would you feel if your doctor changed your diagnosis from a short label to a longer, more descriptive wording? For example, instead of having mild asthma, you might be told you have a tendency to wheeze when you exercise.

Or having low mood following the death of a close friend may be a more helpful description than being told you are depressed.

In a parallel of sorts, coroners’ courts in the UK are now allowed to reach “narrative verdicts”.

It can be difficult to assign a single cause of a death. So, instead of trying to squeeze the evidence into a pre-ordained category, juries may now choose to go for a narrative description. This may describe what has happened and allows the jurors to express a view of what caused the death.

Complexity of health
Writing in the Postgraduate Medical Journal , Dr John Launer wonders why, given the complexity and uncertainty of health, the concept of "narrative diagnosis" hasn't become established in medicine.

“As doctors, we often find ourselves having to try to name things for which there are no easy names, or struggling to pretend that something can be described by a single label when in reality it cannot.

“As a profession we commonly invent labels for dubious ‘grey-area’ conditions that we cannot fully understand or that refuse to fit into existing boxes. A narrative diagnosis would fit these circumstances very well,” he says.

It’s interesting that, despite narrative medicine having an established role in modern medical practice, the concept of narrative diagnosis has not emerged until now. Launer argues that doctors probably use narrative diagnosis quite a lot without necessarily being aware they are doing so.

Illness story
General practitioners, for example, commonly use expressions such as "it's probably a virus", and "it's likely to go away of its own accord".

These narrative threads all carry an important message: a formal, medical diagnosis may do harm, and keeping the conversation within the realm of everyday, colloquial story-telling may serve the patient better.

As someone who teaches narrative medicine, I would argue that having a narrative competence is one of the core competencies required by a doctor.

He or she needs to be alive to the person’s illness story in order to help the patient in the most effective way. And for those with chronic illness, this narrative changes over time, making it vital that the doctor tunes in to the person’s story on a regular basis. By travelling back and forth across this narrative, both doctor and patient benefit.

Diagnostic labels
A key question for medical students and doctors is to ask: why is this patient seeking medical help from me at this particular time? It seems to me that the concept of narrative diagnosis fits nicely with the answer to this question.

As doctors we become better at tolerating uncertainty as we become more experienced. The same principle may apply to using narrative diagnosis.

And it may also be that the modern trend of using exact diagnostic labels and acronyms is counterproductive.

Launer offers an even more radical idea. What if even the most apparently solid of physical diagnoses, such as hypertension, are in fact merely abbreviated narratives – scientific stories if you will.

Formal diagnosis vague
"With exceptions, such as peritonitis or cerebral haemorrhage, many formal diagnoses might be regarded more as vague but pragmatic signposts rather than absolute certainties. They indicate the general area or cluster in which someone's difficulties belong," he says.

And what if it could be shown that, in some cases, formal diagnoses may not provide much in the way of guidance for doctors and patients about what to do next?

Now that would be a paradigm shift that could significantly change the way doctors and patients relate to one another.

mhouston@irishtimes.com
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