Wednesday, 7 March 2018

Is it possible to design a health system without a narrative basis?

Salvador Casado

One of the most complex issues in health organizations is to design structures and processes that combine quality, effectiveness and user satisfaction. So far no one has found the holy grail of “the good, beautiful and cheap” in healing. Where I would like us to pause for a moment is in the analysis of the founding fact of any health system: the clinical act. The point of contact between patients and health professionals is the clinical meeting that will lead to a therapeutic relationship.

The problem is that nowadays this is very expensive and at the moment nobody dares to automate it using technology, algorithms or artificial intelligence. When you're sick, you want someone to treat you, not a robot.

That is why the systems have been trying to generate more service for years, forcing their human resources to perform more at the same cost. But the suffering health professionals are not machines, however high their capabilities may be. Few people realize that we have reached the limit, in fact we have crossed it. 

If we overload the agendas, the clinical encounter will suffer and if it is not of quality, the expense cascades in diagnostic and therapeutic processes will increase progressively. The person in a situation of illness, crisis or stress needs to be listened to, understood and accompanied. If we push her instead to a high-tech sanitary pinball machine, she will bounce from doctor to nurse and probationary test until she is fired by the system without solving the underlying problem in many cases. Re-entry is becoming more frequent and the patient will accumulate episodes in his or her medical history and new incursions that worsen the battered expenditure indicators at different levels.

In primary care, we have been defending the importance of narrative medicine for decades, but we have not been able to explain it well either to citizens or to managers and politicians. Most of the human suffering that reaches the health system is the result of normal life. Couple, work-related and social problems end up in the family doctor's office because there is nowhere better to go. The destruction of family and personal networks of coexistence and the rhythms of urban life, fast and work-centred, make the sick person experience at first hand what vulnerability is.

Helping the suffering person to develop his or her own narrative in the face of their situation would be the most humane, less interventionist and more efficient course of action in a large number of cases. For this purpose, the health professional must be provided with education, training, sensitivity and sufficient time. 

Allowing each citizen to recognize the discomfort they experience inherent in living and to take responsibility for their management and care is a priority that is not being addressed today and which is putting the sustainability of health systems in jeopardy. In addition to the problem of greater chronicity and complexity, we have on the table the increase in requests for care by healthy people who saturate from emergency services to health centers and hospital consultations. 

It is striking that nobody talks about it and corrective measures are not proposed, but, believe me, the excess of consultations for reasons that can be handled by the citizen is reducing the time that should be dedicated to the truly sick.

Will it be possible to protect the clinical encounter so that it has a minimum of time and quality? I can imagine that it is possible, but allowing a family doctor to devote five or six minutes per patient is incompatible with building quality narrative processes. With good will, structures as heavy as sanitary structures are not sustained.

  • CHARON, Rita. Narrative medicine: a model for empathy, reflection, profession, and trust. Jama, 2001, vol. 286, no 15, p. 1897-1902.
  • CHARON, Rita. Narrative medicine: Honoring the stories of illness. Oxford University Press, 2008.
  • Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract 2009;14(4):595-621.
Shapiro J. Narrative Medicine and Narrative Writing. Fam Med 2012;44(5):309-11.

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