The importance of stories

Part of my story is in British Columbia. When my wife, Bev, and I began our nursing and medical careers together, we went as far as you can go in British Columbia and 40 miles farther—the Queen Charlotte Islands. At the end of a year full of memory investments, we returned east to start our family. Time passed …. In the early ’90s Bev and I returned to BC to attend a family medicine meeting in Whistler. Tony Bennett left his heart in San Francisco; I lost some of my heart in Whistler. Time passed …. In the past year our youngest daughter and her husband have begun their careers in Kelowna. The cycle begins again.

What I’ve just told you is narrative: the what and the then … and then. Now if I told you I lost some of my heart in Whistler trying desperately to win a tennis game from John Keddy, that’s plot: the why.

In family medicine we deal with the what and the why—narrative and plot.

Dr Arthur Frank gave this address last year in Calgary, Alta,1 honouring the family medicine story award winners.* A few years earlier Dr Frank wrote the introduction to In Our Hands, a collection of stories by medical students from across Canada, edited by Linda Clarke and Jeff Nisker.2 Dr Frank refers to the word liminal in his introduction. He defines liminal as being neither this nor that; for example, the area between the cultivated fields of a village and the forest. The medical students who wrote the stories in the collection were liminal: in a transition state, no longer lay persons, not yet doctors. He writes, “liminal transitions can be both dangerous and fascinating.”2 Our patients are often liminal (in transition states): health to illness, illness to health, illness to death, single to couple to family, couple to divorce, employment to retirement, innocence to adolescence. Daily we listen to individuals who have their own narratives and plot lines, and their stories too can be dangerous and fascinating.

Can we be better physicians if we learn to see our patients in their contexts, in their stories?

There was a patient in our practice. She was young and had come from the country to the city in search of her future. She had well-controlled asthma. One day a discharge summary arrived from the hospital. Our patient had had a severe asthma attack. She had been intubated but had made a good recovery. Over the next few months we saw her with increasing frequency. She had changed. Her lung findings were normal but she looked tired, at times desperate. “Can you help me breathe?” she would ask. We consulted a respirologist. She fine-tuned her medication. It made no difference. At night our patient haunted the emergency department. Her diagnoses went from asthma to anxiety to panic attacks. We talked about a referral to psychiatry. “Can they help me breathe?” she asked.

One day our resident concluded that we really hadn’t established our patient’s problem. It wasn’t acute asthma, she was sure. So she took a different approach and said to our patient, “Tonight I want you to write down what has happened to you and why you can’t breathe.” The next day our patient brought this written explanation: I was having a very bad asthma attack on the night I arrived at the emergency room. A nurse started an IV and someone injected something into it. Suddenly I couldn’t breathe. I couldn’t speak. I was paralyzed. I was in a room full of nurses and doctors and I couldn’t tell them my problem. Someone shoved something down my throat and then I was gone. I woke up in a dark room with a tube in my mouth on a machine. Since then I keep reliving that moment when I was paralyzed and couldn’t breathe.

Over the next few months our patient made a steady recovery. The next year she married. We delivered her first baby.

The resident had found a way for our patient to reveal the “why” in her story.

Jacques Ferron is considered in writing circles to be Canada’s pre-eminent physician-writer, and yet he is largely unknown to Canadian medical students and physicians. He was born in Louiseville, Que, in 1921, received his medical degree from Laval in 1945, and practised as a rural physician in Rivière-Madeleine, Gaspé, and later in Longueuil opposite Montreal on the south side of the St Lawrence River. During the October Crisis of 1970, he was chosen as a mediator between the government and the Laporte kidnappers. He founded the Rhinoceros Party. He was a playwright, essayist, novelist, and most of all a short story writer. His first collection of short stories won the Governor General’s Award. The stories are molded from his cultural heritage and his physician’s insight.

Betty Bednarski has compiled and translated a new Ferron collection published by McClelland and Stewart, Tales from the Uncertain Country and Other Stories.3 In the Afterword she outlines Ferron’s technique as he transforms the folktale, a combination of the magical and the commonplace, “from a spoken into a written art” and “broadens [its] relevance and appeal.”3 Likewise, in her award-winning story of therapeutic interconnectivity, “Throw Me a Line,” Dr Pauline Pariser takes the key question she asks her patient and his answer and broadens their relevance and appeal.4

You will find in Ferron’s tales contradictory elements of “pathos and humour,” “blunt down-to-earthness,” and “unrestrained fantasy.” These elements combine to “disconcert and delight.”3 Dr Nicole Audet, in her award-winning story, “Le pouvoir de l’écoute,” needs to connect with her resident who is not patient-centred and who is at risk of failing her rotation. Dr Audet does this by learning her resident’s story. A key element she discovers is that her resident loved to go fishing with her father. Then, using metaphorical fantasy, Dr Audet teaches the resident that the patient’s concerns become fish that the resident must catch! The results are delightful and practical, and the resident passes her rotation and her exams. She later tells Dr Audet, “When I went into the five [exam] rooms, I caught every one of the patients’ fish.”

Ferron’s tales often have a traditional pattern: an enigmatic beginning, a repetitious refrain, and a stereotype ending. Magbule Doko, in her award-winning story, “Why are you here to see the doctor today?” uses this traditional pattern in her effective “Knock, knock” repetitious refrain.6

Our award winners are using Ferron’s techniques and very effectively.

“Cadieu” is the third story in the new Ferron collection.3 The protagonist, Cadieu moves from the country to the city and abandons his name. He becomes rootless, without a past and therefore without a future.

Medicine trains us in deductive reasoning, taking information and reducing it to a diagnosis. In this story Ferron uses an inductive approach. Cadieu’s problem, an individual’s problem, can occur on a much larger scale. It can happen to a group of people, a society, a culture, the Province of Quebec. It could happen to family medicine. If we lose sight of our past and become rootless, will our future be endangered?

Ferron helps us to see a problem with fresh eyes. He does it with a story.

Other stories from the collection are instructive: “Little William” explores delivery positions (the lithotomy position and the Sims position—one is traditionally French, one English) and doctor-midwife roles and how they interact. In “The Grey Dog” we see collaborative care and distributed responsibility, change, decline in power, and how that is symbolically portrayed. The empty nest is a theme in “The Parakeet,” and it contains the wonderful loving and grumpy refrain about a husband as seen by his wife: “The old woman looked at him and thought what a fool he was, what an old fool. What disconcerted her was that he had always been this way and that she loved him.”3

“La Mi-Carême” deals with the question, when a mother delivers at home, of how to explain the cries of pain to little children. La Mi-Carême is a legendary witchlike creature who flies into the room at the time of the delivery and beats the mother, resulting in the anguished cries. The midwife in turn takes her stick and beats La Mi-Carême, who in her hurry to get out of the room leaves behind a little baby. The narrator of the story, the oldest child, a boy (the nipper), concludes the story by saying, “My father bent over the tiny bundle. When he stood up he looked happy and younger than I’d ever seen him. The herring scales glistened on his arms. He rubbed his hands and stomped his feet in his big boots. And I thought to myself, I the nipper, that La Mi-Carême ought rightly to have beaten him.”3 The nipper had made the reality connection, and we the reader are given a little window on the moment when observation and knowledge fall into place and a child is transported out of the age of innocence.

Are narrative, plot, words, the importance of listening, the importance of stories, and their value in the effective relationship between patients and doctors vital in the practice of medicine?

I had a patient who in his mid-50s had a crisis of identity and purpose. I asked him to return in a week and tell me about his very first memories. He chronologically moved forward with his memories in 15-minute weekly sessions. By the sixth session he had reconnected with his story and rediscovered himself.

Pellucid means admitting the maximum passage of light without distortion. It also means easy to understand.

If we listen to our patients’ stories carefully and ask clarifying questions, the narrative and plot will become clear and we will understand: the Pellucid Moment.

The relevance of the Pellucid Moment in our profession is that it can derive from a story and lead to a written story with a much broader relevance. It is that relevance that we are celebrating today: the importance of stories.

• Copyright© the College of Family Physicians of Canada