Choosing our narrative wisely

Patient narrative

It has been well established that more than 80% of diagnoses can be made by virtue of history alone in medical outpatients.³ In the absence of clinical examination maneuvers or the gestalt of laying eyes on someone, allowing the patient’s narrative to unfold is important. Research shows that prolonged listening—before physicians start the rapid fire of questions—allows most pertinent positives and negatives to be revealed.⁴ Coupled with the wisdom that has stemmed from the relationship over time, the patient’s story reveals the feelings, ideas, functions, and expectations that we seek to understand in order to guide management.

Openness to resource stewardship

Multiple colleagues, including Dr Peter Kuling in the related article in this issue of Canadian Family Physician (page 582),⁵ have noticed some patients are now more open to the idea that more is not always better. With the perceived risk-benefit equation weighted in favour of risk, some patients are deciding to forgo or delay certain tests or procedures. Providers might have considered some of these practices to be unnecessary before the pandemic, but the discussions felt thorny or even futile.

Now, the opportunity is ripe to discuss the usefulness of screening mammograms in average-risk 45-year-old women, the need for a yearly battery of tests, or the effect of vitamin D measurement in the average Canadian. With preventive care and screening essentially ground to a halt, we might find the time to rehearse new approaches to conversations about “choosing wisely.”

Provider narrative

The pandemic has provided time for reflection. There were the early weeks of quiet, anxiety, and uncertainty. Now, there is the slow resumption of some part of practice, alongside increased calls from patients who have put off or ignored primary care needs and questions.

The pandemic has also offered an opportunity for self-reflection for the family medicine community. Who are we? In the broad scheme of things, what is important to us, to our families, and to our communities? In which areas of family medicine have we been practising wisely? When all this ends, what will we hang on to and what will we discard? Both in practice and in our lives, have we chosen wisely?

We might be imagining how practice will look after the pandemic. We might decrease our office time and add a half-day or two of virtual medicine from home. Periodic health examinations could be structured entirely differently. After a virtual review of social history, family history, current concerns, and medications, patients might be booked for 15 minutes in the office for the purpose of checking blood pressure, weight, and height; administering vaccinations; and—if needed—conducting a focused physical examination. This, of course, assumes that virtual practice will remain funded.

Choosing Wisely inCanadian Family Physician

Since 2016, Canadian Family Physician has offered space for insights on choosing wisely from primary care providers across the country. The Choosing Wisely Canada series is now launching its third installment. The series in many ways reflects the evolution and maturity of the Choosing Wisely Canada campaign. Initially framed as an awareness-raising exercise about the harms of overuse, it has now broadened to focus on sustainable implementation of campaign recommendations in practice. The series, which interviews family physicians from across the country, first focused on specific recommendations and how clinicians implemented them. The subsequent theme focused on shared decision making and how conversations with patients could avoid unnecessary tests and treatments. The 2020–2021 series will focus on the stories within practice and is entitled Choosing Our Narrative Wisely. This iteration will be led by a family physician in the first 5 years of practice, Dr Aaron Jattan, who will bring a fresh perspective on the challenges, opportunities, and rewards of embedding narrative medicine approaches into practice. The series remains focused on amplifying the voices of family physicians from across the country.

Choosing our narrative wisely

At the core of Choosing Wisely is a focus on having conversations about what matters to patients. It can be challenging to shift our approach away from ordering tests and treatments, which often addresses our own compulsion to do something rather than nothing. It can be equally challenging to meet perceived patient expectations for services.

Our new series will be a space for primary care providers to reflect on a particular clinical conversation that has stayed with them and served as a catalyst for the development of a renewed approach to practice. In our evolution as individuals and as primary care providers, certain experiences give pause for reflection, invention, and rehearsing new ways of being. The pandemic has been that for many.

Our patients continue to look to us for information, reassurance, and stability as we navigate unchartered waters. In this seismic change is an opportunity to use thoughtful listening and deeper conversations to provide care to patients.