Reflective practice in medicine

Medical writers have recently questioned our blind faith in diagnosis.

dotMD22 is over – long live dotMD. It was great to be back in Galway post-Covid. What a blast we had. A big thank you to those who attended, both virtually and in person. 

Sarah Fitzgibbon has already graced these pages with an insightful look at the highlights of this year’s event. So I won’t bore with you with a repeat from me. 

What I would like to do is to focus on John Launer, whom I was privileged to interview in Galway. We had fun discussing “Why are doctors so difficult?”, and were treated gently by the audience when we moved it up a notch to look at “why are doctors assholes?”. But I would like to examine John’s role in the development of narrative-based medicine. 

He writes about narrative-based practice rather than narrative medicine. Are the terms the same or are they deliberately unrelated? He doesn’t see a huge difference, except to note that narrative-based medicine was the title of the seminal book by Trisha Greenhalgh and Brian Hurwitz, published in the 1990s. The term narrative-medicine was emphasised by Rita Charon, the US champion of the area, and I get a sense of a not unhealthy European vs US divergence in the nomenclature. I’m probably biased, but I sense a greater practicality about the direction of travel of the European movement. 

John Launer is a GP, family therapist, educator, and writer. He has written or edited a number of books on interactional skills and medical humanities, including How Not to Be A Doctor. His latest publication, Reflective Practice in Medicine and Multi-Professional Healthcare, continues his exploration of narrative in a post-Covid-19 world. 

One question I had for John was why the habit of recording patients’ actual words in clinical notes had fallen away? It seems to have been a casualty of early and overly rigid computer software programmes. John lamented the decline in recording of patient quotes. However, I was heartened by colleagues, whom I met after the interview, who told me the facility to record free text is now easily accessed in the latest software. 

In his latest book, there are a couple of what could be labelled contrarian chapters – Launer labels the section ‘Provocations’. One is named ‘Against Diagnosis’, in which the author sets out some arguments against diagnosis. I love his rule-of-thumb conclusion: Avoid them when you can; be humbler about them when you cannot; and seek permission from their rightful owners whenever possible. He is not the only writer to recently question our blind faith in diagnosis. In her latest book, The Imaginary Patient – How Diagnosis Gets Us Wrong, Consultant Neurologist Jules Montague takes aim at some of the hitherto unshakeable certainties associated with clinical diagnosis. She looks at ways to improve diagnostic accuracy, asking who gets to construct our diagnoses. She also makes the case for the need to report conflict of interests by those making a diagnosis, and the interesting concept of de-diagnosis, an annual appointment with a patient where a diagnosis is routinely challenged. 

Launer has run training courses in interactional skills for over two decades. He bases them on the ideas and skills of therapists who see families and children. He labels the technique ‘conversations inviting change’ (CIC). Much of the training is based on narrative-based medicine, which teaches that everyone – doctors and patients – has a need to tell stories in order to make sense of their experience. 

“Sometimes these stories can become stuck, but if we question people sensitively they will generally find a way of telling the story in a different way, and then see the problem in a different way too. Encouraging patients to develop a new and more hopeful story about themselves can be as much a part of healing as any physical treatment,” he writes. 

John has run a CIC course here in Ireland and is open to running more. There is the genesis of an interest group here, which will hopefully develop and grow. He concludes the chapter on CIC, as follows: 

“All conversations, whether with patients or colleagues, can be therapeutic. Collectively, good conversations can transform a working culture from one that is technocratic, impersonal, and potentially dangerous, to one that is kinder and safer. We need to persuade doctors everywhere that the lifelong development of interactional skills is a core professional need.” 

John Launer, a very wise doctor, whom it was a real pleasure to spend time with.