If you bring your dog to the veterinarian’s office because he has started urinating in the house, does the doctor simply perform a clinical exam followed by x-rays and blood work, or does she add in some questions that help her learn the story of the dog’s life? For instance, a vet might ask, “Has anything changed lately? Have you moved, or has someone moved into or out of your household? Has there been a divorce or some other difficult event?” That way, the doctor may find out that the dog is stressed, perhaps because he is sensing your own stress, and that is what is making him urinate indoors.
That’s narrative medicine. It turns the dog from a symptom or collection of symptoms into a living being that has a full life unfolding in time. And that viewpoint can save unnecessary headache, not to mention money. In a groundbreaking 2001 article in the Journal of the American Medical Association, Rita Charon, MD, PhD, makes the point that if the patient [or patient’s guardian] doesn’t get to tell the whole story, “the resultant diagnostic workup might be unfocused and therefore more expensive than need be, the correct diagnosis might be missed…and the therapeutic relationship might be shallow and ineffective.”
The article was aimed at physicians, but the same principle applies to veterinarians, and becomes even more important when you consider that the vet needs to understand both the dog’s life and the life of the person caring for the dog. “It’s two sets of variables” that need to be accounted for, says Tufts veterinary school graduate Karen Fine, DVM, who believes narrative medicine has great potential in the veterinary field and uses it herself. “If you frame a story,” Dr. Fine remarks, “things come out that otherwise might not have.”
Dr. Fine likes to tell the story of a client who called her because her dog, who had been taught to urinate on newspapers and had been doing so for years, had begun peeing right on the living room floor. “I went over for a house call,” Dr. Fine says, “and saw that the woman had decorated for Christmas and moved a giant planter to where the newspapers had originally been in order to make room for the tree. The newspapers, in turn, had been moved out of the corner the dog had become accustomed to.”
Before ordering a battery of screening tests, Dr. Fine helped the woman move the planter and also move the newspapers back to where they had always been. Voila! “The dog went right over and peed on the papers,” she says.
Narrative medicine is a young field in human medicine (although you can now get a master’s degree in it from Columbia University’s Medical School) and even younger in veterinary medicine. But some of the best veterinarians practice narrative medicine instinctively.
What it feels like
You’ll be able to sense if your dog’s doctor uses narrative medicine in her approach because it will feel like a collaboration between you and her rather than a top-down approach. She will be eliciting your input to help her arrive at a diagnosis.
Along the same lines, you’ll be able to sense what Dr. Charon in her article calls “authentic engagement” rather than perfunctorily going down checklists. She calls it “diagnostic listening.” Such listening leads to more empathy on the vet’s part, which in turn yields more engaged treatment because the doctor feels moved to act on the patient’s behalf.
For narrative medicine to work, you need to be authentically engaged, too. “Some clients do drop-offs,” leaving their pet at the front desk with the intention of picking it up after the appointment,” Dr. Fine says. “I don’t like drop-offs. I don’t get a read on the client — or the client-patient pair. I need to see what’s going on.” In other words, a two-way street for effective dialogue gives your dog the best chance for improved health.