Storytelling in the Exam Room

By Patricia Kullberg

Mrs. Truong is tired inside, dizzy behind her eyes, and her sleep is no good. There is a buzzing in her chest. The left side of her body feels swollen, her left arm hurts and doesn't work right. The pain, she says through the interpreter, is very deep. Perhaps worst of all, her bones are cold. Impossible, I think to myself. Yet, how miserable it must be to suffer a chill in such a deep and inaccessible place. She is middle-aged, a refugee from Vietnam and has come to consult me, as her primary care doctor, about her medical problems. She wishes to know what is wrong with her and she wants a remedy. Like all patients, she expects me to re-construct her story in medical terms, to make clinical sense of it in a way that will produce an effective therapy and relieve her suffering.

Her physical examination is normal and diagnostic testing reveals nothing but the minor findings of a well-controlled thyroid condition. She appears, however, indescribably sad. I know what is wrong with her. I see it already at the first visit. In that same moment I suffer the premonition that I will not be able to help her. Mrs. Truong has lost nearly everything dear to her: her husband, most of her family, her community, her cultural surrounds, and her homeland. She’s been cast adrift in urban America, isolated and lonely, with precious little to occupy her time. She is, as most anyone would be in her circumstance, depressed.

Over months of encounters I try to read her as one would read a book, drawing on information from her daughter and the interpreter and my own perspectives on the Vietnam War. I read between the lines of her story, rich with unintentional metaphor and striking for what neither she nor her daughter can or will tell me. I construct a narrative that takes into account the social, psychological, political, and moral dimensions of her illness. What’s the point? My hope is that a more complete and comprehensive assessment will deepen our therapeutic alliance and help me tailor my therapeutic approach to her values, desires, understandings, and circumstance.

But clinical encounters are constrained in so many ways that can sabotage this process. In Mrs. Truong’s case, our respective stories about her illness are embedded in two irreconcilable understandings of disease and disorder. We are unable to breach this gap. The idea of mental illness is too problematic. Her rejection of my story spirals into unnecessary investigations and leads to a therapeutic impasse. I am not, as I had feared, able to help her feel better.

As a speaker for the Northwest Narrative Medicine Project, I will discuss the role of storytelling in the exam room, drawing on narratives from my book, On the Ragged Edge of Medicine: Doctoring Among the Dispossessed, to explore various factors that impinge on the power of storytelling to enhance the clinical encounter. The stories I will tell speak to both sides of the stethoscope, the patient and the practitioner. I expect that participants will have their own stories and perspectives to share. I will pose problems for discussion. I won’t have the answers. But good answers always start with good questions.

Patricia Kullberg, MD MPH, will speak on Tuesday, March 14, 7:00-8:30 pm, in the second floor auditorium of the Collaborative Life Sciences Building at 2730 SW Moody.