Stories, healing, and communication

In her book, Kitchen Table Conversations: Stories that Heal (Penguin USA, 2006), physician Rachel Naomi Remen recounts stories told to her by physicians and patients she has counseled during her career. These are considered sufficiently valuable that the book is used as a text in introductory clinical medicine courses in 18 US medical colleges.

There are 3 basic themes in the book that point out the role communication plays in medical practice that also apply to veterinarians. The first is not to overlook the power of stories when communicating with others. Even though he doesn’t think of it that way, Dr. Matheson’s relationship with his clients is based on stories. It begins when Ms. Kurtz tells him the story of her geriatric poodle’s intermittent diarrhea. Her descriptive narrative becomes a mystery that he solves following a specific process of tests and procedures that ultimately reveal the animal’s problem.

At this point, the veterinarian can share his science-based who-done-it with his client, or he can describe what the terminal diagnosis it reveals will mean for her and her pet. If he opts for the former, unless Ms. Kurtz possesses the necessary background to understand the data-based story, it will have little value for her. In that case, she can either accept this or ask the veterinarian to convert his story into one that makes sense to her. If he lacks communication skill, he might reduce the data to a very short story: “It means that Cleo is going to die.” If he possesses more skill, he might use appropriate case histories and/or analogies to explain how the metastasized cancer is affecting and will affect the animal’s body.

Later when Dr. Matheson discusses the case with his colleagues, the story may contain references to other animals with the same condition or how Ms. Kurtz’s response to the bad news compared to that of other clients in similar circumstances. And later still when he discusses it with his partner, the heart of the story may be how inadequate such cases make him feel.

An example involving a terminally ill animal was chosen because such cases in many ways represent the epitome of the art of veterinary practice. One of the most powerful sections of Remen’s book tells the story of a man who attended one of her support groups for those with terminal conditions. It had become clear to him that the chemotherapy for his advanced cancer was no longer working and that the negative side-effects far outweighed any benefits. But when he told his oncologist that he would like to stop the treatments but still continue seeing the physician for regular appointments, the oncologist rebuffed him. Unless he could physically do something for his patient, the oncologist believed that he had nothing to offer. And because the patient believed that there was no one who understood what he was going through and could better explain it to him than his oncologist, he continued with the painful, life-shortening treatments in order to maintain that relationship.

The story would have been powerful if it had ended there, but it did not. Coincidentally Remen was counseling the oncologist who suffered from depression. He complained that his life had no meaning. His wife and children defined him strictly in terms of what he could do for them.

These 2 stories illustrate another theme in the book that also occurs in veterinary practice. In the first story, a patient is willing to pay the oncologist to talk to him to help him understand his disease, a request the oncologist rejects because he equates such patient communication with doing nothing. In the second story, that same highly skilled professional suffers from depression and bemoans the fact that his loved ones only see him in terms of what he can do for them instead of what he is. He does not see that his professional and personal lives are connected. He does not see that the greater value he places on himself as a dispenser of medical expertise and as a person who protects himself from having to engage in anything beyond the most basic communication with his patients is the same orientation that makes him miserable at home.

These stories hit home with Dr. Matheson because his professional life has been dominated by what he considered the most important business mantras: “time is money” and “talk is cheap.” Although he told himself that this was a temporary orientation that was necessary only until his business became established and he had more time to engage in more in-depth communication, by the time that had happened he faced 2 stumbling blocks. One was that he had lost the ability to communicate with, as opposed to what he readily admitted amounted to pontificating to, his clients. The second was that his family had little time or inclination to communicate with him.

That the result of this could be just as depressing for Dr. Matheson as it was for the oncologist brings us to the third theme in Remen’s book: the difference between curing and healing. When Dr. Matheson purchased his clinic as a young veterinarian, the retiring practitioner he bought it from did some reminiscing when he handed over the keys: “Back in the old days, drugs cured the causes of a lot of diseases we saw and vaccines eliminated a lot of the rest. Things are a lot more complicated now.” But in spite of the fact that Dr. Matheson accepted this intellectually, he still thought of himself as a curer.

Like other veterinarians who define themselves as curers, Dr. Matheson set himself up for some rough times in his mixed, rural practice. By definition, to cure means to restore to health. Consequently, if his treatment does not do this, then by his own definition he is a failure. As a result, offering palliative care, to say nothing of offering his clients emotional support as they face the inevitable loss of a beloved companion animal or valuable livestock, only serves to increase his awareness of his inadequacy. Had he been good enough to cure the animal, none of this would be necessary.

Second, Dr. Matheson’s definition of himself as a curer may compel him to want to keep trying different procedures and treatments in hopes of finding that cure. While such an approach is admirable if such a cure is available and if it is a viable option for his patient and client, imposing such a process on them when it is not to maintain the illusion that he has the power to cure only undermines the veterinarian’s credibility. Were his approach to cause what his clients considered needless animal suffering and/or themselves unnecessary expense, the veterinarian could find himself in an even more professionally and personally uncomfortable position.

Third, those who define themselves as curers inadvertently may inject an element of instability into the lives of those who work or live with them. On the days when Dr. Matheson can fulfill his definition of himself as a curer, all is well. He is more relaxed which relaxes those around him and quality communication flows more easily. On the days when reality foils his definition and darkens his mood, others try to avoid him and what little communication occurs is superficial at best.

For some, curing and healing may be synonymous terms. But as the numbers of immune-mediated and other conditions for which no cure exists continue to grow, for increased numbers in the healthcare and general populations, healing does not carry the same “back to the way things were” implication as curing. Healer-based communication provides an emotional as well as data-based component that contributes to the patient’s and/or client’s ability to cope with the animal’s condition. Dr. Matheson the “curer” cannot offer Ms. Kurtz’s aged animal with widespread metastatic cancer a cure. But Dr. Matheson the “healer” can offer his client his knowledge, experience, and compassion as she faces what lies ahead. Similarly, Dr. Matheson the “curer” has nothing to offer the rancher whose prized ram cannot be used for breeding. But Dr. Matheson the healer can provide appropriate support for that client, too.

In both cases, the healing approach also preserves the relationship with the client even though the animal may not be cured and may even die. This, in turn, will benefit the practice. While the high degree of specialization in human medicine increasingly erodes the physician-patient relationship, such is not the case in many veterinary practices where serving as the primary and sometimes the only healthcare provider from the animals’ birth until death is the norm. When this role of lifelong primary caregiver is combined with the shorter lifespan of domestic animals, this also means that practitioner-client relationships may outlive that of any one animal during that time. Ultimately, the ability to effectively communicate in this environment will determine the quality of the stories and the memories practitioners will have to share with others about themselves and their work.