What do doctors learn from patients? A narrative-based study of doctors’ stories in three settings

Problem

It is generally accepted that doctors “tell each other stories”, or “parables”, about patients (Charon), and that narratives are of value in developing professionalism (Stern and Papadakis). Yet, though GP Training often invites reflection on individual patients, through portfolio work and random case analysis, eg, there is little understanding of what the “learning” consists of, nor of whether Trainers use the narratives which have guided their own learning when they teach. The present study looks at narratives where GP Trainers say they have “learned from patients”, collected in UK, Ireland and Spain.

Approach

The methodology builds on previous narrative work (O’Riordan et al 2008) by members of the team. To date, 64 respondents have offered stories to an interviewer with two prompts: “Tell me about a patient you’ve learned from”, and “Do you use this story with trainees?” Data were analysed using thematic analysis. Qualitative results were triangulated by linguistic analysis, using a concordancing program (Antconc), to identify patterns of word frequency and use. Ethical permission was given for each setting.

Findings

Data were transcribed. Spanish-language interviews were professionally translated. No substantive thematic differences were noted between settings. Concordancing confirmed thematic findings. A major theme was the porous boundary between the professional and the personal. Concepts such as “offering yourself as a person” were common. “Learning” was typically interpreted as learning about oneself/the human condition, eg with the patient as a role model of living or dying. “Learning” often meant serving patients better by understanding oneself better. Secondly, learning was frequently conceived of as happening where there was a team effort, involving perhaps the Primary Care team, but also outside agencies (social services, police). Thirdly, many of the stories focussed on the element of trust, sometimes conceived of as truth-telling about difficult news. Respondents used narratives in teaching, but not systematically: one respondent spoke of the risk of narratives being misunderstood as “evidence”. Finally, while some stories had a straightforward learning point – like parables, they had a clear conclusion (“fight hard to the end”, eg), some stories seemed resistant to a reductive summary: they were complex and irreducible.

Consequences

The main conclusion is that the richness of narrative data renders such terms as “doctor/patient relationship”, or “reflective learning”, as these terms are normally used, somewhat misleading. The type of relationship presented was often more intimate (while remaining therapeutic and professional), and the quality of reflection was more profound than required for portfolio entries. The interest among respondents in using narratives suggests an opportunity to develop the concept as a learning resource further. The fact that themes remained constant across the three settings implies a commonality of General Practice culture, though we do not know how generalizable this finding is.