The Bigger Picture: Are Stories Dead?

June 1, 2006

Are EMRs destroying the narrative elements of medicine - taking histories, talking to patients, understanding their stories?


Confession: I once made medical students read George Eliot’s “Middlemarch.” That’s 800–plus pages of 19th century musings on philosophy, art, and medicine. Boy, did they hate me. But the novel was a required part of a course about storytelling and medicine that I was teaching during my prior life in academia. The idea was that the ethics and art of medicine lie within narrative.

After all, what is the physician-patient interview but an opportunity to tell a story? “The story is what it’s all about. When you learn in medical school to give a report, the ones who did really well told a story,” says Jonathan Bertman, a practicing family physician and founder of Amazing Charts, an electronic medical record (EMR) company.

But the fine medical tradition of storytelling seems threatened in the era of EMRs. Electronic medical records are great at capturing standard information, but not so good at structuring patient experience into a narrative.

We’ve been told that EMRs merely change the way information is gathered and organized. But when you think about it, isn’t that the same thing as changing the way medicine is delivered?

Conducting a patient interview while following EMR templates can be like “doing inventory,” Bertman worries. Is that how we really want doctors practicing medicine? “Patients want doctors who listen, care, and grieve with them,” says Bertman. “Objective findings should be objective, but to try and standardize emotions is difficult.”

He adds that a story derived solely from a checklist tends to exclude some interesting details, while also giving too much information on nonrelevant items. “You have to wade through [too much] material,” he says. “It’s a struggle to … find the nugget of new or relevant information.” Stories told as narratives make it easier to detect “the point.”

But Jack Coulehan, MD, author of “The Medical Interview: Mastering Skills for Clinical Practice,” isn’t worried about narrative in the age of the EMR. That’s because medical records never really contained them to begin with, says Coulehan, who is also director of the Institute for Medicine in Contemporary Society at Stony Brook University School of Medicine, and a published poet.

“A lot of times - or even most of the time - we confuse the written record with the narrative. It’s an impoverished idea of narrative to think that what goes in the chart is a narrative,” even in a dictated or handwritten record, he says.

“The real problem with narrative in medicine is to … have physicians develop the narrative skill - that way of looking at patients and understanding patients - it’s not so much about writing it down” in the chart.

Indeed, Coulehan is hopeful about another technology and its impact on patient stories. “Paradoxically, e-mail has brought back narrative a little bit. It’s at least an opportunity to open up a new means of communication between physicians and patients.” There is less time pressure, less embarrassment.

Could it be that technology can save physician-patient relationships rather than kill them? I’d say the ending has yet to be written.

What do you think? Are EMRs crushing storytelling in medicine? Does it matter? Write me at pmoore@physicianspractice.com.

This article originally appeared in the June 2006 issue of Physicians Practice.