Results
We found that each narrative illustrated a particular dilemma and a strategy to deal with chronic pain patients.
Dr A
Dr A was middle-aged male who had worked as a GP for more than 10 years. He told a story about a woman who, despite her long term problem with diffuse pain, mainly had been working. He told about several phone calls and exhausting consultations about a disagreement over a sickness certificate. A pain rehabilitation clinic later supported half-time sickness absence but the relationship remained strained.
The narrative is fragmented and the narrator often moves from descriptions of scenes to generalizations, especially when describing something negatively charged. The narrative shows a power game between doctor and patient in which the doctor has the upper hand. The following consultation occurred after a telephone conflict:
Stanza 28 - distressed, offended, and disappointed
...a few weeks later so, so she came very distressed and I think she was crying in the waiting room already and, and she had really prepared for the meeting and really wanted to tell me how I had offended her and how disappointed she was with me and...
Stanza 29 - receive a dressing-down
I had to sit here in ten minutes and sort of receive what she had to say.
Strong words are used to portray her. He is passive and has to "receive ". Dr A describes this as part of a "chess game". She thinks he offended her on the telephone, and he now steps back while she moves forward. We note the ping-pong effect of the repeated use of "she", "I":
Stanza 73 - want to examine before a doctor's letter
"Well, in the conversation today I said so: - O.k. you want me to refer you for an X-ray, eeh then I want to examine you first. You'll get an appointment before lunch tomorrow."
Stanza74 -"good" and hang up
Good she said and we hung up.
They negotiate. The opposition of the pronouns "she" and "I" underline lack of mutual understanding. Eventually they agree and he expresses a rare "we" with his patient. Otherwise "we" in this narrative refers to colleagues. Negotiation is not between equals, however. Throughout the narrative it is the doctor who defines the terms of engagement. For example, Dr A hesitates about renewing a sickness certificate initiated by another doctor:
Stanza 51 - not obvious without own assessment
/---/ Oh then I said that it wasn't all that obvious that I should do it...eeh, naturally not without having made my own assessment and maybe not even on principle /---/
He stresses his professional duty to make his own assessment. His reluctance "on principle" expresses power. At the end of the interview he explicitly states how difficult it is to have power over people's finances, a major part of their conflict.
The informant stresses how demanding these consultations are, but he also describes how he handles them:
Stanza 129 - prepare for a race
Eeh...so then I try to stick to my method, not to let, to see to it that I have a good time before, this is as I said a demanding meeting. Sort of like an athlete prepares himself for a race, you don't go there the day after a big party and without having tied your shoes and so on, but you make sure your equipment is ok, you go and pee first, you have like....maybe switched on this lamp as we have done /the lamp showing if occupied or not/, and you make sure that there are good preconditions so you have a good chance...to make it.
Dr A's methods of preparing, staying calm and listening attentively are also ways of maintaining control of the circumstances of the consultation. The narrative shows conflict, strained negotiations, and power imbalance, but at the end she is still his patient, and his method seems to work.
Dr B
Doctor B was a younger woman, halfway through specialist training. When they met, her middle-aged female patient had been on sickness absence for more than a year with pain related to cervicobrachial syndrome. Initially Dr B prolonged her sickness certificate. The trouble started when she wanted her patient back to work.
The central dilemma is about an unwilling patient who is persuaded against her own will and despite her gain from a sick-role. The result is disappointment for patient and doctor, conflicts with other professionals, and a new sick leave. It is also a story where the doctor's good intentions and methods fail. The narrative gradually reveals an uncertainty in the description of their relationship. However, it first declares Dr B's intention to create a platform for their relationship, and why she initially prolonged her patient's sick leave:
Stanza 4 - build a safe relationship
/---/ and the first time I met here I felt that, no I can't just make a break here, but in some ways I felt that we had to build some kind of form of contact so she can like feel safe with me and feel that what I say is like the best for the patient.
The narrative contains components of a good doctor-patient relation. Dr B allies with her patient by using "we". However, a distance between doctor and patient is created by referring to her as "the patient". Shortly this distance is increased by use of the pronoun "I", a figure that has the power to consider if the patient's sickness absence should be ended or not.
Stanza 7 - see how it goes
But then we had yet the time before decided that: Next time I think probably that we will finish this and see like...how it goes.
"I" is now used consistently and the narrator tries to persuade her patient:
Stanza 9 - very high risk
But still I didn't feel convinced that it was the absolute best for the patient. And I had said to her, in fact already from the beginning that if you don't start to work when you have been on sick leave as long as this there's a great risk that you...said that the risk is that you'll never work again, and it is really high. Ooh...
One responsibility of the doctor is to give advice based on medical knowledge. In stanza 9 this is done in an affirmative and persuasive way. Gradually the description displays uncertainty and doubt about the patient and their relationship. Already in stanza 4 where Dr B declares her good intentions, the word "like" is interwoven. The rest of the narrative is permeated by small hesitant words:"like","probably","yet". She recalls what happened when she suggested ending the sick leave.
Stanza 11 - wants to try
Eeeh...and...when we finally had discussed it I felt yet that, well I did get the patient on my side quite well. She wasn't completely satisfied, but she said that: no but I still want to try, I don't want to be on sick leave for the rest of my life and/---/, then I said let us try.
The stanza tells us that the persuasion was successful, but at the same time the hesitant words undermine this success. Note again the use of "I" and "she" instead of "we". Dr B is initially satisfied:
Stanza 13 - helped her
Yes an' that felt good at the time. It did, it felt really good then, I felt that I had really helped to do the patient a service and I had like, I had like....helped her.
Dr B is convinced that she has acted according to professional standards, and that her patient has been helped. But soon the patient seeks conflict through the medical social worker.
Stanza 14 - she was really sad
But then some days later she called our medical social worker who she had contact with and she was really sad about this and felt that she didn't at all want like to be unemployed /---/
The distrust is obvious and in Dr B's narrative the question is not the need for sick leave, but a question of the patient's preference for sickness absence before unemployment. Dr B does not however give in to these demands. Dr B has not seen this patient since, partly due to training on another clinic. She expresses frustration that another doctor has given the patient a new sickness certificate. One of the basic professional intentions, to help people, failed:
Stanza 18 - no help
Oh I thought in what way does that help the patient?.../---/
Eventually she shares one thing with her patient - their mutual disappointment:
Stanza 19 - she disappointed
But I get the feeling that she, she probably doesn't want to see me again, I do think so. She was probably...disappointed that it ended as it did, I think so...mmm/pause/
The struggle to build a stable relationship and change the patient's life comes to a dead-end in frustration and disappointment. The professional method gives rise to backlash and the unwilling patient manages to stay in her sick-role through another doctor.
Dr C
Dr C was in her sixties and had been a GP for about three decades. Her narrative was about an obese middle-aged woman with diabetes and possibly fibromyalgia. She was a former patient of two of Dr C's colleagues, but had now registered with Dr C. She wanted a prolonged sickness certificate, which her previous doctor had denied her. Dr C tried to judge whether this was a reasonable request, but decided that they needed another meeting to sort things out. Their first meeting was the day before this interview.
This narrative is about the overwhelming feeling of getting a patient's whole life on your lap. The patient is described as unbelievably tired and dysphoric, exhausted even by doing the washing up. The narrative is told in a tired voice, with sighs and long pauses; the stanzas are generally short. This transfers tiredness, disbelief, and dissociation from the patient to the listener. The consequential use of "she" and "I" emphasize this distance, and the use of "we" is reserved for cooperation with the medical social worker. This reflects Dr C's major method of dealing with these patients: teamwork with other categories of professionals.
After their first consultation Dr C argues with her colleague:
Stanza 8 - scolded
/---/ First I went out and scolded the other doctor who had had her [the patient] listed for a long time and who should have written this certificate that now was placed on my lap /coughs/
She expresses anger but also a sense of that something has been dumped on her:
Stanza 9 - her whole tiredness over me
/small laugh in the voice/ Oh when I came home yesterday, I have never been so tired, so I got somehow her whole tiredness over me...I think that was what happened. /short pause/I was completely finished...
Dr C is not in control. The patient's choice of Dr C as her GP is out of her control, as is the emotional drain on Dr C after meeting the patient. Before these stanzas words expressing tiredness were used five times in a couple of minutes, here emphasised with "never". However, Dr C's colleague offers to write the sickness certificate anyway, but is stopped by Dr C:
Stanza 11 - will be challenged
/---/ I feel a bit challenged by these kind of patients too. And...eh..I thought that if she now has decided that I should be her doctor and then I have to meet that challenge even if it can be really hard, and even if I can't help her at all!/---/...oh eh /sighing/
This stanza shows for respect for the patient's choice and interest in grasping the reasons for a patients' life situation. But the description of the patient contradicts this:
Stanza 26 - while away one's days
/---/...and how she whiled away her time I never clearly understood so that was no good ....[meeting]...
Stanza 26 phrase implies that the patient is not using her time for anything meaningful at all. The description of this woman is illustrative:
Stanza 38 - sad and still
This is a short woman, but she weighs 118 kilos or something like that so she is totally square and she sat there like a big lump and was perfectly still and looked . . . /short pause/ dejected.
She even reflects that in this case she might not want to know the whole story anyway. It all boils down to a conclusion:
Stanza 33 - a person's whole life
/---/...oh, it isn't easy to do your [job], you have a half hour and you sit there, with a person's whole life /quiet again and a little laughter/ oh it's not possible, it is a pretty . . . pretty impossible assignment really, and still, it is what we are supposed to do /smacking her lips/ mmm.
A doctor's duty is difficult when a person's whole life is the problem causing the pain.
Stanza 52- life hurts
/---/ It is possible that she has fibromyalgia, or else it's just life that hurts . . . /pause/ ah /sigh/ and that, that I don't know that much about . . . /laugh/
Several times we find laughs as in stanza 52. Dr C acknowledges that some cases are impossible and distances herself from the patient as well as from her own professional standards. Later in the narrative she seeks support from other health care professionals. Keeping some distance and asking for support are Dr C's methods for handling the difficult situation
Authors' contributions
MHK, MD, has been a radio journalist and has a BA in literature. CW is a MD, house officer, PhD, and has a BA in anthropology. AB is MD, PhD and specialist in general practice. MT is MD, PhD, senior lecturer and specialist in general practice. Both have extensive experience of qualitative research and studies of patient-physician relationships. Our backgrounds influence our use of the narrative method. MT was responsible for the major planning of the study. MHK performed the interviews. MHK, AB, and CW performed the analysis. All researchers contributed to the writing process. All authors read and approved the final manuscript.