Narratives in Hand Therapy

SPECIAL ISSUE

JHT READ FOR CREDIT ARTICLE #186.

Narratives in Hand Therapy

Cynthia Cooper, MFA, MA, OTR/L, CHTClinical Specialist in Hand Therapy and Clinical FacultyOrthopedic Physical Therapy Residency Program,Out-Patient Therapy Services, Scottsdale Healthcare,Scottsdale, Arizona

Correspondence and reprint requests to Cynthia Cooper, MFA,MA, OTR/L, CHT, 28612 North 150th Street, Scottsdale, AZ85262; e-mail: <[email protected]>.

0894-1130/$ -see front matter � 2011 Hanley & Belfus, an imprintof Elsevier Inc. All rights reserved.

doi:10.1016/j.jht.2010.06.003

132 JOURNAL OF HAND THERAPY

ABSTRACT: This article reviews literature on NarrativeMedicineand applies this knowledge to hand therapy using brief case exam-ples in which the narrative message of each example is illustrated.The value of narratives in hand therapy is thereby described.Level of evidence: 5.

J HAND THER. 2011;24:132–9.

STATEMENT OF THE PROBLEM: THEILLNESS EXPERIENCE

Clinicians and patients do not always use the sameend points to define the patient’s recovery as asuccess. Clinicians may include in their definitionsof success measures of reductions in disease andimpairment, whereas patients tend to measure theirsuccess in terms of recovery of function.1 Given thestrong correlation between disability and mood,stress, and beliefs and the usually more limitedcorrelation with disease or impairment,2 a patient’sphysical problem, such as a hand injury, cannot beseparated from the personal experiences that givethe problem its meaning. The meaning a problem orinjury embodies for a patient is idiosyncratic, circum-stantial, and personal. The illness experience can helpexplain how a person’s diagnosis affects his or herlife.3e5 Narrative medicine helps therapists treat theillness experience, not just the disease. This involveslistening empathetically, trying to imagine how thesituation feels to the patient and also how it changesthe patient’s life and story.6

Narrative Example of the Illness Experience

Martha’s Story

An 80 year-old retired woman fell while walkingand fractured her left dominant distal radius. Sheelected cast treatment and healed with some mala-lignment. She presented for hand therapy threemonths later with a stiff, edematous, dysesthetic

hand and wrist. She relied on her right hand forself-care. She told the therapist that she loved to takewalks but had not resumed this activity.

Therapist Reflection

Through conversation, Martha revealed that hermorningwalk was not just for exercise. She explainedthat it could take her more than two hours to walkaround the block because she paused and visited herfriends and neighbors along the way. Walking washer social outlet, and her illness experience haddisrupted it.

Solution

With further discussion, her hand therapist helpedher explore ways to reestablish sufficient confidenceto resume taking walks. She gradually incorporatedarm exercises into her walking.

Narrative Message

The patient was very pleased to be able to resumewalking. Recovering her social connection helped herreconnect with her preinjury experiences and gaveher a renewed sense of hopefulness about restoringher involvement in other activities as well.

INTRODUCTION TO NARRATIVEMEDICINE

Dr. Rita Charon’s appreciation that a substantialportion of medicine involves the exchange of storiesmotivated her to earn a PhD studying narrative inEnglish literature while she was active in her primarycare practice. Finding that her improved understand-ing of narrative helped her better connect with herpatients, she developed this aspect of her practiceand coined the term “narrative medicine.” Absorbing

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http://dx.doi.org/10.1016/j.jht.2010.06.003

and interpreting the patient’s story and being able toretell that story and give it form and meaning helpedher and her patients realize the complexity of theillness experience, creating new possibilities forhealing.7 The narrative approach asks health pro-viders to absorb, interpret, recognize, and be movedby patients’ stories.

Operationally, narrative medicine looks like casualconversation between the provider and patient. Theprovider uses communication techniques that elicitpersonal and meaningful information from the pa-tient. Both the patient and the provider are engagedin the exchange, with the provider listening actively,reflecting, maintaining eye contact, avoiding inter-ruptions, and asking open-ended questions.8 Patientsfeel listened-to by being given opportunities to con-vey personal and emotional aspects of their illness.

When we listen to patients’ stories, we collaboratewith them and can empower them to create new lifestories. In other words, providers who facilitate theunfolding of patients’ stories6 help them to becomeauthors of their lives, which restores or enhances asense of control.9 To do this requires engagementwith the patient. In other words, just listening is notenough; the therapist must also be engaged in theinteraction.10

Another aspect of the practice of narrative medi-cine is the process of reflection. Charon10 describesthe “reflective space” that leads to a fresh or clearerversion of the meaning of one’s story. When thera-pists state the patients’ narrative back to the patient,they show they are listening and reflecting.

The narrative fallacy occurs when we create a storythat confirms our flawed interpretation of a circum-stance.11 When patients’ stories are reinforcing theirillness, pain, or disability, therapists can help developa more accurate, adaptive, and enabling story. For ex-ample, a patient who is having trouble performingrange of motion soon after tenolysis for fear of hin-dering healing may do better when encouraged toadopt the more accurate and adaptive narrative ofperforming range of motion to remodel soft tissueand prevent adhesions.

EMOTIONAL LABOR

Practicing narrative medicine is not easy. It re-quires emotional labor. Emotional labor occurs whenclinicians regulate the emotions they display to con-vey a desired professional image.12 Narrative medi-cine helps physicians (and therapists) become moresupportive as colleagues, enhancing self-reflectionthat fosters greater sensitivity to the complexity ofpeoples’ lives. In this way, narrative medicinepromotes a sense of physician (and therapist) society,where individual patient stories matter.10

Regulating one’s emotional display while lookingsincere can be challenging at times, such as when a

patient’s ideas about the injury are very dissimilar tothe clinicians. Understanding the importance andstrength of one’s intuition can help depersonalizethese disagreements and keep the relationship frombecoming adversarial. It is not that the patientlacks respect for your views as the expert, it is justthatdright or wrongdthey value and respect theirown intuition and gut feelings more than your expertadvice.

Narrative Example of Emotional Labor

Jack’s Story

An active 60-year-old male executive sustained aradial collateral ligament injury to his right dominantsmall finger proximal interphalangeal joint whilebicycling, which was one of his favorite activities.


This patient loved to ride his bicycle. Whendiscussing his progress and the typical timeline forrecovery, he was shocked to learn that it could takelonger than two weeks for him to recover from hisinjury. He could not accept this and demanded thathe recover normal range of motion and resolution ofall symptoms in two weeks’ time.

Solution

The therapist helped him explore other activities todo temporarily while recovering, which helped himoccupy his time more effectively, and the hand teamprovided enthusiasm and encouragement for hisprogress.

Narrative Message

Thispatientwasused tobeing in charge inall aspectsof his life, and he was going stir-crazy not being ableto perform his usual high-demand athletic activities.

PROCEDURAL REASONING VERSUSINTERACTIVE REASONING

Narrative medicine emphasizes interactive overprocedural reasoning. Procedural reasoning is wherean expert uses structured actions (procedural knowl-edge) to accomplish goals. Procedural reasoning isused to decide what treatment to use at whatfrequency or intensity.13,14 There is a certain comfortin having procedures and rules for care but whenproviders use only procedural reasoning, evaluationand treatment may resemble a cookbook approach.By comparison, when providers collaborate withpatients to understand their unique needs, it is calledinteractive reasoning.13,15 Interactive reasoning lookslike a social interaction but is actually a purposeful

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process that helps the therapist understand thepatient while also building rapport.13 Interactive rea-soning uses the patient interaction to bring to lightand amplify information that is relevant to recovery.4

This is facilitated when the therapist elicits the pa-tient’s story and appreciates the patient’s emotionaltone and nonverbal communication.6 By elicitingand restating the patient’s narrative, both the patientand therapist come to a better understanding of howthe patient makes sense of his or her illness experi-ence.14,16 This insight can create new opportunitiesfor addressing the illness.

Narrative Example of Interactive Reasoning

Ms. Jones’ Story

Ayoungwomanwas experiencing nonspecific painrelated to typing at work. She was taught posturalexercises by a hand therapist as part of a program tohelp her bemore comfortable atwork. She returned tothe therapist reporting that she hadnot performedherpostural exercises as instructed, although she coulddemonstrate that she understood them.


After confirming her desire for relief of symptoms,the patient noted that she was feeling self-consciousbecause she had been gaining weight and she wasconcerned that practicing better posture would makeher look heavier and “less attractive.” The conse-quent discussion of weight management options wasmeaningful to the patient. Once she started partici-pating in a program for weight reduction, she mightbe willing to practice better posture as well.

Solution

The patient’s narrative helped the therapist under-stand the lack of follow-through. Elucidation of thepatient’s experience of the illness and suggestedtreatments improved the therapist’s connection withthe patient and led to useful support and guidancewith participation in a weight reduction program.

Narrative Message

What looked like noncompliance was not straight-forward refusal to follow suggestions. This patientwas not able to practice better posture at work if itmade her feel like she looked heavier.

MECHANISTIC PARADIGM VERSUSPHENOMENOLOGICAL PARADIGM

A study of clinical reasoning among occupationaltherapists identified two paradigms of treatment: the


mechanistic paradigm and the phenomenologicalparadigm. The mechanistic or Newtonian paradigmassumes that humans work much like machines. Thishas also been referred to as the biomedical model. It isprovider or expert centered and has an authoritariannature, with the provider telling the patient what todo. Objective measures and quantitative languagetypify this paradigm. The therapist focuses on mea-surable improvement in impairments rather than onthe patient’s quality of life and function/disability. Inthe mechanistic approach, the therapist is in controlof the treatment process and the measures of success,and the patient is expected to comply with thetherapist’s instructions and derive satisfaction fromimprovements in the measures.

The phenomenological paradigm places emphasison how things appear to be as being as important ormore important than how things actually are. Thisparadigm centers on the patient’s experience of theirillness and promotes shared decision making.Subjective measures and qualitative language repre-sent this paradigm.17 This is also referred to as thebiopsychosocial in contrast to the biomedical modelof medicine.

In this model, the therapist sees the whole person,not just the injured part or the pathophysiology(disease). There is collaboration between patient andtherapist, and patients’ interests, abilities, and moti-vation are consideredwhenworking together tomakedecisions about treatment.18 The therapist under-stands the impact of the illness on the patient’s lifeand addresses this while also performing the tissue-specific interventions of mechanistic care. The effortinvolved in this more holistic approach is well worthitdpatients’ compliance is reported to be greaterwhen they are encouraged to tell their stories.19

Narrative Example of PhenomenologicalParadigm

Emily’s Story

A female music professor found it difficult to playher instrument because of pain in her left wrist.Her pain increased after operative treatment of anulnar styloid nonunion and triangular fibrocartilagecomplex defect.


Emily told the hand therapist that music was herpassion and “her life.”

Solution

Working within this narrative, the therapist ad-dressed the uniquely personal and symbolic (i.e.,phenomenological) aspects of her illness by

suggesting that she bring her flute to hand therapyand by incorporating the functional demands ofplaying the flute in her hand therapy program.

Narrative Message

This patient found it very distressing that she couldnot even assemble, let alone play, her flute because ofthe pain in her wrist. She later told the therapist thatbringing her flute to therapy was very important forher because it was like bringing her best friend totherapy for support.

THE MEDICAL HISTORY IS ONLY PARTOF THE STORY

Patients’ lives and experiences are complex andmultifaceted. Time constraints may force therapiststo focus on the medical history, but this should notpreclude our efforts to learn more about the patient.The use of a narrative approach broadens awarenessof our patients’ illness experience. Hand therapistsand other medical providers may feel required tofocus on pathology. Clinical conversations tend toemphasize impairments and symptoms. Mattingly6

refers to this as chart talk. An alternative is to placeemphasis on the patient’s story. The use of storytell-ing in narrative medicine leads to greater apprecia-tion of the complexity of the illness experiences andpromotes more patient-centered care.

Narrative Example of Learning More of theStory

Mrs. Smith’s Story

A middle-aged woman with hearing impairmentand cochlear implants was sent to hand therapy witha diagnosis of left hand numbness. Nerve conductionstudies were normal. Her symptoms were vague,variable, and not characteristic of a specific disease.When the patient was encouraged to tell her story,she revealed that she had recently been to the emer-gency department with uncontrolled right hand andupper extremity spasms and had been told that hersymptoms were “psychological.” She expressed con-cern to her physicians that she wondered if she mighthave multiple sclerosis. She has been told by herdoctors that because of her cochlear implants, she isnot a candidate for a computed tomographic scan.


During her visits to the hand therapist, the patientexplained that she works two jobs, her son’s friendrecently committed suicide, and her daughter wasmissing the year in school because of illness. She alsoexplained that her hearing diminished as a young girl

at a time when her parents were divorcing and shewas being taken care of by her older sister who“yelled all the time.” The patient describes sponta-neously losing her hearing, but after a few years sheexperienced some return of hearing. After seeingmany experts, she was diagnosed with hearingimpairment of psychological origin.

Solution

When therapists feel that patients’ stories aredifficult to relate to and hard to imagine, theyshould draw on their resources of professionalbehaviors and think of these differences as anopportunity to react sensitively and to be movedby the life challenges and adversities that arerevealed in patients’ stories. Doing so can clarifythe differences between impairment and disability,disease and illness, increasing empathy and decreas-ing frustration. It can also help the therapist placerealistic limits on their role, without taking hopefrom the patient.

Narrative Message

The narrative approach requires therapists to try tounderstand what it must be like to be in the patient’ssituation.20,21 It is easiest to experience empathy withpatients who are similar to ourselves.12

STORIES ARE NOT TRIVIAL

What looks like idle chit chat in the clinic may infact be essential for uncovering and incorporatingnarrative in hand therapy. A brief remark or detailfrom a patient may seem to be trivial from themechanistic viewpoint but may be quite significantfrom the phenomenological viewpoint. Said moreplainly, a detail that seems trivial from a physicalpoint of view may actually be very important to thatpatient from a psychological point of view.4

Narrative Example of a Seemingly SmallDetail

Rebecca’s Story

A 64-year-old female sustained an embarrassingfall in public, with resulting right dominant shoul-der pain and rotator cuff tendinopathy. Her painworsened during her initial therapy sessions. Shechanged providers and was diagnosed with com-plex regional pain syndrome. She received multiplestellate ganglion blocks, along with other medica-tions and attended hand therapy after her blocks.She developed severe stiffness of her wrist anddigits. Her hands were edematous and dysesthetic.In the patient’s words, “I thought I would be cured

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after the first injection, even though I had been toldotherwise, so it was disappointing when I was notdramatically better all of a sudden.” She furthercommented, “It is exhausting to hurt all the time.And my pain affects my entire family. I have learnedto appreciate those who have to live with constantpain.”


Before the fall, the patient had been very indepen-dent. She was widowed and had raised five childrenon her own. She told the therapist: “I was used totaking charge of things. It is very difficult to have torely on others to help with driving, dressing, andpersonal care. This cannot be me.”

Solution

The therapist provided extra time for conversationand discussion with Rebecca. She made good func-tional improvement over time and valued the oppor-tunity to tell her story.

Narrative Message

Having to rely on others was extremely difficult forthis patient who was proud of her independence andself-sufficiency. Talking helped her recognize this andled to her being able to receive help from friendstemporarily. In her words, “I am the type of personwho has to talk about things. Physicians typically donot have time to do that. It has made a big differencefor me to be able to listen, learn, and talk in handtherapy.”

HAND THERAPY CAN HELP EVEN IF ITCANNOT CURE

Hand therapists need to know their limitations,but even with limitations, the listening skill canstimulate powers of self-healing for the patient.Narrative medicine helps therapists have an impacton patients’ well-being beyond the upper extremity.An underacknowledged but substantial part ofhand therapy involves the mind and the spirit ofthe patient. Therapists who present a positive andrespectful regard establish more of the rapportneeded to elicit patients’ stories.22 Some patients’stories are so sad or complex that the hand therapistmay feel overwhelmed. It will help to rememberthat therapists are not expected to solve all thepatients’ problems. It is amazing how effective itcan be just to listen. Even in the most challengingof clinical cases, details will surface in patients’stories that open new avenues for problem solvingleading to productive hand therapy interventionsand experiences.


Narrative Example of Helping without Curing

Mrs. Miller’s Story

An elderly patient was referred to hand therapywith bilateral wrist tendinitis and trapeziometacarpalarthrosis. She had a medical history including lungcancer, diabetes, balance disorders, and chronic pain.The hand therapist provided several interventionswith minimal relief of pain.


Mrs. Miller had weathered multiple illnesses in thepast. She had surely developed strategies that helpedher through these prior challenges.

Solution

Attention was focused on the patient’s illnessexperience. The therapist encouraged her to describethe strengths she drew on in difficult times.

Narrative Message

This patient’s stories led to an exploration ofstrategies for temporary pain relief. The patientacknowledged that hand therapy had not been ableto cure her pain, but it had helped her to manage andlive with her pain.

PATIENTS AS ACTORS IN THEIR REALWORLDS

Ahand injurymay disrupt an entire life. Therapistswho appreciate this can help patients mend thedisruption. By seeking information from the patientand then modifying therapy goals accordingly, atruly individualized treatment program is achieved.4

Narrative medicine helps therapists create experi-ences for patients that give them identities otherthan that of an ill person, instead becoming actorsin their real worlds.6

Narrative Example of Idiosyncratic andPersonal Intervention

Jean’s Story

A middle-aged woman fractured her distal radiusin a fall while hiking. She did not go to a doctor untilmore than a week after the injury. The fracture wasdisplaced and was treated with external fixation andpercutaneous pin fixation. She told the hand thera-pist that she was bipolar and had attention-deficitdisorder and other psychiatric diagnoses. Duringsome of her therapy sessions, she was medicatedand lethargic. It was frequently difficult for her to

maintain her attention and focus at the hand therapysessions.


Jean required a unique and very nontraditionalapproach to hand therapy. She told the hand thera-pist that she loved to dance and that she would like toperform “theatrical dances” in hand therapy toexpress herself.

Solution

Jean performed dances in which she used herentire body, and she received the stretch and stimu-lation to the upper extremities that she needed.

Narrative Message

Traditional hand therapy did not fit this patient’snarrative. Hand therapy by way of dancing allowedher to choreograph and accomplish her hand therapyin her own world and way.

LISTENING

Listening to a patient’s story is one aspect of theirhealing.23 When patients describe their stories, it istherapeutic because finding words helps contain thedisorder and its associated worries, while also pro-viding a sense of control over the chaos of illness orinjury.7 There are some situations where simply lis-tening helps patients with their pain more success-fully than the actual physical treatment.

Narrative Example of Listening

Patty’s Story

A 30-year-old right dominant female dishwasherwas referred to hand therapy with a diagnosis ofright arm pain. She reported that an aggressivecoworker who “had hurt other employees before”had maliciously shoved a crate of dishes forcefullyinto her, hitting her right forearm. X-rays andmagnetic resonance imaging were normal.


Sally presented with an intense expression of pain,wincing andmoaning even when her armwas at rest.She told the therapist that she had been transferredby her employer from another state and had not beentold that she would have a significant pay cut withthe transfer. For this reason, she had to work 60 hoursper week to make ends meet. She described acrowded and underresourced living situation withfamily members and her children.

Solution

After having an opportunity to tell about herself,she stated that her pain was improved and that bylistening, the hand therapist had helped her morethan anyone else had.

Narrative Message

This patient hadnoone to confide in. Simplyhavingan opportunity to express problems and frustrationsand be listened to can help quiet an illness.

ENTER THE PATIENT’S SUBJECTIVEWORLD

Narratives do not always have to reveal deeperpsychological issues but may also assist the therapistin interventions such as complicated ergonomic anal-ysis. The art of hand therapy occurs when we allowpatients to guide us to and through their problems.24

To do this, our patients must have time to talk.25

Yerxa21 encourages us to enter the subjective worldof our patients and to welcome the complexity of hu-man nature.

Narrative Example of Entering the Patient’sSubjective World

Mrs. Clark’s Story

A 35-year-old woman who was wheelchair boundbecause of complications from surgery for a heartproblem resulting in incomplete quadriplegia as ateenager, presented with nonspecific right dominantwrist and hand pain. She is a certified recreationaltherapist and an administrator at a center for inde-pendent living, where she also teaches independentliving skills. There was no objective impairment, but9/10 pain in response to palpation of the A-1 pulleyof the right long finger. There was crepitus withcomposite digital flexion but no locking in compositeflexion. She had no edema and no sensory complaint.She did demonstrate pain at the metacarpophalan-geal (MP) joint of the right long finger, which wasworse with passive MP hyperextension and hyper-flexion, positions she used with transferring fromwheelchair to bed and when crawling on the floor,which she did regularly at home. In addition, shehad inconsistent vague pain at the ulnar right wristthat was worst when keying at the computerdatask that was necessary for work.


When asked what she thought had caused orcontributed to her right upper extremity pain, Mrs.Clark identified two factors: propelling her manual

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wheelchair and transferring from her wheelchair toher bed. When asked if she could perform transferswith more neutral MP joint positioning, she feltstrongly that this would not be possible for variousreasons. Splinting options were offered as part of acomprehensive treatment program, but she hadparticular needs and requests that were, frankly,contrary to the textbook solutions.

Solution

Ergonomic recommendations were made to ac-commodate the extremes of motion that Mrs. Clarkused with propelling her wheelchair and transferringto her bed. In addition, nontraditional splints weremade to help with soft tissue protection.

Narrative Message

Through narrative, patients may show us how tohelp them achieve their goals, sometimes in uncon-ventional ways.

CONCLUSION

The practice of narrative medicine allows patients’stories to unfold so that their hand therapy care can bemade personal and meaningful to them. This articleapplies the concepts of narrative medicine to handtherapy. The illness experience is explained, alongwithbackground on the development of narrative medi-cine.Obstacles topracticingnarrativemedicine suchasemotional labor are addressed.Procedural reasoning iscomparedwith interactive reasoning, andmechanisticversus phenomenological paradigms are discussed.Case examples based on the author’s clinical experi-ence are provided to illustrate a narrative approachand methods of interaction that elicit self-healingpowers among our hand therapy patients.

CLINICAL PEARLS

The recommendations below are based on theauthor’s personal experience and on the literature26

� Try to listen initially in the visit withoutinterruption.

� Do not condescend or criticize patients when theyexpress their views or beliefs.

� Ask patients and escorts open-ended questionsabout their view of the problem. For example,“Tell me more;” “Is there anything else?;” “Thismust be very difficult.”

� Be yourself with the patient and trust your feelings.


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2. Vranceanu A-M, Cooper C, Ring D. Integrating patient valuesinto evidence-based practice: effective communication forshared decision-making. Hand Clin. 2009;25:83–96.

3. Mattingly C, Fleming MH. Clinical Reasoning. Philadelphia,PA: F.A. Davis, 1994.

4. Mattingly C. What is clinical reasoning? Am J Occup Ther.1991;45:979–86.

5. Jackson J. Living a meaningful existence in old age. In:Zemke R, Clark F (eds). Occupational Science: The EvolvingDiscipline. Philadelphia, PA: F.A. Davis, 1996. pp. 339–61.

6. Mattingly C. The narrative nature of clinical reasoning. Am JOccup Ther. 1991;45:998–1005.

7. Charon R. Narrative medicine: a model for empathy, reflection,profession, and trust. JAMA. 2001;286:1897–902.

8. Boyle D, Dwinnell B, Platt F. Invite, listen, and summarize: apatient-centered communication technique. Acad Med. 2005;80:29–32.

9. FrankG. Life histories in occupational therapy clinical practice.Am J Occup Ther. 1995;50:251–64.

10. Charon R. Narrative Medicine: Honoring the Stories of Illness.New York City, NY: Oxford University Press, 2006.

11. Taleb NN. Nassim Nicholas Taleb. Wikipedia, Available at:http://en.wikipedia.org/wiki/Nassim_Taleb Accessed Mar21, 2009.

12. Larson EB, Yao X. Clinical empathy as emotional labor in thepatient-physician relationship. JAMA. 2005;293:1100–6.

13. Higgs J, Jones M. Clinical Reasoning in the Health Professions.2nd ed. Burlington, VT: Butterworth/Heinemann, 2000.

14. Schell BAB, Schell JW. Clinical and Professional Reasoning inOccupational Therapy. Baltimore, MD: Lippincott Williams &Wilkins, 2008.

15. Fleming MH. The therapist with the three-track mind. Am JOccup Ther. 1991;45:1007–14.

16. Mallinson T, Kielhofner G, Mattingly C. Metaphor and mean-ing in a clinical interview. Am J Occup Ther. 1995;50:338–46.

17. Gillette NP, Mattingly C. Clinical reasoning in occupationaltherapy. Am J Occup Ther. 1987;41:399–400.

18. Brody H. The biopsychosocial model, patient-centered care,and culturally sensitive practice. J Fam Pract. 1999;45:585–7.

19. Barrier PA, James T-C, Jensen NM. Two words to improvephysician-patient communication: what else? Mayo ClinProc. 2003;78:211–4.

20. Yerxa EJ. Seeking a relevant, ethical, and realistic way of know-ing for occupational therapy. Am J Occup Ther. 1991;45:199–204.

21. Yerxa EJ. Confessions of an occupational therapist who becamea detective. Br J Occup Ther. 2000;63:192–9.

22. Pipe TB. Fundamentals of client-therapist rapport. In: CooperC(ed). Fundamentals of Hand Therapy: Clinical Reasoning andTreatment Guidelines for Common Diagnoses of the UpperExtremity. 1st ed. St. Louis, MO: Mosby, 2006. pp. 126–40.

23. Charon R. Narrative medicine creates alliance with patients.Medscape Med Students. 2006;8, Available at: http://www.medscape.com/viewarticle/520704. Accessed May 20, 2010.

24. Morris MB, Morris B. Personalized medicine and patient-centric learning: a core requirement for informed decisionmaking. Per Med. 2008;5:265–71, Available at: http://www.medscape.com/viewarticle/576151. Accessed May 20, 2010.

25. Marvel MK. Soliciting the patient’s agenda: have we im-proved? JAMA. 1999;281:283–7.

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http://www.medscape.com/viewarticle/520704




JHT Read for CreditQuiz: Article #186

Record your answers on the Return Answer Formfound on the tear-out coupon at the back of this is-sue or to complete online and use a credit card, go toJHTReadforCredit.com. There is only one best an-swer for each question.

#1. The article contends that most often patients eval-uate successful outcomes in terms of
a. reduced painb. increased ROM and strengthc. increased secondary gaind. restored function
#2. The best type of listening to the patient’s narra-tive is described as
a. syntheticb. sympatheticc. empatheticd. emphatic
#3. The most effective narrative process is
a. interactiveb. attentive listening
c. uninterrupted listening to the patient’s storyd. facilitated by recording the patient’s story for

later review
#4. To draw out the patient’s story use
a. a story boardb. open ended questionsc. a written form that suggests a beginning, a

middle, and an end to the storyd. a so called Perry Mason style of cross

examination
#5. When the therapist summarizes the patient’s
story during the narrative, we are said to beutilizing
a. recitalb. reflectionc. reductiond. revision
When submitting to the HTCC for re-certification,please batch your JHT RFC certificates in groupsof 3 or more to get full credit.

AprileJune 2011 139

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Narratives in Hand Therapy