Made to measure?

324 British Journal of General Practice, June 2013 My next patient walks in confidently wearing a big smile. All the training I’ve done in non-verbal communication kicks in and I suspect that his depression is starting to get better. He hands me a PHQ-9 with a flourish which confirms my initial impressions. I’m usually sceptical of these scoring tools, but this is no ordinary PHQ-9, this a luxury M&S patient-modified version, with; ‘Feeling a lot better since I’ve started to speak to the doctor about my problems’ written across the top. Over the years I’ve learned to be wary at taking praise. I know that usually I have a peripheral role in patients getting better or worse. Whether I’m being praised or panned I tend to take the view that Kipling took of triumph and disaster, and ‘treat these two impostors just the same’. But I do feel a little glow on the inside this time, pleased that the patient felt it was important to tell how he felt and not just tick a few boxes. I feel as if I’m buckling under the weight of scoring systems, pathways, and questionnaires. Every condition from sore throats to suicide now has a score accompanied by a clumsy acronym and each referral has to be on a form with 5 pages of tick boxes. It’s refreshing for something to come along and remind me that words, and the stories they bring are ultimately often more powerful and meaningful. Scores and figures have a superficial appearance of being more objective and avoiding individual error. It seems, especially during austere times, that those responsible for the purse strings believe facts and figures are a better use of resources and that words are a frivolous luxury. Yet throughout history, when existence was a constant daily battle to just survive, people have craved stories, from cave paintings to stories sung and spoken by wandering bards from ones written down by novelists and playwrights to the huge output of the film and TV industry. When times are tough we seem to delight in the power of the imagination even more. Hollywood boomed and had it’s heyday during financial depression and war. Being entertained added meaning to grim day-today existence and seemed to be as valued as keeping a tally on numbers. In fact the very words we use to describe them seem to blur the distinction. Telling can apply to stories or numbering and counting objects has its shadow meaning in recounting tales. In a recent radio programme ‘Being Normal’, the writer and broadcaster Jon Ronson examined the way that certain behaviours are classified as pathological by the use of checklists for example, in The American Diagnostic and Statistical Manual. This categorises people into anonymous groups rather than celebrating individuality. In the end he sums it up succinctly; ‘Checklists kill stories dead’. And stories can convey more meaning in a few words than a whole telephone directory full of figures and data. A few nuanced words can convey a lifetime of meaning. There is an anecdote that Ernest Hemingway was challenged to write a short story in six words. He won the bet with the poignant ‘For Sale, Baby Shoes, Never Worn’. In the case of my patient the heartfelt sentence at the top of the form was far more descriptive than the tick box information in it. The irresistible rise in scoring tools such as PHQ-9s, that focus on the easily measurable and auditable will nudge nuance and narrative out of the way and choke a powerful drive that seems hardwired into our natures. Changing THAT will be a different story.