Dr. Oladipo Kukoyi's Insights into Narrative Medicine

How do you think narrative medicine enhances clinical outcomes and patient care?

Narrative medicine is an approach to healthcare that emphasizes the importance of patients' stories in the healing process. It recognizes that understanding a patient's life, experiences, and context, through their personal narrative, can significantly enhance medical care. As a psychiatrist and family physician, I believe this approach is key in caring for the patient before you, something also embodied in the concept of holistic medicine, or whole health care. This approach sees the patient before you as a human first, with goals and desires, rather than a diseased person, who is there to be healed. This method encourages healthcare providers to listen attentively and empathically to patients' stories, understanding that illness is not just a biological condition but also an emotional, social, and psychological experience.  In fact, no less an authority than Sir William Osler, the 19th-century physician and chair of Clinical Medicine at the University of Pennsylvania, said, “Listen to your patient; he is telling you the diagnosis.” This recognizes the fact that listening to the patient’s narrative is often the way to a diagnosis, even more efficiently than tests or checklists, which would surprise many modern clinicians.  Asking the patient what matters to them, rather than what is wrong with them, acknowledges their humanity, hopes, aspirations, and fears in a way that connects the clinical outcome with a patient-oriented outcome rather than a disease-focused one. So, for example, instead of harping on why the blood sugars need to be below a certain number in a patient with diabetes, asking them about their family, and their dreams of seeing their kids or grandkids grow up, might be the key to connecting why controlling their blood sugar matters. So, the patient wants to control their diabetes not because you told them a certain number matters, but rather because they want to be alive for a family member’s graduation. Or make their high school reunion.  

In what ways have patients’ narratives of illness informed your diagnostic reasoning and treatment plans?

I remember when I decided I didn't want to choose between being a physical or a psychiatric doctor. It was the end of the third year of medical school, and I was doing an extra internal medicine rotation where I was an acting intern. I had more responsibility in caring for the patient, more than a typical medical student. One patient came in with sores throughout her gastrointestinal tract, and it turned out that she had a rare autoimmune disease, which responded well to steroids. The team started her medicine and moved on, yet I stayed with her to chat. I then learned she had these outbreaks of sores as flares, every few months. It turned out that she was dealing with significant personal stress related to family issues. Anytime she endured these significant family issues, she ended up in the hospital with these sores from her mouth to her anus. And there I had it, her illness was her body’s reaction to the stress in her life. Sure, the steroids could treat the acute flare, but learning to manage the stress of her family issue would keep her well and out of the hospital. I was excited to make this connection and ran to tell the rest of the medical team. To my surprise, no other physicians cared; their attitude was to just give her the steroids and get her out. They didn’t seem to be concerned about the connection between her personal narrative and her recurrent illness. That’s when it was sealed for me – I wanted to be the kind of doctor who talked to and listened to patients and tried to care about their whole self, and not just the disease they presented with.

When using the sentiments of narrative medicine in clinical settings, how do you navigate the shift from the question “How can I treat my patient’s disease?” to the more all-encompassing inquiry “How can I help my patient?”

I’ll tell another story from my training that explains why one should make that shift. I was a first-year resident, straight out of medical school. One afternoon, a patient came to my clinic who shared with me aspects of her life and work. She had extremely elevated blood pressures that were potentially dangerous, as I had read about in school, and I felt the need to immediately lower her blood pressure to a normal range. I was worried about her being at risk for an imminent catastrophic event, such as a stroke, heart attack, or kidney failure. I ordered an array of tests and had her prodded from top to bottom. I ordered scans and further studies. I told her I was worried for her and glad she had come to get care, but getting control of her blood pressure was an emergency. She tried to tell me she felt well and didn’t want or need all these studies or medicine, but I was determined to fix her. After the second visit, her blood pressure was no better, but all the tests were still negative, and I was determined to keep testing her till I understood her condition and could lower her blood pressure to save her life!! She never came back to see me again. She would see me in the hallways and avoid me. I was stunned – how could she not see I was trying to save her life? It was later, as I matured as a clinician, that I realized I had driven her away by treating her disease instead of helping her as a whole person. As I tell my students now, just because a patient walks in with a significant disease that they didn’t know about, it doesn’t mean mortality or morbidity are nigh; my patient had survived many years with uncontrolled blood pressure, and if I had taken the time to actually build a relationship with her and address what had brought her to me, I may have been able to gain her trust so that she might be certain the tests I ordered were important and intended to help her in the long-term. I really learned a lot from that experience, and it informs how I approach newly diagnosed ill patients to this day.

To what extent does narrative medicine enable the foregrounding of human subjectivity in medicine?

Human beings are complex machines – we are more than the sum of our parts. So a reductionist approach that reduces us to symptoms and checklists to be fixed misses the complexity of the human experience and shortchanges both patient and physician. In my field of psychiatry, this is an active debate as many feel the use of pharmacology can substitute for psychotherapy in which a lot of the healing takes place in talking – patient story-telling and the physician interpreting the story-telling and coaching the patient, as it were, allow both the patient and physician to reflect and learn from their experiences and grow more resilient as a result of this. So, even though the biological revolution promised to change psychiatry for good with the discovery of antidepressants in the 1950s, we have learned that nothing beats the combination of talk therapy and medicine together. In many anxiety conditions, including PTSD, talk therapy is actually superior to medication. This shows that the power of the human relationship, present in the therapeutic rapport between patient and physician, is a powerful medicine in and of itself, as potent as any pill that pharmaceutical companies can make, and can never be replaced by the powerful AIs that we have now.

How has your remarkable commitment to veteran healthcare shaped your approach to narrative medicine, particularly when addressing trauma, memory, and physical impairment?

Being able to work with veterans reminds you that every veteran has a story, and their stories are unique. I try to remind myself that the person I see before me is the product of their life experiences, which leads me to take the time to learn about how they became who they are now, enabling me to empathize, understand, and perhaps, help them with why they are where they are. Hearing powerful stories of losing battle buddies, of carrying the guilt with oneself into sleep (which is where you’re supposed to get refuge from the day’s worries), seeing physical scars that remind one of the commitment and sacrifice some of these men and women have made on our behalf, reminds you that this person, no matter how flawed they may be now, have often made choices that we have never had to make, helping to explain why they are who they are now. This process lets me, as a physician, have patience: when someone snaps at you or is rude, that makes you pause just a second. Before you react with anger to someone who’s feigning symptoms to avoid sleeping in the cold another night, it makes you ask why this person would be so hateful towards certain things and avoid particular behaviors, till he tells you he was a prisoner of war in Vietnam – then it all clicks. We are all human and deserve to be treated with dignity. If you seek first to understand the patient in front of you, before you yourself are understood, then, maybe, you might be able to help this person who incites so much anger in your hospital staff, all because you took the time to talk to this patient, listen to them, and see them for who they are, not what they do. And maybe, just maybe, you can help them make better choices to avoid using the hospital to get housing, food, or clothing. Maybe you can help this patient tell their story, guide them to the right people who can heal them clinically, and connect them with the resources they need to live. Maybe.

Author Biography

Dr. Oladipo Kukoyi, MD, MS 

Executive Director/CEO

Birmingham VA Health Care System (BVAHCS)

Dr. Kukoyi is responsible for a health care system serving over 70,000 Veterans throughout Alabama at a 141-bed tertiary care teaching medical center and nine Community-Based Outpatient Clinics. He served as the Interim Executive Director of BVAHCS from May 2021 to September 2021, and prior to that, served as the Chief of Staff. Dr. Kukoyi is dual board-certified in Psychiatry and Family Medicine. He has held academic appointments at a variety of higher institutions of learning and is currently a Clinical Professor in the departments of Psychiatry and Family Medicine at the UAB SOM, his alma mater. Dr. Kukoyi has expertise in psychosomatic medicine and in treating a wide array of psychiatric conditions and has a research interest in the interface between psychiatric and medical conditions.  He is well-published in this field. 

Dr. Kukoyi has a Master's in Clinical Investigation and has pursued research in the neuropsychiatry of epilepsy, and has been recognized for his teaching and mentoring excellence of trainees.  He is a 2012 graduate of the Health Care Leadership Development Program (HCLDP), a 2017 Federal Executive Institute (FEI) graduate, and a VHA Certified Mentor.

Dr. Kukoyi is a Distinguished Fellow of both the American Psychiatric Association and the Academy of Consult Liaison Psychiatry and received the UAB SOM Distinguished Alumnus Award of 2024.