The fifth vital sign

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An excerpt from Narrative Medicine: The Fifth Vital Sign.

“If you don’t take a temperature, you can’t find a fever.”
— Samuel Shem, The House of God

I enrolled in a creative writing course at a local university to better understand the parameters of narrative medicine. I learned about the pillars of the narrative, such as poetry and creative nonfiction, and our class talked extensively about the healing power of storytelling. Toward the end of the semester, I commented that narrative medicine should be the fifth vital sign, because just like the four traditional vital signs (temperature, pulse, respiration rate, and blood pressure) provide critical information about a patient’s physical health, narrative medicine provides direct insight into a patient’s emotional, psychological, and social health. It helps the clinician glimpse the patient’s personal experience with their illness, fears, concerns, and hopes.

Narrative medicine adds a dimension of care that complements and enriches the information obtained from the traditional vital signs. Just as vital signs can indicate a physical condition that needs immediate attention, narrative medicine can help identify important emotional issues early on. The concept of narrative medicine as the “fifth” vital sign suggests that patients’ stories are equally crucial as their physicality for a comprehensive understanding of their health. Why shouldn’t personal narratives be considered the fifth vital sign?

Everyone in my class seemed to agree. They liked The Fifth Vital Sign as a title for a book about narrative medicine. (The obvious first choice was simply Narrative Medicine.) My instructor commented: “The “fifth” is magic for the alchemists. Mercury is the fifth element [in numerology] and the only one that embodies masculine and feminine (solid and liquid) properties at room temperature. And the fifth anything turns a square into a circle. Quintessential stuff, Art!”

I was puzzled by my instructor’s use of the phrase “the fifth anything turns a square into a circle.” I had to do some research to decipher its meaning. Metaphorically, in a medical context, if we consider the four corners of a square as the four traditional vital signs, these provide a structured, quantitative assessment of a patient’s physical state. Adding a fifth element, such as narrative medicine, introduces a qualitative, humanistic aspect to patient assessment. This “rounds out” the picture, making it more holistic and complete, just as adding a dimension to a square can transform it into a circle (or more accurately, a sphere in a three-dimensional context).

Even my instructor’s use of the word “quintessential” was apropos. Ancient Greek philosophers claimed there were five elements: earth, water, air, fire, and a fifth substance that made up objects in the heavens. This idea was passed down through the ages to Latin-speaking scholars who called the fifth element quintessence – from the Latin words quintus, meaning “fifth,” and essentia, meaning “being.” In the Middle Ages, people believed the quinta essentia was integral to all kinds of matter, and if they could somehow isolate it, it would cure all disease. Eventually, the word’s meaning evolved into our modern definition: the essence of a thing in its purest and most concentrated form. In other words, the narrative in medicine.

Narrative medicine represents purity because it focuses on the humanistic aspects of medical practice – the personal stories, emotions, social context, and experiences of patients and health care providers. It symbolizes the core of medicine, which is not only about diagnosing and treating diseases but also about understanding and empathizing with patients as whole individuals. Narrative medicine embodies the ideal of quintessence – the fifth essence – the most essential part of something. It should be considered the fifth vital sign, a useful tool for detecting or monitoring a range of medical problems.

Readers’ heartfelt comments to my many essays and commentaries bear witness to the problems yet to be solved in the medical profession. It’s clear that we are facing ongoing challenges such as burnout, high stress, long hours, increasing health care costs, and evolving health care delivery models. However, it’s essential to note that the state of any profession, including medicine, can be influenced by various factors such as technological advancements, societal changes, economic conditions, and health care policies.

The health care industry is continually adapting and innovating to meet these challenges. Investments in telemedicine, mental health resources for health care workers, and the recognition of the importance of work-life balance are all efforts to support the profession. Yet, while multiple stakeholders are busy addressing these problems, the utility of the medical narrative is virtually overlooked as a viable means to support clinicians and patients through turbulent times. Narrative medicine attests to the healing power of putting words to experience, and it has done so since antiquity by promoting empathy, enhancing communication, fostering reflection, facilitating interprofessional collaboration, informing clinical practice, and educating students.

The third law in Samuel Shem’s House of God is, “At a cardiac arrest, the first procedure is to take your own pulse.” It’s a reminder that we need to take care of our own mental and emotional health in order to effectively take care of our patients. We can’t rely exclusively on other people to fix medicine’s problems. We also need to look inward for a solution by becoming our own patients, scheduling our own personal checkups in which we constantly re-examine ourselves and assess our well-being. Quite simply, we need to monitor our vital signs and place greater emphasis on the fifth vital sign. Narrative medicine is as much a tool for us as it is for our patients.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine, Medicine on Fire: A Narrative Travelogue, and Narrative Medicine: The Fifth Vital Sign.

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