New York City, United States
Story is ubiquitous. It’s no wonder that it shows up in medicine.
How does narrative feed medical language?
|Photography by teachandlearn|
“I have over 500 patients,” the heart surgeon raised her voice in exasperation. “I just want you to hear my side of the story,” the patient countered. Too late. The doctor had already closed the door on any storytelling, leaving only a limp excuse for a kind exchange of words. How often do such exchanges occur?
Many doctors do try to listen and reflect empathy in their language. Their language often does show a willingness to hear; and there’s some talk of a new field called “narrative medicine.” But for everyday occurrences, it is still often business as usual. Doctors talk to other doctors, giving little time to the patient’s story, because they have “over 500 patients.” Many physicians sadly still practice without any sense of other.
This sense of “other” requires an understanding of what is by the language of narrative, of dealing with persons’ experiences, and how this approach is serving people with illness? It raises the question whether doctors really need to speak a different language, one that creates empathy and a connection between them and their patients?
Twenty-five years ago, in the late 1980s, Cynthia Ozick, an American short story writer, novelist, philosopher, and essayist, received an unusual request to speak as a writer to physicians for the purpose of increasing the doctors’ “capacity to imagine.”1 Feeling unprepared for a conversation without any true scientific knowledge, Ozick relied on what she knew. She said she wanted doctors to enhance their feeling and understanding of what it meant to be a sick person, begin to understand what a sense of other means. To do so, Ozick believed she needed to bring to the physicians a sense of story, with the “engine” of this train being metaphor.2 She further contrasted in her lecture the ancient Greeks, whose culture had nothing to do with a conscience or moral life, compared with the Israelites, whose memory of being slaves in Egypt and foreigners had given them the power to “envision the stranger’s heart.”3,4 Through metaphor and storytelling, Ozick concluded, doctors can imagine what it means to be their patients. “Those at the center can imagine what it is to be outside,” the way strangers can imagine “the familiar heart of strangers.”4
* * * *
Another scholar from the 1980s decade, Arthur Kleinman, MD, Harvard psychiatrist and anthropologist, wrote about medical stories from an anthropological view in his book, The Illness Narratives – Suffering, Healing & the Human Condition. His work makes a case for making real connection with patients through “mini-ethnographies.” His observations—based on interviews, available household data from financial, family tree, and life history—show a most respectful interpretation of his informers’ life story.5
In conducting mini-ethnographies, Kleinman said that he tried to imaginatively perceive and feel the illness experience, as the patient understands it. “This experiential phenomenology is the entrée into the world of the sick person.” As the patient narrates the illness, it “creates the experience because of the cognitive, affective, moral concerns patients bring to the events and their career of chronic illness.”6
Kleinman said, “One of the great privileges of medicine is to be given access by the patient to the intimacy of his life. The patient’s biography becomes part of the care and helps to lessen the dehumanizing of the patient.” To record, one needs to borrow skills from the biographer and the historian’s craft to see relationships and patterns easily missed in the first exchange. Recording these patterns is no small skill. “The moment that a clinician-biographer [realizes he has created] a unifying form to a patient’s life is a thrilling one.”7
Narrative Medicine Today
Rita Charon, MD PhD, Director of the Program in Narrative Medicine at Columbia University, first used the term “narrative medicine” in 2000. She understood how the skill of listening to patients’ stories was enhanced by reading fine literature. She started a new program at Columbia University in Narrative Medicine where the language of the mission statement is as much about narrative skill as it is about medical effectiveness. The mission states:
Narrative Medicine fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness. … The Program in Narrative Medicine helps doctors, nurses, social workers, and therapists to improve the effectiveness of care by developing the capacity for attention, reflection, representation, and affiliation with patients and colleagues.
“Narrative competence,” Charon calls it. She set up the program around three movements and skills—attention, representation, and affiliation. The approach begins with attention because the physician needs to bring a reflective capacity and a willingness to learn from the patient to the conversation. That discourse opens up a better chance of the patient being heard.
Like French philosopher Simone Weil, known for her compassion for others’ suffering and who often asked this one question: “What are you going through?” Charon similarly makes one simple statement: “I need to learn a lot about your body, your health, and your life. Please share with me what you think I need to know.”
Starting this way, Charon helps the patient to feel comfortable entering the conversation. From giving that attention, the doctor moves on to representation, to configuring the patient’s story into a form, which “renders the doctor audible, the patient visible, and the treatment a healing conversation. Until this writing, there are two isolated beings—the doctor and the patient … but by virtue of the writing, there is hope for connection, for recognition, for communion.”8
When doctors take the time to read and study literature, they grow in their abilities to understand, hear in empathy, and express understanding empathically. They are more present, analytic, and observant. Literary stories help the reader, doctor or medical student, to become comfortable with the everyday stories of human suffering. For doctors carry about a powerful tool in black bag: the ability to “take complicated issues and framing them in simple, clear ways so that patients can understand and relate to, even when they are worried or frightened.9 And there is considerable evidence that doctors exhibiting high degrees of empathy are more likely to have good patient outcomes.”10 Their approach requires scientific and technical skill, a skill and an art based on practical experience and listening, resulting in a fuller and more appropriate picture upon which to base further treatment.11
The Philosophical View
Art educator, Elliot Eisner spoke to the sense of other contained in plots that he believed were particularly courageous—Schindler’s List or Death of a Salesman. Such works, says Eisner, “actually structure our minds to understand someone other than ourselves.” He said that such works of art can “relate us to a form that generates certain qualities of life in us. We grasp meanings that would otherwise elude us.”12 When doctors take time to listen to small or large events in one patient’s life, they acknowledge what this other person is going through. Is it not so different from what we do when we acknowledge important events of our shared past. We acknowledge more than the event, we acknowledge our memory of it and our debt to the people and events of our past.
Fiction portrays these times and events, daring us to stay engaged in others’ experiences. Ricoeur states that “in the fictions that help us understand human actions by reconstructing them in an imaginary universe, we can see our profoundly human capacity for transforming our practical experience through the composition of narrative”.13 To return to Cynthia Ozick’s notion of metaphor in language and fiction, we find grand implications. “Novels transform experience into ideas because it is the way of metaphor to transform memory into a principle of continuity. By “continuity” I mean nothing less than literary seriousness, which is unquestionably a branch of life-seriousness.”14
- Cynthia Ozick, “Metaphor and Memory,” in Metaphor and Memory (New York: Vintage International, 1991) 266.
- Ibid., 266.
- Ibid., 277–279.
- Ibid., 283.
- Arthur Kleinman, M.D., “A Method for the Care of the Chronically Ill,” in The Illness Narratives – Suffering, Healing & the Human Condition (New York: Basic Books, Inc., 1988) 232.
- Ibid., 233.
- Ibid., 237.
- Rita Charon, MD PhD, “What to do with stories,” Canadian Family Physician, August 2007, 53:1266 [1266-1267].
- Maggie Kozel, MD, “How doctors can shape the health reform narrative,” Policy, June 27, 2011, http://www.kevinmd.com/blog/2011/06/doctors-shape-health-reform-narrative.html
- Tracy Granzyk, “Using Stories & Narrative to Develop Empathy in Medical Students,” The Doctor Weighs In, October 22, 2012, http://www.thedoctorweighsin.com/using-storytelling-narrative-to-develop-empathy-in-medical-students/
- Troels Monsted, Madhu C. Reddy, and Jorgen P. Bansler, “The Use of Narratives in Medical Work: A Field Study of Physician–Patient Consultations,” S. Bedker, N.O. Bouvin, W. Lutters, V. Wulf and L. Ciolfi (eds.) ECSW 2011: Proceedings of the 12th European Conference on Computer Supported Cooperative Work, 24–28 September 2011, Aarhus, Denmark.
- Elliot Eisner, “What educational reformers can learn from the arts,” Symposium: Exploring imagination—a search for alternative possibilities in society, education, and the lives of children, November, 1994. New York: Teachers College, Columbia University.
- See Paul Ricoeur, Time and Narrative Volume II, trans. Kathleen McLaughlin and David Pellauer (Chicago: University of Chicago Press 1985), passim.
- Ozick, op.cit., 282.
ANN REDPATH, PhD, is a writer/editor/ project manager for the publication of curricular and academic content. As editorial director, she has worked at publishing companies on children’s books, adult trade, and most recently at curriculum and course development for all grades through college. Ann was director of products that twice won the Bologna International Children’s Grand Prize. As publisher, she started a publishing company and ran it for seven years. She has three children and lives in New York City.