Narrative medicine

"We treat our patients. Do we know our patients?"

I was simply so glad, so very glad, when I went thru this article.

When I was doing the home visit report in CFM module, I deliberately presented her discharge summary (as medically termed as possible) followed by a narrative completely in laymen terms and in Ms Keung (my patient)'s angle. I wanted to create the contrast between somebody's medical notes and a personalised illness story. I stressed the importance of listening to the patient's story as they are the experiencer. Medical professionals tend to be "objective" and we kind of have the power to "judge" whether our patients "should" or "should not" experience some discomfort. However what patient experience is what they experience, and we ought to respect their bodies and feelings instead of dismissing their experience.

I was pretty worried when I handed in my home visit report as this was not something people normally do. Now, finally, I've found something emerging that matches my idea.

This article is an excellent introduction to narrative medicine, and to any medical professionals who have a human heart able to experience and emphathise.


Narrative Medicine Creates Alliance With Patients
Posted 01/19/2006, Medscape Med Students. 2006;8(1)
Rita Charon, MD, PhD

A Patient's Unusual Request

A dozen third-year medical students sat around a conference table with me for an hour-long narrative medicine workshop. They had just finished their internal medicine clerkship at the university teaching hospital. Some of the students were far-flung -- one from Alabama, one from Belgium, one from North Carolina. I asked them to reflect on their 6 weeks of training on the internal medicine wards.
"Think of a patient who moved you particularly -- to sadness, to attachment, to despair, to love. Write a description of what happened the last time you saw that patient, and be prepared to read aloud here whatever you write."
I gave the group 5 minutes to write a paragraph or poem or dialogue about the chosen patient, and then I asked a few students to read their writing aloud to the group. One student wrote of an elderly woman with newly diagnosed and untreatable gastrointestinal cancer. She was alone in the world, having lost her family in the Holocaust and having had no children of her own. She knew she was dying and that she was dying alone. She had 3 requests of her medical student.
"Sit with me," was the first, and the student was happy to comply. "Bring me for a walk in the fresh air," was the next and also easily honored request. The third was more complex and daring: "Listen to my autobiography." Floored by this request, the student stayed the course and listened as his patient told of her life.
Our seminar was the first chance he had had to write about that experience. The paragraph he wrote and then read to us was the beginning of a memorial to this woman's life and the fulfillment of his promise to honor it.
This student was extremely fortunate to care for a patient who knew to ask for what she needed from her doctor. What a brilliant request! "Listen to my autobiography."
Most patients and healthcare professionals have yet to learn that one aspect of healing is exactly this, listening to the telling of the self. The body, it turns out, is the portal to the self, and caring for the ill body can open the door to a moving and healing intimacy with the self. As one diagnoses and manages the asthma, the cancer, the dementia, the alcoholism, one recognizes and enters into relation with the full self of the patient -- the hopes, the dread, the strengths, the dreams. As one accompanies the patient's self along with the body through improvement or decline, one almost magically recognizes and accompanies one's own self, for the self that is summoned by the call of the patient is the authentic self.
We doctors are learning from oral historians, trauma scholars, chaplains, and those in testimony studies how to bear witness to our patients' narratives of trauma, loss, and suffering. Along with the technical aspects of an ever-complex medical science, we can equip ourselves with the narrative competence to listen to and honor our patients' stories of self.
What we call "narrative medicine" is a medicine practiced with these skills to recognize, absorb, interpret, and be moved by the stories of illness. To practice narrative medicine -- be it in internal medicine, family medicine, pediatrics, obstetrics, surgery, or psychiatry -- means developing the sophisticated skills to attend to what patients emit, to represent in language what they tell, and to affiliate with them and their families and other healthcare professionals in communities of care.

The Clinician as Witness, Not Judge

Narrative medicine had its start in such related efforts as patient-centered care and medical humanities. The clinical cousin of literature-and-medicine, narrative medicine takes those skills that one develops as a close reader or a reflective writer and bends them toward effective clinical practice. The close reader -- whether of fiction, poetry, or memoir -- follows the narrative thread of a story, enters into the teller's narrative world, and sees how that teller makes sense of it. The close reader identifies the images and metaphors, recognizes the temporal flow of events, follows allusions to other stories, and is imaginatively transported to wherever the story might take the one who surrenders to it.
The skilled writer can represent formless or chaotic experience by conferring form on it so that it can be seen by both the writer and the audience. The previously formless experience thereby becomes like an edifice, around which the writer can walk, seeing it from all directions, understanding aspects that, until form was conferred, were invisible.
When medicine is practiced with these skills, the clinician or trainee has much to offer the patient. By listening with the close reader's attention, he or she can hear and receive in full complexity what the patient conveys in words, silences, gestures, positions, and physical findings. By representing with accuracy and skill what the patient conveys, the clinician honors what is told in all its detail and contradiction and dimensions and connotation.
This clinician with narrative competence becomes a witness and not a judge, a companion and not an interrogator, an ally and not simply the bearer of bad news or inflictor of discomfort. The clinician or trainee with these skills of attention and representation has the grounds of knowledge and of motive to develop a sturdy and clinically useful affiliation with the one who suffers.

Developing Narrative Competence

Narrative medicine had its start at Columbia University, in part because our departments of English and creative writing are well connected to our medical school. We have a tradition of teaching literature and creative writing to medical students, doctors, nurses, and social workers. We give medical school credit to medical students who enroll in courses on the main university campus in humanities departments.
Because we are convinced that narrative competence increases our effectiveness as clinicians, we have committed ourselves to teaching narrative skills throughout the curriculum and the hospital. Emerging findings in outcomes studies encourage us, for we are learning that students exposed to narrative training seem to, by virtue of it, develop greater clinical skills in interviewing and allying therapeutically with their patients.
One corollary to such thinking is that students who enter medical school already equipped with narrative skills may have an advantage. We already know that humanities majors do as well as science majors on such measures as board exams and medical school grades. We have yet to discover whether, in fact, they may outperform their science major peers in the more interior and narrative dimensions of clinical practice. Such questions are actively being asked, not only at Columbia but at many other medical schools.
The opening scene I described took place in a medical school in Israel. Scenes very similar to it have taken place lately in Denver, Nashville, Sydney, Montreal, Albany, and Albuquerque. I am by no means the only doctor to be teaching such narrative seminars. Programs in narrative medicine currently exist at Vanderbilt University, University of Pennsylvania, University of Florida, and Dalhousie University, and narrative medicine practices are emerging at George Washington University, University of Colorado, and McGill University. My colleagues in literature-and-medicine programs at Pennsylvania State University, University of Texas at Galveston, Northwestern University, and University of Illinois at Chicago, among others, undertake similar work in reading and writing.
Finally, doctors and those who teach medical students are by no means alone in learning about the power of narrative in healing. Patients and their families have been writing their autobiographies of illness with more and more frequency and force. Read these pathographies to learn what only patients can teach us about the experiences of illness. Read the collections of stories being published by doctors, nurses, social workers, and students about their clinical practices. Take in the news from the increasing number of literary journals published by medical students.
All of these stand as evidence that illness and the care of the sick are saturated by narratives and the urgent need to respect and learn from them. Narrative medicine, in the end, functions as a bridge between doctor and patient, between teacher and student, among healthcare professionals, and even between the sick and the well, as we all together commit ourselves to healing, to authenticity, and to honoring one another's stories.

Suggested Readings

Bauby J. The Diving Bell and the Butterfly: A Memoir of Life in Death. New York: Vintage; 1998.
Berger J, Mohr J. A Fortunate Man. New York: Pantheon Books; 1967.
Borkan JM, Reis S, Steinmetz D, Medalie JH, eds. Patients and Doctors: Life-Changing Stories from Primary Care. Madison, Wis: University of Wisconsin Press; 1999.
Charon R. Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press; forthcoming 2006.
Davis C, Schaeffer J, eds. Between the Heartbeats: Poetry and Prose by Nurses. Iowa City: University of Iowa Press; 1995.
Frank A. The Renewal of Generosity: Illness, Medicine, and How to Live. Chicago: University of Chicago Press; 2004.
Middlebrook C. Seeing the Crab: A Memoir of Dying. New York: Basic Books; 1996.
Remen R. Kitchen Table Wisdom: Stories That Heal. New York: Berkley; 1997.
Verghese A. My Own Country: A Doctor's Story. New York: Vintage/Random House; 1995.
Winckler M. The Case of Dr. Sachs. Translated by Linda Asher. New York: Seven Stories Press; 2000.

Rita Charon, MD, PhD, Professor of Clinical Medicine and Director, Program in Narrative Medicine, Columbia University, New York, NY

Disclosure: Rita Charon, MD, PhD, has disclosed no relevant financial relationships.