lawyer as storyteller
James R. Elkins
Narrative Medicine
Narrative
Medicine: Learning to Listen
[Gina Kolata, New York Times,
December 29, 2009]
On Dr. Rita Charon (described as the "leading advocate of the emerging discipline known as narrative medicine") : "Through literature, she learned how stories are built and told . . . ." [Dr. Charon is a general internist and a professor of clinical medicine at Columbia University's College of Physicians and Surgeons. She holds a Ph.D. in English.][In one article, Charon refers to herself as "a general internist and literary critic."]
The aim of narrative medicine, according to Gina Kolata, is "to treat the whole person, not just the illness."
Kolata reports on a newly minted Master of Science in Narrative Medicine that began in the fall 2009 at the School of Continuing Education at Columbia. The program's first round of courses, Kolata reports, focused on philosophy, literary theory, psychoanalytic theory, autobiography, and illness literature. ["The core curriculum of this pioneering M.S. in Narrative Medicine combines intensive exposure to narrative writing and close reading skills, literary and philosophical analysis, and experiential work, with the opportunity to apply this learning in clinical and educational settings."] ["Our Program in Narrative Medicine at Columbia has developed an agenda in . . . examining and studying the relations of narrative thinking and practice to being sick or taking care of sick people." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261, 262 (2005)]
The NY Times article on the origins of narrative medicine says: "Narrative medicine does not spring from nowhere. Its lineage includes biopsychosocial medicine, primary care, medical humanities, and patient-centered medicine.""Sick persons and those who care for them become obligatory story-tellers and story-listeners. Hippocrates knew this, Chekhov knew this, Freud knew this, and yet knowledge of the centrality of storytelling was obscured in medicine throughout much of the last century. With the rise of interest in the humanities in general and literary studies in particular among medical educators and practitioners, today's medicine is being fortified by a rigorous understanding of narrative theory, appreciation of narrative practice, and deepening respect for what great literary texts can contribute to the professional development of physicians and the care of the individual patient." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261 (2005)
"Narratives have always been a vital part of medicine. Stories about patients, the experience of caring for them, and their recovery from illness have always been shared—among physicians as well as among patients and their relatives. With the evolution of 'modern' medicine, narratives were increasingly neglected in favor of 'facts and findings,' which were regarded as more scientific and objective. Now, in recent years medical narrative is changing—from the stories about patients and their illnesses, patient narratives and the unfolding and interwoven story between health care professionals and patients are both gaining momentum, leading to the creation or defining of narrative-based medicine (NBM). The term was coined deliberately to mark its distinction from evidence-based medicine (EBM); in fact, NBM was propagated to counteract the shortcomings of EBM." ~ Narrative-Based Medicine: Potential, Pitfalls, and Practice [Vera Kalitzkus & F. Matthiessen, The Permanente Journal]
Narrative
Medicine
[Dr. Rita Charon, LitSite Alaska]
"I have been practicing internal medicine for over twenty years. After a few years of practice after residency, I realized that what patients paid me to do was to listen very expertly and attentively to extraordinarily complicated narratives—told in words, gestures, silences, tracings, images, and physical findings—and to cohere all these stories into something that made at least provisional sense, enough sense, that is, to be acted on. I was the interpreter of these often contradictory accounts of events that are, by definition, difficult to tell. Pain, suffering, worry, anguish, the sense of something just not being right: these are very hard to nail down in words, and so patients have very demanding 'telling' tasks while doctors have very demanding 'listening' tasks."
"A narrative, at its simplest, is a story. Doctors listen to and tell stories every day. At morning report, on rounds, at case conferences, while taking a patient's history in clinic and when signing out in the evenings, stories are told, revised, and retold. These narratives are the foundations of clinical practice and the currency of patient-physician and physician-physician relationships." ~ Megan Alcauskas & Rita Charon, Right Brain, Reading, Writing, and Reflecting: Making a Case for Narrative Medicine in Neurology, 70 Neurology 891 (2008)
On the skills of the physician aided by narrative: "I realized that the narrative skills I was learning in my English studies made me a better doctor. I could listen to what my patients tell me with a greater ability to follow the narrative thread of their story, to recognize the governing images and metaphors, to adopt the patients' or family members' points of view, to identify the sub-texts present in all stories, to interpret one story in the light of others told by the same teller. Moreover, the better I was as 'reader' of what my patients told me, the more deeply moved I myself was by their predicament, making more of my self available to patients as I tried to help."
On the term "narrative medicine": "I invented the term 'Narrative Medicine' to connote a medicine practiced with narrative competence and marked with an understanding of these highly complex narrative situations among doctors, patients, colleagues, and the public."
"I first used the phrase 'narrative medicine' in 2000 to refer to clinical practice fortified by narrative competence—the capacity to recognize, absorb, metabolize, interpret, and be moved by stories of illness. Simply, it is medicine practised by someone who knows what to do with stories." ~ Rita Charon, What To Do With Stories: The Sciences of Narrative Medicine [Canadian Family Physician, vol. 53, 2007]
By one account, narrative medicine has been adopted in the core curriculum at more than half of North America's medical schools. ~ Stories for Life: Introduction to Narrative Medicine [Dr. Miriam Divinsky, Canadian Family Physician, vol. 53, 2007]
What narrative medicine offers: "[N]arrative medicine offers . . . a disciplined and deep set of conceptual frameworks—mostly from literary studies, and especially from narratology—that give us theoretical means to understand why acts of doctoring are not unlike acts of reading, interpreting, and writing and how such things as reading fiction and writing ordinary narrative prose about our patients help to make us better doctors. By examining medical practices in the light of robust narrative theories, we begin to be able to make new sense of the genres of medicine, the telling situations that obtain, say, at attending rounds, the ethics that bind the teller to the listener in the office, and of the events of illness themselves. It helps us make new sense of all that occurs between doctor and patient, between medicine and its public."
"[N]arrative medicine provides the means to understand the personal connections between patient and physician, the meaning of medical practice for the individual physician, physicians' collective profession of their ideals, and medicine's discourse with the society it serves. Narrative medicine simultaneously offers physicians the means to improve the effectiveness of their work with patients, themselves, their colleagues, and the public." ~ Rita Charon, Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, 286 (15) JAMA 1897 (2006)
Narrative
Medicine Creates Alliance With Patients
[Rita Charon, Medscape Today][log-in
required; free access]
"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."
Dr. Charon on narrative competence: "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." Charon goes on to note that "we are learning that students exposed to narrative training seem to, by virtue of it, develop greater clinical skill in interviewing and allying therapeutically with patients."
"Narrative medicine brings a useful set of skills, tools, and perspectives to all doctors. Not only does it propose an ideal of medical care—attentive, attuned, reflective, altruistic, loyal, able to witness others' suffering and honor their narratives . . . ." ~ Narrative Medicine [Dr. Rita Charon, LitSite Alaska]
Narrative competence is "the competence that human beings use to absorb, interpret, and respond to stories. . . . [Narrative competence] enables the physician to practice medicine with empathy, reflection, professionalism, and trustworthiness." ~ Rita Charon, Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, 286 (15) JAMA 1897 (2006)
"More can be gained from a patient's story than dry facts placed in a sequential pattern. Absorbing, interpreting, and responding to a patient's narrative require a special skill set. These skills, called 'narrative competence' by narrative scholars, include those that are practical, such as recognizing a story's structure and appreciating metaphors and illusions, those that are creative, such as envisioning multiple endings, and those that are emotional, such as feeling empathy and recognizing a story's mood. By developing narrative competence, physicians can better understand a patient's experience and thereby be better equipped to help him or her." ~ Megan Alcauskas & Rita Charon, Right Brain, Reading, Writing, and Reflecting: Making a Case for Narrative Medicine in Neurology, 70 Neurology 891 (2008)("Narrative competence rarely is taught as part of traditional medical school courses or on hospital wards." Id.)
On narrative medicine: "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."
On the training of narrative competence: "[W]e provide narrative training (ie, rigorous training in close reading, attentive listening, reflective writing, and bearing witness to suffering) . . . ." ~ Rita Charon, What To Do With Stories: The Sciences of Narrative Medicine [Canadian Family Physician, vol. 53, 2007]
"Curricula in narrative medicine typically include two parts: reading of literary texts related to health and illness to gain practice in hearing and interpreting the stories of others and reflective writing about the patient's and the professional's individual and shared experience." ~ Megan Alcauskas & Rita Charon, Right Brain, Reading, Writing, and Reflecting: Making a Case for Narrative Medicine in Neurology, 70 Neurology 891 (2008)
Narrative medicine draws on patient-centered care, medical humanities, and literature and medicine: "[N]arrative 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."
"It became clearer and clearer to my colleagues and me that doctors, nurses, and social workers need rigorous and disciplined training in reading and writing for the sake of their practice. I am by no means the only one to have observed that being a close reader equips one to perform some of the most difficult tasks of the health care professionals: attentive listening, simultaneously being transported by a text while analyzing it most meticulously and critically . . . , adopting alien perspectives, following the narrative thread of the story of another, being curious about other people's motives and experiences, and tolerating the uncertainty of stories." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261, 262 (2005)
"The narratively competent reader or listener realizes that the meaning of any narrative—a novel, a textbook, a joke—must be judged in the light of its narrative situation: Who tells it? Who hears it? Why and how is it told? The narratively skilled reader further understands that the meaning of a text arises from the ground between the writer and the reader . . . ." ~ Rita Charon, Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, 286 (15) JAMA 1897, 1898 (2006)
From
the Inside Out: Interview with Rita Charon
Rita Charon and her focus on writing as a part of the training of narrative competence for health care professionals: "Writing is one of the easiest and most cost-effective methods of exposing the 'unthought known,' a brilliant phrase from the work of psychoanalyst Christopher Bollas. We know things that we don't know we know. We need specialized methods—psychoanalysis, dreaming, and, I suggest, writing—in order to rescue this known from falling prey to boredom, fear, censure, or simply being overlooked. Invariably, when doctors and nurses and social workers write about their patients, they have 'aha' moments—'oh, I didn't know I was afraid of his disease,' or 'I want to be like her when I'm dying.' These insights accumulate in the course of sustained writing about practice to let the writer understand the complexity of this interior life as a clinician, to appreciate the bonds formed between us and our patients, and to simply take stock of the magnitude of what it is we do. This is, I think, nourishing, whereas practice without reflection becomes automatic and not unlike starvation."
The writing of medical students and the preparation of what Dr. Charon calls the "parallel chart": "I wanted to find a way to help the students focus on what they themselves were going through, and a way to focus on what their patients had to endure in the course of being ill. It's a tremendous cauldron of experience, and I wanted to have a way to let them reflect, consider, think about what they themselves were going through. And so I made them write. And I invented the Parallel Chart. I told them every day you write in the hospital chart of your patients. You may have 3, or 4, or 5 patients, and every day you write in each chart, and you know exactly what to write. It's very proscribed. I told them, there are things that are critical to the care of your patient that don't belong in the hospital chart, but they have to be written somewhere. And I would say, if you're taking care of an elderly gentleman who has prostate cancer, and he reminds you of your grandfather who died of that disease, every time you go in his room, you weep. You weep for your loss, you weep for your grandfather. I said, you can't write that in the hospital chart. I won't let you. And yet, it has to be written. Because this is the deep part of what you yourself are undergoing in becoming a doctor. Only when you write do you know what you think. And there is no way to know what you think, or even what you experience, without letting your thoughts achieve the status of language. And writing is better than talking."
"[T]here are critically important aspects of the care of patients that do not belong in the hospital chart, but that, I submit, have to be written somewhere. In the Parallel Chart, students and doctors write about their own anguish in caring for patients as well as their victory when things go well, their rage and mourning and dread, their fear of mistakes, their inability to know what to do, their sense of loss as patients sicken, no matter what they do. And when students or doctors read to one another what they have written in the Parallel Chart, they take heart that they are not alone in their sadness and their dread, their sense of isolation among sick and dying persons diminishes, and they feel accompanied by their colleagues on their journeys." ~ Narrative Medicine [Dr. Rita Charon, LitSite Alaska]
Charon finds an urgency on the part of clinicians "to tell of these meaningful and grave clinical situations that build up inside us, plucking at the sleeves of our attention, queued up to be brooded about."
On "bearing witness": "Bearing witness means letting another's suffering register on you. You recognize the suffering not, right now, for instrumental reasons of fixing it or doing something yourself in response to it. This will come, perhaps, but the fixer or the doer thereby becomes the agent while the sufferer becomes the passive recipient of the fixing or the doing. In bearing witness, we invite the sufferer to be the active agent while we, simply, behold that active one. Our witness does not diminish or replace the active one. Our witness, instead, recognizes the magnitude of what the patient does and lives through. Our witness takes account of the gravity of that other person's lived experience. I don't mean to sound mystical, but it is indeed a matter of some awe in the presence of profound human experience. This is important for the health care professional because the posture conveys to the patient that the doctor or nurse grasps the gravity of the patient's situation and respects the magnitude of his or her plight."
"The relentless specialization and 'technologization' of medicine undermine the therapeutic importance of recognizing patients in the context of their lives and of bearing witness to their suffering." ~ Rita Charon, Narrative Medicine: Form, Function, and Ethics [Annals of Internal Medicine, vol. 134 (1), pp. 83-87, at 86, 2001)]
"How can we respect our patients' stories, while getting on with the technical business of identifying and treating their diseases? At a more basic level, how can we open ourselves to their pain and suffering without being weighed down by their problems, or allowing our hearts to be swayed from sound medical judgment? Indeed, this dichotomy between connection and detachment, listening and categorizing, compassion and objectivity has a long history in medicine." ~ Jack Coulehan, The Patient's Story: The Doctor Machine [LitSite Alaska]
What
To Do With Stories: The Sciences of Narrative Medicine
[Rita Charon, Canadian Family Physician, vol.
53, 2007]
On the "science" of narrative medicine (that is, the academic, theoretical basis): "What emerged as our science derived chiefly from narrative theory, autobiographical theory, phenomenology, psychoanalytic theory, trauma studies, and aesthetics." [Another physician provided this terse formulation: "Medicine is a narrative art based on science." Dr. Elisabeth Gold, From Narrative Wreckage to Islands of Clarity: Stories of Recovery from Psychosis, Canadian Family Physician, vol. 53, 2007]
Charon identifies "three movements" in narrative medicine: attention, representation, and affiliation.
On attention: "The clinician caring for a sick person must begin by entering the sick person's presence and absorbing what can be learned about that person's situation. A combination of mindfulness, contribution of the self, acute observation, and attuned concentration enables the doctor to register what the patient emits in words, silence, and physical state. Contemplative practices, aesthetic appreciation, and Freud's evenly hovering attention all have something to teach narrative medicine about the attainment and use of attention."
"The teller of an illness needs a listener. How can one develop the state of attention required to fulfill the duties incurred by virtue of having heard accounts of illness? [Attention] seems the most pivotal skill with which to endow a health professional who wants to be a healer. How does one empty the self or at least suspend the self so as to become a receptive vessel for the language and experience of another? This imaginative, active, receptive, aesthetic experience of donating the self toward the meaning-making of the other is a dramatic, daring, transformative move." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261, 263 (2005)
"I find that I have changed my routines on meeting with new patients. I simply say, 'I'm going to be your doctor. I need to know a lot about your body and your health and your life. Please tell me what you think I should know about your situation.' And patients do exactly that—in extensive monologues, during which I sit on my hands so as not to write or reflexively call up their medical records on the computer. I sit and pay attention to what they say and how they say it: the forms, the metaphors, the gaps and silences. Where will be the beginning? How will symptoms intercalate with life events? I listen, not with Freudian or Lacanian or gestalt frameworks of meaning-making, but with narratological ones. The first time I did this, the patient started to cry after a few minutes. 'Why are you weeping?' I asked him. He answered, 'No one ever let me do this before.'" Id. at 264.
On representation: "[W]e have come to realize that narrative writing in clinical settings makes audible and visible that which otherwise would pass without notice." Charon goes on to note that "[e]ven unpractised writers find themselves surprised by the discovery process of writing, and often the most striking discoveries are made not in what is written but in how the text is configured. Our students learn to examine their texts' genres, figurative language, temporal structures, the stance of the narrator, and allusions to other texts—the narrative features that a literary scholar would consider in the study of any written text."
"Sometimes the acts of representation are accomplished privately by the clinician, producing texts not for the patient to read but in order for the clinical-writer to discover thoughts, feelings, perceptions. In our narrative medicine practice, we are finding that the clinician must represent what he or she has witnessed. In many different settings . . . we give clinicians permission to write in ordinary language about what they observe and undergo in the care of patients. Without extensive training or practice, clinicians are able to produce complex and moving descriptions of their patients and their work with them." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261, 265 (2005)
"When health professionals write, in whatever genre and diction they choose, about clinical experiences, they as a matter of course discover aspects of the experience that, until the writing, were not evident to them. It is a commonplace by now for us to hear writers say, 'Yes, now that I have written that description, I understand what I thought or felt about this patient." We see that the representational act is a critical positional step. By giving the formless experience a form, the creator can perceive and display all dimensions or facets of the situation. By form, I mean all the aspects of a narrative text that a writer puts in it, whether or not he or she is aware of that putting—diction, genre, figural language, narrative situation, focalization, allusion, temporal scaffolding. Once the experience has had a form conferred on it—once it becomes a poem or an obituary or a letter to someone else told with a certain chronology, metaphors, and voice from a chosen perspective and narrative distance—the writer can, in effect, walk around the representation, seeing aspects around its back or over to its side that were, until bestowing form, unavailable to the subject." Id. at 266.
"Better than just talking about these things . . . the actual writing endows the reflections with form so that others can join the writer in beholding it. . . . We realize that they [physicians] are getting better and better as writers, able with greater and greater power to capture what they undergo in language. In turn, their language is able to convey their experiences to others. If they can capture it with greater force and accuracy, it means that they are perceiving it better as it occurs." Id. at 267.
On writing: "Sickness and healing are, in part, narrative acts. Patients write about their illnesses with increasing frequency, which suggests that finding the words to contain the chaos of illness enables the sufferer to endure it better. We physicians, too, write more and more frequently about ourselves and our practices. In many forms of narrative writing, doctors are endorsing the hypothesis that writing about oneself and one's patients confers on medical practice a kind of understanding that is otherwise unobtainable." ~ Narrative Medicine: Form, Function, and Ethics [Rita Charon, Annals of Internal Medicine, vol. 134 (1), pp. 83-87, at 83 2001)]["There are at least five distinct genres of narrative writing in medicine: medical fiction, the lay exposition, medical autobiography, stories from practice, and writing exercises of medical training."] [Id.]
On affiliation: Affiliation is "the authentic and muscular connections between doctor and patient, between nurse and social worker, among children of a dying parent, among citizens trying to choose a just and equitable health care policy. The affiliation extends inward, too, to join doctors or nurses with themselves in a sustained habit of clinical reflection or to allow the suddenly ill patient to recognize the same self who existed before illness came. Instead of lamenting the decline of empathy among medical students or the lack of altruism among physicians, narrative medicine focuses on our capacity to join one another as we suffer illness, bear the burdens of our clinical powerlessness, or simply, together, bravely contemplate our mortal limits on earth."
Attention and representation "can enable us to know in earthy, rich detail that we are affiliated as humans, all of us humble in the face of time, ready to suffer our portion, and brave enough to help one another on our shared journeys." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261, 269 (2005)
"What is it that doctors and patients go through together? These relationships are indeed technical relationships, but they also carry the gravity of meaning. Both doctors and patients travel through time toward some realization of self, of goals, of the principles by whose light a life is led. Examining the lives that doctors and patients lead together—and recognizing the meaning accrued in both those lives by their mutual experience—offers knowledge and insight that make of clinical relationships a communion of sorts. Although some doctors and patients may be alarmed by the breach in the container of objectivity and detachment implied by such examination, all must admit that—with or without inspection—these doctor-patient relationships cannot but be intersubjective, mutually resonant, inflected with what it means to be human." ~ Rita Charon, Medicine, the Novel, and the Passage of Time, 132 (1) Ann. Internal Med. 63, 67 (2000)
Thorough
Patient History Essential to Treat Pain
[Allison Gandey, Medscape Medical
News][David Morris, PhD, retired from the University of Virginia Health
System in Charlottesville]["Dr. Morris says narrative competence
is the difference between asking, Where does it hurt and What is the matter?
The first question can be answered with the point of a finger and may
shut down communication, while the second encourages conversation."]
"Dr. Morris said, 'I believe clinicians with strong narrative abilities can help reduce their patients' fear, lower perceived pain intensity, and improve overall quality of life.'"Dr. Morris further noted that "Narrative medicine might be most successful in allowing physicians to return to what drew them to medicine in the first place—a desire to help patients and to improve their quality of life."
The
Patient's Story: The Doctor Machine
[Dr. Jack Coulehan, LitSite Alaska]
"On the one hand, we teach students that narrative constitutes the heart of medical practice; and that respect and empathy are the basis for healing relationships. Yet when these young women and men reach the hospital, they encounter an extremely powerful anti-narrative culture that teaches them that stories—subjective and mutable as they are—may actually obscure the problem. Very quickly stories degenerate into 'hard' data, like lab values and computer scans. In a surprisingly short time, students learn to avoid speaking (to themselves, as well as their patients) about meaning, suffering, value, and belief. Rather, they devote their energy to body parts, machines, and biochemical processes.
"Faculties of medicine have been brought to task for churning out physicians with poor interpersonal skills. Despite attempts to include physicians' skills development in our curriculums, the focus of our training is on the science of medicine: anatomy, pathophysiology, pharmacology. At the University of Ottawa, we spend some time in first year learning how to take medical histories—chief complaint, history of the current illness, past medical history, family history, social history, medications, allergies—but the skill of listening with sensitivity to people's stories is not emphasized. We are evaluated on our ability to be methodical, not empathetic." ~ Medical Anthropology [Nili Kaplan-Myrth, Interpreting People as They Interpret Themselves: Narrative in Medical Anthropology and Family Medicine, Canadian Family Physician, vol. 53, 2007][Dr. Kaplan-Myrth is a medical anthropologist, and at the time of this writing, was a 3rd year medical student at the university of Ottawa, Ontario.]
"Sick people need physicians who can understand their diseases, treat their medical problems, and accompany them through their illness. Despite medicine's recent dazzling technological progress in diagnosing and treating illness, physicians sometimes lack the capacities to recognize the plights of their patients, to extend empathy toward those who suffer, and to join honestly and courageously with patients in their illnesses. A scientifically competent medicine alone cannot help a patient grapple with the loss of health or find meaning in suffering. Along with scientific ability, physicians need the ability to listen to the narratives of the patient, grasp and honor their meanings, and be moved to act on the patient's behalf." ~ Rita Charon, Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, 286 (15) JAMA 1897 (2006)
An
Extraordinary Moment: The Healing Power of Stories
[Dr. Shayna Watson, Canadian
Family Physician, vol. 53, 2007]
"In the name of efficiency, it is easy to block out patients' stories and deal only with the 'facts,' to see the chat, the time, and the stories as luxuries for when there is a cancellation. The study of narrative tells us, however, that in these easily neglected moments, we might find more than we expect; there can be understanding, relationship building, and healing—the elements of our common humanity."
On the beginning of a physician-patient relationship: "Our professional relationship to story begins early. One of the first clinical experiences we can have is to 'take a history.' We don't say that we 'listen to a patient's history.' We take the history and we make it our own, trying to turn it into symptoms and findings. We are not hearing the patient's story; we are eliciting answers, pieces of stories, to fit them into our evolving diagnosis or story template, or into one of a few possible story templates that are the differential diagnosis. We are interpreting what people tell us as we apply our medical framework to their stories."
Connecting narrative medicine to Jerome Bruner's constructivist approach to narrative: "I am drawn to a constructivist approach—one that sees narrative as one of the ways we seek and create meaning. If I view a story with detached clinical gaze, I remain external to it; I see the story as an object and relegate the patient to 'other.' If, however, I am able to enter into that patient's world even slightly, to be open to somehow leaving mine, then perhaps I can do what has been described as 'think[ing] with stories.'"
"We must help learners to value their own humanistic development as a way of placing value on the patient-centred approach."
Physician heal thyself: We "have moved so far away from our own sense of self and our own stories that we need to first heal ourselves."
"It takes a whole doctor to treat a whole patient . . . . In the case of a narrative-based practice of empathetic witnessing, it also takes a whole (embodied) doctor to hear the whole patient. Such ‘wholeness' must involve a self-aware practice that incorporates both professional and personal realities." ~ Sayantani DasGupta & Rita Charon, Personal Illness Narratives: Using Reflective Writing to Teach Empathy [Acad Med 2004;79(4):351-356][synopsis]
"Narrative medicine suggests something revolutionary—that we need to stay in touch with our emotions and develop what Jack Coulehan calls 'emotional resilience,' which he defines as 'being able to function in a steady or objective fashion, while also experiencing the emotional core of physician-patient interactions.' That is, we can only fulfill the promise of patient-centred care if we let down our defences." ~ Stories for Life: Introduction to Narrative Medicine [Dr. Miriam Divinsky, Canadian Family Physician, vol. 53, 2007]
"Physicians and nurses, in most places, most of the time, see themselves as under siege: set upon by more social ills than they have personal or institutional resources to address. So—and a complex story lies behind that little 'so'—they practice their work within barriers, more or less strictly limiting their sense of who they can be in relation to their patients." ~ Stories and Healing: Observations on the Progress of My Thoughts [Arthur W. Frank, LitSite Alaska]
"It is our duty to bring our full selves into our practice—not just our cognitive apparatus but all our resonant imaginative, meaning-making capacities so that patients' journeys toward health and meaning can be illuminated." ~ Rita Charon, Narrative Medicine: Attention, Representation, Affiliation, 13 (3) Narrative 261, 269 (2005)
Stories
for Life: Introduction to Narrative Medicine
[Dr. Miriam Divinsky, Canadian
Family Physician, vol. 53, 2007]
"Stories offer insight, understanding, and new perspectives. They educate us and they feed our imaginations. They help us see other ways of doing things that might free us from self-reproach or shame. Hearing and telling stories is comforting and bonds people together."
"In scientific terms—if we make sense of the world by recognizing patterns and thinking in categories—being able to narrate a coherent story is a healing experience."
Stories
and Healing: Observations on the Progress of My Thoughts
[Arthur W. Frank, LitSite Alaska]
"[D]eep illness disrupts life in all its facets—in sense of self, in personal relationships, and in how a person feels related to the cosmos, whether that means God, fate, or the quantum universe. Healing requires finding a new balance, a new sense of who you are in relation to the forces and people around you. Healing requires telling a new story about your life."
"[W]e draw on modes of narration—constructing plots, setting scenes, establishing points of view, building suspense—that we have learned from other stories. Maybe most importantly, we draw on sources of value that we have learned from other stories, and we call on those who hear our stories to accept those sources of value. Stories are much more than telling the news to those who weren't there to see it happen. Stories relate teller and listeners in evaluations of what happened. As we tell each other stories, we share our affirmations as well as our indignations."
Epiphanies:
Writing for Compassion
[Deirdre Maultsaid, 8 (3) Spirituality
& Health International 157 (2007)]
From the abstract: "Interest grows in the concepts and applications of narrative medicine. Medical practitioners and healthcare educators can use stories to describe experiences. When practitioners and educators use the principles of creative writing—plot, imagery, character, sensations—they are listening differently and expressing their understanding in narrative form. When practitioners and educators describe experiences in these ways, they are more likely to see the ethical dilemmas, and feel compassion for others. When patients write of their experiences in narrative ways . . . they may feel that their lives have meaning. Narrative helps make communication transformative between the practitioner and patient. Narrative can inspire us to better medicine."
Stories as
Medicine
[Sunwolf, Storytell, Self, Society, vol.1, 2005,
pp.1-10]
"The beneficial effects for those who are ill of telling their story has long been recognized in many cultures and has received attention from philosophers, social scientists, and medical practitioners alike." [2]
When
Medicine Meets Literature
[Marguerite Holloway, Scientific
American Magazine, April 25, 2005]
[subtitled: "Writing and humanities studies produce better physicians,
Rita Charon
argues, because doctors learn to coax hidden information form patients'
complaints"]
Dr. Charon and others seek "to improve the relationship between physicians and patients using literature and writing. The goal is to make doctors more empathetic by getting them to articulate and deal with what they feel and to develop sophisticated listening skills, ears for the revelations hidden in imagery and subtext. The field—alternatively called narrative medicine, literature and medicine, or medical humanities, depending on the approach—began by most accounts about 30 years ago and is now widely reflected in medical school curricula around the country. According to the American Association of Medical Colleges, 88 of 125 surveyed U.S. medical schools offered humanities courses in 2004; at least 28 required literature or narrative study in some form."
On the medical humanities:
Medical Humanities
["A conversation about the intersection between medicine and the arts."]Medical Humanities Academic Program--Drew University
["Medical Humanities . . . deals with the intersection of human experience, medical practice, and scientific technology. The field transcends the disciplinary boundaries of academe and engages all aspects of human culture-science, history, ethics, philosophy, literature, religion, art-in a discursive dialogue centered on what medicine means in relation to the individual and society."]Institute for the Medical Humanities--University of Texas Medical Branch
["The Institute for the Medical Humanities is committed to moral inquiry, research, teaching, and professional service in medicine and health care. In today's often bewildering world of scientific, technological, cultural, and political changes, medicine faces human problems and possibilities that transcend traditional academic disciplines. Members of the Institute engage in research on ethical and legal problems in clinical practice and biomedical research; and on philosophical, historical, visual, literary, and religious dimensions of medicine and health care."]Department of Medical Humanities--Brody School of Medicine--East Carolina University
["The department teaches required courses in all four years of medical school, including courses on the ethical and social aspects of medicine in the first and second years, case-based ethics seminars with third-year students during their various clinical clerkship rotations, and "selective" in ethics, law, philosophy, history, literature, and social policy for fourth-year students."]Department of Medical Humanities--Southern Illinois University School of Medicine
[Offering two courses on "The Role of Narrative in Medicine"--Integrating Personal and Professional Identity and Knowing The Patient as Person. The Courses " explore the role of narrative in medicine and healing. Integrating Personal and Professional Identity helps students to identify and to integrate their distinctive values and personal gifts into their profession of medicine. The [course] provides students with the opportunity to explore the core values and motivations that led them to choose medicine as a profession and enables them to envision a style of practice that will both nurture and be nurtured by these aspects of the student. To this end, students read and reflect on the autobiographical narrative that they submitted with their admission materials and write a mission statement that will shape their future practice of medicine."]["Knowing The Patient as Person invites students to explore the personal meaning that illness has for patients. Students learn to identify the component parts of illness narratives and to understand how they function to bring narrative sense to the life-changes that illness may bring. Students write an illness narrative about some health event in their own life and use course concepts to interpret their narrative as well as the narratives of other patients."]
Division of Medical Humanities--University of Arkansas Medical Services, College of Medicine
["The UAMS Division of Medical Humanities was formed in 1982 as part of a nationwide trend toward addressing the ethical issues raised in healthcare delivery and research. The division has achieved a national reputation for its integration of science and human values within the medical education curriculum. In its seminars students move beyond scientific analysis to consider the broader context of healthcare delivery. They consider social and human values as presented in literature, art, anthropology, history, and the social sciences."][For another medical humanities program founded to address the ethical issues in medicine, see: Medical Humanities & Bioethics Program, Feinberg School of Medicine, Northwestern][See also: Center for Ethics and Humanities in the Life Sciences--Michigan State University]Medical Humanities--University of California-San Francisco
["The Medical Humanities provide an interdisciplinary and interprofessional approach to investigating and understanding the profound effects of illness and disease on patients, health professionals, and the social worlds in which they live and work. In contrast to the medical sciences, the medical humanities–which include narrative medicine, history of medicine, culture studies, science and technology studies, medical anthropology, ethics, economics, philosophy and the arts (literature, film, visual art)–focus more on meaning making than measurement."]Medical Humanities and Narrative Medicine--University of Florida
["Why medical humanities? Essentially, medical humanities help us understand that medical practice is a human- and a humane endeavor. The humanities help us recognize past mistakes- and their mirrors in the present, to see biases and celebrate triumphs, and they provide a window into human nature. Through this understanding, the humanities help to develop better relationships with patients. In short, effective practice requires grounding in the medical humanities."]Center for Medical Humanities, Compassionate Care, and Bioethics--Stony Brook University
["It is through the humanities that health professionals are sensitized to the patient as a person with a distinctive worldview and who is coping with illness against the background of a healthcare system that can often be de-humanizing. It is through the writing of novels, short stories and poems that professionals and those coping with illness are able to express their insights and experiences."]Division of the Medical Humanities--Rochester University
[The Division focuses on "critically medical issues and practices using the methodologies and materials from humanities and social science disciplines, including philosophy, history, literature, drama, religious studies, cultural studies, visual arts, law and anthropology."]Medical Humanities--Baylor University
[An undergraduate program: "Medical Humanities is an interdisciplinary program, involving courses from literature, religion, philosophy, history, economics, and ethics and emphasizing the history of Christian spirituality, models of medical knowledge and practice, patient/physician relationships, hospital-based ministry, and the nature of health care in the 21st century."]Program in Medical Humanities--College of Medicine, University of Arizona
["[T]he exploration of the human experience, in illness and health, through all available venues and mediums"]Dr. Mahala Yates Stripling--Medical Humanities
["Dr. Stripling is an independent scholar who draws from a rhetoric, literature, and law background to lecture and to write about the intersection of the humanities and medicine."]Literature, Arts, and Medicine Database
[New York University]
Medical
Anthropology
[Nili Kaplan-Myrth, Interpreting
People as They Interpret Themselves: Narrative in Medical Anthropology
and Family Medicine, Canadian Family Physician, vol. 53, 2007]
"As anthropologists, our modus operandi is collecting narratives. We undertake field work, during which we often spend a year or more living in foreign communities, immersing ourselves in people's daily lives. We ask men, women, and children about their families; their religion; their understanding of the cosmos; their politics; their roles and status within their societies; and their perspectives on the body, the self, sexuality, sex roles, aging, child rearing, work, diet, violence, the economy, and international affairs. We then publish our ethnographic accounts using narrative as an analytic tool to support our arguments and as a literary tool to enhance our writing."
"Medical anthropologists argue that illness narratives are not merely accounts of symptoms but a mechanism through which people become aware of and make sense out of their experiences. A transformation takes place from something lived (full of complexity but not given a single, crystallized meaning) into something interpreted (given structure and meaning through the dialogue that takes place between the patient and physician)."
Susan Baur, Confiding: A Psychotherapist and Her Patients Search for Stories to Live By (New York: HarperCollins, 1994)
John Berger & Jean Mohr, A Fortunate Man (New York: Pantheon Books, 1967)
Suzanne E. Berger, Horizontal Woman: The Story of a Body in Exile (Boston: Houghton Miflin, 1996)
Lucy Bregman & Sara Thiermann, First Person Mortal: Personal Narratives of Illness, Dying and Grief (New York: Paragon House, 1995)
Howard Brody, Stories of Sicknesss (New Haven, Connecticut: Yale University Press, 1987)
Anatole Broyard, Intoxicated by My Illness: And Other Writings on Life and Death (New York: Clarkson Potter, 1992)
Rita Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford University Press, 2006)
Deepak Chopra, Return of the Rishi: A Doctor's Story of Spiritual Transformation and Ayurvedic Healing (Boston: Houghton Mifflin, 1988)
F. Gonzalez-Crussi, There is a World Elsewhere: Autobiographical Pages (New York: Penguin Putnam/Riverhead Books, 1998)
Julia Epstein, Alterned Conditions: Dieseas, Medicine, and Storytelling (New York: Routledge, 1995)
Marc Flitter, Judith's Pavilion: The Haunting Memories of a Neurosurgeon (South Royalton, Vermont: Steerforth Press, 1997)
Arthur W. Frank, The Wounded Storyteller: Body, Illness, and Ethics (Chicago: University of Chicago Press, 1995)
Sandra M. Gilbert, Wrongful Death: A Medical Tragedy (New York: W.W. Norton, 1995)
Lee Gutkind (ed.), A View from the Divide: Creative Nonfiction on Health and Science (Pittsburgh, Pennsylvania: University of Pittsburgh Press, 1998)
Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography (West Lafayette, Indiana: Purdue University Press, 2nd ed., 1999)
David Hilfiker, Healing the Wounds: A Physician Looks at His Work (New York: Pantheon Books, 1985)
Kathryn Montgomery Hunter, Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton, New Jersey: Princeton University Press, 1991)
Arthur Kleinman, The Illness Narratives: Suffering, Healing & the Human Condition (New York: Basic Books, 1988)
Elizabeth Morgan, The Making of a Woman Surgeon (New York: G.P. Putnam's Sons, 1980)
Robert Pensack & Dwight Williams, Raising Lazarus (New York: G.P. Putnam's Sons, 1004)
Oliver Sacks, An Anthropologist on Mars (New York: Random House/Vintage Books, 1996)(1995)
__________, A Leg to Stand On (New York: Summit Books, 1984)
__________, The Man Who Mistook His Wife for a Hat and Other Clinical Tales (New York: Summit Books, 1985)
William Styron, Darkness Visible: A Memoir of Madness (New York: Modern Library, 2007)
Abraham Verghese, My Own Country: A Doctor's Story (New York: Vintage, 2005)
_______________, The Tennis Partner: A Doctor's Story of Friendship and Loss (New York: HarperCollins, 1998)
William Carlos Williams, The Doctor Stories (New York: New Directions, 1984)(compiled by Robert Coles)
Richard Zaner, Conversations on the Edge: Narratives of Ethics and Illness (Washington, D.C.: Georgetown University Press, 2004)
Bibliography of Writings: Faculty of the Columbia Narrative Medicine Program
