lawyer as storyteller
Medicine: Learning to Listen
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
["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)]
"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."
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."
Medicine Creates Alliance With Patients
"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."
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."
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."
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."
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."
To Do With Stories: The Sciences of Narrative Medicine
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."
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."
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."
Patient History Essential to Treat Pain
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."
Patient's Story: The Doctor Machine
"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)
Extraordinary Moment: The Healing Power of Stories
"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."
for Life: Introduction to Narrative Medicine
"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."
and Healing: Observations on the Progress of My Thoughts
"[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."
Writing for Compassion
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."
Medicine Meets Literature
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:
Humanities Academic Program--Drew University
Institute for the Medical
Humanities--University of Texas Medical Branch
of Medical Humanities--Brody School of Medicine--East Carolina University
Medical Humanities--Southern Illinois University School 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."]
of Medical Humanities--University of Arkansas Medical Services, College
Humanities--University of California-San Francisco
Humanities and Narrative Medicine--University of Florida
for Medical Humanities, Compassionate Care, and Bioethics--Stony Brook
of the Medical Humanities--Rochester University
in Medical Humanities--College of Medicine, University of Arizona
Mahala Yates Stripling--Medical Humanities
and Medicine Database
"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)