45: Narrative Medicine

A group of physicians, writers, and educators sits around a conference table in a busy medical school, eating hurried lunches, coordinating course materials for medical students, reviewing with excitement or concern what just happened in their first-year medical interviewing courses. More people gather, and the room quiets. Today, the novelist on the faculty reminds them, they are reading “Aquarium,” a personal essay written by writer Aleksandar Hemon who has lost his baby daughter to brain cancer. The mood in the room shifts from light camaraderie to an attentive sense of purpose. “I had such a hard time reading this,” a seasoned family physician sighs. “It made me want to run home and pick up my baby,” offers the hospitalist.

As the conversation develops, the novelist draws the group’s attention to the essay’s title and its governing image, an important metaphor for his experience with illness and loss. “The whole thing is about an aquarium,” an internist and literary scholar offers. “You feel very much like an outsider reading this,” admits a pediatrician.

After some discussion, the novelist offers a writing prompt: Describe an aquarium that you yourself have been in. The group members take out pen and paper and, heads bowed, write intently for 4 minutes. When the time is up, many offer to read their work. Some read aloud descriptions of experiences with literal aquariums, marveling at the foreignness of aquatic life. A psychiatrist and a general internist each read aloud what they wrote about-times when they felt isolated in family or work and unable to truly communicate with those around them. Some wrote about feeling that, as doctors, they are inside an aquarium; others wrote about the experience of being on the outside. “The whole patient experience is like being in a fishbowl,” reflects a pediatrician, “and in the story, the doctors are in a fishbowl too.” The internist and literary scholar replies, “But this story is like instructions about how not to be marooned. It gives a glimpse into that fishbowl, but also says and then you can write. It opens up a way to talk about and then use the imagination and the power of words.”

This session is a typical example of the kind of work this group does every week. They are medical educators, the faculty of Foundations of Clinical Medicine (Columbia’s “doctoring” course) who employ the techniques of narrative medicine to sharpen their clinical skills, deepen their teaching, and reflect on their work. Narrative medicine developed out of the integration of medicine and literary studies to fortify clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness. Its unifying tenet is that the giving and receiving of accounts of self are the central events in health care—whether the account is given by a patient, family member, student, clinician, or members of the lay public and whether it is received by a doctor in the office, a circle of peers in a teaching session, a multidisciplinary team meeting in a clinic, or a Congressional hearing about health reform. Although arising only in 2000 from earlier efforts in humanities and medicine and primary care medicine, narrative medicine has spread quickly first at its home at Columbia University and then throughout the United States and abroad. Synthesizing theories and methods from the humanities, the social sciences, and the behavioral sciences, narrative medicine models a bridge among disciplines and, more importantly, supports the interior integration of cognitive, behavioral, imaginative, aesthetic, and affective states to which the effective clinician aspires.

Narrative medicine unfolds in three broad and simultaneous movements—attention, representation, and affiliation. These movements conceptualize and then guide a clinical and teaching practice that can establish contact with self, patients, students, colleagues, and the public that medicine serves. We will first define these movements and then follow with real-life examples.

Attention is that state of receptivity whereby a listener or witness or reader can receive the account given by another. To attain the state of attention, the receiver focuses closely and deeply on the person giving an account, whether that person is a patient, a student, a novelist, a poet, or even a painter or a composer. The receiver does not efface himself or herself but rather offers the contours of the self as a container for what is given by the other. Combining mindfulness with curiosity, the receiver captures all that the other transmits, squandering no word or silence or gesture or mood from the evidence that emerges from the encounter.

Representation includes the means by which any attentive witness confers form on what is received. Typically this is done with language as one writes a story or a vignette or a progress note to capture that which has been received from the other. (Although visual representations can also be made, we restrict ourselves here to written representations.) What is represented can be read—by the writer, by the subject of the representation, or by others involved in the clinical process. Because, as psychotherapist Hans Loewald suggests, writing is a sensorimotor act that transforms the immaterial into the material, it allows the writer to communicate what was not known until the writing to self and then to others.

Affiliation is the ultimate goal of any clinical act—affiliation between patient and clinician, between clinician and colleagues, between clinician-teacher and student, and between health care professionals and the public we serve. Robust affiliation provides the grounds for any event of healing.

These movements intensify one another, attention fueling the capacity to represent, representation fortifying the capacity to attend, and both of them spiraling toward affiliation. Doctor and patient write their way through clinical events. Medical students write reflective essays about early clinical experience, and their teachers receive them with newly developed skills in close reading. Patients and clinicians share writing groups to write about their lived experiences with illness. Multidisciplinary teams meet on the wards or the clinics to develop their own capacity to collaborate and unite. These methods permit us to get under the distinctions that typically isolate us from one another and bring us, in common, onto the grounds of human suffering and the desire to lessen that suffering.

Querying all faculty of Columbia’s Foundations of Clinical Medicine course, we compiled a table of goals that have been accomplished in clinical practice through the use of narrative methods (see Table 45-1). Selections from our respondents’ accounts of accomplishing some of these goals in practice thicken the descriptions of our listed goals. We categorize these goals according to the three movements of narrative medicine, although it is easily seen how these movements converge and occur simultaneously.

Attention

Representation

Affiliation

These examples demonstrate some of the guiding goals and powers of narrative medicine. As a discipline based in textual practices, narrative medicine can train its students to do what close readers and writers do—enter alien narrative worlds, comprehend those worlds from others’ points of view, co-create with the inhabitant of these worlds the substrate for meaning, and be nourished by the process. Adopting the policy that every word counts, close readers learn to take account of the formal features of a text—its genre, diction, temporal structure, metaphors, narrative strategies—so as to receive the full “message” of what is written. Whether reading Aleksandar Hemon’s “The Aquarium” or a Stephen King thriller, the reader surrenders to the demands of the text, wondering why the story is told the way it is told or why it triggers particular moods or thoughts. Perhaps one reason that serious readers seek out opportunities to read with others or to read what others have written about a text is to learn how infinite are the potential interpretations of any stretch of text. Readers learn to honor the text as an entity unto itself as well as a powerful mirror for the self of the reader. When in the clinical setting, these readerly skills get transposed to powerful skills of attentive listening to patients’ words and silences and bodies. The reader/listener enters the patient’s world with openness and curiosity, able more effectively to imagine the whole, to raise consequential hypotheses about what goes on, to accept the strangeness of any alien world as plausible if not necessary and ultimately to make contact with the patient. The reader/listener seeks out groups of peers to work with, realizing how enriched is one person’s interpretation by congress with others.

As is demonstrated in our clinicians’ responses to our query, narrative medicine has developed many forms of writing in its practice. In all cases, the writer needs a reader. The faculty-participants in this project were trained in close reading as they wrote in concert with their peers. Always, what any of us wrote was read or listened to closely and skillfully by our peers. By developing the reading capacities of our faculty, we could assure that when students are asked to write about their experiences, they will obtain close and skilled reading of their texts. We furnish faculty members with “readers’ guides” instead of rating scales so that they can attend to what their students express, not to judge and rate the levels of reflection achieved but rather to read the text closely enough to be able to say what is seen.

Some reflective writing practices are practical means to concentrate attention on a particular clinical situation—write about a challenging patient; write about a patient you brood about; write about a patient you love. Other practices that engage clinicians and patients in writing seem farther afield from clinical practice, although these too circle back very directly to the writer’s capacity to offer or receive health care. Often, the writing is encouraged by first reading a literary text with a group—a poem, a paragraph of a novel, a short story, an intern’s progress note, a prayer. A narrative medicine group adopts close reading techniques in which one inspects the form, the tempo, the mood, and the movements of the text. You might feel like you were in English class for this part of the narrative medicine seminar. But unlike the English teacher, the narrative medicine teacher will offer a writing prompt that invites you to consider some aspect of your own experience. Creating the writing prompt is the hardest part of teaching narrative medicine, for it has to be an economical and compelling invitation to expand the mind of the learner toward both the “business” of the text and the interiority of the reader.

Here are a couple of examples.

The prompt used sometimes in teaching this poem is, “Write about the things themselves.” One of us recently taught this poem using this prompt to a group of palliative care fellows. No matter how many deaths these doctors had accompanied, they wrote about “the things themselves” in their own lives. One intensivist wrote four words: “Love, Family, Work, Joy.” Those of us hearing these words told him he had just written the words on his own family crest. It was as if he had found a direct line to those essentials within the edges of self, thereby bringing into immediate contact the dilemmas of his dying patients with his own search for meaning in his life.

A paragraph from a book on illness narratives offers the following story written by Eduardo Galeano that, Arthur Frank heard years ago and finds himself still brooding about and sharing with others:

The prompt we have used with this paragraph, taken from Art Frank’s explanation of what stories can do to their readers is, “Write about a story that is working on you.” This prompt can be met either with a clinical story still gripping the writer or, as likely, an event from childhood, a fairy tale, or a parable from a Gospel.

These examples of writing prompts suggest, we hope, the function of the writing of narrative medicine. The learner is not asked to write “about” the text but, rather, from within the mood and train of thought of the text and the conversation the group has experienced about it. Writing in the shadow of the text suggests that powerful states of contemplation and reflection can be entered—oftentimes very quickly—by paying serious attention to well-written texts. Close reading might be a form of meditation, in which the reader concentrates on the text in its entirety—not only its linguistic freight but its music, its echoes to other texts, its balance, its jar, its form. Captivated, the reader can then be taken to places, in his or her writing, that might have been hard to achieve without first reading. Another way to say this is that the reader is quickly made permeable to the text, first, and then that permeability is extended to self. Such states, we know, are achieved when beholding great works of art or hearing great musical compositions. These findings fuel the recent trend in bringing medical students to art museums or symphony halls, not to civilize them but to confront them with the otherness of great beauty, a confrontation that invariably brings them closer to their selves.

These examples from narrative medicine practice hint at the pleasure and freedom available in simple reading and writing exercises. When a writer reads aloud to a group what he or she has written in the shadow of a text, the group members expand their minds toward the text as well as toward the writer. Writing as discovery, as Loewald describes it, these learners gain access to what they know but might not realize they know. They then accept the risks of exposing this “newly known” to self and listener, thereby intensifying both self-awareness and contact with peers. Even when a narrative medicine group is composed of persons unlike one another—nurses, social workers, patients, doctors, administrators might be in the same group—the reading and writing actions release them from the distinctions that typically separate them. They are equals in the reading and writing if not in the hierarchical structures that contain them.

Armed with an understanding of the important clinical goals reachable through the use of narrative methods, we turn to ways in which we have used narrative medicine methods in our teaching practice. The educational goals parallel the clinical goals. Here, we display the educational experiences in a developmental sequence, starting with the premedical student and ending with the senior resident, suggesting which movements and specific goals have been reached in each example.

We see a developmental sequence unfolding for learners in our school and teaching hospital. Since narrative work has been adopted as one of our teaching and practice methods, the students are exposed to it longitudinally while their own skills deepen and complicate. From the premedical and first-year students’ early experiences of “seeing” what goes on either in office hours or in some lecture in the amphitheater, the students progress to more consequential telling of the self and claiming for oneself the formative force of autobiographical truths. They discover their peers to be valuable witnesses and confirmers of their own experiences. Their skills as readers of texts and spoken language come to represent valuable resources for their lives as doctors and as persons. More seasoned students write their ways through the inevitable assaults and sadnesses of ward medicine. By turning their developing writing powers to face actual conflicts or dilemmas with patients, they start to use these techniques to establish genuine contact with patients and then to solve clinical problems.

What Is Narrative Medicine For?

A short poem by Philip Larkin gives us courage to ask, “What is narrative medicine for?”

These examples, whether from clinical practice or in classroom or ward teaching, demonstrate the utility and gifts of narrative routines in health care. We hope you can trace the similarity of our work with patients and peers and our work with students. We fuel our own teaching of these skills with the benefits that these skills have given to us in practice. Our own clinical-narrative experience gives us a place from which to continue to develop these skills, to research their outcomes for other groups, and to convey them to learners who have entrusted us with their educations.

Narrative medicine methods donate methods of teaching, methods of doing, and methods of studying what might have been accomplished. As this young field develops, a robust outcomes research agenda is unfolding. Using various methodological approaches, researchers are measuring and articulating the consequences for clinicians, students, and patients of rigorous narrative work in clinical settings. Already, researchers in narrative medicine have documented improvements in team cohesion, deepening of cultural sensitivity, improvements in individual practitioners’ ability to adopt patients’ perspectives, improvements in medical interviewing and relationship-building skills, decreases in burnout, and decreases in compassion fatigue.

The field of narrative medicine is continuing its search for insight, for contact, for affiliation. In days of health care reform, of now drastic movement toward accountable care organizations and medical homes, where the care will be delivered and funded on the basis of not just cost effectiveness but continuity, the health of teams and the inner health of individual practitioners will be critical. We think that narrative training will equip both seasoned and emerging clinicians with the wherewithal to come to know the self, to be permeable to peers and patients, to make that healing contact with patients and peers now so dangerously lacking in the care we give to our sick. We close with Henry James’s description of what the reader does:

We acknowledge our faculty colleagues in the K07 seminar and the students in the Foundations of Clinical Medicine course at the College of Physicians and Surgeons of Columbia University. This work is supported by NIH NHLBI R25 HL108014, “Enacting the Behavioral and Social Sciences in the Clinical Setting: Institution-Wide Teaching of Effective Team-Based Patient Care.”

Program in Narrative Medicine web site with events, resources, seminars. http://www.narrativemedicine.org/. Accessed February 2014.

Master of Science in Narrative Medicine, Columbia University. http://ce.columbia.edu/Narrative-Medicine. Accessed February 2014.

Online bibliography on Literature, Medicine, and the Arts from NYU. litmed.med.nyu.edu/. Accessed February 2014.