The Triple Helix @ UChicago

Spring 2014

"Narrative Medicine: Story as Prescription" by Carrie Chui

 

The hospital is rife with stories of human fragility and compassion. For Dr. Rita Charon, MD, PhD, the way to discover them is an act of close listening and observing: a practice she calls narrative medicine. The concept of narrative medicine, conceived by Dr. Charon in 2000 at the Columbia University College of Physicians and Surgeons, seeks to understand the clinical potential of the humanities and medicine.[1] To Charon, narrative medicine, which describes the ability to sense a story, interpret it, and then consider it through a retelling, is a model of humane and effective medical practice that, in her opinion, is especially important today, in the modern age of bureaucratized medicine. 

Narrative medicine is by no means the only paradigm to recognize the confluence of humanities and medicine. Many medical school programs often cite medicine and the humanities together, believing in the ability of medical humanities to help doctors develop clinical acumen, compassion, and empathy, today.[2,3] To better understand the concept of narrative medicine, Charon describes it as a source of knowledge, which, by revealing itself only in the doctor-patient experience, works in a logic opposite to that of “logicoscientific knowledge,” a generalizable notice that can be discovered by being kept at a remove.[4] However, for Charon, these two types of knowledge need not be viewed in direct competition with each other. In fact, Charon, acknowledges the importance for both in a successful clinical practice, going as far as to say that the clinical merits of narrative medicine can only be readily manifest when both sets of knowledge are applied.[4] 

For Charon and other practitioners, practicing narrative medicine can mean that the clinical encounter with the patient begins not with a systematic set of questions about the patient’s health, but by inviting the patient to describe his or her condition to the doctor in a self-introductory manner.[1] In this act of temporarily suspending the doctor-patient dichotomy, Charon quickly finds that what is revealed in conversation and suggested through body language is not only information about the patient’s state of health, but also insight into who they love, what they love, their greatest passions and most gripping fears.[1] To have the ability to sense the story, recognize it, receive it, and then be moved by it to action by retelling it—be it verbally, through writing, art, or another medium, is to be fluent in the practice of narrative medicine. Described as a practice “fortified by the knowledge of what to do with stories,” narrative medicine is proposed as a way to consider patient stories thoughtfully and productively.[1] 

Beyond the rewards of a better emotional connection with the patient, Charon suggests that narrative medicine is, on many levels, transformative for doctor and patient.[4] The potential of narrative medicine can directly be beneficial to the physician, who can better understand his patient, and steer this newfound understanding towards the development of a thoughtful and more accurate treatment plan [4]. Physicians who exercise their narrative capacities can also become more reflectively engaged in their practice, cultivating “affirmation of human strength, familiarity, and suffering”.[4] Charon cites her own encounter with a patient, in a scenario in which both of these effects unfold. The patient, she recalls, was a survivor of cancer who, convinced that her cancer has come back despite seeing recurring negative results, was only able to find some comfort and peace in Charon’s writing about her, which she had shared upon their next clinical encounter.[4] 

Finally and perhaps most relevant to thinking about health policy, Charon argues that in as far as caregivers are able to sustain a narrative situation with their patients, so too might they be able to nourish a relationship of public trust with greater society as a whole, a situation she believes is crucial for filling in the gaps of a bureaucratized health system.[5] In an issue of JAMA, Dr. Michael H. Monroe, MD, a practicing physician of 14 years describes what, in his opinion, is sacrificed in the bureaucratization of medicine, for which narrative medicine might suggest a solution: 

“There needs to be sufficient space for that which will always remain uncounted because it cannot be counted; because it cannot be counted should not diminish it. The bureaucratization of medicine with increasingly complex rules, codes, algorithms, prompts, bylaws, schedules, and administrative structure is leaving its mark, but medicine at its fundamental is still about suffering, healing, and comforting; it is about individuals; it is about relationships and trust; it is about stories.”[5] 

The notion of “relationships and trust” that Monroe refers to is heavily implicated in Charon’s concept of public trust achieved in narrative medicine. To engage in narrative medicine is to yield towards the patient’s yearning for rescue and healing, subscribing to the accountability of the caregiver to these public expectations.[4] Narrative medicine facilitates honest conversations with the patient, and for Charon, these conversations might often consist of talk about “meaning, values, and courage that scientific or rational debates can’t often compass”.[4] Enacted through a retelling, physicians become a critical vessel for delivering authentic, valuable “uncounted” knowledge to policy makers, fulfilling their duty in greater society. [4,5] 

If it is true that the skills of narrative medicine is as accessible as the teachings of Charon’s program in narrative medicine seems to suggest, then for the benefit of the patient, physician, and greater society, narrative medicine may be an important means for achieving a greater sense of fidelity that the practice of medicine necessarily embodies.[1,4,6] By donating the expertise to better understand the situation of the patient beyond the clinic, the practice of narrative medicine reaffirms the role of a doctor, a commitment that avows to the betterment of the patient, to his peers, and to greater society.

References

[1] Charon, Rita. 2011. “Honoring the stories of illness: Dr. Rita Charon.” Talk presented and filmed at an independently organized TEDx event.  
[2] Lisa Pevtzow. “Teaching compassion: Humanities courses help aspiring doctors provide better care.” Chicago Tribune, March 2013. Accessed May 20. http://articles.chicagotribune.com/2013-03-20/health/ct-x-medical-school-arts-20130320_1_doctors-students-humanities. 
[3] Brown University. 2013. “Creative Medicine Series: A four-part lecture series examining and celebrating the link between medicine and the arts.” Accessed May 20. http://www.brown.edu/Departments/Humanities_Center/events/creativephysician.html. 
[4] Charon, Rita. 2001. “Narrative Medicine: A Model for empathy, reflection, profession, and trust.” The Journal of the American Medical Association 286: 1897-1902. 
[5] Monroe, Michael. 2011. “A piece of my mind. Drawer on the Right.” The Journal of the American Medical Association 305: 1176-1177. 
[6] Narrative Medicine. 2014. “The leader in narrative best practices and team-based healthcare programs.” Accessed May 20. http://www.narrativemedicine.org/mission.html

 
UChicago Triple Helix