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Storytelling In The News: #111

New England Journal of Medicine endorses narrative

April 6, 2004

One could argue that the New England Journal of Medicine (NEJM) is to medicine what the Harvard Business Review is to management: it is the arbiter of what is currently viewed as mainstream within the profession. And just as Harvard Business Review endorsed the importance of storytelling as a tool for management and leadership with its article in June 2003, so the New England Journal of Medicine endorsed the importance of storytelling in medicine in its issue of February 26, 2004.

Listening to the patient's story

The NEJM article by Rita Charon argues that health care professionals and patients are increasingly recognizing the importance of the stories they tell one another of illness. This is not only a diagnosis encoded in the narratives patients tell of symptoms, but also deep and therapeutically consequential understandings of the persons who bear symptoms are made possible in the course of hearing the narratives told of illness.

Such fields as medical interviewing, primary care, literature and medicine, and relation-centered or patient-centered care have revolved around these "tellings" — whether the patient's private account in the office, the intern presenting on visit rounds, or the physician dictating a death summary after decades of now-ended care.

In turn, doctors have learned about therapeutic listening from practitioners of oral history, trauma studies, autobiography, and psychoanalysis. Only in the telling is the suffering made evident. Without the telling, not only treatment but suffering, too, might be fragmented.

Listening to the doctor's story

There is an increasing focus on the doctor's own story. Like their patients, some doctors have learned that it helps to represent, in words, what they go through in practicing medicine. More and more doctors write about their practices not in scientific reports but in narrative records of meaningful human interactions.

In books and essays for medical and lay audiences or in private notes for themselves, doctors describe the emotional and personal aspects of their care of particular patients. Some authors report that such writing helps them to comprehend both their patients' ordeals and their own lives with the sick. By rendering whole that which they observe and undergo, doctor-writers can reveal transcendent truths, exposed in the course of illness, about ordinary human life.

Charon recommends that students and residents to keep what she called "Parallel Charts" on the patients in their care. She believes that there are critically important aspects of medical care that do not belong in a hospital chart, but that need 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 competence of doctors

Charon says that in the effort to help doctors understand what they and their patients experience in the presence of illness, medical educators have been paying increasing attention to narrative competence, defined as the set of skills required to recognize, absorb, interpret, and be moved by the stories one hears or reads. This competence requires a combination of textual skills (identifying a story's structure, adopting its multiple perspectives, recognizing metaphors and allusions), creative skills (imagining many interpretations, building curiosity, inventing multiple endings), and affective skills (tolerating uncertainty as a story unfolds, entering the story's mood). Together, these capacities endow a reader or listener with the wherewithal to get the news from stories and to begin to understand their meanings.

While narrative was once considered a civilizing veneer for the gentleman physician — reading literature, studying humanities, writing in literary ways about practice — narrative competence is now being recognized as central to medical training for empathy and reflection. Capacities that medicine now sometimes lacks — attunement to patients' individuality, sensitivity to emotional or cultural dimensions of care, ethical commitment to patients despite fragmentation and subspecialization, acknowledgment and then prevention of error — may be provided through a rigorous development of narrative skills.

Programs are emerging in "narrative medicine" or "narrative-based medicine" that develop specific skills. They encourage health care professionals and students to write about their patients in non-technical language, helping them to uncover and understand their implicit feelings toward and knowledge of their patients. These programs provide rigorous training in reading literary texts to supply health professionals with the equipment to interpret and make sense of the stories of others. Clinicians who receive such training often encourage patients to write — or, as with the young man in my office, to tell — in uninterrupted narrative flow about their illnesses, demonstrating the therapeutic benefit for patients of such narration.

Benefits of narrative competence for doctors

Charon argues that narrative competence enables a doctor to more quickly and accurately hear and interpret what a patient tries to say. (Although the article does not give specific evidence to support these claims, it does cite Charon's own personal experience and also research under way in federally funded research projects.) According to Charon, the doctor who has narrative competence uses the time of a clinical interaction efficiently, wringing all possible medical knowledge from what a patient conveys about the experience of illness and how he or she conveys it. Not only the story of an illness, but the illness itself unfolds as a narrative.

Charon also argues that narrative competence enhances the doctor-patient relationship. To enter a story is to make room for its teller, and the doctor with narrative skills habitually confirms the patient's worth in the process of attending seriously to what he or she tells. Such a doctor will demonstrate concern for a patient while concentrating on what the patient says and, as a result, can achieve the genuine inter-subjective contact required for an effective therapeutic alliance. Narrative competence includes an awareness of the ethical complexity of the relationship between teller and listener, a relationship marked by duty toward privileged knowledge and gratitude for being heard.

Charon also suggests with less certainty that narrative competence will lead to broader social goals: "perhaps strengthening the narrative competence of doctors might help them to achieve such elusive goals as humanism and professionalism by providing them with graduated skills in adopting patients' points of view, imagining what they endure, deducing what they need, and reflecting on what the physicians themselves undergo in caring for patients."

Who is Rita Charon?

Rita Charon, M.D., Ph.D. is a general internist and Associate Professor of Clinical Medicine at the College of Physicians and Surgeons of Columbia University where she directs the Programs in Narrative Medicine, Humanities and Medicine, and the Clinical Skills Assessment Program.

Charon graduated from Harvard Medical School in 1978, trained in internal medicine at the Residency Program in Social Medicine at Montefiore Hospital in New York, completed a year’s fellowship in general internal medicine at the College of Physicians and Surgeons of Columbia University in 1982, and has practiced general internal medicine since 1981 at Columbia.

She received the Ph.D. in English at the Department of English and Comparative Literature at Columbia University in 1999, having written her doctoral dissertation on the use of literary methods in understanding the texts and the work of medicine.

Charon (M.D., Ph.D.) is a pioneer and national authority in the field of literature and medicine, and has written and lectured extensively on literature’s salience to medical practice as well as on the doctor-patient relationship, narrative competence, medical ethics, and empathy in medical practice. Her research has focused on communication between doctors and patients, seeking ways to improve the ability of doctors to understand what their patients tell them. Columbia University is the only medical school with a program in narrative competence, in which medical students learn how to better "read" their patients' stories through literary studies.

How did Charon get into narrative medicine?

Charon has been practicing internal medicine for over twenty years. After a few years of practice after residency, she realized that what patients paid her 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.

These recognitions sent her to the English Department of Columbia, figuring that they could help her understand how stories are built and told and understood. She ended up getting a doctoral degree in English.

She felt that the narrative skills she was learning in her English studies made her a better doctor. She felt she could listen to what my patients tell her 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.

At the same time, she began coaching her medical students and colleagues in writing reflectively about their practices to more accurately understand what their patients go through and also what they themselves endure in the care of the sick, exploring the use of Parallel Charts, discussed above.

Gradually, she began to realize that medicine is deeply saturated with narrative practices, not only in creating therapeutic alliances with patients and instilling reflection in our practices but also generating hypotheses in our science, learning our fabulous tradition of explanations about the human body, teaching students and colleagues what we know about sickness, acting with so-called professionalism toward one another and our patients, and entering into serious discourse with the public about what kind of medicine our culture wants.

She 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.

Charon contends that narrative 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."

Charon says that more and more medical schools and medical centers are adopting narrative methods of study in reading, writing, reflecting, and bearing witness to one another’s ordeals. It is hoped that the research to understand the outcomes of these practices will keep pace with their growth. Ultimately, narrative medicine may offer promise as a means to bridge the current divides between doctors and patients, between doctors and doctors, between doctors and themselves, illuminating the common journeys upon which all are embarked.

Bottom line

The medical profession is inter alia one of the world's largest businesses. The "official" recognition of the role of narrative in medicine by NEJM is a further step towards the mainstreaming of storytelling in business.

Read the New England Journal of Medicine
(Volume 350:862-864; February 26, 2004 Number 9, Narrative and Medicine by Rita Charon)

Hunter K. Doctors' stories: the narrative structure of medical knowledge. Princeton, N.J.: Princeton University Press, 1991.

Verghese A. The physician as storyteller. Ann Intern Med 2001;135:1012-1017.[Full Text]

Halpern J. From detached concern to empathy: humanizing medical practice. New York: Oxford University Press, 2001.

Greenhalgh T, Hurwitz B. Narrative based medicine: dialogue and discourse in clinical practice. London: BMJ Books, 1998.

Pennebaker JW. Telling stories: the health benefits of narrative. Lit Med 2000;19:3-18.

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