In the narrative medicine course I teach at the University of Washington I have been using Rita Charon’s narrative medicine close reading drill (as described in her chapter “Close Reading” from her book Narrative Medicine: Honoring the Stories of Illness, Oxford University Press, 2006). I was taught this narrative medicine close reading drill in the workshops I have taken with Dr. Charon at Columbia University.
As she writes in the opening of her chapter on close reading, “Narrative medicine makes the case that narrative training in reading and writing contributes to clinical effectiveness. By developing narrative competence, we have argued, health care professionals can become more attentive to patients, more attuned to patients’ experiences, more reflective in their own practice, and more accurate in interpreting the stories patients tell of illness” (pg 107).
I was first introduced to narrative medicine in the fall of 2010 when I took the Narrative Medicine ‘101’ workshop at Columbia University. I wrote two reflective (and in retrospect, rather cheeky yet truthful) blog posts about my experience: “The Cult of Narrative Medicine” and “Postpartum Narrative Medicine.” I stumbled into narrative medicine through my mid-life existential crisis of questioning the meaning of all my striving in terms of clinical practice and teaching nursing–and by practicing the mid-life crisis ‘cure’ by doing the Jungian thing of returning to my adolescent passion of reading (and writing). Then, using the crystal ball of Google searches, I discovered Rita Charon and narrative medicine.
That is the backstory. What I want to highlight in this blog post is my continual nagging–no niggling–suspicion that something is just not right with Rita Charon’s narrative medicine close reading drill. It has taken me years to be able to articulate what bothers me about her drill. I find that it is too cold, cerebral, intellectual; to practice it somehow further objectifies the ‘patient’ and holds them at arm’s length in order to dissect and measure. I have come to that conclusion by applying it to my own clinical practice as well as to my teaching of health professional students.
While trying to practice a ‘close reading’ of an actual patient and his or her story, I kept returning to the lesson of the Test Your Awareness video: “It’s easy to miss something you’re not looking for.” I became so wrapped up in noticing the minute details of what the patient was saying, that I missed the gestalt of the person telling the story. I also missed the fact that I was in a (professional) relationship with this person, that I was an active participant in the clinical encounter, and that I was being affected emotionally by this encounter: their story was ‘reading me.’ And in using this narrative medicine close reading drill with health professions students, I have found that they get all hung up with their anxieties over ‘doing this drill thing correctly’ as though I’m testing them on pathophysiology. (This applies to medical students who one would think have had a more liberal arts education, as well as to more ‘technical college’ nurses who have not likely had university-level courses). None of this can be viewed as ‘humanizing’ the practice of medicine.
What I find most compelling in narrative medicine or medical humanities more broadly, is the application of reflective (and reflexive, self-reflective, but not the ‘bathetic trip to nowhere of importance,’ sentimental, navel gazing variety) practice for health care professionals. My colleague, family medicine physician, teacher, and writer Sharon Dobie has written about this in terms of the importance of self-awareness and mindful practice in relationship-centered health care (“Reflection on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education” Academic Medicine vol 82, issue 4, 2007, pp422-427).
I’m still in the process of refining my approach to ‘teaching narrative medicine,’ but here is my alternative to Rita Charon’s narrative close reading drill. My closer (to home) close reading drill:
- Emotion: What do you feel while reading this (or while listening to this patient illness narrative)? What is the overall mood or emotional effect of the piece? And why do you think it evokes this particular response for you?
- Surprise: What stands out to you the most? What is unexpected? This is like Roland Barthes’ term ‘punctum’ in Camera Lucida, or as Arthur Frank puts it “what distracts you but is not the focus of the narrative.” (from a narrative analysis workshop I took with him at a qualitative research conference in Banff, Canada years ago).
- Silence. What is unsaid in this? Whose voices or perspectives are included and whose are left out?
- Metaphor (and it’s close cousin simile). The use of imagery and the poetics of the piece.
That’s it. The most important components of a narrative medicine ‘close reading.’ The next time I teach a narrative medicine course, I plan to use these as a close reading guide.
Thanks for this framing. The reading I have done about close reading has puzzled me for the reasons you mention. Of course I am a die hard gestalt person. Those four questions you name seem key to me and really do ask the listener both to be engaged within the encounter and to listen reflectively to form thoughts about what they hear and what more they might like to ask.
We never really objective, it seems to me. Better we know what we are bringing to the conversation and not pretend we are a tabla raza. I really like the relationship centered care paradigm with four components (more keeping it simple for me): 1. We are in this professional relationship as persons not as a role; 2. Affect is present (of course); 3. There is an ethical/moral framework within which the relationship exists; and 4. There is reciprocity. (Beach and Inui; http://www.ncbi.nlm.nih.gov/pubmed/16405707). That paradigm helps me manage myself in a present way and to be authentic in my work with patients….not always of course. The questions you pose help to draw us in.
And I am guessing, put together with the purpose you pose about narrative advocacy, some powerful work can emerge.
I have come to understand that writing stories about our patients & reflective writing are both part of narrative medicine. However they are quite different in what they require of us as clinicians. Reflective writing stimulated by a poem or reflective observing (one could look at a painting) allows the writer to apply “close reading” and then plumb the depths of her/his unconsciousness and “let out” what surfaces. Such an exercise by its nature translate to being more attentive in the exam room, even if the poems or paintings have nothing to do with medicine. It is good training for observing both the details and the whole.
Writing about our patients is in a basic way less about them and more about our response to them. Therefore it is only necessary to write about what transpired through the lens of how we experienced it. I don’t think it over objectifies our patients, because we should only be good clinicians as we listen, exam and talk to them. The story may develop in our minds later, but shouldn’t detract from the care of the patient.
Does anyone else see this differentiation?
J-thanks for your thought provoking post & S- thanks for your perspective on it, too!
Hi Ouri,
Thanks for the comment and perspective. What I’ve been wrestling with in terms of applying the NM close reading drill to patient care is that I end up paying more attention to all the little nuances of what they are saying that I feel I am no longer really ‘hearing’ them. It felt like just one more medical checklist to attend to and that’s not what draws me to health care practice.
I have been thinking about this for a few days to sort out my own feelings and understanding of narrative medicine in order to draw what I think is an important distinction. Having studied with Dr. Charon and her colleagues and experienced what you call “the NM close reading drill” many times I would offer the following:
The workshop (“drill”) is intended to help practicing and in-training clinicians reconnect with their own humanity in order to help them be more empathetic care givers with better listening skills. It is not intended as another tool or check list to employ when one-on-one with patients. You are spot on with your bullet items: Emotion, Surprise, Silence, Metaphor. These are all aspects of a clinician’s attentive listening and presence that can be practiced and enhanced by the workshop. The clinician gets (back) in touch with: “How does this make me feel?”, “What stands out about this story?”, “What is she NOT saying or why did she not finish that sentence?”, and “Why did he use that image to describe his pain?”.
As you have discovered, the close reading drill is not for direct application in the clinical setting but use of it in a workshop setting will, if designed properly, and as Ouri wrote, “… by its nature translate to being more attentive in the exam room, even if the poems or paintings have nothing to do with medicine. It is good training for observing both the details and the whole.”
Hi Phillip,
Thanks for your thoughtful reply and perspectives from having gone through Columbia University’s Program in Narrative Medicine. While I understand what you are saying, I still have a concern about the praxis of narrative medicine–where the rubber of theory hits the road/pavement of ‘real life’ practice of medicine/nursing/health care. In this age of the ‘quantified clinician’ and ‘checklist manifestos,’ presenting something that is complex (literary and/or critical theory) in a ‘drill’ format somehow misses the mark of what I think medical humanities can (and should) do well: opening up what Seamus O’Mahony calls ‘hinterland and perspective.’ Hinterland being the connection with the broader culture beyond the narrow culture of biomedicine, and perspective as understanding modern medicine’s ‘place’ in society, in history, etc. I’d add a more critical slant to that so that power, oppression, social justice issues are all foregrounded. Source: (for other people reading this who may not already know of this: Seamus O’Mahony “Against Narrative Medicine” Perspectives in Biology and Medicine, 56.4, 2013, 611-619. I don’t agree with everything he says in his article, but I do like his use of hinterland and perspective.
How do you differentiate between the navel-gazing variety of “reflection” and actual narrative reflection?
Excellent question. My flip answer would be, “You know you’re navel-gazing when you start sneezing from all the lint.” But seriously, I think it’s a matter of where the reflection is taking you–where your ‘gaze’ is. I think critical self-reflection is the more uncomfortable sort of reflection, because it requires us to examine and challenge our own biases and values and to shift the gaze from the individual self to consider others (human, animal, planetary!) and to acknowledge (and hopefully do some to redress) injustice in the world.