Tag: Columbia University

Narrative Medicine “Closer” Close Reading In Practice

1384151134Over the past several weeks, in the narrative medicine (NM)  summer course I am teaching, we have been using the ‘closer’ NM close reading approach that I proposed in my last blog post: focusing on the elements of emotion, silence, surprise, and metaphor/imagery. I’ve also asked the students for written feedback on what it is like to use this closer reading technique, as well as how they envision incorporating what they learn from it into their practice as health care providers.

The course is offered through the innovative School of Interdisciplinary Arts and Sciences at the University of Washington, Bothell Campus. The majority of the forty students in my course are nurses, most with Associate Degree preparation, who are now in their BSN completion program (finishing the equivalent of a four-year undergraduate degree program). It is a very diverse class in terms of age, gender, country of origin, ethnicity, race, years of work experience within health care, etc. Earlier in the quarter they all read/learned/practiced Charon’s close reading drill for narrative medicine: frame (includes gaps/silences), form (includes metaphor/imagery), time, plot, desire.

For in-class practice of the closer NM close reading approach, I used various poems from Between the Heartbeats: Poetry and Prose By Nurses, edited by Courtney Davis and Judy Schaefer (U of Iowa Press, 1995). “Burnt-out Offerings” by Sandra Smith with the stanza “We have become/those old crusty nurses/we used to pity and avoid.”–and Courtney Davis’ haunting “The Nurse’s Pockets” both resonated strongly with the students. I also used Kelly Siever’s more nuanced “Breath” and “Between the Heartbeats.”

Students commented that emotion and surprise in the poems were the easiest and most immediate for them to identify, and that metaphor and silence “…need more digging to discover and are more challenging.” Many of the students said that silence was something they had not considered before, that they found it intriguing but difficult. Overall, students felt this NM ‘closer’ reading approach was less technical, “less reserved and detached,” and that it “comes more easily and is something I can see myself using in practice.” One student wrote: “I can see this being used with patient interactions. Taking time to asses one’s reaction to a patient statement or story can prompt further questions, clarify biases, and create deeper understanding.”

I’m still refining how I teach this closer NM close reading approach, and especially how to guide students in how to listen for the silences, for whose voices and perspectives are heard and whose aren’t, and why.

 

A Narrative Medicine “Closer” Close Reading Drill

DSC00673In 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.

 

The Problem(s) With Narrative Medicine

booksNarrative medicine is growing in popularity in academic medical centers and healthcare settings. Developed over the past decade by physician and literary scholar Rita Charon and colleagues at Columbia University, narrative medicine (as defined by Charon), “fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness.” There are textbooks on narrative medicine (such as the one by Charon shown here), workshops, undergraduate courses, and masters degree programs in narrative medicine (the Program in Narrative Medicine at Columbia University), and even the venerable Modern Language Association is considering establishing a new forum related to narrative medicine (to be called Medical Humanities and Health Studies). I love narrative medicine and I teach narrative medicine, but I don’t love/teach it without having some serious questions and reservations about this whole ‘movement’ or religion as it sometimes seems to be.

Current narrative medicine discourse assumes an ideal encounter between an empathic physician and a cognitively intact, compliant adult patient. What does this mean for providers or for patients who fall outside these parameters? What does it mean for people excluded from health care? What does it mean to be attuned to the narratives, not only of individual patients, but also to the larger, often silenced metanarratives (grand narratives or ‘big granddaddies of stories’) of power and exclusion?

In its current form, narrative medicine allows little room for critical reflection or exploration of larger structural inequities and structural violence within health care, including those from the medical gaze (a term from Foucault to describe how modern medicine often treats patients as just a physical body, instead of treating the person who is ill or injured). Narrative medicine largely ignores the limits of narrative, especially within the contexts of trauma, suffering, and oppression. What I mean by this last statement is that there are times when people have experiences that don’t fit neatly into a story-line, a narrative of what happened. There are human experiences beyond narrative, and this is where poetry/metaphor and gesture can be more effective means of  personal meaning-making and communication. This is where Arthur Frank’s chaos stories can occur.

Even within narrative, we often have a rigid, scripted notion of what a good, straight, linear, satisfying (and effective) story arc should be. It is usually the hero slaying demons and dragons of some sort, having a nice masculine climax, and emerging at the end triumphant and transformed–and even stronger and more handsome! We want soft-focus lens Hallmark moments that make us feel all warm and cozy inside. As applied to the treatment of cancer, Barbara Ehrenreich’s hilarious yet disturbing essay “Welcome to Cancerland” (Harper’s Magazine, November 2001) is a terrific take on this topic.

I’ve been thinking about these problems recently in regards to my work with narrative advocacy/ policy narrative, and to my teaching of narrative medicine to nursing and other health professions students. Over the next month or so I’ll be writing a series of posts exploring ways to ‘do’ narrative medicine and narrative advocacy differently. I’ll also include a list of resources that I’ve found to be helpful.

The first resource I’ll make a pitch for is the work on narrative humility by physician and writer (and faculty member at Columbia’s Program in Narrative Medicine) Sayantani DasGupta. She recently wrote a brief essay, “Narrative Medicine, Narrative Humility: Listening to the Streams of Stories” for the journal Creative Nonfiction (Summer 2014). In her essay, DasGupta describes her work in narrative medicine as teaching people to listen,  “…(but) what I’m ultimately interested in is teaching people to listen critically, to listen in socially just ways. I want to teach healthcare providers to listen not only to comfortable stories, or stories of folks who are just like them, but also stories that challenge them, stories that are from the margins, stories that are traditionally silenced.”

Hear Hear!!

When Is It OK to Write About Patients?

DSC01479I write about patients; I ask my students to write about patients. I do this as part of reflective practice and with the knowledge that it can contribute to humanizing health care for patients, families, and health care providers. But writing about patients has to be done in a respectful way, with adherence to certain ethical and legal guidelines. By now we all know that it is not okay to write about patients in an identifiable way, and certainly not on social media platforms while in a knee-jerk, bleary-eyed state. But when is it okay to write about patients and patient care?

Many physician writers I know adhere to fairly strict personal guidelines to only publish stories about patients with the patient’s permission–preferably written permission. Rita Charon, MD of Columbia University’s Program of Narrative Medicine is a staunch advocate of this patient privacy ‘rule,’ as is my colleague at the University of Washington, Sharon Dobie, MD (see her excellent recent blog post “Writing About Patients”).  Nurse writers who I have talked to about this (like Theresa Brown, RN who writes for the NYT Well blog) point out that hospital hierarchies and power differentials make it much more difficult for nurses to be able to seek patient permission to publish a story about them. The nurse writers also make the case that in many clinical situations, tracking down former patients to seek such approval would itself be a breach of patient privacy under the federal HIPAA (Health Insurance Portability and Accountability Act) rules.

When I write personal narratives for publication I alter some biographical details of patients and change their names in order to protect their identities. I typically don’t change the names of co-workers and friends, and when I do I clearly indicate that in the text. My most recent published essay, “No Place Like Home(less)” (Pulse: Voices from the Heart of Medicine, 5-30-14), was really about me as the ‘patient’ and I purposefully left out names of co-workers since it wouldn’t have added anything (except length) to the essay. I avoid the use of composite patients (merging together details of two or more patients into one) because to me that enters the realm of fiction and I mostly stick to writing non-fiction. One recent exception to this though is my non-fiction/fiction piece “Steps to Footcare” (The Intima: A Journal of Narrative Medicine, February 2014). It was published as fiction because that’s the category I submitted it under. If I were to include it in a print book collection in the future (something I plan to do), I will most likely have it as a non-fiction essay with an explanation of how I crafted the essay.

Here are some current journal submission guidelines pertaining to writing about patients:

Pulse: Voices from the Heart of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine:

“Does your piece describe a patient? Pulse–voices from the heart of medicine is committed to protecting a patient’s right to privacy. Ideally, you will obtain written permission from any patient you write about; as an alternative, you must change his or her name and omit or alter other identifying characteristics. A reader should not be able to pinpoint a neighbor, friend or family member as the subject of your writing.”

The Intima: A Journal of Narrative Medicine, Columbia University Program of Narrative Medicine:

“Patient Privacy Notice
The Intima adheres to legal and ethical guidelines in accordance with academic and health community publication standards.  As clinicians, patients, and family members, we feel strongly that patient privacy and confidentiality be maintained at all times.  We simultaneously recognize that narrative power depends on intimate, singular encounters and the sharing of personal accounts in a respectful and safe environment. To maintain these standards, contributors should review the confidentiality guidelines in the Health Information Portability and Accountability Act (HIPAA), with particular attention to the 18 commonly accepted “unique identifiers.” We also encourage contributors to seek permission before submitting patient stories, and to fictionalize or change identifiable information whenever possible and appropriate to maintain patient confidentiality and privacy.”

 

American Journal of Nursing, Reflections (personal narratives):

“CONFIDENTIALITY Please use fictional names for all persons and institutions in your story. Locations may also have to be disguised.”

 

Storytelling for Policy Advocacy

PoppyStoryTimeWhen I tell people that my work focuses on narrative advocacy, they mostly look at me funny and ask, “What’s that?” It is a more concise way of saying ‘storytelling for policy advocacy.’

A common definition of narrative is a story with a teller, a listener, a time course, a plot, and a point. Storytelling is as old as campfires and cave-dwelling. (The photo here is of my father telling Appalachian ‘Tall Tale’ stories to his grandchildren). Storytelling is how we learn about our world, about ethical living, about history, about ourselves. Within the healthcare arena patients and family members tell their stories to nurses and doctors and other members of the healthcare team. It is still a truism that something between 80-90% of the information needed to make a correct medical or nursing diagnosis comes from the patient’s history, from their story.

Storytelling and story-listening are not only important at the individual patient level. They are also important at the community and public health level. Stories can be effective ways to educate and persuade the public and lawmakers on a variety of health and policy topics. Storytelling  (pathos) is part of Aristotle’s three essential components of rhetoric: the art of persuasion. The other two components of rhetoric are logic/reasoning/facts (logos) and the credibility of the speaker (ethos).

Several years ago at The Examined Life: Writing and the Art of Medicine Conference at the University of Iowa, I co-led a workshop “Narrative Advocacy: Writing Lives, Making Changes.” My co-leaders were Marsha Hurst, PhD, a core faculty member in the Program in Narrative Medicine at Columbia University, and Carol Levine the director of the United Hospital Fund’s Families and Health Care Project in NYC. Here’s the abstract of our workshop, which I still refer back to as my own guide and articulation of what I am passionate about:

“Narrative advocacy is the practice of using narrative competencies to advocate for improvements in care. It involves moving beyond the individual stories, to include the connections made within the wider community, and acting upon common interests in order to effect positive change in clinical care, in institutions of caring, and in health policy. In the U.S. there is a long history of health advocacy built on narratives of lived experience of illness and disability, and more recently, grassroots narrative advocacy has expanded through the use of social media. For health care providers and students in the health sciences, narrative advocacy can be a powerful avenue for engagement in health policy because it connects the unique individual experiences with larger issues. As powerful as narrative advocacy can be to engage and persuade policy-makers, it can and has been misused. It is important to have both knowledge and skills in how and when to use narrative advocacy responsibly and ethically.”

This past week I had the opportunity to participate in an excellent online training “The Role of Narrative in Public Health” sponsored by the Center for Digital Storytelling located in Berkley, California and facilitated by Amy Hill. She gave four reasons personal stories are so powerful: 1) stories are universal and typically follow a familiar structure, 2) stories are intimate and touch the heart in a way facts/figures can’t, 3) stories are honest and aren’t as slick and sensationalized as they often are in journalism, and 4) stories don’t (typically) tell us specifically what to do. The Center for Digital Storytelling uses a participatory media and group process to help people create and share their personal stories. Working in groups makes the individual stories more powerful, and the process can be empowering and healing for the participants.

The Center attends to the ethical practice of digital storytelling (would be the same for any type of narrative/storytelling work I think). They ensure storyteller well-being, use principles of cultural humility, and adhere to a set of guidelines in working with people impacted by trauma. They point out that consent is an ongoing process, that the question of story ownership and of sharing and distribution of the stories should be clearly addressed from the very beginning of the project. Amy showed us several powerful digital stories from their various projects. My favorite was on motherhood and women’s rights from their “Silence Speaks” project: Dear Ayhan by Rawan Bondogji. A perfect story for Mother’s Day. It is beautifully done.

Here are some additional narrative advocacy pieces that I use in my teaching:

 

 

 

 

 

 

 

The Intima: A Journal of Narrative Medicine

IMG_0678In case you haven’t run across this journal before, I encourage you to check out The Intima: A Journal of Narrative Medicine. It was created by some of the students in  the Narrative Medicine Master’s Program at Columbia University. They state, “…we seek an ongoing mode of self-expression as a group, to continue outside the classroom that which was created within. With that in mind we call ourselves and our efforts The Intima, resonating on the concept that Narrative Medicine defines itself as the intimate interface between two people, one as healer, one as being healed, yet both yielding and both gaining from the experience. (…) The Intima is an electronic journal dedicated to promoting the theory and practice of Narrative Medicine, an interdisciplinary field aiming to enhance health care through the development of effective communication and understanding between caregivers and their patients. By providing an online venue for the expression of personal experience within the medical arena, The Intima creates space for caregivers, professionals, patients, and families to share their narratives in a format that fosters empathy, reflection, and deeper understanding of the diversity inherent in effective delivery of care.”
In their Spring 2014 edition under Fiction, I have an essay “Steps to Footcare” about my work as a faculty preceptor with the University of Washington’s Teeth and Toes Clinics, where we provide basic foot and dental care to Seattle’s homeless population. This particular essay takes as its form the actual list of instructions we give students to follow when providing care. I fictionalized it by creating a composite female character based on several ‘real’ patients.

Celebrity Docs and the Ick and Quack Factor

"Beware of Quack Doctors"
(Photo credit: Courtarro)

Today on a listserve I am active on, a health reporter from Florida wrote that she recently received an e-mail invitation from a marketing firm basically bribing her to write a blog post on Dr. Colbert. The offer was for $5 for a 100 word ‘unique content’ blog post about Dr. Colbert. The offer also included a $25 dinner certificate (Florida Blueplate special anyone?) and the “opportunity to earn commission on each and every sale you generate.” I knew about–and have fended off–blogging bribes/product placement like this, but the bribes I get are nursing school related. I hadn’t realized that physicians as ‘brands’ had gotten into this. Silly me: everything in our country seems to be for sale. Never having heard of Dr. Colbert or what he sells, I looked him up.

From his website (based in Orlando, Florida and purposefully not linked here) , Dr. Dan Colbert states he is “board certified in Family Practice and practices Anti aging and Integrative medicine.” You have to dig for that though as what first pops up on the website is “Cyber Monday Extended! 20% off! This Christmas give them the gift of health!” with a photo of the tanned, fit, blond-haired Dr. Colbert holding out a wrapped Christmas present to an adoring crowd of people all reaching for it. He sells many products including vitamins, nitric acid capsules, weight loss drops, and green coffee bean extract. As a description for each he includes dubious health claims such as: “Reduction of and sometimes complete recovery from food-related and seasonal allergies” and “Provides detoxification of heavy metals, pesticides, and other toxins that may accumulate over time.” There’s the ever so tiny * at the bottom of the page with the oddly worded disclaimer: “These statements have not been evaluated by the Food and Drug Administration.”

Dr. Colbert is the author of many books (also for sale on his website), including What Would Jesus Eat? The Ultimate Program for Eating Well, Feeling Great, Living Longer. (Proving that anything can be published in our country). Not surprisingly, he obtained his medical degree from Oral Roberts University and he holds no academic appointments. I won’t get into details here, but he has had several fines and reprimands by Florida Health/Medical Quality Assurance, the professional licensing body of Florida (available to the public on their website). And he (of course!) has appeared on the celebrity doc/ick factor Dr. Oz show. Dr. Oz of the “how many orgasms does it take to have per year to be healthy and live to old age?”  (I think the correct answer is 200 and as our year is running out, get busy!) Dr. Oz of the TV episode “Dr. Oz’s 13 miracles for 2013” that included his endorsement for red palm oil as an anti-aging remedy. Dr. Oz, a Harvard-trained Columbia University cardiothoracic surgeon who consults with psychics on his show and seems to take them seriously. Does anyone remember that Oz was a very fake wizard in a very green place with a very yellow-(gold)brick road?

Who exactly is supposed to be monitoring the professional practices of these “mediatainment” “mega-brand” physicians? (quotes from the article below).

For an excellent critical reflection article on Dr. Oz and his ilk, I highly recommend you read Michael Spector’s New Yorker article “The Operator: Is the Most Trusted Doctor in America Doing More Harm Than Good?” (Feb 4, 2013).

* I suppose I could, but will not, submit this blog post  to the “Dr. Colbert Paid Blogger Opp + More” in order to receive my $5 and $25 Florida Blueplate  special. My elderly father in Florida will have to get something else for Christmas this year. And it won’t be What Would Jesus Eat? either….

** I am aware that even negative publicity is publicity. Dr. Oz needs no publicity and I tried to minimize/eliminate direct links to Dr. Colbert in this post.

A Place To Stop

 

Stop
Stop (Photo credit: Swamibu)

 

In our narrative medicine course we have moved into group presentations. On the first day of the quarter I had students sign up to be in one of eight groups to work on group projects and to do a group in-class presentation. I picked eight topics, using the list of topics (keywords) from NYU’s Literature, Arts, and Medicine
database as a guide. The eight topics I chose this summer were: Aging, cancer, death/dying, disability, drug addiction, infectious disease, mental illness, and racism. The group assignment was to research and expand upon the topic resources listed in the NYU database—to approach this as if they were doing an in-service training on the topic at their work site. I asked them to produce a one-page (front and back) handout of their favorite resources, along with two to four possible in-class writing prompts and reflective questions. Each group was given 45 minutes to present on their topic and to lead the class in discussion and reflective writing. (Note: our class sessions are four hours long, although we don’t typically go quite that long).

This past week the first two groups did their presentations (on aging and cancer) and both did an excellent job. The groups used an interactive PPT presentation, weaving in poetry, prose, artwork, comic books, YouTube videos, and movie clips. I was impressed by the range and depth of their presentations and class discussions, as well as their application of the close read drill adapted from Dr. Rita Charon’s work. Group members also shared some of their personal stories related to their health topic and did this in a moving but professional way.

 

When I was planning this narrative medicine summer course, I was resistant to the idea of building in group projects. As a student I always preferred to have individual assignments since I could then control the time commitment and the outcome. I knew that the majority of my students in this course would be busy with their nursing jobs and families as well as with school. But a colleague convinced me to use group projects, saying the students were used to them and that what they came up with was typically of high quality. I have purposefully allowed time at the end of each class session for students to meet in their groups for planning purposes and I stay around to answer any questions that may arise. Some groups have also set up online discussion boards on our course website to facilitate their group planning. (In my mind, this is the only really useful function of online discussion boards.) That seems to have worked well for them so they don’t have to meet in person outside of class.

 

Two things particularly struck me from the in-class presentations and discussions. One was the number of students who had personal experience with either a close friend or family member or a patient who was given a diagnosis of a serious cancer over the phone or in a voicemail message. We talked about how insensitive that is and what nurses can do to influence physicians, nurse practitioners, and other healthcare providers to think through how to give bad news in a more supportive way. The other thing that stood out to me in the class discussion was a comment a student made that this narrative medicine class is “A place to stop and to process these things we don’t get to process.” Other students said they agreed with what she said and talked about how nurses are so much into the care giving role, not only at work but also in their personal lives, that having a time and space to stop and reflect on how it is affecting them is a powerful thing.

 

Ah yes. There were really three things that struck me during last week’s class session. The third was that this is all heavy stuff to process and write about and how much environmental context matters—as in the actual physical classroom setting. We have a nice smallish amphitheater classroom with excellent acoustics, state-of-the-art audiovisual equipment that is easy to use, reasonably comfortable chairs and tables, and a full bank of windows looking out over a grassy marsh full of birds. I’d forgotten what a pleasure it is to teach in a classroom with windows. It also helps that it is one of the loveliest summers in Seattle’s history. Teaching this narrative medicine course in a windowless classroom in the middle of a Seattle winter would have a much different feel.

 

 

Close Reading Drill Simplified

This past week in the Narrative Medicine course I am teaching, I introduced students to the approach to close reading (she refers to it as a drill) as taught by Dr. Rita Charon and her colleagues at Columbia  University’s Program in Narrative Medicine. I then had students apply this to do their own close reading of JD Salinger’s short story “To Esme, With Love and Squalor.”

As a way of introducing them to close reading I had them read Rita Charon’s chapter “Close Reading” in her book Narrative Medicine: Honoring the Stories of Illness (Oxford University Press, 2006). This is a weighty chapter in a weighty book and I have discovered that many of my students were simply overwhelmed by it. So here is my streamlined version of ‘doing’ a close reading drill as applied to narrative medicine. I present the elements of close reading in the order I like to do them myself because it is more the way I read and analyze what I read.

1.     Desire (Dr. Charon’s term). What appetite or emotion is satisfied by reading this? What bodily sensations do you have while reading this? What intellectual or emotional desires arise? Put more simply: what is the overall feeling you have when reading this? (A related and interesting question would be: And what does this reveal about you as the reader?)

2.     Frame. What’s included and what’s left out of this narrative? Where did this first appear—what was the intended audience of the work? For instance, Salinger’s short story first appeared in the New Yorker in 1950. What can we surmise about his intended audience?

3.     Temporal scaffolding. How is time handled in the narrative?

4.     Form. Structure, genre, narrator, use of metaphor, allusion (especially what other works are referred to either explicitly or implicitly?), and diction

5.     Plot. What happened.

Dr. Charon makes the case that learning the skills of close reading as applied to narratives, whether written or in plays, movies, etc, can help health care providers learn to be more attuned to the illness narratives of their patients. Careful reading, careful listening, it makes sense at some level and I am teaching that to my students. Salinger’s short story that I had them read and analyze through close reading is a complex but engaging piece of writing. It has enough content about the health effects of war—PTSD especially—that nurses and others in the health professions find it interesting. Salinger’s use of frame, time, diction, and metaphor are exquisite. So this short story makes for a good—but sufficiently challenging—narrative on which to practice close reading. I found that most students did well with this assignment and really dug in. Since class this past week fell on July 4th, this was an individual take-home assignment, so I have not yet had the opportunity to discuss it with them in class.

I always have these nagging questions in the back of my mind: Does close reading detract from the pleasure of reading? And by extension, does ‘close reading’ a patient’s illness narrative detract from the pleasure of the patient-provider interaction? Do we start thinking about patients less as people and more as stories to be analyzed, stories to be recorded in our heads and then later used as material for our own written stories? Does that start to distance us from our patients? Is it like walking up a familiar flight of stairs—pleasantly distracted—then thinking about walking up the stairs and by paying attention to it, tripping? If writers consciously try to pay attention to the craft of writing, does the art of their writing suffer?

I’ve been re-reading one of my favorite books, David Ulin’s The Lost Art of Reading: Why Books Matter in a Distracted Time (Sasquatch Books, 2010). He raises these questions as well—for writers and readers in general. He states, “(…) I recognize this as one of the fallacies of teaching literature in the classroom, the need to seek a reckoning with everything, to imagine a framework, a rubric, in which each little piece makes sense. (…) leaving us with scansion, annotation, all that sound and fury, a buzz of explication that obscures the elusive heartbeat of a book.”

If I used this class assignment again I would add the personal reflection writing prompt: Write about a time when you were so overwhelmed by emotions that you had difficulty communicating—or write about a time when you were caring for a patient experiencing this.

 

 

A Patient Named Noname

IMG_0787I once had a patient named Noname. She was a thin wisp of a young woman who came to the community health clinic where I worked as a nurse practitioner. This was back in the late 1990’s soon after I had moved to Seattle from the East Coast. I was still having a bit of culture shock, getting acclimated to Seattle’s rain, tree-huggers, and serial killers. When I first met Noname I was dating a man who was a tree-hugger but thankfully was not a serial killer. He was way into natural food and meditation, so I had Namaste continually playing in my head like an annoying Bee Gees song. So when I looked at the new patient name ‘Noname’ on the patient chart and entered the exam room, I greeted her as Noname, pronouncing it as if she were a cousin of Namaste. She laughed nervously and corrected me: her name was no name. As in she didn’t want to give her real name, so it was just a placeholder of sorts. It wasn’t as if she was in clinic that day for any sort of health complaint that would make her concerned for her privacy. I never did get the story of her name, of her no name.

I remembered Noname this past week as I began teaching an eight-week Narrative Medicine course at the University of Washington, Bothell. I have close to 45 wonderfully smart and creative nursing students, all in their BSN-completion program. That means they all have their RN either from diploma or community college programs and are back to take the courses necessary for their BSN. They are all working full or part-time as nurses so they have a lot of ‘real life’ experience to draw upon.For the first in-class writing prompt I used one of my favorites learned from Dr. Rita Charon and her colleagues at Columbia University’s Program in Narrative Medicine: Write the story of your name. Everyone has rich stories to tell about their names—including the patient named Noname. I find this writing prompt to be an excellent starter prompt, as well as a way of allowing people to introduce themselves in a unique way. Of course, with 45 people in class we didn’t have time for everyone to read their stories out loud, but I have had the privilege of reading all of them and it helps me to get to know the class. I pointed out that this writing prompt can even be used effectively with patients. For instance, I’ve found that it is so much better to ask a patient (with a strange to me name), “Can you tell me the story of your name?” versus the usual “What country are you from?”

After presenting them with some basics of Narrative Medicine—what it is, where it came from, Dr. Charon’s approach to close reading—we practiced close reading together using a variety of short pieces of poetry and prose and film clips. The poetry I used was from Cortney Davis (I Want to Work in a Hospital), Raymond Carver (What the Doctor Said), Rachel Haddad (Stereotactic Biopsy), and Suzanne Edison (Teeter Totter). For the film narrative/close reading I showed them clips from the movie Magnolia (1999)—specifically two clips that are available on YouTube. One clip is the regret deathbed soliloquy by Earl Partridge (played to perfection by Jason Robards), and the second clip is of the male hospice nurse (played also to perfection by Philip Seymour Hoffman) on the phone trying to track down Earl’s estranged son (played—OK—also to perfection—by Tom Cruise). I love these two clips because they portray hospice care and hospice nursing so truthfully. They lent themselves to some rich class discussion and close reading skill building.

For the last in-class close reading and writing exercise I turned to writing by one of my favorite local authors, Judith Kitchen (Distance and Direction/ Coffee House Press, 2001); Half in Shade: Family, Photography, and Fate/ Coffee House Press, 2013). I used her sample short essay F-Stop, which is surprisingly complex for such a short prose piece (available on her website). We first did a close reading of this essay. Then I showed them a photograph of a man reading to three small children around a campfire. I asked them to write the story of this photograph—to just make one up—thus pushing (or pulling?) them into the realm of fiction writing. I could tell that many of the students struggled more with this writing prompt. Some told me they had never been asked to write fiction before in nursing school. But they persevered and came up with some wonderfully rich stories.

I’ll be writing a series of posts over the next seven weeks of this Narrative
Medicine (for nursing) course. Since Narrative Medicine isn’t ‘done’ very much in nursing schools—and I think it should be—my hope is to share my experiences with others who may adapt it for their own teaching.