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.

 

 

Blockbuster Moment

English: Camden, New Jersey is one of the poor...
English: Camden, New Jersey is one of the poorest cities in the United States. Camden suffers from unemployment, urban decay, poverty, and many other social issues. Much of the city of Camden, New Jersey suffers from urban decay. 日本語: ニュージャージー州カムデンのスラム. Svenska: Camden, New Jersey is one of the poorest cities in the United States. Kiswahili: Camden, New Jersey ni moja ya mataifa maskini zaidi katika miji ya Marekani. (Photo credit: Wikipedia)

Dr. Jeffrey Brenner, a family physician in Camden, New Jersey, talks about this as being a Blockbuster Moment in US health care in the US, a time for game changing innovations. He is the head of one such health care game-changer, the Camden Coalition of Healthcare Providers.

Camden, New Jersey is one of the poorest and most crime-ridden cities in the US. After completing his residency in family medicine here in Seattle in the late 1990’s, Dr. Brenner returned to his hometown of Philadelphia to establish a family practice. But a series of events–including the murder of young man outside his house– led him out of his private practice and into community work in nearby Camden.

Working with hospitals and local physicians, Dr. Brenner was able to map and identify the high utilizers of health care–people who were the most medically complex and the most expensive to treat. He found that 1% of the Camden residents accounted for 30% of all hospitals charges, mostly for emergency department visits for health problems that could have been treated and prevented with primary health care. After some good old-fashioned community coalition building, Dr. Brenner and his group hired a team of nurse practitioners, social workers, and community health workers to work with the “high utilizers” to help coordinate their health care, housing, benefits and other needs. The Camden Coalition model of care is showing results indicating they are able to provide better health care at lower cost to the most difficult to treat patients in one of the poorest cities in the US. As Dr. Brenner states, “If Camden can do it, it makes the rest of the country look silly.”

There is a very good 13min PBS Frontline video “Doctor Hotspot” by Atul Gawande highlighting the work of the Camden Coalition of Healthcare Providers. It features an interview with Dr. Brenner and also follows Coalition nurse practitioner Kathy Jackson on a home visit with one of her patients, a young man with asthma and a seizure disorder. Through her work with this young man, his ER visits went from 35 over six months to just 2 over six months.

In the Frontline video, Atul Gawande points out to Dr. Brenner that “there’s a catch” to the work of the Coalition being too successful. The catch is that they are taking away from the hospitals their most expensive, most lucrative patients and the hospital administrators will resist that change.

Atul Gawande also published an interesting article “The Hot Spotters” related to Dr. Brenner’s work in the New Yorker (1-24-11).

Also–for anyone with a NJ RN license, check out the two open RN positions on the Camden Coalition of Healthcare Provider’s website. They both look like exciting jobs with a terrific team. They also have volunteer opportunities listed.

Complications/ September 28, 2010

Yesterday I started reading Atul Gawande‘s book Complications: A Surgeon’s Notes on an Imperfect Science. It is good and I briefly considered taking it with me to Virginia to read while I am caring for my Dad. The cover photograph is a bit disturbing to flash around in a hospital waiting room though. I decided to take something more soothing and distracting, so Dicken’s An Uncommercial Traveler is accompanying me instead. His chapter “Nurse’s Stories” has given me the idea to tell my father ghost stories when he’s in the hospital.
I have read all of Gawande’s recent New Yorker essay: “Letting go: what medicine should do when it can’t save your life” (available at Gawande’s website: http//gawande.com). His main point in this article is that US doctors–and US patients— just aren’t very good at “knowing when to stop” expensive treatments even when the benefits aren’t clear. What interested me the most was his reference to a study of Medicare patients with heart failure who I assume were randomized to either conventional or hospice care. The patents in hospice care lived on average 3 months longer than the conventional care patients (and I also assume with better quality of life). That study finding may come in handy this next week in discussions with my Dad and with his doctors. Gawande discusses how the tough ‘breakpoint discussions” (when to stop fighting for time/life) between patients and doctors aren’t done very often because the discussions take time and aren’t reimbursable/billable activities. I also think it is because doctors often view these discussions as failures because they are hard-wired for curing and not for caring. I am interested to find out how my Dad’s doctors handle this–and how my Dad and I will handle it. A difficult conversation or series of conversations. My Dad told me last night he’s getting tired more easily and he hopes the cardiac surgeon can fix that soon.