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.



Burnout and Crazy Cat Ladies

Image by Rakka via Flickr

Question: What do professional burnout for nurses and crazy cat ladies have in common?

Answer: Pathological altruism.

This, according to a recent NYT book review “The Pathological Altruist Gives Till Someone Hurts.” (Natalie Angier, 10-3-11). The book is an anthology entitled Pathological Altruism  (Barbara Oakley, et al, editors/ Oxford University Press) due out December 2011. Altruism—behavior aimed at helping another person. True altruism is said to spring from empathy (vs. self-interested egoism). Authors included in this book link pathological altruism to animal hoarding, anorexia, personality disorders, codependency, and professional burnout for health professionals—especially nurses.

Barbara Oakley seems to have gotten the idea for this anthology while she was researching and writing her somewhat creepy (among other things—a cover photo of a black-widow spider), cumbersomely titled book Cold-Blooded Kindness: Neuroquirks of a Codependent Killer, or Just Give Me a Shot at Loving You, Dear, and Other Reflections on Loving That Hurts (Prometheus Books, 2011). A pseudo-scholarly take-off on Capote’s In Cold Blood, her book examines the story of Carole Alden, a Utah artist who killed her husband in what she claims was self-defense/Battered Woman’s Syndrome—but who was sentenced to 15 years for manslaughter. A collector of animals (and of drug-addicted men), Carole was known for her compassion.

But Oakley contends that Caroles’ type of compassion is an example of diseases of caring, of empathy gone awry. She quotes research by Jean Decety, a University of Chicago scientist who examines the neural pathways that underlie empathy. According to Decety, empathy has four components. Empathy is a mixture of all four, and if any one of them gets distorted—by genetics, developmental issues, or stress—empathy can become pathological. Decety’s four elements of empathy are:

1)   ability to share someone else’s emotions

2)   awareness of yourself and other people—and knowledge of where you “end” and where others begin

3)   the mental flexibility to set your own perspective aside and view things from another person’s perspective

4)   the ability to consciously control your emotions. (as quoted pg 57 Cold-Blooded Kindness)

Empathy can either lead to compassion/acts of kindness, or it can lead to empathic distress when the suffering of others becomes or compounds our own suffering. Empathic distress is something that nurses are particularly prone to, leading to burnout. There are empathy brain cells (of course!) called mirror neurons located in the right frontoparietal lobe—in left-handed people. And they’ve identified this area as being active when health care professionals are able to emotionally distance themselves from images and sounds of a patient’s pain and suffering. Researchers are looking at ways of teaching health care providers to be able to emotionally distance themselves “just enough” to protect themselves, while still providing compassionate care. A different kind of Universal Precautions.

In the NYT article referenced above, Angier writes, “Train nurses to be highly empathetic, and, yes, their patients will love them. But studies show that empathetic nurses burn out and leave the profession more quickly than do their peers who remain aloof.”

We know that educating nurses to be aloof Nurse Ratcheds isn’t the answer to burnout prevention. I think that a lot of what is called burnout in nurses is really moral distress: wanting to do the right thing by a patient, but being blocked by factors in the health care system that are outside the nurse’s control. And for prevention of real burnout in nurses, I think we can do a better job in nursing education—by helping students (and ourselves) examine and process the sometimes complex and unsavory motivations for ‘doing’ nursing. Otherwise we will continue to graduate burnout-to-be nurses, along with future crazy cat ladies (and lads).