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!!

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.