Everyone has a life story. But rarely does anyone get to tell it.
A novel approach to medicine seeks to change that. Narrative medicine emerged as a field of study in the early 2000’s, with the first program in the country established at Columbia University. Its founder and current director, Dr. Rita Charon, holds both an MD in internal medicine and a PhD in literature, reflecting the interdisciplinary nature of the field. She defines narrative medicine as “medicine practiced with the narrative competence to recognize, interpret, and be moved to action by the predicaments of others” in her article “Narrative Medicine: Form, Function, and Ethics”.
In other words, what narrative medicine teaches its practitioners is the art of empathy. In a clinical setting, empathy is crucial to the doctor-patient relationship, allowing the doctor better insights into how to treat the person and the complex emotions that accompany disease, not just the disease affecting them. Narrative medicine thus casts patient as storyteller and doctor as audience. Patients are given uninterrupted time to tell their physicians the full story of their illness, outlining the warning signs and symptoms in the story of their lives and relationships. The doctor in turn is expected to give the patient their full and undivided attention. Scribbling notes, or, these days, keyboard clicking are kept to a minimum, as are questions and interruptions. With this approach, Charon writes in her “Narrative and Medicine” that doctors “can quickly and accurately hear and interpret what a patient tries to say” when the patient reveals what’s wrong.
This seems like a small, almost insignificant adjustment. But narrative medicine isn’t just a set of actions taken on top of a doctor’s standard duties—it’s a different frame of mind. The idea is that the doctor considers the patient not only as a series of afflictions that need to be written, tested, and diagnosed, but also as a human being whose life’s context matters. Perhaps asthma is exacerbated by a father who smokes heavily, or chronic back pain is triggered from having to ride a dilapidated car to work. These kinds of details, crucial to understanding the patient’s health, may go unnoticed or unsaid in a typical clinical interaction. According to Greenhalgh and Hurwitz in “Why study Narrative?”, “The narrative provides meaning, context, and perspective for the patient’s predicament”. Drs. Vera Kalitzkus and Peter Matthiessen, in their overview of narrative medicine “Narrative-Based Medicine: Potential, Pitfalls, and Practice”, note that “The development of NBM has to be understood in the context of patient-centered approaches—bringing the patient as a subject back into medicine”. Indeed, as medicine in general shifts its focus towards holistic treatments of the patient as an individual, practitioners of narrative medicine would seem well-equipped to handle the change.
Narrative medicine thus finds itself both in support of and at odds with traditional medical practice. On one hand, second-year medical students at Columbia who completed the narrative medicine course claimed they learned the key traits of “attention, representation, and affiliation—and endorsed all three as being valuable to professional identity development” in the study “Sounding Narrative Medicine”. Not only did the seminar series seem to increase the students’ practical abilities, but for many students it also led to new self-reflection and connections with their peers, who previously had little chance to talk with each other about anything other than “the normal classroom mentality”. Thus, narrative medicine could boost the doctors’ teamwork and create new coping mechanisms for the incredible stresses of their jobs.
On the other hand, critics point out that narrative medicine clashes with clinical objectivity, the kind that allows a doctor to treat a patient without bias or unprofessional concern. Drs. Kalitkus and Matthiessen point out that narrative medicine for new physicians “can lead [to] a phase of destabilization and doubt about one’s own approach to medical practice” in “Narrative-Based Medicine: Potential, Pitfalls, and Practice”. They go on to caution that “Narrative is not the only thing that counts in medicine: by no means is it meant to devalue medical knowledge”. The other reality is that narrative medicine cannot fit every patient-physician relationship: “Also there are patients who are not interested in telling their story or sharing their innermost feelings, and not every topic raised in a consultation calls for detailed narrative exploration”. The limitations of narrative medicine are not insurmountable, but it is true that it cannot entirely replace typical, efficient, evidence-based diagnosis and treatment.
Still, narrative medicine has the powerful potential to heal in ways regular practice cannot. Dr. Charon describes how the personal connections forged between doctor and patient in narrative medicine “became a source of comfort for the patient’s whole family” in one case in “Narrative Medicine: Form, Function, and Ethics”. In another case Dr. Charon shared with two of her patients some excerpts of narrative reflections she had written about them outside of work. The patients responded by “[bringing] to my attention aspects of their histories that were salient to their current emotional and physical health. It was as if my writing about and for my patients quickened a process of disclosure that may have come much later, if at all, in the relationship”. Sharing stories, evidently, built trust through vulnerability: for Dr. Charon in her disclosure of her personal writing, and for the patients in the secrets they’d previously reserved only for their closest confidents.
Whether or not narrative medicine ever becomes mainstream, the skills it requires of its practitioners could be well utilized across general medicine. Certainly, all doctors could benefit from learning how to empathize and connect with their patients on a more personal level. The story of narrative medicine may still be in its opening chapters, but its potential to positively impact the field has yet to be written.