At a time when modern technology, superior medical imaging, robotic surgery and the sheer volume of patients have changed the face of medicine, there are some things that have fallen by the wayside — the human touch, the bond between the doctor and patient, and the hand-holding through times of ill health. As doctors become more and more data-driven, with lab results and scan findings getting more importance, they maintain a clinical distance from their patients and do not have a detailed dialogue on the patient’s health concerns, or listen to the patient’s narrative, by giving it the importance that it deserves.
Dr. Rita Charon, Professor of Clinical Medicine, and Director of the Program in Narrative Medicine at the Columbia University College of Physicians and Surgeons, who coined the term ‘narrative medicine’, says, in an email interview, “Doctors don’t listen to patients in typical medical practice. Doctors and nurses don’t get trained in the demanding skills of receiving and interpreting what another person says regarding bodily experiences and health fears. I first used the term ‘narrative medicine’ in 2000, to refer to clinical practice that is fortified by narrative competence — the capacity to recognise, honour, metabolise, interpret and be moved by stories of illness that patients, families and healthcare professionals tell. Pain, suffering, worry, anguish and the sense that something isn’t right — are hard to put down in words. So, patients have a difficult task ‘telling’ the doctor, while doctors have a difficult task to ‘listen’.”
Dr. Rita’s interest in Narrative Medicine was sparked off in 1982, when she attended a Literature in Medicine Seminar (incidentally, she holds a PhD in English as well).
She is quick to acknowledge that she was by no means the first to see the close relationship between the two. “There were people in Philosophy, History, Ethics and Literary studies who had come into medicine and were helping us to improve practice based on human learning, in addition to the scientific knowledge that we had.”
Narrative trainingAt Columbia University in New York, narrative training, that is, rigorous training in close reading, (of literary texts related to health and illness to get practice in hearing and interpreting the narratives/stories of patients), attentive listening, reflective writing and bearing witness to suffering is provided to doctors, nurses, social workers, psycho-analysts, therapists, literary scholars and writers who attend their intensive workshops.
All this has brought in vast changes in the doctor-patient interaction of trainees. Says Dr. Rita: “Today, I have changed my routine for meeting new patients.” (She no longer starts with the checklist of questions that go from, ‘Do you have headaches? Do you have nose bleeds? Any allergies?’ but opens up a conversation with her patients.)
“I simply say ‘I am going to be your doctor. I need to know a lot regarding your body and your health and your life. Please tell me what you think I should know regarding your situation’. And patients do exactly that in extensive monologues, during which I sit and pay attention to what they say and how they say it — the forms, the metaphors, the gaps and silences, and refrain from writing or reflectively calling up their medical records on the computer."
One patient was surprised and reacted initially with a quizzical ‘you want me to talk?’ This conversation almost always yields a minefield of information and could even be cathartic. Another patient started to cry a few minutes after speaking of the loss of his father, his brother and the troubled relationship with his son. When she asked him why he was crying, he told her, ‘Because no one has ever let me do this before.’ The bottom line is that patients are eager to give information.
Continues Dr. Rita, “I realised that what patients paid me to do was to pay exquisite attention to the narratives that they gave me, captured in their words, their silences, their facial expressions, in how their bodies changed, in the tracings and pictures we had of their body, and in what people said regarding them. It was my task to make these stories coherent, at least provisionally, so that they would make sense, and to take multiple contradictory narratives and build something that we could act on.”
Parallel chartOne of the interesting things she has introduced is the parallel chart, for doctors trained in narrative medicine to maintain. In the parallel chart, students and doctors write of “their own anguish in caring for patients, as well as their victory when things go well, their rage and mourning, their fear of mistakes, their inability to know what to do sometimes, and their sense of loss when the patient’s condition deteriorates, no matter what they do. When doctors read to one another what they have written, they take heart that they are not alone, and feel supported by their colleagues on their journeys. If the doctor is taking care of an elderly gentleman who has prostate cancer and reminds him of his grandfather who died of the disease, every time he goes into the room he weeps for the loss. You can’t write it in the hospital chart. Yet it has to be written because this is the personal part of what the doctor is undergoing in becoming a better doctor. And there is no way of knowing what you think, what you experience, without narrative writing in clinical settings, which makes audible and visible that which could pass by without notice.”
Talking of how Narrative Medicine has transformed her practice, she says, “It ensures that the knowledge on which clinical decisions are made is accurate. It conveys the commitment, and may be, even the compassion of the clinician towards the patient, thereby increasing the likelihood that the patient will trust the doctor or nurse and so might do what they recommend.”
Do doctors who are hard-pressed for time have room in their schedules to listen to the narratives of their patients?
“As it turns out, narrative routines do not take necessarily more time than non-narrative ones. One might spend more time with a patient on a first visit, but subsequent visits are often streamlined because of the increased understanding between doctor and patient. From my experience, doctors and nurses are eager to improve the contact they make with patients, and to strengthen their engagement with them. They are willing to invest more time if it enables one to reach the ultimate goal of improving the effectiveness of care,” says Dr. Rita.
In closing, she emphasises an important dimension of Narrative Medicine, that is, narrative writing and the need for doctors to take time to reflect on their practice. “By speaking of what we undergo in illness or in the care of a patient, we are coming to recognise the layered consequences of illness and to acknowledge the fear, hope and love revealed in sickness.” Most of all, it helps to make doctors more empathetic, encouraging them to treat the patient as a person in the context of a de-humanising system.
