Published On Jan 15, 2010
The Literary Physician
Rita Charon, director of a new program in narrative medicine at Columbia University, discusses how developing narrative skills can create better physicians.
When physician-writer William Carlos Williams was asked how he managed his dual careers, he replied: “It’s no strain. In fact, the one nourishes the other, even if at times I’ve groaned to the contrary.” It’s a philosophy shared by Rita Charon, director of a new program in narrative medicine at the Columbia University College of Physicians and Surgeons, where students and clinicians learn to shape the fragments of medical work—a symptom, a conflict, a difficult conversation—into coherent narratives that reflect not only their points of view but also the patient’s. Charon, who trained as an internist and as a literary scholar, explains how a habit of narrative writing can change the way a medical professional sees her patients and herself.
Q: What is narrative medicine?
A: It’s knowing what to do with stories. My group and I have developed many, many narrative practices and routines for teaching and clinical work. One is called the “parallel chart.” We give clinicians or students this instruction: Write the things about your care of a patient that do not belong in his or her chart. These parallel charts expose matters that open up in the care of an individual patient, even if they’re simply things like “I’m angry at this guy,” or “This woman makes me sad.”
Q: How is a parallel chart different ?from a diary?
A: It doesn’t absolve the physician from having to write down a patient’s blood pressure or glucose reading. It’s a way to remember the other dimensions of care—your own response or concerns. Narrative skills help in articulating a disagreement, help everyone tolerate the reality that there are many ways to look at something. It is a matter of enlarging the perspective, one patient at a time.
Q: And are physicians good at it?
A: Not just physicians—nurses and social workers, chaplains, physical therapists and administrators too. The writing is gorgeous, and I’m not surprised, because it’s serious writing about grave matters. Even if it’s done in three minutes, it’s being done for a purpose. It canonizes the ordinary things we do every day.
Q: You’ve said such writing shouldn’t be done in a vacuum.
A: Right. The more this can be discussed with colleagues, the better. Each narrative is unique; each of us sees things others don’t. One person may be very aware of the setting, of where a story takes place. Another says, “Why does that matter?” ?The point is to widen the discourse of medicine.
Q: Has there been research to quantify the impact of narrative medicine?
A: We did a study in the pediatric oncology department at Columbia after six weeks of narrative seminars. Participants said what they did in the seminar spilled over onto the ward: Things they learned about patients’ situations or about their colleagues’ observations influenced their work. My next goal is to test the clinical effectiveness of these methods on how well patients can care for themselves, because narrative medicine allows a physician to relate to a patient in ways that increase the patient’s understanding of her situation and can improve the ability to go along with medical recommendations. There’s a sense of partnership and investment, of the physician not feeling like a stranger. If a patient feels respected, empowered, attended to by the doctor—if a patient feels her values and opinions are going to matter—she’s more likely to feel that the decisions she makes belong to her. Plus, a patient can better comprehend what she is thinking about by virtue of having a competent listener.
Q: Were there specific authors who informed your ideas?
A: From the beginning of my graduate training in English, I was consumed by Henry James. What James does better than anybody is perceive. When he describes a conversation, not only do you know what words people use, you know every nuance of feeling. Likewise with Marcel Proust, whose narrator in À la Recherche du Temps Perdu perceives at such a degree of fineness. Reading Proust, we find ourselves more porous to our surroundings, to our affective states, to what happens during the day.
Q: Your fourth-year students are examining another key to narrative medicine.
A: In one of several components of an intensive monthlong elective for fourth-year medical students, I teach a contemporary fiction seminar. This year I have chosen four contemporary novels:So Long, See You Tomorrow by William Maxwell, The Sea by John Banville, Out Stealing Horses by Per Petterson and Kyra by Carol Gilligan. All use associative methods of telling, braiding story with story, telling one story by virtue of telling another. The combination is an unforgettable experience in the how of telling—how some things cannot be told except aslant and how the dutiful reader has to follow his or her teller at such a pitch of imagination and alliance. It’s wonderful training for doctoring.