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Narrative Medicine
By Rita Charon, M.D., Ph.D.

Special to LitSite Alaska

Dr. Rita Charon is a pioneer and national authority in the field of literature and medicine, and has written and lectured extensively on literature's salience to medical practice as well as on the doctor-patient relationship, narrative competence, medical ethics, and empathy in medical practice. Her research has focused on communication between doctors and patients, seeking ways to improve the ability of doctors to understand what their patients tell them. Columbia University is the only medical school with a program in narrative competence, in which medical students learn how to better "read" their patients' stories through literary studies. We asked Dr. Charon to share with LitSite Alaska how and why she came to develop this program for Columbia University.

Dr. Rita Charon

I have been practicing internal medicine for over twenty years. After a few years of practice after residency, I realized that what patients paid me to do was to listen very expertly and attentively to extraordinarily complicated narratives -- told in words, gestures, silences, tracings, images, and physical findings -- and to cohere all these stories into something that made at least provisional sense, enough sense, that is, to be acted on. I was the interpreter of these often contradictory accounts of events that are, by definition, difficult to tell. Pain, suffering, worry, anguish, the sense of something just not being right: these are very hard to nail down in words, and so patients have very demanding "telling" tasks while doctors have very demanding "listening" tasks.

These recognitions sent me over to the English Department of Columbia, figuring that they could help me understand how stories are built and told and understood. My plan was to take a course in English; this became a Master's and, soon enough, a doctoral degree. I couldn't bear to stop my studies in literature, not only because I was powerfully drawn to the study of literature but also because it made the medicine make more sense.

I realized that the narrative skills I was learning in my English studies made me a better doctor. I could listen to what my patients tell me with a greater ability to follow the narrative thread of their story, to recognize the governing images and metaphors, to adopt the patients' or family members' points of view, to identify the sub-texts present in all stories, to interpret one story in the light of others told by the same teller. Moreover, the better I was as "reader" of what my patients told me, the more deeply moved I myself was by their predicament, making more of my self available to patients as I tried to help.

With the encouragement of literary scholars Joanne Trautmann Banks and Kathryn Montgomery, I found myself writing about my patients in order to understand what they were telling me, because I learned that thoughts and sensations have to achieve the status of language before they can be useful to anybody. I then found myself showing my patients what I had written about them so as to make sure I had heard them correctly. "This is what I think you told me in the office last month. Did I get it straight?" And I found that patients were grateful for my having done this writing, not only as a sign that I tried to understand them but also for the chance to say, after reading my little summaries, "Well, we left something out."

At the same time, I coached my medical students and colleagues in writing reflectively about their practices to more accurately understand what their patients go through and also what they themselves endure in the care of the sick. I asked students and residents to keep what I called "Parallel Charts" on the patients in their care. We all know what gets written in the hospital chart or the office chart. However, there are critically important aspects of the care of patients that do not belong in the hospital chart, but that, I submit, have to be written somewhere. In the Parallel Chart, students and doctors write about their own anguish in caring for patients as well as their victory when things go well, their rage and mourning and dread, their fear of mistakes, their inability to know what to do, their sense of loss as patients sicken, no matter what they do. And when students or doctors read to one another what they have written in the Parallel Chart, they take heart that they are not alone in their sadness and their dread, their sense of isolation among sick and dying persons diminishes, and they feel accompanied by their colleagues on their journeys.

For some time, I was writing essays like "The Narrative Hemisphere of Medicine" or "The Narrative Dimensions of Medicine." Gradually, I realized that most all of medicine is deeply saturated with narrative practices, not only in creating therapeutic alliances with patients and instilling reflection in our practices but also generating hypotheses in our science, learning our fabulous tradition of explanations about the human body, teaching students and colleagues what we know about sickness, acting with so-called professionalism toward one another and our patients, and entering into serious discourse with the public about what kind of medicine our culture wants. I invented the term "Narrative Medicine" to connote a medicine practiced with narrative competence and marked with an understanding of these highly complex narrative situations among doctors, patients, colleagues, and the public.

Narrative medicine does not spring from nowhere. Its lineage includes biopsychosocial medicine, primary care, medical humanities, and patient-centered medicine. What narrative medicine offers that the others may not be in a position to offer is a disciplined and deep set of conceptual frameworks -- mostly from literary studies, and especially from narratology -- that give us theoretical means to understand why acts of doctoring are not unlike acts of reading, interpreting, and writing and how such things as reading fiction and writing ordinary narrative prose about our patients help to make us better doctors. By examining medical practices in the light of robust narrative theories, we begin to be able to make new sense of the genres of medicine, the telling situations that obtain, say, at attending rounds, the ethics that bind the teller to the listener in the office, and of the events of illness themselves. It helps us make new sense of all that occurs between doctor and patient, between medicine and its public.

The Program in Narrative Medicine at Columbia has sponsored a number of research and educational projects. We host a number of reading groups that function as graduate-level literature seminars, some for students, some for faculty and staff, and some for readers at all levels of the medical hierarchy. Often times, I'll invite a professor from English to teach a particular text. They love being asked to speak at the medical school, because they find a group of very smart grown-ups who come to literature for help in living. My Program sponsored a Writer-in-Residence program this past semester, and we were fortunate to host novelist Michael Ondaatje for the fall. He taught two intensive literature seminars, hosted readings of medical center writers, and invited such friends of his as Joan Didion and Paul Auster to come read from their works. The Program has also undertaken outcomes research to document the consequences of narrative writing for doctors and medical students.

Narrative medicine brings a useful set of skills, tools, and perspectives to all doctors. Not only does it propose an ideal of medical care -- attentive, attuned, reflective, altruistic, loyal, able to witness others' suffering and honor their narratives -- that can inspire us all to better medicine, it also donates the methods by which to grow toward those ideals. Any doctor and any medical student can improve his or her capacity for empathy, reflection, and professionalism through serious narrative training. More and more medical schools and medical centers are adopting narrative methods of study in reading, writing, reflecting, and bearing witness to one another's ordeals. It is hoped that the research to understand the outcomes of these practices will keep pace with their growth. Ultimately, narrative medicine may offer promise as a means to bridge the current divides between doctors and patients, between doctors and doctors, between doctors and themselves, illuminating the common journeys upon which we all are embarked.

Selected Publications

  • Charon R. To build a case: Medical histories as traditions in conflict. Literature and Medicine. 1992; 11(1): 93-105.
  • Adelman R., Greene M., Charon R., Friedman E., Content of elderly patient-physician interviews in the medical primary care encounter. Communication Research. 1992; 19 (3): 370-380.
  • Charon R. Medical interpretation: Implication of literary theory of narrative for clinical work. Journal of Narrative and Life History. 1993; 3 (1): 79-97.
  • Charon R. The narrative road to empathy. In Empathy and the medical profession: Beyond pills and the scalpel. Edited by Howard Spiro. New Haven: Yale University Press, 1993: 147-59.
  • Charon R. Narrative contributions to medical ethics: Recognition, formulation, interpretation, and validation in the practice of the ethicist. In Beyond Principlism: Currents in U.S. Bioethics. Philadelphia: Trinity Press International, 1994:260-83.
  • Greene M., Adelman R., Freidmann E., Charon R. Older patient satisfaction with communication during and initial medical encounter. Social Science and Medicine. 1994;38:1279-88.
  • Charon R., Greene M., Adelman R. Multi-Dimensional Interaction Analysis: A collaborative approach to the study of medical discourse. Social Science and Medicine. 1994; 39:955-65.
  • Charon R. The internist's library: Doctors at the heart of the novel. Annals of Internal Medicine. 1994;121:390-1.
  • Charon R., Greene M., Adelman R. Women readers, women doctors: A feminist reader-response theory for medicine. In The empathic practitioner: Empathy, gender, and medicine. Edited by Ellen Singer More and Maureen A. Milligan. New Brunswick, NJ: University of Rutgers Press, 1994:205-221.
  • Charon R. Narrative accuracy in the clinical setting. Medical Encounter. 1994;11(1):20-23.
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About the Author: Rita Charon, M.D., Ph.D. is a general internist and Associate Professor of Clinical Medicine at the College of Physicians and Surgeons of Columbia University where she directs the Programs in Narrative Medicine, Humanities and Medicine, and the Clinical Skills Assessment Program. Dr. Charon graduated from Harvard Medical School in 1978, trained in internal medicine at the Residency Program in Social Medicine at Montefiore Hospital in New York, completed a year?s fellowship in general internal medicine at the College of Physicians and Surgeons of Columbia University in 1982, and has practiced general internal medicine since 1981 at Columbia. She received the Ph.D. in English at the Department of English and Comparative Literature at Columbia University in 1999, having written her doctoral dissertation on the use of literary methods in understanding the texts and the work of medicine.

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