Narrative Medicine: Honoring the Stories of Illness
http://www.100md.com
《新英格兰医药杂志》
An exercise in the trendy 1979 art manual Drawing on the Right Side of the Brain had the would-be artist copy a Picasso drawing of Igor Stravinsky that was printed upside down. The results were remarkable: a far more faithful rendition than the untalented could produce by transcribing the image right side up. The inversion forced readers to look at the picture in a new way, leading them to take the drawing on its own terms, to follow its own unique lines rather than try to assimilate them into an unconscious (or conscious) prototype.
In a sense, Narrative Medicine proposes a similarly fresh way of looking at patients. Instead of approaching each patient with the same schematic and eliciting the information required to fill in the blanks, narrative medicine would have doctors take their lead from what patients want to tell them and the way in which they want to tell it. That approach, as author Rita Charon describes it, does seem to draw on a different "side of the brain," an unaccustomed mode of thinking. "Narrative," writes Charon, "makes its own paths, breaks its own constraints, undercuts its own patterns. . . . can make new out of old, creating chaos out of linearity while, subversively, exposing underlying fresh connections among the seemingly unrelated."
In this case, however, the "new" approach may be novel only to physicians acting in their professional role — for nonphysicians, becoming acquainted with people and their medical problems has always meant listening to stories. And as is true of literary narratives, the way in which such stories are told is often as revealing as the events they relate. So, in another sense, the narrative approach, far from being analogous to viewing Stravinsky upside down, resembles our everyday way of knowing another person.
Of course, when friends, relatives, or acquaintances hear others' medical tales, they usually need only commiserate and console — or call a doctor. Physician-listeners, by contrast, must glean clinically significant facts from these stories and use them to make diagnostic and therapeutic decisions. But in Charon's view, this means only that physicians, like literary critics or writers, need to be expert story readers, attuned to the structure of stories and their levels of meaning. Engaging with patients in the way well-trained readers engage with novelists, narrators, and characters, the theory goes, is one way to restore to medicine its lost humanity, rendering physicians more humble, more respectful of patients, and more able to see things from their patients' perspectives.
Such expertise is not easy to develop; whereas Charon is a physician with a Ph.D. in English literature, the average doctor cannot necessarily interpret the form and content of a story in a valid or clinically useful way. But Charon defines five features as key to medical narratives — temporality, singularity, causality or contingency, intersubjectivity, and ethicality — and trains students to attend to them when they keep a "parallel chart," a record of their own experiences of patients' illnesses. She says that a study at Columbia University is finding that such students become "more effective in conducting medical interviews, performing medical procedures, and developing therapeutic alliances with patients"; that they have "more confidence in their ability to care for seriously ill and dying patients"; and that they "improve their ability to adopt the perspectives of others."
Charon brings narrative into her own practice as well. In clinic visits, for example, she listens as patients tell their stories and then, stepping out of the room while they undress, writes down everything she remembers, in the order in which it was told. Physicians will say they do not have time for this approach. Charon will counter that it "doesn't take any longer than the write-as-you-go method" and that her "notes are far more telling than they used to be." More important, she says, this approach has ripple effects: the narratively retrained eye finds a full three dimensions when it examines any patient. "I do not write about many patients in my practice," she notes, "but I find that writing about some of them intensifies the attention I am able to pay to all of them."
The first portion of Narrative Medicine summarizes the intellectual underpinnings of the field that Charon has helped create, but it is in describing her own practice that her story becomes most compelling, as she enacts her thesis that the narratives through which we understand much of life draw us closer to one another. In a chapter entitled "Telling One's Life," Charon tells of an "89-year-old African American woman with hypertension, breast cancer, spinal stenosis, insomnia, and uncontrollable anxiety" who reveals to her, after a 20-year clinical relationship, a secret she has kept for 80 years — that her anxiety stems not from having fallen off a horse in childhood but from being raped by a white boy. The revelation frees her of a whole host of symptoms. Such emotionally compelling stories hook us and allow us to "know" patients in an apparently fuller way than a sterile medical chart generally permits. If physician-readers are sufficiently moved, perhaps they, like Charon, will feel compelled to do something about it.
That something may begin with eschewing the interview script taught in medical school, but if Charon's practice is any indication, the subversion of conventional professional boundaries won't stop there. As Charon's story unfolds, we see her paying for one patient to join a gym, providing (guided but amateur) psychotherapy to another, and springing a third from a nursing home to care for her in the patient's home. Having come to know patients through the sorts of stories that link us to our friends and relatives, she responds as a whole person to them as whole people, unconfined by the traditional strictures of her profession (and sometimes, as she acknowledges, teetering on the edge of riskily inappropriate behavior).
Recognizing that such work "may sound excessive," Charon assures us that these instances are rarities, but she believes that her relationships with these patients have benefited not only them and her other patients but herself as well. Reminding her of what is fulfilling about being a doctor, connecting her with people whom she is in a position to help, "these new approaches to medicine," she writes, "have given me tremendous pleasure and lift." The test for narrative medicine will be whether physicians in whom it reawakens passion and compassion can master it and learn to stick their necks out just far enough to improve patient care, even in this era of speed visits.
Debra Malina, Ph.D.(By Rita Charon. 266 pp. N)
In a sense, Narrative Medicine proposes a similarly fresh way of looking at patients. Instead of approaching each patient with the same schematic and eliciting the information required to fill in the blanks, narrative medicine would have doctors take their lead from what patients want to tell them and the way in which they want to tell it. That approach, as author Rita Charon describes it, does seem to draw on a different "side of the brain," an unaccustomed mode of thinking. "Narrative," writes Charon, "makes its own paths, breaks its own constraints, undercuts its own patterns. . . . can make new out of old, creating chaos out of linearity while, subversively, exposing underlying fresh connections among the seemingly unrelated."
In this case, however, the "new" approach may be novel only to physicians acting in their professional role — for nonphysicians, becoming acquainted with people and their medical problems has always meant listening to stories. And as is true of literary narratives, the way in which such stories are told is often as revealing as the events they relate. So, in another sense, the narrative approach, far from being analogous to viewing Stravinsky upside down, resembles our everyday way of knowing another person.
Of course, when friends, relatives, or acquaintances hear others' medical tales, they usually need only commiserate and console — or call a doctor. Physician-listeners, by contrast, must glean clinically significant facts from these stories and use them to make diagnostic and therapeutic decisions. But in Charon's view, this means only that physicians, like literary critics or writers, need to be expert story readers, attuned to the structure of stories and their levels of meaning. Engaging with patients in the way well-trained readers engage with novelists, narrators, and characters, the theory goes, is one way to restore to medicine its lost humanity, rendering physicians more humble, more respectful of patients, and more able to see things from their patients' perspectives.
Such expertise is not easy to develop; whereas Charon is a physician with a Ph.D. in English literature, the average doctor cannot necessarily interpret the form and content of a story in a valid or clinically useful way. But Charon defines five features as key to medical narratives — temporality, singularity, causality or contingency, intersubjectivity, and ethicality — and trains students to attend to them when they keep a "parallel chart," a record of their own experiences of patients' illnesses. She says that a study at Columbia University is finding that such students become "more effective in conducting medical interviews, performing medical procedures, and developing therapeutic alliances with patients"; that they have "more confidence in their ability to care for seriously ill and dying patients"; and that they "improve their ability to adopt the perspectives of others."
Charon brings narrative into her own practice as well. In clinic visits, for example, she listens as patients tell their stories and then, stepping out of the room while they undress, writes down everything she remembers, in the order in which it was told. Physicians will say they do not have time for this approach. Charon will counter that it "doesn't take any longer than the write-as-you-go method" and that her "notes are far more telling than they used to be." More important, she says, this approach has ripple effects: the narratively retrained eye finds a full three dimensions when it examines any patient. "I do not write about many patients in my practice," she notes, "but I find that writing about some of them intensifies the attention I am able to pay to all of them."
The first portion of Narrative Medicine summarizes the intellectual underpinnings of the field that Charon has helped create, but it is in describing her own practice that her story becomes most compelling, as she enacts her thesis that the narratives through which we understand much of life draw us closer to one another. In a chapter entitled "Telling One's Life," Charon tells of an "89-year-old African American woman with hypertension, breast cancer, spinal stenosis, insomnia, and uncontrollable anxiety" who reveals to her, after a 20-year clinical relationship, a secret she has kept for 80 years — that her anxiety stems not from having fallen off a horse in childhood but from being raped by a white boy. The revelation frees her of a whole host of symptoms. Such emotionally compelling stories hook us and allow us to "know" patients in an apparently fuller way than a sterile medical chart generally permits. If physician-readers are sufficiently moved, perhaps they, like Charon, will feel compelled to do something about it.
That something may begin with eschewing the interview script taught in medical school, but if Charon's practice is any indication, the subversion of conventional professional boundaries won't stop there. As Charon's story unfolds, we see her paying for one patient to join a gym, providing (guided but amateur) psychotherapy to another, and springing a third from a nursing home to care for her in the patient's home. Having come to know patients through the sorts of stories that link us to our friends and relatives, she responds as a whole person to them as whole people, unconfined by the traditional strictures of her profession (and sometimes, as she acknowledges, teetering on the edge of riskily inappropriate behavior).
Recognizing that such work "may sound excessive," Charon assures us that these instances are rarities, but she believes that her relationships with these patients have benefited not only them and her other patients but herself as well. Reminding her of what is fulfilling about being a doctor, connecting her with people whom she is in a position to help, "these new approaches to medicine," she writes, "have given me tremendous pleasure and lift." The test for narrative medicine will be whether physicians in whom it reawakens passion and compassion can master it and learn to stick their necks out just far enough to improve patient care, even in this era of speed visits.
Debra Malina, Ph.D.(By Rita Charon. 266 pp. N)