Summary:
INTRODUCTION
Writing for
all the co-authors, Rita Charon challenges “a reductionist, fragmented medicine
that holds little regard for the singular aspects of a person’s life” and
protests “social injustice of the global healthcare system” (p.1). She gives a
history of narrative medicine, lists its principles, and summarizes the book’s chapters,
mentioning that several come as pairs that present theory then practice. The
six principles are “intersubjectivity, relationality, personhood and
embodiment, action toward justice, close reading (or slow looking), and
creativity” (p. 4). The basic
thesis is that healthcare can be improved by narrative medicine because
“narrative competence can widen the clinical gaze to include personal and
social elements of patients’ lives vital to the tasks of healing” (p. 1).
This is a dense, theory-laden book from the group at Columbia University. The summaries below touch of some of the major points.
PART I, INTERSUBJECTIVITY
Ch. 1, Account
of Self: Exploring Relationality Through Literature
Maura Spiegel and Danielle Spencer describe the richness of literature
that allows readers to respond creatively. In clinical settings, a caregiver
may similarly listen attentively and help co-construct a narrative with the
patient. Literature can help us explore “the limits of rationality and
positivism” (p. 29) and move from “a model of autonomy to one of relationality”
(p. 34).
Ch. 2, This
is What We Do, and These Things Happen:
Literature, Experience, Emotion,
and Relationality in the Classroom.Spiegal and Spencer write that current medical education
does a poor job of helping future physicians with their emotions. Clinicians profit from a
more integrated self and will listen better to patients and respond to
them.
PART II, DUALISM, PERSONHOOD, AND EMBODIMENT
Ch. 3,
Dualism and Its Discontents I:
Philosophy, Literature, and Medicine
Craig Irvine and Spencer start with three literary examples
that illustrate separation of mind and body. This dualism has pervaded modern
medicine, causing losses for patients and caregivers, especially when there are
power imbalances between them. The “clinical attitude” (p. 81) dehumanizes both
caregivers and patients.
Ch. 4,
Dualism and Its Discontents II:
Philosophical Tinctures
Irvine and Spencer argue that both phenomenology
(appreciative of embodied experience) and narrative hermeneutics (privileging
reciprocal exchange of persons) help us move beyond dualism. Theorists Edmund Pellegrino
(also a physician), Richard Zaner, and Fredrik Svenaeus help us understand how
caregivers and patients should relate.
Ch. 5,
Deliver Us from Certainty: Training for Narrative Ethics
Craig Irvine and Charon write that various humanistic
disciplines “recognize the central role narrative plays in our lives” (p.111).
There is, however, “indeterminacy” in stories that “cannot be reduced by
analyzable data” (p. 113). Narrative ethics urges us to consider issues of
power, access, and marginalization for both the teller and the listener. The
authors review recent ethical traditions of principalism, common morality,
casuistry, and virtue-based ethics. They believe that narrative ethics,
emerging from clinical experience and now allied with feminist and structural
justice frameworks, will provide a better approach for many reasons. “Narrative
ethics is poised to integrate the literary narrative ethics and the clinical
narrative ethics” (p. 125).
PART III, IDENTITIES IN PEDAGOGY
Ch. 6, The
Politics of the Pedagogy: Cripping, Queering and Un-homing Health Humanities
Sayantani DasGupta urges attention to issues of power and
privilege in classrooms, lest they “replicate the selfsame hierarchical,
oppressive power dynamics of traditional medicine” (p. 137). “Cripping” and
“queering” provide new perspectives on knowledge, for example the untested
binaries of physician/patient, sick/well, elite/marginalized, teacher/student.
Drawing on disability studies, health humanities, and queer politics, DasGupta
challenges “medicalization” and the “restitution narrative” (p. 141).
PART IV, CLOSE READING
Ch. 7,
Close Reading: The Signature Method of Narrative Medicine
Charon stresses “the accounts of self that are told and
heard in the contexts of healthcare” (p. 157). Close reading, traced from I. A.
Richards through reader response theorists, is “a central method” for narrative
medicine (p. 164). Close reading enhances attentive listening,
and both of these deepen relationality and intersubjectivity, allowing for
affiliation between caregiver and patient (pp. 175-76). Such linkages aid
healthy bodies and minds, even the world itself (p. 176).
Ch. 8, A
Framework for Teaching Close Reading
Charon describes how she chooses texts and provides prompts
for responsive creative writing. She illustrates “the cardinal narrative
features—time, space, metaphor, and voice” (p. 182) in literary works by Lucille
Clifton, Henry James, Galway Kinnell, and Manual Puig.
PART V, CREATIVITY
Ch. 9, Creativity: What, Why, and Where?
Nellie Hermann writes that “healthcare in particular has a
vexed relationship to the notion of creativity,” in part because of issues of
control (pp. 211-12); values of “evidence based” and “numbers-driven” medicine are
also factors. Narrative medicine, however, “is about reawakening the creativity
that lives in all of us” (p. 214).
Ch. 10, Can
Creativity Be Taught?
Hermann reports on techniques used in the College of
Physicians and Surgeons at Columbia, including prompts and a Portfolio program.
A “Reading Guide” helps clinical faculty (and others) respond to student
writing. Responses to writing can nourish the “creative spark.”
PART VI, QUALITATIVE WAYS OF KNOWING
Ch. 11,
From Fire Escapes to Qualitative Data: Pedagogical Urging, Embodied Research, and Narrative Medicine’s
Ear of the Heart
Edgar Rivera Colón suggests that “we are all lay social
scientists of one kind or another,” seeing people in action in various
contexts. He affirms an “assets-based approach to public health challenges, as
opposed to a deficits-based and pathology-replicating paradigm” (p. 259). We
are all embodied actors in relationship to power, privilege, and social
penalty.
Research through interviews and participant observation show
“meaning worlds” in tension with “systemic inequality and structural violence”
(p. 263).
Ch. 12, A Narrative
Transformation of Health and Healthcare
Charon presents and analyzes a case study of patient Ms. N. as treated
by internist Charon. They’ve been working together for decades. Charon writes
up her perceptions and shares them with Ms. N. Speaking together, they “became
mirrors for one another” (p. 274). Psychiatrist Marcus discusses transference
and transitional space in that experience. A caregiver as witness can
shift healthcare from “instrumental custodianship to intersubjective contact”
(p. 288).
Ch. 13, Clinical
Contributions of Narrative Medicine
Charon describes applications of narrative medicine, all with the aim
of improving healthcare. She describes techniques for interviews of patients,
writing methods, and ways to improve the effectiveness of healthcare teams, as
well as changes in clinical charts and other narrative descriptions of
patients.
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