Narrative Medicine: Honoring the Stories of Illness
- Carter, III, Albert Howard
- Date of entry: Apr-26-2006
This is an ambitious and far-ranging book, the result of years of thinking, teaching, and working with patients. An internist at the College of Physicians and Surgeons at Columbia University, Charon sees a wide range of patients in an urban setting. Also a Ph.D. in English literature, Charon has devised a "Parallel Chart" and other means for caregivers to write personally about the dynamics between healer and patient, to read texts--narratives in particular--and, as a result, to listen better to patients, thus improving the delivery of medical care.
Charon defines narrative medicine as "medicine practiced with these skills of recognizing, absorbing, interpreting, and being moved by the stories of illness" (4). She calls this a "new frame" for medicine, believing that it can improve many of the defects of our current means of providing (or not) medical care. Caregivers who possess "narrative competence" are able to bridge the "divides" of their relation to mortality, the contexts of illness, beliefs about disease causality, and emotions of shame, blame, and fear.
Charon finds that medical care and literature share five narrative features; she argues that careful reading of narratives builds skills that improve medical care, including intersubjectivity between caregiver and patient, and ethicality. Beyond the theory, there are powerful and persuasive examples of interactions between caregiver and patient, many from Charon's own practice. A mother of a sick daughter experiences stress that makes her ill; when she sees a narrative connection, she begins to heal.
Charon sees wider applications. As caregivers understand better concepts of attention, representation, and affiliation, they become more ethical, more community minded, and better healers to their patients. Patient interviews will be different: instead of following a grid of questions, physicians will converse with patients in an open-ended way. What is most important will emerge and emerge in ways that are most beneficial to the patient. Yes, this method will take more time but it will be more efficient in the long run. Bioethics, Charon argues, has been limited by legal approaches and philosophical principles. For her, narrative bioethics offers more human values in how people feel, experience reality, and relate to each other. Finally, there are implications for social justice: why are the poor underserved in this country and in many others?
One of the most exciting and radical formulations comes late in the book: ". . . practitioners, be they health care professionals to begin with or not, must be prepared to offer the self as a therapeutic instrument" (p. 215). This notion links up fruitfully with concepts of energy medicine (v1377v), therapeutic touch (Tiffany Field), and intentionality (Wayne W. Dyer).
Oxford Univ. Press
Oxford & New York
Charon's work is a most welcome impulse to a medical world fraught with many restrictions: limits on doctor's time, underserved populations, the webs of insurance, economics, HMOs, protocols and more. There are also the reductionisms that are the relics of 19th-century positivism: medical reasoning that blindly follows statistical likelihoods, regardless of variations by age, sex, ethnicity, or individual psychologies. As medical care becomes routinized, mechanized, and rationalized, many of the healing comforts of a kind word, a calm look, a loving touch have been lost. The underlying message of this book is that medicine must be re-humanized, a theme we find in some medical schools, in the Complementary and Alternative Medicine movement, in the New Medicine, and in the Planetree Alliance of over a hundred hospitals across the U.S.
Charon's argument is important. The book is carefully laid out and well researched. She blends together a wide range of clinical experiences including her own medical practice and writings from many areas, literary theory, literature, pathographies, bioethics, and cultural criticism. There are 20 pages of references.
Charon's particular approach is focused on realistic literature, especially from Anglo-American writing on either side of 1900. There are no mentions of the stories of absurdist drama, ancient myth, fantastic literature, or the Beat generation. And there is a specific critical assumption: she sees literature as instrumental and moral. She writes, "An author achieves an enduring ethical vision, developed or repeated in work after work, that can educate his or her serious reader" (56). The reader, as well, has specific, preordained jobs: "One task is to seek out the most fruitful 'implied reader' for each text, selecting among countless possible readers . . . " (110). Such claims represent a limited viewpoint about writing and reading, but they do not damage Charon's over-all argument that healthcare works best when it is humanized by caring people who listen sensitively to each other. Indeed her subtitle, "Honoring the Stories of Illness" is not only helpful but inspiring.