The Principles and Practice of Narrative Medicine
Charon, Rita, DasGupta, Sayantani , Hermann, Nellie, Irvine, Craig, Marcus, Eric, Rivera Colón , Edgar , Spencer, Danielle , Spiegel, Maura
Primary Category:
Literature /
Nonfiction
Genre: Treatise
-
Annotated by:
- Carter, III, Albert Howard
- Date of entry: Feb-07-2017
- Last revised: Feb-07-2017
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.
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.
Miscellaneous
The book
offers discussion of a rich range of texts, graphic novels, and film.
The book is very well researched: the chapters contain over 500 footnotes; the bibliography runs 20 pages.
Charon acknowledges William Osler’s The Principles and Practice of Medicine as the model for the book’s title (p. 2).
Charon celebrates the handsome Mark Rothko image on the hardbound cover for artistic appeals that go beyond “content” and “contemplation” (p. 183).
While some technical terms are explained in the text, readers may need a dictionary or Web access for words such as “interpellated,” “Hyperuranion,” and “imbrication” (pp. 25, 77, 263).
The book is very well researched: the chapters contain over 500 footnotes; the bibliography runs 20 pages.
Charon acknowledges William Osler’s The Principles and Practice of Medicine as the model for the book’s title (p. 2).
Charon celebrates the handsome Mark Rothko image on the hardbound cover for artistic appeals that go beyond “content” and “contemplation” (p. 183).
While some technical terms are explained in the text, readers may need a dictionary or Web access for words such as “interpellated,” “Hyperuranion,” and “imbrication” (pp. 25, 77, 263).
Publisher
Oxford University Press
Place Published
New York
Edition
2017
Page Count
347
Commentary
The book does well by recognizing emotions, but there is scant regard to the religious or spiritual status of people sick or well. Chaplains are mentioned a handful of times, but many hospitals have departments of pastoral care and welcome clergy who visit patients. In times of serious illness or injury, patients of faith and their caregivers turn to that faith’s narratives about suffering, death, and, typically, a life beyond death. Many caregivers make faith part of their practice, their calling. Narrative medicine can readily and profitably be extended in this direction.
This book emphasizes medicine in its own “restitution narrative” (p. 71) of recovery from illness more than extension of health or avoidance of illness or injury. The practice of the title is primarily in clinics, hospitals, or classrooms. While healing from injury and illness is important, maintaining health is important as well: health promotion, incremental care, long-term relations between patient and primary care doctor (and other clinic staff) are low-cost and high yield. Enabling narratives of self-care can be powerful and useful over decades of a person’s life, even as death approaches.
Discussion of careful listening and witnessing is mostly from the doctor’s perspective. Nursing is mentioned (p. 286) but neither nurses nor the many allied healthcare workers. Everyone in healthcare should practice attentive listening, providing the values of attention, representation, and affiliation. The “widening of the clinical gaze” can go well beyond physicians. Health Humanities emphasizes, as well, unpaid caregivers such as family members, probably the largest group of caregivers around the world.
The book is fueled by a decade of experience and strong commitment. Besides its many benefits, there are some claims that seem overstated, for example, “At the core of the concepts of narrative medicine…is our framing principle that the central events of healthcare are the giving and receiving of accounts of self” (p. 286). The account of Ms. N. illustrates this claim but cannot be taken as a model for all of healthcare. Sharing stories of self are context-dependent (think of the Emergency Room) and, often, role-dependent (as patients, we typically don’t want to hear all about our doctor or our nurse). Even small clues of social equality between caregiver and patient (small talk, a smile, a pat on the arm) have their own power to comfort, encourage, and heal.
Although recognizing the “indeterminacy of stories,” Ch. 6 affirms “rules of conduct” and the “moral compass” in literary texts (p. 113). Further, according to narrratology, the reader judges the “moral limits and claims within the story” (p. 133). Such statements risk reducing literature (or spoken stories) to allegories or morality tales. Values of many kinds, including morals, vary widely by cultures, literary traditions, and the individual tellers and listeners.
The timing for this fine and useful book is good. It is needed to improve “reductionist, fragmented medicine” (p. 1), and it joins other intellectual currents that deepen our sense of caregiver and patient, for example the emerging field of Health Humanities. Indeed Chapter 6 offers six links to that field.