Journal of the Oklahoma State Medical Association Introduction: A Symposium in Seven Parts “Jerry Vannatta, MO; Ronald Schleifer, PRD Shella Crow, PhD ay the nglecof the study of the humanities, which has been farto0 general. the profession loses aver precious quality Sr Wiliam Osler’ PREFACE This paper is the first of an eight-part symposium that describes "the role of narrative in the everyday practice ‘of medicine” This subtitle, which prefaces each of the subsequent parts of the symposium, Is adapted from the title of a work that the authors wrote and produced in 2005, Medicine and Humanistic Understanding: The Significance of Narrative in Medical Practices, published by the University of Pennsylvania Press. We say “produced,” because this work is an interactive DVD-Rom, consisting of more than 700 screens and 3 hours of video interviews, simulations, and montages. Much of the contents of the symposium is based upon and elaborates the work of Medicine and Humanistic Understanding, and interested readers will find there in- depth discussions of issues examined in the symposium, The authors are all members of the faculty at the University of, ‘Oklahoma, Dr. Jerry Vannatta, MD, is John Flack Burton Professor of Medical Humanities and David Ross Boyd Professor at the University of Oklahoma. He is Professor of intemal Medicine, Adjunct Professor of English, and former Executive Dean of the University of Oklahoma College of Medicine. Dr.Vannatta isalso Adjunct Professor of Humanitiesin the HonorsProgram, Oklahoma City Univesity Professor Ronald Schleifer, PRD, is George Lynn Cross Research Professor of English at the University of Oklahoma. He has written or edited sixteen books - including studies of narratology, literary criticism, and the relationships between science and literature in the twentieth century ~ and is the former editor of the literary journal Genre: Forms of Discourse ‘and Culture. He is also Adjunct Professor in Medicine. Professors Schleifer and Vannatta have team-taught undergraduate and medical-college courses in medicine and literature for many years. Correspondence t:Jrry 8, Vannatta MID, Jahn Flack Burton Profesor of Hamanites in Medicina, Davia Ross Goyd Professor of Medicine, University of Oklahoma College of Medicine, WP 1160 2D. Bex 26901, Olaho™a City, Oklahoma 73190 2+ Narrative Medicine Shella Crow, PhD, is Director of the Office of Educational Development & Support in the College of Medicine at the University of Oklahoma. She is an Associate Professor in Pediatrics and Adjunct Assistant Professor in Human Relations, Professor Crow is responsible for organizing many of the humanities related activities in the undergraduate and graduate program, as well as faculty development in this area. INTRODUCTION For the majority of physicians who practice medicine, at least in the westem world, the practice can be said to be primarily narrative in nature, This is because by far and away the most ‘common task ofthe physician is eliciting stories ~ interviewing, ‘negotiating with or teaching ~ a patient. It has been estimated that most physicians will perform this task around 200,000 times in a career? Interviewing, discussing, listening and teaching all involve stories (or narrative). The patient is telling the physician a story ~ one that represents why they made the ‘appointment or the essence of how they are suffering. We call this story the History of Present Iliness (HPI). The patient and the physician may be discussing a diagnosis or treatment = narratives concerning why the patient should participate in a certain therapy ~ or why the patient is skeptical about that therapy. The physician may be attempting to teach the patient enough about their particular illness to convince them that they should participate in the treatment prescribed. All of these activities are narratives ~ stories in short, These storied ‘messages — of the physician, of the patient, and the patient’s family — function in the same way all stories do. They are designed to communicate time frames, motives, characters, plot, and often an “unsaid” message as well as the one clearly verbally articulated, All of this is common sense to the physician who has been practicing medicine, even for a short period of time. Most physicians learn from the mistakes of not getting the HPI exactly right, We suffer the consequences ‘of missing the diagnosis, or providing a service that missed the mark because we listened more attentively to the “Chief Complaint” rather than the “Chief Concern.” Unlike the Chief Complaint, which describes a patient’s ailment mostusually in physiological terms, the Chief Concern describes the way that whatever brings him to the physician affects his quality of life. For this reason, whether explicit or implicit, it presents itself as a narrative, Such narrative information, as ‘we shall se, is crucial to treatment and patient (and physician) satisfaction, However, our profession has spent little time training medical students residents, and practicing physicians in the competences associated with the task of apprehending narrative, Furthermore, we have spent virtually no time at all discussing the consequences of misapprehending the story ~ of being narratively incompetent. Ifwe accept the premise that the history of present iliness ~ the patient's story of suffering — is the most powerful diagnostic information available to us, then ‘we must conclude that filing to properly understand that story can be devastating ~to the patient and to us as professionals. It is the thesis of the articles that will follow in this symposium that the physician can improve his or her apprehension of the patient’s story by attending to the skills of narrative competence, and therefore practice better medicine. This we believe will create a physician who will have, in addition to the skills of scientific practice and evidence based medicine, those necessary to practice patient centered, empathic medicine. Narrative competence will, we believe, Jead a physician more commonly to engage with their patient rather than detach — which is what commonly occurs, The aticles in this series will accomplish three goals toward an exploration of Narrative Medicine, The first goal isto define Narrative Medicine and explore its many roles inthe everyday practice of medicine. This goal will be met in this next paper in the series, “Definition of Narrative Medicine,” and in the second, Development of a Patient-Physician Relationship. The second goal isto explore the competencies associated with the ‘engagement withthe patient's story: 1) to acknowledge it, 2) absorb it, 3) interpret it, 4) and act in response to it. Each of these four competencies will be discussed in detail in the third and fourth papers of the series, “Narrative Knowledge” and “Making the Diagnosis.” The fourth competency, responsive and responsible action, encompasses the ethical action within a physician's professional behavior. This ethical action of everyday medical practice is explored through virtue ethies in the fifth and sixth papers of this symposium, “Medical Ethics and Narrative” and “Ethics and the Everyday Practice of Medicine.” The third major goal of this series of articles is to explore a strategy to improve the narrative competence of Jeamers, ie. medical students, residents, and those of us who perform this task many times a day in the everyday practice of medicine. This strategy is designed to improve communication and understanding — between doctors and patients — and to make the relationship between physician and patient more ‘meaningful and fulfilling for both It is also a strategy that can be woven into a physician’s everyday life as well as planned like any other continuing medical education activity. These strategies will be discussed in detail in the seventh and last paper of the series, “Developing Narrative Competence.” REFERENCES 1 Osler, ila, Montreal Medica Journal 26: 186, 1887, 2 Upkin, M. et al The Medical Interview, Clnieal Care, Education, ond (hnical Research New York Springer verlo, 1995, reace Narrative Medicine «3The Journal of the Oklahoma State Medical Association Part One: Definition of Narrative Medicine Jerry Vannatta, MD; Ronald Schleifer, PhO; Shella Crow, PhD “Medicinestsef< more nanntivey inflected enterprise than trees its procticei suffused with ttenvon toes temporal hovzens, wth the commitment describe the singular wit the urge to uncover plot ond with an enarenessof he inesubjectve and ethical nature of healing ita Charon, M.D, PRD! DEFINITION OF NARRATIVE MEDICINE Narrative Medicine is @ term invented by Rita Charon M.D. Ph.D., professor of both medicine and literature at Columbia University. Dr. Charon is a general internist and has a Ph.D. in English literature, focusing on the narratives of Henry James, She is the director of the Narrative Medicine Program at College of Physicians and Surgeons, Columbia University, She defines narrative medicine, as “medicine practiced with the narrative competence to recognize, absorb, interpret, and be ‘moved by the stories of illness.” By this term she implies that ‘much of what we da in medicine is narrative in nature and that a physician can practice better medicine by becoming narratively competent Examples of narrative activities in medicine are: ‘The initial history of present illness, the physician’s retelling of that story to the patient in a medicalized form, the negotiation of a diagnosis, and the negotiation ofa treatment plan Although stories seem simple, these medical stories ~ like all stories — involve complex arrangements of time sequence, motive, character, plot, and desire, Narratologists use a variety of frameworks t0 organize and study narratives, However, the basic categories of time, motive, plot, desire, and character are common and are specifically used by Dr. Charon in an essay “Literary Concepts for Medical Readers: Frame, Time, Plot, Desire.” We will discuss each of these categories as they relate to stories in general and to how they function particularly in the practice of medicine. Quite simply, if we accept the proposition that encountering narrative is a crucial component of the practice of medicine ‘and that a physician can be better at narrative apprehension by practice much like getting better at performing a colonoscopy, then we can define the idea of narrative competence and wonder how one would increase his or her competence in i, Narratively competent individuals — those trained in literary studies ~ are better at analyzing the story, recognizing its genre, articulating its meanings and themes, understanding. its metaphors and similes. Those who are better at these skills are also better at reading what remains “unsaid” in the course of a story and figuring out how the unsaid fits into the motive of the characters, the events of the narrative, and the desire of 4+ Narrative Medicine the author, These people can better read or listen to a story, and because of their understanding of narrative, its structure, components, and their profound understanding of the language, better apprehend the “meaningful whole” of the story. The meaningful whole is an important concept in any discussion of narrative medicine and narrative competence. The scientific concepts in medicine are mostly derived from a reductionist science where the whole equals the sum of the parts. Narrative is a non-reductionist enterprise where the whole is greater than the sum of its parts, just as a sentence has meaning greater than the sum of the individual words or letters comprising it. The meaningful whole of medical narrative includes, among other things, the biomedical content, its emotional affect, body language, and social, religious and cultural context. An important part of the whole of narrative is an emotional domain that is absent in the logico-scientific part of medicine This ‘domain is an essential component of the meaningful whole that the competent physician is “reading” in the text of the patient because it is closely tied to the pationt’s Chief Concern, AS physicians, we are all familiar with the range of emotion patients bring to our offices. Such emotion is a powerful resource for building the patient-physician relationship, uncovering. vital information, and negotiating treatment plans that will be followed. It is also a resource for much joy of our profession. "Narrative Medicine isa field that includes not only the story the patient tells the physician but also the many other stories of, medicine. It includes among others the stories associated with diagnostic tests, the possibilities of treatments and their possible failures. Italso commonly includes a story about the end of life. ‘This symposium will focus on literature as narrative and apply ‘what we have leamed about the intersection of literature and medicine. This is not to minimize the importance of all other narratives as they apply to our clinical enterprise but to allow us a medium sufficient to explore in enough depth to provide the reader and practitioner of medicine an understanding of its application. Literature, insofar as it presents narratives that are ‘written, rewritten, polished, and professionally discussed, offers stories that often starkly reveal the workings of the hundreds of everyday narratives we encounterWe will now turn our attention to a set of concepts used by some narratologists (0 analyze stories. Just as we need a vocabulary to understand physiology and pathophysiology we also need a vocabulary to discuss and analyze stories. We will borrow the vocabulary Dr. Charon used to discuss stories in the article, “Literary Concepts for Medical Readers: Frame, Time, Plot, Desire.”* NARRATIVE TIME Al stories have a beginning, middle, and an end. ‘The story js told in some sort of time sequence. Most stories prior to the “post-modern” era were told in @ manner in which we ‘could easily discern the chronological order of beginning, middle, and end, even when there were flashbacks and other disruptions of chronological order. For instance, in Madame Bovary, Flaubert begins the story by introducing a comical, ironic little boy wearing a ridiculous hat. ‘The boy grows to ‘2 man, marries a woman, Madame Bovary, and ends with hher commiting suicide. The middle of the story proceeds in chronological sequence. In the post-modern era of literature, the story, especially inthe form ofthe novel, the events suggest confusions in time so thatthe story might begin at the end and then vibrate in time, coming back to the beginning to end it, The ability to comprehend events as narrative is to grasp the organization of beginning-middle-end. Such comprehension ~ getting the story “right” — frequently allows us to discem causal sequence, the difference between important and trivial events in the story, and even what is missing from the narrative, the “unsaid.” It is common for our patients to tell us stories about their illnesses, starting in the middle, jumpingaround chronologically, and maybe even getting their ideas of cause and effe backward. If we are not Keenly aware of this “time problem’ ‘and competent at apprehending it, we will likely fail to get the story exactly right. This will lead to getting the HPI wrong and missing the best diagnostic evidence available. Attending to the time sequences ofthe patient's story is therefore very important, and in fact is the basis for the basic logic of diagnosis, arguing from effect to cause. MOTIVE Motive speaks to the characters in a story. Stories have characters who behave in certain ways, their behavior molded bby motives. The behavior of the characters drives the plat (what happens) and the category of motive makes explicit the connections among the events of a story. In this way, it commonly gives the reader of the story insight into the themes being explored in the narrative, Motive is commonly “unsaid.” ‘The discerning listener or reader must make educated guesses as to what motive drives action. Experienced readers of difficult literature, who are also good students of the human condition and its attendant psychological nuances, are better at understanding the motive behind the character’s behavior. The reader must make educated guesses along the way in reading the story, and then ensure that their guesses make sense and “work” in apprehending the meaningful whole. In Richard Selzer's short story “Imelda” a physician on a mission trip to South America agrees to operate on a young git!’s cleft palate, Her mother is overjoyed at this act of kindness, Unfortunately, the girl dies of malignant hyperthermia before the operation. The surgeon returns to the morgue that evening ‘and fixes the girls deformity before the mother views the body. The motive behind this surgeon's action is ambiguous ~ unsaid . Selzer invites his readers to interpret it for themselves. Ambiguity is certainly important for seeing the ways that narrative competency can contribute to success in the practice ‘of medicine. Most of a medical education is concentration on the abstract sciences in which ambiguity is minimized if not ignored altogether. Maybe because the physician prepares him or herself for a medical education by studying these sciences = or possibly because a career in medicine attracts people ‘who seek unambiguous solutions to problems ~ the medical student commonly arrives to medical school with a significant discomfort with ambiguity. As the student visits the clinic they discover that there is much ambiguity. Most of the ambiguity is in the patient’s story. It is therefore important that the education of the physician contain some experience with and investigation of this ambiguity The stories that patients tell physicians have characters whose behaviors are driven by motives and belief systems as well. In medicine, the reader of the story — the physician — has the advantage over the reader of a written story, in that they ‘can ask the teller of the story about his or her “hunches” as to motive. This checking with the teller patient, asking appropriate ‘questions along the way, commonly helps the teller improve clarity and helps the listener avoid mistakes in apprehension of the meaningful whole. One of the most common errors the physician-listener makes is to “assume” motive and belief systems of the “character” in the story, ie. the patient. This assuming leads to misinterpretation of the meaning of the story, and therefore can lead to misdiagnosis and mishaps in treatment. One of the most unfortunate words in medicine = unfortunate because it implies blame and closes down the dialogue between physician and patient ~ “non-compliance” ~ implies motive. While the motive or the reason for “non- compliance” is commonly assumed, when the physician more carefully “reads” his patient’s narrative relating tothe treatment, hhe or she finds thatthe assumption thatthe patient is motivated, somehow, to resist the treatment was wrong. There is almost always another story — the patient couldn’t afford medications, the patient distrusts the medical system, the patient simply never understood the physician’s advice. If this careful reading is ignored, or worse yet, not done at all, the outcome for the patient will not be maximized and might in fact lead to harm, CHARACTER As we have seen, characters in a story move the plot along, In well constructed literary narrative they are rich and colorful, causing us to engage with their feelings, their ambitions, and their desires. The effective author creates in the reader feelings for his or her characters. These feelings of disgust, anger, identification, and empathy among others work to engage the reader in the story. There is good evidence that there is a physiological basis for such responses ~ the so-called mirror Narrative Medicine «5—_—_— neurons which allow individuals to “share” the experience of others — and itis equally clear that narratives can provoke such, responses. As readers we become participants in the lives of the characters. Sethe, the protagonist in Toni Mortison’s novel Beloved is a slave woman living in Ohio several years following ‘emancipation. She escaped slavery, pregnant, alone, bare foot and scared. The text is riveted with gut wrenching descriptions of her memory of the inhuman torture at the hands of slave ‘owners, At one point in the book Sethe kills her baby rather than. allow the slave owner who has tracked her down to take the baby into a life of slavery. The reader identifies with Sethe as well as other characters in the novel, Feelings of anger, frustration, ‘and empathy wash over the reader. Ambivalent feelings about 1 mother killing her own children emerge as well. The reader is let to wrestle with the ethics of Sethe’s action, as well as the ‘multiple emotions elicited by the text In medicine, the stories we hear can be equally riveting. ‘They have characters as well. One of the main characters, the protagonist of the story, is usually the patient. However, there are other characters; sometimes they are mentioned, and Sometimes the listener must hypothesize their existence and ask ‘about them. This is an example of the “unsaid” that plays such ‘an important role in narrative competence. An example of this, tse of characteris the middle aged woman who presented to the hospital with severe abdominal pain. The characteristics of the pain, its time sequence and description did not lead immediately to a diagnosis. Instead it made the physician listener wonder about her motive. When asked about her family, she stated she had three sons. She became happier and in detail deseribed two sons who were quite successful, married with children and living happy lives. She described a husband that had left, and a marriage that ended unhappily. However, she never mentioned the third child. Is this an oversight? Is this an important “unsaid”? When the careful listener asked about the third child, he learned that this son was in prison. He leamed in just a few minutes of another narrative, more related to the abdominal pain, The son was in prison, accused of murder she was certain he did not commit, and one she was sure ‘nephew had perpetrated. Every time she was in the company of the extended family, including this nephew and his mother, the abdominal pain returned. The dynamics of this illness are not difficult to understand, However, the skill to recognize the “unsaid” ~ the description of the third son, a missing “character” jn the patient's story ~ and thus apprehend the meaningful whole of the patient's story is essentially a narrative skill. In addition to making the correct diagnosis, by connecting the social content to the physical symptoms, the physician found ‘a way to engage with this lady who might otherwise have been “not t00 interesting” because she had no obvious abdominal illness. PLOT ‘The plot ofa story is what happens. Since Aristotle's Poetics, wwe have understood the story to have action that develops conflict, culminating in consequences. To apprehend the meaningful whole of the story, we must be able to correctly, 6 + Narrative Medicine understand the character’s motives, get their actions exactly right whether said or unsaid ~and articulate the consequences of their actions, Articulating these consequences allows for 2 narrative ethies to emerge, atopic to which we will return in the fifth paper in this series Tn Anton Chekhov's “A Doctor's Visit” a young Dr. Korolyov is called to the country to visita young factory heiress ‘who is chronically ill and complaining of palpitations. He listens to her history, examines her briefly and immediately knows there is no serious illness, The family begs him to stay the night and he reluctantly agrees, The plot thickens by his observing the factory at work during the night, his imagining the horrible life of the factory workers in late nineteenth-century Russia, and his making the connection between the difficult lives of the factory workers and the symptoms of his patient — this patient he had so easily dismissed just hours earlier. Because of this new insight, he revisits the patient and has a long discussion bout her symptoms and what he feels is causing them. The reader is left to understand that the patient was helped through his insight into her social and personal predicament, Because he apprehended the meaningful whole of her he was “moved” toward engagement, as Dr. Charon commonly says, rather than remaining “detached.” The narrative process that leads doctor Korolyov to a proper diagnosis is the way it allows (pertaps forces) him to imagine himself in the situation of another and thus grasp the whole state of affairs of another “character.” ‘When our patient tells us their story of suffering ~ the HPL = they are giving us symptoms. These symptoms can also be thought of as analogous to characters in a short story or novel. (Thus patients offen say “my back is hurting me,” making their back an active character in their stories.) The motives of the teller, the experience of the characters, and the actions (plots) ‘of these symptoms culminate in the comprehension of the plot 1s a whole — the “meaningful whole” of the narrative ~ that wwe call diagnoses. The skills at apprehending the meaningful whole of this plotting of the patient's story is identical to the skill of apprehending plot of the literary story. For the plot to make sense and in the final analysis to illuminate a diagnosis, requires that the listener get the motives, time sequences, and descriptions correct. (In Part 4 of this symposium we explore how narrative knowledge can help with diagnosis.) DESIRE Desire in this context is the desire of the storyteller, the author ‘ofa literary work or the patient-author of an HPI. The question the skilled reader asks is: why is this author writing this short story or novel? Understanding the desire of the author ~ different from the motive of the character insofar as it takes in the story as a whole — helps the reader apprehend the story at ‘a deeper level. Reading for the desire of the author is a meta- skill of apprehending literary text. Understanding the desire of the author of a literary text adds depth to the understanding Of the text, just as does reading for the desire of the author of the HPI add depth and meaning to our practice. We need only to study secondary texts about the great novels of the world’s literature to know that there are multiple interpretations of the desire of the author. This, however, does not detract fromits importance, In fact, reading for desire of the author is but cone area in narrative studies where the learner becomes more comfortable with ambiguity. A classic ambiguous authorial desire is that of Albert Camus in his novel The Plague. The text isa story of a modern day plague caused by the bacteria, Pasteurella pestis, spread by rats, a plague in every way a classic one. Critics began reading into the text a desire of the author to create an allegory of the Nazis occupation of France during the Second World War. The allegory works beautifully upon a more “careful reading,” but the reader is left to interpret ~ to make “educated guesses” about ~ this desire for himself A.common ambiguous authorial desire in medicine is the patient who presents with chronic pain. We in medicine, for 1 variety of reasons, are commonly suspicious of the intent of the patient and commonly assume that the patient is seeking financial reward for this pain more than relief from it. Unless we read the narrative of the patient, including the story, the exam, and the lab and imaging studies carefully, we risk misreading the intent of the author — jumping to conclusions and harming the patient. As mentioned earlier, becoming more comfortable with ambiguity is indeed one of the goals of using literature to teach medicine. With experience physicians learn that there is much ambiguity in medicine, but because of the scientific training and education many are never comfortable with it. Just as discussed with motive, the physician-reader of the patient hhas an advantage of being able to test hypotheses regarding desire by asking questions, verifying, and getting the desire “just right.” The key here, however, is the same as with careful reading. ‘That is, the reader of the patient's story must care enough, engage, and take time enough to get the story as accurate as possible. CONCLUSIONS ‘As we apply the above concepts to our careful reading of texts, and as we wonder how these concepts apply to the stories of ‘our patients we discover a different category of knowledge — narrative knowledge. Narrative knowledge implies a certain way of knowing. Throughout these papers we will use the term narrative knowledge to mean the knowledge we take away from narrative which, unlike scientific knowledge, explores rather than expels ambiguity and uses our natural engagements ‘with others as a resource, Narrative knowledge can be more specifically designated as its “meaningful whole” — the thought ‘or “point” or “theme” of a story, where the whole is greater than the sum of its parts. This is opposed to the scientific — non-emotive ~ language of logico-scientific medicine, where ‘the whole is equal to the sum of its parts, Yet, like science, it is not simply “intuitive” but can be systematically taught and learned. ‘The practice of discovering this narrative knowledge ‘as we read and apprehend good literature provides us with skills ‘we can apply directly to patient care. ‘The third paper explores this conceps in depth, but all the papers explore the domains of ‘our clinical practices where narrative knowledge is best applied to make our work and its fulillments better REFE 2 3 ERENCES Charon, Rite, M.D. PRO, Nararive Medicine, Oxford University Press 200639. Charon, Rita. Nartatve Medicine, Honoring the Stoves of Hes. ‘Oxford England, New York OxTorsUnleraity Pres. 2008, Preface ui Charon, fta. "Literary Concepts for Medial Readers: Fame, Time, Plot, Desire” Teaching Literature and Medicine. Edited by Anne Hunsaker Hawkins and Maryn Chandler MeEniyte. New York The Modern Language Associaton, 2000. p, 29-1 Vannata, JB, sclefer, Ry Crow, 3. Medicine and Humanistic Understanding The. Signiscance of Nanative in_the Practet of ‘Medicine, 8 DVD ROM. Philadelphia, University of Penn Press. 2005. Chap. 4p, Vonnatt ik Selzer, &“melda eres to a Young Doctor, San Diego, New York London, Harcourt Brace and Company. 1982, pp.2136. Dr. Richard Selzer was practicing surgeon fo many years, CChekoy, A."A Doctors Viste A Doctors Usk: Short Stoves by Anton Chekhov. New York, Bantam Books. 1988, pp. 96-106. Anton Chekhov ‘was practicing physician thoughout his writing career Narrative Medicine+7The Journal of the Oklahoma State Medical Association: Part Two: The Role of Narrative in the Everyday Practice of Medicine Development of a Patient-physician Relationship ‘Jerry Vannatta, MD; Ronald Schleifer, PhO; Sheila Crow, PhD Anew potientalvay: created an extement an anipaton wanted my fest mpression abe uncliedI wanted ito be pure, ea velb stuck note nen I think backo some those arly patients ts that ist Impression chat lingers wr they wore, what word they used ttl er story, who was wth them, he scentofthe rom, how the enlarge spleen et rebounding off ry gers how th smocth bt dstended Iver slid under my hond. The writer Milan Kundera says thatthe first en minutes between a mon and oma are the most importantintheisubsequen istry, apredictarof things come, Solas with me: the fest ten minutes were a determinant of how | woud color that patient in my memo. ~ Abraham Verghese, M.D, My Ow County! The patient brings to the clinical encounter a story, the history of present illness (HP). As the physician listens to the story, a special kind of relationship begins to form. itis, often charged with deep felt emotion by the patient ~ fear and anxiety, anger, sadness, ora combination of these. As we suggested in Part One of this symposium, when the physician, attends to the patient's story, both its biomedical content and the emotions with which itis told, a special therapeutic relationship is born. This relationship Is the basis ofall future interactions between physician and patient. PATIENT-PHYSICIAN RELATIONSHIP: POWER DIFFERENTIAL ‘The patient-physician relationship, because of the physician's privileged knowledge and also, as sanctioned by the state, privileged power, has embedded in it a power differential One of the responsibilities of the physician is to recognize this differential and respond appropriately. That is, there are appropriate as well as inappropriate uses of this power differential. In general terms, Anatole Broyard has described the appropriate use of a physician's knowledge and power. “My ideal doctor,” he writes, ‘would resemble Oliver Sacks, the neurologist who wrote Awakenings and The Man Who Mistook His Wife ‘for a Hat. Ucan imagine Dr. Sacks entering my condition, Tooking around at it from the inside like a benevolent landlord with a tenant, trying to see how he could make the premises more livable for me. He would see the genius cofmmy illness... My ideal doctor would “read” my poetry, my literature, He would see that my sickness has purified ‘me, weakening my worst parts and strengthening the best ‘Corespondence te Jey & Vansatta MD, John Flack Burton Professor of Humonities in Medicine, David Ross Boyd Professor of Medicine, University ‘of Oktahoma College of Medicine, WP 1160 PO. Box 26901, Oklahoma Cy. ‘okiahoma 73190 8+ Narrative Medicine ‘On the other hand, there are many examples of the abuse of this power. Two categories of this abuse of power are paternalism and arrogance. By paternalism we mean that the physician treats the patient, even though he is an adult, as a child, Inhis novel, The Woman Who Walked into Doors, Raddy Doyle presents a woman, Paula, who is the victim of spousal abuse. Her husband brutally beats her, and then takes her to the emergency department for care. The physicians and the other personnel treat her with a paternalistic attitude, leaving Paula to play the role of a child. [No questions asked. What about the burn on my hand? The missing hair? The teeth? I waited to be asked. Ask me. Ask me. Ask me, I'd tell her. I'd tell them everything. Look at the burn. Ask me about it. Ask, No? ‘The nurses and doctors who treat Paula respond to her as if she is a child, They allow the abusive husband to remain in the room, and in fact to answer most of her questions. They call her silly and tell her she surely must be more careful. Falling down stairs and running into doors are the activities of careless children, Reading this narrative creates empathy for Paula, and generates antipathy toward the physicians and nurses for not only heir paternalistic indifference, but their confederacy in the conspiracy against Paula. Nowhere in the story do the medical personnel treat Paula as an adult; there is never an alliance built between patient and physician, although Paula is screaming inside for help: “Ask.” By arrogance we mean a subtler form of power and paternalism that is often displayed by physicians, and which, again, is easily discernable in narrative, In her story, “The Interior Castle.” Jean Stafford tells a story of @ Woman undergoing exceptionally painful nose surgery. In this narrative, the doctor never validates the pain, doesn’t invest time or energy in developing rapport, and demonstrates no‘empathic understanding of the patient’s horrible suffering. The patient, Pansy, we are told, “fought two adversaries: pain and Dr. Nicholas.™ The doctor tells her there is no danger even though he wonders to himself “if she knew in what potential danger she lay.” This patient-physician relationship results in ‘only technical manipulation of the nose and virtually no caring forthe patient. Using these and other stories to teach both practicing physicians and medical students works particularly well precisely because the elements of narrative we described in Part One ~ narrative time, motive, character, plot, and the overall “desire” or purpose of a story — allow those encountering such stories to grasp an overall sense of the professional and interpersonal relationships that arise inthe practice of medicine. ‘These stories provide the doctors or students examples of abuse of power at a distance from the particular occurrences of the patient-physician encounter ~ the doctor's busy day, her necessary attention to details of physiology, the need to attend to her own professional standing — and allows them to reflect on the suffering ofthe patient and his concerns as a whole. The careful reading of stories like these allows doctors or students, to practice narrative skills, just as musicians — and surgeons ~ “practice” their skills. Moreover, since they are written in ordinary language, they also remind their readers that the specialized language of medicine should not forget the overall, goal of healthcare as the attending to the suffering patient. DEVELOPMENT OF RAPPORT Encouraging physicians to develop rapport with the patient ‘early in the relationship is one ofthe goals of medical education, Rapport is usually defined as agreement and harmony between people, a close and trusting relationship. Most medical schools use a variety of methods to teach the development of rapport, including observed interviews with standardized patients, and feedback provided of those interviews, The use of literature in teaching strategies for achieving rapport with patients is relatively new. It is a method that is contextual in nature; that is, the literary text provides a context — a vicarious experience within which the reader can recognize and even feel harmony, agreement or disagreement, trust or distrust with characters or ‘with the author. In literary narratives, the reader is presented with a learning environment devoid of the learner's ego investment. ‘The reader can reflect, write, and discuss the content ofthe story and develop analyses, connections, and analogies to his own life experiences — including, for physicians, clinical situations ~ without actually experiencing it. In the above example of Paula in Doyles” novel, the reader has the experience of observing the doctor mistreat Paula out of distain for alcoholism. This allows readers to imagine themselves in situations and, as we noted in Part One, experience the emotions that arise out of those situations unhampered by the dismissive shorthand of stereotype. (It is such shorthand that allows physicians to dismiss the lower-class Paula so easily.) Narratives can present such shorthand, yet at the same time they are able to provoke critical judgment — both intellectual and emotional ~ of those situations. When done well, the representations of situations Cf interpersonal relationships provoke in learners emotional responses that often arise in actual clinical situations. Anexcellent example of the doctor developing rapport with his patient isin Fervol Sams” story “Epiphany.” In this narrative, Dr. Goddard is treating an uneducated, poor, ex-convict, Gresry MeHTune. Rapport is required in tis relationship, as itis in most, because future effectiveness of treatment depends upon it, Dr. Goddard recognizes the social and educational gap that exists between them, He does an excellent job of bridging it. Gregry’s response to Dr. Goddard intially demonstrates that the patient fels rapport with the doctor. After receiving medical samples, Gregy tells the doctor: won't forget, Doc, but hell, you didn’t have to do this. Pm a pore man, but {ain't no charity case.” “You're accommodating you habits and wishes to mine, Grogry, and I'm tying to accommodate mine to yours. T'lsee you next week.” “TIL sure be here.” There was a pause, almost of embarrassment, “I ain't never run into no doctor like you before." He hesitated, “Ifyou cae, eare.”* Throughout the narrative, Sams portrays Dr. Goddard as, caring for his patient and develops an emotional connection to his patent, the harmony and agreement of rapport. The eare and connection take the forms of respect and honor for the patients story taking the time to listen carefully, and finaly, responding to his patient in terms of the values and vocabulary thatthe patient brings to the patient-physician encounter. Rapport is a relationship built on trust and emotional ality. The physician has the responsibilty to demonstrate genuineness, honesty, and commitment. The patent will respond to this honesty emotionally. This forms the beginning of & relationship based upon rapport. Rapport is more easily developed with patients who are like the physician ~ when te patent and physician are of same gender, similar cultural background, age, and interests. But when the patient and physician are not similar ~ as in the case of Dr. Goddard and Gregry ~ development of rapport can be more difficult to achieve. Reading literary narrative —especiallyin group setings that allow the expression of different understandings and points of view ~ has a role to play in the education of physicians about development of rapport. Literature provides a wealth of experience - vicarious experiences — with other cultures, gender roles, and socioeconomic groups thatthe physician may never have experienced, Narative is about something particular and ‘therefore creates memories and images in the reader's mind that often provoke an emotional response. Both the images and the emotions of narrative that ean give rise to vicarious experiences are stored in memory. This library of images and emotions, built up overtime in response tothe reading of excellent stories, is available to the physician. As the physician remembers the story, the character or situation, and once again experiences the remembered emotion, he is often able to transfer that emotion to the patient at hand and use that emotional energy to make ‘8 connection with this particular patient. Once rapport is established, the physician conceives of her work witha patient as a relationship, a collaborative effort, and the nature of her role and weight of her burden change. Narrative Medicine «9————— In the DVD-Rom we developed, Medicine and Humanistic Understanding, Dr. Vannatta relates an epiphany ~ a vicarious ‘experience with a piece of literature and its use in creating ‘apport with a patient in his care. Itis worth citing this narrative description at length. “T.came to this whole interest in narrative, literature, and the practice of medicine,” Dr. Vannatta notes, through an experience I had in my own practice. I'm a general intemist, and I had an elderly African American ‘woman who came back tothe office for an office visit after hhaving been in the hospital. I didn’t get to know her real wellin the hospital because she was cared for primarily by the residents and the medical students on my service, but when she came back for an office visit, was providing the cate. And she rapidly told me that she was having trouble getting her medications, but as I was interacting. ‘with her, there was just really no connection being ‘made, That makes me so uncomfortable when I'm really not connecting with the patient, so, as [usually do when I’m. not connecting well, I backed up and sort of took a psychosocial history. I basically just said, “Tell me about ‘yout life.” She began to tell me a story about having grown up in east Texas on a sharecropping farm where her father was f sharecropper, and he, when she was fifteen, made her ‘marry a man who was twenty-one. It really wasn't the man she wanted to marry; she was in love with a sixteen year old, but he made her marry the twenty-one year-old because he could provide for a living. In fact, she said to ‘me during the story that he wasn’t very good at making a living, but he was sure good at making babies, and she had seventeen of them, And I thought at the time she said that, “My goodness, that could have rolled right out of ‘a wonderful novel or short story.” She went on to say that she, oftentimes, to make ends meet, walked two miles 10 a white man’s house and two miles back to do domestic work. And she told me that sometimes the white man ‘would give her a dozen eggs, and sometimes he would give her a two-gallon pail of milk to carry back to the family. And then she looked at me and said, “Doctor, have you ever carried a two-gallon pail of milk two miles?” ‘And, in fact, did grow up on a farm, and can remember ‘carrying those galvanized pails of water around the farm to the chickens and whatnot, and I could just see that wire handle just burying and cutting into her hand, But more importantly, { was thinking that I was seeing her carrying this pail of milk on a dusty, sort of rocky road, probably ‘with not very good shoes. And as I was thinking about her feet, making this journey back, I began to think of this novel, Toni Morrison's novel, Beloved, which I had just read a few months earlier, at that time, the most remarkable novel I had ever read, a very disturbing story about slavery jn America. And the protagonist, Sethe, is running from slavery. She's pregnant, she’s trying to escape, and she’s tired and she’s about to deliver a baby, and she’s hiding up under a bush and a little white girl finds her. One of the things that’s striking about that scene is her swollen, bleeding and pussy, infected feet. And that image of those 10 + Narrative Medicine feet came back to me justin a flood, and the emotions that had felt, think, when I read the novel were seemingly stored in memory. And along with the image of the feet, these emotions came flooding back to me.” ‘And the remarkable thing that happened in the room was ‘hatthose emotions were available to meto beable toconnect with this lady, not that she was a slave, but in some way she was telling me a story about her economic enslavement land somehow they connected. I don't know how that works, but nonetheless, it happened. It was an experience ‘that was dramatic for me, and from that point on, we began to make a more meaningful connection, and we rapidly sort ‘of problem solved her ability to buy her medications and get them so that she could take them. And at the end of the interaction, we stood up to leave and a remarkable thing hhappened, which usually doesn’t happen in my practice, which is we embraced. And she knew that a wonderful relationship had begun, and so did I. Above all, Dr. Vannatta is telling a story with a beginning, middle, and end. Moreover, it ends with the “remarkable thing” of remembered and re-experienced emotion, that now becomes, in this new narrative, thea remarkable combination of Morrison's lengthy narrative, particular experiences of Sethe, Dr. Vannatta’s, patient, and Vannatta himself ~ combined in a new experience that brings together emotion and knowledge. That new experience grows out of the elements we described in Part One of this symposium ~ narrative time, motive, character, plot, and the overall “desire” or purpose of a story. Here, the time is that of the patient interview; the motive for the physician is to make 1 “connection,” for the patient to receive care; the characters, remarkably, are remembered people strugaling to walk; the plot is the transformation of dissociation to rapport. And the “desire” of the story both in the DVD and here ~ is to demonstrate the power of narrative inthe practice of medicine, DEVELOPMENT OF EMPATHY Empathy, akin to rappor, is a quality that physicians can bring to or develop within their relationships with patients, The quality of empathy is, in many ways, at the base of rapport. ‘The following is a short discussion of empathy by Rita Charon ‘extracted fom Medicine and Humanistic Understanding. Empathy is the method, or the tool, that gets you towards engagement. Empathy is that ability to recognize the plight of another person and to be moved by it. Empathy ddoes not require that I have experienced what the patient is experiencing, Tt doesn’t require that I imagine it happening to myself necessarily. I mean, I can’t really say “I'm a 98 year old demented woman.” That doesn’t work, but it does require that I can imagine the whole situation, and if she’s 98 and demented, I have to say as | use my imagination, “Well, what does that mean?” Probably she can’t do very much cooking in the house if she can’t remember where she put the rice, and perhaps this means she can't use the telephone any more, and those very practical things. And, also, even though her memory is askew, it doesn’t mean that her feelings are askew, $0, how can I dignify her, how can 1 treat her with nobility eventhough she thinks it’s 1930? So, this ability to imagine the predicament or the plight of the patient pus us in position to treat them all the more effectively? The “recognition” discussed by Dr. Charon is a type of understanding of the patient's plight. It i also being willing to invest one’s self emotionally in the patient and in her story in the direction, as she says, towards engagement. When the physician and patient engage in this manner, they experience a deeper, more meaningful relationship — one built on mutual understanding, trust, and a kind of love, This engagement deseribes rapport, and it is established through the development of empathetic recognition and understanding. Empathy is a response and an emotion generated by an act of recognition, as De. Charon has said. Such recognition can be provoked by an image, an imaginative identification, a sense of “whole” story falling into place, as it does in Dr. Vannatta’s narrative of his patient interview. Empathy is more readily demonstrated by some individuals, as if tis built into their personality structure. For those to whom empathy is “second nature,” the study of the humanities can provide deep experiences that validate theit impulses to connect with and comfort others. For those who, for a variety of reasons, do not readily feel or acknowledge their own feelings of empathetic understanding, the study of the humanities ean provide promptings for such feelings. Many physicians argue that too much empathy is overwhelming and inhibits their ability to practice, but Dr ‘Charon describes the “rewards of engagement.” Physicians ‘who train themselves to be more empathic almost universally report higher job satisfaction, and, as Dr. Charon suggests, the ‘engagement to which empathy leads the physician is what the patient needs. The patient then gains from the relationship as 4 result ofthis “recognition and understanding” by the doctor. ‘This patient satisfaction is obvious tothe physician and, in retumn physician's satisfaction is improved as well. It seems a paradox ‘that when physicians work hard to find ways to “connect” with patiant, they commonly receive more out ofthe resulting relationship than they invested. For most physicians, this return on investment ~the ability to adequately care for others—is one of the reasons they entered medicine in the first place. ‘The efficacy of empathy in making a difference in care is mulifold. It fosters the patient's honest storytelling, the physician's attentive listening, and most importantly, the Aiagnosis that arises from the patient-physician encounter. Moreover, empathy can be taught and learned. The very practice of reading narrative, as we suggested in Part One, provokes neurologcally-based empathetic responses, which readers Team to attend to more fully. Moreover, simple practices of asking for stories and explanations from patients, as Dr, Vannatla did, cteate opportunities of such “narrative” responses. And when this happens a remarkable thing often ‘occurs: patients recognize empathy, respond with greater care, and physicians find themselves engaged by the simple act of ‘exchanging stories. Reading and discussing narrative enriches this engagement, as we saw in Dr. Vannata’s case, where the ‘combination of different narratives created a complex emotional ‘and cognitive response. REF! 1 2 “ERENCES, ‘Abraham Verghese, MD. My Own County: A Doctors Story. New ‘ork Vintage Books, 1995p. 111. ‘Anatole Broyrd ntxicaied by ity ness, New York: Clarkson Potter, 1992, 4. Roddy Dose, The Woman Who Meiked no Doors New York: Penguin Books, 1996:p. 168. san Stafford, “The Intevior Castle, The Collected Stories of Jeon Stafford, New yor: arr Straus, and Giroux, 1969, pp 17593, Fora fine discussion arguing that the gos” of meditine s the oli of suffering, see Erle Cassell, The Notute of Sufering and the Goals ‘of Medicine. New Yor: Oxford University Press, 1997. Ox Caseell was Dracticing physician, FerolSams, Een, Alant: Longstreet Press. 1994.12.01 Sams vasa practicing physician, Vannatta, J. Sehleter A, Crow, S, Medicine and Humanistic Understanding, The Significance of Naratve inthe Practices of Medicine, \ OVO ROM. Philadephia, University of enn Press. 2005 GET SCREEN REF Vannata, 18, et al. Medicine and Humanistic Understanding, The Significance of Warratve inthe Practices of Medicine, & DVD ROM Philadelphia, University of Penn Press. 2006. Chap I-p 35. Vannatta, JB, et al Medicine and. fumanstie Understanding, The igncance of Waratv inthe Practes of Mediie, & BVD ROM. Paladelpha, University of Pena Press. 2008. Chap I. p42. Narrative Medicine + 11