Medical humanities and narrative medicine
Wednesday, December 2nd, 2015
Medicine is both an art and a science. While modern medical training teaches the scientific and technical aspects of medicine well, the humane aspects of medical education remain relatively neglected at university level in Australia. “Medical humanities” and “narrative medicine” have been proposed as solutions to correct this imbalance. The inter-disciplinary field of “medical humanities” brings the perspectives of academic disciplines within the humanities to bear on medical practice. “Narrative medicine” teaches us how to hear our patients’ stories and how to respond to
them. These approaches provide crucial opportunities to develop attention to narrative, critical thinking and empathy, and thus to deploy the scientific tools of medicine more wisely.
“The art of tending to the sick is as old as humanity itself.”
~ Goldman Cecil’s Medicine 
The practice of medicine is both an art and a science. Both aspects require due attention, but throughout my
university medical training it always seemed clear that scientific and technical topics were considered more important. After all, they received the majority of attention in the curriculum, and were more thoroughly examined. Important topics such as bioethics, social determinants of health, and the history and philosophy of medicine were balanced precariously at the periphery of our studies or even absent from the core curriculum.
Modern medical training emphasizes the scientific, technical and practical. Although patient communication, empathy and professionalism are rightfully given prominent places in modern medical school curricula, these are approached in typically pragmatic fashion – for example, how might one convey the impression of interest to a patient? We learn how to sit, how often to nod, when to make eye contact, and what we might say to appear to be listening. The evidence of my patient communication tutorials is scribbled in the margin of my first year textbook: “I see …”, “please go on …”, and “mm-mm …”. We learn this by rote, like everything else. This is an excellent place to start. But why bother at all? Mostly, we talk in terms of establishing rapport, taking better medical histories and improving the end results for our patients. However we never discussed the bigger questions that underlie all this effort to appear caring, for example, how to stimulate and sustain genuine interest in the endless stream of people we will meet as patients, let alone why we seek to relieve suffering or value human life at all.
From my own experience as a student, peer reviewing reflective essays or participating in tutorial discussions, the result of this heavily unbalanced emphasis is that medical students think no more subtly about important ethical issues in medicine than the typically hackneyed discussions one reads in the newspapers. This is despite our experiences with doctors and patients everyday in clinic and hospitals, for whom these are not abstract issues. For example, when discussing dilemmas encountered by doctors who are religious, someone may always be relied upon to pipe up with the peculiar remark that doctors ought to leave their personal values at home and not bring them to work – as if the doctor with no values was anything other than monstrous to contemplate. Why aren’t we able to transform this abundance of clinical experiences into better thinking on “big” questions? This mediocrity in critical thinking and imagination is dangerous for both our future patients and ourselves. However, the issue is larger than simply a lack of time for bioethics in the curriculum. The loss of space in the curriculum for this endeavor is but one manifestation of the lack of importance accorded to the humanities as a whole in medical training.
“Medical humanities” and “narrative medicine” have proposed themselves as solutions to this lack of the humane in modern medicine, to balance its increasing focus on the reductionist and scientifically technical. [2-3] Here I address the question of what it means to recover the sense of our profession as a humane art, especially via narrative medicine.
What are the medical humanities and narrative medicine?
Training in narrative medicine and medical humanities now forms part of the core curriculum at more than half of all North American medical schools.  However, despite the considerable influence of these fields in Europe and America, the concepts remain little known in Australia. “Medical humanities” refers to the interdisciplinary fields created when the perspectives of the humanities, social sciences and the arts, such as literature, history, music, languages, theology and fine art are brought to bear on medical practice and other areas relevant to healthcare. 
“Narrative medicine” in turn belongs within the wider field of the medical humanities. It is more than simply the observation that patients and their illnesses have stories, but this simple statement is where it all begins. The field of narrative medicine grew out of the work of physician Rita Charon who formally defined “narrative medicine” as medicine practised with “narrative competence”, that is, “competence to recognize, interpret, and be moved to action by the predicaments of others”.  Elsewhere, Charon describes narrative medicine more simply as “medicine practised by someone who knows what to do with stories”.  Training of medical professionals in this field teaches the application of formal literary theory and creative writing skills to the situations and interactions commonly encountered in medicine, as well as various interpersonal skills. To this end, the narrative medicine program directed by Charon at Columbia University trains participants in “close reading, attentive listening, reflective writing, and bearing witness to suffering”. 
One way of understanding about how to “do” narrative medicine is conceived in terms of three “movements” – attention, representation and affiliation.  Attention refers to the skill, when in the presence of our patients, of absorbing as much as possible about their condition. We recognize this as what we do during the observation phase of physical examination, for example. Representation refers to the act of writing about patients and our clinical experiences, “taking chaotic or formless experiences and conferring form”, for example as prose or poetry, a piece of written dialogue, or even as an obituary. This process creates meaning from our experiences. Finally, affiliation refers to “authentic … connections between doctor and patient”.
First movement: attention
Observation is the first step in any medical examination, and all-too easily overlooked when one is learning. All medical students soon develop some favourite trick for overacting this step during OSCEs, to impress our keen skills of observation upon the examiners. But how is one really to develop this skill? The obvious answer is by practice and experience with observation of real patients on the wards – learning to see the walking aids, asthma puffers, sputum containers, hearing aids and every other manner of salient item in the jumble of medical equipment and personal items at the patient’s bedside.
However, it is also possible to practice the skills required for observation in medical contexts in other settings, such as art galleries and museums. This approach was developed at U.S. medical schools, to teach skills such as objective observation, communication, disagreeing respectfully with peers and managing ambiguity. At the University of Melbourne, a method first developed at Harvard University (“Training the Eye”) is being used at the university’s Ian Potter art gallery for improving the observation skills of medical and dental students.  This program is based on the hypothesis that the process of understanding a complex, narrative-based painting requires many of the same skills as required for medical diagnosis. Access to this training is not routine for medical students, but can be sought out in elective sessions at the medical school’s annual student conference. In one such session, we used the wonderfully intriguing painting “Bushrangers”, painted by William Strutt in 1852. It is not immediately clear that the painting involves a highway robbery in what is now downtown St Kilda in Melbourne; drawing this inference requires deliberate searching through the painting’s details and debate about the significance of aspects of the painting with others. This approach has been shown substantially to improve the observation skills of medical students.  It is useful not only for observing our patients, but for a variety of other situations, such as understanding medical imaging and communicating our findings to colleagues and patients.
Second movement: representation
A crucial aspect of narrative medicine is learning to write about one’s practice and patients. Opportunities to develop this skill begin during medical school with reflective writing exercises about our clinical experiences and patient encounters. Another way to improve one’s own writing, apart from regular practice through reflective writing, is to read published examples of this kind of writing, of which endless excellent examples by both doctors and patients are available.
The genres of narrative medicine have been classified in various ways. One simple classification recognizes four different genres.  Firstly, there are the classic illness narratives that patients write about being sick, and which might include surrounding circumstances explaining how they were diagnosed, how they were treated, how they coped and the impact it had on them and their families. An excellent, recent Australian contribution to this genre is Myfanwy and Donald Horne’s experience of Donald’s palliative care for chronic obstructive pulmonary disease (COPD), and the aftermath, chronicled in, “Dying: a memoir”.  Helen Garner’s “Spare Room” is an interesting Australian variation on the patient memoir, written from the perspective of a concerned friend.  “The diving bell and the butterfly”, Jean-Dominique Bauby’s compelling memoir of locked-in syndrome, is a classic in the genre. 
Secondly, many doctors write about their experiences of caring for their patients. Many will be familiar with the thoughtful writing of the Melbourne-based oncologist, Ranjana Srivastava, both in her regular newspaper column and her books, such as “Tell me the truth: conversations with my patients about life and death.”  The delightful books of Oliver Sacks, detailing the curious cases he encountered in his long practice as a neurologist, such as “The man who mistook his wife for a hat” also belong within this genre.  “The hospital by the river: a story of hope” by Catherine Hamlin about establishing the Ethiopian fistula hospital with her husband is a must-read for Australian medical students ; I found a copy on the midwives’ shelves during my obstetrics term and read it late at night between calls to labour suite. There are memoirs at all level of practice; the notorious memoir of life as a junior doctor in an American hospital, “House of God”, is by now legendary, along with its questionable additions to the medical vocabulary. 
Thirdly, there are doctor-patient narratives. These are narratives which show how not only the patient’s perspective on their illness, but also how their experience of illness was affected by the interaction with their doctor. These make us aware of how our reactions to patients and explanations of their symptoms can affect a patient’s understanding and experience of their illness. These narratives form in the interplay between doctor and patient in the taking a history, and in forming a diagnosis. Both the doctor and patient will begin to form stories about the illness in this process, which will necessarily be changed by the therapeutic encounter. This might be observed, for instance, when a newly diagnosed patient commonly asks whether anything might have been done to prevent their illness – did they do something to cause it – are they somehow to blame?
Lastly, we need to be aware of meta-narratives, which are the grand, over-arching stories our societies and cultures tell about illness and health, and which provide a framework within which we conceive and construct our own stories. A classic work in this area is Susan Sontag’s seminal “Illness as metaphor”, which examines the power of metaphor and myth in cancer, and was written during her own experience (we will not say “battle”) with cancer.  Arthur Frank’s “The Wounded Storyteller” is likewise a seminal text, as a collection of essays discussing the roles and limitations of different categories of illness narratives, and written in light of the author’s own experience of serious illness.  Jonathon Miller, although understandably better known for his influential stage production of Gilbert and Sullivan’s The Mikado starring an operetta-singing Eric Idle as Ko-Ko, was also a neurologist. His multi-series documentary and book “The body in question” is another influential endeavor in the genre of medical metanarrative, dealing as it does with metaphors of illness, and cultural ideas about the body. 
Third movement: affiliation
How then does one “do” narrative medicine in daily medical practice? The most important element in building the required therapeutic affiliation with patients in narrative medicine is “a specific openness to towards patients and their narratives”.  Charon notes that when she began to try this approach with her own patients, she asked only one question during the initial consultation: “I have to learn as much as I can about [your] health. Could you tell me whatever you think I should know about your situation?”.  While most of us would worry about the extra time it would take in a consultation if patients were allowed to speak without direction, one study showed that two minutes was long enough in General Practice for 80% of patients to explain all of their concerns, if the doctor was trained in active listening and even if the patients had complex medical concerns.  Nevertheless, ensuring that a consultation with a patient “meets both narrative and normative requirements” is unquestionably difficult and requires training and daily practice. 
Proponents of narrative medicine argue that literature is an important way to develop the narrative mindset for medical practice of this kind. The touted benefits to doctors of reading “good books” include that reading offers a wider experience of life than one may encounter in the everyday of a single lifetime.  The narrative perspective, it is claimed, also has the potential to develop the imagination on which empathy depends, by crossing barriers into the inner lives of others in a way that is not possible in real life, even with the unique insights into others’ lives provided by medical practice.  It is also said that literature can also refine moral perception, and teach one to manage with ambiguity and paradox.  However, despite these optimistic expectations, medical students have proven resistant to the projected benefits of reading for this purpose. The obviously frustrated authors of one study document students refusing to participate in their carefully prepared class (“the literature we selected would have made Tolstoy proud”). They had hoped to discuss passages from novels covering themes such as illness, family violence race, gender, social class and sexual identity.  The students responded in a way that will be familiar to any of us who have attended classes on topics commonly deemed by the student body to be “fluffy” – questioning the basis of the class, not taking it seriously, treating presenters with disrespect and even not attending the class. Some of this resistance is laudable – the impatience of the practically-minded for weasel words and time wasting, and a weariness with endless jostling to advertise various medico-political agenda within our curriculum. However, it is also likely that the resistance arose, as the authors suggested, from a refusal to persist with uncomfortable topics which also ask a group of students who see themselves as triumphant meritocrats to reflect on the undeserved social advantages that have enabled them to study medicine at all.
Much has been claimed for the benefits of narrative medicine. However, writers in the field caution against over emphasizing the artificial dichotomies of humanities versus the sciences, the subjective versus the objective, the clinical and reductionist versus the human and holistic. [26,27] Competent medical practice necessarily requires compassion and imagination, and cannot avoid “big” questions such as the nature and meaning of pain, suffering and death. However, a doctor who is able to respond usefully to these fundamental questions requires training and skills beyond the merely technical and scientific. Other potential benefits suggested for this approach include the preservation of empathy throughout medical training, reduced doctor burnout, exhaustion and disillusionment, and better outcomes for our patients. 
How can we learn narrative medicine? At medical school, this might be about making time to read widely and explicitly resisting the pressures towards reductionism and technical focus. Another important way to preserve and develop narrative sensibilities is by writing about our own clinical experiences and patients. An obvious example in this respect is simply to take reflective writing opportunities seriously, and to expect high standards of writing from others when asked to give peer feedback. For junior doctors, opportunities for joining Balint groups at hospitals or during GP training are also becoming more widespread. These small groups meet to present and discuss cases from members’ own practice, with focus on narrative, the doctor-patient relationship, and self-reflection.  However, the options in Australia for formal academic training in the humanities, as a medical student or doctor, are limited. The only explicit university program in medical humanities in Australia is at the University of Sydney, which offers “health humanities” as a specialization in the Masters or Graduate Diploma of Bioethics.  Another option is attendance at shorter workshops that overseas institutions offer from time to time, and which we might seek out during study leave. The most well-established of these are those offered at mid-year at the University of Columbia Medical Center in the U.S. 
Medicine practiced without attention to the humane has the potential to harm both our patients and ourselves. While science provides us with safe, effective tools to deploy in medical practice, the humanities teach us how to use them wisely.  Currently, university medical training focuses on the former, with limited opportunities to develop the attention to narrative, critical thinking and empathy which help us to develop wisdom in response to clinical experience. Oliver Sacks summaries this aptly, “With the rise of technological medicine and all its wonders, it is equally important to preserve the personal narrative, to see every patient as a unique being with his own history and strategies for adapting and surviving. Though the technical terms may evolve and change, the phenomenology of human sickness and health remains fairly constant …” 
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