Narrative Medicine PDF

Narrative Medicine Financial Times Sarah Neville is the FT’s global health editor Stepping into Rita Charon’s studio, in a Jazz Age-era building in Greenwich Village, I get a quick view over the Lower Manhattan skyline. Everything in the room seems considered, from the Bach playing in the backgrou...

Narrative Medicine Financial Times Sarah Neville is the FT’s global health editor Stepping into Rita Charon’s studio, in a Jazz Age-era building in Greenwich Village, I get a quick view over the Lower Manhattan skyline. Everything in the room seems considered, from the Bach playing in the background to the paintings on the walls. My meeting with Charon, founder of the “narrative medicine” movement that trains health professionals to use the power of storytelling in their work, is one I’ve been contemplating for 20 years. How, I’ve wondered, can such a humane approach t into the time- and cash-constrained world of 21st-century healthcare? And who is this woman who, sometimes unsung, has done so much to change the way we think about the doctor-patient relationship? As I sat down, she said to me: “This is exactly what happens in the actual [moment of] two humans sitting, contacting one another with language, with the embodied self”. So we begin the interview. Charon graduated from Harvard Medical School in 1978 and began practising general medicine. In the late 1980s, she started doctoral studies at Columbia University, focusing on Henry James and the role of literature in medicine. The work of the second half of her life has been to bring these two super cially oppositional realms together. She believes the emotional and imaginative insights contained in literature, art and music can transform the way healthcare workers treat patients and each other. Around 1990, she began teaching narrative medicine at Columbia and in 2009 launched a masters degree in the subject, the rst of its kind. Since then, her approach has been deployed by healthcare practitioners across the US and abroad, from Greece to China. Formal evaluations have shown it improves participants’ capacity for re ection, in one study even reducing racial bias. Charon tells me that for decades doctors were taught to conform to a model of ‘detached concern’. At one point, she goes to a ling cabinet containing all medical records form her late father (who was a doctor), which she acquired after he died. This part of his life had always been shut fi fl fi fi fi off to her. But it turned out that his les combined the usual medical notations with far more personal references. It seemed to re ect a recognition that ailments could not be divorced from the wider context of their sufferers’ lives. Inspired, Charon began making more fulsome and impressionistic notes about her own patients. The practised narratologist, she says, can pick up a lot in a short period, even at a time when there is pressure on doctors to keep appointments as brief as possible. “As you develop your skills of attention, you will notice things about your patients. You will be listening at a much higher pitch.” As doctors, the human body is, she says, “our material... I’m sitting here looking at you, noticing how you sit in the chair.” My sense of her, which deepens over the next three-and-a-half hours, is of a woman with a vast well of compassion, lit by a righteous fury about the inequities of US healthcare. Truly listening to patients can be transformative, she says. “Patients on the whole really know what they need.” She recalls a young woman with poorly managed diabetes who arrived in her consulting room angry and frustrated. “I did my routine, which is get away from the computer, put my hands in my lap. Don’t write. Just say, ‘I’m going to be your doctor. Tell me what you think I should know.’” The woman looked as if she was going to cry but pulled herself together and glared. “You really want to know what I need? I need a new set of teeth.” It was only then Charon noticed she’d had her hand covering her mouth as she talked. She had no upper teeth. Instead of focusing on the woman’s insulin levels, Charon arranged for her to be seen in the university’s dental clinic. “She shows up in a couple of months, and she is dazzling. She started a [catering] business in her house. Her [blood] sugars were better than they had been in a while. And she was much more active — she’s going to parties, she’s dancing! It was such a lesson to me. Why on earth would you start anywhere else but ‘Tell me where we should start’?” I’m intrigued by the extent to which this approach requires an inversion of the traditional power relationship between doctor and patient. She tells me that for decades doctors were taught to conform to a model of “detached concern”. In fact, “engaged concern is going to get you farther than detached concern. Detachment looks an awful lot like coldness.” Instead, fi fl  Charon believes in making space for the imagination. “The more you exert your own creativity, the better your medicine will be. It’s making leaps... I don’t like the word intuition because it sounds like magic. But the ability to see the known from the unknown — that’s what poetry does.” In the early 2000s, Charon tried something new. After nishing a consultation and making notes like any doctor would, “I would turn the keyboard and the monitor around and say, ‘I know what I saw. But please nish the note.’ I would leave them alone for ve minutes, and they wrote the damnedest things!” A college professor wrote “that she knew that she was a good teacher and that this really gave her pride.” As a physician, the scope for moments of generosity is “drastic”, she says, whether ringing a patient’s sister to update her, helping put someone’s socks on after an examination or rubbing the feet of a terminally ill patient. There is something heartbreaking about the disproportionate gratitude these interventions elicit, she says. “I think their expectations for us are so low.” Narrative medicine can, she suggests, endow clinicians with the ability to see an issue from multiple perspectives, a power she likens to “the compound eye of the y”. It can help them to understand and value those they care for in all their uniqueness and complexity. “We ought to treat every patient as the deepest mystery,” she says. I. True or False Sentences: 1. Rita Charon founded the narrative medicine movement, which combines storytelling and creativity to improve healthcare. 2. Charon’s approach to medicine primarily focuses on detached concern, as she believes emotional distance leads to better outcomes. fi fl fi fi  3. The master's degree in narrative medicine launched by Charon at Columbia University was the rst of its kind. 4. Charon often encourages her patients to write their medical notes at the end of their consultations, believing it enhances their engagement. 5. One of Charon's most notable experiences was helping a diabetic patient by adjusting her insulin levels, which drastically improved her condition. 6. Narrative medicine has been adopted only in the United States, with limited international interest or application. 7. Charon believes that healthcare professionals should rely more on their imagination and creativity to better understand their patients. 8. In one study, narrative medicine was found to reduce racial bias among healthcare practitioners, improving the quality of patient care. II. Practice Here are three medical situations inspired by the principles of narrative medicine. Each includes a patient problem and some initial notes that you can expand upon. Keep in mind the key concepts: listening deeply, understanding the patient’s broader life context, and showing engaged concern. Situation 1: Chronic Back Pain Patient Problem: A 45-year-old woman, Ana, has been suffering from chronic lower back pain for several years. She’s frustrated because none of the treatments have worked, and her pain is now affecting her ability to work and care for her children. Initial Notes: fi  "Ana appears visibly tired and is shifting uncomfortably in her chair. She mentions feeling 'invisible' to doctors who only adjust medications but don't seem to hear her concerns. She looks tense when she speaks about her job and family responsibilities. She mentions missing family events due to the pain and feels guilty.” Directions: Continue the doctor's notes by expanding on Ana’s emotional state. What else could you ask her about her daily life and the impact the pain has on her relationships and job? How might this deeper context help you create a better treatment plan? Situation 2: Teenage Anxiety Patient Problem: A 17-year-old boy, Lucas, comes in with complaints of stomach issues, but after speaking for a while, it becomes clear that he’s struggling with anxiety about school and family expectations. Initial Notes: "Lucas seems reluctant to make eye contact. After discussing his stomach problems, he mentions feeling a lot of pressure from his parents regarding his grades. He says he hasn't been sleeping well, and his hands tremble slightly when talking about upcoming exams. He feels isolated at school and doesn't want to talk to his friends about it." Directions: Complete the notes by exploring Lucas’s emotional and psychological state. What open-ended questions could help you understand his anxiety better? How would you encourage him to share more about how his school and family life are affecting his health? What steps might you suggest to address both his anxiety and his physical symptoms? Situation 3: Elderly Woman with Diabetes Patient Problem: An 80-year-old woman, Maria, has poorly controlled diabetes. She has been missing some medical appointments and is struggling with diet management. She also lives alone and seems isolated. Initial Notes: "Maria comes in looking slightly ill, mentioning that she often forgets to take her medication. When discussing her eating habits, she talks about missing her husband who used to do all the cooking. Her voice cracks slightly when mentioning how lonely the house feels without him. She seems hesitant to ask for help." Directions: Continue by delving into Maria’s feelings of isolation and how this might affect her ability to manage her health. What questions can you ask to learn more about her living situation? How could you involve social support in her care plan? What creative solutions might you offer to help her feel less alone while improving her diabetes management?