Narrative in Health Care
John D. Engel, Joseph Zarconi, Laura Pethtel, Sally Missimi
Radcliffe Publishing; 2008.
288 pp $55.00
Narrative medicine has always seemed to me to be a high-falutin’ way to describe the process whereby doctors ask open-ended questions and actually listen to what their patients have to say. In fact, one of the authors of this book writes that during an internist’s round many years ago, “[I] was most struck by the variety of stories that were exchanged and the power that they had to either heal or dehumanize. … Although I did not have an intellectual framework (a disciplinary language) to discern the phenomenon as narrative … it was clear to me that the stories which I witnessed mattered to patients, physicians, and students.”
Where I come from, we used to call this phenomenon “caring.”
In the foreward to this book, Rita Charon, the eminent narrative medicine theorist, writes: “The narrative skills that [the authors] deem salient to effective health care are reading and telling complex stories, reasoning with stories, writing reflexively, compassionate presence, mindful listening, practising empathy, and exercising the moral imagination.” Which makes sense: as a writer I’ve always felt that writing and medicine are complementary. But are the two compatible for everyone? If you asked clinicians if they listened to their patients, I’m sure that they would say yes; if you asked them if they were compassionate, yes again. While working locums in many family doctors’ offices, my clinical discussions with my colleagues always started with the patients’ complicated and fraught family contexts. As this book maintains, and as any good doctor knows, context is all.
Charon promises a transformation in the clinician who reads this book, but I don’t think that writing about experience and feelings is patently a new medical technique. The authors are merely codifying what is already there. Narrative medicine is really just one means to empathy, and has only one “new” idea: the idea of harnessing a very old idea, bibliotherapy, and updating it by the addition of clinicians and patients writing, and reviewing these writings, with one another. The idea at its root is ancient, beginning with the Socratic maxim: “The unexamined life is not worth living.” Remember that the library at Thebes bore the inscription Psyches Itraeon, meaning “the healing place of the soul.” Haven’t psychiatrists been doing that kind of thing for a long time as part of their mental status examination?
The first part of the book considers the historical and theoretical underpinnings of narrative medicine (proving that the practice, if not the theory, has been around forever) by allowing narrative medicine to make its case for itself. This is a critical point: without citing the evidence and without the context, it could be written off as a touchy-feely clinical digression. The tone is happily not strident; the authors don’t argue for the primacy of narrative medicine over the evidence-based approach, rather they purport a complementarity of both approaches. But readability suffers in these early sections due to the sheer amount of abstraction, compounded by an annoying repetitiveness in stating what everyone already knows: that stories have a beginning, middle, and an end, and that they take place in time.
The second part of the book is, thankfully, practical, as it deftly touches on concepts, but places emphasis on exercises, such as meditation and interpreting poetry and photographs, in order to get the practitioner immersed in narratives, interpreting them, furthering them, comprehending them. These examples are where the rubber meets the road and do not require any kind of intrinsic narrative skill. One merely has to imagine what it’s like to walk in another’s shoes, which is easy enough to say that one does, but the magic is in actually sitting down and writing it out, and often surprising oneself. Creativity is inherently empathic.
The book does have some revealing gaps. For example, it fails to address the question of compassion fatigue. Narrative medicine suggests that every patient has a narrative, but mining each narrative can be painful for the doctor. The text blithely states that “it rejects the idea of detached concern prevalent in biomedical models of relationship and clinical training.” The book outright dismisses detachment as a strategy of self-preservation. Yet I believe there is a place for detachment in medicine; there is such a thing as the catharsis of burnout, and by using a one-size-fits-all approach the authors fail to recognize that self-preservation is sometimes saying, I am not of this, it is not me.
And what of the question of aesthetics? The authors suggest that the experience of narrative medicine need not concern itself with the quality of the writing, and emphasize process and content over form. This is perhaps the chief weakness of the narrative medicine trend: good writing is keener observationally and possesses more penetrating insight, than the mere doodlings of amateurs. Narrative writing, as advocated here, is like a kindergarten class where everyone is praised. The authors’ bizarrely abandon “literary autobiography” in favour of “lived first-person autobiography,” which seems to me to be self-defeating: the best kind of biography of the self is the self speaking well, although this may be my own high-falutin’ sneer right back at narrative.
I have only raised a few objections in this review. There is much, much more to chew on. Though the book is resolutely earnest and enthusiastic in tone, refreshingly encouraging and wishing and willing to better the practice of the profession, the amount of time spent circumnavigating — or validating — narrative medicine through the pertinent theorists is best suited to the academic physician charged with teaching students and is of little relevance to the most obvious audience, namely family physicians.
To the average clinician, the main message is the simple (and not necessarily new) idea that in writing about what one knows (one’s own experience) one discovers what one actually knows, and in writing the approximation of a patient’s experience and moving emphatically closer to the patient, one cannot help but improve the relationships of one’s practice.