The effective practice of medicine requires narrative competence, that
is, the ability to acknowledge, absorb, interpret, and act on the stories
and plights of others. Medicine practiced with narrative competence, called narrative medicine, is proposed as a model for humane and
effective medical practice. Adopting methods such as close reading of literature
and reflective writing allows narrative medicine to examine and illuminate
4 of medicine's central narrative situations: physician and patient, physician
and self, physician and colleagues, and physicians and society. With narrative
competence, physicians can reach and join their patients in illness, recognize
their own personal journeys through medicine, acknowledge kinship with and
duties toward other health care professionals, and inaugurate consequential
discourse with the public about health care. By bridging the divides that
separate physicians from patients, themselves, colleagues, and society, narrative
medicine offers fresh opportunities for respectful, empathic, and nourishing
medical care.
Ms Lambert (not her real name) is a 33-year-old woman with Charcot-Marie-Tooth
disease. Her grandmother, mother, 2 aunts, and 3 of her 4 siblings have the
disabling disease as well. Her 2 nieces showed signs of the disease by the
age of 2 years. Despite being wheelchair bound with declining use of her arms
and hands, the patient lives a life filled with passion and responsibility.
"How's Phillip?" the physician asks on a routine medical follow-up visit.
At the age of 7 years, Ms Lambert's son is vivacious, smart, and the center—and
source of meaning—of the patient's world. The patient answers. Phillip
has developed weakness in both feet and legs, causing his feet to flop when
he runs. The patient knows what this signifies, even before neurologic tests
confirm the diagnosis. Her vigil tinged with fear, she had been watching her
son every day for 7 years, daring to believe that her child had escaped her
family's fate. Now she is engulfed by sadness for her little boy. "It's harder
having been healthy for 7 years," she says. "How's he going to take it?"
The physician, too, is engulfed by sadness as she listens to her patient,
measuring the magnitude of her loss. She, too, had dared to hope for health
for Phillip. The physician grieves along with the patient, aware anew of how
disease changes everything, what it means, what it claims, how random is its
unfairness, and how much courage it takes to look it full in the face.
Sick people need physicians who can understand their diseases, treat
their medical problems, and accompany them through their illnesses. Despite
medicine's recent dazzling technological progress in diagnosing and treating
illnesses, physicians sometimes lack the capacities to recognize the plights
of their patients, to extend empathy toward those who suffer, and to join
honestly and courageously with patients in their illnesses.1,2
A scientifically competent medicine alone cannot help a patient grapple with
the loss of health or find meaning in suffering. Along with scientific ability,
physicians need the ability to listen to the narratives of the patient, grasp
and honor their meanings, and be moved to act on the patient's behalf. This
is narrative competence, that is, the competence that human beings use to
absorb, interpret, and respond to stories. This essay describes narrative
competence and suggests that it enables the physician to practice medicine
with empathy, reflection, professionalism, and trustworthiness.3
Such a medicine can be called narrative medicine.4
As a model for medical practice, narrative medicine proposes an ideal
of care and provides the conceptual and practical means to strive toward that
ideal. Informed by such models as biopsychosocial medicine and patient-centered
medicine to look broadly at the patient and the illness, narrative medicine
provides the means to understand the personal connections between patient
and physician, the meaning of medical practice for the individual physician,
physicians' collective profession of their ideals, and medicine's discourse
with the society it serves.5,6
Narrative medicine simultaneously offers physicians the means to improve the
effectiveness of their work with patients, themselves, their colleagues, and
the public.
To adopt the model of narrative medicine provides access to a large
body of theory and practice that examines and illuminates narrative acts.7 From the humanities, and especially literary studies,
physicians can learn how to perform the narrative aspects of their practice
with new effectiveness. Not so much a new specialty as a new frame for clinical
work, narrative medicine can give physicians and surgeons the skills, methods,
and texts to learn how to imbue the facts and objects of health and illness
with their consequences and meanings for individual patients and physicians.8,9
The turn toward narrative knowledge
Not only medicine but also nursing, law, history, philosophy, anthropology,
sociology, religious studies, and government have recently realized the importance
of narrative knowledge.10-13
Narrative knowledge is what one uses to understand the meaning and significance
of stories through cognitive, symbolic, and affective means. This kind of
knowledge provides a rich, resonant comprehension of a singular person's situation
as it unfolds in time, whether in such texts as novels, newspaper stories,
movies, and scripture or in such life settings as courtrooms, battlefields,
marriages, and illnesses.14-16
As literary critic R. W. B. Lewis17 writes,
"Narrative deals with experiences, not with propositions." Unlike its complement,
logicoscientific knowledge, through which a detached and replaceable observer
generates or comprehends replicable and generalizable notices, narrative knowledge
leads to local and particular understandings about one situation by one participant
or observer.18,19 Logicoscientific
knowledge attempts to illuminate the universally true by transcending the
particular; narrative knowledge attempts to illuminate the universally true
by revealing the particular.
Narrative considerations probe the intersubjective domains of human
knowledge and activity, that is to say, those aspects of life that are enacted
in the relation between 2 persons. Literary scholar Barbara Herrnstein Smith20 defines narrative discourse as "someone telling someone
else that something happened," emphasizing narrative's requirement for a teller
and a listener, a writer and a reader, a communion of some sort.
The narratively competent reader or listener realizes that the meaning
of any narrative—a novel, a textbook, a joke—must be judged in
the light of its narrative situation: Who tells it? Who hears it? Why and
how is it told?21-23
The narratively skilled reader further understands that the meaning of a text
arises from the ground between the writer and the reader,24,25
and that "the reader," as Henry James writes in an essay on George Eliot,
"does quite half the labour."26 With narrative
competence, multiple sources of local—and possibly contradicting—authority
replace master authorities; instead of being monolithic and hierarchically
given, meaning is apprehended collaboratively, by the reader and the writer,
the observer and the observed, the physician and the patient.
Narrative competence in medicine
Medicine has never been without narrative concerns, because, as an enterprise
in which one human being extends help to another, it has always been grounded
in life's intersubjective domain.27,28
Like narrative, medical practice requires the engagement of one person with
another and realizes that authentic engagement is transformative for all participants.
As a legacy of the developments in primary care in the 1960s and 1970s,
patient-physician communication, and medical humanities, medicine has become
increasingly schooled in narrative knowledge in general and the narratives
of patients and physicians in particular.29-31
This growing narrative sophistication has provided medicine with new and useful
ways in which to consider patient-physician relationships, diagnostic reasoning,
medical ethics, and professional training.32-35
Medicine can, as a result, better understand the experiences of sick people,
the journeys of individual physicians, and the duties incurred by physicians
toward individual patients and by the profession of medicine toward its wider
culture.36-38
Medical practice unfolds in a series of complex narrative situations,
including the situations between the physician and the patient, the physician
and himself or herself, the physician and colleagues, and physicians and society.
The following sections will summarize the contributions of narrative medicine
to each of these 4 situations. Other important narrative situations exist
in medicine as well, although they will not be discussed in this essay, such
as between the physician and his or her family, between patients and their
family members, and among patients.
Patient-physician: empathic engagement
As patient meets physician, a conversation ensues. A story—a state
of affairs or a set of events—is recounted by the patient in his or
her acts of narrating, resulting in a complicated narrative of illness told
in words, gestures, physical findings, and silences and burdened not only
with the objective information about the illness but also with the fears,
hopes, and implications associated with it.39
As in psychoanalysis, in all of medical practice the narrating of the patient's
story is a therapeutically central act, because to find the words to contain
the disorder and its attendant worries gives shape to and control over the
chaos of illness.40-43
As the physician listens to the patient, he or she follows the narrative
thread of the story, imagines the situation of the teller (the biological,
familial, cultural, and existential situation), recognizes the multiple and
often contradictory meanings of the words used and the events described, and
in some way enters into and is moved by the narrative world of the patient.44,45 Not unlike acts of reading literature,
acts of diagnostic listening enlist the listener's interior resources—memories,
associations, curiosities, creativity, interpretive powers, allusions to other
stories told by this teller and others—to identify meaning.46 Only then can the physician hear—and then attempt
to face, if not to answer fully—the patient's narrative questions: "What
is wrong with me?" "Why did this happen to me?" and "What will become of me?"
Listening to stories of illness and recognizing that there are often
no clear answers to patients' narrative questions demand the courage and generosity
to tolerate and to bear witness to unfair losses and random tragedies.47 Accomplishing such acts of witnessing allows the
physician to proceed to his or her more recognizably clinical narrative tasks:
to establish a therapeutic alliance, to generate and proceed through a differential
diagnosis,48 to interpret physical findings
and laboratory reports correctly, to experience and convey empathy for the
patient's experience,49 and, as a result of
all these, to engage the patient in obtaining effective care.
If the physician cannot perform these narrative tasks, the patient might
not tell the whole story, might not ask the most frightening questions, and
might not feel heard.50 The resultant diagnostic
workup might be unfocused and therefore more expensive than need be, the correct
diagnosis might be missed, the clinical care might be marked by noncompliance
and the search for another opinion, and the therapeutic relationship might
be shallow and ineffective.
Despite—or, more radically, because of—economic forces that
shrink the time available for conversation and that limit the continuity of
clinical relationships, medicine has begun to affirm the importance of telling
and listening to the stories of illness. As practice speeds up, physicians
need all the more powerful methods for achieving empathic and effective therapeutic
relationships. Narrative skills can provide such methods to help physicians
join with their patients, honoring all they tell them.
Physician-self: reflection in practice
Altruism, compassion, respectfulness, loyalty, humility, courage, and
trustworthiness become etched into the physician's skeleton by the authentic
care of the sick. Physicians absorb and display the inevitable results of
being submerged in pain, unfairness, and suffering while being buoyed by the
extraordinary courage, resourcefulness, faith, and love they behold every
day in practice.
Through authentic engagement with their patients, physicians can cultivate
affirmation of human strength, acceptance of human weakness, familiarity with
suffering, and a capacity to forgive and be forgiven. Diagnosis and treatment
of disease require schooled and practiced use of these narrative capacities
of the physician. Indeed, it may be that the physician's most potent therapeutic
instrument is the self, which is attuned to the patient through engagement,
on the side of the patient through compassion, and available to the patient
through reflection.51
Reflective practitioners can identify and interpret their own emotional
responses to patients, can make sense of their own life journeys, and so can
grant what is called for—and called forth—in facing sick and dying
patients.52,53 When sociologists
studied medicine in the 1960s, they observed physicians to practice medicine
with "detached concern."54 Somehow, this field
observation became a normative prescription, and physicians for decades seemed
to consider detachment a goal. Today, relying on newly emerging knowledge
from narrative disciplines, physicians are learning to practice medicine with
not detached but engaged concern, an approach that requires disciplined and
steady reflection on one's practice.55-57
As reflective practitioners, physicians have turned to a study of the
humanities, especially literature, to grow in their personal understanding
of illness.58 Literature seminars and reading
groups have become commonplace in medical schools and hospitals, both for
physicians to read well-written stories about illness and to deepen their
skills as readers, interpreters, and conjurers of the worlds of others.59-61 Having learned that
acts of reflective narrating illuminate aspects of the patient's story—and
of their own—that are unavailable without the telling, physicians are
writing about their patients in special columns in professional journals and
in books and essays published in the lay press.62-65
Increasingly, physicians allow patients to read what they have written about
them, adding a therapeutic dimension to a practice born of the need for reflection.66 Through the narrative processes of reflection and
self-examination, both physicians and patients can achieve more accurate understandings
of all the sequelae of illness, equipping them to better weather its tides.
The ordinary, day-to-day professional actions of physicians in research,
teaching, and collegial life are saturated with narrative work and can be
made more effective once recognized as such. It is only with narrative competence
that research proceeds, teaching succeeds, clinical colleagueship achieves
its goals, and the profession of medicine remains grounded in its timeless,
selfless commitment to health.
Scientific research results from the muscular narrative thrust of first
imagining and then testing scientific hypotheses, and it relies on narrative
inventiveness and imagination as well as scientific training.67
Like medicine's theoretical knowledge, its practical knowledge is issued in
narrative and mastered through time. The student becomes the physician by
functioning as a medium for medicine's continuity of knowledge, learning about
diseases in the process of living through their passages.68
No physician mobilizes his or her practical knowledge about a disease without
having mastered the sequential stories imagined, over time, to explain its
symptoms, from dropsy to the downward limb of the Starling curve to diastolic
dysfunction.
In professional life, physicians rely on one another—as audience,
witness, reader—for honesty, criticism, forgiveness, and the gutsy blend
of uncertainty and authority contained in the phrase, "We see this."69 From interns up all night together to the surgeon
and the internist moving through the dark of a patient's illness, physicians
grow to know one another with the intimacy and the contention of siblings,
affirming one another's triumphs, hearing one another's errors, and comforting
one another's grief.70
Medicine is considered a profession because of, in part, the strength
of these bonds among physicians. Certified to educate and to police one another,
physicians accrue responsibility for one another's competence and conscience.
Recent urgent calls for professionalism signal physicians' widening failures
to accept and enact their commitment to individually and collectively uphold
their profession's ideals.71,72
Instead, physicians seem isolated from one another and from their colleagues
in nursing, social work, and other health professions and divided from their
ideals and disconnected from their broad professional goals in the face of
narrow, competitive drives toward individual distinction or reward.73
To profess is a narrative act. Perhaps the most effective methods to
strengthen professionalism in medicine are to endow physicians with the competence
required to fulfill their narrative duties toward one another: to envision
the stories of science, to teach individual students responsibly, to give
and accept collegial oversight, and to kindle and enforce the intersubjective
kinship bonds among health care professionals. Only when physicians have the
narrative skills to recognize medicine's ideals, swear to one another to be
governed by them, and hold one another accountable to them can they live up
to the profession to serve as physicians.
Physician-society: the public trust
Physicians are conspicuous members of their cultures, anointed as agents
of social control who deploy special powers to rescue, heal, and take command.
Granting tonic authority to its physicians while regarding them with chronic
suspicion, the public commands physicians to understand and treat disease
while doing no harm. While holding physicians accountable to these public
expectations, patients also yearn for such private benevolence from their
physicians as tenderness in the face of pain, courage in the face of danger,
and comfort in the face of death.
Of late, medicine in the United States has experienced highly publicized
reversals in public trust with accusations of overbilling for services, withholding
from patients the potential risks of research, and deriving financial benefit
from professional knowledge.74,75
Medicine's—if not individual physicians'—trustworthiness has been
called into question.76,77 Yet,
patients realize that they cannot explicitly tell physicians how to practice
medicine. They must have implicit trust in the virtue and wisdom of those
who care for the sick.
The contradictions between a medical system that must be governed from
outside and a medical system that has earned the public trust have achieved
great urgency. The US culture is now actively and contentiously restructuring
its health care system. Having experienced the early phases of a marketplace-driven
health care system and having failed in its first attempt at health care system
reform, the nation is attempting to open collective discourse in politics
and the media about the value to be placed on health and health care.78,79
Only sophisticated narrative powers will lead to the conversations that
society needs to have about its medical system. Physicians have to find ways
to talk simply, honestly, and deeply with patients, families, other health
care professionals, and citizens. Together, they must make responsible choices
about pain, suffering, justice, and mercy. Not scientific or rational debates,
these are grave and daring conversations about meaning, values, and courage.
They require sophisticated narrative understanding on all conversationalists'
parts of the multiple sources of meaning and the collaborative nature of authority
called on to resolve issues of health and illness. With the narrative competence
necessary for serious and consequential discourse, patients and physicians
together can describe and work toward a medical system undivided in effectiveness,
compassion, and care.
Research and programmatic implications
Narrative medicine suggests that many dimensions of medical research,
teaching, and practice are imbued with narrative considerations and can be
made more effective with narrative competence. Already, a spontaneous interest
in narrative medicine has germinated from many centers in the United States
and abroad, confirming the usefulness and fit of these frameworks and practices
for medicine and other health care professions.80-82
As the conceptual vision of narrative medicine becomes coherent, research
agendas and action plans unfold.
The hypotheses to be tested are provocative and wide ranging. It may
be that the physician equipped with the narrative capacities to recognize
the plight of the patient fully and to respond with reflective engagement
can achieve more effective treatment than can the physician unequipped to
do so. Medical educators may find that applicants already gifted with narrative
skills are better able to develop into effective physicians than are students
deficient in them.
Programs have been under way for some time in incorporating narrative
work into many aspects of medical education and practice. The teaching of
literature in medical schools has become widely accepted as a primary means
to teach about the patient's experience and the physician's interior development.83 Narrative writing by students and physicians has
become a staple in many medical schools and hospitals to strengthen reflection,
self-awareness, and the adoption of patients' perspectives.84-87
The practice of bioethics has adopted narrative theory and methods to reach
beyond a rule-based, legalistic enterprise toward an individualized and meaning-based
practice.88,89 Certainly, more
and more patients have insisted on achieving a narrative mastery over the
events of illness, not only to unburden themselves of painful thoughts and
feelings but, more fundamentally, to claim such events as parts, however unwelcome,
of their lives.90,91
Adding to early evidence of the usefulness of narrative practices, rigorous
ethnographic and outcomes studies using samples of adequate size and control
have been undertaken to ascertain the influences on students, physicians,
and patients of narrative practices.92,93
Along with such outcomes research are scholarly efforts to uncover the basic
mechanisms, pathways, intermediaries, and consequences of narrative practices,
supplying the "basic science" of theoretical foundations and conceptual frameworks
for these new undertakings.
The description of Ms Lambert at the beginning of this article was written
by her physician (the author) after a recent office visit and shown to her
on the subsequent visit. As Ms Lambert read the words, she realized more clearly
the anguish she had been enduring. Her sisters had dismissed her concerns,
saying she was imagining things about Phillip, and that had added to her own
suffering. She felt relieved that her physician seemed to understand her pain,
and she told the physician what her sisters had said.
"Can I show this to my sisters?" Ms Lambert asked her physician. "Then
maybe they can help me."
This essay has outlined the emergence of narrative medicine, a medicine
infused with respect for the narrative dimensions of illness and caregiving.
Through systematic and rigorous training in such narrative skills as close
reading, reflective writing, and authentic discourse with patients, physicians
and medical students can improve their care of individual patients, commitment
to their own health and fulfillment, care of their colleagues, and continued
fidelity to medicine's ideals. By bridging the divides that separate the physician
from the patient, the self, colleagues, and society, narrative medicine can
help physicians offer accurate, engaged, authentic, and effective care of
the sick.
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