First, listen. Narrative medicine heals.
David Schleich, PhD
Not wanting to be purveyors of what Foucault called the “medical gaze” (treating the body and not the person), Naturopathic Doctors have long understood the high value of knowing patient stories from the biopsychosocial dimensions of their lives. In the rush among standards of care, treatment protocols and the ever present reimbursement squeeze, such private narratives often languish, communicated in fragments if at all, or festering unspoken. Naturopathic Doctors and other natural medicine providers know this. Increasingly, biomedicine Doctors are cluing in.
The literature of professional formation in the last two decades has included reference to concerns often attributed to a reductionist model of care, such as the unfortunate fragmentation of the clinical experience, the impersonal nature of bureaucratic decision processes about health care choices and reimbursement, and the loss of individuality in the patient encounter. Essentially these issues are about the autonomy and uniqueness of the patient, but concomitantly about the quality of the relationship with the provider, such as how much time the patient spends with the provider and what constitutes the form and content of the communication between them. In such a loaded terrain, the potential for a costly divide between the doctor and the patient crops up more often than those providers intend. Naturopathic doctors, in this regard, have been the longtime placeholder profession for biopsychosocial, patient-centered medicine, and have championed empathic engagement since Lust, Lindlahr and others systematized its modalities and approach back at the beginning of the 20th century.
The history of the evolution of the American Health Care system is hugely complex, shifting sharply in reach, range and purpose, both pre and post WWII, and proliferating with astonishing rapidity non-stop into the present era. The players, governance and reimbursement elements of that mainstream health care system, with all its silos, departments and turnstiles has developed for many reasons into an extraordinarily expensive and unequal structure. It got to the point where an ACA (the Affordable Care Act) was needed.
The tripartite framework of the ACA (philosophical, political, economic) was very much about access, cost and collaboration, but also about restoring better therapeutic alliances between the doctor and the patient. It was hoped by many that the ACA over time could help weed out the rotters and rascals who were enabling and profiting from a heavily commodified and unsustainable system of diagnosis and care which was not making Americans healthier. It was also intended as a legislative effort to do something about globally embarrassing outcomes related to the actual health of the nation's citizens, data about which health outcomes made no sense given how much of the national treasure the custodians of that system were taking year after year.
In the mainstream, contemporary U.S. health system, issues of affordability and access ricochet all around the patient’s experience of illness and the process of treatment itself. Allopathic doctors in particular are frustrated, being too often straightjacketed by processes and protocols whose short leash insurance and reimbursement arrangements and vulnerability to the pharmaceutical industry involve contentious notions such as pre-existing conditions, uncovered calamity, varying and severe prescription drug crises, and the dilution of the preventive potential of general practice providers.
In the middle of all this fuss and rattle, the patient’s story doesn't easily come into focus and stay crisp. Only when there is clarity, as Dr. Rita Charon, MD, PhD puts it, “… 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?’ (https://jamanetwork.com/journals/jama/fullarticle/194300are often not patient-centered)
In the mainstream health system, there is urgent financial reckoning. There are other strictures fueling the medical cascade of insurers and providers such as caps, co-pays, codes and qualifiers. The very human story of the patient’s illness risk being missed on that path. There is no time. The particular story is not as important as symptoms, presenting conditions and the rush to diagnosis. Naturopathic care takes more time and has historically been successful in overcoming much of this worrying interface. In the Naturopathic tradition, stories of illness not only nourish empathy and provide invaluable insights into the mind-body-spirit elements of the patient's life, but embody the difference between treating disease and treating the patient; eschewing, thus, Foucault's “medical gaze”.
The origins of narrative medicine
It took a PhD in English, who also earned an MD, to sharpen the focus on the power of the patient's story, and on the doctor's obligation to invite that story, listen to it, and learn from it. A decade ago Dr. Rita Charon, PhD, MD, of Columbia University got busy improving allopathic clinical practice by providing training focused on renewed attention to patients. Top of mind was attentive listening, coupled with what the designers of its “narrative medicine” program called “creative contact, singular accuracy, and personal fidelity”. Other elements in this approach proffered for option by allopathic students in the curriculum included skills well known by Naturopathic Doctors such as “empathic interviewing, reflective practice, narrative ethics, self-awareness and intersubjective contact”( https://www.narrativemedicine.org/about-narrative-medicine/).
Dr. Charon introduced the notion of narrative medicine back at the beginning of our new century. She explained at the time that it was, essentially, “a model for humane and effective medical practice". She writes, "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." (Charon, 2001, JAMA, p. 1897)
In those early days Columbia partnered with the revered Canossiano Institute in Venice to teach medical doctors and nurses and other biomedicine professionals how to “nourish empathic doctor-patient relationships,” to “replace isolation with affiliation,” and to establish “patient-centered and life-framed practices”. Sound familiar? Naturopathic doctors, deeply rooted in humanistic health care, have been predicating their clinical programs on just such a personalized approach for a very long time. That particular Columbia – Canossiana workshop attracted U.S. and European medical credits. Presenters were from Columbia, the University of Toronto, George Washington University, Technion in Haifa, and the University of Milan. Its value was recognized immediately and has persisted. Not surprisingly, the biomedicine profession did not include presenters from what in those days were labeled as the “CAM professions”.
Today Columbia continues its pioneering Master of Science degree in narrative medicine. The program includes narrative writing, reading, literary and philosophical analysis, and these are coupled with practicums which include practitioners and patients. As Charon suggests, the whole idea is to “draw on the study of art and literature to enhance students’ listening and observation skills and to expand their view of patients to encompass more than just medical histories.” (https://news.aamc.org/medical-education/article/narrative-medicine-every-patient-has-story/)
A few years after Dr. Charon started the ball rolling, the University of Iowa sponsored a conference called “The Examined Life” in the same vein. Participants assembled to explore “links between the science of medicine and the art of writing”. The elements explored at that event and others like it have been central to naturopathic care for decades (human interaction, information and education, the presence of loved ones/friends and social support in the healing journey, spirituality and inner resources, the importance of human touch, the nutritional and nurturing aspects of food, and an ambience often which is personal and inspiring). Additionally, workshops advancing this approach focused on thoughtful listening, nurturing talking, and meaningful time spent with the patient. Some elements of this narrative road to empathy have persisted as messaging in the “integrative” and “functional” medicine sectors of contemporary allopathic medicine. There are critics, though, of this humane face on medicine who worry that narrative medicine is an aspect of assimilation at work.
Narrative Medicine as co-optation
In that regard, some contend that narrative medicine is more evidence of an accelerating co-opting of the essence of the natural medicine professions, or at least of the more human face of holistic medicine. Narrative medicine, whatever its patina, is emerging in plain sight on the front lines of the biomedicine landscape. The alternative to objectified patient care is chunking into turf and market share of biomedicine and MDs and U.S. DOs are encountering well informed patients who want more than seven minute prescriptions, emotional distance, and more tests.
The biomedicine terrain has been described by those excluded from its orthodoxy as compressed, characterized by quantified time allocations per patient, embarrassed by the uninsured, scourged by the tangle of rules for the insured, dominated by HMOs, and contained by reductionist medical reasoning which “blindly follows statistical likelihoods, regardless of variations such as age, sex, ethnicity, or individual psychologies” (Charon, 2006).
Dr. Charon, the principle architect of “narrative medicine”, has articulated over many years a strategic communications approach for the biomedicine profession which seeks to warm up that landscape. She teaches that clinicians need to “develop a sturdy and clinically useful affiliation with the one who suffers”. In such a universe, the MD becomes a “witness” and not a “judge”; a “companion” and not an “interrogator”. Were Dr. Charon to have had an inter-professional framework for her original research and development, I’m certain she would have found Naturopathic Physicians to be keen, accomplished, long time practitioners of such empathy.
Charon adds that “narrative medicine had its start in … patient-centered care and medical humanities” (2006). In an allopathic universe where where insurance, pharmaceutical companies and health networks, despite presenting themselves in the community as non-profits, snare providers in a profit equation, where biomedicine students learn quickly that emotional attachment can hurt, where time is money, and where medical training for the longest time objectified the patient enough to spawn Patch Adams satire about such alienation.
The idea is, in her words, is that by really listening to the patient (more than a few moments), the doctor can “receive in full complexity what the patient conveys in words, silences, gestures, positions, and physical findings” (Charon, 2008). Charon further suggests that doctors who possess "narrative competence" are able to “bridge the divides of their relation to mortality, the contexts of illness, beliefs about disease causality, and emotions of shame, blame, and fear.” (2006)
This isn’t just some lingering byproduct of, say, Angelica Thieriot’s earlier Planetree Alliance approach, transformational as that remarkable nonprofit’s one hundred plus hospital strong organization from Derby, Connecticut had been in the fuss and rattle of the hospital business in America back in the day. Rather, the advent and spread of narrative medicine education signals awareness of the consequences of decades of treating patients impersonally and a century of understanding their presentations through the limited reductionist lens.
Frankly, naturopathic doctors already know narrative medicine and have always understood what they’re doing as a relationship. In the initial intake and well beyond, NDs relate to their patients as individuals, as persons, rather than being obliged by paradigm and insurance codes to gather in detail in a rush to diagnosis using an inevitable battery of tests, keyboarding into being EHR charts on the spot. The health insurance companies don’t much like the relational approach of the ND because it takes a long time and is tough to prescribe and quantify. The doctor and the patient get lost in such a continuum. Charon puts it another way: ". . . practitioners, be they health care professionals to begin with or not, must be prepared to offer the self as a therapeutic instrument" (p. 215).
The narrative medicine model puts one in mind of Tiffany Field’s “therapeutic touch” (established thirty years ago at the University of Miami School of Medicine) or Wayne Dyer’s notion from a few decades back that intention is a “force in the universe” to which everyone and everything is connected. Biomedicine communicators, in any case, can learn handily from Naturopathic Doctors because of the expansion of integrative and inter-professional arrangements in our day. The fellows in the AIHM program, for example, see reflected in action, in the clinics of natural medicine providers, standards of patient-centered care which the Naturopathic medical education community presents routinely in its
Dr. Charon's work has been widely recognized over the years. She has received honors from numerous groups, such as the Association of Medical Colleges, the American College of Physicians, the Society for Health and Human Values, and the Society of General Internal Medicine. The recognition built quickly because of the robust value-added of the new curriculum. For example, just after the 2010 Columbia workshop referenced earlier, a related June 2011 workshop at the same university filled right away and had an instant waiting list. The ideas quickly crossed the Atlantic, and the University of London's School of Advanced Study Institute of English Studies held a conference about, of all things, the use of ‘comics in medical and public education and their role in health communication and scholarship’. Mucho ado about story and health. And it continues.
Useful to note, from the point of view of curriculum design, is that the Columbia “Narrative Medicine master's program” recruited in the humanities and social sciences, organizing their curriculum to “educate a leadership corps of health professionals” who understand the “intimate, interpersonal experiences of the clinical encounter”. They have attracted professionals from numerous clinical fields to learn more about becoming “narratively competent clinicians”. They too are building “a different kind of caregiver”, not unfamiliar to the naturopathic community.
The “narrative medicine” initiative also took root at that time at the New York-Presbyterian Hospital/Columbia where resident, Dr. Abigail Ford, said: “Narrative medicine changed my entire approach to medicine. As a doctor you are really a co-author of patients’ experiences and need to hear their story and take it on.” (New York Times, 2008). Other residency programs popped up, such as at Vanderbilt University’s Department of Surgery.
There are many more such examples which persist into the closing years of this decade. At the University of Nevada School of Medicine, another good example, medical students can benefit from narrative medicine as a concentration or as an elective in fourth year. Temple University launched a narrative medicine program in 2016. The Warren Alpert Medical School (Brown) offers students a narrative medicine course too. Even the legendary Kripalu Center for Yoga and Health is offering this year its sixth iteration of a conference entitled “Narrative Medicine: A Cutting-Edge Approach to Healthcare” featuring Natalie Goldberg among others. Seminar breakout groups abound now on such topics as: Psychoanalysis and Narrative Medicine, The Therapy of Writing: An Analysis of Medical Prose in JAMA, and A Perspective on the Role of Stories as a Mechanism of Meta-Healing.
Healing the gap
Essentially, “narrative medicine” adds back into the transaction between caregiver and patient the relational, respectful dimensions which biomedicine bleached out of the experience prior to and after Flexner. It is a curriculum and communication technique which constitutes what Cooke et al meant when they described in the same year as the Columbia conference, the need for a “synthesis of the cognitive and moral aspects of professional work” (2010, p. ix). Cooke and her colleagues, in that important Carnegie Foundation centennial treatise, Educating Physicians: A Call for Reform of Medical School and Residency, [published one century after Flexner] take great care to delineate the “poor connections between formal knowledge and experiential learning and inadequate attention to patient populations, health care delivery, and effectiveness” (p. 3). Cooke saw this need as manifesting not only in thorough reports of disease symptoms at the expense of listening for and hearing about the patient’s life and feelings, but also in the steep shift in careers of procedural specialties rather than primary care.
The debate strengthens these days, then, about how belief cannot just be biology in medicine and in people’s lives. As Fosse (2002) puts it: “How can macroscale phenomena like thoughts and feelings be shown to exert downward causal influence over microscale phenomena like biological processes?” (Fosse, 2002, p. 8). Narrative medicine is the tip of an iceberg in this sea of transformation about what constitutes “health” and what the physician’s role in it must be.
Narrative medicine inspires a broader discourse and critical reflection about the structural inequities in the American health care system. Narrative medicine helps grow awareness that health professionals need to incorporate patients' life stories, including their unique underlying value system, into medical treatment options that fit each individual.
Narrative ethics refers to how a doctor listens for, and hears, more than a report of disease symptoms. Narrative medicine, reflectively practiced, encourages shared, ethical decision-making regarding the patient's care, particularly at the end of life. It balances treatment options between the belief systems and life of the patient, and the technological possibilities the doctor advocates.
Ideally, whatever the treatment goals, narrative medicine’s own narrative is that those goals should be in harmony with the way the patient has lived his or her life from the beginning on through the middle and up to the end. Narrative medicine is a special tool and serves that end.
REFERENCES
Charon, Rita. (2001). Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA. 2001;286(15): 1897-1902. doi:10.1001/jama.286.15.1897
Charon, Rita. (2008). Medscape Today. Accessed April 22, 2011. https://www.medscape.com/viewarticle/520704
Charon, Rita. (2006). Narrative Medicine: Honoring the Stories of Illness. Oxford: Oxford University Press.
Cooke, M., Irby, David M., and O’Brien, Bridget C. (2010) Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco: Jossey-Bass.
New York Times https://www.nytimes.com/2008/10/24/health/chen10-23.html