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Rita Charon, M.D., Ph.D., center, set the narrative medicine wave in motion from Columbia University. It's here at Vanderbilt, in a second-year medical school class taught by A. Scott Pearson, M.D. She recently visited the class and delivered the Spring Ethics Grand Rounds lecture. Photo by Dana Johnson

Stories we could tell: a look into narrative medicine

BY: CLINTON COLMENARES

4/23/2004 - Second-year Vanderbilt medical student Gautam Jayaram entered a patient’s room toting the biases natural to most young people not yet fully engaged in the medical world.

But when he later wrote about the hourlong encounter for his narrative medicine class, he learned in the retelling of the patient’s story a lesson about himself and how to care for patients differently, looking beyond symptoms “to understand people and patient care better,” he said.

Narrative medicine “goes deeper” than a physical diagnosis, said A. Scott Pearson, M.D., assistant professor in Surgical Oncology, who has given the movement a foothold at Vanderbilt with a class for second-year medical students like Jayaram.

At the spring ethics grand rounds recently, Rita Charon, M.D., Ph.D., director of the Program in Narrative Medicine at Columbia University, explained that narrative medicine and medical ethics mesh when a clinician folds a patient’s story into patient care.

Increasingly, health care providers view ethics episodically, as when they need to call for an ethics consult in end-of-life situations. Instead, she said, ethical medicine is a continuum, one which narrative medicine helps facilitate by encouraging health care providers to recognize what’s important to the patients.

“Each doctor, nurse and social worker needs to be very, very aware of and cognizant to and equal to the task of fulfilling what comes to us, not because we have to turn a respirator off but because we now owe this person something. They’ve told (their story) to us,” Charon said. “We’ve heard it and now it is our responsibility.”

“Truly ‘hearing’ a patient’s story allows us to care for a patient in a way that’s more connected to the patient’s perspective, and thus better fits the patient’s beliefs, values and understandings,” said Stuart Finder, Ph.D., director of the Center for Clinical and Research Ethics, which co-sponsored Charon’s lecture.

Such “hearing” requires many of the same skills it takes to read a narrative in literature — letting go of preconceived notions or agendas and allowing oneself to be drawn into a story in order to discover what’s important — and can be applied in narrative medicine, Finder said.

In her lecture, Charon, whose doctoral degree is in literature, described her experience with an elderly Spanish-speaking woman who suffered from depression and who was wracked with fears about illnesses that had recently killed some of her family members.

“She needed me to bear witness to her despair,” Charon said, but instead the doctor fidgeted uncomfortably, literally sitting on her hands trying to focus on her patient. “Very often doctors tend to focus on the technical bodily problems of health — the glucose is too high or the blood pressure is too high — and we tend to shy away from the very messy domains like sadness and fears and depression.”

Pearson, a fellow of Vanderbilt’s Robert Penn Warren Center for the Humanities, tackles those conventions in his class, which was developed with support from Bonnie Miller, M.D., associate dean for Medical Students. He challenges his handful of students to write creatively, visiting their imaginations, putting it all on a page for further inspection and introspection, to gain perspective and understanding of themselves and their patients.

“As technology, or as information, increases, sometimes medicine is less patient- centered,” Pearson said. “Patients tell us that ‘I never really knew my doctor,’ or ‘my doctor doesn’t know me.’ They were never asked what’s important to them. “Narrative medicine is a patient-centered approach to the practice of medicine that rescues the patient’s story and integrates what is important to them into decisions about their health care.”

Jayaram’s narrative recounts prefabricated uneasiness about his patient, similar to Charon’s experience with the elderly lady. The man, Jayaram writes, lay in a rehabilitation bed four weeks following a liver transplant. When he learned he had liver disease, the student incorrectly pre-judges him to be an alcoholic. But he lets the patient roll out his story: he has no family and he’s never been to see a doctor, much less been admitted to a hospital. The man has never had a drink; the cause of his disease is cryptogenic — unknown. Finally, Jayaram asks the man if he thinks he’s making progress. The patient breaks a dam of emotion and cries, then asks for the nurse to help him.

Narratives, Charon said, have what medicine lacks, namely characters, plots and storylines. “Only in telling a story that I can live in the face of time, that I can see something singular,” she said, referring to an individual person and that person’s story, rather than a name on a chart.

“It makes it not just a technical puzzle but a lived experience,” she said.

In recounting his patient encounter, Jayaram also confronted, with bold, frank honesty, his own apprehensions about medicine and guilt for lacking the ability to tend properly to the patient.

“The reason I took the class was to do something different, to understand the subjective and personal side of caring for people,” Jayaram said. “I learned it’s very important to step back and look at what you’re doing. Writing in this context gives you a chance to sit down and not only understand your patient better, but also to understand your own shortcomings and strengths as a physician, and I think that can lead to better patient care.”

His attitude shifted from somewhat callous apathy for someone he made inaccurate assumptions about to empathy and understanding, and with new thoughts on how to treat his patient by incorporating the patient’s values.

Not every encounter, Jayaram said, is as dramatic as the one he wrote about. Most are more mundane. And there’s hardly enough time to listen to every patient’s detailed story. But, Finder said, narrative medicine is about being attuned to patients so well that in brief exchanges with patients, clinicians detect the patients’ values.

And, Pearson said, it takes practice. Often, he said, “we talk or interrupt patients to redirect them to what we think is important. Narrative competence is the ability to listen, absorb and act on the stories of others, to skillfully direct them to let us know what’s important to them. We are striving to enhance this competence through innovative approaches in the medical curriculum.”

In addition to the second-year class, Pearson incorporates narrative medicine reading and a written report into the surgical rotation of third-year medical students.

Charon closed saying, “If sickness calls forth stories, then healing calls forth a benevolent willingness to be subject to them, subjects of them and subjected to their transformative power.”

Next year, Pearson and colleagues in Arts and Sciences will foster that dogma in undergraduate students in a new class, “Narrative Medicine: Stories of Illness and the Doctor-Patient Relationship.”

“If it’s important for medical students to have these concepts, we should emphasize them before students get to medical school,” Pearson said.

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