on 29 June 2008
The first sentence of Dr Rita Charon's book, at the start of the preface, begins as follows: "I invite readers to look with my colleagues and me at this form of clinical practice we have come to call narrative medicine, defined as medicine practised with the narrative competence to recognise, absorb, interpret, and be moved by the stories of illness."
In addition to being a physician, the author holds a PhD degree in English.
Dr Charon points out that medicine becomes transformed when it is practiced with a real respect for time and timeliness, that patients lament when their uniqueness is not valued, that a clinician should not stop with the obvious or evident story line but should keep looking, in a creative way, to construct a wide and deep diagnosis, open to various possibilities, and that medicine is "based on complex texts which are shaped between doctor and patient, texts that encompass words, silences, physical findings, pictures, measurements of substances in the body, and appearances."
Further quoting Dr Charon, "Medicine is itself a more narratively inflected enterprise than it realises. Its practice is suffused with attention to life's temporal horizons, with the commitment to describe the singular, with the urge to uncover plot....and with an awareness of the intersubjective and ethical nature of healing."
These aspects of temporality, singularity, causality/contingency,intersubjectivity (two people relating to each other) and ethical concern are the hallmarks of storytelling or narrative. The use of the term "intersubjectivity" emphasises that "it is in meeting with other selves that the self comes alive."
To help the reader develop competence in handling narrative, the practical centrepiece of the book is Dr Charon's drill wherein she teaches students to closely read a text or story for the five aspects of frame, form, time, plot and desire. She also has her students involved in reflective writing; each piece of writing produced by her students is also analysed by this "five-fold" method. Let's apply this drill to Dr Charon's own book "Narrative Medicine: Honouring the Stories of Illness."
1) FRAME. The frame is the scope of the work and author's intent.
Dr Charon tells us that she intends her book to be a primer for this new field of narrative medicine and to be a manual for teachers of reading and writing in the medical context. Another quotation from Dr Charon: "What needs to be contested in medicine is seldom the accuracy of observations but the restriction of interest--- the frame drawn so tightly--- to the biological."
2) FORM. Here the author teaches us to look at genre, visible structure, narrator, metaphors, allusions, and diction.
Let's apply these to Dr Charon's work:
Genre--- Regarding the type of literature, overall the feel of the work is didactic--- to teach the reader practical lessons while looking at the underlying theoretical frameworks.
Visible structure--- The work has four main parts: Part I) What is Narrative Medicine ? (The Sources of Narrative Medicine, Bridging Health Care's Divides, Narrative Features of Medicine), Part II) Narrative of Illness (Telling One's Life, The Patient- The Body- and the Self), Part III) Developing Narrative Competence (Close Reading, Attention- Representation- and Affiliation, The Parallel Chart), and Part IV) Dividends of Narrative Medicine (Bearing Witness, The Bioethics of Narrative Medicine, A Narrative Vision for Heath Care).
Narrator--- The author herself is the narrator in the text; she speaks to us as a teacher and guide.
Metaphors--- The overarching metaphor is that life is lived out and related as a story. It's pointed out in this book that a team of anthropologists and linguists have said that "all thinking is metaphorical...., because metaphor is how the human brain travels." Throughout the book Dr Charon gives us over thirty different case histories of patients, told in the form of vignettes or brief stories. The actual words from the patients, students and doctors add a rich variety of imagery and metaphor to the book.
Allusions--- This refers to how one text brings in echoes from and speaks to other texts. The author Dr Charon writes: "I recognise my debt to Henry James, who is ever-present in my life as a companion and model, and whose thinking and language have transformed my own."
(Henry James was an American novelist who spent much of the latter half of his life living in England. He was born in 1843 and died in 1916, having become a British citizen shortly before he died. His brother, William, was a well-known psychologist. One critic wrote that the works of novelist Henry James were noted for psychological and moral realism, masterful creation of character, low-key but playful humour, and assured command of the language.)
Diction--- This refers to the style or tone of language used. Dr Charon writes in a scholarly, intellectual style that elevates, broadens, and adds respect to the subjects under discussion.
3) TIME. The steady drumbeat underlying the work is gradual development punctuated with flashes of insight as seen in the lives of the author, her students, and patients. The author writes that her approach was sparked when she attended a "literature-in-medicine" seminar in 1982, and that the frame for her book began in the Spring of 2001. The book itself was first published in 2006.
4) PLOT. Usually one does not think of a textbook of sorts as having a plot, but for the sake of this exercise, one of the plots of this book is how the stories of patients and students come in and out of the author's life and how she interweaves her gleanings from the theoretical bases of the allied disciplines of literary studies, narrative theory, general internal medicine, and bioethics.
5) DESIRE. The author teaches us to ask of every text: What appetite was satisfied in you by virtue of reading the text? What seems to be satisfied by the writing of it? Dr Charon writes that asking a reader to articulate the desires awakened by a text is a reliable method of guiding the reader to the heart of the encounter with the text, and the better one can identify the needs and longings that are satisfied in one's readings, the more accurately can one name what the text has accomplished.
For me, the last line in Dr Charon's book "Narrative Medicine" encapsulates the longing satisfied by reading her book. She writes that the care displayed through developing a narrative competence "envelopes us all with meaning, with grace, with courage, and with joy."
(The front cover of the book shows a painting by Mary Cassatt entitled "The Conversation." . The picture shows two women engaged in a heart-to-heart conversation.)
To leave you with some quotations from the book, we see how Dr Rita Charon applies narrative competence in her everyday professional life: "As the patient tells, I listen as hard as I can--- not taking notes during this segment of the interview, not interrupting unless critical, not indicating one way or another what I consider salient or meaningful or interesting. I try my best to register the diction, the form, the images, the pace of speech. I pay attention--- as I sit there on the edge of my seat, absorbing what is being given--- to metaphors, idioms, accompanying gestures, as well as plot and characters represented for me by the patient," and elsewhere, "I listen not only for the content of his narrative but also for its form--- its temporal course, its images, its associated subplots, it silences, where he chooses to begin in telling of himself, how he sequences symptoms with other life events. After a few minutes, the patient stops talking and begins to weep. I ask him why he cries. He says, 'No one ever let me do this before.' "