What Is Narrative Medicine? Finding Humanity in Health Care

Health care requires humanity.

At its roots, narrative medicine embodies this ideology. Coined in 2000 by internist and scholar Rita Charon, MD, PhD, the field is “medicine practiced with the narrative competence to recognize, interpret, and be moved to action by the predicament of others.”¹

Without specific examples, however, narrative medicine can slip into a vague, abstract practice within the cultural consciousness. After all, the field is bolstered by philosophers such as Judith Butler, Emmanuel Levinas, and Maurice Merleau-Ponty — the likes of whom may leave anybody wondering: what does all this talk about “identity” and “self” have to do with medicine?

In short, it has everything to do with medicine. The longer answer, on the other hand, requires a bit more deconstruction.

What Is Narrative Medicine? A Theoretical Framework

Narrative medicine is less a specific practice and more a theoretical framework that equips caregivers and health care professionals with tools to provide more holistic care. These tools stem from storytelling principles and literature, which can hone our empathic and listening skills.

But how does literature inform medicine? 

Craig Irvine, PhD, a co-founder of the Master’s in Narrative Medicine program at Columbia University, puts it this way: “Literature honors medicine’s imperative to clothe the naked. Making the Other an object of reflection, literature mirrors medicine’s thematization, its bringing to light — its way of knowing.”²

In other words, medicine is founded upon a responsibility to alleviate the suffering of the “Other,” or the patient who is separate from the “I.” Just as literature provides a platform for the reader to interpret the “Other’s” experience, the goal of medicine is to comprehend and remedy the suffering of the patient.

Dr Irvine takes heavily from Levinas, who “places science and art on parallel representational planes.” Literature is representational, in that we will read a novel and become immersed in the reality of its characters; yet, we simultaneously understand that a story paints only one picture of humanity that each reader will interpret differently. We can thus critically conceptualize medicine in the same vein.

“Seeming alien to medicine, literature represents the unrepresentability of its infinite distance from the Other,” Irvine posits.

When we read a novel and become infused with the truths of a story, we acknowledge that this story is not reflective of the entire human experience. Likewise, we can practice medicine by honing into the unique experiences of a patient while also accepting that this exchange is multifaceted and impossible to condense into words.

Considering this dynamic between patient and provider, Sayantani DasGupta, MD, MPH’s concept of “narrative humility” offers a new way of thinking.³ At its core, narrative humility acknowledges the shortcomings of medicine and seeks a different route. The provider will never be able to completely understand a patient’s experience, regardless of the depth of their training. We are human — universal yet undefinable. And that’s okay.   

Teaching Spaces

Medical schools across the country are increasingly tailoring their curricula to include humanities-focused aspects, which may require medical students to attend narrative medicine workshops facilitated by narrative medicine practitioners.⁴

“I always think of [narrative medicine] as 2 things,” says Eve Makoff, MD, MS, Regional Medical Director of the AltaMed Health Services PACE Program, a government-funded program for low-income geriatric patients.

“One is a way of being as a clinician — and it doesn’t necessarily have to be a doctor but any kind of health care provider in an encounter with a patient. It’s sort of an open stance — a way of listening, a way of attending. But it’s also this sort of pedagogical workshop method that we’re taught…to help health care providers become narrative medicine informed providers in the clinic.”

A fundamental narrative medicine workshop is called a close reading workshop, in which a facilitator provides a medium — a piece of writing, a painting, a song, or even a video — and encourages participants to first analyze the medium. The participants will then share their observations with each other before the facilitator provides a writing prompt for a 5-minute reflection exercise.

As a result of these workshops, participants hone their listening and analytical skills. Moreover, we learn to slow down and absorb the medium in its entirety — the speaker’s point of view, the implications behind each word choice, the backdrop of a painting that eluded the perceiver’s eyes at first glance.

According to Charon and colleagues,

“The goal of this work, ultimately, is for learners to achieve a state of attentive and empathic affiliation with a patient, born of their efforts to represent what they perceive, to seek the necessary perspectives beyond their own, to register that which is mysterious or unclear, to wonder about the mysterious, to ask questions about the unclear, to generate hypotheses about the patient’s situation, and to test those hypotheses in the growing affiliation with the patient.”⁵

In other words, the workshop refines our ability to perceive. It prepares us to become closer to the patient.

Clinical Implications

In a clinical setting, the workshop method is a practice in attention.

As rapidly developing technology transforms our health care spaces, attention has become all the more valuable. “We’ve also really lost a face-to-face piece of our encounter with patients and families,” Dr Makoff says. “The way that I model what narrative medicine teaches us… is a kind of attention that notices, which you can’t do with a screen in front of your face.”

Each clinical encounter can be viewed as an exchange of stories. The clinician can either condense the patient’s narrative into a list of symptoms (each necessitating a pharmaceutical to alleviate one’s suffering), or recognize that much like a piece of literature, the physician’s reading of a patient — and the patient’s truth — cannot be captured by an electronic health record.

For example, a patient who suffers from chronic illness may embody a constellation of symptoms that don’t quite fit the currently established guidelines for care. Narrative medicine is a potential framework for mediating this dilemma.

Detailing her own experience conducting a narrative medicine intervention among patients with advanced-stage cancer, Dr Makoff recalls, “I would go and sit with them when they were having their chemotherapy infusions and we would read a poem, look at a painting, read a graphic strip. We would talk about it. We would close read. I would make them slow down and go back…and then we would write together and read each other’s writing. I themed the sessions in uplifting ways — finding joy, or making meaning or identity outside of cancer.”

Dr Makoff’s example of an intervention with patients with cancer is by no means the remedial substitute for chemotherapy. However, from a palliative care perspective, much can be said about how the patients reacted to this experience.

“Interestingly, one of the major things they said was that it made them more empathic,” she recalls. “It made them recognize different perspectives. It also made them realize they had more life to live regardless of their prognosis.” 

Ultimately, the experience was an “opportunity for them to become narrative medicine experts themselves and to apply it to their own life and healing.” Through narrative medicine practices, patients can become equipped with the skills and awareness to facilitate their own care.

Other applications of narrative medicine and storytelling techniques have also demonstrated promise within the clinic. In the first randomized controlled trial that evaluated a narrative skills intervention in group educational sessions for the management of type 2 diabetes, patients participated in either a close reading and creative writing approach or a classic educational approach.⁶

Compared with the usual care group, the narrative intervention group demonstrated not only noninferior reductions in glycated hemoglobin levels, but also increased satisfaction with the therapist and group process.

In another randomized controlled trial (ClinicalTrials.gov Identifier: NCT03766438), a digital storytelling intervention, compared with usual care, was associated with improved glycemic control among Hispanic patients with type 2 diabetes.⁷

These practices are not exclusive to one specialty. The applications are endless, and the future of medicine is evolving, one story at a time.

Conclusion

Regardless of one’s feelings about health care infrastructure in the United States, narrative medicine illuminates a profound truth — more can be done to accommodate patients of different backgrounds. Narrative medicine can offer health care providers a new way of thinking, attending, and recognizing. It could bring us closer to the human condition than ever before.