Narrative is something we all do a lot of the time. It is a natural, human impulse, often enacted instinctively. Narrative can be defined as the process or product of organising experiences or sensations in such a way that they make sense. The instant we link nouns with verbs we are constructing a narrative: we’re using words to impose a temporal dimension – i. e. a dimension relating to time. Time is an important aspect of narrative: it is expressed in the tense of verbs we use to explain events. ‘I arrived at the operating theatre’ is different to.
‘I arrive at the operating theatre’ or ‘I am going to arrive at the operating theatre’: there is a sense of time inherent in the way our language allows us to relate our thoughts and experiences. Narrative is often associated with storytelling. We tend to think of it in relation to reading novels, or watching films – especially when the usual conventions of narrative are challenged in some way. It is testament to our narrative sophistication that we are capable of sorting out the various strands of a story which jumps from place to place or back and forwards in time.
We’re so familiar with the conventions surrounding the way flashbacks or dream-sequences are portrayed in novels, film or on TV that we effortlessly collate them with other parts of the story in order to make sense of things (one of the best-known examples of subverting narrative order in movies is Memento in which the action flows in reverse: Porter Abbott (2002, p. 9) calls this refusal to satisfy narrative perceptions ‘narrative jamming’). However, storytelling is not limited to fiction: it is an interpretive mechanism we all use as a way of making sense of what is happening, what has happened and what we expect to happen.
All stories are ‘constructed’ to some extent – we direct meaning in stories we tell and create meaning from stories we hear in different ways. Not all stories do have a clear-cut resolution: sometimes the lack of a conclusion is itself the epiphany or climax of the story. The story- interpreting process is dependent on a multitude of factors, often too complex to articulate, but including at least previous experience, cultural context, ethical stance, notions of identity and social awareness.
The multivarious constructions and interpretations of stories led the philosopher Jean Paul Sartre to say ‘that there are no true stories’. Critics have pointed out that because stories can be told or interpreted in different ways doesn’t necessarily render them false. Certainly they are ‘real’ – if not transcendentally ‘true’ – in that we use narratives and organise meanings within narratives all the time (Porter Abbot, 2002, p. 20). 1 The value of studying narrative extends well beyond the ability to sequence events as a clue to meaning. Narrative is concerned with individuals (or ‘characters’ in a fictional story) which means that point-of-view is important.
The reason that reading a well-written story is enjoyable is that we are able to identify with the feelings and actions of other people. This is an important skill in all walks of life. Narrative also supplies context to a set of information. Narrative is not an object, a set of statistics or an X-ray. When these are interpreted, however sketchily, they become narratives. The stories we tell or hear imbue a situation with the potential for meaning.
The novelist E M Forster puts it thus: ‘[Narrative could be] truer than history because it goes beyond the evidence, and each of us knows from his own experience that there is something beyond the evidence. ’ (Forster, 1971, quoted in Greenhalgh and Hurwitz, 1998 p. 5). So what has narrative specifically to do with medicine? Narrative is important in several contexts. Narrative approach to the clinical encounter The narrative interpretation of the clinical encounter might seem very straightforward: the patient tells the doctor the symptoms. The doctor prompts the patient to fill in gaps in the forensic narrative: ‘How long have you had the pain? ’, ‘Is there a history in your family of heart disease?
’ Then the doctor integrates the patient’s narrative with his or her own biomedical narrative: comparing the symptoms with cases seen on ward rounds, an article read in a medical journal, a lecture given in medical school. The doctor then delivers a deliberative narrative (a plan of action) that might involve further tests, a diagnosis or possible diagnoses, a course of treatment, or a recommendation for a change in lifestyle, for example. Some clinical encounters might indeed be this straightforward – particularly if a condition has non-serious symptoms, is readily recognisable and easily treatable.
When serious illness is involved though, the patient’s narratives become critical to diagnosis and the doctor’s narratives are paramount to effective treatment. Dr Jerry Vannatta, former dean of the University of Oklahoma College of Medicine, says, ‘It is easy to lose sight of the fact that still, in the 21st century, it is believed that 80 to 85 percent of the diagnosis is in the patient’s story’ (New York Times, 11 October 2003). 2 Possibly the most vigorous advocate of bringing an understanding of narrative to medicine is Rita Charon, an American academic who teaches a programme on narrative medicine at Columbia University.
She says, ‘Patients have suffered long enough the consequences of a medicine practiced by doctors without these [literary] skills – doctors who cannot follow a narrative thread; who cannot adopt an alien perspective; who become unreliable narrators of other peoples’ stories; who are deaf to voice and image; and who do not always include in their regard human motives, yearnings, symbols, and the fellowship born of a common language. ’ (Charon, 2000, pp. 29–30).
This might be putting it a bit strongly: we all have these skills to a certain extent – without them we wouldn’t be human – but she has a point when she implies that they should not be taken for granted: ‘narrative competence’ is a valuable asset. Charon’s basic premise is that ‘good readers become good doctors’. The study of narrative allows a medical student to bring to the clinical encounter, the ability to engage with ‘their relation to the teller, the transparency of time and memory in the life being lived or relived, the ways in which the story’s actions change the world, and the thirst and hunger expressed by the rustle of language’ (Charon, 2000, p. 39).Narrative and doctor writers Doctors have always written about patients. A patient’s chart constitutes a type of narrative, albeit one which follows strict rules of form and notation.
There is, however, a growing trend for doctors to write for a more general audience, and these writings inevitably incorporate patients’ stories. It’s hard to know whether the plethora of platforms for doctor-writers is a response to demand or if it has encouraged more doctors to write about their experiences. Many newspapers have columns by doctors, most medical journals welcome personal essays, and a number of journals are devoted exclusively to literary aspects of medicine with a strong bent for creative writing, including Literature and Medicine, and the American magazines The Bellevue Literary Review and Mediphors (ouch! ). More recently, blogs have become a platform for individual doctors to find their narrative voice.
Ethical issues dictate that writing about the practice of medicine for a public audience will have fictional elements. Names and details are changed to avoid breaking patient confidentiality. This genre of writing, therefore, is a curious hybrid of fact and fiction. Doctor 3 writers are probably more acutely aware than most of the ‘constructed’ nature of autiobiographical / biographical narrative: there are lots of different ways to tell the same story and not all the details have to be factual for the story to be ‘true’.
Coulehan and Hunsaker Hawkins (2003) have written about the practical implications of this issue. Narrative and healing A lot of work has been done in the field of arts therapies, yet they have struggled to gain mainstream acceptance as an effective intervention. There does seem to be a distinction between the value of creative writing in promoting health (uncontested) and its value as an interventional treatment (more controversial).
The World Health Organization’s definition of health is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1948), and there is much evidence to show that creative writing has a beneficial effect on ‘mental and social wellbeing’ (Fuller, 2003). From a biomedical point of view, the effects of creative or reflective writing are harder to evaluate: does writing have a physiologically beneficial effect? There have been attempts to measure outcome differences for patients who undertake creative writing. Smythe et al.
(1989) found, in a randomised trial, that arthritis and asthma patients asked to write about stressful experiences showed ‘clinically relevant improvement in health status’. Philipp conducted a study of nearly 200 patients with psychological problems in 2002. Seven per cent said they were able to stop taking anti-depressants or tranquillisers using poetry and (tellingly) with their GP’s help (reported on BBC news, 10 October 2002). Philipp speculated that poetry writing could potentially save the NHS ? 190,000 a year in drug costs. Evaluation of the value of arts interventions in healthcare settings continues to be an active field of research, at which the Arts Council’s initiative ‘Arts for Health’ is at the forefront in the UK.
The act of reading has also been deemed to be therapeutic. ‘Books on Prescription’ is a scheme run through GPs’ surgeries and libraries to promote so-called ‘bibliotherapy’. Patients suffering with mild depression or other mental illness are ‘prescribed’ a self-help book by their doctor. Conclusion This has been brief overview of a few of the uses of narrative in medicine.
Although narrative is instinctive, an understanding of the way it works contributes to our ability to carry out effective analytical and critical evaluation. The ways in which we make and tell ‘stories’ have 4 effects. These are not always well understood, but manifest their influence at the level of attitudes, interpretations and events (for a further exploration of ideas about this, see Donald, 1988). In our study of literature we’ll be analysing the form and content of a variety of narratives in detail, in the expectation that this activity will be useful to our own uses of narrative and the way in which we relate to the narratives of others. References Atkin, G. , Walsh, C. and Watkins, S.
(1995) Studying Literature: a Practical Introduction, Hemel Hempstead: Harvester Wheatsheaf Charon, R. (2000) ‘Literary concepts for medical readers: frame, time, plot, desire’, in Hunsaker Hawkins, A. and McEntyre, M. C. (eds), Teaching Literature and Medicine, NY, Modern Language Association, pp. 29–41 Coulehan, J. and Hunsaker Hawkins, A. (2003) ‘Keeping faith: ethics and the physician- writer’, Annals of Internal Medicine, 139(4), pp. 307–11 Donald, A. (1998) ‘The words we live in’, in Greenhalgh, T. and Hurwitz, B. (eds) Narrative Based Medicine, London: BMJ Books Fuller, C.
(2003) Creative Writing and Healthcare, report for project funded by Catherine Cookson Trust, University of Newcastle Upon Tyne Greenhalgh, T. and Hurwitz, B. (1998) Narrative Based Medicine, London: BMJ Books Hunsaker Hawkins, A. and McEntyre, M. C. (eds) (2000) Teaching Literature and Medicine, NY, Modern Language Association Hunter, K. M. (1991) Doctors’ Stories, the Narrative Structure of Medical Knowledge, Princeton, New Jersey, Princeton University Press Porter Abbott, H. (2002) The Cambridge Introduction to Narrative, Cambridge, Cambridge University Press Smythe, J. M. et al.
(1989) ‘Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis’, JAMA, 281, pp. 1304—09 Verghese, A. (2001) ‘The physician as storyteller’, Annals of Internal Medicine, 135, pp. 1012–17 World Health Organization (1948), Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. GD 27/01/10.