Every patient has a story that goes beyond the symptoms they bring into the doctor’s office.
Those stories can illuminate how a person became ill, the tipping point that compelled them to seek help, and, perhaps most importantly, the social challenges they face in getting better. Stories can offer the kind of contextual richness that promotes and nourishes empathy, prompting a provider to switch from asking “How can I treat this disease?” to “How can I help my patient?” The difference may seem subtle at first, but knowing how to get patients to share their stories can be transformative in improving patient care, say proponents of this approach called “narrative medicine.”
Indu Voruganti, MS, now a third-year medical student at Brown University Warren Alpert Medical School, had just that type of realization. Voruganti had originally planned to head straight to medical school after completing her bachelor’s studies in biology. After taking an undergraduate creative writing class, however, she decided to take a slight detour.
“I immediately felt [creative writing] exercised a unique part of my brain that seemed to offer a different lens [with which] to view health care,” said Voruganti. “Then I learned there’s a whole world of physicians out there who are also writers.”
That lightbulb moment led Voruganti to enroll in the Program in Narrative Medicine at Columbia University College of Physicians and Surgeons, an interdisciplinary master’s program that seeks to improve clinical care through narratives. In a nutshell, narrative medicine draws 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.
“[Narrative medicine] is a commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.”
Rita Charon, MD, PhD
Columbia University College of Physicians and Surgeons
“Narrative medicine can help us deliver more humanistic health care,” said Voruganti, who went on to create and teach an Art and the Medical Narrative elective course for first- and second-year medical students at Brown in 2015.
Learning to empathize
Rita Charon, MD, PhD, executive director of Columbia’s Program in Narrative Medicine, is widely recognized as the originator of the field. “The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others,” Charon wrote in a 2001 article in JAMA.
“It’s not a stretch to say we need help to look at our own processes or to see and appreciate what patients are telling us. For me, it became a way for patients to feel heard and noticed,” Charon said of her early experiences integrating narrative skills into her clinical practice. “It’s a commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.”
A core component of narrative medicine education is “close reading,” or learning how to thoughtfully and critically analyze a text. This approach helps students develop empathetic listening skills to better understand and connect with patients. Today, all Columbia medical students are exposed to narrative medicine in their first years, when they’re required to take one of 14 seminars on topics ranging from memoir writing to visual arts to medical journalism. The medical school also offers a fourth-year elective for medical students, as well as a scholarly track in Narrative and Social Medicine that Charon also directs.
While Columbia University is the only school with a graduate degree in narrative medicine, many medical schools have followed its lead, offering a variety of courses and seminars.
At the University of Nevada, Reno (UNR) School of Medicine, medical students can take narrative medicine as a scholarly concentration or as a fourth-year elective. Assignments include 10,000 words of reflective writing on clinical encounters that students must submit to a medical humanities publication. Susan Palwick, PhD, who teaches narrative medicine at UNR, said most students are drawn to write personal essays, though many try their hand at fiction and poetry as well.
“It’s easy for patients to get reduced to a specific illness. Narrative medicine is a way of integrating everything back together; it’s a way of staying curious about people.”
Susan Palwick, PhD
University of Nevada, Reno School of Medicine
“It’s easy for patients to get reduced to a specific illness,” said Palwick, an associate professor of English and adjunct professor in UNR’s Office of Medical Education. “Narrative medicine is a way of integrating everything back together; it’s a way of staying curious about people. Ultimately, it’s a form of love.”
She said the experience can help students unpack their biases, too. For instance, Palwick said a student who was feeling particularly judgmental of patients undergoing bariatric surgery decided to write a series of vignettes imagining why such patients struggle with their weight and why they can’t lose it without the help of surgery. The process, Palwick discovered, “helps you stay empathetic and sympathetic."
Reflective writing also provides a “safe space” for students to discuss the stresses of medical school and their professional fears, she added.
Jake Measom, a fourth-year medical student at UNR, said that participating in the narrative medicine scholarly concentration has pushed him to be more creative in his approach to patient care. He also sees narrative medicine as a “remedy to burnout,” noting that while the practice of medicine can sometimes feel monotonous, narrative medicine reminds him that “there’s a story to be had everywhere.”
“It not only makes me a better physician in the sense of being able to listen better and be more compassionate,” he said, “it also helps you gain a better understanding of who you are as a person.”
Storytelling as a means of coping
“First you get your coat. I don’t care if you don’t remember where you left it, you find it. If there was a lot of blood, you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother’s name and you use her child’s name. You may not adjust this part in any way.”
That’s an excerpt from “How to Tell a Mother Her Child Is Dead,” which was published last September in the New York Times in the Sunday Review Opinion section. Authored by Naomi Rosenberg, MD, a physician at Temple University Hospital, the piece is a heart-wrenching example of how narrative medicine can serve as an outlet for coping with the harrowing experiences that providers regularly encounter.
Pulitzer Prize-winning journalist Michael Vitez encouraged Rosenberg to submit the piece in his new role as director of narrative medicine at Temple University Lewis Katz School of Medicine. After retiring from a 30-year career as a reporter at the Philadelphia Inquirer, Vitez approached the school’s dean about using his skills to help students, faculty, and patients translate their experiences into words. The idea morphed into Temple’s new Narrative Medicine Program, which launched in 2016.
Currently, the Temple program is fairly unstructured, with students and faculty working one-on-one with Vitez on their narrative pieces. For example, Vitez said a third-year medical student recently sent him a poem she wrote after an especially difficult day in her psychiatric rotation: “It helped her process her emotions and turn a really bad day into something really valuable,” he noted. Eventually, Temple hopes to offer a certificate and master’s degree in narrative medicine.
“I believe that stories have an incredible power,” said Vitez. “Understanding what a good story is and learning how to interview and ask questions will help you connect with your patients, understand them, and build relationships with them.”
Jay Baruch, MD, associate professor of emergency medicine at Brown’s Warren Alpert Medical School and faculty advisor to the narrative medicine course there, likewise maintains that the type of creative thinking often associated with the arts and humanities—and that narrative medicine often promotes—deserves a more central role in medical education.
“[Students and physicians] need to know the anatomy of a patient’s story just as much as the anatomy of the human body,” he said.