Listen, Tell, Learn, Heal: Narrative Medicine Now
For more than a century, naturopathic medicine continues to be building a caregiver profession predicated on relationship and characterized by careful communication. There are the communication pathways, of course, associated with charting, summaries, test analyses, and so on. There's also patient stories.
Not attempting to be purveyors of what Foucault called the “medical gaze” , naturopathic doctors have long held the area where stories in the biopsychosocial size of the patient's life are valued and their expression welcomed. At the same time, in the literature of professional formation, we have often seen concerns stated in studies of orthodox medicine outcomes and practice which may be described as the fragmentation of the clinical experience, the impersonal nature of bureaucratic decision-making processes about healthcare choices, and also the loss of individuality within the patient encounter. Essentially, these kinds of issues are all about not only the autonomy and uniqueness of the patient, but also about relationship and time spent. In such a terrain, the opportunity of a costly divide between your doctor and the patient crops up more frequently than providers want. Naturopathic doctors – long the placeholder profession for biopsychosocial, patient-centered medicine – have championed empathic engagement since Lust yet others systematized its modalities and approach back at the beginning of the twentieth century.
The governance and reimbursement structures of mainstream medicine accumulated to a point where an ACA was needed to build better therapeutic alliances between your doctor and the patient and to weed out the rotters who were taking too much from the heavily commodified system of diagnosis and care. As problems with affordability and access ricochet all around and thru a person's experience of illness and also the approach to treatment itself, doctors are often straightjacketed by reimbursement and protocol systems which are accompanied by contentious notions such as preexisting conditions and calamitous health events. In the middle of all this fuss and rattle, a person's story can't easily enter into focus and stay crisp. Only when there is such clarity, as Rita Charon, MD, PhD , puts it, “- can the doctor hear-and then attempt to face, otherwise to answer fully-the patient's narrative questions: 'What is wrong beside me?' 'Why did this occur to me?' and 'What will end up of me?'”
In the mainstream health system, there is often urgent financial reckoning occurring through the transaction, especially given the strictures and cascade of insurers and providers. The very human story from the patient's illness risks being diluted on the way. Naturopathic care, though, has historically been successful in overcoming this worrying interface because of its long history of patient-centered care, where stories of illness not only nourish empathy, but embody the main difference between treating disease and treating the patient; eschewing, thus, the “medical gaze.”
The Origins of Narrative Medicine
A decade ago, Columbia University got busy improving allopathic clinical practice by giving training focused on renewed focus on patients by means of attentive listening, coupled with what the designers of its “narrative medicine” program called “creative contact, singular accuracy, and personal fidelity.” Other elements that are presented for adoption by allopathic students in the curriculum of that longstanding Columbia University program include familiar naturopathic skills, for example “empathic interviewing, reflective practice, narrative ethics, self-awareness and intersubjective contact.” . The champion of this initiative was Dr Rita Charon.
Dr Charon introduced the idea of narrative medicine back at the outset of the brand new century. She explained at that time that it was, essentially, “a model for humane and efficient medical practice.” She writes,
In 2009, Columbia University partnered with the revered Canossiano Institute in Venice to teach medical doctors and nurses along with other biomedicine professionals how you can “nourish empathic doctor-patient relationships,” to “replace isolation with affiliation,” and to establish “patient-centered and life-framed practices.” Sound familiar? Naturopathic doctors, deeply rooted in humanistic healthcare, happen to be predicating their clinical programs on just such a personalized method for a very long time. That specific Columbia -Canossiano workshop attracted US and European medical credits. Presenters were from Columbia, the University of Toronto, George Washington University, Technion in Haifa, and also the University of Milan. Its value was recognized immediately and has persisted. Unsurprisingly, the biomedicine profession didn't invite presenters from what in those days were called the “CAM professions.”
These days Columbia has continued its pioneering Master of Science degree in narrative medicine. Their program includes narrative writing, reading, literary and philosophical analysis, coupled with practicums including practitioners and patients. As Charon suggests, the whole idea is to “draw around the study of art and literature to enhance students' listening and observation skills and also to expand their view of patients to encompass not only medical histories.”
A couple of years later the University of Iowa sponsored a conference different color leaves, called “The Examined Life.” Participants assembled to explore “links between the science of medicine and also the art of writing.” The elements explored happen to be central to naturopathic take care of decades . Additionally, workshops centered on thoughtful listening, nurturing talking, and meaningful time spent with the patient. Some aspects of this narrative route to empathy have migrated into messaging as part of the “integrative” and “functional” medicine sectors in contemporary allopathic medicine. There are critics of the humane face on medicine who worry that narrative medicine is an element of assimilation at the office.
Narrative Medicine as Co-optation
In that regard, some contend that narrative prescription medication is more evidence of an accelerating co-opting of the essence of the natural medicine professions, or at least from the more human face of the more holistic medicine. Narrative medicine, whatever its patina, is emerging more and more right in front lines of the biomedicine landscape. Since the alternative is chunking into turf and share of the market, increasingly MDs are encountering well-informed patients who want a lot more than 7-minute prescriptions, emotional distance, and more tests.
The biomedicine terrain continues to be described by those excluded from its orthodoxy as compressed, seen as a quantified time allocations per patient, embarrassed through the uninsured, scourged through the tangle of rules for that insured, covered with HMOs, and contained by reductionist medical reasoning which “blindly follows statistical likelihoods, no matter variations for example age, sex, ethnicity, or individual psychologies.” Dr Charon, the key architect of “narrative medicine,” has articulated over many years a strategic communications approach for the biomedicine profession that seeks to warm-up that landscape. She teaches that clinicians need to “develop a sturdy and clinically useful affiliation using the one that suffers.” In this universe, the MD is a “witness” and never a “judge,” a “companion” and not an “interrogator.” Were Dr Charon to possess had an interprofessional framework for her original research and development, I know she'd have discovered naturopathic physicians to be keen, accomplished, long-time practitioners of such empathy.
Charon adds that “narrative medicine had its begin in – patient-centered care and medical humanities” . In an allopathic universe, doctor time is expensive ; insurance, pharmaceutical companies, and health networks – despite presenting themselves in the community as non-profits – are caught inside a profit equation; biomedicine students learn quickly that emotional attachment can hurt; and medical training for a long time objectified the individual enough that Patch Adams got famous satirizing the alienation.
The idea is, in her own words, that by really listening to the individual , the doctor can “receive entirely complexity exactly what the patient conveys in words, silences, gestures, positions, and physical findings.” Charon further suggests that doctors who possess “narrative competence” can “bridge the divides of their relation to mortality, the contexts of illness, beliefs about disease causality, and emotions of shame, blame, and fear.”
This isn't just some lingering byproduct of, say, Angelica Thieriot's earlier Planetree Alliance approach, transformational as that remarkable nonprofit's 100-plus-hospital-strong organization from Derby, CT, have been within the fuss and rattle of the hospital business in the usa in older days. Rather, the advent and spread of narrative medicine education signals understanding of the effects of decades of treating patients impersonally along with a century of understanding their presentations with the limited reductionist lens.
Frankly, naturopathic doctors know narrative medicine. They have always understood what they're doing like a relationship. Within the initial intake and well past, naturopathic doctors connect with their patients as individuals, as persons, instead of being obliged by paradigm to collect at length in a rush to diagnosis, assign a test battery or zip through charts of data and findings, refine a prognosis, or interpret and additional diagnose variations. The health insurance providers don't similar to the relational approach from the ND because the time it takes is hard to run a tab on in terms of immediately quantifiable and prescriptive outcomes. Charon puts it by doing this: “. . . practitioners, be they health care professionals to start with or otherwise, must be ready to provide the self like a therapeutic instrument” .
The narrative medicine model brings to mind Tiffany Field's “therapeutic touch” or Wayne Dyer's notion from the many years back that intention is a “force in the universe” to which everyone and things are connected. Biomedicine communicators, in any case, can learn handily from naturopathic doctors due to the growth of integrative and interprofessional arrangements nowadays. The fellows within the AIHM program, for example, see reflected for action in the clinics of natural medicine providers, standards of patient-centered care which the naturopathic medical education community presents seriously in its curricula and which routinely characterize how naturopathic doctors relate to their patients.
Rita Charon's work has been more popular. She's received honors from numerous groups, like the Association of Medical Colleges, the American College of Physicians, the Society for Health insurance and Human Values, and also the Society of General Internal Medicine. Soon after the 2009 Columbia workshop referenced earlier, an associated June 2011 workshop in the university filled immediately and had a waiting list. As interest continued to spread, the University of London's School of Advanced Study Institute of English Studies held there a celebration, also in 2011. The theme, of other nutritional foods, was the use of “comics in medical and public education and their role in health communication and scholarship.” Back then, there was much momentum about and around narrative medicine, and it continues.
Important to note, in the perspective of curriculum design, is that Columbia's “Narrative Medicine master’s program” recruited in the humanities and social sciences, organizing their curriculum to “educate a leadership corps of health professionals” who comprehend the “intimate, interpersonal experiences of the clinical encounter.” They have attracted professionals from numerous clinical fields to explore becoming “narratively competent clinicians.” They're building “a different of caregiver,” not unfamiliar towards the naturopathic community.
The “narrative medicine” initiative also took root a decade ago at the New York-Presbyterian Hospital/Columbia, where resident, Dr Abigail Ford, said, “Narrative medicine changed my entire approach to medicine. Like a doctor you are really a co-author of patients' experiences and need to hear their story and take it on.” . Other residency programs, for example at Vanderbilt University's Department of Surgery, soon followed a similar path. And, there are lots of more such examples which persist into the closing many years of this decade. In the University of Nevada Med school, for example, medical students can usually benefit from narrative medicine as a concentration or being an elective in fourth year. Temple University launched a narrative medicine enter in 2023. In the Warren Alpert Medical School , students may take a narrative medicine course too. Even the legendary Kripalu Center for Yoga and Health is presenting this very year a celebration entitled “Narrative Medicine: A Cutting-Edge Method of Healthcare,” featuring Natalie Goldberg, amongst others. Seminar breakout groups abound now on such topics as: Psychoanalysis and Narrative Medicine; The Therapy of Writing: An Analysis of Medical Prose in JAMA; along with a Perspective around the Role of Stories like a Mechanism of Meta-Healing.
Healing the Gap
Essentially, “narrative medicine” adds into the transaction between caregiver and patient the relational, respectful dimensions which biomedicine bleached from the assembly line of the business, just before after Flexner. It's a curriculum and communication technique that constitutes what Cooke et al mean when they describe the requirement for a “synthesis of the cognitive and moral facets of professional work” . Cooke and her colleagues, in that important Carnegie Foundation centennial treatise, Educating Physicians: A Call for Reform of School of medicine and Residency [published one century after Flexner], take great care to delineate the “poor connections between formal knowledge and experiential learning and inadequate focus on patient populations, healthcare delivery, and effectiveness” . Cooke saw this need as manifesting not just in thorough reports of disease symptoms at the expense of listening for and listening to the patient's life and feelings, but additionally within the steep shift in careers of procedural specialties rather than primary care.
The debate strengthens these days about how belief cannot just be biology in medicine as well as in people's lives. As Fosse puts it: “How can macroscale phenomena like feelings and thoughts be shown to exert downward causal influence over microscale phenomena like biological processes?” . Narrative medicine is the end of the iceberg within this sea of transformation by what constitutes “health” and what the physician's role in it should be.
Narrative medicine must welcome a broader discourse and critical reflection concerning the structural inequities in the American healthcare system. Narrative prescription medication is part of a growing awareness that health professionals have to incorporate patients’ life stories – including their unique underlying value system – into treatment options that fit each individual. Narrative ethics describes the way a doctor listens for, and hears, more than a report of disease symptoms. Narrative medicine, reflectively practiced, encourages shared, ethical decision-making regarding the patient’s care, particularly at the end of life. It balances treatments between the belief systems and lifetime of the individual, and also the technological possibilities advocated through the doctor. Ideally, whatever the treatment goals, narrative medicine's own narrative is the fact that those goals ought to be in harmony considering that the patient has lived his or her life through the beginning and middle and end. Narrative medicine is a special tool serving to achieve that.