By David Woods, PhD, FCPP
In his impious 1911 glossary The Devil’s Dictionary Ambrose
Bierce defined a physician as “one upon whom we set our hopes when ill and our
dogs when well.”
But in today’s medicine, our hopes are more likely to rest with an array of sophisticated technologies and gadgetry, rather than with a human being. Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine, says: “This technology has become a religion within the medical community. It is easy to lose sight of the fact that still, in the 21st century ... 80 to 85 percent of the diagnosis is in the patient’s story.”
Yet many physicians today lack either the skill, the time or the inclination to listen to that story – a talent that used to be called bedside manner. This is a shame because of the four elements in communication – speaking, reading, writing and listening – listening is learned first, is used most through life and is taught least through all the years of schooling. Yet deficiencies in listening and the ensuing failures of communication are a major source of wasted time, ineffective operation, miscarried plans and frustrated decisions. In medicine, they can also be a source of error and litigation.
But according to the New York Times “It is this lost art of
listening to the patient that has been the inspiration behind a burgeoning
movement in medical schools throughout the country: Narrative Medicine.” This
is part of a growing trend towards exposing medical students to the humanities
in much the same way as Drexel provides such courses to first year engineering
students.
Narrative Medicine’s founder, Dr Rita Charon, teaches such a
course at Columbia University’s medical school. In the 19th century, she says, doctors
carefully and humbly visited with patients – listened to them; and not just
with a stethoscope. Parenthetically, the inventor of that instrument, R.T.
Laennec, required his medical students to take exhaustive notes after
seeing a patient. Dr. Charon believes that medicine has been struggling to come
close to the patient ever since that time. “Medicine,” she says, “is beholden
to the singular experience of individual patients; we’ve always known this. But
it’s been eclipsed by a heady optimism that because we understand organ systems
and molecular biology we understand the patient.”
If you listen to patients’ lament, she says, “It’s not that ‘my
doctor can’t open my stent;’ it’s that ‘my doctor doesn’t listen to me.’” Not
that Dr Charon has much time for bland exhortations to create a more caring and
empathic medical profession. “What’s needed,” she says, “is the prescription;
the How.”
And that’s what Narrative Medicine is about: reading, writing,
perceiving – paying attention. Since 1982, Dr Charon’s students have been
analyzing in literary terms that which they hear and read. It has to do with
eliciting nuance and subtlety.
She emphasizes that this is no soft option course. Not only are
Columbia med students required to take graduate level humanities courses, the
material itself is presented in a highly rigorous and disciplined manner. Says
Dr Charon, who is an internal medicine physician who also has a doctorate in
English: “When I teach Henry James here, I do so as I would in the English
Department.”
Dr Charon’s group also produces a seminannual journal, Literature
and Medicine, which is published by Johns Hopkins University Press. And
Oxford University Press published her
book Narrative Medicine: Honoring the Source of Illness.
Another well-known exponent of communication skills for medical
students was the late Norman Cousins. Cousins, who wrote Anatomy of an
Illness, the story of his diagnosis and treatment for ankylosing
spondylitis, was an eminent journalist who went on to teach medical students at
UCLA. In an interview with him some years ago, he told me that he’d developed a
survey of 500 patients. One of the questions was: ‘If you’ve ever changed
doctors – why?’ “That really got the attention of the students,” he recalled.
Cousins went on to say that “What is required {of a doctor} is the
deepest possible understanding of what the patient is talking about. Respect
for the patient” His survey yielded such responses as ‘He was a very competent
physician but he really didn’t know what my problem was;’ or ‘I admired him as
a doctor but I had no confidence in him as a human being.’ Cousins’ conclusion:
It’s the style of the physician, not the competence of the physician,
that is the yardstick people use for keeping or changing their doctors.
Cousins further believed that “medicine begins with science but
treatment of human beings involves artistry. Physicians need to marry art to
science.” Moreover – shades of Narrative Medicine – Cousins told me that
“novelists portray the physician not just as a prescriber of medicaments but as
a symbol of all that is transferable from one human being to another.”
All of this is not simply to create a new layer of kinder, gentler
doctors ... or to graft some Gray’s Elegy onto Gray’s Anatomy. It’s to
rediscover a fundamental part of the diagnostic and therapeutic process, one
that will make the patient’s medical encounter more productive and less
frightening. ‘Doctorspeak’ too often means jargon that’s incomprehensible to
patients, who may not be at their receptive or emotional best. And the
impersonal “put the emphysema in the other ward and bring the prostate biopsy
in here” doesn’t help. Nor does the absolving “We” -- also favored by royalty
and editorial writers -- as in “How are we, today?” or “We see a lot of that.”
Novelist and psychologist Liam Hudson says there’s a “crisis of
intelligibility” among scientists, and notes that the truth can best be grasped
by prose that is itself vigorous, disciplined, and plain. Noting that
scientists are barely able to utter a sentence that does not include the key
words situation, interaction and role, Hudson says that by
contrast the business of writing a novel or a poem is one of highly-wrought
discipline. What lies between scientists and their subject matter, he says, is
an inadequate grasp of the English language. Their grasp can be tightened by
reading, interpreting – and understanding -- the great writers.
Tennyson, anyone?
