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Narrative Medicine’s Story Continues

By Alex Lyda

Rita Charon, M.D., Ph.D., director and founder of the Program in Narrative Medicine at P&S, has been standing up for what is right and important – for both the doctor and the patient – with a distinctive brand of passion that first led her to forge a field that continues to grow in popularity among budding physicians seeking to deliver better medical care through the age-old practice of telling and listening to stories.

Through narrative training, doctors, nurses, social workers, and therapists learn how to improve the effectiveness of care by developing the capacity for “attention, reflection, representation, and affiliation with patients and colleagues.” The narrative program conceived at P&S has taken root at other academic medical centers across the country aiming to fortify clinical practice with the “narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness,” according to the program’s mission statement – now embodied by a rather peculiar mascot, the Volvox algae.

For her work, Dr. Charon has been recognized by the Association of American Medical Colleges, the American College of Physicians, the Society for Health and Human Values, the American Academy on Healthcare Communication, and the Society of General Internal Medicine. While she is not the first to join literary practices with medicine, Dr. Charon (her Ph.D. degree is in literature) first coined the term narrative medicine in a January 2001 article in the Annals of Internal Medicine and has been its leading international advocate ever since.

As inseparable as Dr. Charon is from the program, however, it is really about the students, she says. Narrative medicine is now firmly embedded in the way P&S molds its students, thanks in part to a $1.35 million NIH grant awarded to Dr. Charon in 2006 to “enhance social and behavioral sciences teaching” in the curriculum. Medical school faculty made major changes in the required courses currently called “Foundations of Clinical Medicine,” which teaches students the skills of the clinical transactions (medical interviewing and physical examination), reflective practice, social aspects of illness and health care, and narrative competence. In addition to the changes in the medical school curriculum, the Program in Narrative Medicine offers a master of science degree in narrative medicine (through Columbia’s School of Continuing Education) and intensive workshops designed specifically for health care professionals and academics.

The program caught the attention of Barry Gurland, M.D., the Sidney Katz Professor of Psychiatry at Columbia University Medical Center’s Stroud Center for the Study of Quality of Life. Dr. Gurland has been studying doctor-patient interactions for more than 30 years at Columbia and has led a number of studies of the quality of those interactions. Among his many findings, Dr. Gurland has concluded that doctors typically lock in a first impression during the first three minutes of a clinical encounter, even when presented with new or conflicting information later in the visit. According to Dr. Gurland, the doctor and the patient approach the interaction from slightly different perspectives: the patient to the doctor says, “please help me keep my quality of life through this pain” and the doctor to the patient says, “let me find the disease as quickly and efficiently as I can.” Differing approaches can get magnified over time. What’s lost is the big picture, Dr. Gurland says.

“The issue of time is not necessarily the ultimate concern,” he says. “The [medical] field seems to have been labeled with the misperception that there is no time for narrative-type training in the ‘real world’ of modern health care, where practices are stretched thin and quick patient interactions are of the essence.”

Trying to speed things up and “stick to the facts or symptoms” might actually be counterproductive. For any enduring relationship that is predicated on increasing levels of information exchange, it is often key to spend extra time in the beginning, to avoid overlooking important aspects of a patient’s life story. Missing certain clues or not genuinely being interested in a patient outside of the exam room can lead to the ordering of superfluous tests and diagnostic dead ends, when the disease might be more easily uncovered through dialogue. Adds Dr. Gurland: “We’re seeing that the patient also has a big role to play in the clinical encounter,” and this realization led to discussions between the Stroud Center and the Program in Narrative Medicine – the very kind of cross-cutting, algae-like focus that Dr. Charon has promoted since the program’s official founding in 1996.

Central to the program is the Foundations of Clinical Medicine course, which helps medical students learn how to be doctors from their first day at P&S. Foundations is now a required, four-year course that highlights the physician-patient relationship, how health care is structured, access to health care, and issues related to specific problems within medical communities. During their second year, medical students are required to enroll in a narrative medicine seminar, choosing from among 12 or 13 concurrent small group seminars in such topics as non-fiction writing, fiction writing, contemporary novels, cinema studies, or art courses at the Metropolitan Museum of Art, the Frick Collection, or the Museum of Modern Art. During their fourth year, P&S students can take a narrative medicine elective, an entire month devoted to close reading, fiction writing, and reflective practice with faculty chosen from a range of departments.

The Program in Narrative Medicine is not without its detractors. Shannon Arntfield, M.D., who studied in the master’s program while on leave as an OB/GYN, encountered an attitude that mistook the intent of the program for something superficial and “fluffy” when she traveled back to Ontario, Canada, for clinical work during the winter holiday. After explaining that she was in New York for a year studying narrative medicine at Columbia, a fellow clinician smiled, patted her on the back, and said, “It sounds like you’re learning how to hug better!”

Doctors agree that medical knowledge and technical competence are at the forefront of training needs, Dr. Arntfield says. “While these skills are undoubtedly essential, the ability to provide good bedside care is an equally necessary skill.” For her, the training she has received from P&S and Columbia humanities professors is a way to show the patient that care is being taken and that there is a genuine effort to listen. “All doctors care, but practicing narrative medicine provides a clinician with the skills to foster and better demonstrate their care.”

For Manny Hinds’57, who became a flight surgeon in the U.S. Air Force upon graduation from P&S, demonstrating care was a top priority when he started working as a doctor. Dr. Hinds did a number of procedures with helicopter recovery teams – “pretty much everything except brain surgery,” he says. He recalls no training at P&S that was specifically devoted to deeply listening to patient stories and understanding their narrative arcs, he said. “I came from a family that listened to each other and paid attention so some of the skills were natural to me. Other doctors thought I was a rare breed of surgeon, spending so much time with patients before surgery, sometimes even praying with them.” Medical education was much more about teaching technical skills then, he adds.

Relating to each other in a fundamental way is one reason why Craig Irvine, Ph.D., a humanities and philosophy professor at Columbia, was brought in early as a founding member of the program. In addition to teaching a master’s level class, “The Self and Other in the Clinical Encounter,” he teaches an elective at P&S, “The Philosophy of Death.” Second-year medical students in the “Philosophy of Death” course read Tolstoy, Camus, Plato, and excerpts from Columbia faculty member Maura Spiegel’s “Grim Reader,” a selection of classic and contemporary writings on mortality. The course probes issues of death and disease and how death is viewed in different cultures and times. “The mission of medicine is often to frame death as the enemy,” Dr. Irvine says. “The growth of the palliative care movement shows that some of these attitudes are changing, but often when working with a new med student, it’s clear that some of them are just beginning to think about the many dimensions of death for the first time.”

Dr. Irvine, academic director of the master’s program in narrative medicine, teaches classes that form a bridge to Columbia College and its renowned Core Curriculum. Long a hallmark of the undergraduate experience at Columbia, the Core began with the idea of a seminar-style class devoted to a weekly reading and discussion of the “Great Books” as first conceived by English professor John Erskine in 1917. The Core today is comprised of six classes that every Columbia College student must take.

“What we are doing on the medical center campus is in some ways an extension of what Columbia has done all along,” Dr. Charon says. “And a grounding in the humanities, the arts, and in literary traditions only makes for better doctors.”

Many P&S students with arts backgrounds are drawn to the narrative medicine aspect of the curriculum. A graduate of Sarah Lawrence College, Eliza Miller’12 was a professional dancer for 10 years before completing her postbac and becoming a medical student. To her, the exposure to narrative training has translated to clinical skills that cannot be forgotten. “A lot of medical education is based on learning massive amounts of information over a short time. The idea that one can retain all of it beyond school is ridiculous,” Ms. Miller says. “The skills we learn in the narrative medicine curriculum are not the kind of thing you forget, for example, how to stand still and look carefully at works of art. These skills turn out to be at least as clinically useful as memorizing molecular pathways.”

For Shady Grove Oliver, an EMT pursuing her master’s degree in narrative medicine,  relating to the field of narrative medicine – and the promise she sees in the program – is much like the way Volvox algae propagates. A type of green algae, Volvox produces new colonies through rapid, repeated division. The picturesque and vividly colored algae can take over a pond quickly with the use of special “eyespots” in each of its cells. These eyespots, with the help of moving flagella, enable whole Volvox colonies to swim toward new light.

“As a student, one of the most interesting aspects of the program to me is the plethora of backgrounds and experiences of my fellow classmates,” Ms. Oliver says. “With everyone from doctors and chemical engineers to literature majors and journalists participating, there is no shortage of unique perspectives and ideas in every class discussion.”

And that is part of what Dr. Charon has built: diverse colonies of students who are effusive and serious about the program – clinicians and others determined to bring what they’ve learned to new frontiers.

More about the narrative medicine program at P&S is available at the program’s website.

Previous articles on narrative medicine at Columbia:

Spring/Summer 2009 P&S

Fall 2006 P&S 

Fall 1999 P&S