Saturday, September 20, 2014

Stories are 'clearings' that unite patient, clinician

By Louise Kinross

In a Buenos Aires hospital, pediatricians carry an unlikely medical tool: a transparent umbrella decorated with strips of multi-coloured chiffon that sway, forming curtains. 

When doctors invite a child into this intimate space, “this little colourful cave, children will tell them things in the umbrella that they wouldn't tell them otherwise,” said Dr. Rita Charon, founder of the graduate program in Narrative Medicine at Columbia University College of Physicians and Surgeons.

Dr. Charon, a general internist with a primary care practice at New York-Presbyterian Hospital, was speaking about the role of stories in health care at a three-day workshop in New York that drew clinicians, writers, academics and advocates.

Stories open wide the doors between self and other, and through these open doors move the teller and the listener, and through the power of the stories the teller and the listener get to inhabit the other and, as a result, to even better inhabit their own self,” she said.

Dr. Charon said that when she first meets a patient, she asks: “What should I know about your situation?” She then types into her computer what the patient tells her, making particular note of themes. She asks the patient to read the story she's transcribed, and to correct anything she got wrong or that's missing.

This simple narrative routine in the office makes for a different answer to the underlying question 'What is health care for?'” Dr. Charon said. “We can answer that, in addition to other things, health care is for recognition—self-recognition, other-recognition, mutual recognition.”

Stories told in clinics and hospitals are universal “because they exclude no one,” Dr. Charon said. “We are all human, we have bodies, we are mortal and we will die and so when we engage in telling or listening to stories of illness, we are responding to some foundational feature of being that unites us all. Stories get under the distinction between the sick and the well,” between those with and without disabilities.

Spaces of attention” can be found anywhere in the health-care setting—underneath the Argentinian pediatrician's umbrella or in the medical clinic, emergency room or on hospital rounds, Dr. Charon said.

Attention requires the clinician “to listen carefully, to perceive, to take in and absorb that which the other is saying,” Dr. Charon said.

Representation is the writing of the patient story. “Until we confirm form on some formless, chaotic thing, we don't have it visible to us,” Dr. Charon said. “So attention and representation are two side of one medallion swinging.”

The patient story is co-constructed by the teller—the patient—and the listener—the clinician. Dr. Charon noted that the art collector and critic Leo Stein said: “No art work exists without a spectactor. The spectator completes the work.”

What results is affiliation, or attachment, between doctor and patient. “The reason to do this is being with the person whose narrative you are responsible for hearing,” Dr. Charon said.

The Canadian short-story author Alice Munro likens a story to “entering a house.” Dr. Charon thinks of stories as clearings: “Within the bower of a story persons gather and things happen differently when persons are gathered. We're all under the story's spell, we're all united in the climate and the diction and the images and the illusions.”

Because of the reciprocal, circular nature of stories, “attachments and affiliations happen that never would have happened if you were just talking about patient safety.”

Getting a patient story is not easy. “Stories are risky to tell and listen to,” Dr. Charon said. “They make you feel doubt. If they're well written, they don't have answers, only a question. That makes some people queasy.”

Close reading of a patient story “is a kind of reading where every word counts,” Dr. Charon said. “It's not easy, it takes skill. Stories don't reliniquish their treasures easily. Like us, the stories guard their treasure.”


Beautiful. If we are looking for a way to make health care better, specifically children's health care, this is definitely a good place to start. Thank you for this, Louise! Beth

Beautifully captured Louise! The concept of co-creation is such a valuable awareness for all of us in health care.