The Bigger Picture
Charon Espouses Power of Narrative Medicine
Everyone has a story to tell. We seek compassion. We want to be heard.
Dr. Rita Charon has pioneered a whole movement around this idea, encouraging the medical community to think beyond their checklists of symptoms and embrace patient narratives. Actively listening to and empathizing with patients, she believes, can improve health outcomes.
Charon is professor and chair, department of medical humanities and ethics and professor of medicine at Columbia University, where she launched the first narrative medicine program nearly 20 years ago. She spoke at the second annual Howard Gadlin Lecture on Sept. 24 in Masur Auditorium, delivering a presentation filled with art and culture.
Most of her slides contained no words, just images, often of a famous painting, to illustrate her message. Charon showed, for example, the 19th-century painting Violet and Silver – The Deep Sea by James Whistler, who painted it while on a boat. Rocking on the sea, she said, he was conveying his reality at that time—the ever-changing wispy clouds, the sea’s whitecaps—which are never identical from one moment to the next.
Often, doctors miss the boat entirely, too consumed with data entry, their eyes glued to the monitor, to give patients the time and attention they deserve, Charon contends.
“Patients have critical information to share with us about their illnesses and somehow we lack the means to harvest it,” she said. “In practice, the checklists and the online portals have really taken the place of authentic conversation.”
Sometimes there’s a story hidden beneath the surface, waiting to be unearthed. Charon displayed a 16th-century painting by Dutch artist Pieter Bruegel. It’s bustling with activity: a shepherd with his flock, a fisherman, ships, a castle and mountains in the distance. Only when we learn the painting’s title, Landscape with the Fall of Icarus, do we notice the figure from Greek mythology kicking his legs in the sea.
“What would it take for medicine and science to listen,” asked Charon, “for our physicians and investigators not to turn away from the disaster of illness and the suffering it confers?”
Charon beckons doctors to face the face of the patient, moving from the larger landscape to that of the individual, not only looking at the impersonal medical chart, but also listening to the personal story.
In health care, even before the advent of the latest technologies, doctors sometimes faced ridicule for focusing on individual patients. Doctors typically would preface their observations with, “at the risk of sounding anecdotal,” she recounted. Now, though, times are changing with the vision and rise of precision medicine.
“The more we have come to understand the human genome and all the biological controls that go into our organism’s responses to injury or disease,” she said, “the more we can really concentrate on each individual who has that disease, and concentrate and select with such wisdom the treatment that will best help that individual.”
And, in treating the individual, each narrative is powerful. NIH director Dr. Francis Collins, in his introduction, said conversations with patients have long been a driving force in his research.
“Stories are much more compelling, perhaps, than reeling off a list of grant mechanisms or particular principles that we’re trying to understand,” said Collins. “It’s stories that drive us; it’s stories that we’re wired to respond to.”
Dr. Howard Gadlin, the lecture’s namesake, also knew a thing or two about the power of narrative in his distinguished career, having served as NIH ombudsman for 17 years before retiring in 2015.
Narrative medicine, which developed into a master’s program at Columbia and has evolved into an international movement, can be a model for compassionate health care that strengthens the doctor-patient bond, said Charon.
“How many questionnaires and checklists would you have to give each patient,” she asked, “to learn efficiently and comprehensively about his or her medical condition, health fears, sense of the world, beliefs about how our body works, characterological build, sense of how to face adversity, resilience, capacity to change and enter a trusting relationship?”
Instead of using questionnaires and checklists, Charon learned to say to each new patient, “I will be your doctor, so I need to know a great deal about your body and your health and your life. Please tell me what you think I should know about your situation.” And patients would tell her what she needed to know.
But there’s a skill to extrapolating the intricacies of narratives.
“You have to have learned how to listen to an autobiography,” said Charon. “You need to listen for the tempo changes, the metaphors used, the spaces described, to really listen for the unsaid.”
And, what’s actually happened usually differs from how the story is told. Narrative includes causality, intention, motive, emotion, imagination and ideology, Charon said. Each telling generates a new story. The medical student won’t hear the same story the attending physician hears.
Stories help doctors understand the illness by providing them a natural history of it, offering clues into the patient’s mental state, concerns, values and priorities.
In turn, stories help doctors respond to what patients want from their medical care. In focus groups and national surveys, Charon said, patients have said their top health care priorities are the doctor-patient relationship, evidence-based medicine and care coordination among their different doctors and specialists.
In a self-portrait of Rembrandt, we see the artist’s face full of conflicting emotions, from achievement to worry and doubt. It reminds us, said Charon, that we’re seeking a certain personalized level of attention to our contradictory knowledge and emotions.
More than the sum of his or her symptoms, each patient is a complex amalgam of unique life experiences, she said.
“Most patients want us [doctors] to know not just what’s the matter with them, but also what matters to them.”