Listening to the Surgeon General

Nicole Kim, 2017

On November 28th, 2016, then Surgeon General and Harvard College alumnus Vivek Murthy took center stage at Harvard’s John F. Kennedy Forum of the Institute of Politics. Moderated in a discussion by renowned Harvard health economics professor Amitabh Chandra, Murthy addressed the many issues currently facing American health, including the opioid crisis, gun violence, as well as the harmful stigma that surrounds them. About halfway through his talk, he gave advice for college students, especially those pursuing a career in medicine, in searching for solutions to these issues. He warned, “science can’t explain everything,” for a crucial aspect of understanding a problem is rooted in the artistic way through which people express themselves. “Storytelling in medicine often gets sidelined to science.”

What is narrative medicine? In fact, it is the very “sidelining” to science Murthy articulated, the artistic expression necessary for the creation of health solutions in present day. It is a novel medical approach that specifically recognizes the value of people’s narratives in the diagnosis, research, and treatment of illness, a holistic strategy accounting for the relational and psychological features inherent in physical disease. By treating the patient as an individual entity rather than a collection of isolated symptoms, narrative medicine aims to encourage creativity and self-reflection in the physician.

As a freshman in college, taking introductory math and science courses, the idea of narrative medicine was quite intriguing. A pre-medical student myself, I felt fairly knowledgeable about medical narratives and novels, having read the best-selling works of Oliver Sacks, Atul Gawande, and other physician-authors throughout high school. However, as Murthy succinctly stated, solutions to the health issues of our time cannot be solved with purely scientific methods, an idea that heavily influenced my taking of social science and humanities focused classes, such as medical ethics and sociology. It is the recognition of this fact, the necessary consideration of unquantifiable factors often less apparent, that drives a holistic education despite the inherently technical and quantitative nature of medicine.

Narrative medicine is being pioneered by individuals like Rita Charon, executive director of the Program in Narrative Medicine at Columbia University Medical Center. With both an M.D. and professorship in clinical medicine as well as a Ph.D. in English, she defines herself as one who came to medicine as a “lifelong reader” [1]. However, she realized she did not know much about stories as a doctor early in her career, and instead went to the Columbia University English department to ask, “Could you teach a doctor about stories and how they work?” The department joined her in the idea that specialized, narratological knowledge could do some good in the world, particular in the field of medicine. Charon defines narrative medicine as simply “clinical practice fortified by the knowledge of what to do with stories.” It is not just having a sense of story, but rather also being able to recognize when someone is telling you a story, and being able to receive all of it, especially details left unsaid. What then matters is how one interprets, honors, and is moved to action by these elements.

Through her novel and TEDx Talk, both entitled “Narrative Medicine: Honoring the Stories of Illness,” Charon has recounted examples in which narrative medicine has changed the way she conducts clinical medicine. For example, most doctors usually acquaint themselves with new patients by asking a seemingly infinite list of symptom-related questions: what hurts, where it hurts, to what extent does it hurt? Instead, Charon begins by stating to patients: “I will be your doctor, and so I need to know a great deal about your health, your body, and your life. Please tell me what I need to know about your situation.” Simply sitting and absorbing what is said, without the distraction of typing or note-taking, she realized that what patients yearned for most was an audience, someone to eager to listen to the detailed and profound accounts of themselves they were equally eager to give. Some patients were perplexed when given the opportunity to speak, while others broke down in tears with gratitude.

The novel approach of narrative medicine is considerably relevant, for there exist many effective, yet economical ways to teach the skills needed to enhance the clinical experience to all types of health care professionals. These techniques are at most a basic understanding of reading, writing, storytelling, and listening, skills often overlooked by medical schools and other sources of preparation for careers in health. Once this knowledge is disbursed, all that is left is the effort and unrelenting determination of the physician, nurse, or other to practically implement changes that will positively impact their patients, and hopefully improve their outcomes as well.

What are the most pressing issues facing health care systems today, and how do we reform them? This is the million dollar question, something that academics, experts, and Congress having been trying to address for decades. Many blame the rising cost of care, rooted in an uncontrollable, hasty proliferation of medical technology over time. However, as shown by the many ineffective proposed solutions of present day, meaningful change cannot be incurred by means as scientifically based as the technologies that created the problem.

For instance, patient safety standards have seen improvements as a result of methods specifically catered to individual patient interests and characteristics. Peter Pronovost of Johns Hopkins School of Medicine spearheads CUSP (Comprehensive Unit-based Safety Program) and TRIP (Translating Evidence Into Practice), programs that address doctor-nurse culture and norms to maximize efficiency while minimizing harm [2]. The success of Pronovost’s efforts are evidence of the importance of the intricate interpersonal relationships that form the basis of administrative efficiency in day to day care. Instead of attacking the problem with complex, costly technology, Pronovost used the knowledge of such a toxic health professional hierarchy, and used additional knowledge and research of how to break down this hierarchy to formulate a solution. This is narrative medicine.

Narrative medicine has distinctive implications in the field of cancer, an area characterized by a wide range of symptoms, courses of illness, and often variability and volatility in regard to recovery and success of treatment. The multifaceted nature of cancer parallels its equally nonspecific definition, “an uncontrolled division of abnormal cells in a part of the body.” Man’s knowledge of the disease is likewise considerably limited. Solutions are almost invariably specific, so what steps does one take in order to tackle a broad problem? Rather, it becomes necessary to utilize patient stories to individualize treatment and uncover the subtle nuances that could ultimately determine a patient’s fate. As medicine has increasingly seen in recent years, specialized therapies tend to engender success over general ones.

In her TEDx Talk, Charon champions the idea that “illness exposes,” that in the presence of disease, there is little to nothing either physically or psychologically separating doctor and patient. In a time of a patient’s extreme vulnerability, narrative medicine can help make this special connection endure by revealing the deepest, most profound truths, creating a lasting relationship effectual in all aspects of life. It can allow patients to come to terms with death and dying, as physicians can urge them to see death not as a failure of modern medicine, but rather as an external, inevitable outcome we as humans must ultimately accept. A novel entitled Being Mortal by physician-author Atul Gawande speaks of this psychological complexity and its implications in end-of-life care [3]. He stresses that the ultimate goal is not a good death but a good life all the way to the very end, that palliative care and the medicalization of aging, frailty, and death can unnecessarily prolong life. Through the new framework of meaning of narrative medicine, we can hopefully avoid these types of situations.

Surgeon General Murthy ended his talk at the Institute of Politics with some valuable insight. Rather paradoxically, he said, in an increasingly connected and networked world, we as individuals are becoming ever more divided and compartmentalized. By recognizing the essence of the aggregate, it is possible to bridge inherent variance and dissimilarity to form a comprehensive whole. Narrative medicine allows us to do just that, in the extremely impactful context of great potential: the beneficence of saving and significantly prolonging life.

Endnotes

[1] Charon, Rita. “Honoring the Stories of Illness.” TEDxAtlanta. Sep. 2011. Lecture.

[2] Pronovost, Peter J., and Eric Vohr. Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the inside out. New York: Hudson Street, 2010. Print.

[3] Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Toronto: Anchor Canada, 2017. Print.

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