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What's the Use of Narrative?

In certain circles, narrative has always been its ownreward. But there are other surroundings in which narrative is seen as a poorsubstitute for something else, for something more . . . serious. In recentyears, more medical professionals have embraced narrative, while otherscontinue to regard it with suspicion -– or at least as something not to be usedin a scientific or medical context. Earlier this spring, the University ofPennsylvania Biomedical Library hosted an event to explore some of theimplications and possibilities of narrative in medicine. “Penn Projects inNarrative Medicine: A Visual and Storytelling Journey in Modern Medicine”brought together a novelist, a columnist, a photographer, an illustrator, and aplastic surgeon. Only the illustrator was not an MD -– but she has worked in aninteresting fashion with the plastic surgeon.

The “narrative medicine” under discussion and on display atthe event may not have fit precisely with the term as popularized by physicianslike Columbia University’s Rita Charon, MD, PhD. Narrative competence, as shedefines it, “enables the physician to practice medicine with empathy, reflection,and trustworthiness.” Penn’s event took a broader view of narrative, while stillassociated with medicine and patients.

In fact, the first speaker, Jason Karlawish, MD, is anovelist as well as specialist in geriatrics and medical ethics. In The Open Wound: The Tragic Obsession of Dr.William Beaumont (2011, reissued this year in paperback), Karlawishreimagined one of the most unusual medical cases in American history. In 1822, Beaumontsaved the life of a young French-Canadian fur trapper who had accidentally beenshot in the stomach. As Karlawish explains on his personal web site: “The youngtrapper’s injury never completely heals, leaving a hole into his stomach thatthe curious doctor uses as a window to understand the mysteries of digestion.Eager to rise up from his humble origins and self-conscious that his medicaltraining occurred as an apprentice to a rural physician rather than at an eliteuniversity, Beaumont seizes the opportunity to experiment upon his patient’sstomach in order to write a book that he hopes will establish his legitimacyand secure his prosperity.” The doctor-patient relationship rarely comes morecharged!

Karlawish noted how Beaumont became a “character” for him,not just a mad scientist. Alluding to the writer Robert Coles, Karlawishsuggested that the value of narrative resides not in high drama or major acts,but in the everyday events of our lives.

 

Facts and Figures AreNot Sufficient

Zachary Meisel, MD, MPH, has been a frequent columnist for Slate and for Time.com. An assistantprofessor of Emergency Medicine and a senior scholar at the Leonard DavisInstitute of Health Economics, Meisel has tackled such topics as patient-directed“Google medicine” and whether better access to health care would actually lowercosts. He spoke about the need to leverage the power of narrative in dealingwith patients –- and, in other contexts, with doctors and policymakers. Alludingto a 2011 essay in The Journal of theAmerican Medical Association that he wrote with Karlawish, Meisel notedthat they’ve found that patients often are not happy with evidence-based care.To patients, it seems primarily to be about cost. In the JAMA piece, Meisel and Karlawish write that “Facts and figures areessential, but insufficient, to translate the data and promote the acceptanceof evidence-based practices and policies. . . . Moreover, evidence from socialpsychology research suggests that narratives, when compared with reportingstatistical evidence alone, can have uniquely persuasive effects in overcomingpreconceived beliefs and cognitive biases.”

At the Biomedical Library, Meiselurged doctors to “get into this game” -– to use narrative and life stories ofpatients not just to undermine false claims and dubious evidence but to supportthe sound evidence: fact supported by narrative, directed to patients, doctors,and policy makers.

 

Images with NarrativePower

From word to image: John Hansen-Flaschen, MD, professor ofMedicine and chief of Pulmonary, Allergy, and Critical-Care Medicine, spokeabout some of his recent photographs, taken in HUP’s Intensive Care Unit. As heput it, during the intense two-week blocks he spends providing care oninpatient service in the ICU, it used to feel like a “tour of duty” in asubmarine. Now, however, he’s calling it “my temple or my cathedral. . . . Ilearn so much about human experience in this tiny, confined space.” One of thedetails that absorbed him were the “shrines of hope” that the families membersof the patients would construct, arranging photos, objects, letters, words ofencouragement, and the like on bulletin boards and walls. These collages appearedto him to be “visual poems of hope and redemption,” even though the patientsdid not always survive. A photographer who has exhibited his work on othertopics, Hansen-Flaschen began to photograph these shrines. Today, four ofHansen-Flaschen’s photos of the collages hang in the Biomedical Library.

 

Personalizing Anatomyand Surgery

What Caryn Babaian, a science/medical illustrator andbiology instructor at Bucks County Community College, and Ara Chalian, MD,professor of Otorhinolarygnology and director of Facial and Plastic &Reconstructive Surgery, teamed up to do was rather different. Babaian said thatshe had noted the similarities between surgery and drawing –- a comparable“eye-hand synergy.” She also argued that drawing is a way to intensify an experienceand to help retain its memory; it helps in learning anatomy and develops the“noticing skills” of the practitioner. The joint project with Chalian developedfrom his request for illustrations of the trachea for use in teaching –- butBabaian saw the opportunity to make it more personal. “What if it was your thyroid?” she asked him. Would themedical residents care more about it? So Chalian indeed became part of theillustrations, personalizing what might have been a dry topic. One of the moreeye-catching images depicts Chalian dissecting his own neck. Acknowledging someinitial discomfort, Chalian became more enthusiastic. And, he noted, “Myteaching scores went up.”

 

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