It's always instructive to hear how someone who started a movement, like that of Narrative Medicine, defines it. Listen in to how Narrative Medicine began for Dr. Charon, why narrative capacity is a better term than narrative competence, and what burnout might really mean. Dr. Rita Charon, MD PhD is a physician, literary scholar, and founder of the narrative medicine program at Columbia University. She is a Professor of Medicine and Professor of Medical Humanities and Ethics at the College of Physicians and Surgeons of Columbia University. She has received numerous awards, including a Kaiser Faculty Scholar Award, a Rockefeller Foundation Bellagio Residence, a John Simon Guggenheim Fellowship, the Virginia Kneeland Frantz Award for Outstanding Woman Doctor of the Year, Outstanding Woman Physician of the year in 1996, the National Award for Innovation in Medical Education from the Society of General Internal Medicine in 1997, and the 2018 Jefferson Lecturer in the Humanities by the National Endowment for the Humanities.
It's always instructive to hear how someone who started a movement, like that of Narrative Medicine, defines it. Listen in to how Narrative Medicine began for Dr. Charon, why narrative capacity is a better term than narrative competence, and what burnout might really mean. Dr. Rita Charon, MD PhD is a physician, literary scholar, and founder of the narrative medicine program at Columbia University. She is a Professor of Medicine and Professor of Medical Humanities and Ethics at the College of Physicians and Surgeons of Columbia University. She has received numerous awards, including a Kaiser Faculty Scholar Award, a Rockefeller Foundation Bellagio Residence, a John Simon Guggenheim Fellowship, the Virginia Kneeland Frantz Award for Outstanding Woman Doctor of the Year, Outstanding Woman Physician of the year in 1996, the National Award for Innovation in Medical Education from the Society of General Internal Medicine in 1997, and the 2018 Jefferson Lecturer in the Humanities by the National Endowment for the Humanities.
[00:00:00] Christine Ko: This is a continuation of my conversation with Dr. Rita Charon, and I will insert her bio here again for those who weren't able to listen to part one of this conversation. Dr. Rita Charon, MD, PhD, is a physician, literary scholar, and a Professor of Medicine and Professor of Medical Humanities and Ethics at the College of Physicians and Surgeons of Columbia University. She has received numerous awards, including a Kaiser Faculty Scholar Award, a Rockefeller Foundation Bellagio Residence, a John Simon Guggenheim Fellowship, the Virginia Kneeland Frantz Award for Outstanding Woman Doctor of the Year, Outstanding Woman Physician of the Year in 1996, the National Award for Innovation in Medical Education from the Society of General Internal Medicine in 1997, and the 2018 Jefferson Lecture in the Humanities by the National Endowment for the Humanities.
[00:00:52] Dr. Charon is the founder of narrative medicine, and we talked today about her definition of what that is and how that can really help doctors in diagnosis. Here's a continuation of our conversation.
[00:01:07] If you could talk about narrative medicine and a term that you told me is not used anymore before we started, "narrative competence".
[00:01:15] Rita Charon: Yeah. So narrative medicine is a term that we created at Columbia in like 2001. It's a long time ago. And it was because I had just finished my PhD in English, and we pulled together a group of literary scholars and philosophers and social scientists, anthropologists, pediatricians, family medicine, patient advocates into a group; and I got some money from the NEH. And I was able to pay them to come to my group. And we met two, three times a month for two, three hours at a time. And we brought in other people. We brought in novelists. We brought in filmmakers. We brought in ethicists. And we answered the question of, why might reading and writing be good for doctors? What's it do? And we found ourselves writing a whole lot. We didn't know we would, but we fell into the habit of writing a lot. And we understood that it's only when you represent something in your mind, either in writing or in other kinds of, images, it's only when you capture something like that, that you understand it or that you even see it. So we developed this mantra. We're using it still. I'm writing a paper on it right now. Attention, Representation, and Affiliation. That's what we aim to equip our learners with. Undiluted attention. Nothing escapes you. Representation. You write it out, you capture it, you sketch it; we teach our medical students figure drawing and cartooning and playwriting. What it's all for is the affiliation with a patient, with a family, with a colleague, with a nurse. with the receptionist in your practice, the affiliative investment in the wellbeing of another.
[00:03:25] So that's what we mean by narrative medicine. It's not just, oh let's give the kids a break. Let's bring them a poem. It's not that. It's really deeply a gradually transforming set of capacities to humbly listen to another, to not get, pulled away by your own ideology, your own position. No. It's I, I tell the students, sometimes we have to be dumb. We don't know anything about this person. You can't make assumptions, so the attention, and then, I'm convinced that the better you are as a writer, the better you are as a doctor. Because you're noticing things, you're valuing the detail, the handbag she carries all the time... and then the affiliation is what we're all after.
[00:04:26] So that's what narrative medicine is, and early on I used the word narrative competence, but I stopped using it because competence became a code word in medical education. And it doesn't mean strength or capacity, it means, oh, you've shown me that you know how to do a spinal tap. Check. You're competent for that.
[00:04:54] And that's not what I had in mind. So now I say narrative capacity. But there are just so many, trends in how we do the medicine and how we learn the medicine. And some of them are trending us away from the genuine, difficult, painful, ultimately rewarding contact with a person who, to some degree, is in our hands.
[00:05:29] Christine Ko: Yeah. Listening to you describe what narrative medicine really is on that very deep level. In a way, it goes back to when you touched on earlier, you can tell me if this is true or wrong or not, when you talked about an ontological event. So it seems to me like narrative medicine, the way you described it creates that ontology, for some.
[00:05:56] Rita Charon: Yes. Yes, gradually, these forms of being in the world will alter the foundational ground. Years ago a colleague said, Rita, you're not just teaching me how to be a better doctor, you're teaching me how to be a better father. So, Thank you. It's a gradual realignment of values and strengths and capacities, but it is a shift in who the self is.
[00:06:36] Christine Ko: I just spoke with a philosopher who's here at Yale, her name is Laurie Paul. She wrote a book called Transformative Experience back in 2014. This conversation has some parallels to that. One thing she says is that because you don't know the self that you're going to become after a transformational experience, you don't know how that self would decide anything for one thing. [Ah. No.] There's no way to know.
[00:07:04] Rita Charon: It sounds like that's part of the conversation about advanced directives. But no, absolutely. How mysterious are we that we're not calcified, and I think it's not infrequent that people become calcified.
[00:07:20] Christine Ko: Yeah. When you were talking before about the industrialization of healthcare, and many doctors I think are idealistic, or at least were at some point, and when someone who is an idealist is in such a system, I think it's impossible not to become hardened in order to survive.
[00:07:42] Rita Charon: Yes. You just made me think a new thought about what we, by now, call, by reflex, burnout. And you just made me wonder whether the disillusionment and the discouragement and the defensive posture might not even be a sign that there is a self there trying to hold on. And it's like a self protective, but it's not giving up on one's humanity.
[00:08:19] Christine Ko: Absolutely.
[00:08:20] Rita Charon: Don't you think?
[00:08:22] Christine Ko: That, that's how I think of burnout. I do. There was an article where you said something like that narrative clinical routines can help you recognize, I think it's for the doctor, to be able to recognize what a patient has.
[00:08:36] Rita Charon: Yes. Indeed, if you choose not to use the routine review of systems, if you choose not to keep your EPIC open and type in it all the time you're talking to a patient. If you let yourself ask openly, what should I know about you? I want to be your doctor. What should I know about you? And if the grandmother comes in because she has back pain, and the doctor starts with the, ordinary questions about numbness in the feet and injuries. And the grandmother says, it doesn't hurt all the time. It just hurts when I pick up my grandson. And, okay, so that's weight bearing. Okay, so that's not, necessarily spinal stenosis or... If you ask the patient, tell me about your grandson. You find out that he's in his forties, has Down syndrome, she's raised him all his life, and he's now way bigger than she, and you can't pick him up.
[00:09:45] So that means a whole different plan, doesn't it? See? So now how did I know to ask? Tell me about your grandson. That I can't tell you exactly, alright? But it's freeing ourselves from these automatic drills. And of course the drills are governed by even how the epic note is built. So none of this is an easy fix, and it does require a sustained commitment on the part of the physician or nurse or social worker to search for. The kinds of knowledge about a patient that may not come out on their, what do you call it, pre visit checklist, right?
[00:10:36] Christine Ko: Do you have any final thoughts?
[00:10:37] Rita Charon: Well, narrative medicine is exploding. We now have, allegiances and partnerships with people in 12 different countries. And it's in Eastern Europe, Western Europe, Pacific Island. We're starting something in Malaysia. And Beijing and Tokyo. And of course, in each culture, in each language, it's a different practice. But there is an increasingly global unity about what is needed beyond what we're so very technically good at. And in the States, there's wide variation. I know Anna Reisman and Lisa Sanders and the people at Yale, I've been visiting there. It was very different from what we do at Columbia, but that's good. And the same for, UNC and Brown.
[00:11:30] And the students come in to the study of medicine from backgrounds in literature, in music. Do you see that at Yale? I'm sure you do. The students are tremendously skilled creatively. Medical Humanities, that's a major at Columbia College? You can major in Medical Humanities? It's the most popular one of all the majors. So that means that creative persons, artists, writers want to be doctors. This is a good sign.
[00:12:03] Christine Ko: I think you've started a revolution in medicine with Narrative Medicine. I think it's wonderful. It's amazing that It's international now.
[00:12:11] Rita Charon: Yeah. And, like I say, we have partners, they don't all call themselves narrative medicine, it's medical humanities, it's health and humanism, it's... but the concept of we must get beyond the technical fix we're in is a force.
[00:12:31] Christine Ko: Thank you so much for spending time with me.
[00:12:34] Thank you.