When Medicine Meets Literature

Writing and humanities studies produce better physicians, Rita Charon argues, because doctors learn to coax hidden information from patients' complaints

On a recent Wednesday, 10 members of New York┬┐Presbyterian Hospital's oncology staff gather around a long table in a windowless conference room, sharing sandwiches and fruit, discussing their work. Discussing it in terms that might well surprise their patients. A social worker reads a short essay describing nearly two decades of entering patients' rooms after the doctor has given a diagnosis of cancer as "coming into their winter, their horror," unable to keep herself warm or impervious. A physician reads a piece about how she came to understand the loss motivating one of her colleagues to treat cancer. A nurse reads what sounds like her letter of resignation: she has to get out, she says, "to dissociate my living from your dying."

Rita Charon responds as a literary critic to each author. The "you" changes over the course of the piece, she says to one, "we get confused in a lot of these writings about who is the 'you' and who is the 'I.'" Of another piece: "It is so very intimate, it could be written to a lover." She relates a woman's image of a tree and sharp pain to Eden's snake. For an hour or so, Charon parses point of view, prologue and metaphor; she identifies a "shimmering moment" in a piece where the writer undergoes a transformation from deep anger toward a patient to forgiveness. It is a typical meeting for the narrative oncology group, which has met voluntarily twice a month for three years. In no way is it a typical meeting for a hospital staff.

Charon is trying to change that. Besides being a general internist and a professor of clinical medicine at Columbia University's College of Physicians and Surgeons, she holds a Ph.D. in English. She and others are seeking to improve the relationship between physicians and patients using literature and writing. The goal is to make doctors more empathetic by getting them to articulate and deal with what they feel and to develop sophisticated listening skills, ears for the revelations hidden in imagery and subtext. The field--alternatively called narrative medicine, literature and medicine, or medical humanities, depending on the approach--began by most accounts about 30 years ago and is now widely reflected in medical school curricula around the country. According to the American Association of Medical Colleges, 88 of 125 surveyed U.S. medical schools offered humanities courses in 2004; at least 28 required literature or narrative study in some form.

Charon, who coined the phrase "narrative medicine," stands at the forefront of this movement. She has established voluntary groups, such as the one in narrative oncology, and designed required courses for medical students and residents in which they read literature and write to reshape how they listen and think. She is also trying to study what it is about this method that seems, anecdotally, to work.

"What Rita has done so successfully is to bring the skills we learn as literature students--point of view and how to frame a story--and she has brought those to bear in the medical interview," says Anne H. Hawkins, a professor of humanities at Penn State College of Medicine. "She can listen at a different level. For instance, your doctor might ask, 'How long have you had shortness of breath?' You say, 'Since I divorced my husband.''' The next question typically might be "How long ago was that?" Hawkins notes. In contrast, "a Rita Charon would then say, 'Tell me about that relationship.' She teaches them how to listen and what to listen for."

The 55-year-old Charon--petite, sharply blue-eyed and, as would be expected, an intense and earnest listener--says this kind of listening, which began for her more than two decades ago, has changed her relationship with patients. She spends more time with them and writes about them, often sharing what she has written. The documentation makes her more curious, more engaged, she says. "I have had very vexed, ineffective relationships with patients, and by writing about it and saying, 'Does this sound like us?,' the whole thing changes."

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