Storytelling with the pioneer of ‘narrative medicine’
Stepping into Rita Charon’s studio, in a Jazz Age-era building in Greenwich Village, I get a quick impression of a white-walled space bathed in the sunshine from two large windows that offer a sweeping view over the Lower Manhattan skyline. Everything in the room seems considered, from the Bach playing in the background to the paintings on the walls. One of them, “The Doctor”, is an idealised Victorian depiction of a devoted medic ministering to a child while anxious parents look on. It used to hang in Charon’s father’s office.
My meeting with Charon, founder of the “narrative medicine” movement that trains health professionals to use the power of storytelling in their work, is one I’ve been contemplating for 20 years. How, I’ve wondered, can such a humane approach fit into the time- and cash-constrained world of 21st-century healthcare? And who is this woman who, sometimes unsung, has done so much to change the way we think about the doctor-patient relationship?
Then, just as we sit down, I realise I’m setting out to tell the story of a practised assimilator of other people’s stories. At the core of her work, she says, is “what happens in the actual [moment of] two humans sitting, contacting one another with language, with the embodied self”. So we begin.
Charon graduated from Harvard Medical School in 1978 and began practising general medicine. In the late 1980s, she started doctoral studies at Columbia University, focusing on Henry James and the role of literature in medicine. The work of the second half of her life has been to bring these two superficially oppositional realms together. She believes the emotional and imaginative insights contained in literature, art and music can transform the way healthcare workers treat patients and each other. Around 1990, she began teaching narrative medicine at Columbia and in 2009 launched a masters degree in the subject, the first of its kind. Since then, her approach has been deployed by healthcare practitioners across the US and abroad, from Greece to China. Formal evaluations have shown it improves participants’ capacity for reflection, in one study even reducing racial bias.
Her father, a doctor in Providence, Rhode Island, was an important influence. At one point, she goes to a filing cabinet containing all his medical records, which she acquired after he died. This part of his life had always been shut off to her; the close community in which they lived meant confidentiality was especially vital. But it turned out that his files combined the usual medical notations with far more personal references. It seemed to reflect a recognition that ailments could not be divorced from the wider context of their sufferers’ lives. Inspired, Charon began making more fulsome and impressionistic notes about her own patients.
The practised narratologist, she says, can pick up a lot in a short period, even at a time when there is pressure on doctors to keep appointments as brief as possible. “As you develop your skills of attention, you will notice things about your patients. You will be listening at a much higher pitch.” As doctors, the human body is, she says, “our material . . . I’m sitting here looking at you, noticing how you sit in the chair.”
Emboldened, I ask what else she has picked up about me. She has spotted that my purple outer coat tones with the pink lining of my jacket: “You have taste because you’re not just helter-skelter putting the aqua with the olive green.” She has noticed my eyes: “Mostly the expression is filled with curiosity.” My sense of her, which deepens over the next three-and-a-half hours, is of a woman with a vast well of compassion, lit by a righteous fury about the inequities of US healthcare. “In Yiddish, we call it the Shanda, which is ‘the shame’. The shame of the system,” she says. “More and more clinicians . . . feel they’re being used by their employers. They know they’re doing shoddy work . . . They get tired of saying, ‘I’m sorry, I can only listen to one complaint per session. Bring that up the next time.’”
Truly listening to patients can be transformative, she says. “Patients on the whole really know what they need.” She recalls a young woman with poorly managed diabetes who arrived in her consulting room angry and frustrated. “I did my routine, which is get away from the computer, put my hands in my lap. Don’t write. Just say, ‘I’m going to be your doctor. Tell me what you think I should know.’” The woman looked as if she was going to cry but pulled herself together and glared. “You really want to know what I need? I need a new set of teeth.”
It was only then Charon noticed she’d had her hand covering her mouth as she talked. She had no upper teeth. Instead of fussing with the woman’s insulin levels, Charon arranged for her to be seen in the university’s dental clinic. “She shows up in a couple of months, and she is dazzling. She started a [catering] business in her house. Her [blood] sugars were better than they had been in a while. And she was much more active — she’s going to parties, she’s dancing! It was such a lesson to me. Why on earth would you start anywhere else but ‘Tell me where we should start’?”
I’m intrigued by the extent to which this approach requires an inversion of the traditional power relationship between doctor and patient. She tells me that for decades doctors were taught to conform to a model of “detached concern”. In fact, “engaged concern is going to get you farther than detached concern. Detachment looks an awful lot like coldness.” Instead, Charon believes in making space for the imagination. “The more you exert your own creativity, the better your medicine will be. It’s making leaps . . . I don’t like the word intuition because it sounds like magic. But the ability to see the known from the unknown — that’s what poetry does.”
In the early 2000s, Charon tried something new. After finishing a consultation and making notes like any doctor would, “I would turn the keyboard and the monitor around and say, ‘I know what I saw. But please finish the note.’ I would leave them alone for five minutes, and they wrote the damnedest things!”
A college professor wrote “that she knew that she was a good teacher and that this really gave her pride.” The sentiment astonished Charon because it had not surfaced during their conversations, which had been dominated by the woman’s health woes and difficult relationship with her daughter.
An idea occurs. As I am drawing our conversation to a close, I ask her to finish this interview. Is there anything else I should know? She confides that after she quit her practice in 2015 to concentrate on running her programme at Columbia, she felt an overwhelming sense of relief that she could hand over responsibility for her patients. (“Somebody else is going to worry about Lucy.”) It was several weeks before she identified the gap that had opened up in her life: “I was terribly missing the chance to do random acts of kindness.”
As a physician, the scope for moments of generosity is “drastic”, she says, whether ringing a patient’s sister to update her, helping put someone’s socks on after an examination or rubbing the feet of a terminally ill patient. There is something heartbreaking about the disproportionate gratitude these interventions elicit, she says. “I think their expectations for us are so low.”
Narrative medicine can, she suggests, endow clinicians with the ability to see an issue from multiple perspectives, a power she likens to “the compound eye of the fly”. It can help them to understand and value those they care for in all their uniqueness and complexity. “We ought to treat every patient as the deepest mystery,” she says.
Sarah Neville is the FT’s global health editor
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