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July 03, 2013 // By John Shea // Comments

What's the Use of Narrative?

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In certain circles, narrative has always been its own reward. But there are other surroundings in which narrative is seen as a poor substitute for something else, for something more . . . serious. In recent years, more medical professionals have embraced narrative, while others continue to regard it with suspicion -– or at least as something not to be used in a scientific or medical context. Earlier this spring, the University of Pennsylvania Biomedical Library hosted an event to explore some of the implications and possibilities of narrative in medicine. “Penn Projects in Narrative Medicine: A Visual and Storytelling Journey in Modern Medicine” brought together a novelist, a columnist, a photographer, an illustrator, and a plastic surgeon. Only the illustrator was not an MD -– but she has worked in an interesting fashion with the plastic surgeon.

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

In fact, the first speaker, Jason Karlawish, MD, is a novelist 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), Karlawish reimagined one of the most unusual medical cases in American history. In 1822, Beaumont saved the life of a young French-Canadian fur trapper who had accidentally been shot in the stomach. As Karlawish explains on his personal web site: “The young trapper’s injury never completely heals, leaving a hole into his stomach that the 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 medical training occurred as an apprentice to a rural physician rather than at an elite university, Beaumont seizes the opportunity to experiment upon his patient’s stomach in order to write a book that he hopes will establish his legitimacy and secure his prosperity.” The doctor-patient relationship rarely comes more charged!

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


Facts and Figures Are Not Sufficient

Zachary Meisel, MD, MPH, has been a frequent columnist for Slate and for An assistant professor of Emergency Medicine and a senior scholar at the Leonard Davis Institute of Health Economics, Meisel has tackled such topics as patient-directed “Google medicine” and whether better access to health care would actually lower costs. He spoke about the need to leverage the power of narrative in dealing with patients –- and, in other contexts, with doctors and policymakers. Alluding to a 2011 essay in The Journal of the American Medical Association that he wrote with Karlawish, Meisel noted that 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 are essential, but insufficient, to translate the data and promote the acceptance of evidence-based practices and policies. . . . Moreover, evidence from social psychology research suggests that narratives, when compared with reporting statistical evidence alone, can have uniquely persuasive effects in overcoming preconceived beliefs and cognitive biases.”

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


Images with Narrative Power

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


Personalizing Anatomy and Surgery

What Caryn Babaian, a science/medical illustrator and biology 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 that she had noted the similarities between surgery and drawing –- a comparable “eye-hand synergy.” She also argued that drawing is a way to intensify an experience and to help retain its memory; it helps in learning anatomy and develops the “noticing skills” of the practitioner. The joint project with Chalian developed from his request for illustrations of the trachea for use in teaching –- but Babaian saw the opportunity to make it more personal. “What if it was your thyroid?” she asked him. Would the medical residents care more about it? So Chalian indeed became part of the illustrations, personalizing what might have been a dry topic. One of the more eye-catching images depicts Chalian dissecting his own neck. Acknowledging some initial discomfort, Chalian became more enthusiastic. And, he noted, “My teaching scores went up.”


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