PRESCRIBING EMPATHY: The healing power of stories in healthcare and the role of narrative medicine

By :

Dr Mukundhan Murali

Junior Resident, Radiodiagnosis,

Stanley Medical College and Hospital, Chennai – 1.

“First you use your coat. I don’t care if you don’t remember where you left it, you find it. If there was a lot of blood, you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother’s name and you use her child’s name. You may not adjust this part in any way”

Excerpt from “How To Tell a Mother Her Child Is Dead”, Naomi Rosenberg MD, New York Times

The story of stories:

A long long time ago, the Apes that walked the earth gave up brain areas that gave them insane eidetic memory in order to evolve complex language areas. Ultimately Homo sapiens used those areas to tell stories.

Our lives are fast, full of unexpected confusing moments, and stories are how we give meaning to our days and months and years and generations. It can be a small self-told story like ‘I am studying right now so I can become a better doctor’; to large grand constructs like nationalism and religion, which are built on the stories of Gods and saints and demons and patriots. All classic epics, including the epic of Gilgamesh, the Odyssey, and the Ramayan, feature a hero’s journey, beginning with a setting, then the conflict and its resolution.

Applying this basic structure of a story into the health context, a person living his daily life (setting) acquires a disease that disrupts their normal life(conflict), which they have to overcome to reestablish normalcy(resolution) with the help of a doctor. The patient is not only physically distressed, but also could not make sense of how it is affecting their life. In real life, there are many more factors at play – unreliable history of illness, possibly confusing investigations , and complex social, psychological, and cultural scenarios around the patient. In this situation, sick people want doctors who can understand what’s wrong with their health, treat the medical problem, and accompany them in their illness with kindness, and empathy. This requires a doctor to listen closely to the narrative of the patient, respect their feelings, and be moved to treat the patient.

Narrative Competence – A doctor’s toolkit for holistic healing;

Narrative medicine is the approach to the practice of medicine in which we are conscious of this huge importance of stories and how it paves way for a more efficient and empathetic practice, with possibly better clinical outcomes. Evidence based medicine gives us scientifically proven, rigorous protocols for the diagnosis and treatment of diseases, while narrative medicine is related to what the patient feels. Logical scientific knowledge takes an approach to diseases that is entirely detached from the individual person, while narrative knowledge strives to understand particular situations and individuals.

A good practice of medicine requires narrative competence, with the ability to acknowledge, absorb, interpret, and act on the stories of themselves and others. Engaging closely with literature and reflecting on it will help a doctor in their interactions with – the patient, their inner self, the medical community, and the society at large.

The doctor-patient bond:

A doctor’s narrative journey with the patient begins the moment they start ‘taking history’ from their early college days, and continues with every patient interaction they have. As they listen to their patient, a story unfolds in their mind about the situation of the patient (including their physical, psychological, social, cultural, and existential scenario) and their illness. Like in any well written character introduction in literature, the doctor tries to understand not only what the patient says, but also curiously tries to understand their fears, curiosities, and deeper emotions – whatever is pertinent to their well-being. This way, the doctor establishes a strong bond with the patient, proceeds through the diagnostic and treatment process, and addresses their concerns effectively. If the doctor could not carry out these narrative tasks, the patient may withhold history and information essential for diagnosis, may doubt the competence of the doctor, may not understand their illness and the proposed treatment, may want to go for a second opinion, or may not stick to the therapeutic recommendations.  

Systematic sensitization of young doctors on effective approaches to empathetic communication can help them engage with their patients with great compassion, even when time and financial constraints make it challenging.

A doctor’s journey of self-reflection:

The life of a doctor is a lot more than drugs and sutures – we see fellow humans at some of the absolutely worst times of their lives. We bear witness to unfair losses and miraculous recoveries. In such a torrent of heavy human emotions, what keeps us going are traits such as altruism, generosity, honesty, compassion, humility. Hence these are considered the hallmarks of a good doctor.

When a doctor engages with their patients with self- reflection and a good understanding about the depth of the situations they come across daily, it can really help them understand themselves, their life’s purpose and their personal journey. This is why we see doctors who claim they are extremely satisfied with how they live a meaningful life.

Band of brothers (and sisters):

The hospital is a place where medical professionals develop bonds like that of siblings – from the days of interns staying up nights together to take care of their wards, to the team of doctors working together in treating a patient, from junior doctors policing each other as they learn the practice of medicine, to senior physicians sharing their invaluable experience in conferences. In addition, the very core of our scientific pursuit is driven by strong interpersonal cooperation, for instance, doctors engaging in research or peer reviewing, or doctors teaching and discussing cases.

We celebrate wins together; we comfort each other during times of griefs – a lot more can be done with a greater and finer understanding of our place in the hospital together which we can nurture by a close engagement with literature and art. This will also give us the right tools to realise and voice out against disgraceful professional behavior and workplace toxicity.

The doctor and the masses:

A doctor is seen as a godly figure who saves lives; they are well respected members of their societies. At the same time, we see a lot of suspicion and distrust on doctors amongst the public – They are accused of overbilling their services, being cold in their dealings with the patients, and some more. In addition, for any major shortcomings in the public health setup, the blame goes to the doctor.

In order to have a paradigm shift in the way the common man perceives doctors, a good public discourse must be started in politics and media; and doctors themselves have to communicate honestly with the masses regarding their responsibilities, contribution, and the challenges they face. These must go beyond PSAs about diseases and health policies – there must be dialogues on values and justice regarding health. This way, the public can realize that the doctors are on their team (and question them if they feel otherwise), and start making genuine decisions that can benefit everyone.

Prescribing stories for well being – Narrative Therapy:

Narrative therapy seeks to reevaluate the stories that we live by, hence making a change for the better. By changing the way the patients think about their lives, bodies, and suffering, we can empower them to head in the direction of healing. Consider the following instances :

Scenario 1 : I am Kumar, in 2nd standard. I am happy I don’t have school today, but my tummy aches and the big doctor with the yellow ‘sethocope’ told my mom I need operation in my ‘appendits’. I don’t understand but I am scared of injection. Doctor told me all heroes have scars, showed me a picture of iron man with scar and said I may get one too. He is nice. I want to go back to school to show my friends my iron man scars, is all.

Scenario 2: I am an orthopedic surgeon who derives satisfaction from my consistent wins. My trauma patients have their lives turned upside down in an instant, and my complex surgeries and procedures get them quickly back on their feet, quite literally. On the contrary, my friend is a medical oncologist, and a lot of her patients are terminal. She tries to cure them of this deadly affection, and when she cannot, she eases the extremes of their pain and discomfort. It is a heavy feeling when sometimes, despite a lot of efforts from her, the cancer ends up winning in the end. Despite this, she sees herself proudly making the last stand before its mighty charge.

Scenario 3: I am a neurosurgeon, I just spent the last 14 hours operating on this patient with a brain tumour, without food or rest. The surgery was too complex and taxing, and despite a gargantuan effort from the team, the patient’s recovery is highly doubtful. The frequency of such bad outcomes have worn my morale out, and I find it difficult to bring myself to work everyday.

Along with close reading and reflection on literature, many narrative therapy techniques like Expressive Writing intervention have been developed. In this, patients and doctors reflect and write about negative past life experiences, aiming to improve their emotional expression. With such an intervention, the budding neurosurgeon from scenario 3 can start feeling – “All the members of our team have grown used to this kind of results, we place higher emphasis on the internal satisfaction that comes from the realization that we have done our absolute best for our patient, whatever the outcome be. We have started to take ourselves less seriously, and focus on honing our skills to help our patients survive the toughest cards that life deals them.”

Another strategy is dignity therapy intervention for patients at end of life care – where patients write their life story and events they want to be remembered – this has reduced depression symptoms and suffering in many studies. Other intervention methods such as storytelling, theater class performance, drawing therapy are also employed, and patients report being more confident and more in control over their illness. Although extensive research is underway, current research on these techniques have already shown considerable improvements in psychological as well as somatic symptoms.

Conclusion:

To take steps in the direction of narrative medicine, we can begin with literature clubs in medical colleges where we can nurture our humane sensibilities with the help of literature and art. Many institutions have started incorporating narrative medicine techniques in various aspects of their formal training. King’s College, London, and Columbia University, USA offer Masters in Narrative Medicine; their curriculum preview on their websites describe various facets of medicine where narrative competence can improve and empower.

Medicine, in essence, is one human helping another. And if words can enable us to do this holy task better, let us harness the power of words to offer an authentic and effective care of the sick. Because sometimes, words can, what medicine can’t.

References :

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2. Narrative Medicine – A model for Empathy, Reflection, Profession, and Trust, Rita Charon MD, PhD, JAMA, October 17, 2001—Vol 286, No. 15
3. Fioretti C, Mazzocco K, Riva S, et al. Research studies on patients’ illness experience using the Narrative Medicine approach: a systematic review. BMJ Open 2016;6:e011220. doi:10.1136/bmjopen-2016011220
4. https://sps.columbia.edu/academics/masters/narrative-medicine/master-science/curriculum-courses
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