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.
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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." [break]
For instance, Charon recalled a patient who had high cholesterol and chest pain. During their first meeting, she recounts, "he started his story with the death of his father when he was a boy." By not restricting the conversation and treatment to his cholesterol and physical pain, Charon and her patient began to talk about his own challenges as a father. "It made for a very productive alliance," she says. "And his chest pains went away."
Many experts concur that such careful listening can lead to better diagnoses and approaches. Ron B. Loewe, an anthropologist and authority on narrative medicine at Mississippi State University, recalls interviewing doctors and patients at Cook County Hospital in Chicago about diabetes because few patients were complying with their doctor's orders and many were doing poorly. Loewe found that patients thought the doctors had given them diabetes when administering shots of prednisone, commonly used to treat inflammation. "What are the issues for compliance if your patient thinks you caused the disease?" asks Loewe, adding that many doctors remain uninterested in eliciting such stories. "They are under such pressure to see lots of patients in a very short period."
In addition, some doctors remain critical of medical school curricula that include humanities and communication skills, arguing that time is better spent on scientific subjects. "As with any change to an establishment as solid as medicine, there is skepticism," says Kelly Caverzagie of the University of Nebraska Medical Center and a member of the American Medical Association's Council on Medical Education. The old guard may harbor skepticism, but, Caverzagie points out, "the students themselves are embracing this movement."
Charon's own involvement with new movements is long-standing. In 1966 she entered Fordham University and quickly joined an experimental education project in which 30 students and six teachers designed their own curriculum. She tackled various jobs, among them teaching at a newly established progressive elementary school, before becoming a medical student at Harvard University in 1974. Her interest in narration and medicine formed during a lecture by Elliot Mishler, a Harvard social psychologist renowned for bringing narrative theory to sociology. "I was riveted," she says. She studied with Mishler, developing what she describes as a way of seeing patients as whole people, not as cases, and using her mentor's attention to the patterns of speech to hone her listening skills.
Her engagement with narrative ultimately led to a doctoral dissertation at Columbia on Henry James's late works, including The Wings of the Dove, in which one of the three central characters is a very ill woman; the creation of a writer-in-residence program at Columbia's medical school, in which visitors, including Susan Sontag and Michael Ondaatje, have shared their perceptions of illness with medical students and faculty; and a practice called "parallel charts," in which residents write about their patients in a nonmedical format. Charon is now designing studies to assess the impact of parallel charts and of groups such as the one in narrative oncology. Charon and oncologist Gwen L. Nichols say the readings have improved relationships among the oncology staff, prevented burnout and, therefore, led to better care.
"When a very junior nurse is in a position to give comfort and sustenance to the service chief, and when the head doctor of oncology finds himself weeping to hear what this junior nurse has written, that does something you don't do on rounds," Charon declares. "We have team meetings, we go on rounds. But it doesn't happen there because--well, that is what we are trying to learn."