Odd ducks

by Michael

Jacques de Vaucanson's Digesting Duck, 1739

Jacques de Vaucanson’s Digesting Duck, 1739

A doctor told us a story of a patient he’d almost failed.

I suppose there are three basic stories in medicine, from the doctor’s perspective, at least:

  1. We did all the right things and the patient did well;
  2. We made some mistakes which put the patient at risk and the patient did not do well;
  3. We made some mistakes but we corrected ourselves and the patient did well in the end.

Of course, 1 is too boring, 2 is too hard to admit, and so 3 is the only one with the drama and redemption to warrant narration. This was a good example, though: the doctors (working in the Emergency Room) were distracted by this patient’s profile and by the way he told his story, so that they almost missed the critical piece of the picture. But a detail in the patient’s story niggled away and eventually led to them calling for the right procedure which turned out well for everyone in the end.

The doctor telling the story, Rishi Goyal, is an ER physician but also happens to teach literature at Columbia University in New York, whose Narrative Medicine Program was one of the two organisations behind the conference I’ve been at this week. Goyal’s analysis of his own story suggested that more important than identifying with his patient (which he failed to do perhaps because of their disparate profiles) was finding a point of interest in his story, upon which the doctor could hang the care and attention required to do a good job. It made me think about what details I need to include in my stories to provide readers with a point of interest to care and attend to each character.

This was all part of what might be my favourite session in the conference: Kazuo Ishiguro, blues music and Shakespearean tragedy were lined up to help investigate emotions in literature and medicine. It was most enjoyable.

The last breakout session for me was also good although a bit more staid, not having any blues music played or lines from King Lear performed. But the speakers addressed currently relevant topics such as ‘mystery’ illnesses (I am trying to write a feature about Alzheimer’s disease as if it were the crime at the heart of a good detective story) and metaphors in descriptions of illness (eg Susan Sontag was against the use of metaphors in illness narratives because they too often collapsed a moral burden onto the patient’s shoulders).

Summation

Having reached the end of the conference, it would be nice to attempt a definition of narrative medicine, but I’m not sure that I can, really. The conference ended at the right time for me. The last speaker was Arthur Frank, apparently an early prophet of the field, a sociologist whose own illness drove him to construct an ‘illness narrative’ for himself, having found none existing for him to use. I wonder at this: the field has developed such that everyone is expected to construct their own narrative – patients, clinicians, carers, academics, you name it – not adopt anyone else’s. So even if there had been a host of illness narratives to comfort him in his sickness, would Frank really have been satisfied without telling his own story?

As an academic field, narrative medicine goes beyond the simple act of story-telling. It examines those stories and how they are constructed, as well as examining how they are interpreted and understood, and will probably go so far as to examine how the study of these narratives takes place in a particular context, affecting the stance that the field takes towards itself. If this sounds circular and introspective, it is my intention to display that possibility. It is evident in the way that the same methods clinicians are encouraged to use with their patients are also used by ‘supervisors’ with clinicians, and are used among the supervisors and academics themselves as well. The directional method of the clinic becomes a circular method of reflection in the academic levels.

But the techniques themselves aren’t all that novel – there are certainly large overlaps with the coaching training I have had through my employment, intended to bolster my ability to help colleagues develop, and the narrative focus reminds me enormously of Freud’s approach to psychoanalysis, which was essentially (in my limited understanding) to interpret human experience through the medium of literary stories (Oedipus et al) rather than settling for taking these stories as interpretations of human experience. And there is a lot about narrative medicine that reminds me of psychoanalysis: certainly at the moment it seems to be a way of interacting with patients (or ‘clients’, or ‘citizens’, or ‘colleagues’) that requires a lot of time, mental space, attention, and is dependent on both parties having the sort of personality that will put enough into it to get something meaningful out. (Referring to Peter Carey’s talk on Thursday, in which he described building part of a narrative around the historical mechanical duck pictured above (which then lost out to a historical mechanical swan), at least two speakers yesterday referred to themselves (or the field) as “the odd ducks”, and I worry that today’s practitioners of narrative medicine do indeed represent a possibly quite rare type of person who has the patience and curiosity and broad interests to pursue it.) Can such a resource-intensive practice survive in the culture of commodified healthcare?

Gosh, what a cynical soul I have. Positively Foucauldian in its suspicion. Ann Jurecic, of Rutgers University in New Jersey, spoke about Michel Foucault in her keynote talk yesterday. His concept of the ‘medical gaze’ as a political act underpins a lot of the theories of narrative medicine, it seems, and people have referred to Foucault almost as much as they have referred to Frank these past few days. Jurecic suggested that in later life Foucault lost some of his suspicious rejection of medicine when his own body began to fail. In one of his later books about care, he apparently wrote about ancient practices of keeping notebooks of fragments of conversations and thoughts, the better to reflect on life and its meaning. I recognise this in my own writing practice, which positively endeared Foucault to me and made me resolve to read some of his works that are on my bookshelf but to which I have not yet mustered the courage to turn.

Writing and reading as a means of thinking is pretty fundamental to me – it seems I only really get creative when I have other texts alongside. I don’t mean that they are direct influences (or that I am plagiarising or copying), but reading an intelligent book while considering writing something of my own enables ideas to fly back and forth, to mature and sometimes transmogrify into something actually interesting for my writing.

Several people at the conference today talked about this notion some people have, that they only know what they think once they’ve tried to articulate it. “I don’t know what I think until I see what I say,” for example. I recognise this phenomenon but I also acknowledge the danger, which is that I sometimes find myself articulating a sentence that doesn’t quite convey what I think but it has a sort of linguistic logic that carries it through anyway. When my elder daughter was a bit younger, she would babble away and she would obviously flit between descriptions of real events and ‘imaginary’ events, but I wonder if these ‘imaginary’ events are not, in fact, constructed on the fly by her effort to keep talking and because certain words follow certain others in a nice fashion without necessarily describing anything real or even imagined before they were spoken. Of course, as a 4-year-old, Edith would then defend her sentences as absolute intentional truths.

This is the danger if we accept whatever we say as a true representation of our self; this is the obstacle I encountered with counselling – that I often felt I was being held to the strict construct of what I had said rather than being allowed to have a few goes at articulating what I was trying to say; and this is the potential limit of narrative medicine, which at the moment consciously strives not to question the narratives that emerge but to accept their veracity as what the patient has constructed, regardless of its (immeasurable) absolute degree of truthfulness.

Final thought

In fact, looking back through my notes now, I see that Frank said one thing that really did seem to capture the spirit and intent of (practical) narrative medicine. Considering the hospice movement, he said: “Why do you have to be dying to get hospice care?”

In the end, it seems that narrative medicine is built on an attempt to add weight to the importance of care and attention for patients, and offering any medical assistance we can offer in the individual context of their illness as it is happening to them, and not in the generalised context of clinical practice. The narrative element both identifies the individual’s context and demonstrates the care and attention being given to them. With that in place, I guess the theory goes, medical treatment can then have its fullest effect.

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