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Literature helps: listening to the narrative of medicine

2005; Elsevier BV; Volume: 365; Issue: 9475 Linguagem: Inglês

10.1016/s0140-6736(05)66645-7

1474-547X

Rainer Brömer,

Empathy and Medical Education

Medicine and Humanistic Understanding: The Significance of Literature in Medical Practices Jerry Vannatta, Ronald Schleifer, Sheila Crow. University of Pennsylvania Press, 2005. DVD runtime about 15 hours. $39·95/£26·00 (individual licence). ISBN 0-8122-3851-6. Registration with the US-based Accreditation Council for Continuing Medical Education (open to physicians not licensed in the USA) is carried out by mail, and a charge of $10·00 per chapter ($60·00 for 12 credits) applies. Registration with the US-based Accreditation Council for Continuing Medical Education (open to physicians not licensed in the USA) is carried out by mail, and a charge of $10·00 per chapter ($60·00 for 12 credits) applies. A “silly expression” is what an unnamed British consultant called medical humanities in a recent conversation. Similar remarks can be heard from many clinicians, even those who otherwise show high regard for the human dimension and the humane qualities of their interaction with patients. It would seem that sometimes, giving a concept a name leads to name-calling. And, speaking about names, narrative medicine might sound similarly vague to the hard-pressed clinician and the even harder pressed medical student, even if few would doubt that, like any narrative, the experience of illness has a beginning, a middle, and an end. How fruitful is it to single out humanities from science, trying to separate the art of medicine from its scientific foundations, harking back to C P Snow's ill-fated Two Cultures debate of half a century ago? After all, not many practitioners would claim that medicine is simply the application of scientific findings to sick bodies and minds. First of all, the patient comes with a story and the doctor's clinical reasoning is based on an examination of the whole history, the bit revealed in common language as much as the readings of symptoms and laboratory tests—or so we would think. At medical school, learning to read symptoms and laboratory reports has for a long time been accorded priority over listening to the patient's story. Much discord can ensue when patients perceive a lack of attention to what they have to say, and crucial clues to the nature of their condition go unnoticed until too late. So it seems timely that an interdisciplinary team at the University of Oklahoma has produced a high-quality DVD offering a concise self-study course in narrative medicine at post-qualification level. At a time when medical humanities have an ever greater role in the undergraduate training of tomorrow's doctors, contributions to the continuous professional development of today's doctors seem all the more desirable, and self-study material that leads to required continuing medical education credits is an ideal way of combining learning and professional activity. The best way to increase sensitivity to narrative is to study narrative, and the most obvious form of narrative comes to us as literature. The importance of literature in medical practices is what the user of this DVD will encounter. Short stories and poems, contemporary and classical, are discussed to foster an ethical, more reflexive, and less paternalistic approach to clinical practice. Each of the disk's six units offers a stimulating mix of introductory texts alongside excerpts from prose and poetry, which are used as the basis of commentary and analysis. Throughout there are insightful video clips from round-table discussions with some of the leading exponents of the medical humanities community in the USA. The course systematically introduces notions of patient-physician relationships and the role of the patient's story in relating the “History of Present Illness”, using not only literary examples, but also simulations and vignettes from current clinical practice. Learners will be introduced to some basic ideas from the philosophy of science, which allow for a critical discussion of the relation between narrative knowledge and scientific logic. The depth of this discussion seems appropriate for nurturing reflexive clinical practices. An interesting argument distinguishes the chapter on ethics: the dominant principles of beneficence, non-maleficence, autonomy, and justice are here relegated to the realm of “neon ethics”, a term Anne Hunsaker Hawkins uses to describe dramatic, large-scale dilemmas that she considers of limited relevance to everyday medical ethics. For most of ethical “housekeeping” (Howard Brody), Aristotelian virtues ethics is preferred over principlism. Consequently, the focus is almost exclusively on narrative in virtues ethics, a remarkable but plausibly defensible choice. A surprising absence, however, is Alasdair MacIntyre's After Virtue, which has been a key text in this debate. The course ends with a larger case study, an in-depth discussion of Tolstoy's novella The Death of Ivan Ilych, of which a complete version is provided. Tolstoy's engaging writing is used to bring together the narrative and ethical aspects of a memorable patient's story—one that is not handled particularly well by the characters involved. The complexity of this narrative makes for a thought-provoking discussion, because it confronts the reader with the protagonist's perspective of suffering. Does the study of literature help physicians become better doctors? The evidence may be quite anecdotal, but is consistent, indicating an increased sensitivity in dealing with patients and a better ability to recognise and work through difficult and ambiguous situations more ethically and efficiently. At the same time, formalised assessment of learning in the humanities is notoriously problematic. This training DVD comes with a series of short tests that need to be completed to claim educational credits. The emphasis of the multiple-choice testing facility is not on setting a high summative barrier, but on using the testing activity itself as a formative learning opportunity, and it seems to be very efficient at that. Physicians build up a stock of experiences and intuitions to govern their relationship with patients, but often they do not have the opportunity to step out of the immediate setting and reflect upon the wider implications of their actions. Junior doctors, particularly, may not yet have acquired the resources to always respond appropriately to difficult situations. Most undergraduate education integrates exposure to patients right from the start of medical courses, with the use of patient-actors and an emphasis on the importance of sensitivity to the patient's story. But the vignettes practised by students cannot usually reveal more than brief snippets of an imaginary history, and later, in the frenzy of clinical practice, there may be even fewer chances to grasp the complexity of illness experiences. This is where working with Medicine and Humanistic Understanding offers both experienced and junior doctors a unique opportunity for deep learning in broader contexts at the user's own pace. Fictional literature undoubtedly has a great deal to offer the health care professional, since “humanistic understanding” applies to the very fabric of medicine. The pursuit of biomedical science and the process of clinical reasoning involve the humanity of the researcher and the carer every bit as much as receiving a medical history or managing a terminal illness. The study of novels and poems is one way of gaining a depth of insight into the human condition of which clinical practice can only reveal fragments most of the time. But more than that, understanding the reactions of readers to writers' fiction can help to elucidate patients' reactions to doctors' facts, which to them are as ineluctable and as ambiguous as the narrative of a novel or the outlook of a poem. All medical practices write history and make a contribution to literature, in the factual as well as in the fictional sense.