Narrative Medicine Teaches Doctors How to Listen to Patients’ Stories
In a sleek, glass-walled room in Columbia University Irving Medical Center’s Roy and Diana Vagelos Education Center, 11 first-year medical students stand around a table doing a free-form choral reading of Catalog of Unabashed Gratitude, a poem by Ross Gay. “We’re essentially creating a remix, an interpretation of the poem,” said Teachers College Professor Nicole Furlonge. “This is an improvisational exercise in composing on the spot,” she added, “but mostly, it’s an exercise in listening and hearing what emerges.”
The class is called “Race Sounds: The Art of Listening in African American Literature,” and it is part of a robust seminar series for first-year medical students in the Vagelos College of Physicians and Surgeons' Division of Narrative Medicine.
“We’re investigating different forms of listening in this course,” said Furlonge. “Why would we want to focus on listening as it pertains to race?”
“To better understand people I know and relate to, in their own words,” one student responded.
“Listening is care, extending care to someone else,” offered another student.
“Yes,” said Furlonge. “As future doctors, you will walk into a patient’s room, and have to figure out what’s happening. A lot of that comes down to your listening skills.”
A Multidisciplinary Program With a Mission
In 2018, the medical school established the Department of Medical Humanities and Ethics, which encompasses the narrative medicine program, an Ethics program, and one in Social Medicine. The department chair is Rita Charon, a general internist and professor of medicine, who gave up her clinical practice in 2018 when she became chair.
Although narrative medicine is now a large field, and is taught widely both in the U.S. and abroad, Charon founded it at Columbia, and coined the term in a publication in 2000. At Columbia, narrative medicine is a multidisciplinary program designed to promulgate the uses of narrative practices in clinical care and medical education. The discipline is at the intersection of humanities, the arts, clinical practice, and health care justice, and aims to improve clinician-patient relationships by training clinicians in reflective practice.
“Let me give you an example of how narrative medicine works,” said Charon, a petite, vibrant woman who speaks slowly and thoughtfully. She was seated at a round table in her office at the uptown Columbia University campus. The room, located on the 15th floor of NewYork-Presbyterian Hospital on West 168th Street, has a sweeping, south-facing view of sky, Manhattan, the Hudson River, and New Jersey.
“An elderly woman comes in with a complaint of lower back pain,” said Charon. “A physician asks, ‘Have you had an X-ray or are you taking any medication? Have you seen a neurologist?’ The woman says, ‘Well, I can tell you what makes my back hurt. It’s when I pick up my grandson, and I get this feeling at the base of my spine.’ The doctor might then say, ‘What happens if you try aspirin or Motrin? Does that help?’”
“But another doctor, if he was trained by us,” continued Charon, “would say, ‘Tell me about your grandson.’ And the grandmother would say, ‘He’s 18 years old and has autism, and I’m the one who’s been raising him since birth, but he’s bigger than I am now, so it’s very hard to pick him up.’”
“That is an instance of the difference that some narrative skill can make in understanding even the most elementary parts of what is bothering this patient,” said Charon. “Some physicians aren’t interested in the social stuff, and will send that patient to see a social worker. A doctor with a grounding in narrative medicine, however, will have a desire to hear what patients really have to say.”
An Activist at Heart
Charon, of course, realizes the challenges of such an approach to patient care in today’s health-care world of 15-minute medical appointments and increasing corporatization. Yet she maintains that listening to a patient’s entire story as opposed to just listing various symptoms is possible—and vastly preferable.
“My practice isn’t going to make huge changes,” said Charon, “but a movement is growing because the current state of medicine is alarming. We train our students in activism and advocacy."
Charon is an activist at heart. She grew up in Providence, Rhode Island, with a father and paternal grandfather who were both general practitioners. “My father had six daughters, and he always assumed one of us would be a doctor—turned out to be me,” she said, adding that two of her sisters are nurses.
She arrived in New York to study premed at Fordham University in the 1960s. “I was very involved in the antiwar movement,” she said. “I became radicalized, got arrested, and remember lots of tear gas.” Next stop was Harvard Medical School, followed by a return to New York, where she trained as a primary care resident at Montefiore Medical Center, and then came to Columbia as a fellow in general medicine.
“I’ve now been here for about 40 years,” she said. “I stayed not only because I became a professor of medicine and had my clinical practice here, but because I also got a PhD in English here.”
Making Connections Between Medicine and Literature
Charon started work on her doctorate in 1989 and received it in 1999. She was intrigued by professors in the Department of English and Comparative Literature who were making connections between things like psychoanalysis and literature. They, in turn, were interested in what Charon was doing—taking the critical analysis skills she was learning in her English classes and transforming her medical practice with them. “It was radical back then,” she said. “By learning how stories work, I changed my patient interactions. When I met a patient, I said that I needed to know a lot, and then, without interrupting, I listened closely and carefully.”
In 2000, Charon and some colleagues who were also involved in developing links between literature and medicine applied for and received funding from the National Endowment for the Humanities. Other doctors and scholars both nationally and internationally were also focused on the growing field, but Charon and her team were the only ones who got money from the NEH to study why teaching such literary practices as close reading and narrative theory to medical students might be beneficial. With the money, she assembled a group of Columbia academics and clinicians—professors of English, art, and cinema studies, along with pediatricians, psychoanalysts, and internists—and set to work.
Over time, they developed a theoretical framework, which is still in use, and Charon wrote Narrative Medicine: Honoring the Stories of Illness in 2008, which describes the ideas and genesis of narrative medicine. This book was followed in 2016 with what amounts to a textbook, The Principles and Practice of Narrative Medicine, written by Charon and contributors.
In the meantime, she and her collaborators also received funding from the National Institutes of Health to research and help put into practice at Columbia what is now a required series of courses for medical students: Foundations of Clinical Medicine. Narrative medicine is an integral part of this curriculum. In these courses, medical students learn “everything except the biotech: The teaching of patient-physician relationships, how to talk to patients, how to do physical exams, how to be trained in the ethics of medicine—all the doctoring,” Charon said.
She describes the way narrative medicine is taught at Columbia as a “sophisticated, rigorous discipline.” In addition to the required courses that medical students must take, the master’s program in narrative medicine enrolls everyone from graduate students and some undergraduates across Columbia to recent college graduates considering a career in medicine and mid-career health professionals—doctors, nurses, social workers—yearning to increase the strength of their own practices.
“There is a long-standing faculty community, many in leadership positions, at this medical school who have come through the narrative medicine program and continue to meet weekly,” said Charon. “We taught them how to teach narrative medicine to their medical students, and, in that process, they became more compassionate clinicians themselves.”
The Parallel Chart
One of Charon’s inventions is the parallel chart, a writing exercise now used widely in narrative medicine. As medical students start to take care of patients in their clinical training, they are encouraged to write down their personal feelings—not in the hospital chart in a patient’s room, but in a parallel chart, which is shared only with their professors and fellow students in small groups.
“If an elderly patient is dying of prostate cancer, and all a student can think about is her grandfather also dying of prostate cancer, then she should write about that. It will give her a sense of her own capacity to care for the patient, and also of what she is going through as a beginning doctor,” said Charon.
“Our narrative medicine courses give us the space to step back from the intense curriculum and reflect,” said Jessica Cho, a first-year medical student at Columbia. “Narrative medicine reminds us that there is a story behind everything, and that what we see as doctors in a moment in time is a snapshot.”
The ability to see that snapshot, as both Charon and Furlonge emphasized repeatedly, lies at the heart of narrative medicine training. Learning the art of active, empathetic, or radical listening—a complex, full-bodied skill—puts front and center why many students like Cho chose a career in medicine: to help their patients navigate the health-illness-death continuum.
In addition to the medical school's narrative medicine program, the School for Professional Studies offers certificate and m.s. programs in narrative medicine.