The Development of Narrative Practices in Medicine c.1960-2000
Jones E M, Tansey E M. (eds) (2015) Wellcome Witnesses to Contemporary Medicine, vol. 52. London: Queen Mary University of London.
Reviewed by Ben Chisnall, Medical Student, King’s College London, UK
“Narrative medicine” is a term used to refer to a number of analytical and interpretative approaches towards medical practice and interactions between patients and doctors. Its remit is broad, and encompassed within its boundaries are examinations of the personal and professional stories of doctors and patients, the sense-making processes of medical discourse, literary representations of medicine and its practitioners, and the scrutiny of medical forms of writing. Yet it remains a nebulous term, and this book – a transcript of the Wellcome Witness Seminar held at Queen Mary, University of London in June 2013 – brings together many of the individuals who have driven the development of narrative medicine studies in the UK, USA and Europe to provide insight into the scholarly currents which have shaped the field as it stands today.
The book takes the form of a discussion in which a series of narrative accounts are provided by academics and clinicians, many of whom can be regarded as protagonists of the narrative medicine movement. These narratives chart the chronological development of narrative medical studies and the reasons behind its integration into universities and medical schools. What comes across as a major concern of those involved is the desire to better hear the voice of the patient, and to incorporate the patient’s perspective into the thought processes of doctors.
The discussion begins in the 1960s and 1970s, with the introduction of humanities academics into US medical schools. The two main reasons for this, the book suggests, were the desire to provide a more balanced education for medical students, and – as Professor Kathryn Montgomery explains – to “keep [students] interested in patients as they went through the great grinder.”
What is hinted at but not answered in the discussion is whether the interest in what is now referred to as “patient-centred care” within the medical profession prompted a reaching out towards the humanities, or whether the development of narrative medicine and medical humanities departments drove the medical interest in understanding the patient’s perspective. One suspects that these explanations are both correct, and that a gradual alignment of interests between clinicians and humanities academics led to a shared interest in narrative practice in medicine.
The book also touches on larger social trends which may have driven and been driven by increasing interest in narrative medicine. The growth in popularity of celebrity illness memoirs – examples given in the text by Professor Arthur Frank include the Newsweek journalist Stewart Alsop’s column about his leukaemia, and the personal accounts of breast cancer by journalist Betty Rollin and First Lady Betty Ford – indicate a growing desire to hear the voice of a patient and their experiences and interpretations of their own disease and interactions with the medical profession. A recent and useful regular addition to the British Medical Journal entitled “What your patient is really thinking” is a good illustration of how patient voices have come to be valued and their experiences seen as enlightening both for doctors and for lay readers and listeners.
Alongside the development of narrative medicine has been the establishment of medical ethics as a field of study in its own right, which the book identifies as a parallel and reinforcing influence on narrative medicine. Literature and narrative can be used to apply ethical concepts in practical situations, and stories can provide the shift in perspective needed to understand complex ethical dilemmas. Yet as Arthur Frank highlights in the discussion, medical ethics as a discipline does not capture the element of suffering inherent in narratives of illness; this is where narrative medicine can act as an influential force on ethics.
Whilst these developments were happening in the English-speaking academy, narrative medicine in mainland Europe – as described here by Professor Jens Brockmeier from the American University of Paris – looked more towards influences from psychiatry, psychoanalysis and Freud. What emerges is the sense of the ideas behind psychoanalysis working their way into the medical academy through the growth of psychiatry as a scientific discipline during the 20th Century. So too is the study of hermeneutics, which runs through much European analytical literature, applied to the process of medical interpretation: of texts, tests and tales of patients.
The discussion in the book is far-ranging in theme and chronology, and contributions are well marshalled by Professor Brian Hurwitz in the chair. It provides valuable and thought-provoking insights into the beginnings of the narrative medicine movement, and the various and geographically diverse voices captured in the text give a heterogenous feel befitting the nature of the subject under consideration. Although narrative medicine is currently a specialised area of study, the topics under discussion in the text are accessible and applicable for those unfamiliar with the field.
Reading the book brought to mind the influence of those principles at the heart of narrative medicine on the reporting of and reactions to two scandals in the NHS which have been in the public consciousness recently – the Francis Report into the standards of care at the Mid Staffordshire NHS Trust, and the revelations of abuse at a number of NHS hospitals by Jimmy Saville in the 1960s and 1970s. Mention is made in the discussion of a “crisis of compassion” in the modern NHS, and the poor standards of care at Mid Staffs were uncovered when patient voices – many of whom were elderly, and therefore less likely to command attention – were listened to and acted upon. Similarly, the rise to prominence of the voice of patients after years of dismissal led to an investigation into Saville’s abuse. These are prime illustrations of not only the impact that narrative can have on modern healthcare, but also on how the ideas behind narrative medicine delineated in this book have become widespread and valued.