Stories Matter: The Role of Narrative in Medical Ethics

By Rita Charon; Martha Montello | Go to book overview

CHAPTER 12

OF SYMBOLS AND SILENCE: USING NARRATIVE AND ITS INTERPRETATION TO FOSTER PHYSICIAN UNDERSTANDING

MARCIA DAY CHILDRESS

Ethical ways of being and doctoring depend on knowledge of human particularity that the physician is always acquiring through attentive observation and reflection. Knowledge so gained—about the patient, to be sure, but also about the doctor—is just as crucial to the physician’s clinical excellence as his or her fund of medical knowledge, and, together with this medical knowledge, it becomes the basis for the physician’s understanding, for action, and for care.

The practice of ethics in the context of clinical medicine is fundamentally a matter of attention and interpretation. In a narrative model of medicine, the patient-physician relationship is cast as an ongoing, constructive conversation leading first and most immediately to diagnosis, prognosis, and treatment. The physician is the “critical reader,” highly skilled both in eliciting and interpreting the patient’s “story,” which encompasses all that the patient says, how he or she says it, and the myriad nonverbal cues (including body language, significant omissions, and broad lacunae of silence) that accompany this telling. The physician’s responsibility is to listen to the patient in a close, careful, and nuanced way in order to elucidate and then explain the patient’s narrative, bring out and reflect its coherence and meaning, and finally translate what the patient has said and enacted into the formulaic tale—the case presentation—with which clinical medicine works. 1

In a narrative model of medicine, the ongoing patient-physician relationship itself becomes a means of continuing the physician’s education. In medical school, we frequently tell students that their patients are, and will be, their greatest teachers. While this seems a sage pronouncement, it is unclear whether faculty physicians really believe it and to what extent they practice it years after being wide-eyed students. What might they be learning, about themselves and about doctoring, from their patients? And how might such learning occur? While a busy practice allows little time for the physician’s reflective analysis of interactions with every patient, there are certain patients who, for whatever reason, preoccupy the physician. In a narrative model of medicine, these patients, through their storied exchanges with the physician, may become to the doctor “teaching cases,” oppor-

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