Question

How does Charon define the components of medicine?

Answer 1

Charon says that it is medicine practiced with narrative competence “to recognize, absorb, interpret, and be moved by the stories of illness.”

Narrative-based medicine (NBM) is often described, somewhat simplistically, as “listening to the patient’s story.” However, NBM entails much more and requires particular skills. Perhaps for these reasons, and despite its benefits, NBM is not as widely practiced as it might be.

The fundamental principle of Narrative Based Medicine (NBM) is that meaning is derived from the stories that we tell. Many stories are told in medicine. Patients tell a story about a symptom or concern, its context, how it is affecting them, and why they came to the doctor. This is a story with infinite variations in content, the person telling it, the language used, and how it is told. It reflects the uniqueness of the patient and his or her experience. Doctors also bring their own stories to the consultation. The doctor understands of what is occurring for the patient, the diagnosis that is formulated, and ideas about causation and management form a story in their own right, which has to be communicated to the patient. The way in which this is conducted reflects the doctor’s personality, experiences, and practice.

Rita Charon, a proponent of narrative, says that while doctors might be knowledgeable about disease, they do not appreciate adequately that illness changes everything for the patient. According to Charon, there are “four divides” that contribute to the disconnection that might occur between doctor and patient.

The relation to mortality: Illness is an unexpected event that elicits many emotions, especially the fear of death. Patient attitudes to illness and mortality are colored by previous experiences, while doctors, because of their training, have a different perspective.

The context of illness: Doctors quite naturally view illness as a biological phenomenon requiring medical intervention. Patients view illness within the framework of their entire lives.

Beliefs about disease causality: Patients do not have the medical knowledge of doctors and so their notions of illness and its causes can differ widely. When ideas of causality are conflicting, care is compromised.

Shame, blame, and fear: Patients are embarrassed revealing intimate aspects of themselves. Illness makes them vulnerable and fearful. They might blame themselves because illness is perceived as having been caused by past misdemeanors, and if the outcomes are not favorable, they might blame the doctor. Doctors equally might be embarrassed to ask personal questions. They blame patients for being demanding or for not looking after themselves, and they fear being sued. These emotions, on both sides, affect the illness experience considerably. Unless they are addressed, they might cause such suffering that they divide doctor and patient irrevocably.

For Charon, therefore, listening closely and acknowledging and exploring the 4 divides are part of understanding the illness experience and what it means for the patient.

Charon compares the patient’s story to literary texts. As with such texts, some patient stories are straightforward and easily understood. Others, however, are more complex or perhaps told in a particular way that requires more background information, further exploration, and someone more expert to assist with the interpretation. Reading of literary texts stimulates the imagination—it opens up the mind to different ideas and varied possibilities—and text analysis promotes a deeper understanding of the narrative. By extending these principles of literary analysis to the patient narrative, much more can be learned and understood about the patient. However, imagination to see things from the patient perspective and to consider different viewpoints is not the only thing that is gained. By reflecting on the encounter, the doctor invariably reflects on the self and his or her own role, thereby gaining insight into the self and his or her own effect on the interaction.

Narrative based medicine (NBM) “is a useful tool to assess the patients’ experience of illness and could be implemented in daily medical practice.”