Evidentia

Dr. House is the most popular television show in the world – perhaps it is the show that people love to hate. The anti-hero of the show, Gregory House (played by Hugh Laurie), is a misanthropic genius, an irascible, combative drug-taking narcissist, who takes pleasure in humiliating his colleagues, in penetrating the lies of his patients and their families, and above all in following the meandering road of patient narratives to uncover the true story of illness and health.

Dr. House turns patient narratives into detective stories, with many twists and turns

In watching the series, I wonder how House, who so frequently breaks the law and breaches codes of medical ethics, can continue practising. And I also wonder how his colleagues, whose incompetence is amply demonstrated by the end of each episode, are allowed to practise. House has always reminded me of Sherlock Holmes, and while many episodes strike me as implausible not to mention impossible, and some of them filled with medical errors, the show illustrates how difficult it is for health-care professionals to figure out what the story is.

The body has stories to tell, and so do patients, but physicians at least often make a point of not listening. This has been my experience, and perhaps it has been yours as well. What is the story?

Dr. Rita Charon of Columbia University is one of the leading lights of the Narrative Medicine movement. In Narrative Medicine: Honoring the Stories of Illness, published by Oxford University Press in 2006, she notes that on the average, during medical examinations, physicians interrupt their patient’s explanation of what is happening after just 18 seconds.

According to Dr. Rita Charon, physicians should listen to their patients (Photo by Integra Rehab)

Rita Charon seems to have started off with her own father as a model: Dr. George Charon, a Franco-American from Rhode Island, kept detailed accounts in the 1960s and 1970s of his patients, of their home and work situation, as a way of contextualizing what they told him. But she seems to have developed a deep-seated frustration in the 1980s and 1990s about the cold and impersonal manner of physicians, who typically act as authorities dispensing expertise, and pay less attention than nurses do to the person in front of them. Through her clinical practise in New York City, she realized over time that in some cases a relationship of trust has to be established between physician and patient for the patient to come forward with personal stories. Rita Charon feels physicians have to learn not to interrupt, not to focus in an emotionally dead way on data, but to listen instead to the patient, to acknowledge what the patient is saying or cannot express, and even to identify emotionally with the patient.

Drawing on the huge body of literature (including fiction) referring to health, well-being, disease, death and survival, she says health-care professionals need to know what narratives are, and how patients (and health-care professionals themselves) shape narratives, based on their own perspectives, etc.

This is a valuable counterpoint to the Evidence-Based Medicine movement, which relies on statistics and clinical studies, and focuses only on what can be measured and then assessed in a rigorous, controlled and somewhat abstract way. Unless, of course, one defines evidence in a way that includes the patient’s own story of his health and illness.

Charon comes back again and again to the theme of intersubjectivity as the key for physicians to understand their patients. “The subject is the self-who-knows,” she writes, “the self-who-acts, and the self-who-observes or, in the philosopher Paul Smith’s formulation, the ‘bearer of a consciousness that will interact with whatever the world is taken to consist in.’

Intersubjectivity, it follows, is the situation that occurs when two subjects, or two authentic selves, meet. It is in meeting with other selves that the self comes alive.”

The first time I came across the term “intersubjectivity” was in reading The Acting Person, by Karol Wojtyła, later Pope John Paul II. Rita Charon’s approach to health-care is scientific but also spiritual, since it includes such notions as humility, empathy, generosity, and the habit of identifying with people who suffer.

Dr. Rita Charon, Professor of Clinical Medicine and Director of the Program in Narrative Medicine at Columbia University

She is also writing from an American perspective – in a country where the latest census statistics show that 47 million Americans have no health insurance at all.
http://www.nchc.org/facts/coverage.shtml
After re-reading her book just recently, I realized that many tens of millions of Americans have no health-care professional listening to their personal narratives of health and illness. According to Rita Charon, it is urgent for these Americans to get proper access to health care.

This fascinating book shows how patients benefit from developing their own narratives – but so do physicians, by going beyond mere data to develop parallel charts, conveying their own emotional responses to patients, as the story of health, illness and sometimes of death unfolds.

I will return to this subject.