Issue #52, Summer 2014

Narrative Medicine, Narrative Humility

Listening to the Streams of Stories

Sayantani DasGupta

Narrative Medicine, Narrative Humility

A story is like water
that you heat for your bath.
It takes messages
between the fire
and your skin. It lets them meet,
and it cleans you!  

                                 — Jalal al-Din Rumi 

When I tell people I am a faculty member at Columbia University’s Program in Narrative Medicine, I usually get the following reaction: “Oh, wow, Narrative Medicine. I love that! That sounds fascinating!” And then, after a beat or two, the inevitable question: “Um . . . what exactly IS Narrative Medicine?”

(Tell the truth: some of you readers were thinking the same thing.)

So I have a couple of elevator speeches I tend to give. The first goes something like this: Narrative Medicine is the clinical and scholarly movement to honor the central role of story in healthcare. Long before doctors had anything of use in our black bags—before diagnostic CAT scans, treatments for blood loss, or cures for tuberculosis—what we had was the ability to show up and to listen; to stand witness to birth, death, illness, suffering, joy, and everything else that life has to offer.

But over the years, as medicine has gained technological developments, we’ve lost that initial, simple ability to witness another’s story. And what my colleagues in Narrative Medicine and I are urging is not that we forget all of our wonderful, lifesaving technological know-how (antibiotics and CAT scans and cures for blood loss are, after all, good things), but rather, that we once again train clinicians to elicit, interpret, and act upon the stories of others, that we hold in equal stead multiple ways of knowing—the scientific and the storied, the informational and the relational.

We would never graduate from medical or nursing or physical therapy school students who didn’t know their anatomy or their physiology; how can we graduate students who don’t know the first thing about how to deal with stories? Stories are the most fundamental and profound way we have of engaging with our fellow human beings, and it is no longer good enough, I argue, to assume that the ability to engage with stories is somehow magical—to say, as some do, that you’re born with it or you’re not, and that if you’re not, then maybe we’ll shuffle you off to some sub-specialty where you don’t have to deal with patients very much. Indeed, if we can take a student and put him or her in English graduate school and teach him or her how to interpret the form, frame, plot, metaphor, point of view, and other nuances of, say, Tolstoy’s 'War and Peace,' why can’t we do the same with medical, nursing, or therapy students? Why can’t we train clinicians to be expert story elicitors, interpreters, and decoders? We can, in fact. And at Columbia (and in other Narrative Medicine programs), with an interdisciplinary approach incorporating everything from philosophy to literary theory to cultural studies to oral history and disability studies, we do.

Of course, in the amount of time that it takes me to say all that, the elevator has come and gone. So when I’m actually in an elevator, I also have a shorter answer, which is to say, “I teach people how to listen.”

What is the deep listening? Sama is
a greeting from the secret ones inside
the heart, a letter. The branches of
your intelligence grow new leaves in
the wind of this listening.

As the beautiful Rumi poem quoted above makes clear, listening to another person is an act of profound humanity; it is an act of profound humility. This is particularly true at those charged moments of illness or trauma, change or suffering. These are the situations of life that call for new stories, because it is at these crossroads that our old stories begin to fail and we need, as sociologist Arthur Frank has said, “a new destination and map” to chart our life’s altered journeys.

Of course, such listening to illness or disability stories must also acknowledge silence—that which is not said, that which remains unsayable. It must acknowledge the limits of our own listening, that there will always be something beyond the emotional frequency of our cochlea, some part of another’s story that remains beyond our reach, or unhearable.

Listen, and feel the beauty of your
separation, the unsayable absence.

In conjunction with my work at Columbia, I have been developing over the years an idea that I call narrative humility. I was inspired to come up with the term by Melanie Tervalon and Jann Murray-Garcia, who in a 1998 essay suggested the term cultural humility, as opposed to cultural competency or cultural sensitivity, to guide clinicians in serving the needs of diverse populations.

The term cultural competency suggests it is somehow possible to become entirely competent about another’s culture. For instance, during my medical training, it was not uncommon for professors to hand students a list of ten health beliefs of Dominican Americans, or ten alternative health practices of Vietnamese Americans, and to tell us to memorize it, upon the successful completion of which the university would deem us “competent” regarding those communities.

As a more socially just alternative to cultural competency, Tervalon and Murray-Garcia suggest cultural humility. Building off that, narrative humility can be a guiding force in the work of narrative, health and social justice. Narrative humility is also, in many ways, a response to my colleague Rita Charon’s term narrative competence—the idea that health and humanities teachers can train clinicians to be utterly competent in eliciting and interpreting patient stories. As Rumi reminds us, there is always that unsayable absence, that screen whose job it is to “shield and partially reveal the light that is blazing inside your presence” (“Story Water”). Or, in the words of my colleague Craig Irvine, writing about the philosopher Emmanuel Levinas, “the sense of humility toward that which we do not know—the face of the Other, the face we cannot know but to which we are responsible.”

Narrative humility suggests an engagement with stories that acknowledges that stories are not objects we can comprehend or ever become entirely 100 percent competent regarding, particularly when those stories are oral interchanges with real live people on the other end. Taking a position of narrative humility means understanding that stories are relationships we can approach and engage with while simultaneously remaining open to their ambiguity and contradiction and while engaging in constant self- evaluation and self-critique about issues such as our own role in the story as listeners, our expectations of the story, our responsibilities to the story, and our ownership of the story. Also, by focusing on narrative rather than cultural humility, we recognize that this is a perspective we take with every story we engage with, and not just when one of “those other people” (whatever that may mean to us) walks into our office. Narrative humility means understanding that stories are not merely receptacles of facts, but that every story holds some element of the unknowable. It simultaneously reminds us that there are larger sociopolitical power structures that marginalize certain sorts of stories and privilege others. Narrative humility suggests an inward orientation, requiring not only that we learn about others, but that we begin by learning about ourselves—how our past cadre of life stories has built our prejudices and preferences, and how by the very act of listening, we ourselves are always changed into different kinds of listeners.

The branches of
your intelligence grow new leaves in
the wind of this listening. The body
reaches a peace. Rooster sound comes,
reminding you of your love for dawn.
The reed flute and the singer's lips.

 

So, yes, narrative medicine and narrative humility are ways to improve health care—creating more satisfactory relationships and, ultimately, more accurate and effective treatments and diagnoses. But they are simultaneously ways to deepen medical practice, bringing satisfaction and joy back to an ancient profession that is so much more than a business.

There's a moon inside every human being.
Learn to be companions with it.

Although when people ask me what I do, I say things like “I teach people to listen,” what I’m ultimately interested in is teaching people to listen critically, to listen in socially just ways. I want to teach healthcare providers to listen not only to comfortable stories, or stories of folks who are just like them, but also to stories that challenge them, stories that are unfamiliar to them, stories that are from the margins, stories that are traditionally silenced. And in that listening, I want them to return to the sources of, as Salman Rushdie would say, the world’s “streams of stories,” the origins of human experience itself.

As Rumi says:
Water, stories, the body,
all the things we do, are mediums
that hide and show what's hidden.
Study them, and enjoy this being washed
with a secret we sometimes know,
and then not.

 

Jalal al-Din Rumi, "Story Water," The Essential Rumi: New Expanded Edition, trans. Coleman Barks and John Moyne (New York: HarperOne, 2004).
Ibid., "Listening."

Author Bio

Sayantani DasGupta

Sayantani DasGupta, MD, MPH, teaches in the Master's Program in Narrative Medicine and co-chairs a University Seminar–Narrative,... read more

Comments

Laura Ann Klein, RN

August 12, 2014

Listening is almost impossible in today's hospital. Everyone needs to move away from their computers and their tablets. We need to stop charting when we assess people. We need to hold their gaze steady, sit in a chair, and maybe hold their hand as we listen. Indeed, patient safety is the most important component of care and the EMR is lifesaving. But rather than creating more systems and more algorithms, we need to listen to the patient. We need to listen to the subtext and hear the story told in the silence between the words.

Lary Robinson, M.D.

August 23, 2014

Early in my training, I was told that I should listen to my patient, and they would tell me what was wrong with them. So true, but this is not taught today to young doctors. Time is so limited in medicine...one patient every 10 or 15 minutes at most, then a mountain of paperwork is needed to justify billing. Listening in depth to patients is becoming a luxury doctors can no longer afford if they expect to survive economically...a real pity. Narrative medicine, I fear, is a luxury...

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