Narrative in medicine

What is narrative?

One day when Pooh Bear had nothing else to do, he thought he would do something, so he went round to Piglet’s house to see what Piglet was doing. It was snowing as he stumped over the white forest track, and he expected to find Piglet warming his toes in front of the fire, but to his surprise he saw that the door was open, and the more he looked inside the more Piglet wasn’t there.

This short excerpt from the opening chapter of one of the best-loved children’s stories of all time’ illustrates a number of features of the narrative as a linguistic form:

  • First, it has a finite and longitudinal time sequence — that is, it has a beginning, a series of unfolding events, and (we anticipate) an ending.
  • Second, it presupposes both a narrator and a listener, whose differentviewpoints are brought to bear on how the story is told. The same sequence of events, told by another person to another audience, might be presented quite differently without being any less “true”.
  • Third, the narrative is concerned with individuals. Furthermore, it concerns how those individuals feel and how people feel about them, rather than simply whatthey do or what is done to them. Both Pooh Bear, trudging hopefully through the snow, and Piglet, mysteriously absent from his usual place beside the fire, are already characters in the story rather than merely the objects of the tale.
  • Fourth, the narrative provides items of information that do not pertain simply or directly to the unfolding of events. This is an important point. In contrast, say,with a list of measurements or a description of the outcome of an experiment, there is no self-evident definition of what is relevant or what is irrelevant in a particular narrative. The choice of what to tell, and what to omit, lies entirely with the narrator (modified, at his or her discretion, by the inquisitive questions of the listener).
  • Finally, and perhaps most crucially for the purposes of this book, the narrative isabsorbing. It engages the listener and invites an interpretation.

Narrative Based Medicine

Trisha Greenhalgh and Brian Hurwitz

BMJ Books 1998

ISBN 0-7279-1223-2

So, you didn’t like my story?

An excerpt from “The Life of Pi”, winner of the 2002 Booker Prize.

Towards the end of the novel, two investigators from the Maritime Department in the Japanese Ministry of Transport interview Pi Patel, who is the sole survivor of a shipwreck. For reasons that I needn’t share with you, he survived for 9 months alone in a life-boat with a tiger! Pi spends some hours telling the investigators the amazingly strange story of what he has been through, and then …..

Pi Patel: “So, you didn’t like my story?”

Mr. Okamoto: “No, we liked it very much. Didn’t we, Atsuro? We will remember it for a long, long time.”

Mr. Chiba: “We will.”

Mr.: Okamoto: “But for the purposes of our investigation, we would like to know what really happened.

“What really happened?” “Yes.”

“So you want another story?”

“Uhh. . . no. We would like to know what really happened.” “Doesn’t the telling of something always become a story?”

“Uhh. . . perhaps in English. In Japanese a story would have an element of invention in it. We don’t want any invention. We want the ‘straight facts’, as you say in English.”

“Isn’t telling about something—using words, English or Japanese—already something of an invention? Isn’t just looking upon this world already something of an invention?”

“Uhh. .

“The world isn’t just the way it is. It is how we understand it, no? And in understanding something, we bring something to it, no? Doesn’t that make life a story?”

“Ha! Ha! Ha! You are very intelligent, Mr. Patel.” Pi Patel: “You want words that reflect reality?” “Yes.”

“Words that do not contradict reality?” “Exactly.”

“But tigers don’t contradict reality”

“Oh please, no more tigers.”

“I know what you want. You want a story that won’t surprise you. That will confirm what you already know. That won’t make you see higher or further or differently. You want a flat story. An immobile story. You want dry, yeastless factuality”

“Uhh..”

The Life of Pi

Yann Martell

Canongate Books Ltd 2002

ISBN 1 84195 245 1

Narrative in Primary Care

Patients come to primary care because they have problems, but invariably they present these problems as a story: ‘This happened, and then happened, and then I felt something.. . I talked to a few people about it. . . Now I to know what to do.’ In one sense, a story like this is merely the way that people communicate their problems. In another sense, the story itself needs treatment. Patients want to go away with a better story: ‘My problem seems less …. I understand it better…… now I know what to do.’

Professionals in primary care tell stories too: ‘This is how I see your problem This is what I think you should do about it – . – These tablets will make you feel better’. Professional stories like these are usually connected to official narratives like biological science and evidence-based medicine. Sometimes they provide patients with a better story and sometimes they do not. Either way, we cannot work without narratives. Whatever the task it is always embedded in a story for the patient and a story for the professional.

Primary care offers multiple opportunities to patients for creating new stories. The same patient may tell different stories to the receptionist, the practice nurse, the doctor and the cleaner — and will receive many new stories in exchange. None of these stories is definitive, nor are any of them distortions. Each is recreated in a different way, the production of the listener as much as the teller. Primary care offers professionals similar opportunities too, as they create stories about their work, in corridor conversations or team meetings. For both patients and professionals, primary care can be seen as a space for continual narrative reconstruction.

A narrative-based approach sees the search for better stories, and the attempt to provide these, as the basis of all the work that is done in primary care. Narrative ideas offer a conceptual framework for understanding all the different discourses — professional and scientific ones, together with lay or folk accounts of the world — that have to be integrated into everyday work. They can help practitioners to make sense

of all the story-telling activities that go on with in primary care: not only with patients, but also between colleagues, within teams and throughout the health service.

Narrative ideas can also provide practitioners with the skills to help patients and

colleagues alike to question, re-evaluate and change their own narratives.

John Launer Narrative Based Primary Care Radcliffe Medical Press 2002

John Launer on narrative based medicine

Narrative: On This Journey We Call Our Life

Your story is enfolded within the world story, and the world story is wrapped around your private story. The moral and spiritual texture of each story is the progressive embodiment of a set of questions, some conscious, some unconscious. The more consciously we address the questions of our lives, the more we will experience our lives as meaningful.

page 16

The more I studied, the further I felt from any sense of satisfaction. Only literature and the arts seemed to get close. In time I realized that these were more satisfying because they consciously employ metaphor and symbol to point in the direction of the larger mystery. They are content not to try to name them, and are more willing than the other disciplines to abide mystery and ambiguity. They embody questionsrather than concrete answers that quickly become mere artefacts of ego-consciousness seeking to contain the evasive gods. (This is why so many oftheexamples I give in my books are from literature and the arts rather than from clinical practice.)

page 24

James Hollis

ISBN 1-894574-04-4

Books about Narrative

  • Achieving Emotional Literacy Claude Steiner Bloomsbury 00-7475-4135-3
  • Emotional Intelligence Daniel Goleman Bloomsbury ISBN 0-7475-2830-6
  • Metaphors we Live By Lakoff & Johnson The university of Chicago Press ISBN0-226-46801-1
  • Narrative Based Medicine Trish Greenhalgh & Brian Hurwitz BMJ Books ISBN 0-7279-1223-2
  • Narrative Based Primary Care John Launer Radcliffe Medical PressISBN 1-85775-539-1
  • Reflective Practice Gillie Bolton Paul Chapman Publishing ISBN 0 76196729 X
  • Stories of Sickness Howard Brody 2nd edition Oxford University Press ISBN 019515140-2
  • Stories We Live By McAdams Morrow ISBN 0-688-10866-0
  • Tao Of Pooh Benjamin Hoff. Mandarin. ISBN 0-7493-0179-1
  • The Doctor Stories William Carlos Faber & Faber ISBN 0-571-14728-3
  • The Illness Narratives Arthur Kleinman Basic Books ISBN 0-465-03204-4
  • The Magic of Metaphor Nick Owen Crown House ISBN 1-89983-670-5
  • The Prophet Kahlil Gilbran. Heinman. ISBN 0-434-29068-8
  • The Seven Habits of Highly Effective People Stephen Covey Simon & SchusterISBN 0-68485-839-8
  • And when did you last see your father? Blake Morrison – a reflection on life’s declining years
  • A leg to stand on Oliver Sacks – a superb account of being injured
  • It’s not about the bike Lance Armstrong –a champion cyclist and his testicular cancer
  • The diving bell and the butterfly by Jean Dominique Bauby – former editor of Elle magazine writing about his severe CVA with his eyebrows!
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