As the physician listens to the patient, he or she follows the narrative thread of the story, imagines the situation of the teller (the biological, familial, cultural, and existential situation), recognizes the multiple and often contradictory meanings of the words used and the events described, and in some way enters into and is moved by the narrative world of the patient. Not unlike acts of reading literature, acts of diagnostic listening enlist the listener's interior resources--memories, associations, curiosities, creativity, interpretive powers, allusions to other stories told by this teller and others--to identify meaning. Only then can physician hear--and then attempt to face, if not to answer fully--the patient's narrative questions: 'What is wrong with me?' 'Why did this happen to me?' 'What will become of me?'

This is narrative medicine, which boldly states, "Effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret and act on the stories and plights of others." It asks physicians to acquire additional tools to "understand the meaning and significance of stories through cognitive, symbolic and affective means" (Charon, 2001), through, for example, close reading of literature and reflective writing. While typical overworked, managed-care-frustrated physicians may not have heard of this, it just might save them if they do. Psychiatrists might argue there's nothing new here for us, but would be mistaken.

Another source of inspiration are some recent advances in sciences of the brain (e.g., neuroscience, linguistics, evolutionary biology, cognitive science). However complex the processing of information is, the human brain/mind still must engage in the construction of meaning. Moreover, often the meaning comes first, and information processing follows. Story and parable precede grammar; language is a complex product of such mental capacities. Metaphor is a foundational, indispensable cognitive tool and only secondarily a figure of speech (Modell, 2003). It will take years, maybe decades, for these insights to gel into mature theories, but it is happening.

The brain possesses multiple memory systems with differing roles in organizing our evolving personal interactions. Its declarative (what we know), procedural (what we do) and emotional learning systems are relatively independent of one another. Transference phenomena, for one, encompass both procedural and declarative memory (Gabbard, 2000) and require the therapist's facility with both. Yet most of our professional learning is in the form of declarative memory. Our procedural memory is, especially early in our careers, a product of our pre- and extra-professional experience. Teaching is more effective the more it activates the building blocks that are already there, the more it makes explicit and available to us for further development something we already "know" but didn't have readily accessible because it was stored elsewhere, habitually activated by different functional neural networks.

This is where literary experiences come in. By partaking in the catharsis of the pity and fear of a great drama, we inevitably put our theatrical experience in relation to our procedural and emotional professional knowledge. To the extent we actively, successfully engage in literary/clinical exercises, we make this potential exchange more powerful and can extend it to declarative knowledge, too. Experiences that connect us with the wonder that is language, and its artful transformation in drama or a novel, will rekindle, recover something we may have already sort of known and will give us building blocks for creating richer, more capable professional selves.

Dr. Podrug, former director of psychiatry at University Hospital of Brooklyn, is leaving the State University of New York-Downstate Medical Center to pursue independent scholarship in New York City, where he is also in private practice.

References

Bloom H (1998), Shakespeare: The Invention of the Human. New York: Riverhead Books.
Pages: 1  2  3  4  5