Verghese Article

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Excerpts from
The Physician as Storyteller
by Abraham Verghese, M.D.
Annals of Internal Medicine 2001; 135: 1012-7

In recent years there has been a steadily growing interest in the narrative aspects of medical practice, as well as in doctors’ writings about their work. Underlying this interest is the assumption that careful attention to the language and stories of medicine can enrich the doctor–patient relationship, improve patient care, and enhance doctors’ sense of satisfaction with their work. The following article inspired— and now initiates—a series by physician-writers who reflect on the interrelationship between their literary and medical work. We hope that these essays will inspire some of our readers to write as a way of exploring their feelings about medical practice or simply for their own pleasure.
–The Editors

As physicians, most of us become involved in the stories of our patients’ lives. Sometimes we are simply witnesses, chroniclers of the story in the medical chart. But often we become players in the stories. Our actions change the narrative trajectory, or else the patient’s or the family’s rendering of the story credits us with influencing the story. We may, as Arthur Frank suggests (1), become the “spokesperson” for the disease, and our patients’ stories “come to depend heavily on repetition” of what we say.

Dr. Schwohrer’s act of ordering champagne and raising a glass with his patient led to a cascade of events (at least in the telling) that ended with the cork popping out of the bottle and the moth escaping. This anecdote summarizes the theses of this paper: 1) story helps us link and make sense of events in our lives; 2) we as physicians create stories as often as we record them—we are catalysts in stories even if our actions are less dramatic than Dr. Schwo¨hrer’s; and 3) we are characters in various stories, walking on and off the stage in the tales that take place in our hospitals and clinics. Indeed, our lives are seamlessly, mostly unconsciously entwined with the stories we hear and tell, with “those we dream or imagine or would like to tell, all of which are reworked in that story of our own lives that we narrate to ourselves in an episodic, sometimes semiconscious, but virtually uninterrupted monologue” (3). It may take years of practice for a physician to appreciate and accept his or her role as storymaker and storyteller.

Can we become better internists by learning about some of the tools that the writer possesses? Clearly, the opposite is true: It is wonderful training for a writer to be a physician, to be an internist in particular. Aphorisms such as “God is in the details” are staples of both medical training and creative writing classes. Learning how to inspect, to palpate, to percuss, to listen, and to develop skills of acute observation is excellent training for any writer. But are there tools that we can pick up from the writer that might improve our skills as physicians? Or, if a writer’s bag of tricks doesn’t improve our medical skills, can it improve the quality of our daily lives, our satisfaction in what we do, and—most importantly— can it improve the lives of our patients? This link between reading and writing and empathetic care giving has been the focus of intense scholarly study (7– 10) to which the reader is referred for more details.

Writing texts commonly state that story is all about conflict, crisis, and resolution. Or that one needs the
“Three Ds”: Drama equals Desire and Danger (15).

How do these ideas about story relate to internists? I believe that all patients we see, no matter how often we see them or how benign we consider their illnesses to be, are in the midst of a story. For patients, story begins the moment they walk through the portals of the hospital or through the doors of our clinics.

Whenever I hear a certain reluctance on the part of my housestaff to discuss or see a patient or when I hear the words “placement problem,” I worry that we are dealing with a story that has not found its epiphany. The challenge is to enter that room despite the magnetic draw of beepers pulling us away and the seemingly more urgent needs of other patients. The challenge is to engage the patient and the family and find the epiphany, even if the epiphany is simply the understanding that there is nothing more to be done medically. The epiphany might simply be a coming to terms with the illness by all concerned— patient, family, and doctors. When HIV landed in the laps of infectious disease specialists (and many of us were caught up in the “conceit of cure” till that point), it was as if we had been forced to don the mantle of the oncologist. Most of usfound out, painfully, that in having no cure to offer, we actually had everything to offer. We discovered what the word “healing” meant and what made the horse-andbuggy doctor of a century ago so effective. By “healing” I simply mean crossing the traditional threshold of a medical–industrial complex and beginning to engage with the patient, with their story, on their turf, in their house, and engaging with their families and loved ones and their stories. A helpful analogy for medical students to understand the distinction between curing and healing is the following: If one day they were to return to their homes and find that they had been robbed of all their valuables, and if the police should in short order find the robber and return all the valuables, the students would be cured . . . but they would not be healed. Their sense of violation would remain for many more days. All illness (particularly AIDS) has these two dimensions: a physical deficit and a spiritual violation. And when there is no cure, the one thing we can offer is to really understand the story that is playing out, to aid and abet its satisfactory conclusion. As Charon says, “Paying close attention to language, diction, metaphor, and reader response in texts permits one to pay similarly close attention to the language, mode of speaking, metaphorical content, and allusiveness of patients’ histories” (19). We can be, in other words, like Dr. Schwo¨hrer, a facilitator of the story. We can order the champagne.

An important lesson a writer learns is that no matter how good his or her story, it is really characters who drive stories. A clever story by itself makes for very dull reading unless a very compelling character makes the story come about. What ingredients make fictional and real characters compelling and memorable? Part of it is their physical appearance and the accouterments of their profession, hobby, trade, interest, ethnicity, and religion. The rare patient in my county hospital who has fluffy organdy lace bathroom slippers, a sheer silk gown, and a tangerine- colored makeup case on the bedside stand is a different patient from the tattooed prisoner who arrives sans baggage other than chains and handcuffs, even if both patients have the same disease. Physicians are tuned in to appearance, trained to spot physical clues that suggest, say, hyperthyroidism, Marfan syndrome, myxedema, or cirrhosis.

Metaphor is at the heart of good literature.

But metaphors do much more than just portray disease. As Ozick (25) writes, “through metaphorical concentration, doctors can imagine what it is to be their patients. Those who have no pain can imagine those who suffer. Those at the center can imagine what it is to be outside. The strong can imagine the weak. Illuminated lives can imagine the dark.”

A sense for the stories unfolding before us will perhaps allow us to be more conscious of bringing people to the epiphanies that their stories require. By being attuned to character, not just through appearance but
particularly through dialogue, we will remember the voice of the patient, even though it is the voice of medicine that we record in the chart. To hear the voice of the patient preserves our capacity to imagine the suffering of the patient. We should be bold with language, willing to recall and to invent new metaphors, willing to write and to think about disease in memorable and metaphorical ways, willing to call up colorful imagery to describe disease (in place of mind-numbing acronyms). We should be not just “doctors for adults” but also ministers of healing, storytellers, storymakers, and players in the greatest drama of all: the story of our patients’
lives as well as our own.