At the Crossroads of Arts and Medicine: A Conversation with Dr. Rita Charon

Have you ever walked in to a medical appointment and felt as if you were simply another name without a face? Imagine if, instead, the doctor asked you to share your life story and the daily obstacles that were contributing to your health condition. This is the idea behind narrative medicine, an approach to healthcare that lives at the intersection of the art of human stories and the science of medical diagnoses.

General internist Dr. Rita Charon and her team of clinicians and humanities scholars at Columbia University developed the field of narrative medicine starting in the late 1990s. Realizing how much her own interest in narrative improved her relationship with her patients by helping her become a better listener, among other things, Dr. Charon completed a doctorate in English at Columbia University while working full-time as a doctor. Now as the Executive Director of Columbia Narrative Medicine at Columbia University—where she also serves as the Bernard Schoenberg Professor and Chair of Medical Humanities and Ethics and Professor of Medicine—Dr. Charon helps medical students and faculty understand the power of their own creative expression as one of the most important skills to have as a health practitioner.

We spoke with Dr. Charon about her “aha!” moment, how narrative medicine has transformed her view of patient care, and her hopes for the future of the field.

NEA: Having completed medical school at Harvard in 1978, what led you to take on a new journey of completing your doctorate in English at Columbia? How do you think that your experience as a literary scholar helped you to become a better doctor?

CHARON: Well, I finished medical school way before I started the English training. I went to Harvard Medical School. I was there in the mid ‘70s. There was already a big movement toward patient power and collaboration with patients, and even in our neighborhood, where Harvard Medical School is, we were [as medical students] protesting the building of power plants in the neighborhood. So, from the beginning, I was very much an activist. I became an internist, and it was really only when I was in my office with my own patients, and I would see them coming back every couple of months or three months, that I understood that what my patients paid me to do was to listen to what they told me. And you know I was a reader and I went to meetings and conferences about literature and medicine, and I [realized that] what I'm doing as a reader is what I want to do for my patients. I want to be a good reader for them in all the ways in which I was learning on my own how to read complex novels— following the time, the temporal complexity, and metaphors, and [hearing] when they stop telling one story and start another one.

When I said to someone who was my mentor at the time, “You know I’m going to take a course in English.” The mentor said, “Rita don't take a course, take a Masters,” and he was right. As soon as I started serious study, it was everything, from contemporary poetry to Aristotle, and every seminar, I would learn something that was important for my care of patients. I found myself doing different things, putting aside the chart…. I would roll my seat away from the desk and put my hands in my lap, and I learned pretty early on to just say to a patient “I will be your doctor. Tell me what you think I should know about you.” I found out how hard it is to really listen.

 NEA: Can you explain what narrative medicine is and how it works?

CHARON: The principles are really very basic. The first principle is to have attention. We help people build their attention, which is giving yourself over to a person so as to capture and contain what it is they say. This is a principle in some religious fields. It's a principle, certainly for artists, you know? Think of Cézanne and the painters who were so devoted to not missing one detail. Representation is our second one, which means you have to somehow catch [what you’re seeing]. We humans have to put some form around things that we see.

Otherwise, we just lose them. The third principle is affiliation, which is the whole point. We're doing this to become trustworthy and to become useful as a partner to a patient who is going through some ordeal. It's different from being a technician. It's also different from being a friend. That's why I chose the word affiliation instead of friendship. We are on the patient’s side, and we are in service to them.

At the beginning, many of the people who I gathered around me to do this work were themselves writers, filmmakers. As time went on, there were more painters, and musicians, and playwrights, and dramatists, and now it's graphic novelists. I just had a call with a medical student who wants to do a project with some of the physicians, and he turns out to be a songwriter. He wants to use his talents as a songwriter to help these young physicians to understand their own traumas. Sometimes people say you're cheating because a painting is not a narrative. Narratives are just poems and novels and we say, “No, you're wrong because paintings tell a story and symphonies tell a story.” Not to trivialize what a story is. So, I guess I'm saying it’s not one thing and only one thing. And those of us who started this, we say, “Look where it's going now.” In the past few years, we've gone deeply into the activism, advocacy, and social justice realm, and we have found that the things we do in narrative medicine are critical in these difficult conversations.

How do you talk about white privilege? And how do you talk about racial inequity? Well, if you've got a bunch of first-year students, and half of them are white, and you know a third are Asian, and the others are African American and Latinx, how do you open that up? And if you start with a paragraph from Toni Morrison, or Baldwin, or Eddie Glaude, you're on the right track, because there's something there for everyone to just look at.

 NEA: How does the practice of narrative medicine benefit patients? How does it benefit medical practitioners?

CHARON: Patients are really not used to doctors who listen to them. When you ask a patient, “Tell me what happened before,” the patient will say, “You mean you want me to talk?” No one knows at the beginning what's going be important. I'm writing a paper for a medical journal, and I put into it something that happened early in in my [narrative medicine research]. A woman who had been diabetic almost all her life, I mean, since childhood comes in, and I was the tenth doctor she had been assigned to. This was a clinic for poor people, and they get passed around from one to the other. When I invited her to just tell me [her story], I said, “I'm going to be your doctor. Tell me what you think I should know about your situation.” It took a few minutes before she realized I was not going to interrupt her. I wasn't going to start saying “Oh, and how much insulin do you take?” She very soon started to express the rage that she felt for being abandoned time after time by doctors and clinics. Her diabetes was terrible. She was in and out of the hospital. I literally said nothing and was just trying to take this in. She almost started to cry, but she didn't. Instead, she looks at me with rage. She says “You want to know what I need? I need a new set of teeth,” Diabetes is terrible for gum disease. She had lost all her teeth on the upper and had a denture made, but it didn't fit anymore. But the point is that she couldn't go out, she didn't have friends. She felt that she was young, and she was pretty, but she was all by herself. I made a fuss at the dental clinic, and I got her an appointment. It was like okay, we're going to get these teeth. Literally in a couple of months she comes in and she was beautiful. And so, we were then inseparable and I don't have to tell you that the diabetes got a lot better. She made friends, and she was going out. She started a business. She started baking. She started hiking. That's one example of how you go completely out of sequence, [following] her priorities and making it clear that she's in charge, and I'm the servant.

NEA: What types of classes do med students take when they are studying narrative medicine? As you’ve developed the program, has anything surprised you about how the students react?

CHARON: We do a lot of narrative medicine teaching from the beginning, and even before we worked with the students, my group worked intensely with the faculty [at Columbia University] because this is hard work to do. It might look easy. Oh, all Rita does is she brings a poem into the class, and then she reads it aloud and they talk about it, and that's it. Anybody can do that. Wrong! Because the whole reason that you're bringing this painting instead of that one to class; the reason you've chosen this paragraph from Beloved, and not that one, is due to the depth of what I, as a literary person, know about how to pay attention to words. So, I spent the first couple of years just teaching teachers. I got some money from the [National Institutes of Health], and we really did this properly. Once a week, for an hour and a half these 20 or so medical faculty would come to our seminar, and they got paid for coming, which is why I mentioned the funding. Because this was not recreational. This was part of their training as medical school professors.

We taught them as much as you can to people who are not trained in literature. Every week we would be reading or looking at images, writing. We would read aloud what one another wrote, and it was from them that we really developed a lot of the methods we use now with students.

Now once a week, our first-year medical students attend their small-group seminars for our doctoring course called Foundations of Clinical Practice. Each group has 12 students and meet with their faculty preceptor—who could be a psychiatrist, a pediatrician, a surgeon, a family doctor, a radiologist, or pulmonologist—once a week for 18 months and then periodically for the remainder of their medical educations. Same group of 12 students, same faculty preceptor who gradually becomes their coach throughout their schooling. These are the faculty members who have been in my narrative medicine training seminars for years. They all have learned from me and from one another about narrative medicine methods and how those narrative skills translate into listening to one another and to patients. I coach them [the professors] ahead of time for what they then do in their small group seminars. By now we've been doing this for years. [The faculty] are really very skilled, as readers and teachers, and they know how to elicit from their students really deep reflections. We just read last week, a poem by Gwendolyn Brooks, called “The Explorer.” That's a gorgeous poem with echoes into the civil rights struggles of the ‘50s and ‘60s. We choose that because it helps engage the students in these difficult conversations, not only about this particular poem by Gwendolyn Brooks, but in the voice of the Black artists who were able to depict the situations. There's a lot of writing. We make [the students] write. We give them a portfolio which is private. Nobody can read it except for them.

We have a very big curriculum. If you're a first-year student in the spring, you have to pick one of the narrative medicine seminars. This year, I have 14 of them. There is one in fiction writing, there's one in poetry writing. There's one in playwriting, there’s one where they watch movies, and then they talk and they write about them. There are a couple of museum courses. We think this year with the pandemic, maybe, being a little lighter in New York, we can let them go in to the MoMA and the Metropolitan Museum of Art and not only look at paintings to say “Oh, that's a painting of somebody with such and such you know skin disease,” but what do you see? What does this evoke in you? And how come, among our eight students, such different responses are evoked? And how come as you listen to your classmates seeing things you didn't see suddenly, your vision gets so much bigger?

Then we have two journalism courses. One is how to write an op-ed, and the other is called “Opinion Writing as Resistance.” There's a seminar in dreams by a psychoanalyst. That's what they do in their first year, and some of them end up, like my songwriter, doing very long research projects in areas of the humanities. We are now starting a review of how narrative medicine training in your first and second years influences what you do on the wards. Are there times when you're taking care of a patient on the wards that you're thinking back to what you learned as a writer or a reader or a painter?

 NEA: What are the challenges and opportunities of championing narrative medicine?

CHARON: The biggest challenge is to prove that it works. Because a lot of this is very unusual. So, we're starting bigger and bigger research projects. This last one we had like 70 people at a cancer center who were involved in [the research project], and they went through the same narrative medicine training over a period of time. We're now analyzing the data from focus groups and interviews to find out: did it matter? [The participants] were doctors, nurses, chaplains, clerical receptionists. At the end of six weeks, they were saying things like, “Well, now that I know more about my colleagues, I'm more likely to help them out or to ask them for help.” And another one says, “I’m in oncology, and didn't know how much it meant for me to be in it. Now I know I belong in this work. I belong in this place.” We know from prior work we've done, that [this training] improves the team cohesion. They do come to know one another. It feeds something in them to be invited to write and to find out they can do it. At the beginning they'll say, “Oh, I'm not a writer. Oh, I’d hate to write. I’m not going do that. Oh, it's terrible! I can't do it.” These workshops bring forth from people even powers that they didn't know they had. They end up using one another much more as confidante and colleague and because they know that one another have been through traumas of their own.

NEA: How do you hope that the practice of narrative medicine will impact patient care?

 CHARON: A lot of it will be through influencing the providers to be more patient, to be more humble, to want more understanding of the patients’ priorities, and to be better at literally hearing what the patients say. There's also benefits to be derived from giving patients access to their own expressiveness and this isn't new. I mean, there are support groups and chat rooms and places where patients are telling stories to one another. But wouldn't it be great if that happened in the doctor’s office? You should be telling your stories to the people who are taking care of you.