Article Text

Literary narrative in medical practice
1. M Kottow1,
2. A Kottow2
1. 1Department of Bioethics and Medical Humanities and Department of Philosophy, University of Chile, Santiago, Chile
2. 2Faculty of Medicine, Institute for the History of Medicine, Free University of Berlin, Berlin, Germany
1. Correspondence to:  Dr M Kottow, Casilla 16168 Correo 9, Santiago, Chile;  guarvie{at}ctcreuna.cl

## Abstract

It is generally accepted that the practice of medicine could be improved by turning to the humanities in general, and to narrative and text interpretation in particular. Neverthless, there is hardly any agreement as to the nature of the clinical text, whether it be the patient's narrative that needs to be richly understood, or the patient as patient who must be both personally and clinically deciphered.

We suggest that literary narratives depicting medical situations might serve as testimonials of the way medicine has or is being practised in a variety of social settings, and of the ways patients experience disease and medical care. By reading these texts, health care professionals could compare the situations and values involved in such narratives with current medical practices, thus perceiving how clinical encounters have changed and improved or, perhaps, continue to carry a burden of past flaws.

• Literature and medicine
• narrative and medical practice

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The humanities are slowly becoming part of contemporary medicine, although their specific role remains controversial. Even though literature is the most plausible of the art disciplines to be linked with medicine, much work is needed to clarify the relationship between the written word and the clinical encounter. A well-read physician may increase his sensitivity in understanding illness and suffering; also, the perusal of literary pieces helps teach graduate students the humane and ethical aspects of medicine. Much less explored is the question of whether literature can become an important, perhaps indispensable part of clinical practice. Such a thesis will require at least an educated guess about what the specific role of narrative might be, a matter on which diverse opinions have been issued. In a recent article, Scheurich speaks of “The Narrative Revolution in Medicine”1 and quotes a number of scholars who have discussed how literary narratives can inform physicians' moral sense, stimulate empathy and compassion, and even increase clinical acumen. Scheurich believes “that the alleged advantages of narrative for medicine lie in two principal domains: ethics and epistemology”.2

Addressing an as yet not fully explored field, this paper suggests that literary narratives may also help us to understand better how medicine has been practised in other times, or is nowadays practised in a diversity of situations, and in different social settings. By contrasting current practices with literary pieces that convey medical situations, health care professionals might better reflect upon the strengths and weaknesses of the kind of medicine they encounter. Literary narratives could render valuable testimony of medical practices that are different from those that physicians currently experience; these narratives might help us to reflect on values and distorsions that the clinical encounter may present in different situations.

## TEXT AND INTERPRETATION IN MEDICINE

According to Hunter, “[W]hat is true of narrative and practical reason is true a fortiori of literature... . To read [fiction and poetry] is literally to subject oneself to a different point of view, to the imaginative testing of one's perspective, even to change”.3 In the medical humanities, Daniel's definition of text as “any set of elements which constitutes a whole and takes on meaning through interpretation”4 has gained solid acceptance. Clinical hermeneutics are not restricted to reading a text; rather they have an “ontological, phenomenological” character where dialogue leads to understanding and thus to a “better healing process”.5 The same features appear in the proposal to develop “medical hermeneutics” to help medicine meet its need “to make its foundation and resolution in the clinical encounter rather than in science. This is to return the explanatory power of medical science to its roots in the human condition.”6

As Svenaeus7 recently pointed out, meaning is not only interpreted, it is also expressed. A text is an intentional setting of signs by a narrator, who envisions and aims at reaching a recipient. In a very lax definition, stories enter medicine as a “narrative organisation and clinical observation whether written or oral”.8 Leder's approach is to ask “what then is the text that defines the clinical encounter,” and his answer is: “[I]n simplest terms I will call this the person-as-ill”. The person-as-ill is a “primary text” that “expounds itself through a complicated series of secondary texts”9: the patient's experiential and narrative texts, the physical text, and the instrumental text. Leder's premise also becomes his conclusion, when he states that “[T]he key question is not whether medicine is hermeneutical but how it is so”.10 A different understanding of the place hermeneutics might have in the clinical encounter is given by Carson's suggestion that the ethical component of the medical act is to be discerned by an attitude that is “personal, responsive, satisfied with probable certainty, and morally engaged with the commonplaces of communities of experience to ascertain ... what is the right thing for us to do?”11

These quotations are but samples of a number of ways in which narrative and medicine have been linked. Some see literary texts as permitting readers to broaden their horizons, gaining empathy with, and compassion for, human suffering, as well as improve their ethical sensibility. Others see narrative as an important clinical tool that not only increases the humane depth of the physician-patient encounter, but also helps reach a more accurate diagnosis. There are, nevertheless, sceptical voices. In the view of Baron, patients' experiences and narratives are too variable to constitute stable reading material. “The shifting nature of the clinical text forces one to confront the question of whether there is any text' there at all.”12 Though not in the majority, Baron nevertheless voices a legitimate uncertainty about the place and importance of text reading in medical practice.

In the face of such divergent and at times incompatible stances, we should like to explore still another approach, using narrative texts that depict the author's perception of the way medicine was, or is, practised in the times and social environment he or she is writing about. Reading these texts might provide a rarely explored path towards obtaining a comparative and critical picture of diverse forms of medical practice, including the contemporary one.

## LEO TOLSTOY: THE DEATH OF IVAN ILLYCH

Ivan Illych only cared for one question: was his illness severe or not? But the doctor ignored it. Ivan Illych's question was out of place. The physician considered it useless and in no need of being clarified. Rather, it was necessary to find out if this was a case of a floating kidney, a chronic intestinal inflammation, or a disease of the cecum. It was not a matter of Ivan Illych's life, but of finding out what his ailment was.13

Tolstoy's text is certainly concerned with disease, but reading it will hardly improve a physician's diagnostic skill. On the other hand, it is a bold and quick picture of a form of medical practice where the doctor is more concerned with nosologic technicalities than with the existential impact of disease on the patient. Tolstoy's narrative is about suffering, dying, and death, and may be enlightening to read for other medical purposes, but our aim is to identify those passages that convey a picture of medical practice as seen by the author. He addresses the indeterminacy and therapeutic poverty of medicine, the asymmetry between patient and physician. An atmosphere of an aloof and authoritarian physician/patient relationship is conveyed, where the patient is no more than an object of scrutiny whose preoccupations are irrelevant. The meekness of Illych suggests that he is experiencing a clinical encounter typical for his times, when patients' expectations were out of place. Therapy is not mentioned in this story: the patient is worried about his prognosis, the physician very vaguely searches for a diagnosis.

## KAFKA: A COUNTRY DOCTOR

Much can be gained by reading a short piece Franz Kafka wrote in 1916–17, although the story is not easy to interpret. In A Country Doctor,14 Kafka presents the soliloquies of an elderly physician as he is being called to attend a young boy who is reportedly very ill. On arrival, the youth whispers “Doctor, let me die”, and the physician, after a cursory examination, concludes:I confirm what I already know: the boy is healthy, he has a somewhat poor blood circulation because his mother soaks him with coffee, but he is healthy and best pushed out of bed.

Having said this, the doctor gets ready to leave but is confronted by the rum-drinking father, next to whom stands the. . .mother, probably disenchanted—really, what do the people expect?—tear-filled eyes and biting her lips, and the sister swinging a bloody towel, so that somehow I am willing, under the circumstances, to concede that the boy may perhaps be sick.

Much more happens in this short and heavily symbolic story, but for our purpose Kafka has shown a model of medical practice radically different from Tolstoy's: the physician's diagnostic conclusion gives way to the convictions and desires of the family. The boy is ill because the family believes him to be, and the doctor bows to their will, even if he does not understand it.

## LIGHTMAN: THE DIAGNOSIS15

This contemporary novel portrays the anguish of a young executive suddenly beset by a progressive dysfunction of a purportedly neurological disease which remains undefined throughout the book. Excerpts from the patient's initial consultation with Dr A Petrov are here summarised.

“At this point,” came a hidden voice from behind the stacks [of lab reports], “I'm afraid to say that we understand very little about your difficulty . . . . We will begin some tests.”

“What do you think the problem is?”

“Dr Petrov?”

“Yes”

“You're doing tests for some reason. What do you think is my problem?”

“Please, Mr Chalmers”, came the invisible voice. “I would only be speculating.... You could have something very rare, such as leprosy . . . . I understand from your chart that the numbness began about two days ago”, said the doctor, “and it was accompanied by an initial loss of memory.”

“Is that significant?”

“It could be significant”, said the doctor. “On the other hand, it might not be significant.”

“Significant or not significant?” Bill shouted and stood up. “I've been here since ten-thirty. When can I be treated? I came here to be treated!”

“Treatment?” said Petrov, without raising his voice.16

The narrative fragment shows a severe distorsion of a clinical encounter—Petrov's invisibility actually denies the possibility of an encounter—with no empathic relationship ensuing between physician and patient. The climate created in the consulting room is reminiscent of Tolstoy's text, with additional emphasis on the predominance of technical diagnosis and the procrastination of treatment, a delay which becomes more blatant as the novel develops.

All three narratives unveil an asymmetric relationship between patient and physician; in Tolstoy's case the patient's anxieties are being ignored by an authoritarian physician, whereas in Kafka's story it is the physician who is manipulated by the family to acknowledge disease where he can find none. Lightman shows medical obsession with diagnosis and the lack of reassurance the patient receives. In the two earlier pieces, the patient's utterances are of lesser import and quite out of tune with present medical practice, in which paternalism is on the retreat and patient autonomy creates a dialogic relationship with the physician. The contemporary text depicts how current medical practice may also fall short of observing well accepted ethical values: the main character protests loudly, but he is unable to focus the doctor's attention on his needs and anxieties.

## DISCUSSION

Medicine has become dominated by the idea that its technical “state of the art'”commands the correct way of identifying and dealing with medical problems. Critical views of such a technological imperative usually come from philosophers, theologians, or bioethicists whose articulate opinions about the values involved remain insufficiently heeded. Edmund Pellegrino, physician and philosopher, has forcefully argued that medicine needs to exercise reflection in order better to understand and guide its endeavours in due observance of its professional ethics.17 Pellegrino's insistence has not gone unchallenged, but he does make a plausible case that the scientific and technical components of the healing professions cannot flourish unless oriented by clearly recognised and accepted values.

Medical practice has cultivated a rigidly unilateral description of itself, which has been adopted and fuelled by society. By definition, state of the art medical acts require scientific, technical, and ethical competence. From its own point of view, medical care needs neither to question nor to invent new modes of approaching its concerns, for we already inhabit a world where rules exist and are pertinent, even though not always followed. “We do not have to discover the moral world because we have always lived there.”18

The unreliability of medicine's views concerning its own practice has recently been described by Puustinen,19 using concepts elaborated by Bakhtin. Any communication, and therefore also the doctor-patient dialogue, is polyphonic in nature. But this richness threatens to distract from the doctor's endeavour of reaching a workable diagnosis, and so (from medicine's point of view) must be overcome: “Medicine tries to reduce this polyphony of voices to a systematic monologised whole', that is, to the prevailing theory of medicine”.20 In Puustinen's view, the clinican is constrained to try and reduce the rich reality of a clinical encounter to a therapeutically efficient “semiology”. Prevalent models of medical practice dictate the way this reduction occurs, in a repeated process of pragmatic reassurance: medical practice dictates how to reduce the patient's over-rich narrative, and the slimmed down text enhances the efficiency of medical actions.

One can argue that there is a crisis in contemporary medicine in the most fundamental sense of this term. “Traditional paradigms and self understanding of medicine are inadequate for contemporary medical practice. Although new paradigms and images have emerged, no [single] one has become dominant for the field of the profession.”21 In spite of bioethics and the philosophy of medicine, the medical profession still seems insecure in determining itself, and one would expect that any clarification, coming from literary narrative for example, might help reach a better understanding of what medical practice is about. This is especially so in the light of the tendency to see the “proposed (goals) of medical practice [as] socially established”.22 Literature excels in describing social relationships and milieus, as well as the prevalent and changing values that occur therein.

Literature has been expected to fulfil a clarifying function in terms of increasing both the reader's horizon of understanding and the richness of his emotional response. Hunter believes that “[L]iterature is unmatched for the access it gives to the experience of others, especially the inner lives of patients and the meaning of circumstances physicians cannot (or do not yet) share”. Furthermore, “[T]o read is literally to subject oneself to a different point of view, to the imaginative testing of one's perspective, even to change”.23 And, according to Nussbaum, “[N]arrative art has the power to make us see the lives of the different with more than a casual tourist's interest—with involvement and sympathetic understanding, with anger at our society's refusal of visibility”.24

Stories are often products of another time or of a diversity of circumstances, and do not necessarily apply to current medical practices; they depict atmospheres, brief encounters of import often heavily charged with conventional attitudes. And this is precisely the point to be made. These texts are masterpieces because they portray their times and their experiences by vividly telling how they have seen the sick and their doctors face each other and interact. They also give insight into the thoughts and feelings of patients as they face disease and medical care. No medical textbook can retain the atmosphere of clinical encounters as they actually occurred in the past or in diverse social settings, but a good literary piece will plausibly recall the form in which medicine has been practised. The three narratives quoted here describe doctor-patient relationships and portray medical paradigms that the authors see as deficient, allowing the reader to acquire a more vivid perception of the way our current clinical practices have improved, or perhaps still carry a burden of past flaws.

A brief digression into the visual arts illustrates how different artistic perspectives enrich the experience of the beholder. In 1617, Michiel Janszoon van Mierevelt painted “The Anatomy Lesson of Dr Van der Meer”, showing a group of gentlemen gathered around the anatomist who is dissecting the abdomen of a cadaver. None of the figures is looking at the dead body; only one has his gaze fixed towards the master, the rest look straight ahead. The picture narrates the social event that the annual dissection represents, and implies the privileged status of those allowed to participate. Only a few years later (1632), Rembrandt painted his famous “The Anatomy Lesson of Doctor Nicolae Tulp”, which also depicts the annual dissection of an executed criminal. Rembrandt's narrative is substantially different. A much smaller group is gathered around Dr Tulp, whose demeanour and dress reflect a higher social standing than that of his students. Most of them are turned towards their teacher, and it is conspicuous that Dr Tulp is dissecting an upper limb. Customarily, dissections began with the abdomen, but it was also well known that Tulp specialised in the anatomy of the arm and hand.25 Whereas Mierevelt's painting tells the story of a social event, Rembrandt emphasises its academic highlights.

The literary fragments presented also show a variety of clinical encounters, from which different values and bad values can be teased out. The perusal of such texts might serve the educational purpose of helping clarify values in the realm of medical ethics.

Literary narrative shows a diversity of alternative forms and atmospheres of medical practices, tempting the reader to exercise his interpretative skills to distinguish between tradition and obsolescence, and thus helping contemporary medicine to understand that “ . . .an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present”.26

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