The humanities have, in their application to medicine, become almost synonymous with narrative. When medical education turned to ‘reflection’ as a means to nurture coherent and ethical professional identity, interventions tended to take narrative as their primary form. Even while promoting ‘mindfulness’ as complete engagement in the present moment, proponents of reflection sometimes subsume reflection under the category ‘narrative’. The author offers a reading of Ian McEwan's novel Saturday, the account of the thoughts of a London surgeon over the course of one day, attending to the novel's reflective and lyrical as well as its narrative passages, in order to suggest that, rather than grouping the various forms that constitute ‘literature’ into a single instrumental method for producing more professional and ethical doctors, it might be valuable to attend to the various modes that constitute literary discourse, of which narrative is only one.
- health professions education
- English literature
- popular media
- public health
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- health professions education
- English literature
- popular media
- public health
Even his awareness of his own existence has vanished. He's been delivered into a pure present, free of the weight of the past or any anxieties about the future. (Ian McEwan, Saturday)1
The sea is calm tonight. (Matthew Arnold, Dover Beach)
Matthew Arnold's poem Dover Beach opens with its speaker's present-tense observation of peaceful stasis: “The sea is calm tonight”. Nothing is happening, save the observation that nothing—here and now—is happening. Arnold sets this still point against the turmoil of history, of late Victorian anxiety, a global loss of faith, opposing ideologies at war. Yet in this context the poem's speaker invites a loved one—and by extension the reader—to focus instead on the intimate and the immediate.
In this way, the poem alerts us to a discordance between two human experiences of time: there is the present moment, and then there is its extension into past and future along plotted narrative trajectories—the retrospect of memory and history, and the anticipation, fearful or desirous, of imagined futures. In contrasting these two experiences of time, Dover Beach also foregrounds the difference between two kinds of work that literature can do: storytelling and reflection. Narrative extrapolates the self into event and change, morally weighted plots of cause and effect, reward and punishment. In contrast, to describe and analyse an object or experience requires us to pause the momentum of plot and to focus down, observe closely and question deeply. In this essay I will consider the role of this absorption in the present, associated with the lyric as opposed to the narrative mode of literary discourse, as it applies to medicine and to the use of reflective practice in medical education.
In tune with the wider ‘narrative turn’ in postmodern Western thought, the humanities have, in their application to medicine, become almost synonymous with narrative. From Kathryn Montgomery's revelation that medical knowledge is structured as narrative, and Howard Brody's, Arthur Kleinman's and Arthur Frank's various influential accounts of the storied forms of patient and clinical experience, through Rita Charon's establishment of narrative medicine as a recognised medical discipline, narrative has come to represent the particular contribution that the humanities disciplines can bring to medicine.2–6 When medical education turned to ‘reflection’—reflective practice fostered by exercises in reflective writing—as a means to nurture coherent and ethical professional identity, the interventions they developed tended to take narrative as their primary form.7–10 Even while promoting ‘mindfulness’, complete engagement in the present moment, proponents of reflection often use ‘reflective writing’ and ‘narrative’ as synonyms.11 12
The activity of reflection, however, seems more fitted to the lyric mode. Lyrical writing does not tell a story. While generally associated with poetry, ‘lyric’ can also refer to those parts of a primarily narrative form, like a novel, that do not further the plot, instead representing subjective analysis of experience. The time of lyric is always ‘now’ rather than the time of what has already happened or what is anticipated. As one critic puts it, “Just as narrative requires temporal succession, lyric eliminates any noticeable temporal succession” (Morgan, p 301).13 The central relationship in lyric is that of “the mind to itself”.13
Perhaps it is time, then, to distinguish more explicitly between narrative and those forms of literary discourse that require writer and reader to withdraw from the demands of passing time. I should emphasise that I mean more than a simple genre distinction between prose narrative and poetry. Poetry taught in medical humanities courses, for instance, can be chosen and treated as a form of verse narrative, read primarily for implied stories. To distinguish between storytelling and the reflective writing more characteristic of lyric meditation, even if the text must sometimes first present the object of reflection in narrative form, may also clarify difficulties in assessing such writing by students.
To examine the distinction, I will focus on a novel—that quintessential narrative form—in which is embedded, at its climax, a recitation of Dover Beach and, by implication, that poem's lyrical retreat into the here and now. Ian McEwan's 2005 novel Saturday consists of the detailed account of a London surgeon's thoughts over the course of a single day, a fictionalised representation of the actual 15th of February 2003, on which massive protests were held, in London and other cities, against the imminent invasion of Iraq by Western forces. These historic global antagonisms frame the novel, providing a context and foil for its more private central concerns. The novel begins early in the morning, with the surgeon going to his window. From it he sees not a calm sea but a burning aeroplane headed for London. The rest of the novel unravels this portentous beginning into a non-story: there is no crash, no terrorist plot, no real news. McEwan's focus instead is the paradoxical and qualified achievement of calm.
Saturday and the uses of literature
Saturday does not make a convincing case for the efficacy of a literary education for doctors. Perowne can live without fiction and is clearly able to be responsive to his patients' stories without first having his sensibilities refined by literature. (Jane Macnaughton, p 74)14
In Saturday, neurosurgeon Henry Perowne resists the efforts of his daughter, a poet, to make him appreciate great literature. He dismisses the value of Tolstoy and Flaubert, resenting the time their books demand. He escapes a violent street confrontation by diagnosing Huntington's disease in his working-class adversary, Baxter, who later retaliates by invading Perowne's home. A hellish night is cut short when Perowne's daughter, naked and threatened with rape, recites Dover Beach. Baxter is so disarmed by hearing the poem that Perowne and his son can distract and overpower him, throwing him down the stairs. In surgery Perowne repairs the resulting injury to Baxter's brain and decides not to press charges. The day ends with Perowne's contented return to bed.
For those interested in the relationship between literature and medicine, Saturday is an irresistible text: its protagonist is a doctor who derides the great novels, only to be rescued by a poem. It can thus be read as a cautionary tale about the cost of failing to appreciate literature, but I think McEwan is subtler than this. Jane Macnaughton has pointed out that any claims McEwan is making for the improving capacity of literature must lie in intrinsic rather than instrumental values, for the surgeon-protagonist seems quite professional enough despite his disdain for Tolstoy.14 But the climactic use of Dover Beach as an instrument—in effect a weapon of self-defence—suggests that McEwan is both alert to, and even possibly parodying, simplistic instrumental claims about the improving value of exposure to great works of literature. Baxter's emotional response to the poem's beauty is such that the Perownes might just as well have hit him over the head with a very large book.
Reviewers of Saturday were quick to pick up on the incongruity of Baxter's sublime literary defeat. One called it “a faintly preposterous episode”,15 and another finds that in this incident “the novel descends to a level of bathos that is hard to credit”.16 In undermining its own credibility, this excessively symbolic action foregrounds the contrasting realism of the novel's expository and descriptive passages, emphasising the tension between narrative and non-narrative aspects of the work.
A more nuanced argument emerges if, instead of categorising all the novels and poems mentioned in Saturday as ‘literature’, we distinguish between the narrative and the lyrical modes and their respective orientations towards understanding experience. Saturday is not meant to be read like the 19th century realist novels that Perowne rejects (for their fictionality). The book's meaning is situated not in the questionable momentum of its plot but in its multiple modes of evading plot: its happy protagonist, who is allowed to retain his contentment, its limited time span, its attention to quotidian detail, and, most important, its discourse which, in its present-tense focus on the protagonist's mental responses to his environment, approaches the lyric mode of reflection aspired to (and maybe mourned) in Dover Beach.
Towards the end of Saturday, after operating on Baxter, Perowne reflects on his own experience of the surgery he has just performed: “For the past two hours he's been in a dream of absorption that has dissolved all sense of time, and all awareness of other parts of his life. Even his awareness of his own existence has vanished. He's been delivered into a pure present, free of the weight of the past or any anxieties about the future” (p 266). The effect of this intensely concentrated retreat from everything but his immediate task is positive and affirming: he “feels calm, and spacious, and fully qualified to exist. It's a feeling of clarified emptiness, of deep, muted joy”. In fact, he thinks of his experience in the operating room as “profound happiness”.
There are other moments throughout Perowne's day when he recognises this escape into the moment. Listening to the music of his son, a jazz musician: “here it is now, a coherent world, everything fitting at last” (p 177). During sex with his wife, “he is freed from thought, from memory, from the passing seconds and from the state of the world” (p 52). Even playing squash, during a good rally, he is temporarily extracted from the win-lose war story of the match: “It's possible in a long rally to become a virtually unconscious being, inhabiting the narrowest slice of the present, merely reacting, taking one shot at a time, existing only to keep going” (p 111). Mindfulness entails momentary elimination of plot.
Compare this with Perowne's observation that morning, as he lies in bed worrying: there “must have been survival advantage in dreaming up bad outcomes and scheming to avoid them. This trick of dark imagining is one legacy of natural selection in a dangerous world” (p 40). Perowne worries with stories, emplotting the consequences of what he has done in the past and trying to predict the effects of what he might (or should not) do in the future. As he acknowledges, such teleological imagining can be an adaptive guide to action. But Perowne finds it also removes him from the present, entangling him in helpless speculation.
The novel's text, though, does not rehearse Perowne's worries so much as represent his reflection on them, the metacognitive processes by which he evaluates his anxious imagining, weighing its survival value against its emotional cost. Both nervous plotting and profound happiness—which he can apprehend as such only retrospectively—are conveyed to us, and by Perowne to himself, through the novel's primary mode of discourse, not telling but reflecting.
Such self-awareness is self-critical and, for the doctor, diagnostic. After surgery, Perowne has no sooner recognised his happiness than he begins to worry about its implications. He says that if his work provokes such ecstasy, “there must be something wrong with him” (p 266).
Is Perowne's experience pathological? Does the fact that his technical work makes him forget everything else mean he is somehow deficient in empathy or the other values we associate with being a good doctor? Has McEwan in fact made him a stereotypical surgeon, technically brilliant but heartless? Worse, does this mean that happiness is at odds with the ethical engagements of narratable plots, or even with self-awareness? Is his happiness just solipsistic selfishness?
To answer these questions we must examine the forms of pathology McEwan gives us to think about. The “something wrong” in Perowne's happiness may be explained in terms of three different sets of criteria: the medical, the aesthetic and the ethical. Perowne's focus on the particulars of the moment rather than the drives of narrative has three possible effects: revealing his identity to be somehow malformed, making him weak and vulnerable; filling the novel with irrelevant detail, ruining a good story; and revealing him to be disengaged from the ethical demands of the world around him. I will consider the representation of these three forms of pathology—all dangers of escaping narrative, we might say—and then show how McEwan has in fact recuperated this seeming flaw to the broader purpose of his novel in ways that medical humanities might find valuable.
Medical pathology: damaged and vulnerable
Two other characters in Saturday are observed by Perowne to inhabit the present moment rather than narrative time. He visits his mother, Lily, in a nursing home. She has advanced dementia. Her son does not try to draw her out into the realities of her past losses and progressive deterioration. Instead he engages her extra-temporal position: “It's a long time since he last tried to explain to her that her mother died in 1970. It is easier now to support the delusion and keep conversation moving along. Everything belongs in the present” (p 168). But Perowne considers this perpetual present—which is perpetual absence—a kind of “mental death” (p 169).
The other neuropathy is caused by Huntington's disease. Perowne observes Baxter's response to hearing Dover Beach:
It's the essence of a degenerating mind, periodically to lose all sense of a continuous self, and therefore any regard for what others think of your lack of continuity. Baxter has forgotten that he forced Daisy to undress, or threatened Rosalind. Powerful feelings have obliterated the memory. In the sudden emotional rush of his mood swing, he inhabits the confining bright spotlight of the present. (p 232)
Perowne sees Baxter's moment of transcendence not as aesthetic bliss but as a trap, a position of profound physical vulnerability: “This is the moment to rush him” (p 232). Perowne's mother and his nemesis both represent the danger of relinquishing that evolutionarily advantageous ability to imagine and scheme. Small wonder, then, that Perowne finds his own experiences of dissociation problematic.
There is a fundamental difference, though, between Lily's and Baxter's confinement in the present and Perowne's escape to it: neither Lily nor Baxter is capable (as far as McEwan allows us to know) of recognising that position or reflecting on it. The lyric mode requires one not only to step out of the current of narrated time, but then, from such a position, to examine what it means.
Aesthetic pathology: random and irrelevant
I recently taught Saturday as part of a medical humanities and bioethics MA course. Several students expressed their impatience with what they called an excess of ‘random’ details in the novel, wondering why McEwan included so much information about Perowne's day that did not seem ‘relevant’. Relevant to what? I asked. And, random in what way, since each detail had to have been invented and deliberately included by the novelist?
This distinction between the random and the relevant maps onto that between lyric and narrative in the novel. For my students, the relevant contributed to the narration of the events of the plot; what seemed random was the descriptive and analytical writing that did not appear to ‘move the plot forward’, observing instead the details of the physical world at a particular moment, the protagonist's relationship to them, and the meaning of both.
Outside the urgency of story, the minutiae of Perowne's observations and his weighing of dilemmas demand of the reader the same kind of attentiveness Perowne himself gives such things—but for Perowne these are not a novel; they are his own thinking. Thus challenged to attend to another's mind, the reader may come to share Perowne's own concerns about the relevance of fiction: why read literature when we have wars to win, patients to save?
Narrative may be so dominant in medical humanities because it is a way to keep the literary embedded in the action of medicine, in the adaptive plotting of diagnoses and treatments, rather than in-depth contemplation of meaning. The physically impossible stasis of complete health would mean the absence of medicine's stories (and its purpose). Perowne is predisposed, then, to convert his own happiness, by dwelling on it, into “something wrong”. He knows what to do with pathology.
Ian McEwan has claimed that in writing Saturday he was “challenging the notion that… we're drawn to forms of misery and conflict because they're easier to describe, while happiness is bland”.17 Paraphrasing the beginning of Anna Karenina, he observes:
There's supposed to be a universality to happiness while there's a distinctly individual quality about misery. I thought, if I'm going to write about an anxious world, it would be more interesting to put a very happy man into it… It was a desire to braid together private happiness and public anxiety.18
The novel was widely criticised, though, less for being ‘bland’ than because the happiness of its main character felt morally offensive.
Ethical pathology: complacent and irresponsible
How restful it must once have been, in another age, to be prosperous and believe that an all-knowing supernatural force had allotted people to their stations in life. And not see how the belief served your own prosperity—a form of anosognosia, a useful psychiatric term for a lack of awareness of one's own condition. (pp 73–4)
Contentment is intrinsically conservative. Happiness does not desire change, and it resists the moral re-ordering that characterises stories. It does not demand punishments or rewards. This appearance of ethical stasis—or of unethical moral detachment—was a problem for many of McEwan's readers, who seem to envy and resent Perowne's contentment. Yet Perowne himself rather wistfully imagines not being guiltily self-aware. The paradox is that to do so, he must in fact have insight into his condition, and reflect upon it.
Perhaps the harshest criticism of Saturday demands that contentment and complacency should, in a good story, be punished. The Irish novelist John Banville concludes in his review that Saturday is “a dismayingly bad book”; he wants bad things to happen (to Perowne), both for aesthetic reasons (the story seems to need them in order to be a ‘good story’) and for ethical reasons (what right does the privileged Perowne have to escape things going wrong?).16 Banville calls Perowne “an unashamed beneficiary of the fruits of late capitalism”, meaning that in good literature such beneficiaries must be either ashamed or punished, and he says he can accept Perowne's “cloying self-regard” only “on the assumption that something nasty is going to rise up and put a dent in it”.16 An article in the Evening Standard described evidence of a backlash against McEwan, giving this vivid example of a reader's outrage: "McEwan's smug, self-satisfied doctor was such a fatuous git I was rather looking forward to his getting a good thumping from the Cockney wide boys whose car he dented midway through the book. But, no, the squash-playing surgeon weasels out of the confrontation”.17
There is something more going on here than boredom with dull happiness. There are class-based objections to the representation of socioeconomic privilege, embodied in the city surgeon, who is, as such, also in a position of power over patients, including his quasi-patient, Baxter. Why is Perowne's articulated self-doubt not enough? He is, after all, a fictitious character. Reading the novel's communication of Perowne's ongoing observations and self-judgements, we have access to this awareness of his condition. He is, the novel's discourse demonstrates, far from anosognostic.
Torn between contentment and conscience, Perowne is given the chance to examine both through conversations with his adult children. Discussing the anti-war protest, his daughter Daisy argues that committed and active engagement in history is ethically necessary. She urges him to take a stand: “Are we sending the troops in or not? It's happening now. And making guesses about the future is what you do sometimes when you make a moral choice. It's called thinking through the consequences” (p 193).i
Perowne's son, Theo, provides the alternative perspective. Watching the news with his father, he justifies his own detachment from the demonstrations: “When we go on about big things, the political situation, global warming, world poverty, it all looks really terrible, with nothing getting better, nothing to look forward to. But when I think small, closer in… then it looks great. So this is going to be my motto—think small” (p 35).
Perowne does not explicitly take sides, but Banville, in his review, sees Theo's position as the book's “vapid and self-serving” motto, and is amazed that McEwan has not set it up in order to demolish it. But maybe Banville underestimates the very hard work—moral work—that goes into thinking small when such thinking means avoiding the reductionism of big-picture thinking in order to carry out the strenuous attentiveness that McEwan attributes to Perowne.
Noticing and judging: the balance of reflective time
Novels and movies, being restlessly modern, propel you forwards or backwards through time… But to do its noticing and judging, poetry balances itself on the pinprick of the moment. Slowing down, stopping yourself completely, to read and understand a poem is like trying to acquire an old-fashioned skill like dry-stone walling or trout tickling. (p 129)
The three ‘pathologies’ of inhabiting the present moment exclude the effects of reflecting on such moments to uncover and construct their meanings. Perowne's happiness is predicated on a loss of awareness but also on the recognition, in short retrospect, of that loss. Reflective or lyric time is, despite its focus on ‘now’, in fact divided, like the present tense of Saturday's narration reliant on retrospect.
In perhaps the definitive account of romantic lyricism, Wordsworth called poetry the “spontaneous overflow of powerful feelings”. The second half of the definition is less often remembered: “… recollected in tranquillity”. It is this recollection, itself outside the current of plot, where the construction of lyric meaning—reflection—takes place.
It is worth noting just how the discourse of Saturday works. It feels like a first-person narration, but is not. Despite having its point of view limited entirely to that of its main character—the reader is allowed to know only what Perowne knows—Saturday is not narrated in the first-person ‘I’, and it is written in the present tense. The novel's first sentence is exemplary: “Some hours before dawn Henry Perowne, a neurosurgeon, wakes to find himself already in motion, pushing back the covers…” (p 1). Perowne is not telling us, as if in his own words, of something that he experienced some time ago. Instead, we are receiving a commentary upon the experience of someone who is examining himself as if he were someone else: we are told that he wakes and at once observes himself as an object-other even as he is in the course of coming to consciousness.
This seems the epitome of self-reflection: the subject observes himself as object, analysing what he sees with the distance, and the closeness, of a mirror-image. It is in this commentary, rather than in the narration of events, actual or imagined, remembered or anticipated, that reflection occurs and it is here, I argue, that McEwan's book tells us something valuable about what literature can do for the understanding of professional (and personal) identity.
Musing on his daughter's literary sensibilities, Perowne thinks that he lacks the “lyric gift” to see beyond the “iron weight of the actual” (pp 172–3). But in reaching this conclusion about himself, he must first enact exactly the gift he supposedly lacks, imagining how “wondrous” his present situation (stuck in traffic in 2003 London) would seem from the perspective of the past. He “mentally… shows it off” to the “men of the English Enlightenment”, trying to “see it, or feel it, in historical terms” (p 172). His diagnostic self-analysis again finds him wanting—and then the process of analysis itself remediates the lack.
Terrence Holt, in an admirable essay on the role in medical-professional identity of negative capability, a tolerance for ambiguity and multivalence and contradiction, argues for the value of accepting “the essentially fractured nature of ourselves” rather than trying to reconcile the irresolvable in striving to develop a unified professional self.19 McEwan uses his writing to demonstrate the same thing: this meta-cognitive step—thinking about thinking—implicitly characterises the narration of the entire novel. The paradox of reflection is its demand that you stop time and step away from yourself. To reflect on one's self is to split off, to be at once subject and object of attention.
In recognising his anxiety and describing it to himself, Perowne becomes doubled for us: the worrying man, and the man with insight into that worry. I might then argue that one value for literature such as Saturday is that it models the process of insightful self-reflection. This is not the same as storytelling. Yet Saturday is nonetheless a novel, a narrative form, that is trying to teach us a lyrical position, to make us step outside narration. The Perowne whose mind we read is not telling, then; he is reading, observing and interpreting. What we read is not his narrating but his self-reading, the report of his observing and judging, as if of a different person, the story of a day in the life of Henry Perowne, an experiencing text.
Reflection as reading
In short, to teach a student to read, in the fullest sense, is to help train him or her medically. To ask the medical student what is being said here… is to prepare him or her for the doctor-patient encounter. (Trautmann, p 36)20
A reader reading well is simultaneously experiencing the text, responding to it emotionally, and at the same time analyzing that response, tracking it to its sources… Doing one without the other is not reading. And it is not doctoring either. (Holt, p 330)19
A founding thinker in the medical humanities, Joanne Trautmann Banks, focused less on literary textual objects than on practices: she taught that literature and medicine was less about exposure to narratives (or poems, or paintings) than about the practice of reading in, as she put it, “the fullest sense”.
There is a teacher of reading in Saturday: John Grammaticus, Perowne's father-in-law, the famous poet who has been responsible for Daisy's literary education. His name is not an accident: in classical Rome, the grammaticus was a teacher of literature and language and rhetoric. Grammaticus is obnoxiously arrogant and appears at one level to exemplify the claim that absorption in the poetic does not make one a kinder or more sympathetic person—but it is also he who demonstrates the most robust value for being a good reader: at the horrible moment when Baxter orders the naked Daisy to read from her own book of poems, Grammaticus hints that she should instead recite the Matthew Arnold poem (which he had encouraged her to learn by heart many years before). This shields her from exposing her own writing to Baxter's salacious attention. Grammaticus here both evokes and exceeds Matthew Arnold's own claims, in his influential Culture and Anarchy, about the value of a literary education. Grammaticus activates the use of Dover Beach as defensive weapon—but also exposes both Perowne and the reader to the deeper values—existential and social—of the lyric text.
After completing surgery that night, Perowne recognises not only that he has been happy, but that its achievement has been demanding: “This benevolent dissociation seems to require difficulty, prolonged demands on concentration and skills, pressure, problems to be solved, even danger” (p 266). This could as well be an account of reflection and—or as—reading, not as escapism but as profound engagement.
There is a comic scenario where Grammaticus and Daisy argue about the particular metrics of a line of verse: to ‘scan’ a line of poetry is to work out the rhythmic pattern of the words' syllables. Perowne is led by this talk of scanning to think about MRI and imaging technology. This seems to present him as ignorant and prosaic, but perhaps, if we are less prejudiced, can also question the old distinction between ‘hard’ and ‘soft’ cultures by pointing to affinities between the precision of medical technology and the technical demands of close reading, where attention to exact detail is what makes possible the non-reductive observation of the construction of meaning. The “difficulty… even danger” of strenuous reading is what opens up the possibility of insight, in the fullest sense.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i This engagement in consequences is uncharacteristic of Daisy. We learn later that she is pregnant, and it is possible that her new interest in the implications of long-term narrative, the consequences of present actions, is connected to her decision to keep and raise the child, perhaps for the first time anchoring the lyric poet, materially and irrevocably, into the plot of history.