Activity 1: Patient narratives, oral history and empathy (Tracey Loughran)

In February 2020, I designed and ran a session on ‘Patient Narratives, Oral History, and Empathy’ as part of an optional module on historical and contemporary contexts of medical education on an intercalated BSc in Medical Education. I was interested in this topic for several reasons. Some years earlier, one of my students had recalled an incident in which a young friend, recently diagnosed with an illness that had a high mortality rate, was tested for HIV prior to treatment. She overheard a doctor express hope that the test was positive, as he had never seen this particular illness interact with HIV before. I could rationalise the doctor’s response (just) as stemming from the desire to understand illness and so help patients, but saw making this comment within earshot of a patient as demonstrating low empathy. In fact, it was most likely simple carelessness, but, when later editing a chapter on whether reading literature increases empathy in health professionals, prehealth professionals and students outside of medical care, I often recalled this story.22 Later again, I noticed that for some interviewees on the Body, Self and Family project, an apparent lack of empathy among health professionals played an important part in their sense of pain and confusion following traumatic medical events. I wondered whether such stories could be redeployed, in a fashion that made reparation for these experiences, as part of medical students’ education in empathy during the clinical encounter.

The session was attended by almost all students on the module. It started with a short talk on empathy and patient narrative, and a discussion of preset reading from Arthur Kleinman’s The Illness Narratives, which argues that empathetically interpreting the patient’s narrative is essential to understanding the meaning of illness in the patient’s life, and to practising medicine humanely.23 This part of the session ensured that students were familiar with key concepts such as empathy and patient narrative, and allowed us to build up a rapport before moving onto potentially more challenging material. For the remainder of the session, we explored an oral history interview I had conducted with Janet (a pseudonym)24 in 2018 in three different formats: the interview summary (a concise guide to the interview, designed to help users identify parts relevant to their own research), a transcribed excerpt and an extract of the recording.

I chose this interview and excerpt partly for practical reasons: the session dealt with some complex concepts, and it was essential to allow sufficient time for students to engage with the material alone, and to discuss it as a group. It was also important to use an excerpt that clearly illustrated the dynamics of the doctor-patient relationship, and the effects of a specific medical encounter on the patient. In addition, I wanted the students to reflect critically on the role of the person who elicits a narrative (in patient case notes, the doctor; in oral history testimony, the interviewer). It therefore seemed fair to use an interview I had conducted myself. Janet’s interview met all these criteria. However, I also chose this excerpt because Janet’s narrative of a traumatic medical encounter (outlined below) had powerfully affected me during the interview, and I had often thought about it afterwards. I felt most confident that I could encourage students to think about empathy in relation to a narrative that had unquestionably provoked a strong emotional response in me.

The students had not seen any of the material relating to the interview prior to the session, and I introduced each format in successive stages. I asked questions to guide their reading/listening at each stage, and followed their own immersion in the material with group discussion. In introducing the same material in different formats, I hoped students would gain awareness of how the presentation of information in different ways can reveal or conceal different aspects of experience, and that they would reflect on how empathy is created, communicated and maintained.

When reading the interview summary, students were asked to consider what it revealed about Janet’s medical history, her encounters with health professionals, her self-understanding as a patient and whether the summary lacked any of the information necessary to interpret her story. This exercise approximated how health professionals might try to make sense of narratives they have not personally elicited. Despite dutiful reading, the students seemed unengaged with the dry, flat tone of the summary, which describes incidents in the interviewee’s life without attributing special weight or emotion to any of them. Most identified some of Janet’s medical encounters, but none picked out the episode she had narrated with most emotion during the interview.

Next, the students read a transcribed extract from the interview of around 2000 words. Here, Janet recounted her experience of pregnancy loss, including multiple instances when health professionals appeared to lack empathy towards her. I asked the students to note anything interesting or unusual about the form of the transcript, any points where they empathised with Janet, and any points where they felt other emotions. All students commented on the form of the transcription, which includes hesitations, pauses, laughter and interruptions, in the attempt to replicate the pattern of speech and flow of conversation.25 Reading transcriptions of this kind can be very jarring for those who have not previously encountered the form, but it forces the reader to slow down and pay attention to form as well as content. They noted empathy for Janet at the points I had anticipated, and some found her story distressing. Unexpectedly, their empathy for Janet quickly turned to open discussion about their own fears of failing to listen to patients, particularly given the time constraints of their usual clinical encounters.

Finally, we listened to a recording of the extract they had just read. I asked the students to consider whether Janet’s voice or speech sounded different to how they had expected; if she sounded emotional at certain points of the recording, and to identify those emotions; and how the interviewer (me) might have responded differently in any place. After listening to the recording, the students all remarked on Janet’s accent, which was clearly identifiable as belonging to a particular English region. Most (but not all) students felt that hearing Janet’s accent and the rhythm of her speech provided further clues to her personality. They also re-interpreted Janet’s response when she made a formal complaint that was ignored. They read the emotion in this part of the interview as sadness, but they heard it as fury. This prompted another unexpected discussion, on how they might listen for pauses, emphases, repetition and changes of tone in their own clinical encounters. This aspect of the session supports Janet Weston’s contention that ‘something very particular can be lost when oral histories are expressed and analysed in written form: the gestures, the performance, the tone and emotional content, the exchange between interviewer and interviewee, the voice itself’, and emphasises the value of putting audiences in touch with the raw materials of history.26 I also shared my own feelings that as an interviewer, I had handled some aspects of the interview badly, but reassured them that it is possible to make amends for these mistakes by careful listening and attention to body language of the interviewee/patient.

In retrospect, when I initially designed this session, I did not pay sufficient attention to the challenges health professionals face in an underfunded system. As a result of conversations with the module convenors, as well as the session itself, I became aware that medical students usually did not lack empathy, but rather time, resources and knowledge about how to ‘read’ and communicate empathy in the clinical encounter. In addition, as Archer and Greenlees show in their commentary in this volume, medical students may also be struggling with feelings of guilt or shame about their own role as learners in situations where individuals required care. My initial approach to the session did not consider the realities of these students’ experiences, and ignorance borders arrogance. In the months since I ran this session, the COVID-19 epidemic has led to renewed public discourse on the structural constraints under which health, medical and caring personnel operate, and this context has further challenged my assumptions.

Despite flaws in my initial assumptions, postsession feedback showed that students had benefited from the session. They identified as ‘take home’ messages the difficulty of predicting how a patient’s narrative might develop; the need to adapt their own style of communication in response to the patient’s emotional expression; the importance of not unthinkingly deploying medical jargon in response to human tragedies; and the necessity of both listening sensitively, and allowing the patient space to speak. Although the students already felt empathy for patients, the oral historian’s skills in listening and interpretation helped sensitise them to how emotion is expressed in patient narratives, and suggested how empathy might be actively communicated in the clinical encounter. The appropriate means of expression is something they must work out for themselves as their careers develop; as Rosie Harrison’s discussion elsewhere in this special issue shows, professional detachment can be necessary to manage emotion so that an appropriate kind of caring relationship can be maintained. However, this session might provide them with a greater range of tools to build a communication style that suits them and meets both their needs, and those of their patients. Meanwhile, the session prompted me to engage with the extensive literature on ‘compassion fatigue’, as well as popular medical memoirs that explore this phenomenon, so that I could run similar sessions in future with greater sensitivity to the working lives of participants.27 A new awareness of ‘profound differences in perspectives’ between historians and practitioners therefore provides the tools to start bridging that gap in the pursuit of ‘meaningfully engaged’ activities.28

Activity 2: What do everyday health objects sound like? (Kate Mahoney)

In February 2020, the Body, Self and Family team participated in a ‘Valentine’s Late’ event. Led by the University of Roehampton’s Surgery & Emotion project, the event aimed to ‘explore the rich feelings…from compassion and romance, to anxiety and fear’ associated with health encounters.29 Museum and library ‘lates’ are typically promoted to younger adult audiences as an opportunity to view exhibitions outside normal opening hours in a friendly, social space.30 They incorporate talks, workshops, and food and drink. This particular Late was organised in collaboration with the Royal College of Nursing (RCN) Library and Archive, which promotes itself as supporting RCN members to ‘develop professionally and explore nursing and its history’.31 The event therefore attracted a mixed audience. Participants included young adults who were studying nursing and the history of medicine, many of whom attended with their friends; medical professionals; academic historians; and members of the public, young and old, who were interested in nursing and its history.

For the event, I created the activity ‘What Do Everyday Health Objects Sound Like?’, which aligned oral history recordings with historical objects to encourage participants to think about how they might define an ‘everyday health object’. The activity reflects the holistic construction of health we have championed on the Body, Self and Family project. The event’s open atmosphere, however, also engendered discussion on how the participants felt when they listened to the interviews. These exchanges illuminated the various ways in which participants built empathetic connections with the women’s voices featured in the activity. These differing formulations of empathy also prompted my own reflections on its role in the oral history interviews I had conducted for the project. The activity therefore reiterated how engagement activities enable historians to develop invaluable two-way conversations about history, empathy and identification across a range of public audiences.

In developing the activity, I located references to everyday health objects within the Body, Self and Family oral history interviews. One interviewee, born in 1944, cited the significance of a National Dried Milk tin in her childhood memories of health—her mother stored the family first aid kit in a repurposed tin.32 Another interviewee, born in 1942, worked in the shop on her parents’ Canvey Island campsite.33 She described how she served menstrual products to customers in black plastic shopping bags—a process that she felt promoted periods as ‘something horrible’.34 A further interviewee, born in Cardiff in 1966, described the lack of facilities at her primary school when she started her periods.35 She successfully campaigned for her daughters’ primary school to install sanitary bins to ensure they did not endure the same experience.36 In the selected extracts, the objects discussed by the interviewees did not immediately have medical connotations, serving instead as a container for foodstuffs, a receptacle for waste and a carrier for shopping items. By reflecting on their own experiences, however, the interviewees imbued the objects with purposes, emotions and values that rendered them intrinsic to the women’s sense of their everyday health. On the Body, Self and Family project, we explore the expansive ways in which women comprehended their health across their day-to-day lives. I felt that the interviewees’ discussion of everyday objects in the context of their health effectively showcased this aim.

The RCN activity drew on these oral history accounts to bring the objects cited by the interviewees to life. I placed MP3 players containing the interview extracts inside a National Dried Milk tin, a black shopping bag and a small bin, and plugged headphones directly into each object. I wanted to understand if situating women’s voices within the objects enhanced the participants’ listening experience; perhaps introducing an additional tactility or enabling listeners to visualise objects as they were discussed. I thought these factors could lend further tangibility to the events and experiences that interviewees recalled, therefore augmenting the participants’ empathetic engagement with the women’s everyday health experiences.

Multiple participants who engaged in this activity cited an empathetic response to the women’s voices due to their personal identification with the experiences recounted. In her discussion on the psychosocial benefits of oral storytelling, Hibbin asserts that the oral narration of experiences builds empathy because it enhances a ‘double-minded’ understanding of one’s self and others.37 The experiences of listening to oral history recordings and engaging with historical objects, appeared to engender comparable ‘double-minded’ understandings of women’s everyday health experiences in the RCN Late attendees; understandings based on both their own experiences and a desire to understand the women whose voices they heard. These empathetic responses based on personal identification took several forms.

A participant who was also a medical practitioner noted the value in listening to a series of women’s health experiences that were clearly positioned in the past. When working, the practitioner was obliged to respond to patients’ symptoms as they were being experienced. The contemporary immediacy of this exchange meant that the practitioner did not necessarily envisage the medical encounter as an event that the patient would later remember and reflect on. By engaging with a historical health narrative, the practitioner was alleviated of the pressure to immediately respond and provide a practical solution. As a result, they were attributed the mental and emotional space to develop an increasingly empathetic and reflective connection with the interviewee, while concurrently learning more about the long-term impact that everyday health experiences had on women’s lives.

One participant also stated that listening to the recordings and handling the objects ‘took me right back’. Her statement implied that she belonged to the same generation as the women interviewed and therefore felt an empathetic connection because she shared comparable experiences with the interviewees. For some attendees, this personal identification via shared experience spanned divergent national and cultural contexts. One participant—responding to the interviewee who recalled concealing menstrual products in black bags—described encountering comparable practices while growing up in India. In recalling her own experiences, the participant expressed identification with both the account on the recording and the object itself, which she picked up and held with a sense of familiarity. Wilton details how including objects in oral history interviews helps to capture specific aspects of an individual’s narrative. This process imbues the object with its own story, therefore generating new understandings of its significance within the interviewee’s life.38 In using the shopping bag as a prop, this participant reiterated the significance of the object within her own life, while also lending tangibility to her empathetic connection with our oral history interviewee.

Other attendees acknowledged intergenerational identification with the women’s voices. Their intergenerational empathy arose from reflections on similarities and differences between their experiences and those of older women. However, their empathy was also oriented around the sense that the women’s voices could provide insight into the lives and experiences of their own family members—the everyday health encounters of their mothers and grandmothers. This familial expression of empathy appeared to replicate the intergenerational framework within which several of my oral history interviews for the project took place. When conducting these interviews, I was surprised at the extent to which my empathetic connection with the interviewees was based on the fact that they were the same age as my mother. Interviewees also expressed empathy for my thoughts and feelings because they assumed I was the same age as their children, and therefore might share comparable experiences with them. As Roper and Duffett note, researchers exploring history and public engagement routinely find that ‘people are more likely to feel a sense of connection to the past through their family’.39 This research references families as a trusted source of historical knowledge. However, as indicated at the RCN Late and through my own interviews, in both research and public engagement settings, individuals might adopt a familial framework to understand and empathise with past experiences.

Another participant connected her empathetic response to the vocal tremors she could hear on the recordings. She felt that these tremors demonstrated how recalling memories was itself an emotional experience for the interviewees. Her empathetic connection with the interviewees was built on both an understanding of the emotion connected with past experiences, and the emotion associated with its memory ‘even after all this time’. The participant’s response highlights the value of actively encouraging listening as a means to elicit empathy for women’s voices in disseminating them to public audiences. Historians have also emphasised the importance of listening to oral history recordings when reusing interviews in research, rather than simply drawing on transcripts. Gallwey describes how listening to interviews from the British Library’s ‘Millennium Memory Bank’ project drew her into a close relationship with its contributors: ‘I felt very attuned to individual characters, their voices and ways of speaking and to the uniqueness of their stories’.40 Karpf argues that the voice is a ‘rich medium in its own right’.41 She states that the voice requires a historian’s ‘instinctual response which belongs more usually in interpersonal relationships than in traditional scholarship’.42 At the RCN Late, the act of listening personalised the women’s voices. As Godfrey highlights, the empathetic relationship between the historian and participant is invaluable to both the oral history interview and any subsequent analysis.43 In listening to oral history accounts, our public engagement participants also developed an interpersonal relationship with the project’s interviewees, based in part on identification with the women’s emotional vocalisation of particular experiences; we might draw a connection here with Slobogin’s argument elsewhere in this issue that the humanising details in photographs can encourage stronger feelings of empathy by providing access to emotions that are not easily or immediately articulable, or not necessarily articulated in different contexts.

When staging the activity, I included transcripts alongside recordings to ensure accessibility. One attendee, however, chose to read the transcript, stating that they did not like listening. I was surprised at how strongly I felt that this action disrupted the value of the activity. This feeling belied my assumption that the vocalisation of women’s experiences was intrinsic to the activity’s capacity to elicit empathy. In acknowledging this assumption, I also became aware of the significance I attribute to listening effectively in my own oral history practice. My empathy for oral history interviewees is based on both listening to the experiences that they recall, and seeking to understand how the process of remembering makes them feel during the interview process.

During the RCN event, several participants expressed surprise that the oral history recordings contained women’s voices as opposed to the mechanised ‘bleeps’ that they associated with medical objects. ‘It’s not making a sound’, one participant stated, ‘It’s just talking’. In this context, the vocalisation of women’s experiences did not always stimulate an empathetic response among event attendees. My ambition to use oral history recordings to disrupt assumptions about everyday health objects occasionally generated confusion that stymied participants’ capacity to empathise with the women’s voices. This demonstrates the potential for different aims to conflict with each other in public engagement activities.

Activity 3: Could you be an agony aunt? (Daisy Payling)

At the RCN Late, I ran an adapted version of a third public engagement activity drawing on women’s voices. ‘Could You Be an Agony Aunt?’ uses letters and responses from problem pages in 1970s magazines for teenagers and adult women. Women’s magazines have been sites of advice and support for women for centuries.44 The letter-response format was integral to fostering a ‘supportive community’ within and beyond the magazine’s pages.45 Agony aunts, as emotional advisors, played an especially important role in creating this ‘fiction of friendship and trusted relationship’.46 Crucially, however, agony aunts fulfilled a dual role: they offered both ‘serious emotional advice and voyeuristic entertainment’.47 ‘Could You Be an Agony Aunt?’ embraces the dual role of problem pages to provoke empathetic responses in participants to these voices from the past.

Of course, letters to agony aunts only provide brief snapshots of past lives and experiences. Moreover, the voices of girls and women do not appear unmediated in this form. The letters on magazine problem pages were heavily edited. Virginia Ironside, agony aunt for Woman in the late 1970s, claimed that agony aunts ‘are writers first and foremost’, maintaining that she was employed for her ‘writing and editorial skills rather than for her caring and compassion’.48 Nevertheless, agony aunts attempted to retain the individual voices and personalities of readers as they edited the letters down to fit the page.49 As Claire Langhamer argues, the ‘interplay of individual self-knowledge and expert advice’ in printed letters and responses can still offer a window into past subjectivities.50

The premise of ‘Could You Be an Agony Aunt?’ is simple. The activity reproduces questions and answers from problem pages, but presents them separately from each other. Questions are scattered on one half of a table and responses on the other half. Participants must match questions with responses. Some responses could plausibly match more than one problem, so participants have to be aware of tone and content—to a certain extent imagining themselves as 1970s agony aunts. During and after the activity, I ask follow-up questions, including ‘What do you think of this advice?’, ‘What advice would you give to this person if they were your friend?’, ‘Do these problems resonate with you?’ and ‘How do you think teenagers or women’s lives have changed since the 1970s?’. I have run the activity at several events, tailoring it to diverse audiences. The first iteration of the activity was developed for school students aged 14–15 years as part of the University of Essex’s Digital Arts Festival. For this event, I selected five problems representing areas including body image, confidence, sexuality (including homosexuality) and relationships, and made a worksheet instructing participants to draw a line linking the problem to the correct response. These were areas of concern raised by teenage letter writers to magazines, but are also areas that the PSHE Association draws attention to in its current guidelines.51 For stands at public history events with LGBTQ+ audiences and at the RCN Late, I created the tabletop version described above. The LGBTQ+ events stimulated the inclusion of more questions on homosexuality, and for the 16+ audience at the RCN Late I used problems and responses from She magazine’s sex column.

In developing the activity, I had to select and edit letters and responses, taking into account space constraints and the need to avoid overburdening participants with text. In doing this, I replicated the role of the agony aunt compiling the problem page. I empathised with the experience of Nick Fisher, agony uncle for Just 17 in the 1990s, of ‘looking at your page and thinking, “I can't have five letters all about this, so I've got to have a bit of this, a bit of that”’.52 Like many agony aunts, however, I tried to accurately represent the voices in the letters. Also, as with agony aunts, careful selection and editing was necessary to create an activity that would ‘hook’ participants. As Suzie Hayman, former agony aunt for Woman’s Own, explains: ‘As an agony aunt, I think I owe my readers professionalism and empathy and knowledge and understanding… But I also owe them entertainment, because they're not gonna read if it’s just a professional screed’.53 With questions on homosexual feelings, weight loss, spots, feeling apprehensive about going out with friends, and how to get better at walking in high-heeled shoes, I wanted the problems to balance relatability with light-heartedness. These problems were also selected on the merits of their matching advice. Advice needed to be sensitive and sensible, even accounting for changing attitudes over time, so as not to do harm. In particular, the weight loss question and answer pair was selected because it offered no specific suggestions on how to lose weight.

‘Could You Be an Agony Aunt?’ was therefore designed to create empathy with past experiences, and to entertain in the present. The magazine quiz-style title immediately challenges participants to place themselves in the agony aunt’s shoes: an empathetic act and an empathetic persona. Magazine quizzes encourage participants to imagine new selves and can direct the nature those selves take.54 In this activity, the new imagined self is an agony aunt, but the quiz-style title also transports adult participants to the playful spaces of their teenage years, with the challenge of the task reinforcing the sense of play for participants of all ages. It draws on the recognised role of play and creative engagement in supporting learning.55 In asking participants to actively imagine themselves as agony aunts, the activity also follows Jamison’s conception of empathy as effortful. Participants do not simply empathise with letter writers, but need to pay attention both in identifying the real-life advice, and considering the follow-up questions that require reflection on the effectiveness of the advice, and other potential responses. These questions consolidate the empathetic engagement, offering opportunities to reflect on how advice might change and how people might deal with problems in the present.56

In practice, school students were able to identify with the problems and with the advice. They successfully put themselves into the position of agony aunt to complete the activity and extended their empathetic engagement to suggest their own advice. A problem from a 13-year-old who felt happier staying at home with their parents than going out with their friends seemed to encourage a particularly empathetic response, but perhaps this was one that the school students, a few years older than the question writer, felt some distance from, enabling them to talk about it more openly in front of their peers.

Adult participants at the RCN Late engaged with the task in a slightly different way. The inclusion of sex problems from She magazine amped up the entertainment aspect of the task. It drew participants into reading the problem page as a voyeuristic experience, described by Nick Fisher as the ‘slightly guilty pleasure, of reading your big sister’s magazine that you shouldn't really be reading… because it’s given you some kind of Peeping Tom-like experience into human frailty’.57 However, some participants’ surprise at the sexual practices described in letters led them to express their own uncertainty about the matters in question, while others empathised not only with the voices of past readers, but with their own past selves. Although many participants were healthcare practitioners, they tended to relate this task to their own experiences rather than those of their patients. Sympathetic responses to young readers questioning their sexuality in the 1970s prompted spontaneous reflections on how Section 2858 had affected participants’ own adolescent understanding of sexuality, and how they would have welcomed an empathetic ear. Some also expressed surprise at agony aunts’ nuanced responses to these questions. In creating new empathetic connections with the agony aunt, the quiz therefore challenged popular stereotypes of agony aunts as condescending and conservative, and created a new ‘horizon of context’ for these participants.59