The quality of this series of talks is underlined by the importance of the first three speakers: Rousseau for his part in originating the conjunction, “Literature and Medicine”; Oliver Sacks as a famous exponent of the intermingling of the two; and, last night, the “goddess” herself, Dr Rita Charon – who exemplifies in her work and writing the point of it all. She is known, especially in America, for bringing narrative back to medicine in the courses she teaches at Columbia University, in her editorship of “Literature and Medicine” journal and the book she co-edited, “Stories Matter” (2002). A further book, “Narrative Medicine” is due out this year.
Dr Charon sought to give us a very solid understanding of the inter-relationship between narrative and medicine which she both embodies and explores in her work. She used, through her talk, the example of a patient of hers, fictitiously called Miss Nelson, whose medical facts, common enough, indeed easily dismissed as the self-induced morbidity of obesity, were slowly intertwined with information about her life that put these facts into context. Dr Charon weaved the story of her patient into the structure of her talk and gradually led us to see the reflection of this patient’s story, written about by her doctor over a number of years as a story overlying a story. The writing itself revealed aspects of the patient to the writer, and in connecting her back to the patient, revealed her “authentic self” which enabled her to have a healing relationship with this patient as well as to visit her "like a member of the family”.
It led us on to other narratives that weave together fact and fiction. She discussed Michael Stein’s novel, “This Room Is Yours”, in which the author writes his distant now-dementing mother’s story and is thereby changed: to remember it is to inhabit it. Dr Charon described the moment of “epiphany” in which Miss Nelson, sitting in her office, told her she sang in a choir, and Dr Charon, unusually, asked her to sing: their relationship was forever changed to one of mutual respect after this episode.
Another text where the “friction between truth and fiction” is explored is William Maxwell’s “So Long See You Tomorrow” – mutable memory: what appear to be recollected facts are in fact a story, part fiction, part painful memoir. We choose from a broad range of tell-able scenes: and by writing about Miss Nelson, Dr Charon says she thereby spent time in her imagination with her, found words to capture otherwise formless perceptions, become loyal.
From mentioning that transference and counter-transference are not just the province of the psychiatrist – we are all “excavated” by our practice as doctors – we moved to a discussion of Pat Barker’s trilogy, “Regeneration”. From actual case reports of shell-shock published in the Lancet, Pat Barker created the fictional world of the novels, where the psychiatrist, Rivers, uses as therapy the act of remembering. There are implications for us all, Dr Charon declared, having to re-create ourselves out of the fragments of ourselves that are memory. She tries to teach the medical students she leads in the study of these texts at Columbia to inhabit the stories of others. She quotes her favourite Henry James, “to ‘put’ things is very exactly and responsibly and interminably to do them”. In “simultaneous knowings” of herself and her patient – like Rivers in “Regeneration” who attends his psychiatric cases yet seems also to be nourished by them – the patient and doctor emerge together.
To a discussion as to whether this was in fact acceptable – Dr Charon was inspirational in her dismissal of the reluctance of doctors to enter into a relationship as close as that described with her patient Miss Nelson. She defended writing about her patients by explaining how touched they are when they read the account: that their doctor should be thinking about them, should care that much. In these questions after, the Dean of King’s reminded us that he had been instructed as a medical student to stay emotionally detached. There were other questions on this fairly taboo topic, one accusing Dr Charon of egotism, and another questioning exactly where is the line between engagement, identification and unprofessional closeness between doctor and sufferer. With sureness, Dr Charon set us right on the difference between engagement and identification: “I identify with Henry James... I think I am him”. Engaging with her patients was a different matter. The patient and the doctor, both were suffering. Both had to gain from this relationship. The amount of suffering was not equal but this recipricocity became the force for healing.
Her rebuttal of the egotism claim, was two-fold: she introduced us to Dr Andrew Herxheimer who gave us a brief introduction to the web-site he has set up: http://www.dipex.org/main.asp – a database of patient experiences direct from the patients; she then illustrated to us how she had become a better doctor, learning from patients such as Miss Nelson. Now, when a new patient arrives at her office, she explains to them that she will need to know facts about their medical past and their life but instead of firing off a ream of questions she simply says, “Tell me”. Such was the difficulty initially in listening without writing or tapping on a computer, she had to sit on her hands. But what she gets is a revelation. She listens “as a literary person”, noting the frame of what they say, what they include, what leave out, what order, what language they use. At the end of the interview, she has the same medical facts about the patient, but she has learnt so much more. One cried. “No one has let me do this before” he had said. Another said, “what, you want me to talk?”. In this way, Dr Charon showed us how she puts into practice the techniques and thinking inspired by her literary scholarship. How it happened - one can understand why now - that on an elderly patient’s death notice, it said, Mrs X leaves behind a sister, a son, and her doctor, Rita Charon.