Doctor, I was thinking the other day....

Yvonne Lo 盧宛聰

HK Pract 2007;29:369-370

We understand ourselves inescapably in narrative.
Charles Taylor (1989)

Every one loves to hear stories. Hearing and telling stories is consoling and connects people together. It arises in all circumstances and unites people from different cultures and different eras. It allows imagination of the mind and creates new meanings amid normality and chaos of the world. Stories offer insight, understanding and new perspectives.¹ In Family Medicine, we allow our imagination to intertwine with the unfolding events and the emotions of the stories our patients tell us. Their stories have meaning, context and perspective for their own predicaments.² However, patients seldom voice their emotions spontaneously and directly. They tend to offer clues instead.³ Without imagination, we cannot reach out to the meaning in what is said and appreciate what our patients are going through. Without listening, we cannot allow the patient's private experience to become a communicated experience. Without empathy, the unexpressed feelings remain unexplored.

Arthur Kleinman is a physician whose anthropologic training has led him to recognize that illness narratives have to be contextualized: 'Each patient brings to the practitioner a story. That story enmeshes with the disease in a web of meanings that make sense only in the context of a particular life.'⁴ Rita Charon, an internist with a doctorate in literary studies, advocates doctors to practise narrative medicine to strengthen their therapeutic alliance with patients and deepen their ability to adopt or identify others' perspectives.⁵ Narrative medicine, as defined by Dr Charon, is a practice that develops a physician's textual, creative and affective skills to recognize, absorb, interpret and be moved by a patient's stories of illness.⁶ Textual skills enable the identification of a story's structure, the adoption of its multiple perspectives and the recognition of metaphors and allusions. Creative skills allow the imagination of many interpretations and possibilities. They build curiosity and formulate multiple endings. Affective skills enter the story's mood and tolerate the uncertainty as a story unfolds. These skills are collectively known as narrative competence. It is only when physicians can truly appreciate the ordeals that their patients experience and are able to honour the meanings of their patients' tales of illness can medical care pursue humility, trustworthiness and respect.6 In short, narrative medicine reminds us to practise medicine with awareness of what patients go through. It enables us to practise with empathy and sensitivity.⁷ To develop these skills, Dr Charon recommended close reading of literary texts and clinical texts, narrative writing about patients and reflection on one's own clinical experiences.^5,8 In close reading, the reader forms the habit of not only paying attention to the words and the plot but to all various aspects of the text. As the reader moves along with the story, he himself will participate in the play of the text. His curiosity and imagination will be aroused, resulting in various interpretations of the text. In the same way, the doctor listens attentively to his patients, enters into their narratives and shares their experiences. Through analyzing these narratives, the doctor can acknowledge the plights of his patients and offer the most appropriate and humanistic care.

More and more physicians are writing about their patients and the meaningful encounters within. They describe how they are moved and inspired by their patients' stories and how they examine their own experience and make sense of their own doctorhood.⁹ This year, our College has compiled the book with a number of articles describing the experiences of some of our College members in their clinical practise.¹⁰ There are also many collections of short stories such as^{11, 12, 13, 14,} all of which are very popular among our local public and health care professionals. Such is what we called reflective writing. Writing, reading and re-reading these stories can often glean new insights. It brings forward consciousness, engagement, responsibility, and ethicality.⁵ It promotes hope in the patient-physician relationship and aims at reconciliation between physicians and patients.¹⁵

We have all practiced narrative medicine in one form or another, but without actually conceptualizing it. We listen to stories of our patients every day, try to make sense of things that have occurred, sort out the problems presented and offer explanation. But perhaps the one thing that we have not brought to our consciousness is the one important component in cultivating such narrative skills - the ability to reflect on the interplay of patients' perspectives as well as our own feelings, thoughts and actions. It testifies to our self-awareness, the honest appraisal of our very own perspective.¹⁶ It is the capacity of such mindfulness that allows us to recognize our own strengths and weaknesses, to remind us of the need for learning and self improvement, to make justification of our decisions and actions, and to establish rewarding interpersonal relationship.¹⁷ As primary care physicians, we use ourselves as instruments of diagnosis and therapy.¹⁸ With mindfulness, we can understand that the way we communicate and interact with our patients as well as our emotional response to them is influenced by our personality, our upbringing and past experiences, our values, attitudes and biases.^19,20 With personal awareness and mindful practice, we become more sensitive to our own mental processes and more informed of our own behavioural choices, thereby act with principles. There will also be more intensified and more refined understanding of patients' behaviour, leading to compassionate patient care and satisfaction with work, relationships, and our own selves.^17,21

We, as family physicians, have the privilege to grow along with our patients, unfold their stories over time and learn from one another. By telling their stories, we recognize ourselves and others, find meaning in life and illnesses and come to better respect our patients as human being and all that this entails. This is what we value - the art in Family Medicine.