Life is Larger Than Science

Since its inception, Annals of Family Medicine has valued narratives, the stories through which we make sense of our health and our lives.

This issue of Annals features five works of narrative reflection. Why? Because the search to understand and find meaning requires more than facts. Author and healer Rachel Naomi Remen reminds us “That life is larger than our science, larger than our theories, larger than ourselves. That it is possible to research life for years without knowing life at all.”¹

That’s where stories come in.

The Power of Narrative

People have been sharing stories for thousands of years. In the founding text of Western literary theory, Poetics, Aristotle declares humans’ universal delight in “representation”—including storytelling—to learn and make sense of experience. When these stories contain “suffering (…) within friendly relationships,” they move us to compassion and empathy.²

Narrative competence has been offered as a method of teaching and practicing with empathy in the face of an increasingly dysfunctional health care system. Most closely associated with the work of Rita Charon, narrative competence describes the capabilities “to acknowledge, absorb, interpret, and act on the stories and plights of others.”³ Charon organizes narrative medicine into three movements: attention, cultivated through close observation and awareness; representation, as practiced in reflective writing; and affiliation, or being witness to suffering in partnership with the patient.⁴

Charon’s second movement, representation, can have meaningful benefits for those who provide, receive, and witness care. To write about an experience in plain, non-technical language is to externalize it, see it anew, and invite others into making sense of it. As novelist and narrative-medicine educator Nellie Hermann argues, moving what is internal onto the page creates space to examine, share, and sometimes transform it.⁵ Reflective writing helps clinicians process difficult experiences, question what they were taught and the medical culture in which they practice, and imaginatively explore different outcomes and approaches. In a randomized clinical trial, biweekly small-group sessions with physicians organized around facilitated reflection and shared narrative decreased some symptoms of burnout, with effects persisting at 12 months.⁶ Long-running physician writing communities report durable gains in connection, purpose, and personal wellness through translating their experiences into stories.⁷ A humanities and reflective writing elective for fourth-year medical students decreased emotional exhaustion and depersonalization,⁸ and a systematic review found that, among patients and caregivers, narrative medicine helped reduce pain and alienation and increase confidence and activity.⁹

Narrative medicine does, of course, present challenges. Making sense of a complex story is not solely a function of narrative competence. After all, not all stories have plots. Nor is every narrator reliable. Still, “Whether we aim to change health care or just provide a record of our acts, stories may provide a mechanism for finding meaning, sustaining ourselves, and furthering our professional roles and that of our field.”¹⁰

The narratives in this issue of Annals cover territory that is both important and familiar: the ways in which clinicians and patients communicate; the challenges of practicing in a system that values quantity over quality; and the intersection of medical education and professional and personal growth. They do so through the lens of life experience, making each narrative a distinctive contribution that allows us to connect and consider in the context of our own life stories.

Words Matter

More than 30 years ago, literary critic Anatole Broyard wrote, “Since technology deprives me of the intimacy of my illness, makes it not mine but something that belongs to science, I wish my doctor could somehow repersonalize it for me.”¹¹ Two articles in this issue speak to Broyard’s prophetic wish.

Fleming and colleagues discuss the importance of open notes, documentation shared with the patient, as an opportunity to communicate with patients in a meaningful way. When “thoughtfully crafted, narratives in the medical record can foster connection,” the authors remind us, while the inverse, the potentially damaging effects of biased, negative, or unexpected content, is true as well.¹² The authors call for implementing patient-centered documentation curricula beginning in preclinical medical education.

If spoken words are more fleeting than those in the electronic health record, they are no less impactful. MacDonell-Yilmaz shares her experience at the end of a hospital visit in which a tired patient reflexively says goodbye to her, his physician, as he does to his wife, with an: “I love you.” This prompts the author to consider how she can best end an encounter while affirming her ongoing presence in the patient’s journey.¹³

Quantity Over Quality

India’s 1.4 billion citizens are treated within a large and complicated public-private health care system. Perhaps not surprisingly given its size, the system has insufficient resources, including a shortage of health care professionals.¹⁴ At a high-volume primary care clinic, intern Maanas Jain found himself quickly treating patients’ symptoms rather than exploring underlying causes. That changed when he took the time to diagnose and thereby help a patient. Dr Jain calls on his colleagues to change too: “If every doctor in India made an additional few diagnoses each day, given the country’s population, millions more might be adequately treated.”¹⁵

When Medical Training Should—and Shouldn’t—Reshape Us

The formation of professional identity is a complex process, a “profound personal transformation” shaped by “implicit and explicit lessons.”¹⁶ For medical student Benjamin Popokh, a one-month rural family medicine rotation provided such lessons. Being part of small-town practice meant being part of the life of the community, an experience that strengthened his professional identity and commitment to several core primary care values:¹⁷ “I will…approach each new community with a lifelong curiosity that ensures I remain humble and open to new perspectives, even as my experience and expertise grows.”¹⁸

But what happens when those implicit and explicit lessons don’t support a trainee’s evolving professional identity? This was the dilemma faced by John Ukadike. White medical school and residency faculty members advised him, a Black man, to change carefully chosen aspects of his professional identity to meet their perceptions of cultural appropriateness. It was advice he did not take. “It’s easy to forget who you are through the gauntlet that is medical training,” he writes. “The best part is that you get to choose who you are and how you present yourself. Choose to be you.”¹⁹

Life is Larger Than Science

People who are immersed in medicine know that science tells its own vitally important stories. And yet, if life is larger than science, then narrative is an essential companion, expanding vision and empathy, highlighting context, and introducing new ways of knowing. Together, science and narrative can provide meaningful insights into life—that complex, messy, and remarkable stew—that both seek to understand.