Interpreting people as they interpret themselves

I am a third-year student at the University medical Ottawa in Ontario planning a career in family medicine.I also have a PhD in medical anthropology.

I smiled when I read Miriam Divinsky’s “Stories for life. Introduction to narrative medicine” in February’s Canadian Family Physician.¹ Narrative medicine is new to family physicians, but it is the very substance of medical anthropology.

Listening and telling

As anthropologists, our modus operandi is collecting narratives. We undertake field work, during which we often spend a year or more living in foreign communities, immersing ourselves in people’s daily lives. We ask men, women, and children about their families; their religion; their understanding of the cosmos; their politics; their roles and status within their societies; and their perspectives on the body, the self, sexuality, sex roles, aging, child rearing, work, diet, violence, the economy, and international affairs. We then publish our ethnographic accounts using narrative as an analytic tool to support our arguments and as a literary tool to enhance our writing.

Within the realm of medical anthropology, ethnographers turn their attention to the cultural construction of health and illness, biomedical and other models of healing, international health policy and health care systems, and the social determinants of health. To learn something about illness experience, anthropologists elicit narratives and then interpret them. The ethnographic endeavour has been described thus: “Our anthropological productions are our stories about their stories; we are interpreting the people as they are interpreting themselves.”²

Arthur Kleinman is a physician who became an anthropologist.³ Byron Good is an anthropologist who analyzed the medical profession.⁴ They and other scholars, such as Allan Young,⁵ Clifford Geertz,⁶ Susan Sontag,⁷ Victor Turner,⁸ Edward Bruner,⁹ James Clifford,¹⁰ Lawrence Kirmayer,¹¹ George Marcus,¹² and Terence Turner,¹³ shaped medical anthropology’s scholarship on illness narratives and the poetics and politics of writing about people’s experiences of health and illness.

Through his clinical work as a physician, Kleinman was aware of the significance of medical histories: “Since eighty percent of diagnoses in primary care result from the history alone, the anamnesis (the account the physician assembles from the patient’s history) is crucial. The tale of complaints becomes the text that is to be decoded by the practitioner cum diagnostician.”¹⁴ Kleinman’s anthropologic training then led him to recognize that illness narratives have to be contextualized: “Each patient brings to the practitioner a story. That story enmeshes the disease in a web of meanings that make sense only in the context of a particular life.”¹⁵ He also realized that there was value in recording and publishing these stories. As Kleinman recalls, “The Illness Narratives told stories of sickness much as they had been told to me. I felt a deep compulsion to retell these accounts.”¹⁶

Medical anthropologists argue that illness narratives are not merely accounts of symptoms but a mechanism through which people become aware of and make sense out of their experiences. A transformation takes place from something lived (full of complexity but not given a single, crystalized meaning) into something interpreted (given structure and meaning through the dialogue that takes place between the patient and physician). “Narrativization” therefore acts as a reflexive, therapeutic, and even a transformative mechanism for people who have experienced illness. As Becker asserts, “Narratives, my own included, arise out of a desire to have life display coherence, integrity, fullness, and closure.”¹⁷

Moreover, when a person walks into a physician’s office, the physician becomes one of the players in the story. Good eloquently describes how our stories become intertwined: “The narrators—the person with an illness, family members participating in their care, medical professionals—are in the midst of the story they are telling.”¹⁸

Learning to hear

The Heartbeat Project is wonderful. It is reassuring that a group of family physicians has acknowledged the analytic and therapeutic value, for the physician and patient, of listening to and thinking about people’s stories.

But is narrative medicine truly a revolution? Or is it an anomaly, an interest shared only by a select few at the margins of the medical profession?

Faculties of medicine have been brought to task for churning out physicians with poor interpersonal skills. Despite attempts to include physicians’ skills development in our curriculums, the focus of our training is on the science of medicine: anatomy, pathophysiology, pharmacology. At the University of Ottawa, we spend some time in first year learning how to take medical histories—chief complaint, history of the current illness, past medical history, family history, social history, medications, allergies—but the skill of listening with sensitivity to people’s stories is not emphasized. We are evaluated on our ability to be methodical, not empathetic.

Students, like anthropologists, learn a lot through observation. If preceptors and residents do not take the time to truly care for their patients, neither will the next generation of physicians. How many times have staff physicians rolled their eyes and, with an air of distracted frustration, pleaded with students to deliver a quick, one-line summary? We come to realize that connecting with patients is not valued by our colleagues.

I was fortunate insofar as I found a family physician mentor who encouraged me to keep a journal of my encounters with patients. She told me that she wished she had done so when she was starting her career. Although recording patients’ stories is a wonderful start, there is no process in place for physicians or students to discuss these stories with colleagues, synthesize them, and reflect upon them.

As a medical student with an anthropology background, I think about the encounters with patients in the same way I think about my ethnographic encounters. The trouble is, my research has never had such a large cohort. My doctoral dissertation was based on 60 interviews. Yet I’ve already seen more than 100 patients. I think about them, think about them in relation to the health care system, empathize with them, and am overwhelmed at the end of the day. If this were anthropologic field work, there would be some stage at which I would stop collecting data. Instead, this will go on indefinitely.

Politics of stories

Those who know me will laugh, but I cannot end this commentary without adding that we have to be cognizant, as we promote narrative medicine, of the politics of storytelling. How those life stories are told, by whom, and the form that those stories take are fundamentally grounded in politics, history, and culture. “Narrative is always political,” medical anthropologists caution, “because people choose which narratives to tell.”¹⁹