Tag Archives: narrative medicine

How to Write, and do other things

I’ve been studying François Jullien’s book The Propensity of Things: Toward a History of Efficacy in China (Zone Books, 1995, original French 1992). It’s not the book I’d recommend for starting to read Jullien, but I want to work with some of his thoughts. The book is an extended study of the multiple sense of what’s meant by shi, a word that Jullien keeps redefining throughout but basically refers to how factors or forces are disposed, in the sense of the disposition of pieces on a chess board. Shi is an arrangement of what can have an effect, the actors in an Actor-network, to use Bruno Latour’s terms that seem remarkably compatible with the Chinese ideas. Efficacy in any action depends on correct assessment of what is disposed how. And because situations are always evolving, efficacy depends on timeliness, in sensing when the time is right for a particular action. When Hamlet, in Act V, utters his enigmatic line, “The readiness is all” (V.2.200), maybe he’s showing a newly gained awareness of disposition. He can act only within that disposition, and he must sense at what moment the disposition is optimal for his action. Lear, at the start of the play, represents the utter failure to recognize shi. He doesn’t know who’s who, and what could happen when resources are redistributed.

On Jullien’s account, efficacy depends on balancing two factors, which we can call the objective and the unprecedented. He describes these factors: “On the one hand, a historical situation–seen as a set of factors operating in a particular way–can be used to determine events objectively, since it allows one to constrain the initiative of individuals” (178). People can act only with resources at hand, whether those resources are cognitive, emotional, or material. How resources are disposed–which are available to whom on what terms of use–is objective; initiative depends on disposition, not vice versa. But: “On the other hand, every situation is new and unprecedented in character, one particular moment in an evolving process. As such, it cannot be reduced to previous models; it leads the course of things constantly to take new turns.” The measure of Shakespeare’s major characters, and some minor ones, is how they adapt to situations constantly taking new turns.

My whole career has been exploring balances between the objective and the unprecedented: how to give each its due. The core issue of doing any kind of narrative analysis is how to recognize that, on the one hand, a storyteller is working with a disposition of resources: character and plot types, available genres, listener expectations, how long a telling can last, what the censors will allow, and so forth. The versions of structuralism that I started off studying extend that: stories are structured in oppositions that are objective. In post-structuralism, discourses structure telling. So any story is predictable in many of its aspects; it mirrors the objective disposition of which it is part. But any story is also unprecedented. People, individually and in groups, are justifiably committed to the uniqueness of a story as theirs, which can require patience from a listener who has heard what sounds pretty much like that same story from others in pretty much that situation. But the patience is justified because each story is unprecedented and distinct.

Institutional medicine seeks to assimilate the individual patient’s story into a generalized disease trajectory. Healthcare research readily takes up thematic analysis, because it discards whatever is distinct in anyone’s story and holds onto what codes as generalized themes. By contrast, narrative medicine seeks to hold onto what is singular and unprecedented in each patient’s story, because to miss that loses a potential for healing that exceeds remediating the disease. Healthcare professionals working in narrative ways don’t give up using diagnostic categories. They just refuse to understand the diagnosis as all that needs to be known.

Now let me flip this and consider the process of writing, telling the story. Jullien paraphrases and quotes the 17C scholar Wang Fuzhi: “If a writer merely positions words here and there without the conscious mind truly expressing itself, the body of the poem ‘will resemble a sickly donkey laden with a heavy burden'” (142). Which pretty much describes how I see many journal articles, and it may say something about burn-out in healthcare professionals. “This is bound to happen if the inner feelings of the person composing the poem have not been truly engaged and [the writer] is simply opting for some subject or another in an artificial manner, and then decorating it with rhetorical figures.” In social science, such rhetorical figures include excess attention to generic matters of method.

Now we finally get to the punchline, quoting Wang Fuzhi: “Make the emotional will-to-tell the principle (factor) and the shi the next factor” (142). It’s more complicated than the apparent binary opposition of this quotation, because there’s also an emotional shi. What Jullien calls the emotional will-to-tell strikes me as what’s left out either in telling researchers how to write their reports or in teaching clinicians how to intervene. Timeliness, sensing the right moment, is not just intuitive but depends on knowing the objective disposition, through study. Write too soon, and your views lack maturity of reflection; delay and writing goes stale.

Shakespeare’s most successful characters act in small ways, assessing and preparing, and then they catch the moment when the disposition is right. The readiness is all, but it’s the readiness of the situation. At the right moment, the person just has to show up–Imogen (Innogen) in Cymbeline keeps herself in the game, and then is there when being there counts, pretty much what Viola does in Twelfth Night. Northrop Frye and others emphasize Prospero’s sense of acting at the right time, only when the disposition is favourable. Hamlet in Act V senses that, but he will still get killed. Of his death, Jullien provides a fitting epitaph: “What counts is not the individual’s moral caliber, but the age in which [that individual] lives” (178-79). Although throughout Hamlet, we’ve seen how much Hamlet’s moral caliber is a product of the age in which he lives.

The priority between the objective and the unprecedented constantly shifts; what else would we expect? In artistic production, the will-to-tell is necessary but depends on preparation; in politics, objective factors determine outcomes but skilled actors know how to use these factors. Life being a constantly shifting layering of personal and political, we have to attend to both the objective and the unprecedented, their relation always unsettled. But we have Shakespeare’s characters as companions.

Performing Others’ Scripts

I continue to be fascinated by how literary criticism about Shakespeare restates issues that I have been worrying about with respect to illness and the work of healthcare professionals. My most recent example comes from Shakespeare’s Lyric Stage: Myth, Music, and Poetry in the Last Plays, by Seth Leher of the University of San Diego. I hope to return to the issue of music in a later post. For today, I want to share two of Leher’s observations.

Some of Shakespeare’s late plays, especially Henry VIII which was included in the First Folio of 1623, are clearly collaborations, and scholars argue which parts can be attributed to Shakespeare. Leher frames the issue otherwise: “I am not interested in statistical variations to determine which lines are Shakespeare’s and which are Fletcher’s,” he writes. He’s on to something more relevant to most of us who are not textualists: “What I am interested in is how the play raises authorship and individuality, collaboration and response, as themes.”

My thinking moves laterally to consider how health care involves themes of authorship and individuality, collaboration and response. In any healthcare dyad–physician/patient, nurse/patient, physician/nurse, administrator/clinician–each must collaborate with and respond to the other. Yet each engages with a particular other while keeping in mind that they are enmeshed in relationships of collaboration and response with others who are not in the room but who will hear about what happens and react to it. For patients, these others begin with their families and loved ones. For professionals, the others proliferate from colleagues down the hallway to persons in distant offices who exercise authority. What might constitute either authorship or individuality in health care is not easy to think about. Yet because the stakes on what happens are existential–what’s at issue is who a person is, as a soul that is answerable for what it does and leaves undone–questions of authorship and individuality cannot be dismissed.

Leher continues: “Characters like Ariel [the spirit who serves Prospero in The Tempest] and Autolycus [the con man who sells ballads in The Winter’s Tale] … dramatize the challenges of performing the scripts of others while attempting to take on an individual identity.” Health care is hardly the only venue that requires performing the scripts of others, but doing so seems a particular challenge in health care for at least two reasons. One, as I just said, is that the stakes are high; actions count and people remember for the rest of their lives. Another reason is that healthcare institutions are especially saturated with scripts of others, again for both professionals and patients. If I were writing a book about healthcare institutions, The Scripts of Others would make a good working title.

In my 2004 book The Renewal of Generosity I dealt with this problem at the end, when I talked about healthcare professionals as a species of artificial persons. That term was coined a generation after Shakespeare by Thomas Hobbes; it’s late Jacobean period, whereas Shakespeare was writing during the ascendency of James I. But artificial persons comes from a world that’s still recognizably Shakespearean and it remains recognizably our world. In this world, people are called upon to act in consequential ways not on their own moral judgment but according to some script of others. The physician has to follow a standard of practice or an institutional protocol. The patient feels required to do what is indicated by her family, or her religion, or her health insurer, or the medical team whom she doesn’t want to alienate. Yet as the stories of healthcare professionals and ill people eloquently testify, these people still feel an individual responsibility, as well they should.

In the first printed collection of Shakespeare’s plays, the First Folio, the last play is Cymberline. Leher discusses whether its placement reflects a considered choice by the editors or various contingencies of publication, including when the printers received the text. I love that controversy: it’s life, all over. Cymberline has one of the most convoluted plots of any of Shakespeare’s plays; every twist and confusion found in other plays is somehow reenacted in Cymberline. Leher offers a wonderfully generous interpretation, again making this confusion into the topic that the play seeks to explore. He summarizes: “Telling its own story is difficult: for us, for its history of audiences, and for its characters.” And that, again, is a concise statement of the work I’ve been doing ever since I starting struggling to tell the story of my own illnesses back in the 1980s.

Vulnerable reading offers help to those for whom telling their own story is difficult, especially because their story is always-already full of stock phrases, motives, and plots from scripts of others. When people most need to be individual, and responsible in their individuality, they find their words are not their own. Especially Shakespeare’s late plays offer the consolation of sharing that trouble with characters whose struggles are contained in ways that real life troubles are not. Their difficulty is our difficulty. What resolution those characters find does not solve our difficulties, because troubles like these do not resolve. But the solace of a story against which we can measure our own is a form of solution. With the story as a companion, we persevere not better but perhaps more content.

Two Solitudes of Humanities in … What?

People of the academy love disputes over terminology; it’s so much easier than, well, doing a lot of other things we might be doing. And so, feeling like doing something easier myself, let me offer a comment on the ongoing question of whether it’s medical humanities or healthcare humanities.

First, I agree with something Rita Charon once wrote that neither usage is commendable English, and using language that is commendable ought to be a core objective in this work. Neither medical nor healthcare is a felicitous adjective–even a minimally meaningful adjective–to modify humanities. We should say either humanities in healthcare or in medicine. But we probably won’t. So at least add my objection to Charon’s.

Of more interest is which adjective to use. Medical is the older term, so far as I know. The objection, in this context as in others, is that medical at least privileges physicians and at worst is exclusionary of non-physicians. Healthcare came in as the more inclusive term, promising a bigger tent, welcoming everyone. Tess Jones and colleagues published the Health Humanities Reader, but I now gather that health humanities is disfavoured, which is fine with me, although maybe new editions of the book should be retitled. Point is, until now most of the usage controversy was over a mostly symbolic adjectival signifier, a question of word choice. I see that changing. The politics are intensifying.

Some of my recent experiences disturb me. I’m seeing medical humanities and healthcare humanities not as two names for what was fundamentally the same enterprise, but rather as two distinct enterprises. Distinct in terms of what is taken as important topics for study, what counts as a good or publishable study (writing templates and expected citations), what counts as being a proper study at all in terms of meta-reviews, who is accredited as doing the work, whose work is accredited as counting for what, and what the credited publication outlets are–which journals count and whether books count at all. That’s a partial list of what separates academic cultures. Of course there are still significant overlaps in what’s of interest and in who’s doing the work. But I see an increasing drift that I hope will be talked about and written about. What is at issue is central to the politics of the medical-academic complex.

To complicate matters, narrative medicine, with the Columbia program as its flagship, seeks to bridge both, especially the social-justice concerns that are central to healthcare humanities and the medical-education focus of medical humanities. The limitation lies in both words, narrative and medicine. Many of the projects and media of interest to both healthcare humanities and to medical humanities are non-narrative except in such an inclusive sense that narrative loses all specificity of reference. And the possibly exclusionary designator medicine remains, although nurses and other non-physicians study at Columbia and call what they do narrative medicine. I’m interested that the phrase narrative medicine just doesn’t appear on some institutional websites that proudly present their medical humanities work. I count that as what’s lacking in those programs, but for now my point is that straddling both worlds may get more difficult, not less.

If what I see is representative, and there are increasingly two solitudes of healthcare humanities and medical humanities, I’d count that as a loss to everyone. Inter-professional education, by which I mean occasions when students from different healthcare disciplines learn with and from each other, each valuing the other, is something everybody is supposed to approve of, although I have trouble finding venues where it actually takes place (I’d appreciate news of such happenings, which I’m sure are there, somewhere). Humanities in improving care for the ill, and in improving the lives and work of all persons working in healthcare, would seem like the ideal opening for inter-professional education. Can humanities be the level playing field where everyone’s expertise, especially the expertise of persons living with illness, can be valued equally? Because that’s the issue as I see it. Can medical/healthcare spaces offer equal respect for multiple forms of expertise, acknowledging in which moments one expertise or another may be most relevant? It’s all about hierarchy, and the insidious ways that hierarchies are perpetuated, including conventions of academic work, as well as program funding and much, much else.

Or will commitments to sustaining forms of hierarchy create a further drift into two solitudes, neither reading or listening to the other, alternatively suspicious of each other and tacitly deprecating each other? I truly hope my perceptions are skewed. I’d love to be wrong about this.