I want to add a brief addendum to my last post, which was itself an addendum to my 2013 article on the importance of social theory for medical education. At the end of that article, I describe what I call the scarcity loop. By that I mean an assumption or presupposition that underlies so much thinking about healthcare policy, limiting what is able to be thought. In briefest terms, the scarcity loop imposes on our thinking the parameter that there is never enough: never enough money in the healthcare budget, never enough space in the hospital, never enough time in clinical education curricula or in encounters between clinicians and patients. Thinking that proceeds on the basis of the scarcity loop is always already adversarial: the individual healthcare worker is pitted against the relevant scarcities that delimit possibilities of offering care; the patient confronts a system that constantly betrays its own promises of “the best possible care” and continually appeals to the scarcity imposed on it.
The scarcity loop is especially relevant to narrative medicine (or, so-called “narrative medicine”, remembering I use this as a term of convenience). The prime objection to narrative medicine is that it demands time that is already in too-short supply: either curricular time or clinical time. Narrative medicine is framed, as a physician once complained to me (or maybe he was being ironic) as “one more thing” to do. That phrase itself reflects the scarcity loop: clinicians are conditioned to see that work as a checklist of items to be ticked off before the day or night’s work is … never done but accountably completed. Patients are fragmented into to-do lists–I remember one medical resident showing me his daily matrix of assigned patients and tasks to be completed. People who, as patients, are subjected to this fragmentation internalize it. Being ill turns into regimes of self-care that fragment one’s sense of self and its possibility.
Here’s another way to understand narrative medicine: thinking, being, experiencing outside the scarcity loop; seeing the moment as sufficient. Eventually, knowing the moment as even abundant, although that takes time, and I’m certainly not there myself.
How to do this? How to make the refusal of scarcity one’s practice? I suggest beginning small, with the least possible demand. When I used to be in a teaching relationship with clinicians, I suggested beginning by taking nothing more than a few seconds with only one or two patients a day, and at some point during the clinical encounter, simply be silent, doing nothing except being with that patient. And then let those moments, starting with literally 10 seconds a day, grow. We know from studies of conversation that a one or two second pause is hearable, noticeable as a pause; the other person expects talk to continue, and in even a couple of seconds, reflection begins on why the other is silent, what’s going on? Here we get to the part that’s beyond language: projecting your sense of being with the other, so that the other person feels it. I don’t think that’s complicated. I think it just happens; we’re wired for it to happen. But it has to be willed to happen, sought, desired.
In my imagination, narrative medicine as a clinical practice begins before any narrative in the sense of narration in symbolic form. It begins in silence. It begins the clinician sharing silence and so cueing the patient to experience their own silence, which the organization of hospital and clinic care discourages with its pace and noisiness.
The conditions that the scarcity loop responds to are real, and recognizing that reality is crucial to getting out of the loop as a limited way of thinking. There really isn’t enough money, or space, or time, but conditions of lack are made worse in their consequences when the “best possible care” mantra requires not acknowledging that what’s on offer isn’t the best. What I’m recommending are moments that cannot make those real scarcities go away or become less harmful, but these moments of intentional silence can open up the totalization of the scarcity loop, the sense that’s all there is or can be, tasks without end. Fracturing the totalization of a way of thinking enables dealing with it productively, instead of perpetual defensive reactions.
That sounds awfully advice-giving, so please understand that I write this to give advice to myself. I’m at a moment in my life when I’m caught in my own scarcity loop. It’s Sunday, and tomorrow, when offices open, I have more to do that I’m sure I can get done; demands exceed supply, which defines scarcity. Those demands are real, as is the finite nature of time. But on Sunday, I’m trying to convince myself that I do have a choice how I experience Monday’s demands. Perhaps by writing this, I can convince myself. If I’m a little bit convinced, maybe I can do my tasks in ways that don’t enlist others in my sense of scarcity. That’s what narrative medicine seeks to do, either in the classroom or the clinic: refuse to draw others into the scarcity loop; instead, open a space outside it. Breathe, and feel no need to do anything.
Arthur W. Frank 