Johanna Shapiro, Ph.D. is professor of family medicine and director of the Program in Medical Humanities & Arts, University of California Irvine – School of Medicine. As a psychologist and medical educator, she has focused her research and scholarship on the socialization process of medical education, with a special focus on the impact of training on student empathy; and on the doctor-patient relationship, including physician interactions with “difficult”, stigmatized, and culturally diverse patient populations. She is poetry co-editor for “Pulse: Voices from the Heart of Medicine and for Families, Systems, and Health”; and assistant editor for “Family Medicine”. Her book, “The Inner World of Medical Students: Listening to Their Voices in Poetry”, is a critical analysis of important themes in the socialization process of medical students as expressed through their creative writing.
Q. What are Humanities for Health and Narrative Medicine now, in 2015, in your opinion?
J.S. Health Humanities and Narrative Medicine are an opportunity to understand the practice of clinical medicine and healthcare generally from alternative and more critical perspectives. On a macro level, by revealing powerful discourses around health and illness, they allow us to question how power and authority flow in healthcare systems, and how these affect individual lives. On the micro level, the emphasis of health humanities and narrative medicine on intersubjectivities helps learners and practitioners challenge their assumptions and biases, cultivates alternative points of view, helps foreground the voices of marginalized participants, and allows us to move closer to the suffering of others without judgment or blame and with an intention to take actions that will ameliorate that suffering.
Q. Do you think that they are important in clinical practice?
J.S. Narrative Medicine and the broader interdisciplinary field of Health Humanities both clearly have important implications for clinical practice. Again, as above, they offer a different lens (actually, many different lenses!) through which to view patients, family members, doctors, nurses, OTs, PTs, social workers etc. In its simplest – yet perhaps most relevant – permutation, Narrative Medicine is about listening with (in Arthur Franks’ terminology), valuing, respecting, and learning from story – first and foremost patients’ and families’ stories, but also one’s own stories and those of colleagues and co-workers. This is not synonymous with accepting or endorsing those stories wholesale – which is why the tools of narrative medicine that assist us in excavating language, tone, broader social influences and assumptions, in short, how the story was constructed are so crucial to acquire.
Q. What do you think about making Narrative Medicine a specific academic subject? Do you think that it could be a radical change for the Narrative Medicine practice?
J.S. If the question is whether the study of narrative medicine, or some health humanities approach to patient stories, should become part of the required curriculum, I would argue yes. There are several reasons for this. Required curriculum is perceived by learners – and other faculty – as more relevant and valuable. It represents an institutional and disciplinary endorsement of certain bodies of knowledge, methods of reasoning, and even ways of being. Thus, learners might be more likely to take the subject matter – and the reflective, interrogative approach to learning generally – more seriously. Also, exposure to a baseline level of narrative medicine ensures that, just as all medical students are required to study anatomy, all future physicians would have a foundational understanding of the sense in which medicine is a narrative practice. Considering how narrative medicine itself might benefit from required representation in the curriculum, I believe this would encourage its proponents and teachers to remain anchored in clinical realities.
Q. What could we read behind medical students’ narrative forms and expressions?
J.S. It goes without saying that not only patients have stories, but so do physicians and of course medical students. Medical students’ stories, like other stories, are not constructed in a vacuum, but emerge from within a web of powerful authoritative institutional, societal, and cultural discourses. Because students generate at least some of their stories within an educational context, while such stories always deserve respect and suspension of judgment, in my view it is also legitimate to help students see how their stories may reflect unexamined assumptions, biases, and expressions of power. Medical student stories are a valuable educational tool to help encourage students’ critical thinking about how they perceived the world of medicine. Co-reflecting with students on their stories can encourage students to “dig deeper,” to consider events and actors from alternative perspectives, to re-evaluate their own and others’ behavior, and to interrogate underlying values. As well, medical student stories are particularly worthy of examination because they both provide insights into students’ perceptions of their own educational and professional experiences, which will have significant implications for revising medical education.
Q. Could we think about moving from Narrative Medicine to a more “holistic” form of comprehension of illness, body-states, and health, so to come to Narrative Healthcare or Narrative Health Competence?
J.S. I think there may be limitations both with the term “narrative” and with the term “medicine”. It all depends on definition. For example, much excellent work has been done on broken narratives as a characteristic of illness stories. Are broken narratives or anti-narratives still narratives? Perhaps. “Medicine” may also be a limited term, which explains the recent adoption of the more expansive and inclusive term, “Health Humanities”. Medicine has a bad habit at putting the physician and medicine at the center of everything, whereas of course we know this is where the patient should be.
Q. Do you think that this approach could be important in the training of medical students?
J.S. The commendable trend toward team-based medicine has the potential to nuance and adapt doctor-nurse (and other) professional relationships in more horizontal and respectful directions, less interested in hierarchy and more interested in respecting and valuing expertise however and in whomever it manifests. In this sense, approaches in the humanities that honor interdisciplinary understandings of healthcare should be promoted. Language matters. A more inclusive term that acknowledges not only the role of medicine in healthcare, but also nursing, OT, PT, speech therapy, social work etc. is infinitely preferable, especially because by doing so we reify a commitment to honoring multiple perspectives on what it means to be sick and what should be done about it. Even more importantly, interdisciplinary training that accustoms nursing and medical students (and others) to learn and problem-solve together will lay essential foundations for future clinical practice. Narrative medicine (or healthcare) is an essentially interdisciplinary study to begin with, so lends itself well to involving students from different backgrounds and headed for different professions. The enterprise of caring for sick and suffering people is messy, uncertain, and complex (and also at times wonderful). We should embrace the richness of this reality, and the health humanities and narrative healthcare (!) give us important ways of doing so.