Rochester Review
January-February 2010
Vol. 72, No. 3
Story as a PDF
Departments
In Review
COURSE MATERIALS: Medical students Chau Doan and Josh Segal contributed sound effects—including the sound of matches being lit—as part of an exercise in storytelling. (Photo: Brandon Vick)When a patient visits a doctor, one of the fundamental tasks of the appointment is not only medical but also literary: You tell the story of your complaint, including the pertinent information about your circumstances.
“It’s a privilege to hear people’s stories,” says Chau Doan, a second-year medical student from Garden Grove, Calif. “Patients come in, and you don’t know them and they don’t know you—but they divulge the most intimate details about their lives.”
The creation and the conveyance of those stories—from patient to physician, from doctor to doctor, from oral account to written document—is the subject of a seminar offered to second-year medical students through the Division of Medical Humanities, called How to Read (and Write) a Patient: Studying Narrative and Developing History-Taking Skills. Developed four years ago, the course brings literary narrative theory to bear on the day-to-day issues doctors face in taking medical histories from their patients.
“There’s a lot of narrative” in clinical medicine, “but there’s no training in the theory of it,” says Stephanie Brown-Clark, an associate professor in the Division of Medical Humanities and course director of medical humanities seminars. “Standard and classic teaching texts on medical history-taking emphasize the importance of obtaining the patient’s story, and extracting the pertinent details from it, without focusing on the ways that stories work. The assumption is, we all know how to tell stories.
“We tell students to hear the patient’s story—but we don’t teach them narrative skills.”
The course aims to remedy that, helping students to become as perceptive of the choices implicit in storytelling as they are sensitive to recognizing symptoms.
“There are as many ways for a patient to give a history as there are ways for a writer to tell a short story,” says Clayton Baker, an assistant professor of medicine who coteaches the course with Brown-Clark. “An important part of clinical practice is to pick up on things that aren’t obvious.”
Patient histories rarely follow strict chronological time in relating events, for example, and the choices patients make in ordering their stories can be revealing. “Patients tend to order details and events according to what makes the most sense to them, what’s most important to them,” Baker says.
Thus, Baker and Brown-Clark teach the students about dimensions of narrative that will help them to listen more effectively to a patient’s story and then write their own account. They perform “close readings,” the literary practice of attending meticulously to textual evidence, which has obvious parallels in the evidence-based practices of medicine. They become familiar with concepts of narrative structure, plot, context, and relationships between author and reader.
“The physician is not just listening passively as patients relate their history, but actively prioritizing, editing, and rewriting the information he or she is given, says Baker, who practices in a Veterans health clinic and has published his own creative writing in the Journal of the American Medical Association and other medical journals. “One thing we stress to students is that we often do a lot of these things without being consciously aware that we’re doing them.”
There are many formats in which doctors might convey information about a patient, from a momentary encounter with a colleague to a discharge meeting with family members, social workers, and nurses, to Grand Rounds, where doctors make formal case presentations to an auditorium filled with a couple hundred fellow physicians.
“There are a tremendous number of editorial decisions that you have to make whenever you relate a patient’s history, and you’re talking on the patient’s behalf at all times,”
Brown-Clark, who holds both a medical degree and a doctorate in literature. She and Baker identified medical situations in which communication becomes particularly difficult, such as when discussing drug use or sexual history or when delivering a difficult-to-hear diagnosis.
The course materials range widely: stories by Kafka, Chekhov, and Tolstoy; Quint’s monologue from Peter Benchley’s Jaws; sonnets from John Donne; the film Wit; a sketch from the comedy troupe Monty Python that dissects the social agony of embarrassment.
Based on the readings, the students discuss scenarios—not just the questions physicians might ask a patient, but how they might ask them. It’s about “finding the right words that will be sensitive, and that will be clear,” Brown-Clark says.
Because taking a patient history involves so much talking and listening, Baker and Brown-Clark construct class sessions in ways that allow students to practice oral skills. In reading contemporary essayist and physician Jerome Groopman’s “The Last Deal,” for example, students take turns reading sections of the essay aloud, with Brown-Clark stopping them at strategic moments to ask “What do you know now?” and “How do you know that?”
Professional storyteller Marilyn Rosen, a reference librarian at Miner Library, also performs for students, delivering an oral folktale that’s complex, detailed, and ambiguous. Students in turn have to retell the story in written form, and then summarize it again as they merge their version with a partner’s and then with those of all their classmates. The seemingly fanciful task is an effective analogy for working with a tangled patient history, Brown-Clark and Baker say.
“It’s an exercise. You learn by doing,” says Josh Segal, a second-year medical student from Huntington Beach, Calif., and Doan’s classmate in the seminar this winter. “You practice focusing on what’s most important—the things you absolutely don’t want to miss.”
As with all seminars in the medical humanities program, the focus of the course is on enhancing students’ medical proficiency.
“We’re trying to develop skills useful in taking a history and in clinical settings,” says Brown-Clark.
As a result of the course, Segal says, he has “more sensitivity to the background that comes with a patient and how that contributes to their story.”
The biopsychosocial model of medicine for which Rochester is known—taking into account psychological, interpersonal, and societal influences in the diagnosis and treatment of patients—infuses the curriculum, Segal and Doan say.
“I think this school really does believe in approaching the patient as a person,” says Doan. “And that philosophy is demonstrated with classes like this one. They want us to be three-dimensional doctors.”
