Education and debate

Why study narrative?

Trisha Greenhalgh, senior lecturer, ^a Brian Hurwitz, senior lecturer. ^b

^a Department of Primary Care and Population Sciences, Royal Free and University College London Medical School, London N19 5NF, ^b Department of Primary Care, Imperial College School of Medicine at St Mary's, London W2 1PG

Correspondence to: Dr Greenhalgh p.greenhalgh{at}ucl.ac.uk

	What is narrative?

One day when Pooh Bear had nothing else to do, he thought he would do something, so he went round to Piglet's house to see what Piglet was doing. It was snowing as he stumped over the white forest track, and he expected to find Piglet warming his toes in front of the fire, but to his surprise he saw that the door was open, and the more he looked inside the more Piglet wasn't there.¹

This excerpt from the opening chapter of a well known children's story illustrates a number of features of narrative as a linguistic form. Firstly, it has a finite and longitudinal time sequencethat is, it has a beginning, a series of unfolding events, and (we anticipate) an ending. Secondly, it presupposes both a narrator and a listener whose different viewpoints affect how the story is told. Thirdly, the narrative is concerned with individuals; rather than simply reporting what they do or what is done to them it concerns how those individuals feel and how people feel about them. Both Pooh Bear, trudging hopefully through the snow, and Piglet, mysteriously absent from his usual place beside the fire, are already characters in the story rather than merely objects in the tale.

The narrative also provides information that does not pertain simply or directly to the unfolding events. The same sequence of events told by another person to another audience might be presented differently without being any less "true." This is an important point. In contrast with a list of measurements or a description of the outcome of an experiment, there is no self evident definition of what is relevant or what is irrelevant in a particular narrative. The choice of what to tell and what to omit lies entirely with the narrator and can be modified, at his or her discretion, by the questions of the listener.

And finally, the narrative is absorbing. It engages the listener and invites an interpretation. It offers us the experience of "living through, not simply knowledge about" the characters in the story.²

	Narratives in the experience of illness and healing

We "dream in narrative, daydream in narrative, remember, anticipate, hope, despair, believe, doubt, plan, revise, criticise, construct, gossip, learn, hate and love by narrative."³ Episodes of sickness are important milestones in the enacted narratives of patients' lives. Thus, not only do we live by narrative but, often with our doctor or nurse as witness,⁴ we fall ill, get better, get worse, stay the same, and finally die by narrative too.

The narrative provides meaning, context, and perspective for the patient's predicament. It defines how, why, and in what way he or she is ill. The study of narrative offers a possibility of developing an understanding that cannot be arrived at by any other means. Doctors and therapists frequently see their roles in terms of facilitating "alternative stories that make sense from the patient's point of view." ^{5 6} It has been argued that in psychotherapy the role of the therapist goes further: the therapist should assist the patient in his or her attempt to construct and work through the unconscious elements of a half written personal story.⁷

Understanding the narrative context of illness provides a framework for approaching a patient's problems holistically, as well as revealing diagnostic and therapeutic options. Furthermore, narratives of illness provide a medium for the education of both patients and health professionals and may also expand and enrich the research agenda (box). Indeed, it is thought that anecdotes, or "illness scripts," may be the underlying form in which we accumulate our medical knowledge. ^{8 9} Medical students rely on anecdotes of extreme and atypical cases to develop the essential ability to question expectations, interrupt stereotyped thought patterns, and adjust to new developments as a case unfolds.¹⁰

The dialogue in the box took place between one of us (BH) and a patient attending a diabetic clinic in general practice. The conversation was recorded on tape and is reproduced almost verbatim with the patient's consent. There are a number of important points in the story. Firstly, the immediacy of the patient's voicehis particular way of explaining thingscannot be ignored by a listener or reader, although this would be impossible to capture were the story to be retold in the standard forms used for medical histories. Secondly, the onset of this man's disease is inextricably embedded in a narrative structure: he recounts with almost choreographic precision how the symptoms unfolded together with his efforts to communicate them.

Despite the passing of 30 years, the patient's utter helplessness at the hands of his medical attendants is chilling. It is not simply that his doctor did not seem to listen to him: the doctor's advice and inaction were predicated on an entirely different story from the one that required urgent intervention. Asher was graphic in drawing attention to the dangerous tendency of clinicians to see the expected and unconsciously to dismiss the anomalous: "We have to beware of this suppressive faculty which, by producing selective deafness, selective blindness and other sense rejections, can so easily suppress the significant and the relevant." ^{11 12} The box describes a new initiative for collecting these stories and utilising their educational potential for both patients and health professionals.

	The study of meaning

Even the most pompous professors have been known to warn their students, "Listen to the patient: he or she is telling you the diagnosis." A more sophisticated view holds that when doctors take a medical history they inevitably act as ethnographers, historians, and biographers, required to understand aspects of personhood, personality, social and psychological functioning, and biological and physical phenomena.¹³

The notion of interpretationthe discernment of meaningis a central concern of philosophers and linguists, but it is a concept with which doctors and other scientists are often unfamiliar, and hence uncomfortable. Hunter, a professor of literature with a strong involvement in medical education, writes, somewhat controversially, that clinical medicine "shares its methods of knowing with history, law, economics, anthropology, and other human sciences less certain and more concerned with meaning than the physical sciences. But unlike those disciplines, it does not explicitly recognise its interpretive character or the rules it uses to negotiate meaning."¹⁰ She is puzzled by the medical profession's preoccupation with the gold standard of science in clinical practice, and believes that medicine is better characterised as a "moral knowing, a narrative, interpretive, practical reasoning." ^{14 15}

	A lost tradition

The oral tradition of myths and legends, which are continually recreated by word of mouth in successive generations, still features prominently in many non-Western societies and impacts profoundly on the experience of health and illness in these societies.¹⁶ Perhaps it is partly because Western culture has lost its grip on this oral tradition that the skills of listening to, appreciating, and interpreting patients' stories are only rarely upheld as core clinical skills in medical curriculums. Much of the current emphasis in medical training is on the student acquiring the ability to express a patient's problem in the structured and standardised format that has come to be known as the "medical history" in the United Kingdom and "clinical clerking" in North America. It has been shown that somewhere between the first year and the final year of medical education, undergraduate students exchange a native facility for eliciting and appreciating patients' narratives for the learned expertise of constructing a medical history.¹⁷

Narratives frequently appear in a vestigial form in the conventional clinical encounter of modern times. Certain descriptions of symptoms appear as fragments torn from elaborate stories and are alighted on by clinicians as especially revelatory: "My shortness of breath always gets worse when I lie down but the funny thing is the pain only comes on when I climb stairs," or "I was washing the dishes when everything went blackit was like a curtain coming down." Less familiar experiences may be just as important to the patient but the value of such "classic" symptoms to doctors as readers of signs is akin to a mirror held up to nature: so closely are they aligned to physiological and pathological mechanisms that the story fragments faithfully portray, in a linguistic form, particular biological dysfunctions.

At its most arid, modern medicine lacks a metric for existential qualities such as the inner hurt, despair, hope, grief, and moral pain that frequently accompany, and often indeed constitute, the illnesses from which people suffer.¹⁸ The relentless substitution during the course of medical training of skills deemed "scientific"those that are eminently measurable but unavoidably reductionistfor those that are fundamentally linguistic, empathic, and interpretive should be seen as anything but a successful feature of the modern curriculum.

The core clinical skills of listening, questioning, delineating, marshalling, explaining, and interpreting may provide a way of mediating between the very different worlds of patients and health professionals. Whether these tasks are performed well or badly is likely to have as much influence on the outcome of the illness from the patient's point of view as the more scientific and technical aspects of diagnosis or treatment.¹⁸

	Acknowledgments

Series editor: Trisha Greenhalgh

	References

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