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Perspectives

The art of medicine


Narrative humility
So much of a writers life consists of assumed suering, Rita Charon, my colleague at the Program in Narrative
rhetorical suering, writes Anatole Broyard in Intoxicated Medicine at Columbia University, has written extensively
by My Illness, and Other Writings on Life and Death, a memoir about the skills required to witness the patients story. Using
published after his death from metastatic prostate cancer. the language of medical training, in which educational
Like the writer, whose work depends on entering into the milestones are described as competencies, she has named
imagined suering of equally imagined characters, so too this clinical skill set narrative competence. Over the years,
is the doctor intertwined inextricably with assumed or in working with Charon and our other colleagues at the
rhetorical suering. This is, of course, not to suggest Program in Narrative Medicine, I have come to expand
that pain, illness, or disgurement are somehow not upon this notion, realising that, although clinicians should
real to patients and their clinicians; rather, to suggest continually strive for measures of narrative competence,
that entering into a suering which necessarily resides the stance from which we witness stories of suering must
outside the clinicians own physical and emotional being be one of narrative humility.
depends upon the clinician nding an entry point into One very literal aspect of narrative humility is the fact
that suering from within her own imaginative self. This that the patients story, at least initially, belongs entirely
entering into the suering of another is akin to the work of to him. Unlike the physician of mine who, during a recent
the novelist, who must get to know his characters, like new personal illness, interrupted me to say, You dont have
acquaintances, and allow the storys plot to unfold before to say any more. I know exactly how your story ends,
him; it is like the act of the careful reader, who enters into clinicians cannot, of course, ever exactly know how any
the metaphor of the poem while allowing the metaphor illness story begins or ends. As careful interviewers and
of the poem to enter him, granting yet undiscovered witnesses, we become invested in, wrapped up with, and,
meaning to his lifes events. yes, coauthors of our patients illness narratives, but we
cannot ever claim to comprehend the totality of anothers
story, which is only ever an approximation for the totality
of anothers self. In an essay on the work of philosopher
Emmanuel Levinas, medical educator and philosopher
Craig Irvine describes the Other as that which lies always,
and necessarily, beyond the comprehension of the Self.
Endeavours to fully capture, understand, or master the
Other are, then, nothing more than totalising enterprises.
Yet, the primordial ethical act, the act in which medicine is
ideally engaged, lies in answering the call of the suering
Other. In this context, narrative humility is, in Irvines
words, the sense of humility toward that which we do not
The printed journal knowthe face of the Other, the face we cannot know but
akg-images/Banco de Mexico Diego Rivera & Frida Kahlo Museums Trust, Mexico D.F./DACS

to which we are responsible.


includes an image merely Narrative humility is a response to eorts at clinical
mastery, including many well intentioned ones, such as
for illustration my own past work in culture and diversity training with
medical traineeswhat is still sometimes called cultural
competency. Such training, which aims to enable
physicians to better care for patients with socioeconomic,
ethnic, or other characteristics that make them dierent
from their care providers, can sometimes become a sort of
cultural mastery of marginalised communities. Although
this is fortunately no longer the usual case, cultural
competency training still sometimes involves handing
trainees lists of cultural characteristics: when a Dominican
tells a story about susto, this is what she means; when
a Chinese immigrants body reveals mysterious round
The Two Fridas (1939) by Frida Kahlo markings, they are evidence of coining; and so on. This is

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Perspectives

not to say that familiarity with cultural beliefs and practices more clearly. Oral historian Alessandro Portelli has written
does not improve a physicians ease with her patients extensively about mutuality in the relationship between
illness narrative; rather, that the unstated assumptions eld researcher and subject, but his comments can be
of this sort of trainingthat trainees are necessarily from easily applied to the clinical relationship. He writes, an
a privileged cultural group, that patients of a particular interview is an exchange between two subjects: literally
background share homogeneous beliefs, that the complex a mutual sighting. One party cannot really see the other
nuances of dierence can be mastered, and that ethnic unless the other can see him or her in turn. The two
similarity between clinician and patient mandates mutual interacting subjects cannot act together unless some
understandingbelie its well intentioned goals. Most kind of mutuality can be established. Thus, the [clinician]
importantly, traditional cultural competency training, like has an objective stake in equality. In other words, by
traditional medical training, is externally focused, primarily entering into a stance of narrative humility, the physician
concerned with mastering the Other, rather than examining is fostering a state in which, as Broyard has observed, even
the internal cultures, prejudices, fears, or identications of as the physician examines the patient, the patient is able
the Self in relation to that Other. to examine the physician. The witnessing function, so
In fact, my notion of narrative humility borrows from crucial to doctoring, becomes a mutual one, supporting
the work of Melanie Tervalon and Jann Murray-Garcia and nourishing both individuals, while enabling a deeper,
who suggested, in 1998, the term cultural humility as more fruitful clinical relationship.
opposed to cultural competency or cultural sensitivity Narrative humility is not, perhaps, a stance that traditional
to guide clinicians in serving the needs of diverse medicine readily takes, yet its derivatives are profound.
populations. Bringing attention to the internal workings As Broyard writes, Not every patient can be saved, but
of the clinician, they suggest that cultural humility is a his illness may be eased by the way the doctor responds
practice committed to a lifelong process of self-evaluation to himand in responding to him the doctor may save
and self-critique. himself. But rst he must become a student again; he has
Narrative humility acknowledges that our patients to dissect the cadaver of his professional personaIt may be
stories are not objects that we can comprehend or master, necessary to give up some of his authority in exchange for
but rather dynamic entities that we can approach and his humanity, but as the old family doctors knew, this is not
engage with, while simultaneously remaining open to a bad bargain. In learning to talk to his patients, the doctor
their ambiguity and contradiction, and engaging in may talk himself back into loving his workby letting the Further reading
constant self-evaluation and self-critique about issues sick man into his heartthey can share, as few others can, Broyard A. Intoxicated by my
illness and other writings on life
such as our own role in the story, our expectations the wonder, terror, and exaltation of being on the edge of and death. New York: Ballantine
of the story, our responsibilities to the story, and our being, between the natural and the supernatural. Books, 1992.
identications with the storyhow the story attracts Narrative humility suggests the possibilities of something Charon R. Narrative medicine:
or repels us because it reminds us of any number of transcendent, what Broyard calls the opportunity to honoring the stories of illness.
New York: Oxford University
personal stories. Also by thinking about it as narrative become transgured. It approaches what has been called Press, 2006.
humility (and not just cultural humility), we recognise mindfulness in medicine. Indeed, humility is a central Irvine C. On the other side of
that this is a perspective we take with all the stories with aspect of many spiritual traditions, whereby the stance of silence: Levinas, medicine, and
which we engagenot just something we do when those humility is one that enables not only personal growth, but literature. Lit Med 2005;
24: 818.
other people walk into our oce, whatever that may is a hallmark of some degree of spiritual enlightenment
Portelli A. The death of
mean to uswhile simultaneously not losing the idea, whereby the most learned monks are the most humble, Luigi Trastulli and other stories:
the parallel sociopolitical narrative, that there are larger recognising how much they have left to learn. This does not form and meaning in oral
forces that enable the telling of certain sorts of stories and imply that physicians abandon their scientic knowledge, history. Albany: State University
of New York Press, 2001.
silence other stories. Narrative humility allows clinicians or their sense of competence. Rather, narrative humility
Tervalon M, Murray-Garcia J.
to recognise that each story we hear holds elements enables a physician to place herself in a position of
Cultural humility versus cultural
that are unfamiliarbe they cultural, socioeconomic, receptivity, where she does not merely act upon others, but competence: a critical distinction
sexual, religious, or idiosyncratically personal. Assuming is in turn acted upon. in dening physician training
that our reading of any patients story is the denitive So much of a doctors life consists of stories. Narrative outcomes in multicultural
education.
interpretation of that story is to risk closing ourselves o humility is a point of entry into those stories, allowing us to J Health Care Poor Underserved
to its most valuable nuances and particularities. recongure our own relationships to the work of doctoring, 1998; 9: 11725.
Like diversity training, narrative humility also addresses to the Other before us, and to the Self within.
the hierarchical imbalance of the clinical relationship. It I would like to thank my
acknowledges that the socially more powerful player Sayantani DasGupta colleagues Rita Charon, Marsha
the clinicianmust willingly place herself in a position Division of General Pediatrics and Program in Narrative Medicine, Hurst, Craig Irvine, Eric Marcus,
Maura Spiegel, and Pat Stanley
of some transparency. The clinician must not only see, Columbia University, New York, NY 10032, USA for their help in the development
but be seen, and by doing so, enable herself to see even sd2030@columbia.edu of these ideas and this essay.

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