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YALE JOURNAL OF BIOLOGY AND MEDICINE 76 (2003), pp. 87-95. Copyrght © 2003. All rights reserved. HUMANITIES AND MEDICINE Metaphor and Medicine: Narrative in Clinical Practice Jack Coulehan Department of Preventive Medicine, State University of New York at Stony Brook, Stony Brook, New York For decades it seems that the art has cies in humanism, professionalism, com- been slipping away from medicine. Like the munication, evidence-based practice, and ancient Greeks, who lamented the passing social and responsibility, it requires med- of the Golden Age, ical schools and contemporary physi- residencies to develop cians, educators, the general curricula that teach public, and these competencies. especially the sick mourn the loss of Dehumanization can the best be stated in human dimension of medical practice. narrative terms; i.e. nowadays medicine Fragmentation, subspecialization, lack of tends to ignore or minimize the role of nar- continuity, technological demands, rative in illness and burgeon- healing. Narrative ing patient volume, institutional stress, and, medicine is "medicine practiced with the most recently, managed care appear to have narrative to competency recognize, interpret, caused recent generations of and be moved to physicians to action by the predica- devalue relationship-based medicine in ments of others" . Medicine is largely favor of procedures and machines [1, 2]. about storytelling and interpretation, and Commentators have responded to this narrative, metaphor, and symbol are funda- unfavorable diagnosis with various mental tools of the Ill pre- trade [7-9]. persons scriptions. One the earliest was the experience in "bio- meaning their illnesses, they psychosocial model," which see themselves George Engel as characters in a life nar- put forth as a new paradigm to replace the rative, and they approach medicine as a vast reductionistic, disease-oriented network of "biomed- healing symbols. ical model" with a more holistic, Patients illness- understand their illnesses in a centered perspective The narrative . competency- way whether their physicians based initiative for medical realize If education it or not. this is so, and if physi- sponsored by the American Association cians or of ignore devalue narrative, then Medical Colleges and the American health care is Coun- bound to suffer. From the cil for Graduate Medical Education is the patients' perspective, narrative incompe- most recent This tence causes proposed therapy [4, 5]. widespread dissatisfaction, innovative regimen parses the art of and medi- distrust, failed expectations. Within cine into a series of and the topics competen- profession, it leads to the persistent To whom all correspondence should be addressed: Jack Coulehan, M.D., M.P.H., Department of Preventive Medicine, HSC L3-086, State University of New York at Stony Brook, Stony Brook, NY 11794-8036. 87 88 Coulehan: Metaphor and medicine: narrative in clinical practice from cancer are often suspected of having belief that something valuable is lost; i.e., it themselves ("cancer- the old days were better. Today's doctors brought upon the other hand, medical prac- are taught to objectify their patients and to prone"). On with a different remain emotionally detached, but in so doing titioners approach cancer images. Cancer they may not diminish their ability to heal, metaphor based on military and invasive; it seeks to infil- they may also harm themselves by develop- is aggressive ing chronic stress, emotional numbness, trate and colonize by battering down the and burnout. body's defenses. This essay is a brief reflection on the Because of these metaphors, especial- from cancer centrality of narrative and metaphor in ly the first, people who suffer medicine. begin with the anti-narrative experience isolation and shame. They don't position as stated by Susan Sontag, a non- talk about their illness. They delay seeking are similar to, and friends physician, whose sentiments medical care. Their families In Illness and but more eloquent than, many physicians shy away from them. a the nine- who view medicine as purely technical Metaphor Sontag also examined I beliefs about tuber- enterprise . then critique Sontag's teenth century cultural "strip illness of metaphor" position by cit- culosis and found that they, too, detracted Navajo medicine, a system i.e., scientific, understanding ing traditional from a "true," in AIDS of healing built almost entirely on narra- of the disease. Ten years later, as I extended her tive and metaphor. claim that narrative is Metaphor (1988), the author to (or ought to be) an essential component of anti-metaphorical analysis HIV/AIDS, bound contemporary medicine, inextricably which, she claimed, had largely replaced disease in our to the technical or machine-based compo- cancer as the unspeakable it was associated with nent, like the two snakes that are entwined society because and believed to be a punish- on the caduceus. In the final sections of the homophobia God . essay, I provide some examples of the ment from in in both books is importance of language and metaphor Sontag's central claim of everyday practice and discuss detachment that illness should be stripped metaphor. is that illness is not as a barrier to, and empathy as a facilitator She wrote, "My point narrative medicine. that most truthful of, a metaphor, and the way illness - and the healthiest of regarding AFRAID way of being ill - is one most purified of, WHO'S OF SUSAN most resistant to, metaphoric thinking... SONTAG? can and should think of ill- human beings surviving a bout with breast can- ness from a biochemical or physio- After purely in critic and [10, p. 3]. Thus, there cer the mid- 1970s, the literary logical perspective" a book or existential novelist Susan Sontag published ought not be any personal attached to illness, nor cultural entitled Illness and Metaphor . This meaning its ele- with illness. From this work was distinguished by crisp, images associated its rich of medicine should avoid gant prose style; by array literary perspective, metaphor like the and historical allusion; and, ultimately, by plague. the sensation it caused our elegant in style, Sontag's among post- Though modem made two books are deficient in research and full of intelligentsia. Sontag central claims. she that the She fails to her con- First, argued faulty reasoning. place called "cancer" evokes in the clusions about the shamefulness of cancer disease popu- a cultural or in an historical or to data to lace pervasive myth metaphor. context, provide is an and her statements that cancer sufferers Cancer obscene, unspeakable, support shameful condition. The disease is fail to seek medical treat- closely preferentially related to sin or who suffer ment she from guilt. People . Moreover, generalizes Coulehan: Metaphor and medicine: narrative in clinical practice 89 her analysis of a few supposedly negative mony with himself, his family, his clan, cultural metaphors to conclude that, there- and the network of that relationships con- fore, all illness metaphors must be nega- stitute the Navajo Way. To be healed is to she fails to address the human have that harmony restored. In order tive. Finally, to need to experience one's life as a story and accomplish the this, patient, first, has to attribute and context to impor- consult a to meaning diagnostician who, by means of She seems to take for hand trembling or other forms of tant life events. divina- granted the reductionistic myth that the tion, establishes the cause of the illness. more a person approximates a reasoning The diagnostician then an prescribes the better off he or she will be. appropriate or machine, ceremony "Sing," which a primary care physician consists of As young storytelling, chanting, sand I read Illness and Metaphor, I and other elaborate rituals when first painting, that had a few observations of my own about may go on for three to nine days. This for- matter. it seemed obvious mal Navajo healing system is the subject First, almost the monolithic cancer didn't entirely The ceremonies that metaphor symbolic. consist of some delayed of of the exist. Yes, course, people re-telling myths creation and sal- medical or chose to be "non- vation of the Navajo people by gods seeking care, like because their beliefs make them White compliant," Spider Woman, Shell Woman, and the disease or its but the Hero Twins terrified of treatment; [13, 14]. no more often with cancer There was a seeming paradox this happened in with other diseases. almost Lower Greasewood. The than Indeed, Navajo community with serious illness has a every patient enthusiastically accepted Western medical mixture of treatment and complex personal, religious, flocked to the clinic. Yet, and media-based beliefs when a was cultural, regard- person seriously ill, he or she her some positive, also undertook ing his or condition; the complex arrangements some that contribute to for a traditional A some negative; healing ceremony. Sing that it. No matter required the healing, others might delay presence of the ill person's how eloquently Susan Sontag declared, extended family and other clan members, a to I who would "Do not attribute meaning illness," have to set aside their jobs and her just couldn't imagine claiming many other responsibilities to participate in sev- I had returned eral converts. Moreover, just days of chants, prayers and dances. two in northern The from spending years family would also have to butcher Arizona on the Navajo reservation, where sheep to feed the participants, and pool was the only physician at Lower Grease- their resources to pay the hataali or Singer School. and his wood Clinic and Boarding Living assistant. What led them to do all in the Navajo community, found myself this when the Navajo were entitled to free, surrounded by a very effective traditional state-of-the-art medical care through the United States healing system based almost entirely on Public Health Service? and It seemed clear At first I narrative metaphor. that, thought the benefits were among the Navajo, poetry could heal. It cer- entirely social (i.e., getting together with If I friends and tainly wasn't harmful. that is so, asked, family) or psychiatric (i.e., why is it harmful to employ metaphor and treatment of mental disorders). But with in Western medicine? I meaning time realized that an appropriate Sing could "heal" any seriously ill person, even a with terminal "MAY I WALK IN BEAUTY" patient cancer, because prolonging life isn't necessarily the aim of all serious illness Among the Navajo, Navajo medicine. Human beings, like plants and results from disharmony. To become sick, animals and the visible world itself, fallen out of har- a person has somehow participate in a cycle of birth, develop- 90 Coulehan: Metaphor and medicine: narrative in clinical practice ment, maturity, and decline. This cycle in fact, that he saved a man whose life was constitutes the harmonious, natural way of the forfeit to the gods. In retribution, Zeus universe. Attempting to extend an elderly struck Asklepios dead with a thunderbolt. person's life beyond its natural However, later (perhaps as a result of span might well be seen as disharmonious or harmful, Apollo's influence at the Olympian court), rather than healing; what the ceremony Asklepios was made immortal and became would do was to bring the dying person into the god of medicine. In with this keeping a harmonious relationship with the impor- mythic narrative, Asklepios healed his tant persons and values in his or her life. patients through the mediation of priests Moreover, I learned that, for the and ceremonies, and utilized as modalities Navajo, penicillin shots and arthritis pills interpretation of dreams and visions. were not value-free scientific treatments. On the other hand, Hippocrates (470 Rather, the introduction of Western medi- to 410, BCE), the father of scientific medi- cine had caused the Navajo to incorporate cine, was no myth. He found a did, indeed, its procedures and "ceremonies" into their tradition of medicine devoted to naturalistic, cultural narrative. For example, they devel- empirical of disease. He explanations oped the belief that antibiotics (primarily apparently discarded supernatural causation, "shots," since tablets were and focused on behavioral and environ- thought to be less effective) were very efficient in alleviating mental intervention. the oath Nonetheless, the symptoms of pneumonia, but did not developed by the school of Hippocratic address the disharmony that allowed the physicians acknowledges the power of myth person to become ill. When fever and and narrative, rather than the decrying it; cough were gone, oath begins by commitment to the important questions pledging remained: "Why me? Why was I vulnerable symbolic "I swear the world, by Apollo to this illness? What does life mean in physician, and Asklepios, and Health, and my the face of this illness?" Thus, even though All-heal, and all the gods and goddesses..." Western medicine had been incorporated I suspect that the Hippocratic physicians into the patients' cultural expectations, were professionals who understood the would need to a in importance of narrative skills in their they arrange "Sing" day- order to address the more narrative dimen- to-day practices. sions of illness; i.e., to them- The original caduceus of Asklepios, re-experience selves as part of a which became the symbol of the medical meaningful story. profession, consisted of a single snake of ASKLEPIOS AND HIPPOCRATES healing entwined around a staff. However, in the United States relatively we recently, find a parallel in ancient Greek medi- have added a second snake to the caduceus cine between the narrative or symbolic . Although the real historical reason is strand in healing, as the quite I like to that our two exemplified by otherwise, imagine Navajo, and the empirical or instrumental snakes the narrative represent (Asklepian) focus that we strive for in scientific medi- and instrumental or empirical (Hippocratic) cine, and of which Susan Sontag strands of entwined in this uni- approves. medicine, The myth of Asklepios, the god of healing, fied symbol of the art. healing holds that Asklepios was once mortal, the They are inextricably bound. Just as son of the great god Apollo and a human the Navajo views Western medicine patient woman named Coronis. Apollo directed from the perspective of her belief system, that Chiron, who supervises the interface thus antibiotics and incorporating surgery between life and death, teach his son the into her narrative and them a rendering skills of healing; and Asklepios became meaning beyond their instrumental strictly world's most powerful healer, so powerful, so also other his effects, any patient brings Coulehan: Metaphor and medicine: narrative in clinical practice 91 her beliefs or and values to the words spo- single most important element of diagnosis ken (or unspoken) and actions performed and the key to effective therapy. Harrison's by medical practitioners. Textbook of Medicine makes this point in If the physician understands this its first few pages, before devoting the next he or she dynamic, is likely to develop and two thousand pages exclusively to organ in utilize narrative skills practicing medi- systems and biochemistry. cine. Narrative competence leads to better Another example is the statement, clinical outcomes, e.g., more accurate diag- "The patient is a poor historian." The stan- noses, enhanced adherence to therapy, and dard medical meaning of this sentence is greater patient satisfaction. Alternatively, that the patient is unable to tell the doctor if the physician believes that real medicine in a coherent or understandable way what is is confined to the Hippocratic or instru- wrong; it blames the patient. However, isn't mental dimension, his or her influence on the doctor the professional whose responsi- the patient is bound to be less predicable, bility it is to reconstruct a relevant illness depending on whether their beliefs happen story? If so, wouldn't it be more reason- to be synergistic or antagonistic, or whether able to consider the doctor the historian they happen to exchange the right words or and the failure, if any, largely the doctor's? the and In wrong words, so forth. other After all, he or she is expected to have the words, by subscribing to a culture of medi- communication skills and narrative com- cine based on the belief that medicine is petence to elicit and understand stories of above or beyond culture, the doctor is sickness. bound to be a less effective healer. With regard to the iatrogenic suffering The following paragraphs suggest a few caused by inappropriate words in medicine, of the - ways that narrative elements words, the internist Eric Cassell coined the apho- images, metaphors, and symbols influence rism, "Sticks and stones may break your and structure day-to-day practice, even bones, but a word can kill you." Consider when physicians may focus their attention casual (or intentional) statements like the elsewhere and have no idea what is happen- following: "You have a time in bomb your in in ing the patient encounter, or their inter- chest," "The next heartbeat be may your last," with action other health care professionals. "Your life is hanging by a thread," and "There is no choice. We have to operate." WORDS AND IMAGES These common examples taken from the field of cardiology, illustrate well how Common words and phrases in medi- words - perhaps spoken with the best of cine reflect a culture that objectifies intentions - can cause iatrogenic harm patients. For example, the term "history taking" reflects the ambiguous position THE METAPHORS OF MEDICINE that narrative enjoys in contemporary medicine. "History" implies objectification A number of writers have looked of the patient's story, suggesting that "it" is beyond the to day-to-day language discov- an entity we might discover if we search er the basic models or we metaphors use aggressively enough, like a "black box" when about medicine thinking [16-17]. among the wreckage of a patient's life. There are several such that metaphors to a "Taking" implies that the doctor violates large extent generate our of vocabulary the her patient. She wrenches the story, whisks 1 patient-physician relationship. Table lists it away, as if she were pulling a bad tooth three of the most prominent of these and or removing a hot appendix. this some of their Despite implications. Contemporary phraseology, in theory, at least, authorities medicine has officially disavowed the agree that talking with the patient is the parental (or paternalistic) metaphor, which Metaphor and medicine: narrative in clinical practice 92 Coulehan: Table 1. Medical Metaphors War metaphor War statements Disease is the "I treat all enemy my patients aggressively..." Physician is a warrior captain "He's a good fighter." Patient is a battleground 'The war on cancer." Parental metaphor Parental statements Disease is a threat or "She's too sick to know the truth..." danger Physician is a loving parent "We don't want him to lose hope." Patient is a child Engineering metaphor Engineering statements Disease is malfunction "He's in for a tune-up." is an or technician doc... fix it." Physician engineer "Something's wrong, you Patient is a machine "We need to ream out your plumbing." was perhaps the most prevalent way of SYMBOLS OF HEALING thinking about the patient-physician rela- tionship in the past. Biomedical ethics William Osler wrote to his fellow doc- In teaches us to respect our patients as adult tors in 1910 about the "faith that heals." decision makers, rather than simply looking his essay, Osler noted that, while his col- out for their best interests as we would with leagues viewed the practices and parapher- Hospital as children. However, the relative demise of nalia that filled Johns Hopkins paternalism (which at least implied a human, objective and scientific "givens," patients caring interaction) has been accompanied inevitably experienced them as a vast net- by the rapid advance of the engineering work of symbols that promote healing. the contemporary hospital and war metaphors, both of which tend to  Consider objectify and dehumanize the patient. - the white coats, stethoscopes, and beepers. Of course, each of these metaphors is The ritual of daily rounds. The ceremony true in a sense. Each sheds some light on of physical examination. Consider the the patient-physician relationship, but also nuclear magnetic imager as an oven-like casts a shadow. While capturing one char- oracle that sees inside the soul and one's of res- acteristic of illness or healing, each one emergence from this machine a type the treadmill? A downplays or ignores certain other fea- urrection. Or what about set their hearts tures. There are also other, more humane, Sisyphean task that patients All whatever metaphors for medicine; for example, against. of these procedures, are also physician-as-teacher, or physician-as-reader their intended scientific effect, the or editor. Obviously, we need many such symbols or ceremonies that involve images to capture the truth, but we must manipulation of symbols. As Osler wrote, in wonderful than understand that none are exclusive, and some "Nothing life is more - force which are more useful in healing than others. faith the one great moving Coulehan: Metaphor and medicine: narrative in clinical practice 93 we can neither weigh in the balance nor to treat family members and close friends. test in the crucible. Intangible as the Yet, there is surely a vast chasm between ether..." . He went on to that the pole of ignoring explain the screams and the the network of modem symbolic medicine opposite pole of being impaired or devas- generates "an atmosphere of tated by them. optimism, and cheerful that Dr. Adams demonstrates nurses, work(s) just the what is same sort of cures as did called detached Asklepios" . concern. He is concerned about his patient's welfare, yet remains DETACHMENT VS. CONNECTION emotionally detached. This stance has become normative for medical education; "Oh, Daddy, can't you give her some- i.e., we now claim that doctors should to make her thing stop screaming?" asked adopt an attitude of detached concern Nick. toward their patients [20, 21]. Yet, unop- "No. haven't any anesthetic," his posed detachment leads to objectification said. "But her screams are not of - father the patient as a person and not only I don't hear them the important. because patient's body. Since the body is the not primary they're important" . source of "objective" data, the I that our modern commit- suggest person becomes less relevant to medical to detachment and in ment objectivity serves practice, except terms of "soft" concepts barrier to narrative in In like as a medicine. bedside manner. Alternatively, if per- Ernest "Indian sonal narrative Hemingway's Camp," Nick is important, how can one father makes a nocturnal or Adam's trip obtain, assess, interpret such subjective across the lake to deliver an Indian data without woman developing a type of connec- who is a difficult labor. The tion with the having young patient that appears to be pre- Nick for the ride. He cluded the goes along experi- by term "detached concern"? ences a natural with the I like empathy woman, to characterize this tension who in between is writhing pain. Yet, his physician subjectivity and objectivity by remains father detached, explaining that borrowing the words tenderness and screams are steadiness the patient's "not important." from Thomas Percival, the the from British He understands pain a physiolog- Enlightenment physician who ical her wrote the perspective ("all muscles are try- first modem synthesis of med- the but ical In ing to get baby born"), considers it ethics [22, 23]. the first chapter, a potential distraction. He believes that by Percival enjoins physicians to "unite ten- the listening to screams, he would compro- derness with steadiness" in the care of mise his technique. patients . Under "steadiness" Percival in This quotation illustrates a dramat- includes the intellectual virtue of objectivity ic way the tension between detachment or reason, along with moral virtue of in and connection medical practice. Nick's courage or fortitude. By "tenderness" he father is evidently a kindly man, yet he means humanity, compassion, fellow feel- believes that emotional vulnerability will ing, and sympathy. In his letters, Percival impair professional performance. There is, contrasts the "coldness of heart" that often a factual in of course, basis to the belief that develops practitioners who do not culti- too much involvement with another per- vate such virtues with the "tender charity" son's suffering impairs one's functioning. that the moral practice of medicine requires. Indeed, the patient's husband, who is "This coldness of heart, this moral insensi- wounded and lying on a bunk in the same bility, should be counteracted sedulously cabin, eventually commits suicide because before it has gained an invincible ascen- he cannot bear the weight of his wife's suf- dancy" . The contemporary emphasis fering. Similarly, physicians are ill advised on detachment and objectivity promotes 94 narrative in clinical practice Coulehan: Metaphor and medicine: coldness of heart and serves as a barrier to or process of recognizing the other. Some narrative medicine. writers emphasize the intellectual or cogni- tive dimension of empathy. The empathic THE EMPATHIC CONNECTION practitioner attends carefully to the other's verbal and nonverbal expressions, inter- The key to finding an appropriate bal- prets them, and then forms hypotheses ance between tenderness and steadiness, or about the other's subjective experience. subjectivity and objectivity, lies in devel- The practitioner then shares with the other oping three core personal qualities: (a) the fact that he or she has been "heard," empathy - the ability to understand accu- while at the same time testing the hypothe- rately the patient's feelings and experience, ses by further questioning: Is this what you and to communicate that understanding; really mean? Is that how you really feel? (b) genuineness - the ability to be yourself But there is also a strong affective in a relationship, without hiding behind a dimension of clinical empathy. You can't role or facade; and (c) unconditional positive know how a patient is feeling in a given regard- the ability to accept and validate situation without, in some sense, actually patients just as they are. I am unable to dis- experiencing that feeling yourself. Spiro cuss these qualities in detail here, but I expressed the affective aspect of empathy would like to make a few comments on when he wrote, "empathy is more than know- clinical empathy, which I take to be a teach- ing what we see, it is the emotion generated able and learnable set of skills [24, 25]. by the image" . Empathy requires the In A Fortunate Man, John Berger doctor to be emotionally engaged and sketches the life of John Sassall, a general "experience the other's attitudes as presences, practitioner in a rural part in England . rather than as mere possibilities" . In other For Sassall the doctor's central task is an words, interplay of feelings is an essential "individual and closely intimate recogni- part of an empathic connection with a tion" of the patient: "If the man can begin patient. One cannot fully recognize or under- to feel recognized - and such recognition stand the patient without experiencing may well include aspects of his character emotional involvement . which he has not yet recognized himself- the nature of his unhappiness will CONCLUSION hopeless have been changed..." . Sassall is to be a good doctor "because Illness and healing are inextricably acknowledged he meets the deep but unformulated expec- bound to narrative, meaning, and metaphor. tation of the sick for a sense of fraternity. The "strip illness of metaphor" metaphor He recognizes them." In fact, Sassall, suggested by Susan Sontag, and embodied "does not believe in maintaining his imagina- in contemporary medical practice, damages tive distance: he must come close enough doctor, and the healing relationship patient, to the fully" . This because it promotes detachment, objectivity, recognize patient recognition of the patient's subjectivity is a and to the exclusion of connection, autonomy function of which creates the subjectivity, and solidarity; and teaches empathy, connection that the narrative dimension of patients and doctors to ignore the power of as to heal. medicine requires. words and stories to harm, as well Zinn defined empathy as "a process The Hippocratic and Asklepian dimen- for understanding an individual's subjec- sions of healing, as suggested by the two tive experiences by vicariously sharing that snakes of the caduceus, not only inevitably while an observant co-exist, but also are potentially synergistic. experience maintaining narrative stance" There are several possible In contemporary practice the . of at this "vicarious sharing" dimension is often ignored because of our ways looking medicine: in Coulehan: Metaphor and narrative clinical practice 95 12. Clow B. Who's afraid of Susan Sontag? 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