Telling and Listening: Constraints and Opportunities

Dr. Charon makes an eloquent and convincing case for the importance of narrative competence in medical practice and medical training. My contribution to this discussion of storytelling and medicine is from the perspective of cultural studies and its application to medical education and practice. I want to insert culture into the narrative model of physician-patient interaction and make the argument that culture—the "situatedness" of physician and patient—influences telling and listening in important ways. Situatedness presents both constraints and opportunities for narrative medicine; the model of attention, representation, and affiliation that Rita Charon proposes may provide a way to negotiate the constraints. I should note that I do not interact directly with patients (I have no clinical or psychoanalytic training) nor do I conduct "case" interviews of any kind; examples that I cite in this paper are derived from memoirs, essays, and other written materials as well as from my work with medical students and physicians in an academic medical center, and even from my own experiences as a patient and as a relative of patients.

Cultural studies applied to medicine can take several forms. The two forms I will invoke here are an anthropologic-ethnographic-sociologic approach and a critical theoretical approach. Ethnographic studies examine practices and characteristics of human societies, interpret behaviors and draw comparisons. In the context of medicine and our current discussion, this involves studying how different cultures perceive illness, communicate about illness, and what treatment options they expect, and then developing generic methods to apply these insights to medical practice. Medical anthropologists Arthur Kleinman (who is also a psychiatrist) and Byron Good have been particularly active in such research and emphasize the importance of narrative in their work (see below). Sociologist Catherine Kohler Riessman also interviews individuals with medical problems and studies their narratives; she has identified social structures that "work on the autobiographical self, and constrain how it may be legitimately constructed" ("Illness Narratives" 5). This work impels us to ask, what does a particular group or society allow to be said, to be narrated, to be performed, to be thought? In certain cultures it is not encouraged to speak freely, especially in an instructional setting or before authority figures. Some societies have a more stoic response to illness than others, or discourage public revelation and assertions of individuality. As medical education increasingly encourages written and spoken reflection about medical work, and encourages patients to tell their stories, how will those individuals fare who give less credence to verbal communication? Riessman gives an example from her own contact with a Japanese-American graduate student who argued that Japanese people do not trust the spoken word because words cannot capture true essence. For these people, according to the graduate student, the ideal communication is one of tacit understanding, conveyed through gesture and verbal vagueness ("Illness Narratives" 7). How can the narrative medicine model accommodate such diversity?

In the critical theoretical approach to cultural studies of medicine, the institution of medicine and its practices become objects of cultural critique. Medical practices and medical science knowledge, according to such a critique, are "socially determined and culturally specific" (Lewis 10); medico-scientific assumptions and practices can be scrutinized and questioned, while interdisciplinary interrogation draws attention to these assumptions and their consequences. This cultural studies approach focuses more on metanarrative than on individual narratives: "the strong linkages between ideas and normative expectations that pervade specific cultures and that direct the kinds of medical commitments any given culture takes up and elaborates" (Hausman 167). Closely linked to the recognition of normative expectations is the view, derived from the work of Foucault (Power/Knowledge 109–133), that knowledge and power are inextricably intertwined. Foucault made the specific link between medical discourse, medical practice, and power in his early study, The Birth of the Clinic.¹ How do power relations enter into the model of attention, representation, and affiliation that Rita Charon outlines, and can the model respond to the insights of a cultural studies critique? Can medicine interact constructively with disciplines that challenge some of the assumptions made by medical professionals? Can the counter narratives generated in...