Conflicting Plots and Narrative Dysfunction in Health Care

CONFLICTING PLOTS AND NARRATIVE DYSFUNCTION IN HEALTH CARE DELESE WEAR and BRIAN CASTELLANI* You don't have anything ifyou don't have the stories.—Leslie Marmon Silko, Ceremony We know ourselves, our work, our relationships, our world by the stories we hear and tell. Stories form the identities of individuals, families, communities , and cultures by answering the questions, "Who are we? How did we get here? What makes us unique? What do we value? What are our traditions ? What sustains those traditions? What threatens them? Where are we going?" As Peter Brooks tells us, our lives are seamlessly, mostly unconsciously entwined with the stories we hear and tell, with "those we dream or imagine or would like to tell, all of which are reworked in that story of our own lives that we narrate to ourselves in an episodic, sometimes semiconscious, but virtually uninterrupted monologue" [1, p.3]. Thus it is in medicine. What makes a person decide to become a doctor? Stories do. Stories ofdoctors, stories ofpatients, stories ofmiraculous recoveries and devastating loss, stories from the operating room, at the bedside, in the clinic. They are stories filled with the wonders of science, the restoration of health, and the mysterious, almost magical relationship between doctors and patients. A girl doesn't dream of becoming a doctor because her mother is a doctor; she decides because of the stories her mother tells about being a doctor, the stories she composes about what it will be like to be a doctor, and the storied images her culture sends her about being a doctor. These stories make sense. Accordingly, our focus on narrative as a way of knowing is tied directly to our belief in the storied nature of all human activity. *Northeastern Ohio Universities College of Medicine, 4209 State Route 44, P.O. Box 95, Rootstown, OH 44272.© 1999 by The University of Chicago. All rights reserved. 0031-4982/4204-1110$01.00 544 Delese Wear and Brian Castellani ¦ Narrative Dysfunctio In this paper we look to medical narratives—the stories doctors tell—to explore changes in the medical profession, instead of looking to the usual political, market-driven, or sociological venues.1 Examining the storied nature of doctoring is particularly important as U.S. culture reconceptualizes what it means to be a doctor, what it means to be a patient, what health care means, and who's responsible for what. Indeed, as Kathryn Montgomery Hunter points out, medicine is essentially a narrative activity, from the opening stories patients tell their doctors through the translation of that story into medical information to its return to the patient in the form of a diagnostic story. "In this way," she writes, "much of the central business of caring for patients is transacted by means of narrative" [2] . Such stories abound in and around medicine—certainly from doctors and patients of all varieties, but also from CEOs of insurance companies, politicians, other health care professionals, legislators—and all have a stake in rethinking what we as a society want our health care to be, and what role we want doctors to play. Each story has distinct shades and patterns that contribute to a larger, more inclusive compendia of meanings, explanations, and directions for health care; these are added and contrasted to other storied perspectives. Following sociologistArthur Frank's characterization ofillness as a "circuhtion ofstories, professional and lay" [3], we propose that health care is a circulation of stories, not all of which are equal. Furthermore, the medical narrative, limited to doctors' ways of storytelling and making meaning, is one of many competing narratives within the larger health care discourse. Just as we are getting used to the idea that our doctor will probably change each time our employer buys new insurance coverage, or that managed care is here to stay, or that all HMOs are not created equal, a new health care story appears from a consumer or watchdog group, from a salaried doctor fighting for her autonomy, or from a patient who's had a run-in with medicine. These stories replace or challenging existing stories, forcing further debate. The health care plot is thickening: doctors used to be the overpowering taste in...