Why Storytelling Matters in Medicine: An Interview with Dr. Suzanne Koven

Interview by Hart Fogel

The past decade has seen a surge in the popularity of emphasizing the use of narratives in medicine; that is, medical and academic institutions have been stressing the significance of storytelling as a vehicle for introspection and empathy for patients and healthcare providers alike. In 2009, Columbia University began offering a Master of Science in Narrative Medicine. It was one of the first such programs to be established, and various other institutions have followed suit since then.

Dr. Suzanne Koven, a longtime practitioner of primary care internal medicine, was in 2015 named Writer in Residence for the Division of General Internal Medicine at Massachusetts General Hospital (MGH). Drawing on her diverse academic background which includes an M.D. from the Johns Hopkins University School of Medicine, an M.F.A. in nonfiction from the Bennington Writing Seminars and a B.A. in English literature from Yale University, Dr. Koven has written extensively about and led many workshops, discussions and presentations pertaining to topics like the role of narratives and storytelling in healthcare, intersections between literature and medicine and more. Managing Editor Hart Fogel interviewed Dr. Koven via e-mail about her work and perspective on these subjects.

Hart Fogel (HF): In recent years, medical schools, hospitals and healthcare providers have increasingly been implementing “narrative medicine” and stressing the importance of such a practice. For those who are unfamiliar with this concept or are unaccustomed to considering healthcare from a more holistic perspective rather than a strictly medical one, could you start by defining what narrative medicine is and what it looks like in action?

Suzanne Koven (SK): “Narrative medicine,” a term coined—and a discipline founded--by Dr. Rita Charon at Columbia, is the study of literary texts, of reading and writing, as a way to enrich medical practice and training. Storytelling has always been fundamental to medicine, as it is to all human experience, and narrative medicine focuses our attention on it in a critical and mindful way. In the groups I facilitate for staff and trainees we read poems, essays, plays, memoirs, and fiction (sometimes about health and illness, sometimes not) and participants routinely report that thinking about language, metaphor, ambiguity, and meanings beneath meanings changes the way they see patients in real ways. Here’s an example: A few years ago, in my monthly literature and medicine group at MGH, we discussed J.M. Coetzee’s novel Disgrace, which is about, among other things, shame. We spoke about how shame is a powerful but often unrecognized part of what our patients feel. The next day I received an email from a nurse in the group who had just seen a patient who seemed disproportionately upset about a “minor” symptom. With Disgrace fresh in her mind, the nurse understood that the patient was feeling considerable shame. The nurse told me that this awareness, which she acquired from reading and discussing Coetzee’s novel, increased her empathy for the patient and her ability to treat the patient effectively.

HF: Some people might be surprised to see a course that would seem more fitting as part of an undergraduate liberal arts curriculum being offered by more and more medical schools – institutions that inherently provide highly specialized occupational training. What’s driving this trend, and has there been reluctance to embrace it?

Generations ago the humanities were an important aspect of a physician’s training. While in the early years of medicine doctors were thought of as mere technicians who often did more harm than good with bleeding and other dubious “treatments,” in the nineteenth century medical schools became part of universities and doctors were considered highly educated people who’d studied Greek, Latin, history, philosophy, and literature along with science. As scientific knowledge grew in the twentieth century, the humanities got crowded out of the curriculum. What we’re seeing now is a correction, the pendulum swinging back toward the center between art and science. What’s been fascinating to me is that while some physicians and medical educators are reluctant to see the relevance of humanities to medical training and practice, patients have no difficulty seeing it. Patients with whom I’ve spoken about my work totally get it. They understand the connection between study of the humanities and delivery of humane medical care very easily.

HF: You majored in English literature at Yale and then went to medical school. Did you always have parallel interests in the humanities and science, or was it only later that something sparked your passion for medicine?

SK: I’ll confess here what I have confessed elsewhere, including publicly at Harvard Medical School: I have never been all that interested in science. I have always loved reading and writing and conversation—especially conversation about reading and writing. My father was a doctor, and also an English major back in the 1930s, and a self-taught scholar of James Joyce’s Ulysses, which he reread at least once a year. I loved visiting his medical office when I was a child and thought I might enjoy being a doctor, too, but I assumed my indifferent attitude toward math and chemistry was a deal breaker. It was only after I graduated from college that I realized the required science courses were—for me, not for everyone—simply a gate I’d have to pass through to get to where I wanted to be. I have loved being a primary care doctor for thirty years and I’m still not too interested in science. Of course, there is a body of scientific and medical knowledge I need to have in order to practice, but—as I’ve said elsewhere—what I learned reading novels as an English major has been far more useful to me as a doctor than what I learned by taking organic chemistry and calculus.

HF: How was your transition from a humanities-focused undergraduate education to medical school? In what ways was it challenging, and in what ways had your background and the skills that you had developed uniquely prepared you for the experience?

SK: The first two years of medical school were especially challenging for me because I needed to acquire a basic vocabulary that my classmates who’d majored in science already had. But, in truth, those years are challenging for everyone. Anatomy, physiology, and other basic medical science courses are simply not masterable in the way many undergraduate courses are. You can spend a lifetime learning them. The first time I put on a white coat and interviewed my first patient, though, I knew I was in the right place. I felt fully comfortable and fully myself in that role.

HF: What drew you to the niche of narrative medicine? Did you feel that some piece was missing from your medical education and/or practice?

SK: I’m not sure I would call what I do “narrative medicine,” strictly speaking. I write, often about medicine, and I mentor others with their writing in addition to leading reading and writing groups. When I first started taking night-school writing courses twenty years ago I did not anticipate that activity becoming an integral part of my medical career. It was just a fun thing to do. In retrospect, yes, of course, I was yearning for something that felt “missing.” The more I do this work the more I see that so many others in medicine also feel something is missing from medical practice and training: the time and opportunity to think about the most meaningful aspects of our work and to share these thoughts with our colleagues.

HF: In past writings and interviews, you have commented on the benefits that storytelling and narrative medicine can bring to both healthcare professionals and patients. Could you elaborate on this dynamic?

SK: We tell stories in medicine all the time. Morning rounds, grand rounds, consultations, and the eliciting and recording of patient histories are all forms of storytelling. So we don’t need to do more of it, we need to recognize how much of it we already do, and do it better. What does that involve? For one thing, we need to give patient narratives the time and attention they deserve. Making eye contact, not interrupting, asking clarifying questions, and acknowledging strong emotions are a few behaviors that are basic to receiving stories, as we all know from our personal lives, and yet it’s amazing how often we fail do to them. I’m far from a perfect listener myself, but when I ask a patient to tell me their story and then really listen to it, invariably the patient tells me that they feel better, even if I don’t prescribe a drug or order a test, even if I don’t “do” anything.

HF: With the advent of narrative medicine and growing acceptance of its efficacy, how do you envision the role of the doctor changing in the foreseeable future, and how should the manner in which healthcare professionals are recruited and trained change in accordance with this shift?

SK: We’re already seeing humanities majors more welcome in medical schools, and humanities programs in medical schools and residencies. The most powerful interventions in this regard would be to roll back the amount of documentation clinicians are required to enter into medical records and to change the way physicians are compensated so that the number of visits per day are reduced. It’s hard to promote storytelling when you’re tapping away at a keyboard and rushing a patient out of the room. As to the role of the doctor, if we can remove some of those time pressures, that busy work, we can get back to our roots as counselors, consolers, and healers rather than just people who order tests, perform procedures, and enter data.

HF: When helping colleagues and students to hone their narrative skills, you have employed a number of different texts to facilitate discussion and reflection. These have included Shooting an Elephant by George Orwell, Long Day’s Journey into Night by Eugene O’Neill and The Empathy Exams by Leslie Jamison. How do you select the readings, and what are some of the works or genres that you find the most useful, relevant or enjoyable to analyze with peers and budding professionals?

SK: I used to select exclusively medically-themed texts. Some classics are William Carlos Williams’s “The Use of Force,” and Tolstoy’s The Death of Ivan Ilyich. Those are wonderful but now I am more inclined to select works that are thought-provoking, beautiful, meaningful. My feeling is that if a piece of literature is good it has something to say about being human and is therefore relevant to medicine, by definition. Some of my favorite “non-medical” texts to read with medical professionals and trainees are Kafka’s Metamorphosis, John Hersey’s Hiroshima, and just about any story by Alice Munro. Some recent additions to my list of novels are Tayari Jones’s An American Marriage, Jesmyn Ward’s Salvage the Bones, and Mohsin Hamid’s Exit West. The great human themes of love, loss, alienation, and the search for identity are not difficult to apply to medicine. Not difficult at all.

HF: Through offering a narrative medicine curriculum, medical schools are able to help people develop listening, conversational and empathy skills. Furthermore, such programs can inspire individuals to think critically about topics directly related to healthcare like illness, wellness, aging and death. How can narrative medicine also help bridge gaps between professionals and patients of different backgrounds (racial, cultural, socioeconomic and otherwise)?

SK: Short answer: just put them in a room together and get them talking about a literary text. My monthly group at MGH has an age range of 23-80 and includes RNs, NPs, MDs, chaplains, researchers, students, therapists, and hospital administrators. Once we had a med-flight helicopter pilot. Literature, like all art, is great for breaking down barriers, for reminding us that we all human. As we discuss, say, Eugene O’Neill’s Long Day’s Journey into Night, we find that what he had to say, so many years ago, about the effect of addiction on a family feels very familiar. We’ve heard similar stories in our professional and personal lives. We share these stories. The stories echo one another and echo the text. Differences in age and job description melt away.

HF: How has the experience of writing about medicine proven to be personally enriching or enlightening for you? Do you find that taking a step back and contemplating your profession from a broader and more thematic perspective illuminates aspects of your job that you miss during your day-to-day clinical practice?

SK: Absolutely. I have never loved my medical practice more.