'Radical listening'

A seasoned physician goes back to school and finds a quiet revolution underway

Reading Time: 5 minutes

There was a low rumble in the room. I couldn’t hear what anyone was saying above the din, but I feel the excitement in my body even now as my memory-neurons fire.

This new batch of future doctors was about to enter terrain more daunting than the fundamentals of pharmacology: They would read a poem and write a reflection about being a medical student.

Years ago, in my first weeks of medical school, I moved into a small apartment in Providence above a hair salon with my friend Lynn and her wiener dog Zooey. It was the 90s. I kissed a straight-laced but cute boy named Tal and learned the gummy smell of Formaldehyde that lived in the anatomy lab and clung to our clothing. The medical education I would receive was based on a fairly conventional doctor-patient relationship model: patient describes symptoms, doctor examines patient, along with history and vitals, then provides diagnosis and communicates treatment options.

Twenty-five years later I was a “seasoned” doctor, awkwardly sitting in a low rotating chair among students at USC’s Keck School of Medicine, observing. They were about to join a revolution in healthcare—the practice of narrative medicine.

Traditional medical education involves eighteen months to two years in a classroom to learn basic science, and two years in the hospital and clinic doing rotations to immerse students in each of the medical specialties. They study surgery, internal medicine, pediatrics, OB/GYN, and all of the super-specialties within each discipline.

When I went to medical school, we were lucky to have one course focusing on communication and the physician-patient relationship. I remember walking into an exam room as a third-year student and finding a thirty-ish male actor sitting on the exam table looking healthy and fit, ready to answer my litany of prescribed “history of present illness” and “review of systems” questions. He had made-up answers pulled from a script.

I felt a flutter in my chest, a recognition of just how much things were changing in my beloved field. I looked at the young people around me. This was the generation that could change medicine by honing the art of deep listening and self-awareness, skills I only recognized were crucial after decades in healthcare. They will never know the practice of medicine without them.

The session title—“Stories Matter: Listening with Humility”—is nothing like I would have seen in my early training. At the podium was Pamela Schaff, who holds not only an MD but a Ph.D. in Literature and Creative Writing, joined by English Ph.D. professor Erika Wright. The two of them proceeded to delicately subvert tradition by introducing med students to a revolution in the doctor-patient relationship: narrative medicine.

“I am so excited to be here with you today,” Dr. Schaff began. This was also new. She was not trying to intimidate; she was connecting. My mind flashed to the supervising physician for my third-year surgery rotation, a grey tuft of hair who walked five feet in front of me as he “pimped” me with hard questions about obscure surgical facts.

“We are here to help you blend the art and science of medicine. By integrating the humanities into your curriculum, we aim to nurture your imagination, curiosity, and ethical decision-making as physicians. Attending to the same aspects utilized in the study of literature—point of view, tone, diction, syntax, temporality and setting—we will teach you close reading and narrative humility to enhance your clinical practice and your professional development.”

The Association of American Medical Colleges, a body that works to optimize and transform healthcare, published the FRAHME (the Fundamental Role of the Arts and Humanities in Medical Education) report in 2020, laying out the argument and evidence for integrating art and medicine: to enhance the patient experience, improve population health, reduce costs, and promote clinician well-being:

Professional growth and transformation occur when we adopt the perspective of others through acts of sustained attention so we can represent and reflect on what we see, hear, or read, as well as when we develop the ability to think critically and compassionately about human dilemmas. (This)…leads to the ability to integrate one’s deep fund of knowledge, ethical sensibilities, and emotional intelligence to know how to do the right thing in this circumstance, with this patient.

But talking about honing the softer skills of medicine to benefit patients and physicians can only go so far. By the end of the lecture, it was still theoretical, and probably intangible, to the new students in the lecture hall. It was time to practice them in the same way every other competency is acquired in medical education. This time it started in small groups, reading a poem and writing about the experience.

Despite my full-time job as a medical director, I had enrolled in the remote narrative medicine certificate program through Columbia University. By the time I sat in that room, I had completed my first course in close reading. We read poems, short stories, and excerpts from books. We listened to songs and viewed artwork, then we were given writing prompts or discussion points to address in groups.

Each time we were asked to comment on the pieces, or on our colleagues’ writing, we were given the same five questions to help us to closely attend to the piece at hand:

Where does it take place?
When does it take place?
What do you see?
What do you hear?
What do you feel?

The field of narrative medicine and the pedagogy of close reading that underpins it was created in the year 2000 by Dr. Rita Charon, also bearing an MD and a Ph.D. in literature. Combining medicine, literary criticism, anthropology, oral history, phenomenology, consciousness studies, and aesthetic theory among others, she has systematized a way to teach healthcare providers how to garner a kind of self-awareness that clears the path for deep and therapeutic engagement with patients. She urges doctors to engage in “radical listening,” letting patients tell the story of their illness as they see it, going beyond symptoms to include emotions, thoughts, and events. Charon then encourages the physician to write a brief narrative of what they hear, what she calls a “parallel chart” alongside the medical records to inform both future interactions and treatment, a process that closely resembles literary analysis. It’s one way to integrate the humanities into medicine to achieve the aims laid out by FRAHME.

Studies of the practice have shown a greater likelihood of patients to follow instructions from a physician who has engaged in the narrative approach. It can also reduce unconscious bias in the physician, especially for patients in marginalized communities. “Radical listening is the effort to be present, to bear witness, and to listen without your biases and assumptions. It’s about curiosity, not judgment,” Charon says

Narrative medicine provides a teachable set of skills that promise to put the human connection back into the increasingly quantitative and automated practice of medicine.

I sat still in my chair as the bodies rose around me, grasping book bags, whispering with new friends. Were they excited? Anxious? Both? They filed up the aisles to my right, rushing to their assigned rooms, to begin a journey I too had once taken, but with an orienting framework that was so very different. I would not join them for the intimate sessions following the group gathering. A safe space was needed, without outsiders like myself, to optimize the environment and to encourage students to share their thoughts and their writing.

Narrative medicine provides a teachable set of skills that promise to put the human connection back into the increasingly quantitative and automated practice of medicine.

The crowd headed off to read “What the Doctor Said” by Raymond Carver, a poem describing one of the most wrenching interactions these students would face—giving devastating news to a patient:

he said are you a religious man do you kneel down
in forest groves and let yourself ask for help
when you come to a waterfall
mist blowing against your face and arms
do you stop and ask for understanding at those moments
I said not yet but I intend to start today
he said I’m real sorry he said
I wish I had some other kind of news to give
you…

In my car, I thought about the students bowing their heads, reading those beautiful words—being encouraged to feel, to connect to a devastating human story, at the outset of their careers. And as tears streamed down my face, I felt hope for the first time in a long while for the future of medicine.

Eve Louise Makoff is an internal medicine and palliative care physician. She has published essays and poetry focused on both narrative medicine and personal topics. Dr. Makoff is studying narrative medicine...