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The Power of Narrative Medicine

One thing I find myself doing on a daily basis in my job as a paramedic is telling stories. Not only is it a way of relaying information about my patients when transferring care to another health care practitioner, but it is essential in the way I continue to learn.

How other medics have dealt in similar situations, for example, or the decisions they have made in rare or unique circumstances help me prepare for future challenges. It has struck me recently that even more than these obvious examples, storytelling has a direct impact on not only how we understand disease but the process of healing itself -- from the perception and expectations of the patient to the diagnosis and treatment by the physician.

Our brains are wired to tell stories. "A story," as Life-hack blogger Leo Widrich says in this post about brains and storytelling, "if broken down into the simplest form is a connection of cause and effect."

We spend most of our day telling stories. We lay out our short-term goals, put events in the context of our own experience of the world, and let the people around us in on those experiences by relaying these stories to them.

This process is not just cultural in nature; it is how our brains are wired. In a 2001 paper by neurologist Jeffery Savor and English Professor Kay Young they make the point that narrative, central to our lived experience, takes place in many parts of the brain, and damage to any part impairs our ability to create our narrative and tell others our story.

What is even more striking is that our brain regularly makes stuff up to fill in the gaps and make sense of the world. The split brain experiments described here by Michael Gazzaniga in his book "Who's In Charge? Free Will and the Science of the Brain" illustrate this property of the brain to confabulate a story to explain an otherwise inexplicable event. Gazzaniga makes the point quite clearly:

"It is the left hemisphere that engages in the human tendency to find order in chaos, that tries to fit everything into a story and put it into a context. It seems driven to hypothesize about the structure of the world even in the face of evidence that no pattern exists."

Our brains, without us knowing it, make stuff up.

The way we interpret the world relies on our world view right from the start. These world-views, called "frames", colour all of our decisions and interpretations of the world. I, for example, see the world from a social democratic world view, so that may cause me to interpret any move by a large corporation to hide embarrassing facts about its business as anti-social and dangerous, while someone with a more purely capitalist frame might see this as a logical business decision designed to protect the stakeholders from risk. Both of these interpretations are correct and described the same event, but the decisions made based on them by society and individuals will be different depending on where you started from.

The way we frame a question about our health does, therefore, affect the outcome. If you believe in not only a mind separate from the body but the ability of the mind to affect the body then you may be more likely to accept the vitalistic notion that emotions are a manifestation of disease, or that just thinking positive thoughts can cure disease. I am, on the other hand, a materialist, in that I believe that all of our biology is based in chemical reactions and the laws of physics. There are emergent qualities in the brain that create our notions of the self and our own narrative; damage one or several of these mechanisms and we lose the plot in the tangle of dead neurons or a salty soup of neurotransmitters.

Both of us, you the vitalist, and me the materialist, experience life in the same fundamental fashion: our eyes, brains, hearts and intellect have all evolved in more or less the same environment and we live very similar lives. We are both most likely to die of heart disease or cancer, and we have similar tool-kits for dealing with mental anguish or crisis. When we get sick, however, our interpretations of our disease will be different; its cause, its cure, its progression, or its prognosis are constructs of a brain trying to make sense of the world and in some cases structure a story where only chaos can be found. We will both make mistakes, as will the doctors, scientists, homeopaths and chiropractors, when trying to interpret these answers. We all need help, therefore, to understand our confabulations. Enter science.

The best way to describe how science can help is to turn to Carol Tavris, social psychologist and author of "Mistakes Were Made, But Not By Me":

"The scientific method consists of the use of procedures designed to show not that our predictions and hypotheses are right, but that they might be wrong. Scientific reasoning is useful to anyone in any job because it makes us face the possibility, even the dire reality, that we were mistaken. It forces us to confront our self-justifications and put them on public display for others to puncture. At its core, therefore, science is a form of arrogance control."

In other words, science reconciles subjective and objective reality. It helps us remove the conflict between what we think is going on, an illusion built up by our brains, and the real world. However, even though we can focus on the objective using science, the subjective is an indelible part of the healing process, and therefore it is equally important for health care practitioners to really listen to the story of their patients. Their narrative can tell us a lot about our patients and their expectations, and find out what they want from the encounter.

This discipline, called "narrative medicine", is the art of incorporating stories into healing, and is now taught in many medical school programs. The narrative medicine program at Columbia University is internationally renowned for its program and is proof of the emptiness of the claims of exclusive holism by CAM fields like homeopathy or naturopathy. The physician is just as concerned about the first cause of the disease as the naturopath; of course the entire person matters, and while viewing the patient just as a collection of diseases may have been the consequence of 20 century biomedicine, people want to be treated as equal partners in their care, and take responsibility for their wellbeing. Mainstream medicine should heed this and be mindful in ensuring the patient's story is central to care and cure.

In this light, even the placebo effect may have a place in modern medicine. Every illness is a story, and placebo, a character in it. An inert substance that is believed by the patient to be active and helpful, the placebo is woven into the fabric of our story by Gazzaniga's left-brain. The placebo becomes a protagonist that shapes our perceptions into a positive journey to better health. By offering by what most accounts is a strong and careful placebo, many CAM treatments make us feel better. It is important to remember, however, that this is a part of the illusion built by our material brains, and we must ensure that our subjective experience does not take over: a placebo at its heart has no biological effect, we just think it does. In this way, our desire for a coherent personal narrative overcomes our understanding of the world, and in the long run, disease may creep up and consume us still.

Our stories are ourselves. We use them to describe to others our needs, and health care is no exception. Mainstream medicine has a challenge: continue to ignore the patient's story and lose them to a subjective fantasy built of the mistakes of our mammalian brain, or join the patient as a supporting character in their life, allowing science to sort out the fantasy and improve the patient's life while making them the hero in their story of healing.

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