‘Narrative Medicine: Bridging the Gap between Evidence-Based Care and Medical Humanities’ by Maria Giulia Marini (Springer International, 2016).

41aeTjkqFuL._SX330_BO1,204,203,200_How can narrative augment the evidence-based knowledge clinicians gather about their patients? Examining some of narrative medicine’s foundational ideologies, Maria Giulia Marini discusses the epistemological value of interdisciplinary connectedness in Narrative Medicine: Bridging the Gap between Evidence-Based Care and Medical Humanities’. Marini blends disciplinary methods and employs the ‘bridge’ metaphor that emphasises her central thesis: objective clinical data can be enriched by information gleaned from subjective patient and physician narratives and then used to improve healthcare. Narrative medicine ‘is able to connect’ physicians with patients (p. 8) and, more broadly, links science with humanitas, to enhance our understanding of health and illness experiences.

This slim volume (150 pages) contains ten chapters of discussion, a sweeping survey of expansive concepts (e.g. the art of listening, empathy, communication styles) whose scopes often exceed the space limitations. Long block quotes from well-known thinkers in the field elucidate these concepts, sometimes at the expense of the author’s own ideas. Marini interprets literary excerpts in several chapters (1, 2, 4, 5) to illustrate her rhetorical stance and demonstrate the links between disciplines.

Describing the knowledge-gathering potential of narrative analysis, the chapters most clearly depicting the relationship between evidence-based medicine (EBM) and narrative medicine (NM) are 5, on using questionnaires about and narratives for coping; 7, on personalising healthcare and research; 9, on designing healthcare for patient needs and rights; and 10, on pursuing economic investment in the medical humanities. Chapter 11 is a helpful compilation of narratives from research projects conducted by Fondazione ISTUD (independent business institution in Italy). These collected stories—spoken or written by patients, physicians, nurses, and family caregivers—present a range of perspectives useful for study in medical humanities classrooms. A glossary comprising terms from relevant fields within medicine and the humanities (pp. 131-150) is also an informative introductory tool. The book lacks an index.

We found Marini’s writing to be strongest, most natural and compelling when she describes ISTUD trials in which researchers actively integrate quantitative and qualitative approaches to acquire fuller knowledge, a more complete ‘story’ about their subjects. For example, she discusses a nationwide Italian study wherein caregivers—close family members of myelofibrosis patients—completed a self-assessment questionnaire and then wrote a narrative about their experience (p. 43). The quantitative results revealed high stress levels and poor coping engagement in 87% of respondents. But the narratives revealed that many caregivers were actively coping with the stress of their roles. When analysed with ‘semantic analytic software,’ which helped identify language expressing ‘adaptive coping’ (e.g. diction related to love, relationships, responsibility, and the support of health professionals), the narratives presented positive insights into caregivers’ personalities and capabilities.

Marini contends, for this and similarly structured studies, that ‘quantitative measurement tools tend to collect worse results’ than narrative assessments, because ‘participants were extremely severe with themselves in judging their ability to cope’ when using the ‘formal style and format’ of questionnaires: providing Yes or No answers, and ratings on scales of 1-10 (p. 41). Narrative, conversely, calls for longer reflection, broader perspectives of present and future, deeper awareness of resources, and fuller expression. Juxtaposing the two types of results, investigators have found that ‘unifying quantitative and qualitative research would bring energy and richness to both methods’ (p. 46). Marini details several additional studies that highlight the value of narrative, in Chapters 6, 7, 9, and 10, including the VEDUTA Project, which assessed physician burnout by asking pain therapists to narrate their career experiences within the ‘classic morphological structure of fairy tales’ (pp. 100-102), and the CRESCERE Project, which collected and analysed narratives from children and teenagers suffering from Growth Hormone Deficiency, their physicians, and their parents (pp. 62-68). The results repeatedly show the mutually-reinforcing benefits of combining EBM and NM practises.

The reviewers appreciate that Marini’s book considers the role of family caregivers, a group we think merits more attention in medical humanities research. Although doctor-patient relationships rightly receive the lion’s share of scholarly focus, family caregivers play a pivotal role in co-constructing their loved one’s illness experience. They are, like physicians, co-authors of the patient narrative, and as such need to be better understood. Marini uses the Rogerian term ‘person-centred approach’ in the Preface (viii), a term we like, as it suggests the importance of empathy and treating the whole person, whose suffering may profoundly impact others at home, rather than merely the disease. Although she reverts to the term ‘patient-centred’, we value Marini’s consideration of vital sociological and psychological (not just biological) factors that constitute a person’s health.

The author’s close readings and literary examples unevenly achieve their intended rhetorical purposes. While we assuredly favour an alliance between these unlike and complementary fields, EBM and NM, we are uneasy likening it to the marriage of Shakespeare’s Petruchio and Katherina (1, 8-9), an abusive relationship based on domination. And we disagree that the ‘Tower of Babel is one of the most beautiful metaphors to express the possibility and the complexity for human kind to interact through language’ (p. 31). However, we fully appreciate the example from Homer used to illustrate the power of authentic listening. Marini recounts the scene in which Odysseus weeps as he listens to the bard Demodocus’s narrative songs. Concerned, Alcinous questions Odysseus, who then tells the court his story. The Phaeacians listen without judgment while Odysseus narrates his ordeal, healing as he readies ‘for the real nostos, the return to himself’ before his return to Ithaca (pp. 11-13). With this reading, Marini underscores one of the primary tenets of NM: compassionate listening fosters intersubjectivity that can restore a sense of identity to and heal the sufferer.

Although the book holds interesting ideas for medical humanities to further explore, its most serious weaknesses lie in the communication of these ideas. The brevity and weak organization of the chapters often thwart the discussion; several topics need much greater exposition to be persuasive. At the sentence level, numerous errors impede the reader and obscure meaning. Abundant grammatical errors, such as unclear fragments and several run-on sentences, hinder comprehension. Typographical errors abound: e.g. ‘pat[i]ents’ and ‘[t]his book’ (p. 6); ‘embematic’ (p. 77); ‘Sonntag’, ‘[Arthur] Franck’, and ‘Paul Gaugain’ (p. 38, p. 32, p. viii), etc. Diction mistakes (e.g. ‘Among the experts, I like to remind the above-mentioned Michael [sic] Foucault’ [p. 37]), punctuation slips, such as a terminal comma (p. 29), and a struck-through phrase (e.g. ‘Humanitas by itself considers’ [p. viii]) cause the reader to stumble. It is regrettable, particularly for non-specialists, that so many errors obfuscate the ideas. We would like to have understood them clearly.

The book is intended for a wide readership, and different audiences may benefit from various portions of the material. The narratives in Chapter 11 could usefully prompt exercises to help NM students learn to ‘read’ patients. Except for the clarity issues, undergraduates could gain an overview of EBM and NM in Chapters 1-5 and the glossary. Specialists in both fields should be encouraged to further efforts to conduct creative interdisciplinary studies like those ongoing at ISTUD, as well as work together toward economically sustainable healthcare (Chapters 9, 10). Most salient for all readers, and for medical humanists particularly, is Marini’s sustained certitude that only the combined efforts of EBM and NM will yield the most comprehensive knowledge to meet healthcare’s changing needs.

Reviewed by Sandra G. Weems and Paulette C. Hahn, M.D..

Sandra G. Weems holds a Ph.D. in English with a focus in medical humanities from the University of Florida, where she is an Adjunct Lecturer. Her research interests include traumatology, the clinical uses of reflective writing, poetry therapy, and bioethics.

Paulette C. Hahn is Clinical Associate Professor of Medicine at the University of Florida in the Department of Medicine and Division of Rheumatology. Her interests in clinical practice and medical education include humanism through the art and science of bedside medicine. She currently serves as the Associate Vice Chair of Education in the Department of Medicine and is a member of the Chapman Chapter of the Gold Humanism Honour Society.


1 Comment

Maria Giulia Marini · June 14, 2016 at 3:29 pm

Dear reviewers, I wish to thank you for the precious time you engaged in reading through my book, “Narrative medicine. Bridging the Gap between Evidence Based Care and Medical Humanities” edited by Springer.

I’m grateful because the main message I and the researchers at Fondazione ISTUD want to spread is that Narrative Medicine (NM) is not in opposition to Evidence-Based Medicine (EBM). This term is very often mentioned at congresses dealing with medical humanities and science, but hardly ever applied in research projects.

At ISTUD our research projects are trying to combine the different approaches and to fulfilling the dream of NM as integration—and not in opposition to— EBM.
As far as the use of metaphors and analogies is concerned (Odysseus, the Tower of Babel and Catherina and Petrucho in the Taming of the Shrew) these are extremely subjective and may be or not be appreciated by the audience. Certainly, emotions and thoughts on the Odyssey are personal and may very likely differ from those of other readers with a different cultural background. As a matter of fact, the metaphor of the tower of Babel, was endorsed by other readers and evaluators, as fitting to describe the complexity of languages, but this may vary from culture to culture.

Mythic and metaphoric language is ambiguous by definition and again, as Lakoff says, is never a yes or no, I like or I don’t like as current social network as Facebook wants to force us to think, but can be interpreted in an endless way, according not only to the anthropological issue but also to each individual mood, mindset, age…

While writing the book I chose the strategy of staying one step behind, letting the stage to these forerunners (Sacks, Charon, Hurwitz, Greenhalgh, Good, Kleinman, Frank, Launer, and many others), founders of narrative medicine. In the roaring years of EBM (80s and 90s), when nobody seemed to question the validity of EBM, these authors had well perceived the “evident” oversimplification of EBM and openly addressed the biomechanical model with a wider approach, encompassing the illness, the patient’s experience of living with a disease and not only the pathology of body signs and symptoms.
However, studying narrative is always a complicated matter, and reading patients’ narratives is a never ending “game” of inspiration, interpretation and reflection.

My wish is that this book keeps on fostering the dialogue among experts of medical humanities and narrative medicine, but also on experts or scholars for organizing health care system which provides quality of care, keeping into account unfortunately the few investments on this field.

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