[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm honored to be with Dr. Rita Charon. Dr. Rita Charon, MD, PhD, is a physician, literary scholar, and founder of the Narrative Medicine program at Columbia University. She is a Professor of Medicine and Professor of Medical Humanities and Ethics at the College of Physicians and Surgeons of Columbia University. She has received numerous awards, including a Kaiser Faculty Scholar Award, a Rockefeller Foundation Bellagio Residence, a John Simon Guggenheim Fellowship, the Virginia Kneeland Frantz Award for Outstanding Woman Doctor of the Year, Outstanding Woman Physician of the Year in 1996, the National Award for Innovation in Medical Education from the Society of General Internal Medicine in 1997, and the 2018 Jefferson Lecture in the Humanities by the National Endowment for the Humanities. That's really impressive and I just thank Dr. Charon for spending the time with me.
[00:00:54] Rita Charon: Thank you for inviting me to your podcast.
[00:00:57] Christine Ko: Could you first share a personal anecdote?
[00:01:00] Rita Charon: I can. Very recently, I have been inundated in death, not necessarily of persons close to me. And I think it's a link between my two lives of reading and doctoring.
[00:01:18] So I run a reading group and I decided we were going to read George Saunders' novel Lincoln in the Bardo, which is about what happens between when you're alive, and when you're dead. Very eerie, very powerful. We read that, and it led to now our reading in this same reading group, Dante's Inferno. So my literary life is consumed with death, and not death, and living, and dying, and punishing, and it has brought up for me all my ghosts.
[00:01:52] And I find myself dreaming about people long dead. I find myself writing to survivors of close friends who have died. I don't know what you call that. It has located me exactly at the juncture between a life as a reader and writer and a life of being a general internist and seeing lots of people die.
[00:02:19] Christine Ko: That's beautiful, in a way. I think that one thing that I actually really only learned recently as a person, but as a physician, something I feel that I didn't learn in medical training is really about death, that we focus on what the disease is, how to make it better, how to cure it, how to fix things how to cut it out if you're a surgeon.
[00:02:43] And I've been myself pondering that disease is not acceptable, because our goal is to fix it and get rid of it. And death is not acceptable that like doctors just feel like we've failed when someone dies. But it's like a fixed game because no one can win against death.
[00:03:02] So it's, I realized, not a good way for physicians to be thinking.
[00:03:09] Rita Charon: And it's not a surprise that we do think that way. I think there are many things that are not taught to us in medical school. And one of them is, we are fellow mortals. And what happens to our patients will happen to us. And yet, isn't there this fantasy that because we're around death and serious illness so much, by now we must be immune to it.
[00:03:36] And we go to great pains, all that objectivity and the defensive distance from patients. You must protect your objectivity. You must protect your detachment, right? And we are acculturated into this distanced, slightly ironic position, separate from those suffering patients and their frantic families. I think narrative medicine and the medical humanities in general are ways of restoring us to the status of being a fellow mortal.
[00:04:17] Christine Ko: Yes, I've been thinking about what you just said, that we think as doctors that we're not going to be touched by these diseases or these experiences of patients. It's so trying to be a patient. I have at different times through the year wondered, and even now wonder, can I be a doctor and a patient at the same time? Because it's draining. Both are draining. It's hard to be a doctor. It's a difficult job. I admit that I've felt a little bit like, I don't know if this is really possible.
[00:04:52] Rita Charon: Yes. You're allowing yourself to experience the full ontological import of what happened to you. Ontological meaning it changes who you are. [Yeah]. The reality has changed. [Yes]. And we can't sit around and wait until all doctors get sick, although they ultimately will. So we have to intervene, and I think bringing in the imagination, creativity, the immersion in the lives of others, including immersion in the lives of our patients. This will bring us nearer to the understanding because doctors don't have to get mortally ill before they know how to be doctors.
[00:05:40] Christine Ko: You mentioned just now the humanities and much of your work with narrative medicine has been partially on how the humanities have what medicine needs. Can you talk about that a little bit?
[00:05:53] Rita Charon: Yes. I didn't know it until I started studying the humanities seriously. I just, I went to medical school, I got an internship, residency, and it was only when I was in practice that I understood that patients pay me to listen to their accounts and to understand them.
[00:06:16] And I was a reader. I was very involved in reading all my life, but I never studied like how stories work. So I went to the English department. I said, can I take a course? I'm like an Assistant Professor of Medicine. Can I take a course? They said, don't take a course, take a master's. So I did. And that's when I started to understand how complicated stories are.
[00:06:39] And how you don't just say, yeah, where does it hurt? Does it go down your arm? Does it go into your neck? No. That every word and gesture and silence and looking away and beginning to cry and all of those ways that our patients emit their situation has to be so in a sophisticated way absorbed and interpreted as if it's Dante, because every word counts coming out of a patient's mouth, just like it does in a text.
[00:07:16] So the more I learned about all this very specialized narrative theory, my practice was transformed.
[00:07:25] Christine Ko: Can you name some ways in which your practice was transformed? If any are simple that maybe someone could do?
[00:07:31] Rita Charon: Some are quite simple and I've been able to teach students how to do this. You roll your chair away from the computer. You put your hands in your lap. You don't write.
[00:07:42] And you face the patient. Here's what I would say. I closed my practice a couple years ago when I became chair of a department. I'd say to the patient, I will be your doctor. I need to know a lot about your body and your health and your life. Please tell me what you think I should know about your situation.
[00:08:01] And all my friends say, Rita, you ask a question like that, you'll be there for hours. No. No. And patients, and these were strangers, first visit, they would tell me, the death of their father 20 years ago, the death of their brother 10 years ago, the trouble they're having with their son, he was arrested and might have to go.
[00:08:22] And then this one guy, he starts to weep. I say, why do you cry? He says, no one ever let me do this before, see, and you learn about things that never would have come to your attention. If you simply say, what should I know about you to be your good doctor, which is not the same as saying, tell me about your life, see so, and then people do tell you, and they tell you what we should even start with.
[00:08:55] One youngish guy with a big stroke, he says, I need a motorized wheelchair because my wife can't push me. He was a Dominican. He was domineering. He was a big guy. I would not have started with ordering up his motorized wheelchair, but I did. And it let him retain his power. And then another woman, she was a diabetic. She says, you really want to know what I want? I want a new set of teeth. Yeah, she had lost all her teeth. The denture didn't work, and Medicaid wouldn't give her another one, but we figured it out, and I got friends in dental, and we made it happen. And three months later, she's gorgeous and she starts a social life. She starts a business. She falls in love Instead of being in the ER with hypo or hyperglycemia So that kind of stuff.
[00:09:48] Christine Ko: Yeah. I'm a big fan, and I believe in the things you just said, but what about the naysayers who say that, it's all fine and good, but there's not enough time for that. And especially primary care, there's not enough time to even go through, did you get your screenings? Did you get your vaccine? Did you get whatever?
[00:10:05] Rita Charon: Absolutely. And that becomes truer every six months. The reason I chose the date to close my practice was so I would not have to deal with ICD 10. Got it? But this corporatization, this transformation of our practice into predominantly a revenue generating enterprise... um, it's as if we are factory workers on the factory floor in the industrial age. I'm not a Marxist, but I know that the time pressure, the up, what do they call it, upcoding in billing? The fact that you get a denial because the insurance company doesn't want to spend all that money on your checkpoint inhibitor or whatever you're trying to, right? So we have to face the facts. Our noble profession has been corrupted by some people call it an end stage capitalism, and we don't by nature as physicians have the chutzpah to unionize and get out and protest and walk off. It's not how we behave. But that's where we are. And it's not impugning the integrity of the individual persons in the hospital executive suite. We've all been corrupted. So when you say how do you have time for that? The mild answer is, you can get good at this. I can listen to a patient in much less time it takes for other people. Because I know how to do it. But that's just a temporizing answer. The deeper answer is we have to confront how medicine has been deformed by corporate practices.
[00:12:07] Christine Ko: Yeah. I agree. I know I'm part of the system. Is there something that someone who's still practicing can do though? I actually have some agency in the sense that I can determine how long I get with patients still.
[00:12:21] Rita Charon: Yes. And I'm seeing some promising developments. Now I just read this in one of the inside clinical journals, but it seems that Hopkins has moved from a 15 minute visit to a 30 minute visit across the board because they were losing too many physicians. They were just, they couldn't do it. So they left. Because it cost a million dollars to replace and train a physician, they realized it was cheaper to try giving a longer period of time. Now who knows how any physician is going to use those extra 15 minutes? We don't know, but that, I thought, was a a recognition that this has got to stop. And we're making headway in, to call it by its name, desegregating care. Because if you're poor and on Medicaid, you're not going to be able to afford going to the private physicians. And the private physicians cannot afford with their overhead to accept Medicaid dollars. So we are working, it's moving now. It's moving toward what we call payment agnostic care. And it's taking a big commitment by the hospital. To cover those lapses. So I take optimism from both those things. And we have to think about who our allies are. Our allies are like the UAW, but think of who our allies are. It's not just unions. It's other kinds of nonprofits. It's other persons facing this kind of shift in, in banking, in law, in other, in education, public schools.
[00:14:12] Christine Ko: On that optimistic note, I'm going to stop this first part of my conversation with Dr. Charon. We'll continue next week with Dr. Charon defining what she thinks narrative medicine is, the term narrative competency versus narrative capacity, and how narrative medicine can help us in daily practice and daily life. Thank you for listening in.
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