Patients and physicians are fed up with the 15-minute appointment. Using narrative medicine, Rita Charon is teaching a generation of health care providers to listen better — with the help of literature.
When Rita Charon was a young medical student in the 1970s, she paid a visit to a cancer patient on her usual rounds. He stared at her with horrified eyes.
“So this is it,” he said upon seeing her name tag.
In Greek mythology, Charon is the ferryman of Hades, transporting the souls of people who’ve just died across the river Styx to the underworld. The patient thought the appearance of a Charon at his bedside — even a doctor in training who just happened to have the same name — meant his time was almost up.
Two days later, he died. Charon was gutted. She considered running to city hall to change her name, but she didn’t.
“As I came to understand my mission, it’s to know that pass very well — to know that journey, to know that river,” she recounted recently. “And so, from then on, I felt my task was to live up to it.” To do that, she would invent a new field of medicine.
Today, it’s painfully clear that health care is broken. Anyone who has been to the doctor in the US has probably felt this in their bones. Think back to your last appointment: The doctor likely pummeled you with rapid-fire questions about your symptoms before dashing off a prescription and rushing you out the door after 15 minutes. Did you want to express a concern, maybe ask a question of your own? Too bad, time’s up. Take your feelings elsewhere.
Too little time spent on patients, too much time spent on electronic records, and the general sense that medicine has become more a profit-driven business than a noble vocation have driven patient dissatisfaction to a fever pitch. According to a 2019 Gallup poll, 70 percent of Americans believe the health care system is in a state of crisis or has major problems. Doctors aren’t happy about it, either: A 2015 survey of primary care physicians found that 70 percent believe the system needs fundamental changes. The US system spends more money than those of many other developed countries, yet it produces worse outcomes.
Narrative medicine — which Charon pioneered at Columbia University in New York, and which celebrates its 20th anniversary this year — presents itself as a potential antidote. Its teachings have spread from Columbia to schools across the country and won Charon legions of fans in the medical establishment. Now the question is whether it can scale within the for-profit health care industry, or whether it’ll require taking down that industry entirely.
Narrative medicine’s basic premise is that the account a patient gives about their illness is just like a story you might find in a novel: It has a plot, characters, metaphors. Even its momentary silences are telling. You can learn how to do a “close reading” of it, as an English major might say, by noticing and deconstructing all these elements. And — just like an English major — you can learn to do this by studying novels.
That’s why narrative medicine students, including around 150 doctors, nurses, and chaplains trained through Columbia’s program to date, read and write literature. Fiction and creative writing classes are part of their curriculum.
That might sound like a bizarre or wasteful use of their time, but consider the similarities between reading a novel and listening to a patient. Both require you to pay exquisite attention, engaging your sympathy as well as your critical faculties, according to Charon, who has a medical degree from Harvard Medical School and an English literature PhD from Columbia.
“You have to be so present, so alert, with your curiosity so intact,” Charon said. “And you have to assume that the narrators are going to mislead you. When a patient tells you what happened, you’re going to hear the opposite story from their mother or neighbor.”
Doctors, like readers, have to take in all the different narratives and resist the urge to immediately say which is right with premature certainty, Charon said. That’s arguably the opposite of what modern medicine has become.
From her office window at Presbyterian Hospital on West 168th Street, Charon can see all the way down the Hudson River. She keeps a pair of binoculars on the sill so she can observe the comings and goings on the water: big motorboats, tiny white sailboats, and shimmering light on the waves in between.
“I’ve got a thing for water,” she said, pressing the binoculars into my hands and urging me to look. “Do you see?”
I saw a woman in her 70s with sea-blue, seen-it-all eyes, who through formidable force of will has created a mini empire. She helms her own department at Columbia, which offers a master of science degree in narrative medicine. The field anchors her life. She lectures on it, reviews scholarly research on it, and authors books on it. As a result, interest in narrative medicine has grown, with most US medical schools now offering literature courses.
I knew from reading her books that unlike most doctors, Charon does not pummel new patients with questions. She simply says, “I’m going to be your doctor, so I need to know about you in quite some detail. Please tell me what you think I should know about your situation.” Then she shuts up and listens. Narrative medicine practitioners believe that the way a patient tells their story — including what their body language is like — provides the most valuable clues.
Once, a young woman came in complaining of abdominal pain, but there was nothing physically wrong with her. The gestures she used when discussing her symptoms — fingertips interlocked protectively over her upper abdomen — where the same gestures she’d used when mentioning that her father had died of liver failure, Charon pointed out. After a silence, the patient replied, “I didn’t know this was about my father.”
When Charon and I sat down, I simply said, “Please tell me what you think I should know about your situation.”
“You dog!” she said, laughing. “You’ve been reading me!”
Charon set up her story as a classic bildungsroman, starting with her Catholic upbringing in Providence, Rhode Island. Her grandfather and father were both doctors and expected her to become a doctor, too. But it was the 1960s, and the teenage Charon had other plans.
“We had a revolution to run! We had a war to stop!” she recalled. “The medical school thing? There was no way — sorry, Dad! — no way I was going to become an elitist professional.”
Instead, Charon became an activist, teacher, and full-on hippie. She was tear-gassed and arrested protesting the Vietnam War. She taught first-graders how to read at an experimental school. She moved to a commune in the country where everyone brewed their own beer, grew their own vegetables, and wove their own clothes.
But eventually she became frustrated. “At first, the idea of becoming a doctor was like caving into the power structure,” Charon said. “But after working very hard in alternative institutions, it seemed like power might not be a bad thing to have.”
She applied to Harvard Medical School and got in. Although she felt weird about joining the rarefied world of the “Boston Brahmins,” she made lifelong friends there: “Other! Activist! Women!” she said, banging her fist on the table to emphasize each word. She also met the linguist Elliot Mishler — one of the first to analyze how doctors talk to patients (and how much they miss in those conversations) — who mentored her even after she got her medical degree in 1978.
“And then, whoosh! I came to New York!” she told me, explaining that she chose a residency program in the Bronx because it “seemed most politically serious.” But later, she said, “When I moved to New York, it was mostly because I was in love with a filmmaker there.” (Charon’s storytelling style is full of emphatic flourishes — fist-banging, sound effects — but it’s also studded with self-aware unreliability.)
She and her filmmaker crush shot a documentary called To Be a Doctor, which showed the speed with which doctors parachute in and out of their patients’ lives. In the process, she realized two things, she said.
“A doctor needs that sense of, ‘This is my patient, and I’m seeing her through this GI bleed, or this diabetic ketoacidosis, and I know how to do it because I’ve been with her for the whole bloody thing!’” she said. “Patients don’t get that anymore. They suffer because doctors do shift work, piecework.”
Charon also had a happier realization: She was a damn good writer. After she scripted the treatment for the film, it was picked up by NBC’s Tom Brokaw, airing in 1981. She developed a deeper interest in storytelling. And so, in between seeing patients in the Bronx, she began working toward a PhD in English literature.
“I’d go from a session in the emergency room to a Virginia Woolf seminar,” she recounted. “I was out of my socks! It was thrilling!”
Then came the day she met her true love. He was — where else? — in the card catalog.
“I wrote down PS 2128. I went up to the eighth-floor stacks. Haha!” she laughed giddily. “There I see this enormous wall of books by and about Henry James. I got symptoms. My heart started going juh-juh-juh-juh-juh! I was sweating! It was stunning! I had absolutely no idea of the wealth.”
Charon fell for James because of how well he captures what goes on in the consciousness of others. “Try to be one of the people on whom nothing is lost,” he wrote. For Charon, the line perfectly expresses her goal as a doctor.
Parenthetically, Charon also mentioned she’d had a husband. After several years of marriage, they’d separated and stayed good friends. “He got remarried,” she said, “and I got a home on Fifth Avenue and Ninth Street. It is not an accident that I live on that corner. Because in his autobiography, Henry James says that’s his favorite corner in Manhattan.”
I was dying to interject, but I dug a fingernail into my palm as a reminder to shut up. I was rewarded for my silence by a moment of naked honesty.
“I’ve lost all the men in my life,” Charon murmured, listing her mentor, her husband, and more. “So I feel kind of — what’s the word? — not ‘loose ends.’ Just … unaccompanied.”
Eleven seconds. That’s how long doctors listen to patients on average before interrupting them, according to a 2018 study published in the Journal of Internal General Medicine, which analyzed 112 recorded clinical encounters.
It’s an absurdly small window in which to explain your health concerns. But from many doctors’ point of view, it’s also necessary. They’re under pressure to get you out the door in 15 minutes.
Where did the pressure come from?
In the early 1990s, Medicare spending was growing out of control as an aging population became eligible for and needed insurance. So Congress considered various new models to rein in spending. One of them was the concept of “relative value units,” or RVUs, a measure that could be used to calculate doctors’ fees based on several factors, including a doctor’s specialty, the cost of expenses, and liability insurance necessary to run a practice. In 1992, Medicare adopted a formula based on that measure.
“Basically it was a way of trying to combine the number of patients you see with the complexity of care you provide and pay you a certain amount based on that,” said Reid Blackwelder, a Tennessee-based family doctor and past president of the American Academy of Family Physicians.
A typical primary care visit was deemed to be worth 1.3 RVUs, which, according to the coding guidelines of the American Medical Association, translated into a 15-minute visit. Soon, private insurance companies followed Medicare’s lead, and the RVU model became the norm.
“It’s called the fee-for-service model, but I call it fee-for-volume,” Blackwelder said. “Because of the way the formula was designed, primary care doctors especially had to see more patients in order to meet their overhead. It became all about being able to get your bills paid. That’s a horrible incentive.”
Doctors now also have to spend lots of time filling out electronic health records, meaning some of the 15 minutes are spent peering at computers, documenting and checking boxes. “I’m spending more time on chart care than patient care,” Blackwelder said. “It’s incredibly frustrating. And it’s a big part of why physicians are burning out.”
Donna Zulman, a Stanford researcher who studies the fractured doctor-patient relationship, confirmed that physician burnout has become a huge problem. “Many clinicians are finding it hard to practice medicine the way that they set out to do, which is really sad.”
Annie Robinson, who graduated from the master’s program in narrative medicine at Columbia in 2014, now teaches the same subject at NYU School of Medicine. She was attracted to Charon’s techniques in part because of “the brokenness of the medical system,” Robinson told me. “It’s a business now. It feels incompatible sometimes with medicine as an art, a philosophy, a healing practice.”
She fondly recalled a course Charon taught on Woolf’s To the Lighthouse, saying the close reading made her a better doula and wellness coach. “It hones your attention to detail. When else do we learn to pay such close attention? And not just to a singular truth, like when you’re doing an anatomy class. This is being open to seven different ways there are to interpret something.”
Robinson described Charon as a “brilliant mentor and shepherd,” adding that “she’s idolized” for popularizing a more soulful vision of what medicine can be.
Several outcomes studies show that when doctors do receive narrative training, they derive pleasure from it, and it helps them better understand, empathize, and communicate with their patients. This is true in clinical settings ranging from genetics counseling to fetal cardiology to surgical training. In 2016, a systematic review found that narrative medicine has been “a powerful instrument for decreasing pain and increasing well-being related to illness.”
Both Blackwelder and Zulman agreed that narrative medicine shows promise, but said it has implementation challenges. “There are clinicians who’ll really enjoy doing that work, but there are going to be other clinicians who may not have access to the materials or time or resources,” Zulman said.
“The problem is, the payment models will have to adjust and adapt to support that,” added Blackwelder. “Patient care is all about relationships and stories — getting to know patients as people, not as diseases. You can’t do that in 15 minutes.”
On that last point, Charon begs to differ. Ultimately, her goal is system change; she still considers herself an activist, and she wants to shift American medicine away from profiteering and toward the recognition that health care is a human right. But she believes doctors with narrative training can serve their patients well even within the current flawed system. When it’s suggested that doctors can’t reach a deep understanding of a patient’s story in 15 minutes, she replies, “Says who?”
To test this theory, I asked if we could pretend that I’m a new patient. I’d claim to have certain symptoms, basing them on a real illness I’d had years ago.
She was game, so I walked out of her office, started my stopwatch, and walked in again. As she sat, she leaned toward me and said, “Tell me why you’re here.”
I told her about the bite with a ring around it that appeared on my leg, about the three doctors who told me I had Lyme disease and the specialist who said they were all wrong, about how my legs hurt so much that walking and even standing still were brutally painful. And I told her how, after everything, I still didn’t know what caused it — maybe it was just because I’d gone running?
Charon listened without interruption, then asked, “Where are you right now?”
“I’m super confused. Now they’ve sent me to a rheumatologist, and he said he thinks it’s just hypermobility. Each doctor is sending me somewhere else.”
“See, that’s unfair,” she said. “You come with a concern and — pffft, that makes me mad, to hear that they abandoned you. I feel ashamed of my colleagues, all doctors, who set you adrift like this. It adds to whatever distress and symptoms you had to begin with.”
Tongue-tied, I only managed to say, “Yeah.” She’d taken so much sting out of my pain just by expressing anger on my behalf and positioning herself as my ally.
She made a few literary observations. Like: “What we’ve dropped out of the story is that before you noticed this rash, you were fine.” And: “You can hear how many complexities are here: a rash, running, pain. You ask yourself, is this from the bite or from the running? So there’s already this compilation of maybes.” Then she said, “This is very mysterious. What words would you use beyond mysterious?”
“Stressful, painful, faith-destroying,” I told her. “I feel like doctors are supposed to be the ones who have the answers, and now all these doctors are telling me conflicting stories.”
“And they’re not taking responsibility for it,” Charon replied. “One thing I can say to you now is, I don’t know where this is going to end, but you’re not going to get rid of me.” She asked me to come back so we could run some tests, reach a diagnosis, and come up with an action plan together.
I wanted to cry. Finally, someone who wouldn’t push me out of her office and abandon me to the next guy. The real me, not just the actor-me engaged in this bit of make-believe, felt better. I felt … accompanied.
I looked down at my stopwatch. The whole thing had taken 13 minutes.
The questions Charon asked are the same sorts of questions that Columbia’s narrative medicine students are learning to ask — by analyzing novels.
Toni Morrison’s novels came up for discussion at a recent Narrative Medicine Rounds, a guest speaker series that Charon organizes. The speaker, professor Farah Jasmine Griffin, noted that Morrison often depicts black women nursing each other’s wounds and uses language that frames their perspective as wise and authoritative. She told the audience, “Morrison speaks about a ‘language of goodness.’ What would an example be?” One student raised her hand. “It could be, like, don’t call the patient ‘the sickler.’ Call them ‘the child with sickle cell disease.’”
When the lecture ended, people lined up to fangirl over Charon, talking and taking photos with her as you would with a celebrity.
Charon is a ferocious mingler, with a talent for glad-handing that would make some politicians envious. But hers is not a politician’s glad-handing. When someone approached her — an older woman in a neck brace, a young student wearing copious mascara, whoever — she took their hands in hers and leaned in. Then she hit them with The Look: her trademark way of peering at you so intensely that it’s almost uncomfortable, as if she were X-raying your soul. This deep attention — an art Charon learned from studying philosophers like Martin Buber and Emmanuel Levinas — is how she gets you to open up to her, whether you’re her student or her patient.
Afterward, Charon led me to a nearby Irish dive bar to talk more. One question was still niggling at me. Did helping patients craft the narrative of their illness really need to be done by the doctor? Why not delegate to a therapist or social worker?
“When you’re sick, it doesn’t work that way,” Charon said. “You ask a patient who’s contemplating neurosurgery who they’re going to listen to. It ain’t the social worker. It’s the surgeon.”
She paused. “We also have to save the doctors from their worst selves. And the way to do that is to make sure they’re in contact with the suffering. If the doctor says, ‘Oh, I don’t talk about emotion. Are you frightened? Go to the social worker for that!’ — that’s going to corrupt them. So they have to keep doing it.”
She pounded her fist on the table, and then, finally, seemed to tire. By this point, she’d been awake and working for 17 hours. She hopped the A train home to catch a few hours’ sleep, before waking up to do it all over again.
A copy of a Whistler painting hangs on the wall in Charon’s bedroom. It shows a small human figure on the beach. He’s rendered translucent by the sea rushing toward him — either offering itself at his feet, or, Styx-like, conveying him to Hades, depending on how you look at it.
Charon paid an artist to reproduce the painting for her because she wanted to live with its question every day: Is all this water meant to buoy the human being? Or erase him?
The painting does not answer the question. That is the task of a life.
Sigal Samuel is a staff writer for Vox’s Future Perfect. She writes about artificial intelligence, neuroscience, ethics, and the intersection of technology and religion.
Author: Sigal Samuel