Taking Its Pulse: Poetry in the Context of Narrative Medicine
by Jeff Encke
Since its introduction to US medical schools in the early 1970s, interest in literature and medicine has steadily gathered steam, blossoming into a full-fledged academic field featuring a broad range of theories, sub-disciplines, and competing methodologies. Literature & Medicine, launched in 1982, has served as the principal forum for growth and serious conversation around the subject, publishing side-by-side the work of health educators, bioethicists, linguists, anthropologists, cultural historians, and literary critics. By 1999, according to the Association of American Medical Colleges (AAMC), 46 percent of the country’s medical schools were including literature-based courses in their required curricula, while 69 percent were offering literary electives. Clearly American medical culture, medical pedagogy in particular, has come around to the notion that familiarity with literary language can have a profound impact on the quality of healthcare.
Poetry has played a decidedly different role than fiction and non-fiction narrative in this development over the past three decades. Its presence in medicine has been most prominent in the fields of nursing and psychotherapy. In the early 1960s, medical professionals began experimenting with and studying the effects of poetry therapy, itself now a full-fledged field, complete with certification procedures and a national professional association. In the words of Jack Leedy, editor of the 1969 essay collection Poetry Therapy, poetry had become “an adjunctive means in the treatment of emotional illness,” the category “emotional illness” including anyone who has suffered, or is related to someone who has suffered, a traumatic medical experience. More than a dozen book-length studies of poetry therapy have followed Leedy’s.
Poetry has multiple therapeutic applications. One of its primary uses is in the treatment of pediatric and adolescent patients. Nicholas Mazza, a recognized expert in the field of poetry therapy, has observed that the “use of poetry as an adjunctive therapeutic intervention can be helpful in breaking down resistance, encouraging self expression, promoting family and group interaction, as well as providing a sense of validation to the troubled adolescent.” By “adjunctive,” Mazza means that poetry does not by itself constitute a “complete therapeutic modality,” but merely a tool to supplement and enhance other therapeutic practices. Poetry therapy, according to Frances Strodtbeck and Rosanne Perez, can bridge the cognitive gap between pediatric nurses and their young clients, encourage patient introspection, reduce introversion and paralyzing inhibitions, mitigate the duration and intensity of anxiety attacks, and strengthen the ego. Techniques of poetry therapy, which nurses, psychotherapists, and other medical professionals have also used in the treatment of the dying and chronically ill, generally fall into one of three categories: sharing and interpreting poems with patients, either individually or in a group setting; encouraging individual patients to write poetry; and leading a group of patients, or a patient and his family members, in the collaborative composition of poems.
While outcomes studies addressing the impact of poetry therapy on the treatment of patients are both few and limited in scope, ample case evidence suggests that the use of poetry in clinical settings has been meaningful and generally well-received. Particularly interesting are those initiatives that extend the boundaries of poetry therapy. In October 1999, Colin Macduff and Bernice West of the Centre for Nurse Practice Research and Development at The Robert Gordon University in Scotland launched a small poetry project through the Aberdeen Royal Infirmary. The so-called “Poem Post” project involves the distribution of poetry postcards through wall-mounted racks at three sites in the hospital: a short-stay ward for patients with cancer, a surgical ward, and the main hospital foyer. Each post-card features a short poem by a local Northeast Scottish poet and a blank verso, on which the reader (patient, visitor, or staff member) can respond with a comment or verse composition of his own. Adjacent to each wall-mounted rack is a small post box for the return of reader responses, which Macduff and West mine for both new poems and feedback on the project. Another interesting development is the potential use of rhythmic poetry – or in speech therapy circles, “anthroposophical therapeutic speech” (ATS) – to promote heart rate rhythmicity and cardiorespiratory coordination. An article published in the July 2002 issue of the International Journal of Cardiology indicates that researchers may eventually articulate a scientific basis for the belief that reciting rhythmic speech has enduring physiological benefits.
Pedagogical applications of poetry in medicine are relatively nascent, lurking in the shadows of narrative theory. In the context of the medical humanities, poetry is often subsumed within the broader category of “literature and medicine,” and attempts at theorizing its purpose have been for the most part “adjunctive.” An article in the May 1998 issue of Academic Medicine, for instance, examines the role of creative writing in fostering self-reflection among medical students, looking at poems printed in Body Electric, a literary journal published by the University of Illinois at Chicago College of Medicine (UICCOM). Meanwhile, Ronnie Peterson, an RN and Clinical Staff Educator at the University of Wisconsin Medical Foundation in Madison, advocates the use of poetry in nursing staff development. Encouraging new nurses to express and share their experiences through poetry, she contends, may help them cope “with the chaos often found in the workplace” while singing “the unsung joys of patient care.” Others have expressed skepticism, asking pointedly whether reading poetry can render one a better health-care provider. “Being made to read poetry is unlikely to make anyone better at anything, except possibly reading poetry,” observes Miles Little of The University of Sydney. “Some very nice and very clever people read (and even write) poetry for pleasure, but the pleasure is the key: being made to read or write poetry doesn’t make people nice or clever.”
Though the trend of encouraging medical professionals to read and write literature is growing, this by itself does not prove its efficacy, which explains in part the rich, multi-faceted theoretical framework that has grown up around the practice. Apologies on behalf of literature-based medicine fall into one of two categories. The simpler, more self-evident of these proceeds from the observation that reading literature about physicians, patients, and their milieu lends one critical insight into the narrative, emotional, and ethical landscape of medical practice, enhancing sensitivity to patients, colleagues, and oneself. The more sophisticated, less self-evident of the two justifications for literature-based medicine starts from the claim that reading great literature on any theme fosters “narrative competence,” rendering physicians better “readers” of patients and their unique back-stories.
In support of this second justification, Rita Charon, co-editor of Literature & Medicine and director of the Program in Narrative Medicine at Columbia University’s College of Physicians & Surgeons, has for years advocated what she calls “narrative medicine,” a model for medical practice that emphasizes the pervasive impact narratives have on the lives of physicians and patients.
The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence, called narrative medicine, is proposed as a model for humane and effective medical practice…With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care.
“Any doctor and any medical student,” Charon maintains, “can improve his or her capacity for empathy, reflection, and professionalism through serious narrative training,” training that demands listening for more than mere surface-level narrative content, those “deep and therapeutically consequential understandings” that broaden one’s understanding of the narrator. Narrative medicine borrows tools germane to literary criticism, including methodologies for analyzing plot and subplot, point of view, voice, character, image, allusion, and metaphor. In the framework of narrative medicine, then, each patient embodies a unique, dynamic story, and it is the responsibility of the doctor to listen, interpret, and respond to that story effectively, ethically, and compassionately.
Charon’s narrative medicine model reflects the historically recent turn toward narrative knowledge in various disciplines, from medicine, law, and history to philosophy, sociology, and anthropology. In bioethics, the turn toward narrative knowledge has led to the rise of narrative ethics, whose proponents criticize traditional bioethics for relying exclusively on the top-down application of moral principles. Since the 1970s, bioethicists have by and large employed the “four-principles” approach (4PA), affirming prima facie the truth of four basic principles: autonomy, beneficence, nonmaleficence, and justice. Narrative ethicists contend that, when applied, these principles often conflict, failing to provide clear resolutions to ethical dilemmas. According to narrative ethicists, the story at the center of the bioethical case, being both “highly specific and highly culture bound,” provides the most compelling contextual clues for arriving at the right course of action in any given situation. As Rita Charon and Laurie Zoloth explain, “We argue in our teaching that the fictional story (not really real) can help us confront the terrible starkness of the irrefutably real clinical impasse, because narrative, and the way we understand it, allows us to see moral claims in action, allows us alliances, cases, and language for the confrontation.” For the average person, stories are a fundamental source of ethical knowledge, as cultural critic David Morris repeatedly points out: “Thinking with stories is a process in which we as thinkers do not so much work on narrative as take the radical step back…of allowing narrative to work on us.” Narratives, Morris contends, affect not only our beliefs, but our physical health. Even without taking for granted this – what some may consider extreme – view of the place of narrative in medical practice, simply granting narrative superiority over logicoscientific expression as a source of ethical knowledge privileges literature over other modes of bioethical learning.  For it promotes not only mutual empathy and understanding, but critical insight into how physicians and other characters in real-life medical stories should behave.
Many have questioned these claims. The expression “narrative ethics,” Thomas Murray has observed, signifies at least four different meanings: narrative as moral education, narrative as moral methodology, narrative as an appropriate form of moral discourse, and narrative in moral justification. Tom Tomlinson points out that, since stories cannot substitute for first-hand experience, it is unclear why reading literature, as opposed to spending more time with patients, constitutes the best course of action for honing bioethical knowledge and sensitivity. Wayne Booth, meanwhile, puts literary narratives to the ultimate test, questioning by what means narrative ethicists can prove that stories address ethical dilemmas more effectively than series of propositions. When it comes to any ethical conviction, whether represented in narrative or non-narrative form, “Neither side can prove, factually or scientifically, that the other side is wrong…skeptics who claim that, because of these ambiguities, ethical judgments can never be called knowledge will always win if we grant that the test of knowledge is demonstrability in the ‘scientific’ sense: no conviction is demonstrable unless it can pass the test of ‘falsifiability.’” We cannot call an ethical assertion “knowledge” unless we know the deductive steps that would disprove it were it untrue. Ethical convictions cannot fulfill this test of falsifiability, Booth concludes—hence, being “reasonable in moral matters is more like a process of systematic assent than systematic doubt…in any ethical enterprise, we must share the unfalsifiable conviction that some actions are right and some wrong.” The question remains, then, to what extent and in what ways narratives, as opposed to the adjustment, testing, and application of propositions, can teach patients and medical practitioners “essential ethical truths about the world of health, disease, medicine, and right and wrong ways of facing pain and death.”
Proponents of narrative medicine often conflate the categories of “literature” and “narrative,” at times abandoning the term “literature” altogether, neatly excising “non-narrative” species from the equation, among them the lyric poem. The exile of poetry from theories of narrative medicine, of course, stems not from a bias against the genre, but from its apparent incompatibility with the framework its practitioners employ: a poem is relevant only insofar as it possesses narrative elements, or becomes a narrative through interpretation. Indeed, the claims that narrative ethicists make about the ethical value of stories become even more problematic when one applies the same analytical framework to poetry. If there is a certain type of knowledge contained in narratives that is irreducible to propositions, as some have suggested, might there not be another type of knowledge contained in poetry that is irreducible to both propositions and narratives?
Anne Hunsaker Hawkins has offered one of the most compelling—and one of the few—answers to that question. Each of the three principal literary genres, she contends, offers a distinct species of knowledge: narratives impart narrative knowledge, tragic dramas “passional knowledge,” and lyric poems “epiphanic knowledge.” Epiphanic knowledge differs from narrative knowledge, which is “linear, progressive, and chronological,” in its immediate, almost extra-temporal apprehension. “For the lyric,” Hawkins explains,
apprehends those elements in experience that belong to the imagination—things that we understand suddenly and fully, often through images. Although a given rational stance on an issue can usually be explained and justified, epiphanic knowledge does not readily yield to explanation: indeed, it seems the product of nonrational (and perhaps nonconscious) images and thought processes. Moreover, the epiphanic refers to a dimension of experience that cannot quite be articulated.
While poetic epiphanies may not dictate a particular course of action, they often impart intuitions to those experiencing them that, when combined with scientific and narrative knowledge, may ultimately inspire right action. Epiphanic knowledge does not by itself provide one enough information to make ethical decisions, yet it is a critical and often-overlooked ingredient of ethical decision-making without which such decisions would become dangerously uninformed. By becoming better readers of epiphany, Hawkins concludes, physicians can develop, educate, and train their “intuitive and affective faculties” and ultimately improve their understandings of patients, colleagues, and themselves.
While Hawkins makes a convincing case for lyric poems, her focus on the epiphany, especially on its visual character, neglects what most consider poetry’s quintessential characteristic. Meter, rhyme, assonance, consonance, and other forms of musical repetition and variation distinguish poetry as an embodied form of literary art: as the body takes notice of a poem’s physical regularity, intermingling with its imagery and meaning, it begins to react: the stomach twists, heart races, and breathing intensifies; tears well up; tingling sensations run up and down the back and arms; the mouth grows dry and sour. The objective of a successful poem is to create such embodied impressions. A poem’s lyric moment, when music and meaning suddenly converge, marks an epiphany, indeed, but that epiphany involves all of the body’s senses, not simply sight and “nonrational thought processes.”
Lyric moments in poems are, as Hawkins points out, a “dimension of experience that cannot quite be articulated,” much like moments of emotional distress or ethical quandary, but it is unclear whether these experiences represent knowledge, per se. To refer to them as a form of knowledge may obscure their status as unarticulated bodily impressions, as well as the role they play in the subsequent creation of articulated narrative or propositional knowledge. For ultimately we need to determine what practical or ethical impact a doctor’s recognition of lyric moments (or epiphanies) can have on medical practice. Does reading poetry necessarily amplify or mute subsequent epiphanic episodes? Would a physician who had trained his “intuitive and affective faculties” be more apt to recognize and process an epiphanic moment for himself or others? If so, would that necessarily inform his reactions to future epiphanies?
To complement Hawkins’ model of epiphanic knowledge and align it with the reasoning underlying narrative medicine, I would propose a new framework, drawing upon Hegel’s theory of tragedy. Hegel would agree with contemporary narrative ethicists that stories are repositories of a society’s ethical knowledge. In particular, tragedies allow their authors to highlight the limitations of ethical knowledge by dramatizing situations in which legitimate, substantive social powers come into conflict. The ethical obligations to preserve life and respect patient autonomy are familiar examples of such powers. Ethical principles, “acknowledged as powers rightfully claiming human allegiance,” do not always guide one to right action. The body of principles is finite, the scenarios to which we apply them infinite. Tragedies constitute critiques of the inevitable inadequacies of ethical systems. Tragic figures highlight moments of crisis with respect to ethical truth, paving the way for new formulations.
Hegel describes tragedy as the intermediary between lyric poetry and epic. Together, the three principal genres of literary art represent a progression in the evolution of truth over time: the lyric marks present, embodied moments of crisis; the tragedy marks the articulation of that conflict as it encounters narrative language; and the epic marks the socially-accepted outcome, what Hegel would call its synthesis. Perhaps by understanding this progression from a pre-articulated state of truth to one of social acceptance, physicians would be more attuned to what epiphanic moments mean – to themselves and to their patients – and how to leverage them in the improvement of care-giving. Epiphanies, as Hawkins describes them, may signify areas of latent ethical knowledge that physicians, patients, and bioethicists can triangulate with stories and propositions. Lyric poetry represents a sudden recognition, cast in the form of a fully embodied impression reproduced for the reader – knowledge not immediately present in narratives. That knowledge approximates what Jurate Sakalys has described as the “ontological assault” of severe illness that advances “through a nexus of disruptive events.” In the words of Richard Sobel and Gerda Elata, “The experience of illness, with its roots in the threat of nothingness, and the subject matter of a poem share the unsayable elements of fear, terror, anger, sense of loss, or the question of the very sense of living.” Perhaps by reading and writing poetry, medical practitioners can expand the scope of bioethical investigation while improving their sensitivity to the wealth of clinical experiences for which no narratives, much less principles, prove adequate.
“Pain, suffering, worry, anguish, the sense of something just not being right,” Charon has written, “these are very hard to nail down in words, and so patients have very demanding ‘telling’ tasks while doctors have very demanding ‘listening’ tasks.” Certainly poetry has the most demanding of telling tasks in that what it attempts to capture is both subtle and unfamiliar to language, hardly reducible to narrative form. Readers of poetry have the most demanding of listening tasks: like physicians, they must observe with uncommon empathy the gestures and silences of the poem – listen carefully to its breathing and monitor its pulse.
 Notably, the discipline of poetry therapy followed in the footsteps of the Confessional poetry movement in the 1950s and 60s.
 The National Association for Poetry Therapy (NAPT).
 Leedy, Jack J. “The Value of Poetry Therapy.” American Journal of Psychiatry. 126.8 (February 1970): 1184.
 Mazza, Nicholas. “The Use of Poetry in Treating the Troubled Adolescent.” Adolescence. 16.62 (Summer 1981): 403.
 Strodtbeck, Frances and Rosanne C. Perez. “Poetry Play: A Method of Communication with Pediatric Clients.” Issues in Contemporary Nursing. 5 (1981): 129-32.
 Strodtbeck and Perez refer to the patient composition of poetry as “poetry play,” which they distinguish from poetry therapy (i.e., the sharing of poems with patients).
 Macduff, Colin and Bernice West. “Developing the use of poetry within healthcare culture.” British Journal of Nursing. 11.5 (2002): 336. In 2001, the authors added an additional post in the Royal Aberdeen Children’s Hospital.
 Bettermann, Henrik et al. “Effects of speech therapy with poetry on heart rate rhythmicity and cardiorespiratory coordination.” International Journal of Cardiology. 84.1 (July 2002): 77-88.
 Poirier, Suzanne et al. “Songs of Innocence and Experience: Student’s Poems about Their Medical Education.” Academic Medicine. 73.5 (May 1998): 473-8.
 Peterson, Ronnie, MS, RN. “Bringing Poetry into Staff Development.” Journal for Nurses in Staff Development. 18.1 (Jan/Feb 2002): 48-50.
 Little, Miles. “Does reading poetry make you a better clinician?” Internal Medicine Journal. 30 (2001): 60.
 Charon, Rita. “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust.” JAMA. 286.15 (Oct 17, 2001): 1897.
 Charon, Rita. “Narrative Medicine.” Special to LitSite Alaska. [litsite.alaska.edu/uaa/healing/medicine.html]
 Charon, Rita. “Narrative and Medicine.” The New England Journal of Medicine. 350.9 (February 26, 2004): 862.
 From a definition for “narrative ethics” in The Concise Encyclopedia of the Ethics of New Technologies. Ed Ruth Chadwick. New York: Academic Press, 1998. 11.
 Charon, Rita and Laurie Zoloth. “Like An Open Book: Reliability, Intersubjectivity, and Textuality in Bioethics.” Stories Matter. 22.
 Morris, David B. “Narrative, Ethics, and Pain: Thinking With Stories.” Stories Matter: The Role of Narrative in Medical Ethics (Eds. Rita Charon and Martha Montello). New York: Routledge, 2002. 196.
 In “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust,” Charon distinguishes narrative from logicoscientific knowledge in the following manner: “Unlike its complement, logicoscientific knowledge, through which a detached and replaceable observer generates or comprehends replicable and generalizable notices, narrative knowledge leads to local and particular understandings about one situation by one participant or observer. Logicoscientific knowledge attempts to illuminate the universally true by transcending the particular; narrative knowledge attempts to illuminate the universally true by revealing the particular.” 1898.
 Murray, Thomas H. “What Do We Mean by ‘Narrative Ethics’?” Stories and Their Limits: Narrative Approaches to Bioethics (Ed. Hilde Lindemann Nelson). New York: Routledge, 1997. 6.
 Tomlinson, Tom. “Perplexed about Narrative Ethics.” Ibid. 125.
 Booth, Wayne. “The Ethics of Medicine, As Revealed in Literature.” Stories Matter. 12.
 Ibid. 13.
 Booth. 11.
 “Or is it rather that those insights are not wholly reducible to propositions? Are there morally substantive things to be derived from narratives that go beyond propositional moral logic?” Murray. 5.
 Hawkins, Anne Hunsaker. “Literature, Medical Ethics, and ‘Epiphanic Knowledge.’” The Journal of Clinical Ethics. 5.4 (Winter 1994): 286.
 Ibid. 284.
 A.C. Bradley on Hegel. Paolucci, Anne and Henry (Eds). Hegel on Tragedy. New York: Anchor Books, 1962. 369.
 It may be that poems of overwhelming joy also mark moments of crisis insofar as they signify feelings one cannot articulate as knowledge.
 Sakalys, Jurate A. “Restoring the Patient’s Voice: The Therapeutics of Illness Narratives.” Journal of Holistic Nursing. 21.3 (September 2003): 229.
 Sobel, Richard and Gerda Elata. “The Problems of Seeing and Saying in Medicine and Poetry.” Perspectives in Biology and Medicine. 44.1 (Winter 2001): 91.
 Charon. “Narrative Medicine.” [litsite.alaska.edu/uaa/healing/medicine.html]
Jeff Encke taught writing and criticism at Columbia University for several years, serving as writer-in-residence for the Program in Narrative Medicine while completing his PhD in English in 2002. He now teaches at Richard Hugo House. His poems have appeared in or forthcoming from American Poetry Review, Barrow Street, Black Warrior Review, Boston Review, Colorado Review, Fence, Kenyon Review Online, Salt Hill, and Tarpaulin Sky, among others. In 2004, he published Most Wanted: A Gamble in Verse, a series of love poems addressed to Saddam Hussein and other Iraqi war criminals printed on a deck of playing cards.