Terrence E. Holt MD PhD
Program on Aging/Division of Geriatric Medicine
University of North Carolina School of Medicine
Chapel Hill, NC 27599-7005
(919) 966-5945x278
holtter@med.unc.edu

Narrative Medicine, Negative Capability, and Me

Last fall, the critical, educational and literary movement known as “Narrative Medicine” received the definitive stamp of public recognition when it was the subject of feature coverage both in the New York Times and on National Public Radio’s Morning Edition. Both pieces concentrated on the role played by Rita Charon and the Narrative Medicine program at Columbia University in introducing narrative writing and discussion groups into the third-year clerkships at the College of Physicians and Surgeons. Both the Times piece and the NPR broadcast clearly situated their interest in the spectacle of doctors writing-and about themselves-in the broader context of the widespread attention that has been garnered recently by doctors’ autobiographical narratives. The emphasis on autobiography in these features seems anything but surprising; indeed, when seen in cultural context, it has an air of inevitability. Atul Gawande’s essays in The New Yorker, for instance, are only the latest in a long series of narratives that have become a staple in the pages of our most influential journal of literary style, reaching back to the days when Burton Rouche’s “Medical Detective” pieces spliced the disparate genres of public health and the private eye into a literary career. Along the way, practitioners of the medical narrative, in the pages of magazines such as The New Yorker¸ Harpers, and Mademoiselle, have included such well-known doctor-writers as Oliver Sacks, Perri Klass, and Richard Selzer; indeed, when Gawande was still cutting his teeth, Lewis Thomas was ruminating on medicine in the pages of Natural History in a style clearly owing more to Hazlett and Lamb than to Osler or … or … twentieth-century medicine can’t supply the name of a purely medical essayist after Osler. Which is perhaps the point: for much of the past century, medicine has been resolutely estranged from literature. And it was as a response to this that the movement known as Narrative Medicine arose.


But-and this is what makes the recent appearances of Narrative Medicine in the Times and NPR surprising after all-in its origins, the Narrative Medicine movement was not exclusively, or even notably, linked to the autobiographical essay. It was, originally, a much more catholic undertaking, which described itself as a “subdiscipline of literary studies that examine[d] the many relations between literary acts and texts and medical acts and texts.” As such, it sought not so much to import critical methods from the humanities, especially literary studies, into medicine, as to bring medicine under that particular critical gaze. From this beginning, the movement has grown, however, largely under the driving impetus of Rita Charon and her group at Columbia, into an initiative within medical education, one that attempts to imbue medical trainees and practitioners alike with what it calls “narrative competence”: the ability “to recognize, interpret, and be moved to action by the predicaments of others.” As such, Narrative Medicine, as taught at Columbia and other institutions, has continued to emphasize interpretive skills far more than actual narrative composition. This alone has still been regarded in some quarters as revolutionary, and therefore unsavory: Charon has been accused of “advocating … the medical application of … deconstructionism, critical literary theory, or postmodernism.” Indeed, if we choose to ignore the dangers of such “extreme relativism,” in which “there is no knowledge … merely stories, ‘narratives,’” one writer warns us, “we may do so at our own and our patients’ peril.” And it may be that this reaction is correct, at least insofar is it identifies a tendency. Out of this relatively innocuous attempt to articulate points of contact between the interpretive act as practiced by doctors and literary scholars has arisen what may well be the most extreme relativism of all: an unseemly airing of medical laundry, in which doctors, writing from a perspective that sets aside the first-person plural of the journals and the labs, in which the active voice uncomfortably identifies the individual behind each act, confess to having doubts, to making mistakes, to doing harm. Our own and our patients’ peril has in fact been the subject matter of the most widely noticed medical narratives, threatening to unleash a flood of revelation and self-regard that has already sparked a retrograde movement. In several recent essays, Charon herself and others writing from outside Columbia have issued cautionary statements warning practitioners of the potential harm they may do by revealing too much, undermining patient trust, even committing theft of narratives belonging properly to the patient, not the doctor.


This is a lot of history for such a small and youthful movement to have accumulated. But I’d like to suggest that this brief précis is really only the tip of a much larger iceberg, a submerged mass whose actual outline is identified in the popular coverage the movement has only recently received-or, rather, in the difference between the emphasis in the Times and NPR coverage and the official version. For as a literary movement, Narrative Medicine inevitably has its official history.


In an essay titled “Literature and Medicine: Origins and Destinies,” published four years ago in Academic Medicine, Rita Charon grounds the narrative medicine movement in two parallel literary traditions: the classical tradition, stretching back to Sophocles, in which dramatists, poets and novelists have turned repeatedly to tales of illness and its treatment for material; and the lineage of medical writers from Hippocrates on, in which doctors have presented the diagnosis of illness as essentially a matter of narrative and its interpretation. Medicine and literature were united originally in the Golden Age, and it is their destiny to re-unite, overcoming the divisive tendencies of empiricism and quantification that have estranged us from our patients and ourselves.


Charon’s history of narrative medicine speaks of a deep need to overcome the alienation of medicine from the rest of its culture, of doctors from their patients. I think the prescription she offers-to attend, once again, to what can be learned only through language-is the right one. But what interests me is not the history narrative medicine so much as the origins of Narrative Medicine as a contemporary movement within medicine, literature, and medical education. What I would offer here is an alternative history, one located more immediately in the culture that is generating Narrative Medicine in the form we find it in the Times and NPR. Out of that alternative I would like to draw a slightly different moral, one that celebrates division as much as unity. By attending to that alternative, I’d like today to suggest ways in which the narrative movement can be incorporated in the medical curriculum not so much as a foreign body-tolerated, but effectively walled off in a kind of emotional abscess-but as something properly-indeed, already-a central part of medical education.


When I consider the derivation of narrative medicine-the fact that it rises to public attention only when it assumes the form not only of the autobiographical but the confessional-I find my attention drawn to sources more immediate than Hippocrates or Sophocles. I’d like to argue that Narrative Medicine owes its current prominence to two highly influential sites of cultural production: The New Yorker, on one hand, and network television on the other. Between the two of them, they outline an alternative tendency in narrative medicine, one that points to a deeper contradiction within medicine itself, and the educational process that makes doctors the strange creatures they are.


The New Yorker has been for the past generation the unchallenged arbiter of literary fashion in the United States (to the extent that the United States can be imagined as having a single literary culture, which is arguable, but that’s precisely the fantasy that organs like the Times and NPR exist to promulgate, so let’s accept that as a given for the present case). As such, it has enforced a highly distinctive set of formal and substantive criteria on American literary production. On the one hand, there has been an extreme devotion to the canons of literary realism, taking these conventions so literally that several generations of Ivy-League graduates have made their entry into the world of letters in the role of “fact-checkers” for The New Yorker, verifying that the details not only in non-fiction, but fiction pieces as well, and even poems, conform to the specifications of their formidable reference library. One perverse effect of this construction of realism has been a curious blurring of the lines between fiction and fact: when both are expected to portray life with the same fidelity to the world as construed by cartographers and encylopedists, it is natural to wonder where fiction ends and fact begins.


There has also been an understanding that, in short fiction, at least, the function of narrative personae should be as limited as possible, usually through the formal mechanism of irony, by which any statements about the world that might be deemed authoritative (beyond the location of certain buildings on certain streetcorners) are rendered open to multiple and ultimately indefinite interpretations; in other words, the “meanings” of such stories should be apparently opaque, accessible primarily by reference to the larger oeuvre of New Yorker stories, a good liberal arts education, and an arch knowingness. As a marketing technique, this has been highly successful, allowing the creation of an audience larger than might otherwise have accrued to a literary magazine, because in its resistance to definition-fact or fiction, meaning this or meaning that-The New Yorker was able to be many things to many people (a marketing technique that has been explored in a variety of other ways by most of the successful mass media of the past century). But it has had a number of peculiar effects (or perhaps it might be safer to say that it has made the magazine a natural home for other cultural trends that arise similarly from the exigencies of making a living in what the Marxists hopefully call “late” monopoly capitalism), chief among them what has been widely celebrated or condemned as the decentering of the literary subject.


The most familiar and influential instance of this “decentering” tendency has followed a trajectory of close to forty years, beginning with the first essays in “The New Journalism” in the 1960s, and continuing today in the flourishing of a new literary form known variously as “creative non-fiction” or more simply “the personal essay.” The New Journalism, you may recall, was new because it was a product of the ‘sixties, and what marked it especially as a part of that era was its skepticism about authority, which it expressed by re-inserting the first-person singular point of view into journalism. Norman Mailer, Tom Wolfe, Gay Talese, Joan Didion, and a host of others approached what had traditionally been objects of journalistic interest-subjects to be approached, above all, with an Olympian objectivity-with a perverse insistence on the reporter’s identity as an individual, and by implication the limitations of the reporter’s perspective. As such, the movement announced a principled rejection of what it held to be an impossible and irresponsible claim to objectivity: in the complex, highly-charged political and social currents of the time, such a claim could only mask either self-delusion or a hidden agenda. Better to be up front with one’s position and prejudices, and thereby allow the reader to interpret the image in an avowedly flawed lens.


In its abdication of authority, the new journalists tried to put into practice perhaps the most characteristic political axiom of the time, “the personal is the political.” But it also expressed a profound skepticism about the limits not only of knowledge, but also of politics, an epicurean hand-washing of questions of truth and falsehood. As such, the New Journalism expressed a despair of making sense of a society that had seemingly become too complex, too chaotic to see as a whole. But in its strangely sneering tone, the New Journalism also expressed another wish: to hold itself, despite its pose of engagement, above the fray. By eschewing authority, by refusing responsibility for accuracy, the New Journalism also expressed a wish to escape the seemingly inevitable catastrophe toward which the times seemed a-heading. It’s probably not an accident that the political dispute that brought the New Journalism into being was the war in Viet Nam, where a refusal of global entanglements expressed a profound skepticism about what had been verities of geopolitics, a refusal of the Manichean divisions of the world into categories of right and wrong that seemed doomed to reduce both sides to indistinguishable ash. Better not to be involved: at least then one could have the consolation of feeling oneself the innocent victim of others’ mischief-about the only consolation one could imagine, at the time.


If the elements of this story seem familiar, it may be because the key terms-responsibility, objectivity, skepticism and ultimate destiny-are essentially the same as those that anchor Rita Charon’s account of the unity of literature and medicine and the forces keeping them apart. Because as we track the New Journalism forward through the ‘seventies to the ‘eighties, it morphs, as the rest of the culture did, from an intense interest in the political to a quietist concentration on the personal, emerging in the ‘nineties in the form of “creative non-fiction” or “the personal essay.” (For those who aren’t sure what I’m talking about, the career of John McPhee, from The Curve of Binding Energy, through Coming Into the Country to Basin and Plain marks just this tandem process of personal engagement and public disengagement.) And it is over precisely this period that the popular medical essay, which at its start was essentially the province of the traditionally reportorial Burton Rouche or the magisterial (im)personality of Lewis Thomas, gives over to the Carlylean excesses of Richard Selzer, the engaging confessional of Perri Klass, Oliver Sacks’s quirky neuroethnographies, and ultimately the frankly disturbing complications of Atul Gawande. It is an evolution marked by precisely the same re-insertion of the narrator-doctor, once as absent as Joyce’s Olympian creator-god, into what is revealed not as the impersonal marble halls of Aesclepius but a charnal-house of uncertainty and confession, doubt and error. In doing so, the doctor regains a personal contact with the audience, and ultimately (Charon would argue, and I agree), with himself, but at a price.


As several commentators (most notably Charon herself, as well as Coulehan and Hawkins in their recent piece in Annals of Internal Medicine) have observed, the doctor who writes personally and honestly about the uncertainties and conflicts in medicine runs a number of real (and some I think imaginary) risks: from violation of patient privacy to undermining the confidence of the laity in the canons of medical professionalism to theft of literary property properly belonging to the patient to exploitation of suffering for personal gain. A part of that price is the very surrender of authority that was the original point of the New Journalism. In abandoning the traditional prerogatives of the doctor, these critics warn, among them secrecy, detachment, and authority, doctor-writers risk alienating the very patients with whom they want to get personal. Who would trust a doctor who blabs the secrets of the examining room? Who would bare his belly to a surgeon who confesses his mistakes? Who would trust the gnosis or prescriptions of a doctor who doubts? In trying to step down from his singular eminence, the doctor-writer may fall too far. The move to personalize may alienate instead.


What, we might well ask, would drive otherwise respectable doctors to open up the secrets of the sausage factory? And what patients would want to take the tour? When we consider the weight of professional tradition and prejudice, as well as legitimate ethical questions that arise when doctors stoop to story-telling, it’s hard to escape the conclusion that there must be some powerful need driving not only the tellers, but the audience.


I mention the audience at this point for a number of reasons. First, because the tendency in these discussions is almost universally to forget about them. Almost without exception, discussions of the attractions and pitfalls of medical autobiography turn on the doctor-patient relationship, or occasionally the doctor-doctor relationship (but even there the “other” doctor figures usually not as the reader, but an innocent bystander in the story, dragged in unwittingly as an extra in the story-teller’s risqué tale). But more important, because it is the existence (or creation) of an audience that has made-as the notice in the Times and NPR suggests-narrative medicine what it is. These narratives would not exist-not publicly, at least, without people willing-in fact, eager-to pay good money to read them. The question is, why? Where did this audience come from? What’s motivating them to read things that most readers readily admit they find disturbing? And what’s the relationship between that audience and the doctors doing the writing?


I think an understanding of this part of the history hinges on a recognition of one of the most important aspects of audience reception of these pieces. It is not unambivalent. The medical profession itself, in its distinct uneasiness about medical narrative, is acting (as it must) as a part of the larger culture, shocked, a little scared, a little titillated to find the secrets of the examining room and the operating room, the consulting room and the emergency room-all these rooms once closed off-now so readily accessible. This aspect of the trend was most clearly announced several years ago, with the possibly surprising success on niche cable channels of “documentary” programming devoted essentially to close-up images of gory surgery. The shows found a following, but it was clear that the appeal was essentially one of the frisson, of a voyeuristic entry into what should properly be concealed-our own insides, our bloody fragility-a spectacular relationship that has been best explained from the psychoanalytic perspective by Julia Kristeva (in her Powers of Horror) and from a historico-political, or at least French, perspective by Michel Foucault (in his Discipline and Punish) . It is in these recent, pseudo-documentary essays in the form that we find a suggestion that what draws people to such narratives is precisely what we have been warned against: a reveling in what one might call the medical sublime: a front-row seat at a display of mortal danger, where the boundaries of medical competence define as well the mortal boundaries of the self. Without this element of danger, danger constructed especially in terms of medical fallibility, it is doubtful that this audience would exist in the form it does-no more than the ineffably tedious circuit of race cars around a track would draw a crowd, without the implicit promise of a disaster. But however crude or peculiar such attractions might seem, they point to a more general appeal that has persisted for several generations in that hardy (seemingly immortal) subgenre of popular drama: the doctor show, where the fallibility of doctors takes on a more particular form that points us to another domain of medical narrative’s appeal, in the personalization of medicine.


From its origins in radio soap opera through its television manifestations among the most popular primetime programs in every decade since 1960 (Dr. Kildare, Ben Casey, Marcus Welby, St. Elsewhere, ER) as well as its persistence as a staple of afternoon programming, the doctor show has followed a very simple formula: in high-concept terms, it reduces to this: “personal medicine.” Or, better, “sexy medicine.” Perhaps even “family medicine.” No matter how it’s inflected, the fundamental gesture is to take a frighteningly remote institution, frightening because it insinuates itself into the most personal recesses of our lives, our minds, our bodies while at the same time remaining impersonal, aloof-and domesticate it. In these dramas, medicine can be domesticated in a number of ways. Sometimes the gesture is literal, as in the domiciliary architecture of the office in which Robert Young impersonated Dr. Marcus Welby (when we all knew he was really Father Knows Best), or the cozy home offices where Carl Betts went so Donna Reed could clean the house, or whatever it was Cliff Huxtable did. Or it’s figurative, as in the family romance enacted by Ben Casey and Dr. Zorba, or Dr. Kildare and his paternal mentor Gillespie. Or it appears as the most direct shorthand of all, the way sex just keeps happening all over these hospitals-something that, to the best of my knowledge, is not common at the institution where I practice. But I think the most telling way in which this happens is also perhaps the subtlest, a matter of style more than substance. I’ve only watched a medical show once since I went to medical school; before then, while I wasn’t a fan, I’d squandered hundreds of otherwise productive hours watching Richard Chamberlain dance with Yvette Mimieux, or improbably nasty things happen on the roof of St. Elegius. But for the few minutes I tuned into (I think it was) Chicago Hope a few years ago, I was only convulsed with laughter. It wasn’t that they had the facts wrong: they had clearly hired the right consultants. It was something their medical fact-checkers had no power to expunge: in every scene, doctors and nurses talked about their work, their jobs, but especially their patients passionately, intensely as only actors on seasonal contracts can: they talked about them as if they deeply, personally cared.


At which point I have to stop for a brief disclaimer. I’m not suggesting here that doctors and nurses don’t deeply, passionately, and in some sense personally care about the work they do. We do. There is a great deal riding on the work: ego and conscience and fear and even idealism. But what we have to offer our patients isn’t (ideally) eros, or even agape. At best, it rises to caritas, the least personal, most institutional form love can take.


And there we have the crux of the matter, both for the audiences of the doctor shows, and for the doctors who don’t watch them. For the audience, those shows (and to the extent that they follow the logic of personalizing medicine so too do all medical narratives) address a deeply-held wish, and allay (or at least entertain) an abiding fear: that doctors might care for them; that anybody, in the enormous machine that is a hospital, might be personally concerned with their mortality; that somehow in the encounter with our utter helplessness that is the fundamental truth and shock of hospitalization, someone might intervene to make it all go away. Which, of course, we can’t. People come into the hospital, increasingly in this era of economically rationalized medicine, to suffer and to die. And no matter how deeply I may feel my commitment to ease that suffering, to forestall that death (if such forestalling be in fact humane), I know just as deeply that my powers in that regard are, to put it mildly, limited.


I’ll get back to the question of medical narrative in a minute, but right now I find my argument hijacked by something more pressing, a parenthesis that forces itself open under my feet. Here I am in the thick of it. Which is the problem that I think narrative medicine has come into being to address. I’ve been speaking as if the form is something new. This is one of the assumptions that has conditioned the entire discourse, and I think helped determined Charon’s attempt to root the form in ancient Greece. Is narrative medicine really a new form, a response to contemporary pressures on medicine? I actually doubt this. I think the medical narrative is actually ancient, but not in the way that Charon’s optimistic and rational account would have it. There are different ways of writing; one persistent theme of contemporary critical theory would have it that writing happens all the time, that it is the base condition of existence: we live a narrative that inscribes itself in the world around us, and on ourselves. It is a tale not of original and ultimate unity, but of originary, irremeable division, an alienation of the self within the self, the insurmountable gap between desire and its fulfillment, between self and other, that language in its endless significations endlessly repeats.


The narrative I’m thinking of has some affinities to Charon’s creation myth. It is a bildungsroman, but constructed not in essential unity, but in originary loss. It goes like this: out of a complex and poorly-understood motivation, articulated (usually) inaccurately in the AMCAS application essay, every year some thousands of young people go to medical school and start becoming doctors. The first thing that happens to them, as we all know, is that they dissect a cadaver. This is a nasty process, of dubious educational value, but we all know why it is such an essential introduction to medicine: it drives a wedge between the learned and perhaps instinctive taboos that inhabit most of us quite deeply, on the one hand, and the socially necessary instrumentality of the doctor, on the other. Rather, it’s a symbol for this, an initiation that provides a key by which the initiate learns to understand his new relation to the world. Between the human being who feels a proper loathing and horror of the corpse and all it means, and the doctor who will diagnose prostate cancer by a rectal exam, or sexual assault by an excruciatingly prolonged forensic pelvic, or any number of other critical and harrowing conditions and procedures, there must be some division, some lasting estrangement, or else the work will not get done: the cancer will be missed, the rape go unconvicted, unconsoled. How horrible!


I’m not suggesting pity for the doctor-we’re paid for this, and although I doubt the canons of informed consent are really satisfied in the process, we’re all adults. And anyway, we’re not really the victims here. The victims are the patients who find themselves under the care of people who have had their capacity to care deliberately altered. Not that it has been destroyed or incapacitated, but definitely changed, distanced, disconnected from the way it works in most of us. (The difference between this necessary effect of medical training and the textbook description of the antisocial personality disorder is really a matter of context.) I said a moment ago that there was a narrative here, that medical narrative is an ancient form. The inscription left by this process that matters most isn’t marked only on the doctor who can’t adequately respond to a patient’s experience, although that is certainly a part of the story. The larger story is made up of silences, of gestures not made, connections failed, of meanings misunderstood: it is in the entire institution of medicine, with which nobody nowadays, at least in their public statements, seems all that happy.


I don’t really want to speak to the unhappiness of doctors here: as I’ve said, we’re adults, and this is a job. Which is, from my perspective, the ultimate question narrative medicine has to answer. How can narrative make us better doctors? In trying to answer that question I’m reduced, finally, to inserting my own autobiography.
I’d like you to imagine me a few years ago, a resident in the cardiac ICU, leaning against the wall of a patient’s room. It’s about eleven in the morning and I’ve been up since six AM the day before. The patient is dying, by the way. She’s been under my care eleven days. About five minutes earlier, in keeping with the patient’s emphatically expressed wishes, I had turned off the pump that had been keeping her alive. Her family is gathered around the bedside. She is awake, talking quietly. She’s going to be dead within the hour.


As I lean against the wall, tears are coursing down my face. I’m being very quiet about it, but in a very quiet way I’m blubbering as freely as I know how. And meanwhile I’m thinking: if she’s gone by 12:30, I’ve got a chance of getting lunch before I replace the art-line in 24. While the tears are streaming down my face. I’m sad as sad can be, haunted by memories of my father’s nearly identical death ten years before. And thinking: With any luck I can sign out by three. And weeping. Maybe I’ll skip lunch. Just do the art line. And weeping.


I’m reluctant to offer myself here as an example of anything but a tired man on the periphery of someone else’s sad situation. Most doctors I know can tell similar stories. Maybe with not so much weeping, but with the essential two-track mental process intact. The difference between my story and other doctors-the individual particularity that makes it worth casting as narrative-has to do with my relationship to that process. The process itself isn’t all that remarkable, either. Psychiatrists call it “splitting,” and it’s a well-known defense mechanism. When I was holding up that wall in the CCU, reviewing my to-do list and crying my eyes red, I knew exactly what was going on. I was splitting. But what struck me most about it at the time was not that I was splitting: it was that it didn’t bother me that I was doing so. In fact, I was glad. In splitting, I had somehow made myself whole. To myself at least, I was experiencing the truth about my presence in that room. And that, I think was important. It set me free to do what mattered. For the family in that room, the woman dying on that bed, I was there. I was clearly sharing their feelings about what was happening. She wasn’t dying alone.


The point of this digression is not to assign myself any particular virtue: I don’t think anything about this story qualifies me as the historically necessary weeping doctor. But what was it that enabled me to function comfortably within that split; to attend equally to both halves of my experience? Because I should emphasize that both halves were necessary: easing the suffering of that patient and her family in the only way I could, and, along that other track, still performing my obligations to the others who were depending on me that day: to my other patients-who needed that art line, who needed a reliable handoff to the on-call team-to my family, who unaccountably wanted me home. And to me, who needed desperately to get some sleep. But I needed more than that, of course: I needed both of those tracks to function and function equally well: I needed to mourn that patient, to change that art line, to grieve my father, to sign out my patients, to feel something personal in the midst of so much institutional anomie, and to go home. I needed to think I was doing justice to everyone involved-in a situation where a single-minded response would have left many people uncared for. All of them, in fact. If there was anything particular about my performance at that moment, it was simply that I was demonstrating the benefit of my training. Not as a doctor, but as a reader.


As Keats observed long ago, what constitutes the literary sensibility is precisely the capacity to entertain disjunctive thoughts that I demonstrated in that patient’s room, a quality he called “negative capability.” If I was able to do justice, to do my job fully that day, I have to thank Keats as much as Hippocrates, and the people who taught me how to read Keats, probably, more than the ones who taught me to read an EKG. (Although it might be worthwhile to observe that Keats identified this quality in the year he quit his work as a surgeon’s dresser, at a time when he had far more experience in medicine than he did with literature.) So perhaps my initial formulation has it backwards or is only half the story: in being free to entertain two seemingly opposed responses-to pity and to duty, to death and to lunch-I was experiencing a lack, a fragmentation, a division. But it is precisely this experience that unites the worlds of medicine and art-or could, if medicine could come to recognize it through the terms Keats made available two centuries ago. If we could recover a familiarity with, an acceptance of, the essentially fractured nature of our selves and our hearts, we might regain an insight that, for all its explanatory power, the empiricist disposition of contemporary medicine has lost the power to see, to accept, or to express.


A reader reading well is simultaneously experiencing the text, responding to it emotionally, and at the same time analyzing that response, tracking it to its sources in narrative convention, in language, in culture and psychology and economics and all the other disciplines critics poach on these days. Doing one without the other isn’t reading. And it isn’t doctoring either. Rather than ignoring or decrying our negative capability-the gap we pry between our emotions and our function as doctors-rather than hiding it as a dirty secret of medical initiation, scotomizing it or pretending it’s something other than it is, we need to address it: encourage it, cultivate it, learn it and teach it. Make it not a loss but a gift, an instrument as important to medical care as any other technique at our disposal. And in literature we have ready-made the tool our culture has developed for this task: reading and writing are both, as numerous exponents of narrative medicine have observed, performative acts, requiring just this capacity to think and feel simultaneously, to experience and observe oneself in the act, and to know this not as a weakness or a wrong but as precisely what makes us able to give people care.