Narrative Concepts

The idea of narrative is becoming recognized as basic to understanding humans and culture.   Philosopher Alisdair MacIntyre writes, "[W]e all live out narratives in our lives" and "we understand our own lives in terms of the narratives that we live out."   (MacIntyre, 1981) . The default mode of the brain according to Washington University neuroscientist Raichle is to make up stories.   It is what we do easiest.   It is what burns the least amount of glucose.   It is, according to neuroscientists and artificial intelligence experts Shank and Abelson, the template for human memory.   We humans actually think more in terms of verbs than in nouns.   When we see something, we want a story about it.   We want to know what it does or what it can be used for.

What is narrative?   The shortest narrative consists of two action clauses and an orienting clause.   I like to tell a short story that one of our clients told.   She said, "One time I killed my boyfriend, but then he came back to live and tried to kill me.   That was when we were living in Georgia and I was dealing coke."   This short story tells so much.   It conveys the essence of a character, of a human being positioning herself to be seen in a certain light.   It contains values and emotions.   It conveys a richness of understanding far beyond its mere words.   It is a work of social art, complexly rich and detailed.

University of Auckland Professor Brian Boyd argues that our big brains arose to do story.   Brain evolved to do story because story worked.   Story worked because it is the most efficient way to store massive social information as illustrated above.    Each of us can, apparently, know about 500 other people.   The amount of information we need to negotiate relationships with these others is massive.   We retain it in the form of stories.  

Thus, narrative medicine means an understanding of health and disease for humans, that is grounded in the stories humans live out in their lives and the stories that we understand about our lives which give our lives meaning and purpose.   Whatever we do only makes sense in the context of being grounded in a story or two.   When you recognize that I have a belief, that belief only makes sense if I tell about the experiences that led me to form that belief.   This belief rests upon experiences that led to certain conclusions that are stored in a narrative template.

Probably you wonder why this excites me so much!   I would answer, "because it bridges my indigenous parts with my non-indigenous parts.   In growing up, I learned that everything that mattered was a story.   If my grandparents had something important to tell me, they would tell me a story.   I was expected to interpret the story, to make sense of the story and to grasp what they wanted me to know.   I learned that "all there is, is story".   In Lakota, our personhood is the synthesis or integration of a swarm of stories that surround us called the nagy.   These stories consist of all the stories that form us or that we have told or are enacting as we move about in the world.   This nagy also consists of all the tellers of those stories.   We are forever embedded in each other's nagy's.  
To bring that into the practice of medicine, it means that illness is embedded in the stories we are performing and that are performing us.   There is a biological story about how we are organisms who are born, live, wear out, and die.   Our lives are finite.   Within that finitude, however, are multiple social stories which interact with the "how long do I have to live story".   Another story tells us that some events within our lives appear to be random, meaning that I can't make sense of them.   I can't place them within a story.   However, if I find the stories that people are telling and that are told about them, often their illnesses are illuminated in some way.   The illnesses make more sense.  
David B. Morris of the University of Virginia, writes that narrative is above all a form of knowledge (Morris, 2005) .   In this view, narrative knowledge complements and differs from traditional "logicoscientific" knowledge (Charon, 2001) .   For Charon, narrative knowledge is less of a product than a tool.   It is "what one uses to understand the meaning and significance of stories through cognitive, symbolic, and affective means."   Its identifiable properties -- beginnings, middles, endings, characters, conflicts, and turning points -- for Morris are more descriptive than definitive.
Narrative comes from the Latin word, narrare, which means "to tell" and refers to various forms of telling.   Philosopher Richard Kearney writes that, "[N]o matter how distinct in style, voice, or plot, every story shares the common function of someone telling something to someone about something" (Kearney, 2002) .   For Morris, these tellings include the gamut from fragments of discourse to ancient formulaic epic poems like the Iliad or The Odyssey to cryptic post-modern novels.   Other scholars go further than Charon to argue that all knowledge, even the conventional declarative knowledge of modern medicine is narrative because all knowledge is embedded in theory which is a story about how the world is supposed to work.   These stories have characters in the form of biological entities or molecules, they have plot in the sense of operations that take place upon these entities (enzymatic reactions, flows of ions, passage of molecules across membranes).   They have implicit values such as preserving the life of the organism.   Even mathematical proofs can be seen as narratives.   Some neuroscientists see human identity and the operation of human consciousness as narrative (Fireman, McVay, & Flanigan, 2003) .

Narrative is not strictly verbal.   It is visual, bodily, kinetic, musical, and mixtures of all these.   Choreographed dances are stories, such as American Spring as are musicals like Oklahoma.   For Morris, stories also hold the negative, what cannot be told, the gaps, silences, and what cannot be said.   Stories always contain a matrix of choices -- what is valued, what is marginalized, and what is excluded.   Within medicine, narrative reminds us that illness is always caught up in stories involving families, jobs, cultures, and meanings and is not limited to the simply biological rendering, which we call "the natural history of the disease".   Indeed, I suggest that illness is without natural history because it is always affected by human affairs -- by people's search for meaning and happiness, by the relationships in which they find themselves, and by the broader stories of culture.   Biology is not an island unaffected by the sea in which it swins.

Bibliography

Charon, R. (2001). Narrative Medicine: a model for empathy, reflection, profession, trust. JAMA, 286, 1897-1902.

Fireman, G. D., McVay, T. D., & Flanigan, O. J. (2003). Narrative and Consciousness: Literature, Psychology, and the Brain. Oxford: Oxford University Press.

Kearney, R. (2002). On Stories. New York City: Routledge.

MacIntyre, A. (1981). After Virtue: A Study in Moral Theory. South Bend, Indiana, U.S.A.: University of Notre Dame Press.

Morris, D. B. (2005). Success Stories: Narrative, Pain, and the Limits of Storylessness. In D. B. Carr, J. B. Loeser, & D. B. Morris, Narrative, Pain, and Suffering (Vol. 34, pp. 269-285). Seattle, Wash8ington, USA: Intertnational Association for the Study of Pain Press.

Single Payer Health

People's stories about health and disease determine their health behaviors.  I begin with an example of a patient whom I told 25 years ago that he had to take better care of himself and who just dropped dead of a heart attack in his 50's.  I wonder about how we help people change the story that they are living.  How do we help them change health destructive behaviors in a respectful way that honors the story they have brought?

Who should pay for health care?   If health care is a right and not a privilege and we should all contribute to each other's wellbeing, then how do we do that?   Taxation is the main means for governments to raise money, though I suspect that the current profits being generated in our capitalistic health care could go far to reducing the actual cost of health care if we no longer had shareholders and owners to please and CEO's of hospitals and health systems were public servants instead of capitalists.   The last time I checked the CEO of Health Care America was making an annual salary of 150 million dollars plus stock options and other perks.   We wouldn't tolerate salaries like that in the private sector.

I received enough comments related to single payer health systems on my last blog to make me want to write another essay on this topic (rather than respond to each comment one-by-one).

U.S. health care is the most expensive in the world by a factor of four and results in ratings that average about 27^th in the developed world, all factors considered.

I think we should subsidize each other's health care because none of us are willing to sit and watch someone die in the waiting room because they haven't bought health insurance.   The Republicans argue that it is their right to eschew health insurance, but I'm sure few people would renounce health insurance if they could afford it.   Their argument is specious because few of them would stand by and let people die in the waiting room, either.   I'm quite sure some would, however, as they would see it as the will of God.   Like the Catholic Church in the Middle Ages, they would not want to interfere between God and man by helping a person to recover from God's punishment in the form of illness.   Once most of us agree that people can't just be allowed to die, then we have to pay for their care and some people's care is more expensive than others.   How are we to answer the question of people's own behavioral contributions to their ill health?   Should smokers pay a higher tax than non-smokers or is that factored into the tax on cigarettes?   Should people who regularly exercise pay a lower tax than sedentary people?   Should vegetarians be taxed at a lower rate than fast food aficionados?   The list is endless.   Figuring out the nuances of human behavior and how they affect health occupies the lives of endless epidemiology departments in public health schools around the world.   

The surprising downside (though maybe it's not) from some of single-payer health is that your health and your health related behaviors become my business.   I have an interest (because I pay for your illness) in controlling your behavior because "bad" behavior costs me money.   Therefore, matters that we have considered private are now public.   We must debate the cost of providing contraceptive care to which some Republicans object.   From a cost perspective, birth control is much less costly than children.   Only poor people could not afford birth control and the costs of not using it are then borne by all of us in the form of paying for the cost of their raising their children or our raising their children.   One Republican answer would be that many childless families (mostly white) are available to adopt children and should do so.

In the International Journal of Health Care Finance and Economics from 2009 (Volume 9, pages 1--24), in a paper on "Why U.S. health care expenditure and ranking on health care indicators are so different from Canada's", A. H. G. M. Spithoven writes about how the U.S. spends most of all developed countries on health care. Nonetheless, the U.S. ranks relatively low on health care indicators. This paradox has been known for decades. The turning point comparing the U.S. and Canada was in 1972. Health expenditure as a percentage of GDP was higher in Canada than in the USA from 1960 until 1972. Since 1972 expenditure on health care has been higher in the U.S. than in Canada.   The U.S. and Canada are two countries that are sufficiently similar to make comparisons useful. The comparison of factors influencing health care expenditure in the U.S. and Canada in 2002 revealed that health care expenditure in the U.S. is higher than in Canada mainly due to administration costs, Baumol's cost disease and pharmaceutical prices. It was not inefficiency in providing health.

What is Baumol's cost disease?   Assuming that wages in low productivity sectors must keep up with wages in high productivity sectors, prices for labor intensive goods or services will rise relatively to prices of goods and services produced by the high productivity sectors (McPake et al. 2003).

Productivity in health care is difficult to improve because health care relies for a large part on a direct face to face relation between the health care worker and the patient.   For example, washing a patient needs time that cannot be reduced beyond a certain point. Health care, where a large part of cost comes from staff looking after patients, is a low productivity sector. Baumol's costs disease may be overstated because the "output" used in measuring productivity in health care fails to capture major improvements in quality or results. So, while the cost of medical spending shot up from 1960 to 2000, largely as a result of the development and wide-spread use of new medical techniques, the cost per quality-adjusted life year decreased.   Health indicators for both males and females, such as life expectancy at birth and infant mortality rates, reveal that the quality of health care did not improve in the U.S. in comparison to Canada in the 1960--2000 period (United Nations 2005 data).

Administration costs prove to be a significant variable to explain the difference in health care expenditure between the U.S. and Canada. America's health care is characterized by a fragmented payer system, while Canada has a single-payer system. The first has less economies of scale in administration than the latter because competition among providers of health care, on the one hand, and competition among insurers of health care on the other, result, among other things, in extra expenses in billing and administrative operations of health care providers who have to deal with 100s of payers and different rules and prices.

Overhead costs in Canada's single payer system are much lower than in the U.S. with 72 US$ health care administration expenditure per capita in Canada in 2002 and 367 US$ per capita in the U.S. For 1999: "In the United States, health care administration cost $294.3 billion, or $1,059 per capita [. . .] In Canada, health care administration cost $9.4 billion, or $307 per capita [. . .] After exclusions, administration accounted for 31.0% of health care expenditures in the United States, as compared with 16.7% of health care expenditures in Canada". Using the same broad definition, this big difference is also reported by Himmelstein et al. (2003): "The U.S. wastes more on health care bureaucracy than it would cost to provide health care to all of the uninsured. Administrative expenses will consume at least $399.4 billion out of total health care expenditure of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286.0 billion in 2003, $6,940 for each of the 41.2million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage."

Another surprising public debate becomes for what should we pay?   In Canada, the National health system does not pay for dental care.   Apparently, teeth are superfluous.   In Holland, from where I am today returning, the government is about to decide that psychiatrists will no longer be paid for psychotherapy, only for prescribing medications for depression because medication is more cost-effective than psychotherapy and people can get cheaper psychotherapy from others.    I learned this at a Dutch hypnosis conference attended by a number of psychiatrists and family physicians.   Actually, the evidence in the literature does not support this contention.   A number of studies have shown that psychotherapy is more effective than medication or medication plus psychotherapy at 16 weeks.   For depression, a 2010 meta-analysis using the Freedom of Information Act to obtain all the clinical trials ever done on antidepressants (all must be reported to the FDA but not necessarily published) found no difference between medication and placebo.   A 2010 study compared behavioral activation (prescribing behaviors that cause the person to become more active) to cognitive-behavior therapy and to medication over 16 weeks.   Most antidepressant studies last 6 weeks, not long enough for psychotherapy to show its full effect.   

However, how much control should the payer have over how we physicians choose to treat people?   Typically, there are many equally good ways to treat a problem, though bureaucrats are not apt to notice this.   They wish the best way.   They wish a quick and easy answer.   And a bias exists!   Therapies that involve human interaction are always less trusted than technology.   We live in a world in which the bias is toward technology solving problems.   Payers for health care have an interest in what is provided just as do recipients of health care.   Where do the two intersect?   Her again, I would prefer Bernie Sanders (Senator, Vermont) solution of giving control of health care to local governmental units.   I think I would have a better chance of arguing my methods and why they should be compensated to a local board than to a faceless, nameless government agency.

Thus, in thinking about a single payer system, we must consider the politics of power.   Who decides what will be covered.   Who decides what we physicians are allowed to do and what we are not allowed to do.

Even as we consider who pays for health care, we must consider the kind of health care that we wish to have and how to insure that we get it. Today's health care relies extensively on technology which often fails to achieve its desired goals.   Some of us at the margin of health care want more human-oriented care.   We believe that health improves in the context of relationship and that physicians need to take the time to develop relationships with patients.   We need to have the time to develop the relationships to help people change the way they live and to change the way they see the world.   We need ways to provide care that allows us to spend time with patients and provide care that we and the patients believe will help.   The downside of single payer systems that are far removed from the doctor-patient relationship is that the control lies far from the relationship.   Bureaucrats don't necessarily even make evidence-based decisions, and evidence changes constantly.   Doctors and patients need some autonomy over what they decide to do to improve health.

Himmelstein, D. U., et al. (2003). Administrative waste in the U.S. health care system in 2003: The cost to the nation, the states and the district of Columbia, with state-specific estimates of potential savings. Cambridge MA: The Division of Social and Community Medicine, Department of Medicine, The Cambridge Hospital and Harvard Medical School; Washington, DC: The Public Citizen Health Research Group.