ABSTRACT
The fields of communication studies and the medical humanities intersect and inform each other in interesting and important ways; and yet, these connections are rarely made explicit. As such, this special collection of articles from scholars in diverse fields such as disability studies, communication studies, the medical humanities, philosophy, and medicine discuss the ways that these fields diverge and converge and what we can learn from one another when we dissolve disciplinary divisions. In this Guest Editor’s Introduction, I explore broadly how health communication studies informs the medical humanities and medical education, as well as how embracing the philosophical, pedagogical, and methodological approaches of the medical humanities can, in turn, expand and enrich health communication studies. I make my argument by drawing on the various ways the medical humanities can inform communication studies, as illustrated by the essays included in this special issue: by offering more expansive notions of forgiveness at the end of life and what it takes to authentically engage with “difficult” patients; by taking a more critical look at how clinical, social scientific, and communication research on disability, race, gender, or socioeconomic status might reify problematic stereotypes and generalizations; and by centering medical pedagogy on the question of who we want our future clinicians to be, rather than how we want them to behave.
The fields of communication studies and the medical humanities intersect and inform each other in interesting ways and in ways that intrigue me personally. Having a background in both communication studies (MA) and the medical humanities (PhD), I cannot help but notice how our work as scholars interested in health and medicine can be strengthened and enriched by drawing on the wisdom of both. And as I have eagerly accrued more professional experience teaching future healthcare professionals and painfully accrued more personal experience in the medical world caring for loved ones who have been sick or were dying, I have come to see—in very real ways—the need for scholars in these fields to continue to do work that matters. These are among some of the reasons I am excited about and encouraged by this special issue and the contributions of my colleagues that it features.
For those unfamiliar with the medical humanities, it is a field that, generally speaking, gathers together the insights of many disciplines—including literature, philosophy, religion, history, art, bioethics, visual studies, and the social sciences—in order to foster a richer understanding of the human experience of illness, health, dis/ability, identity, gender, embodiment, healthcare, and the like.Footnote1 The medical humanities underscore the fact that medicine is laden with existential questions about the meaning of life and death and that, at bottom, the human being is the one who medicine serves; without people in need, medicine and healthcare would cease to exist.Footnote2 Those of us in the medical humanities, especially those who teach future or current health professionals, are familiar with work from the social and behavioral sciences and draw on it often to make our case with students and clinicians. In our endless efforts to advocate a place for ourselves in healthcare education, we might argue that we need the medical humanities because clinical empathy has been shown to decline during the last years of medical school; because clinician burnout and job dissatisfaction are real problems; or because end-of-life conversations are not happening as often as they need to.Footnote3 Likewise, we make claims drawn from empirical research in order to warn our students that practitioners often perceive they are pressed for time in the examination room and usually interrupt patients less than 25 seconds into the encounter; or to discuss with students how some patients who identify with the lesbian, gay, bisexual, trans, and queer (LGBTQ) community feel misunderstood in their interactions with practitioners; or to teach students how they might broach end-of-life conversations with patients who are seriously or terminally ill.Footnote4 And we can make these claims and address these issues because scholars in communication studies or related fields in the social sciences have taken the time to engage in quantitative and qualitative research that give us this information. Such empirical work usually resonates with students—those who tend to “want to see the data”—and much of what is learned in these studies is used to teach them important verbal and nonverbal communication strategies, patient interviewing skills, or effective listening techniques. Needless to say, the insights offered by communication theory and praxis, public health campaigns, quantitative and qualitative research, critical discourse analysis, autoethnography, and health literacy assessments are integral to healthcare and healthcare education.
This is not to say, however, that research in the behavioral or social sciences is somehow distinct from the work of the medical humanities or that it is something that medical humanists merely “borrow” to make a point. Quite the opposite; the field of medical humanities includes within its purview critical social theory and qualitative research, especially medical anthropology, ethnography, and visual studies. The same is true for communication studies, where the use of narrative—something that has figured prominently in the medical humanities, both pedagogically and methodologically—has gained significant traction, specifically among some health communication scholars.Footnote5 For many engaged in qualitative/interpretive research, an emphasis is placed on the power of story and personal narrative to shape and contest identity(ies) and transform notions of selfhood, especially in the midst of illness, tragedy, or grief.Footnote6 As such, to draw a hard and fast line between these two fields would be mistaken and misleading.
Minding the gap(s)
While these scholarly fields clearly overlap, and while scholars in the medical humanities draw on social scientific research to make their own claims, there still remain areas within communication studies that could benefit from a clearer understanding of what scholars in the medical humanities do and what their work offers health communication research. Though it can be dangerous to paint in broad strokes, an argument can be made that, in general, communication research has yet to loosen its moorings in the postpositivist tradition. In her introductory article to a special issue on critical approaches to family communication for the Journal of Family Communication, for instance, Elizabeth A. Suter points out that “critically framed research has historically accounted for a negligible percentage of family communication research,” comprising only 1% of research in the Journal of Family Communication (while nearly 65% could be considered postpositivist) and only around 8% of total publications in other major outlets for similar research.Footnote7 And, as we see in Carmen C. Goman’s essay in this special issue, the same remains true for the bulk of the literature in health communication.
From my own experience researching and developing medical and premedical curricula, it is clear to me that much of the research and pedagogy in interpersonal communication in medicine is grounded in the assumption that communication is transactional in nature. So, rather than learning how to engage with patients authentically, to be present with the dying, or to bear witness to suffering, we teach future clinicians to memorize checklists and mnemonics to assist with difficult clinical interactions and “deliver” information to patients. When learning to “break bad news,” for instance, many medical students are taught the SPIKES Method (Set the stage, Perception, Inform, Knowledge, Empathy, and Summarize), memorizing the mnemonic in preparation for giving a patient–actor a terminal diagnosis.Footnote8 As Susan McCammon argues in her essay on the suffering of Philoctetes included here, although methods like SPIKES might offer some guidance for novices who have little or no experience addressing existential suffering and mortality, it is unlikely that this programmatic approach will offer much by way of navigating a complex, all-too-human situation fraught with uncertainty, vulnerability, and even repulsion.
It is undeniable that some of the communication research and educational interventions in healthcare are reductionistic and formulaic; yet, their appeal remains. Such approaches seem practical, relevant, and expedient, and therefore perfectly suited for the rational, fast-paced culture of medicine. Although some of the communication research presented to healthcare practitioners and students is, indeed, practical and important, it is equally important to consider critically the discursive power of such information. Take studies that assess or promote public health interventions that reduce the occurrence of diabetes among Hispanic populations, for instance.Footnote9 Although it is necessary to address the increasing prevalence of diabetes and issues associated with poor health literacy among Hispanic populations, we should also consider how such research can perpetuate cultural stereotypes and reify notions about race and biological determinism, thereby obfuscating real issues of socioeconomic status, poverty, and political and structural violence that profoundly affect minority populations in the United States.Footnote10 Likewise, while we must help our students see that race (and racism) continue to contribute to health inequity and inequality, we may be doing more harm than good if we train medical residents to “incorporat[e] messages tailored for use with African American patients … [to] improve doctor–patient communication”Footnote11 without discussing the troubling historical backdrops (e.g. the Tuskegee syphilis study) that can contextualize the reasons why some Black Americans might mistrust the medical system. If this work is not done, then we fail to challenge—and perhaps even perpetuate—assumptions about “uneducated” or “noncompliant” patient populations.Footnote12 As Joel Michael Reynolds points out in his piece included here, something similar can be said about research concerning persons with disabilities that continues to conflate disability with disease, pain, or lack, while simultaneously failing to account for the disturbing national history of eugenic practices that continues to subtly influence how ethicists, researchers, and clinicians frame disability.
Critical medical humanities
The medical humanities have much to offer by way of identifying the important information postpositivist research offers—such as uncovering the social determinants of health—while also remaining critical of how this information is both obtained and disseminated. Medical humanists agree that an exposure to literature, philosophy, history, religious studies, social sciences, and the arts is intended not simply to make students and doctors more “well rounded” or refined, but rather to uncover implicit assumptions that shape medical practice and scientific or clinical research. The point of studying the history of medicine, for example, is not to glorify the triumphs of scientists and clinicians of the past, but rather to draw attention to egregious violations in human subjects research or to question the taken-for-granted progress narrative to which most students unknowingly ascribe in order to show that “unchanging” scientific medical truths are rooted in cultural beliefs and specific historical contexts. Likewise, studying philosophy or social theory allows one to ask how the body is viewed in the context of healthcare. Is the body a passive object to be assessed by the physician–observer? How is gender, culture, or sexuality inscribed onto the body, shaping a patient’s understanding of illness and medical care? Moreover, students exposed to such scholarship might begin to ask whether health and illness are determined only by genetics and behavior or if social factors, such as economic inequality and structural racism, have something to do with the bigger picture. And if health and illness are, indeed, associated with social and economic conditions, then students might begin to wonder how public policy affects the lives of patients, especially if access to healthcare is not granted as a fundamental human right. Learning to ask these critical questions helps students and practitioners develop discernment when reading research reports or developing their own research questions. As evidenced in the essay by Jason Scott Robert included here, it is critical to recognize the sociohistorical milieux in which research is conducted, interpreted, and disseminated, as well as the contexts that shape the kinds of research questions asked and how researchers ask and answer them. Such attention broadens perspectives and can help clinicians and trainees see that the factors contributing to health and illness extend far beyond biology and pathophysiology.Footnote13
Medicine as interpretive and interpersonal
While the medical humanities can bring the historical, ethical, and social contexts of research and practice to the fore in order to make taken-for-granted assumptions more explicit, they also emphasize the hermeneutic nature of medicine—that medical practice, and the clinical encounter in particular, is interpretive and iterative in nature, not merely transactional. Although some would like to believe that the practice of medicine is simply an applied science, and is therefore not subject to the uncertainty and fallibility of some of the “softer” sciences or the humanities, the reality is that the very humanness of medical encounters—the messiness and complexities of the lived experience of illness—precludes the possibility for absolute certainty. As Ronald A. Carson asserts, “Medical practice, by contrast, and contrary to the view of it as applied science, is experiential, relational, and hermeneutical through and through.”Footnote14
In recognizing that the practice of medicine is hermeneutical, one acknowledges that a clinician cannot ever come to know her patient’s specific ailment as it really is but only as it appears to her through both her interpretation and the interpretation of her patient. Although some diagnostic tests may yield verifiable answers, it is almost always the case (except, perhaps, in acute emergency situations) that the physician cannot properly diagnose or treat her patient without the guidance of the patient’s interpretation and description of her symptoms.Footnote15 Physician Carl Edvard Rudebeck emphasizes the importance of the physician recognizing a patient’s lived experience or “body experience,” since clinicians “never meet symptoms independently of the persons having them.”Footnote16 Despite this rather self-evident concept, healthcare practitioners and trainees often become more intrigued by the pathology behind certain symptoms and with determining whether symptoms fall into preconceived categories of disease than they do in attempting to understand how the symptoms might be affecting the patient’s life. As such, important social factors that influence health and illness—such as lack of financial resources, social support, transportation, or access to healthy food—are left unaddressed, leading clinicians to make ill-informed diagnoses and treatment plans and leaving patients feeling as if they have not been heard. Thus, listening to and responding to the patient’s own interpretation of her illness and how it affects her life not only leads to a more informed clinical judgment, but also allows the practitioner to better explain this clinical judgment to the patient in a way that aligns with the patient’s own interpretation of her symptoms, potentially leading to better outcomes. In many ways, Rudebeck’s notion of attending to a patient’s body experience is reminiscent of what physician and philosopher Howard Brody calls the joint construction of narrative. Claiming that the physician cannot really carry out a proper physical examination or order the correct diagnostic tests without being “guided by the patient’s description of his own symptoms,” Brody emphasizes the need to listen to patients’ stories and to listen in a way that allows patients to know that they have really been heard.Footnote17 Fredrik Svenaeus refers to this process as medical hermeneutics. Drawing on the philosophical work of Hans-Georg Gadamer, which emphasizes that all interpretation is mediated by language and centers around “the dialogic meeting between persons who strive toward mutual understanding,”Footnote18 Svenaues helps us to see that the clinical encounter is not simply an opportunity for information exchange, but rather a “coming together” of clinician and patient—of the two separate interpretative “horizons” of scientific medical knowledge and the lived experience of illness—for the purpose of creating a mutual understanding that contributes to the health of the patient. Because the process of coming to know what is the matter with someone who is sick or suffering is an interpretive endeavor involving two or more people, practitioners are “not first and foremost scientists who apply biological knowledge, but rather interpreters—hermeneuts of health and illness.”Footnote19
The practitioner as person
Those like Rudebeck and Svenaeus, who take a more interpretive approach to the patient–physician encounter, have gone to great lengths to stress that the lived experience of illness can only ever come from the patient, from her narrative account of what her illness means to her.Footnote20 And though we must begin to see narrative interpretation as critical for ensuring favorable health outcomes, there is something more to the story, so to speak. The encounter between a clinician and a patient—especially when a patient feels particularly vulnerable, uncertain, or frightened—is about more than diagnosing and treating; it constitutes a moment for two people to come together in mutual recognition of the all-too-human elements of what it means to confront our finite and fragile existence. Perhaps this is best captured by Carson’s explication of the metaphorical “hyphenated space” in the patient–doctor relationship.Footnote21 For Carson, the hyphen between patient and clinician represents a liminal space, a borderland fraught with anxiety and uncertainty that must be negotiated dialogically. This liminal space, however, is also a generative space, a place where meaning is uncovered and cocreated. So, while the hyphen separates, it also bridges. As Carson puts it:
When illness threatens, we seek out experienced conversation partners, notably doctors, to help us get our bearings and get back on course. I want my doctor to tell me the meaning of my symptoms, to be sure, but I also want some help in grasping the personal significance of my malady. I want both to have my “otherness” acknowledged and to be recognized as still belonging to the tribe of the living.Footnote22
Although these profound moments may be fleeting and few, they are possible because medicine is a kind of microcosm of human existence, a concentration of the all-too-human elements of being alive: birth, death, sickness, suffering, isolation, fear, love, anger, care. Those who participate in medical practice are constantly confronted with elements of the human condition that remind us that we should not take our health for granted, that we need each other, that our world as we know it can collapse at any moment. Yet, when we perpetuate the idea that healthcare practitioners simply “deliver” information to patients and their families, ignoring the fact that these practitioners as people are affected by their engagement with others who struggle to find meaning in illness, injury, or death, we deny our caregivers opportunities to find real value and purpose in their profession. Viewing the clinical encounter in this way obscures the fact that, in many ways, nurses, doctors, therapists, and other caregivers are constituted by those for whom they care; indeed, without patients for whom to care, they would cease to be caregivers at all. In recognizing this, those in healthcare might begin to cultivate a sense of gratitude for their patients—gratitude that a patient has come to them for help and that her suffering, her joy, and her loss can offer a new understanding about what it means to live and die well.
Beyond professionalism: connection, character, and trust
If medicine is seen for what it is, as an encounter between two people intended to bring healing in the broad sense of the word, then we begin to see that the patient–clinician experience is never only transactional. So much of medicine—even diagnosing and treating—is dependent on unquantifiable human qualities, such as clinical intuition, personal discernment, and the ability to recognize what is needed most in the specific situation at hand. It involves recognizing that for some patients, silence and compassionate presence can speak more powerfully than any verbal articulation; it is about understanding that clinical encounters are dynamic, textured, and deeply interpersonal. Caring for others requires much more than technical skill and clinical knowledge; since such things fall short when determining what is best for patients who have needs shaped by rich and complex lives.
Some might argue, however, that what patients need most is an expertly trained technician who can perform the task at hand well. While such an argument seems accurate at first pass, what it fails to consider is that there is more to healing than fixing the biological body. Coincidentally (and unfortunately), as I write this, my father is recovering from open-heart surgery—a procedure that terrified me and made me believe for a moment that what my father needed most was an expert technician, regardless of whether he or she was a “good person.” But only for a moment. When the man who would eventually place his hands inside my father’s open chest walked into the hospital room, he seemed very competent, to be sure. He was one of the busiest and most experienced cardiac surgeons in the state. He delivered information to us clearly and thoroughly, outlining the risks and benefits of the surgery. He was professional. He was an expert. And yet, there was something about him—how he patiently listened as we expressed what we feared most, the way he touched my father’s legs and abdomen to show him where incisions would be made, how he simultaneously exuded confidence and humility, the way he acknowledged the change in my father’s face when he spoke about potential complications—that expressed an intangible, but fundamentally critical, quality that transcended expertise. Something about who he was told us we could trust him, that he cared whether my father lived or died, and that he would do his best for a man he had only just met.
It was something I have always known, something I have expressed to students time and again, but in this moment it became real to me for the first time: trust is requisite for healing, and this trust has its foundation in something more than technical skill.Footnote24 We trusted this surgeon not simply because he was skilled, but also because he seemed to care, and without this trust my father and our family would have gone into the surgery with much more hesitance and anxiety. Looking back on this encounter causes me to marvel even more at the statement I so frequently hear: that people would rather have a doctor who is skilled than one who is compassionate. I wonder why so many feel the need to frame things in such a way, as if it is a zero-sum game. Is it not possible to be like my father’s surgeon and be both? Indeed, is it not necessary to be both? Is this not the foundation of trust? And if it is, then much more is at stake when we think about the ways our future caregivers are educated. Ensuring that they learn to communicate effectively and professionally, though necessary, is not enough. We need to be concerned about the kind of people they are becoming, especially because their training has such a profound effect on their development.Footnote25 And if it is the case that many of their encounters with clinical mentors are negative—and sometimes even abusive, as we see in Alan Bleakley and Robert Marshall’s article included here—then we need to take a serious look at how our educational systems are shaping the development of the people who will eventually be caring for us and the people we love.
Looking forward together
Clinician burnout, detachment, and apathy—which can result from working and training in a system that ignores the profundity of illness and death and fails to support the personal development of clinicians—cannot be remedied by attempts to improve patient–practitioner communication alone. Such interventions come too late and do not attend to the core issue—namely, that we have lost sight of the fact that the clinical encounter is not merely transactional or contractual, but rather a coming together of two people in an effort to bring healing during what might be a momentous time in life (and death). It is unlikely that scholars in the medical humanities and communication studies would disagree on this point. Indeed, it is safe to say that both medical humanists and health communication scholars are concerned with many of the same issues and that both desire a more humanistic healthcare system, even if issues of power, oppression, embodiment, and identity development are underrepresented in health communication literature.
If we agree that we want to create a medical culture that cares well for patients and their families, and opens us up to more capacious notions of health, illness, suffering, and care, then the formation of this culture depends almost entirely on educating those who participate and learn in it. Therefore, incorporating the humanities into medical practice and education can lead to the development of compassionate healers who think deeply and critically about their relationships to others, to the systems in which they participate, and to the social and cultural contexts in which they find themselves. Literature, narrative, history, philosophy, and social theory help reveal the nexus of significance that brings meaning to trainees’ own work, allowing them to see why it is necessary to communicate well, why they need to refine their technical skills, or why professionalism is important.
The kind of scholarship and pedagogical approaches that the medical humanities offer should be seen not as an addendum to the real stuff of medicine, but rather as an essential approach to practice, research, and education. The medical humanities remind us that the clinical encounter is always already interpretive; that issues of power, race, gender, dis/ability, and poverty inevitably influence practice and research; and that who our caregivers are and how they are trained matters. If we are committed to improving patient outcomes and making medicine more responsive to human need, then we, as scholars, must not stop at simple answers or easy interventions. It is much easier to offer downstream solutions—models for increasing patient health literacy or reducing physician burnout, for instance—that help practitioners and patients “manage” the consequences of a broken healthcare system than it is for us to acknowledge that so much of American medicine estranges us from each other and from ourselves.
Rethinking our healthcare system is daunting, to be sure. The changes we need to see are big, complex, and difficult to address. However, we can begin to bring them about if we are patient, courageous, and willing to collaborate. Scholars and clinicians from across disciplines will need to come together to consider the kinds of people we want caring for us and the kind of healthcare system in which we want to participate. My hope is that the scholarship presented in this special issue—scholarship that is diverse and wide-ranging, but connected in its concern for creating a medical culture that is more responsive to the deeper needs of both patients and clinicians—is a step in this direction.
Selected further reading
Aho, Kevin. “Heidegger, Ontological Death, and the Healing Professions.” Medicine, Healthcare and Philosophy 19, no. 1 (2016): 55–63.
Barnard, David. “Love and Death: Existential Dimensions of Physicians’ Difficulties with Moral Problems.” The Journal of Medicine and Philosophy 13, no. 4 (1988): 393–409.
Braveman, Paula, Susan Egerter, and David R. Williams. “The Social Determinants of Health: Coming of Age.” Annual Review of Public Health 32 (2011): 381–98.
Cassell, Eric J. “The Nature of Suffering and the Goals of Medicine.” New England Journal of Medicine 306, no. 11 (1982): 639–45.
Coles, Robert. “Medical Ethics and Living a Life.” New England Journal of Medicine 301 (1979): 444–46.
Coulehan, Jack, and Peter C. Williams. “Vanquishing Virtue: The Impact of Medical Education.” Academic Medicine: Journal of the Association of American Medical Colleges 76, no. 6 (2001): 598–605.
Foucault, Michel. “The Crisis of Medicine or the Crisis of Antimedicine?” Translated by Edgar C. Knowlton Jr., William J. King, and Clare O’Farrell. Foucault Studies 1 (2006): 5–19.
Frank, Arthur W. At the Will of the Body: Reflections on Illness. New York: Houghton Mifflin, 1991.
Friedman, Lester D. “The Precarious Position of the Medical Humanities in the Medical School Curriculum.” Academic Medicine: Journal of the Association of American Medical Colleges 77, no. 4 (2002): 320–22.
Gadamer, Hans-Georg. The Enigma of Health: The Art of Healing in a Scientific Age. Translated by Jason Gaiger and Nicholas Walker. Stanford, CA: Stanford University Press, 1996.
Gawande, Atul. Being Mortal: Medicine and What Matters in the End. New York: Metropolitan Books, 2014.
Heidegger, Martin. “Memorial Address.” In Discourse on Thinking. Translated by John M. Anderson and E. Hans Freund, 43–57. New York: Harper & Row, 1969.
Hudson Jones, Anne. “Why Teach Literature and Medicine? Answers from Three Decades.” Journal of Medical Humanities 34, no. 4 (2013): 415–28.
Hunter, Kathryn Montgomery. Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press, 1991.
Kumagai, Arno K. “Acts of Interpretation: A Philosophical Approach to Using Creative Arts in Medical Education.” Academic Medicine: Journal of the Association of American Medical Colleges 87, no. 8 (2012): 1138–44.
McGregor, Sue. “Neoliberalism and Health Care.” International Journal of Consumer Studies 25, no. 2 (2001): 82–89.
McQuellon, Richard P., and Michael A. Cowan. “Turning toward Death Together: Conversation in Mortal Time.” The American Journal of Hospice & Palliative Care 17, no. 5 (2000): 312–18.
Metzl, Jonathan M., and Anna Kirkland, eds. Against Health: How Health Became the New Morality. New York: New York University Press, 2010.
Montgomery, Kathryn. How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press, 2005.
Novack, Dennis, Ronald Epstein, and Randall Paulsen. “Toward Creating Physician-Healers: Fostering Medical Students’ Self-Awareness, Personal Growth, and Well-Being.” Academic Medicine: Journal of the Association of American Medical Colleges 74, no. 5 (1999): 516–20.
Sherwin, Susan. No Longer Patient: Feminist Ethics and Health Care. Philadelphia, PA: Temple University Press, 1992.
Taylor, Charles. “The Dialogical Self.” In The Interpretive Turn: Philosophy, Science, Culture. Edited by David R. Hiley, James Bohman, and Richard Shusterman, 304–14. Ithaca, NY: Cornell University Press, 1991.
Tolstoy, Leo. The Death of Ivan Ilych and Other Stories. Translated by Aylmer Maude and J. D. Duff. New York: Signet, 2003.
Wear, Delese et al. “Slow Medical Education.” Academic Medicine: Journal of the Association of American Medical Colleges 90, no. 3 (2015): 289–93.
Wiener, Linda, and Ramsey Eric Ramsey. Leaving Us to Wonder: An Essay on the Questions Science Can’t Ask. Albany: State University of New York Press, 2005.
Wittenberg-Lyles et al. Dying with Comfort: Family Illness Narratives and Early Palliative Care. Cresskill, NJ: Hampton Press, 2010.
Notes
1. Johanna Shapiro et al., “Medical Humanities and Their Discontents: Definitions, Critiques, and Implications,” Academic Medicine 84, no. 2 (2009): 192.
2. Thomas R. Cole, Nathan S. Carlin, and Ronald A. Carson, Medical Humanities: An Introduction (Cambridge: Cambridge University Press, 2014), 1.
3. Mohammadreza Hojat et al., “The Devil Is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Academic Medicine: Journal of the Association of American Medical Colleges 84, no. 9 (2009): 1182–91; Eric S. Williams and Asheley Cockrell Skinner, “Outcomes of Physician Job Satisfaction: A Narrative Review, Implications, and Directions for Future Research,” Health Care Management Review 28, no. 2 (2003): 119–39; See also Alexi A. Wright et al., “Associations between End-of-Life Discussions, Patient Mental Health, Medical Care near Death, and Caregiver Bereavement Adjustment,” JAMA 300, no. 14 (2008): 1665–73.
4. M. Kim Marvel et al., “Soliciting the Patient’s Agenda: Have We Improved?” JAMA 281, no. 3 (1999): 283–7; Ruth Patricia McNair, Kelsey Hegarty, and Angela Taft, “From Silence to Sensitivity: A New Identity Disclosure Model to Facilitate Disclosure for Same-Sex Attracted Women in General Practice Consultations,” Social Science and Medicine 75, no. 1 (2012): 208–16; Sharon M. Parker et al., “A Systematic Review of Prognostic/End-of-Life Communication with Adults in the Advanced Stages of a Life-Limiting Illness: Patient/Caregiver Preferences for the Content, Style, and Timing of Information,” Journal of Pain and Symptom Management 34, no. 1 (2007): 81–93.
5. For more on the use of narrative in social scientific research related to health and illness, see Lars-Christer Hyden, “Illness and Narrative,” Sociology of Health & Illness 19, no. 1 (1997): 48–69.
6. See Lynn M. Harter, Phyllis M. Japp, and Christina S. Beck, eds., Narratives, Health, and Healing: Communication Theory, Research, and Practice (Mahwah, NJ: Erlbaum, 2005); Carla L. Fisher, Coping Together, Side by Side: Enriching Mother–Daughter Communication Across the Breast Cancer Journey (New York: Hampton Press, 2014); Elaine Wittenberg-Lyles et al., Dying with Comfort: Family Illness Narratives and Early Palliative Care (New York: Hampton Press, 2010); Laura L. Ellingson, Engaging Crystallization in Qualitative Research: An Introduction (Thousand Oaks, CA: Sage, 2008); Elissa Foster, Communicating at the End of Life: Finding Magic in the Mundane (London: Routledge, 2006); Lynn M. Harter, Imagining New Normals: A Narrative Framework for Health Communication (Dubuque, IA: Kendall Hunt, 2012); Wayne Beach, The Cancer Play, https://www.facebook.com/The-Cancer-Play-433814780045649/info/?tab=page_info.
7. Elizabeth A. Suter, “Introduction: Critical Approaches to Family Communication Research: Representation, Critique, and Praxis,” Journal of Family Communication 16, no. 1 (2016): 1–8.
8. Walter F. Baile et al., “SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer,” The Oncologist 5, no. 4 (2000): 302–11.
9. See Xiaoquan Zhao, “Relationships Between Sources of Health Information and Diabetes Knowledge in the US Hispanic Population,” Health Communication 29, no. 6 (2014): 574–85.
10. Ichiro Kawachi, “Why the United States is Not Number One in Health,” in Healthy, Wealthy, & Fair: Health Care and the Good Society, ed. James A. Morone and Lawrence R. Jacobs (Oxford: Oxford University Press, 2005), 19–36.
11. Dominique G. Ruggieri et al., “Perceived Colonoscopy Barriers and Facilitators Among Urban African American Patients and Their Medical Residents,” Journal of Health Communication 18, no. 4 (2013): 372–90.
12. John F. Dovidio et al., “Disparities and Distrust: The Implications of Psychological Processes for Understanding Racial Disparities in Health and Health Care,” Social Science & Medicine 67, no. 3 (2008): 478–86.
13. For more, see Jonathan Metzel, Helena Hansen, and Sewit Bereket, “Structural Competency,” Structural Competency, http://structuralcompetency.org/.
14. Ronald A. Carson, “On Metaphorical Concentration: Language and Meaning in Patient–Physician Relations,” The Journal of Medicine and Philosophy 36, no. 4 (2011): 389.
15. Howard Brody, “My Story Is Broken: Can You Help Me Fix It? Medical Ethics and the Joint Construction of Narrative,” Literature and Medicine 13, no. 1 (1994): 80; Carl Edvard Rudebeck, “Grasping the Existential Anatomy: The Role of Bodily Empathy in Clinical Communication,” in Handbook of Phenomenology and Medicine, ed. S. Kay Toombs (Dordrecht, Netherlands: Kluwer, 2001), 297–316.
16. Rudebeck, “Grasping the Existential Anatomy,” 297.
17. Brody, “My Story Is Broken.” For a similar perspective that emphasizes the phenomenology of illness, see S. Kay Toombs, The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patients (Boston: Kluwer Academic, 1993).
18. Fredrik Svenaeus, “Hermeneutics of Medicine in the Wake of Gadamer: The Issue of Phronesis,” Theoretical Medicine and Bioethics 24, no. 5 (2003): 408, 415.
19. Ibid., 416.
20. For example, those informed by George L. Engel’s biopsychosocial model; advocates of the patient-centered clinical method as put forth by Michael Balint in the 1950s; and those who emphasize the importance of narrative approaches to medicine. See Ian R. McWhinney, “Focusing on Lived Experience: The Evolution of Clinical Method in Western Medicine,” in Handbook of Phenomenology and Medicine, ed. S. Kay Toombs (Dordrecht, Netherlands: Kluwer, 2001), 331–50; Katherine Montgomery, “Medical Ethics: Literature, Literary Studies, and the Question of Interdisciplinarity,” in The Nature and Prospect of Bioethics, ed. Franklin G. Miller, John C. Fletcher, and James M. Humber (Totowa, NJ: Humana Press, 2003), 141–78; Anne Hudson Jones, “Literature and Medicine: Traditions and Innovations,” in The Body and the Text: Comparative Essays in Literature and Medicine, ed. Bruce Clarke and Wendell Aycock (Lubbock: Texas Tech University Press, 1990), 11–24; Joanne Trautmann, “The Wonders of Literature in Medical Education,” Mobius 2, no. 3 (1982): 22–31; Rita Charon, “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust,” JAMA 286, no. 15 (2001): 1897–902.
21. Ronald Carson, “The Hyphenated Space: Liminality in the Doctor–Patient Relationship,” in Stories Matter: The Role of Narrative in Medical Ethics, ed. Rita Charon and Martha Montello (London: Routledge, 2002), 171–82.
22. Ibid., 180.
23. Arno K. Kumagai, “On the Way to Reflection: A Conversation on a Country Path,” Perspectives in Biology and Medicine 56, no. 3 (2013): 367.
24. A recent meta-analysis of randomized control trials shows that elements of the patient–clinician relationship—including trust, empathy, genuineness, and warmth—lead to better health outcomes, including pain relief and control of blood pressure. See John M. Kelley et al., “The Influence of the Patient–Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” PLOS ONE 9, no. 4 (2014): e94207. See also Suzanne Koven, “The Doctor’s New Dilemma,” New England Journal of Medicine 374, no. 7 (2016): 608–9.
25. See Andrew H. Brainard and Heather C. Brislen, “Viewpoint: Learning Professionalism: A View from the Trenches,” Academic Medicine 82, no. 11 (2007): 1010–4; Frederic William Hafferty, “Professionalism and the Socialization of Medical Students,” in Teaching Medical Professionalism, ed. Richard L. Cruess, Sylvia R. Cruess, and Yvonne Steinert (Cambridge: Cambridge University Press, 2009), 53–70; Thomas S. Inui, A Flag in the Wind: Educating for Medical Professionalism (Washington, DC: Association of American Medical Colleges, 2003).