Transformation over Amelioration: Introducing Structural Competency in Undergraduate Education

(The above image, drawn by my friend who prefers to stay anonymous, is a reference to the famous Don Quixote scene with windmills. This scene has always been one of my favourite moments in the history of literature. There are many ways to interpret the meaning behind windmills battle and my aim here is not to engage in literary interpretation; my aim is to give context to my blog post from a personal standpoint. We all encounter windmills and experience windmill battles in the everydayness of our life. Windmills are everywhere. They are gigantic, they all look the same, they come in groups, they blow in the same direction. Don Quixote doesn’t beat the ferocious giants in Cervantes’s novel, but that is not the point – one person can’t change the system. What I think is more important is that Don Quixote undergoes a transformative experience through reading chivalric novels which empowers him to go and fight for what he stands for. I wonder what it would look like if we were to encourage transformation and transformative learning opportunities for students in the early days of undergraduate education? If we were to create spaces in which students would feel touched and moved to action by what they co-learn at Universities? If knowledge was co-created, inspired, underpinned by creative and critical thinking, and value-laden rather then didactic, information-driven and off-you-go?

This blog is about transformation in education.

Throughout this blog post, I use the pronouns “we” and “us” a lot. By that, I am largely referring to the western society where I live. I am also writing this as an osteopath who is active on social media such as Twitter, Facebook, and Instagram, and where I am largely exposed to opinions by colleagues from both osteopathy and physiotherapy professions. I am not affiliated with any educational institution and this post is not targeted at any institution in particular. This blog is written in the spirit of reflection, observation and invitation. The “I” is deeply embedded and held accountable in “We”.)


Is this my mother who is gripped, albeit wrongly, with guilt? Is she in this moment wondering what she did or did not do to ensure her baby, her Monte, be kept safe from the nightmare he’s been cast into? Is my mother the fallout, the collateral damage in the battle to elevate personal responsibility over everything, over all those decisions that were made about state budget priorities, about wages, about the presence of police, and even about damn grocery stores and access to quality food?

Here, in this hour and in this place, in this system of law that is supposed to be adversarial but is instead where the players all side up against her son, my mother accesses the only feeling she’d ever been allowed to access freely. Guilt. Guilt for having a baby young. Guilt for not blindly following patriarchal religious protocols. Guilt for being poor. Guilt for not keeping mental illness out of her son’s brain. Guilt that she could not stop a group of people from divorcing themselves from a useful definition of humanity. Guilt that she could not keep those moral monsters from harming her baby. I put my arms around my precious mother

The excerpt is taken from the memoir “When they call you a terrorist” by Patrisse Khan-Cullors and Asha Bandele. Written through a deeply evocative personal narrative penetrated by political analysis and lived experience of state violence, the memoir portrays the birth of the Black Lives Matter (BLM) movement. In this scene, Monte who has been incarcerated by the police and charged with terrorism, is in the court with his mother and sister. 

Before I outline the aims and hopes of this blog post, the reader is invited to take a pause and re-read the excerpt. I invite the reader to reflect on four things:

  1. What forms of social oppression is Monte’s mother living under? 

2. Remember the times when Monte’s mother visited your clinic – what was your process of self-reflection? 

3. Imagine Monte’s mother is about to enter your clinic – I invite you to reflect on the privileges and penalties you might be bringing into the social situation of that clinical encounter. Write them down. Ask yourself: what are the aspects of her experience that you do and do not share? 

4. What could you do in order to create a safe place for Monte’s mother? 


In this blog post I will propose that if educational institutions want to be dedicated to genuine anti-racial curricula, critical frameworks such as Narrative Medicine and Structural Competency need to be introduced in undergraduate education. I will use quotes from various literary resources that have bolstered and inspired me through my life in order to give weight to my arguments and to encourage reflection. I believe that nothing can transform a human’s heart as powerfully as good literature and art, if approached with genuine curiosity and critical reflection. The position from which I write is drenched in deep passion and love for these subjects. I will approach and examine the framework of Narrative Medicine and Structural Competency through the lens of racial injustice because, in the web of all our current crises, the racial injustice is the most deeply and tragically embedded one. At the end of the post, I will also introduce Narrative Humility as an epistemological stance for Structural Competency as previously argued by DasGupta (2008) and Tsavet et al. (2014). This paper was partly inspired by a recent Twitter post where a physiotherapist posed a question: “Is obesity a choice?” to which 45% answered yes. To think that obesity is a choice is to assume that we live in a world where every human being has a privilege of choice in the first place. Not only is this oblivious to the society we live in, it is rather inimical to the work that we do as healthcare providers. We need, and must do better.


The Master’s tools will never dismantle the Master’s house“, Audre Lorde, 1979

The word apocalypse comes from a Greek word apokálypsis, a derivative of the verb apokalýptein which means “to take the cover off”, “to uncover”, “to lay bare”, “to reveal’. Apocalypse is thus a state in which a veil or curtain is about to be lifted to reveal something that has been hidden and suppressed. The past eighteen months of the Covid-19 pandemic have been apocalyptic in the true meaning of the word as they have exposed much of what has been hidden for decades. Yes, I am talking about the BLM movement, George Floyd, Sabina Nessa, Sarah Everard, and multiple other health and social inequities and structures at play that the Covid-19 crisis unmasked all at once. Not to say that these tragedies have not plagued our humankind for a very long time, but the pandemic had created a distraction-less environment in which nobody had an excuse to look away! The thin curtain of privilege and oblivion was not as soundproof as once thought.

As a response to the Covid-19 apocalypse, many schools and Universities have started talking about their dedication to anti-racist curriculum. But with many educational institutions such actions were performative and did not ignite any real transformation and change. I would like to borrow the term by Fox et al. (2009a) and call such remedial actions ameliorative practices. Ameliorative practices seek to create change within a system without critically examining and deconstructing values, assumptions and underlying power arrangements that underpin the systems and institutions (Fox et al, 2009a). Gutierrez (2020) painstakingly highlights the futility and danger of such practices: 

Consider an institution that says it’s committed to anti-racism and has added mandatory antiracism training, broadcasting that “We’re paying attention to this topic.” Yet it has no Black or Latinx senior faculty, supports no research dedicated to studying racism specifically, has poor retention rates of Black and Latinx clinicians, has a history of retaliating against employees or clinicians who speak up, and presents no plan for addressing these issues or has excluded its own members of color from participating in the planning. What does a new anti-racism curriculum do, set against the backdrop of these structurally racist practices? It directs attention away from their very examination

As an antidote to ameliorative practices, I want to propose two critical and transformative frameworks that seek not to echo populistic ideas, but to use radical critical reflection in order to examine and deconstruct our implicit biases, and the gaze through which we see the world, by approaching and moving us from within. These frameworks are Narrative Medicine and Structural Competency.

“The Master’s tools will never dismantle the Master’s house” are words uttered by a formidable poet, feminist and lesbian Audre Lorde at the feminist conference in 1979. Traditional methodologies and theories, conventional western-society formed epistemologies, and ameliorative practices at large are Master’s tools that can not and will not dismantle the Master’s house – meaning the institutional racism and other social injustice that pervade our society (Bowleg, 2021; Paton et al, 2020). I believe that we need more critical approaches to dismantle the putrid and acidic spaces in which we have seemingly become comfortable in: in education, in clinical practice, in the world. The following paragraphs will outline the two frameworks I am proposing here. 


Narrative Medicine is a critical Medical Humanities that has its own body of knowledge that is infused with intersectionality, qualitative research methods, and creative and reflective practices in place. It is critical in an epistemic sense, in that it pays deep attention to the matters of power and privileges, and examines social injustices through the means of language and art. Narrative Medicine scholars use excerpts of literary fiction, art, poetry as platforms to attend to the matters of power and privilege, using that third object as a catalyst for greater collective consciousness. By paying radical attention to language, narratively competent practitioners learn how to read social structures embedded in language. Educators delivering this type of programme need to be careful when choosing the third object for close reading/looking and make sure they are being truly representative. They ought to be reflective not only of what they teach but how they teach it (Tsavet et al, 2014). As a critical Health Humanities, Narrative Medicine rests on two pedagogical pillars that exist bidirectionally: Structural Competency and Narrative Humility. In the following sections I will introduce these and use them as filters to help engage with a deeper understanding of Monte’s mother’s story.


Structural Competency is a novel critical framework designed by Metzl and Hansen (2014) and it is best defined as the “trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health”. In more simpler term, Structural Competency is about critical attention to power and privilege. When proposing treatments and management plans, understanding social and structural powers and forces at play is an essential skill of each healthcare provider. For example, before proposing exercise and fresh vegetables we may want to ask ourselves whether the person has access to such resources. Before calling people “messed up”, “difficult”, “malingerers”, “hysterical”, “obese”, and “psychosocial”, we may want to take a more critical look at the wider picture. What are the potential embedded oppressive social conditions that might be enacted by giving such advice out of context? 

In a typical Narrative Medicine workshop, students exercise and sharpen the skill of Structural Competency. If we look back at the excerpt above, we should be able to recognise that Monte’s mother lives a life at the intersections of gender, class and race oppression. These oppressions are in dialogue with each other and they all serve to delimit her sense of freedom, her dignity and her humanity, with one goal in mind: to change her mind about herself and ultimately to annihilate her life. This kind of social analysis is different to the traditional framework of Cultural Competency in that it focuses not only on the sociocultural conditions that exist outside of us, but it is inviting us to reflect on our own frames of listening and to the spaces within us. Structural competency is thus inextricably coupled with the pedagogical pillar of Narrative Humility. 


Narrative Humility is a term coined by Sayantani DasGupta, one of the Narrative Medicine faculty members at Columbia University. Narrative humility “acknowledges that our patients’ stories are not objects that we can comprehend or master, but rather dynamic entities that we can approach and engage with, while simultaneously remaining open to their ambiguity and contradiction, and engaging in constant self-evaluation and self-critique about issues such as our own role in the story, our expectations of the story, our responsibilities to the story, and our identifications with the story—how the story attracts or repels us because it reminds us of any number of personal stories” (DasGupta, 2008). In other words, no matter how many times we hear the patient’s story we can and never will know it in its totality. When students of Narrative Medicine join their gazes in order to observe the third object, they become aware of the multiple perspectives they each posses, their own biases and prejudices etched into those perspectives, and the awareness that each story has an element of unfamiliarity about it. Narrative Humility inspires conversation around Emanuele Levinas’s philosophy of the Other and the notion that “the other always lies beyond the comprehension of the self”. As an epistemological stance, this type of humility demands that we, as clinicians, become aware of our own frames of listening, and asks us to examine ways in which we might be contributing to the socially unjust conditions. Within an educational setting, this type of epistemological humility is an invitation to educators to question whether they see their students as co-learners or they see themselves as didactic educators and information providers. An educator who is inviting students to be vulnerable but himself is not modelling that vulnerability is enacting oppressive structures and misusing the position of power. As with Structural Competency, Narrative Humility is about commitment to accountability. 

By attending to Monte’s mother’s story, I may start by recognising my own privilege as a white European woman who, in pursuit of her dreams in this life, not once had to think that colour of her skin may get in the way. Even the very act of pursuing dreams is a privilege I am afforded access and privileges simply by virtue of my skin colour, outlook, sexual orientation which are not deemed threatening to the society I live in. I may want to ask myself, am I a safe person for Monte’s mum? Informed by such thoughts, I may choose to be very attentive to the language I use in the consultation. I may speak less and give her space to tell her story. I may want to recognise that there are parts of her existence that I will never understand in totality but I seek to know so I can inform myself, so I do no harm in my listening to the stories I hear. 


The times we are living in demand our attention and immediate action. Simply talking and paying the lip service to the biopsychosocial model and anti-colonial curriculum is not enough. There need to be real practices in place otherwise we run the risk of doing performance business that reifies oppressive structures. I invite Universities to start changing their cleaning practices (Guerrez, 2021) and hang their laundry in the front garden. Introducing critical Health Humanities is one way to start enacting this process, and it is crucial that it is accompanied by inside-out action. 

Researchers who are in the position of power, should seek to disseminate the research that often stays covered in dust behind the walls of academia: one good example of that is the Words Matter podcast looking at Qualitative Methods and CauseHealth series. Researchers should also encourage their students to take research in matters of racism, gender and wider sociocultural aspects in order to open up spaces for further dialogue. Universities should also start hosting literary scholars, philosophers, disability activists, patient advocates. University staff needs to be comprised of black and brown people, people of wider ethnic minorities, people who live outside of sexually hetero-normative constructs of society; all the people who are regularly marginalised. If this radical practice is not in place then education faces the risk of enacting hierarchical and patriarchal practices. 

If we truly desire to see a change, we need transformation not amelioration (Fox et al, 2009a), we need knowledge not for the sake of knowledge (Collins, 2019) but knowledge that is going to transform us from deep within, bring us face to face with our own racism, homophobia and abjection; knowledge that is going to not only touch us, but move us to action. We need revolutionary and apocalyptic knowledge: a kind of knowledge that reveals.


Some may read my commentary as a form of naiveté or wishful thinking that one can change the system by changing individual frames of mind and/or introducing ‘’some art’’ in schools. I would like to reply to those comments by echoing the words of journalist Reni Eddo-Lodge: It doesn’t matter what you do, as long as you’re doing something. I believe we each have responsibility for what is happening in the world right now. This is therefore not about naiveté and tragic optimism as much as it is about responsibility and hope and we all need hope in this life. Hope grounded in sober narrative, collective discernment and faith in better tomorrow. 

Acknowledgments: Thank you to my dear friend and colleague Robert Shaw for proof reading my blog and for supporting my desire to write about these issues.

People who inspired this blog: all my patients in Lincolnshire Community Pain Management Service, conversations with my dear colleague Laura Rathbone, and peers from the Narrative Medicine course at Columbia University.


Collins, P. H. (2019). Intersectionality as critical social theory. Duke University.

Bowleg, L. (2021) The Master’s Tools Will Never Dismantle the Master’s House: Ten Critical Lessons for Black and Other Health Equity Researchers of Color. 48(3)

DasGupta, S (2008) Narrative Humility The Lancet 371

Evans, S., Duckett P., Lawthom R., Kivell N. (2016) Positioning the Critical in Psychology Community

Fox, D., Prilleltensky, I., & Austin, S. (Eds.). (2009a). Critical psychology: An introduction. Sage

Gutierrez, K. (2020) The Performance of “Antiracism Curricula” The New England Journal of Medicine

Khan-Cullors, Patrisse, and Asha Bandele. When They Call You a Terrorist: A Black Lives Matter Memoir. New York: St. Martin’s Press, 2018.

Lorde, A. (1984b). Sister outsider: Essays and speeches. Crossing Press

Metzl, J. & Hansen, H. (2014) Structural competency: Theorizing a new medical engagement with stigma and inequality

Paton, M., Naidu T., Wyatt T.R., (2020) Dismantling the master’s house: new ways of knowing for equity and social justice in health professions education

Reni Eddo-Lodge, Why I’m No Longer Talking to White People About Race. (2017)

Tsevat R., Sinha, A., Gutierrez, K. and DasGupta, S. (2014) Bringing Home the Health Humanities: Narrative Humility, Structural Competency, and Engaged Pedagogy

Poetry – home to complexity, ambiguity and uncertainty

I am delighted to share that my undergraduate dissertation “Understanding patients’ narratives” A qualitative study of osteopathic educators’ opinions about using Medical Humanities poetry in undergraduate education has been published in the International Journal of Osteopathic Medicine. Link below (open access until 29th June 2021):

. . .

Why poetry?

During my first narrative medicine semester at Columbia University, Dr Rita Charon said golden words that patients speak in poetry and when we listen to our patients’ narratives, we listen for the truth in language. I couldn’t help but feel warmth around my heart as I recognised the astonishing parallel to my undergraduate research paper.

Human beings speak in poems. My pain is walking all over me / I don’t know how to describe this experience, if it was music it would be like Black Sabbath, do you know what I mean? / it’s like it’s hidden in the parts of me that don’t want to be found – are just some of the verbal verses I heard in my clinic recently. When we, as healthcare providers, ask people to describe or explain their painful/illness experiences, we are asking them to summon their world into being; to give concrete expression to something that is novel and unbeknown to them, something that can feel elusive and, as many writers from Virginia Woolf to Elaine Scarry pointed out, is oftentimes utterly resistant to verbal language. This is not an easy thing to do.

Poetry as a medium brings ontological questions to the surface, questions like: What is a person? What does it mean to be alive? What does it mean to suffer? And these questions matter to all of us, regardless of what our medical/healthcare speciality might be.

Unlike prose that often hinges on narrative predictions, poetry offers continual surprise through its unique blend of imagery, mood, metaphors, synesthesia. Poetry refrains from describing and explaining, it simply says This is… – and from this point we are already sucked into the world of feeling, seeing, experiencing, remembering.

For me, poetry has always been about paying a different kind of attention… About activism and social justice, about personal voices as well as communal, about the power of imaginative thinking and (self) compassion. Poetry saved lives, gave voices to oppressed, connected humans through centuries and across cultures, it shaped languages and built nations. If it wasn’t for Dante’s La Comedia Divina, there would be no Italian language in the shape and form we know it today! Pushkin not only created modern Russian language, but invented literary genres so that ordinary Russian people can express their voices. If Rilke didn’t listen to Rodin and went to the Jardin des Plantes to stare at the poor animal until he was unable to do anything else but to write about it, he would have never found a way to express how it felt to live trapped in one’s own body. And many others wouldn’t have felt seen by reading his poem. 

Poetry makes us feel seen and by making us feel seen, it makes us feel connected. It reminds us of our shared vulnerability and humanity.

Poetry also makes us feel uncomfortable. By entering the world of a poem, one enters a world of infinite complexity, ambiguity and uncertainty. A scary territory of vulnerability, felt-ness, and recognition. There is no logic in poetry! I have always thought in order to study creative (and therefore critical) thinking, one should read Rimbaud, Lorca, Lorde, Akhmatova, Plath…

Because of all this, poetry is like life itself (another pearl from Dr. Charon): initially plotless; feels better when you truly surrender to it; it lives and gets born in the body; it is personal and shared but never, ever general! 

Read & write poetry, the world needs it!


Between the Borders of Who We Are

Recently I had the pleasure of co-producing a creative writing workshop “Your Story Matters” as a part of the Footsteps Festival, a volunteer-led, collaborative year-long festival that celebrates people living with pain through the means of art and education. Eighteen of us came together, all across the globe, to meet in togetherness, behind our screens. Just like ten characters from Boccaccio’s Decameron who, wrecked by the horrors of the plague in 1348, found refuge in the villa just outside of Florence, learning how to survive by telling tales to each other, we retreated into virtual storytelling in the time of Covid-19 pandemic. Even seven centuries after the inception of Boccaccio’s masterpiece, the stories have remained the fire that kept our lived bodies warm.

But unlike Boccaccio’s characters who had a privilege of inhabiting the same physical place, we were “restricted’’ to the virtual space grounded in the world of social distancing. Covid-19 crisis ineluctably turned all of us into students of space, more precisely of distance, whether we want it or not. One cannot move freely and uncaringly in space anymore without developing an awareness of physical closeness that those around us are comfortable with. This notion of distance thus brings with itself sub-notions of awareness, attention and recognition. 

I began to ask myself if there is an ethical lesson that we, as healthcare providers, can learn from practising distance? Can space in distance be a fertile ground for recognition? What else can flourish in that space? Some of the answers to my questions I found in our writing workshop. 

Our workshop was based on the principles and practices of narrative medicine: narrative listening, narrative humility and narrative competence. Writing and knowing that your story will be shared is inherently an act of risk taking. With this in mind, my co-producers and I decided to start by reminding our participants that we too are stepping into this space as fellow human beings. My friend Clair, a physiotherapist, tenderly laid down cobblestones of confidentiality and choice, for those that would wish to share their stories and for those who would not. Jenny, our collaborator who lives with pain, generously shared some of her personal writings that we exercised together, and I shared my elaboration on what I had received by listening to her story. Whilst we danced to the music of meaning-making, an instant leap of connection and humility percolated the space between our participants, permeated with smiles, interest, sense of safety. The virtual distance between us transformed into a space of holding, seeing and discovering.

The heart of our workshop was conducted by our friend and collaborator Debra, an occupational therapist. Debra compassionately guided our participants into writing exercises, followed by an invitation to join smaller breakout rooms and hold space for each other’s stories. Our participants were invited to listen and pay attention to each other’s word choices, spaces between the pen and paper, evoked imagery, and to their own embodied reactions as listeners. Instead of launching ourselves into the land of opinion or prompting further questions, we all practiced the art of being with.

I am always amazed at what kind of visceral stories people are able to bring to the fore in such automatic, unintentional writing. I was taken back by the story that erupted from my own body, releasing itself from a hidden position of grip. Even though my listeners were my collaborators whom I knew well, it still felt uncomfortable reading my words aloud. Having them recognising rhythm and musicality in places I saw nothing but interrupted blubbery, truly felt like growing wings and catching myself falling. When somebody pays attention to your craft, they inherently recognise your position as a creator. This can be incredibly empowering. My listeners stimulated my agency as they un-hinged me from a seemingly trapped situation into the space of narrative possibilities. As some other participants noticed, after coming back from the breakout rooms, there was a sense of connection, validation, recognition and a true sense of shared vulnerability. 

One of the final crescendos of our workshop was the moment when we thickened our gazes whilst watching Kae Tempest speaking their poetry aloud. Breathe deep on a freezing beach / Taste the salt of friendship / Notice the movement of a stranger / Hold your own / And let it be / Catching… This line Notice the movement of a stranger strengthened an ethical foundation of our writing workshop – the one that values coming to know one’s own humanity in relationship with others. Our participants left the workshop feeling inspired, strong, empowered, awed, seen, touched. Even though the encounter was virtual which could easily be perceived as disembodied, it felt very much the opposite for it was our spoken stories that communicated our bodies. Our final destination therefore wasn’t in the virtual space, it returned us back to the essence of our very selves.

French philosopher Jean-Luc Nancy captured this in his philosophical concept singular plural, which is entirely grounded in the ontology of relation. Following similar thinking line as Levinas, Nancy points out that there is no being without being with, no body without bodies, no existence without co-existence. He recognises that human beings are borders they share with others, and relational actions (such as listening and paying attention) bring us closer to the edges of those borders, restoring our very relation to the self. 

As I write this, I am reminded of a story I recently read by Haruki Murakami, Samsa in love. In his story, Murakami re-humanises Gregor Samsa, a famous literary character who one day woke up in a body of a gigantic insect, by making him fall in love with an un-named woman (let’s call her Isabel). Isabel reminds Samsa that he is alive and relational. The narrative arc of alienation, commenced by Franz Kafka, is therefore recovered and reinvented by the means of love and desire in Murakami’s story. 

It is the very taste of Boccaccio’s medicine, the medicine of relationality, that saved Samsa, that sustained our virtual workshop and that keeps restoring our sense of humanity over and over again. 

Boccaccio’s medicine is what we do in clinical practice: we bear witness to stories. I would argue that practising some distance sometimes helps us to see each other in a brighter light. And I don’t mean distance in a form of spaceship ethics to reference Arthur Frank, but distance as a disposition of knowing how to hold space for the other by listening and by knowing how to keep our own stories at the bay when that means honouring someone else’s.

As we are all reconfiguring the new coordinates of space in our lives, let’s not forget the spatial poetics that imbue our clinical practice, be it face-to-face or virtual, and beyond. Let’s not forget our active role when it comes to creating spaces that allow for connection and recognition; spaces that honour the borders of who we are and what can flourish in between. 

End note:

Thank You to my friend Clair Jacobs who invited me to join her on this wonderful project. Clair and I met at the narrative medicine course ( last summer. Clair is a physiotherapist who works in NHS and I am an osteopath working in a private practice. What are the chances that we would have met had it not been for this course? I am afraid very small. Perhaps sometimes on the borders of who we professionally are, we build walls that separate us beyond possibility of relation. And in doing so we risk losing the sight of gazing outwards towards our shared space: people in pain and illness. One of the reasons that I love narrative medicine is its ability to flatten hierarchies and allow for multidisciplinary and truly person-centred care. Clair and I came to know each other not only as two healthcare providers passionate about working with people in pain, but as two women. I got to hear Clair’s sorrows as she got to hear mine… The product was this fantastic workshop that was possible only in collaboration.

Thank you, Clair, Debra, Jenny & all who attended our precious workshop. 

Our next workshop “Your Story Matters” is on the 30th of March at 5:30-7PM GMT:

What is Narrative Medicine?

Once upon a time

Different things make different people feel like themselves. For me, that has always been the written word. Even though I can appreciate many forms of art, it is the narrativity, imagery and performativity that lives within the world of text that makes my heart beat a little bit faster. 

During my first degree in Croatian language and (world’s) literature, I dreamed of teaching students the work of Kafka, Cervantes and Dostoyevsky one day. If you watched Dead Poets Society that is exactly how the scenario was playing out in my head. We don’t read and write poetry because it’s cute. We read and write poetry because we are members of the human race. And the human race is build with passion – the words of Robin Williams’s character echo in me to this day. 

But just how it often happens with those early-adolescence-borne-loves, there comes a point when the extent of discrepancy between the reality of how things are and the reverie of how you expected them to be becomes too heavy to bear. Seeing art merely through theoretical lenses tears art apart! After four years of studying, nine years of obsessive reading, and much soul searching and deliberation, I left my college. 

One year later, I found myself living in London embarking on a part-time integrated master’s degree in osteopathy. The ego bruise caused by going from writing literary essays about traces of Homer in Joyce’s Ulysses in my mother’s tongue to learning a whole new language through physiology and anatomy books was real. Nonetheless, I plodded along as a good and eager student, but it was not until my fourth year that I felt like something in me had come to life, a feeling long familiar. It was the year I started my osteopathic placements – the year I started to work with patients, real people, people from all walks of life and many, MANY people living with persistent pain. It was also the year that I discovered the field of narrative medicine, as I stumbled across Dr. Rita Charon’s TED Talk. And it was the year when I decided to do my dissertation about Medical Humanities poetry. 

The silent but ever growing voice in me was heard. The patterns started to build a shape.

I am now four weeks into my first semester as a student of professional achievement in narrative medicine at Columbia University. Not a day goes by without someone asking me what it is that I study. Even though I strongly believe that narrative medicine needs to be experienced, here is my best attempt in trying to explain what it is and what it has to do with pain care. 

What’s in the name: Narrative Medicine?

Put plainly, narrative medicine is an interdisciplinary field where humanities meet healthcare. Put more academically, it is a discipline that blends elements of narratology, literary/aesthetic theory, phenomenology, narrative ethics with health and healthcare. Put for friends and family – narrative medicine teaches one how to be a better listener and a better person altogether. 

Currently, there are different terms and flavours of narrative healthcare so you may have heard of narrative medicine, narrative-based practice by Dr.John Launer (which I am yet to experience), narrative therapy, narrative reasoning. Even though these are all branches of the same tree there appear to be some nuanced distinctions. I believe my present thoughts best resemble form and shape of narrative medicine that emerged from Columbia University in 2000. 

Narrative medicine is often defined by Dr. Rita Charon’s term narrative competence: the ability to acknowledge, absorb, interpret, and act on stories and plights of others. It recognises the centrality of storytelling in healthcare; be they the stories we tell each other, the stories we tell ourselves, or the wider narratives that surround and infiltrate us, with or without our awareness. Nested within the person-centred framework, narrative medicine places value on the relationships between people-selves-world(s).

To further understand the relational foundation of narrative medicine, one has to understand the epistemological pillars upon which it rests: narrative listening and narrative humility.

Narrative listening 

Open your mind as widely as possible, and signs and hints of   almost imperceptible fineness...will bring you into the  presence of a human being unlike any other
Virginia Woolf, How should one read a book

The way we listen informs the way we live says narrative medicine scholar Julia Schneider. I had been thinking about this notion last week when Columbia faculty asked us to think about the story that has “worked on” us. I remembered a novel I read when I was 17, The Unbearable Lightness of Being by Milan Kundera. I remember devouring the story as I recognised my young self in the character of Teresa. At the same time, my mind also embraced alternate possibilities shaped by another character who is pure antithesis to Teresa, Sabina. I ended up making choices in my life based on what Sabina’s character had inspired in me. Listening truly does inform how we live our lives and what kind of persons we become. 

At Columbia, narrative listening is practiced by the process of close reading. Each week we close read different forms of art together. This means that one week I will be gazing at the painting from the 16th century, alongside somebody who lives on an opposite hemisphere, embedded within a culture and history completely different to my own, and in that process of gazing together at the work of art, our worlds will intertwine beckoning us into connection. In that process of polyphonic gazing, we will make ourselves available to see things differently, to adopt different points of views, to enter into what is possible. This is not different to what happens in clinical practice, as we gaze together with our patients at the mystery of the human body, movement preference or the nature of pain. 

Narrative listening is, in itself, an epistemology. It is an ethical choice as my friend Corine Jansen taught me: a radical act that flattens hierarchies and transcends boundaries such as gender identity, language preference and colour of our skin, leaving us naked, covered “only” in our humanity. 

Which brings me to the next pillar, sister of narrative listening: narrative humility.

Narrative humility  

Narrative humility is a term attributed to Sayantani DasGupta, another faculty member at Columbia University. Narrative humility is an epistemological position that recognises the impossibility of ever truly and totally knowing what the other person is going through.

By teaching the process of thinking with as opposed to simply thinking to, using relational prepositions such as with and alongside as building blocks that position patients and healthcare providers on an equal footing, narrative medicine training inherently teaches framework of narrative humility. Framework of trust. It reminds us that professional knowledge is a privilege of knowledge, not a privilege of power, and that professional knowledge needs to always be married with another, equally important knowledge – the lived experience. 

In this way, as healthcare providers, we are starting from a “bottom up” position where we are about to learn from our patients, how that what we know can help them to move forward. The rest is dialogue. 

Narrative medicine and pain care

As I write this, my mind brings up a memory of an avant-garde play by Luigi Pirandello Six characters in search of an author. It’s a story about six nameless characters stuck in an unfinished play searching for the author who allegedly abandoned them. The characters claim their story is incomplete. Sometimes I think this is all of us, as human beings, we all seek in various ways to reaffirm the authorship of our life. Deep down, we want to know that our story belongs to us.  And pain… it seems to me that pain takes that signature of authorship away. 

Pain dis-engages us with the world. It complicates our sense of time, sense of space and erases our sense of self. It robs us from what is meaningful as it paints the world in immutable colours. 

Stories told by people living with pain are no fairy tales. They are complex stories, stories seemingly lacking form and meaning, anti-narratives. They make us, the listeners, feel uncomfortable unless we have a certain threshold to bear witness. My worry is that sometimes we, as healthcare providers, are held back by our commitment to be right and to always have the answer. Learning how to be with these “messy stories” is what the process of close reading nurtures. 

The literature behind the biopsychosocial model of care supports the view that we should be asking our patients open questions, asking them to tell us their story. But I am not sure if we always have the skills needed to receive the story. I am not saying I have those skills perfected either, but I believe, in a clearly biased way, that narrative medicine has the potential to train the ability to hear the stories and know what to do with them. Tell me your story is a great question but only if the person sitting opposite is ready to step into the open. Learning how to recognise if the person is ready, learning how to be comfortable with discomfort, learning how to hear what is hidden in seemingly thin and untold stories is what narrative medicine is all about. 

We know better these days that people living with persistent pain are undergoing testimonial injustice – an injustice of not being believed. Learning how to approach the person from a place of narrative humility is just another way of communicating “I will never fully understand what it means to be you” therefore “I have no other choice but to 100% believe everything you say”. 

Not all “pain stories’’ are told in language, nor the metaphor as a narrative feature is the centrepiece of narrative medicine, but here is one example from my clinical practice where narrativity met pain care. Recently one of my patients told me that she feels like she is locked in a cage. I wondered aloud what would be like to not be locked in a cage? Together we elaborated on the possibilities of opposites. She shared hers, I even shared mine. By gazing at this metaphor together I found out so much about who this person is, what matters to her, what her values are, what is truly lying beneath the metaphor. I did not feel like I was stepping outside of my professional remit – I simply chose to hear what she said from a different angle. Her choice of words bewildered me as I turned a face of curiosity toward her. 

So, what does all this narrative business has to do with pain care? Well, I think it has to do Everything!

I am perpetually amazed by what narrative medicine brings to my professional (and personal) life. Some days, it feels like it comes easy to me, some days accepting that “I don’t know” is the best I can do. There are amazing healthcare providers out there who already practice this type of work without knowing that they “do narrative medicine”. After all, narrativity is inherent to our identities and our sense-making of the world as wounded storytellers

Until the next story,


Further learning:

Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, Rita Charon, JAMA. 2001;286(15):1897–1902

Narrative Humility, Sayantani DasGupta, Lancet, 2008;371(9617):980-981

I also want to acknowledge women who inspire my thinking: Dr.Rita Charon, Julia Schneider, Clair Jacobs, Corine Jansen, Corina Breukel, Lissanthea Taylor, Sara Slack, and many more.