2. M Cole2
high degree of reflexivity. By this I mean a sense of self in the act of recollecting
that recognises the way in which we influence and comprehend events – and the
way in which they influence us.
Hence, as reflective practitioners, it is important to recognise the way in which
we structure and understand the events on which we reflect. We need to be
mindful of the fictionalisation that we engage in when reviewing and analysing a
particular event in our professional practice – both in our minds and on the page.
In accessing memory of an event, we inevitably express it as a story – and that
narrative structuring is as susceptible to reflection and understanding as our role
and actions in the event itself.
If the recollections on which we reflect are fictions, then there would appear to
be virtue in using authentic fiction as a means by which to undertake wider
reflection. After all, the fictions in which we trade as a society – particularly those
that maintain their currency over time – are those that deal with universally
recognisable themes or capture the spirit of a particular time or event.
This has the potential to work at a number of levels. For example, medicine
and its practice appear in a wide range of literary accounts, providing invaluable
historical, social and clinical insight. A superb anthology on this theme, featuring
an extensive selection of aphorisms, fictional writing, poetry and journal entries,
appeared just a few years ago – and, in consequence, provides an excellent starting
point for this type of analysis.2 Furthermore, at least one small-scale study, which
looked at medical students undertaking a medicine and literature module as part
of their undergraduate curriculum, saw very positive results in terms of insight
into illness and experience of treatment.3
There are also many fictional pieces that, while not being about medicine as a
professional activity, have a strong ‘medical’ theme. To take just one example,
Richard Matheson’s 1954 science fiction novel, in which a global outbreak of
vampirism is explained on the basis of bacterial infection, is a text that provokes
the reader to consider the relationship between disease, myth and the role of
modern medicine.4 Less explicitly, of course, Franz Kafka’s curious novella, telling
the story of a man who awakes to find himself transformed into a giant insect,
can usefully be read as an allegory for disease and the reaction to it of both
patients and their significant others.5 However, there are countless texts that make
no direct or indirect reference to medicine or disease but which enrich the
reader’s understanding of life.
Interestingly, it is not simply the literary artefacts that help us to develop
understanding in this fashion. The practice of studying stories provides a means
of analysing all manner of narratives, from our own reflective accounts to the
(hi)stories that patients and clients provide. In an interesting coincidence,
narratologists – those who study narratives in a very formalised fashion – make
the distinction between an ‘act’ and a ‘happening’; the former entails someone in
the narrative actually doing something (‘she administered the drug’), while the
latter is something in the story that merely occurs (‘the waiting room was busy’).
The person doing something in a narrative is called an agent, while someone not
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3. Fictional realities 3
engaging in an act – interestingly enough – is called a patient. It is explained that,
‘Whereas patients are affected by certain processes, agents initiate these processes
and, more specifically, influence the patients, modify their situation (improving
or worsening it), or maintain it (for the good or the bad)’.6
This parallel between terms used in narratological analysis and in medicine can
be seen to show how a great deal of human practice is shaped and structured by
traditions of story telling. It reinforces the view that it is not simply fictions that
provide us with the potential for personal insight in general – and professional
understanding in particular. The ways in which those fictions might be analysed
also help us to critically engage with stories – personal, organisational or clinical
– in a meaningful way. It serves to remind the reader that it is not merely the text
that is significant: there is the issue of its provenance, its context and the structure
within its content, all of which need to be taken into account when trying to make
sense of a text – and how that text might speak very directly in terms of our own
lives.
With all the above in mind, I was asked to review three titles that form part of
a larger series, entitled Case Studies in Contemporary Criticism. Each volume
provides a text to read – in this instance, Wuthering Heights,7 A Portrait of the
Artist as a Young Man,8 and Tess of the D’Urbervilles9 – alongside a range of critical
explorations. As such, the books under consideration here are comprehensive and
fully rounded literary packages, providing an excellent opportunity to engage
with a text and to access quality commentary from expert academics.
A cursory reading of these three texts – or a passing acquaintance with their
respective premises – encourages us to acknowledge that, at the broadest level,
there are a number of shared and important themes here. Matters of class, of
gender and of human potential are to the forefront. Each story provides a very
specific historical prism through which to view these important social trends. The
characters of both Tess Durbeyfield and Catherine Earnshaw are located in times
of great change, and their respective stories, to an extent, hinge around matters of
wider shifts in standing and status.
The texts, then, provide us with an understanding of wider social events of
their times. They also allow for the reader to explore the motivations and actions
of the range of characters. How do we feel about the young Stephen Dedalus in A
Portrait of the Artist as a Young Man, as he wrestles with a strong desire for self-
actualisation that sits uncomfortably with the strictures of family, nation and
religion? What view do we take of Heathcliff lending money to the tragic figure
of Hindley in Wuthering Heights? How should we see Angel Clare’s abandonment
of Tess after their wedding in Tess of the D’Urbervilles? To consider each of these
questions is, of course, an act of reflection, hopefully giving us thoughtful insight
into past and potential behaviour of others and ourselves.
The beauty of novels such as these – and the reason that they are able to
transcend time and seem alive to us today – is that they deal with dilemmas and
themes that recur in the human condition. As such, they enrich our under-
standing of what it is to be a person in the here and now, despite the fact that they
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4. M Cole4
refer to fictionalised events from another time and place.A reading of Shakespeare’s
Hamlet, for example, although set centuries ago and in Denmark, yields the
ageless themes of religion, madness, love, revenge, corruption and disease.10 Such
matters have as much currency in the contemporary age as they did at the time.
So, there is much to be gained from reflectively reading fictional works such as
these. They give us a sense of past times and allow us to use characters as media
through which to think through circumstances and situations in a way that
encourages our own personal growth and development. However, as I intimated
earlier in this piece, the titles being reviewed here include a range of critical essays
that will help the reflexive reader to apply narrative analysis to a wide range of
texts – including the range of stories that exist within our own working milieus.
For example, in the volume relating to Tess of the D’Urbervilles, there is an essay
by JP Riquelme, at that time on the English faculty of Boston University, that
provides a superb introduction to the theory and practice of literary deconstruc-
tion, the technique that is closely associated with the notoriously impenetrable
French writer Jacques Derrida.11 This lucid and useful chapter is in two parts:
there is a preamble (written by the series editor, Ross C Murfin) that provides an
overall editorial introduction to deconstruction and to the analysis that follows,
while the main essay sees Riquelme apply those techniques to Hardy’s novel.
Being able to see deconstruction in contextual use like this clarifies what the
approach means and how it actually works. It brings alive a technique that sees
the reading of any text as something characterised by uncertainty and ‘… as an
act performed with the full knowledge of the fact that all texts are ultimately
unreadable (if reading means reducing the text to a single homogeneous mean-
ing)’.12 In bald terms like this, I notice that the casual reader of this review might
reasonably be left scratching their head ponderously; in conjunction with Riquelme’s
analysis, however, it seems less – how shall I put it? – continental.
For Wuthering Heights, the issue of psychoanalytic criticism – among other
approaches – is explored.13 Using the same format, an introductory segment
precedes a detailed item of textual analysis of the novel in question, opting to
explore the story from the perspective of the concept of the absent mother.
Meanwhile, the title looking at A Portrait of the Artist as a Young Man has both
deconstructive and psychoanalytic interrogations of Joyce’s story.
These are nice titles – attractively produced, cleanly printed and wisely
compiled – that provide a copy of well-known literary texts alongside detailed
critical essays. The latter provide a useful introduction to approaches in literary
theory while, at the same time, illuminating the fictional writing that they accom-
pany. The series from which they are drawn is aimed at US college students,
although the volumes serve as useful introductions for a wider reading public.
And they serve as an excellent reminder of the fact that narrative – whether it is
a genuinely fictional tale, an account of our own practice or an organisational story
from our wider workplace – is susceptible to the sort of analyses being applied here.
In health care, it is vital for all involved to recognise the centrality of story
telling to practice. Whether we look at stories drawn from the wider culture – in
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5. terms of literature, cinema or the arts in general – or at the narratives that give
shape to the work that we do, such as patient histories, medical notes, journal
articles, and reflective writings, it needs to be acknowledged that engaging
critically with such artefacts has an enormous potential to inform the way in
which we work as practitioners – if, of course, we allow it so to do.
This edition of the journal carries four excellent clinical case studies, rich in
detail, reflection and observations in respect of learning. Each of them serves to
remind us of the remark of the French writer and semiotician Roland Barthes,
who describes narrative thus:
‘Able to be carried through articulated language, spoken or written, fixed or moving
images, gestures, and the ordered mixture of all of those substances; narrative is
present in myth, legend, fable, tale, novella, epic, history, tragedy, drama, comedy,
mime, painting … , stained glass windows, cinema, comics, news items, conversations
… Caring nothing for the division between good and bad literature, narrative is
international, transhistorical, trancultural: it is simply there, like life itself’.14
The case studies herein are clear examples of narrative. From my perspective, I
feel that they underscore the fact that story telling is the main means by which we
make sense of, and engage with, the world. As Barthes intimates, the medium by
which these stories are conveyed is largely unimportant: a scientific report, a case
study, a reflective account, a work-related anecdote told to a colleague on passing
them in the corridor, all these are vessels by which a story can be conveyed. But it
is the story – the setting, the characters, and, most importantly in terms of story
telling, the plot – that is vital to the wider understanding of both the narrator and
the listener or reader.
In consequence, these cases studies can – and should – be read as narratives
and analysed as such. When it is observed that a single mother, after a con-
sultation with a paediatrician, ‘… felt helpless and neurotic and she wished she
had the funds for a private consultation’,15 the story gives the reader insight into
the negative impact that healthcare practice can have psychosocially on those who
are subject to it. Moreover, the character of the single mother becomes more
three-dimensional as we consider her feelings and wishes so pithily expressed.
Lastly, we catch a glimmer of the social standing of the single parent, desperately
concerned about the well-being of her child but lacking resources to pursue her
concerns in the way she would wish.
The case study by Sara McMullen contains high drama at one point, when the
writer says, ‘Having administered the benzyl penicillin, his [the young patient’s]
father has suddenly remembered that he was unable to have a certain medicine
but did not know which one’.16 I suspect that this is a narrative that Sara would
like to rewrite; storytelling and reflection allow the reflexive practitioner to do
just that, of course, and to learn from that rewriting.
She also gives us insight into the way in which storytelling can be used in terms
of gathering information. Instead of taking history, a practitioner can gather
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6. stories. For example, Sara – in discussing her learning from the event – looks at
the issue of allergy status in children and suggests that ‘An option would be to ask
if they have had antibiotics in the past and when’.17 As an alternative, I thought
that it might be appropriate to call on story to access this vital information by
asking ‘Can you think of any times in the past when your child has had a strange
or bad reaction to a drug or other treatment?’. This is an invitation to retell a
family story, rather than a bald request for clinical detail.
In the case study by David Bossano, we see how storytelling can allow us to talk
frankly about our reactions and feelings towards key events in a plot. David
allows himself the observation that he ‘… was uncomfortable because I felt I had
broached the subject of weight and lifestyle perhaps too insensitively’.18 As a
healthcare practitioner, to allow these feelings to surface in the text is both to
acknowledge them and to discharge them. But they also enrich the learning that
the clinician can derive from such circumstances because of the level of
personalisation involved.
David also observes that ‘The greatest impact on me was seeing the degree to
which Mrs Hughes’s condition affected her, expressed in writing. For example,
Mrs Hughes indicated … that “she felt bad about herself … nearly every day”’.19
This reminds us of the value of inscription, the way in which committing events
and thoughts to paper somehow makes them more potent and susceptible to
careful examination. (It is for this reason that reflective practitioners are advised
to reflect-on- as well as reflect-in-action, to get their reflections down on paper
so that they can look at them closely, engage in meta-reflection and hence commit
themselves to action arising from their reflection.)20
But, in fact, it is David’s strong reaction to the micro-story that Mrs Hughes
includes in her questionnaire response that is truly important here. In eight
words, she tells a plaintive story of her life that is extremely poignant for the
reader: she felt bad about herself … nearly every day. If you read that line over
several times, if you say it aloud, if you recite it to another human being, then you
begin to sense the story of Mrs Hughes and her condition at that time unfolding.
To reflect on that eight-word story of someone’s life is to gain a greater and more
empathic understanding of his or her situation.
In an echo of the example of Rashomon with which this paper opened, Helen
Halpern and Martin Abbas in effect tell their own distinctive stories of the same
event, namely a mentoring session.21 The sharing of those stories by these two
narrators gives each an insight into the understanding of the other. Neither
account has an overwhelming claim on truth in respect to the events that actually
occurred. As I intimated earlier, this narrative approach is premised on a view
that we have transitive knowledge of an intransitive reality. However, each story
clearly provides a means by which the authors can access greater mutual
understanding of their positions.
Through the comparison and interpretation of their two stories, we see how
the authors are able to articulate their deeper attitudes and feelings towards this
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7. specific experience of mentoring – and, most significantly, of mentoring in
general. To that extent, it is possible to see how this insight might be used to alter
and improve the way in which their specific mentoring occurs. It might also be
said to be a means by which these two people can enrich and deepen the quality
of the mentoring relationship that exists between them.
Let me conclude this exposition on narrative, then, on a lighter note, using
an example in this regard that I confess amuses me greatly but which patently
has serious implications for thought and action. Back in December 1998, the
Canadian Medical Association Journal carried an article by two doctors that
looked at the representation of medicine in the animated TV series The
Simpsons.22 They compared the two medical characters – Drs Julius Hibbert and
Nick Riviera – that appear in the show, in order to decide which was a better role
model for the profession. At first appearance, Hibbert is the better doctor: he is a
conscientious, affable and trusted. Meanwhile, Riviera is a poorly qualified and
venal practitioner.
However, the paper concluded (with the authors’ tongues firmly in their
cheeks) that
‘As a profession, we must shed the dark past embodied by Dr Hibbert – a wasteful,
paternalistic and politically incorrect physician. Instead, the physician of the future
must cut corners to cut costs, accede to the patient’s every whim and always strive to
avoid the coroner. All hail Dr Nick Riviera, the very model of a 21st-century healer’.23
Elsewhere in the same edition, however, a solicited editorial took another view
and presented an alternative role model for physicians in Canada: it was Dr Bones
McCoy from the original Star Trek series.24
Although these were frivolous pieces for the pre-Christmas edition of the
journal, they demonstrate how serious professional issues – in terms of both the
technical rationality of professional activity and the swampy terrain of profes-
sional practice – can be explored using fictional characters. In fact, behind the
question of who represents a better role model for medicine is a more serious
issue for exploration: what do the two cultural representations of modern
medicine in The Simpsons tell us about the social standing of the profession and
the popular appreciation of medical science?
All ‘fictions’ – whether they be our own recollection and retelling of particular
events or artistic creations, such as novels – provide the reflective and reflexive
practitioner with material through which to develop personally and profes-
sionally. The titles reviewed here provide a text on which to work and a range of
technical perspectives by which to achieve greater narrative clarity as a reader.
They provide excellent guides to expanding our reflective potential and, as such,
they are particularly welcome. Moreover, the case studies appearing in this
edition underscore the role that narrative plays in clinical practice – and hence
hopefully provide an excellent bridge between the ideas I have discussed herein
and the day-to-day experience of clinicians.
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8. REFERENCES
1 Kreiswerth M. Merely telling stories? Narrative and knowledge in the human sciences.
Poetics Today 2000;21:293–318.
2 Bamforth I (ed). The Body in the Library: a literary anthology of modern medicine.
London: Verso, 2003.
3 Hampshire AJ and Avery AJ. What can students learn from studying medicine in
literature? Medical Education 2001;35:687–90.
4 Matheson R. I am Legend. London: Gollancz, 2006.
5 Kafka F. Metamorphosis and other Stories. Harmondsworth: Penguin, 1916/1961.
6 Prince G. A Dictionary of Narratology. Aldershot: Scolar Press, 1991.
7 Peterson LH (ed). Wuthering Heights, by Emily Bronte (2e). Boston, MA: Bedford/
St Martin’s, 2003.
8 Kershner RB (ed). A Portrait of the Artist as a Young Man, by James Joyce. Boston, MA:
Bedford/St Martin’s, 1993.
9 Riquelme JP (ed). Tess of the D’Urbervilles, by Thomas Hardy. Boston, MA: Bedford/St
Martin’s, 1998.
10 www.rsc.org.uk/hamlet/learning/themes.html#themes (accessed 4 April 2007).
11 Riquelme JP. Deconstruction and ‘Tess of the D’Urbervilles’. In: Riquelme JP (ed).
Tess of the D’Urbervilles, by Thomas Hardy. Boston, MA: Bedford/St Martin’s, 1998,
pp. 484–520.
12 Ibid, p. 492.
13 Peterson LH (ed). Wuthering Heights, by Emily Bronte (2e). Boston, MA: Bedford/
St Martin’s, 2003, pp. 348–78.
14 Barthes R (1977/1966) Introduction to the structural analysis of narratives. In: Heath
S (ed). Image Music Text. London: Fontana, pp. 79–124.
15 G. Case study: anxious mother, unwell baby. Work Based Learning in Primary Care
2007;5:xx–xx.
16 McMullen S. Case study: a child with a rash. Work Based Learning in Primary Care
2007;5:xx–xx.
17 Ibid p.xx.
18 Bossano D. Empathy and effectiveness. Work Based Learning in Primary Care 2007;
5:xx–xx.
19 Ibid p. xx.
20 Cole M. Reflection in healthcare practice: why is it useful and how might it be done?
Work Based Learning in Primary Care 2005;3:13–22.
21 Halpern H and Abbas M. Baggage. Work Based Learning in Primary Care 2007;
5:xx–xx.
22 Patterson R and Weijer C. D’oh! An analysis of the medical care provided to the family
of Homer J Simpson. Canadian Medical Association Journal 1998;159:1480–1.
23 Ibid, p. 1481.
24 Yeo M. To boldly go: we have to look beyond The Simpsons for a true medical hero.
Canadian Medical Association Journal 1998;159:1476–7.
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9. ADDRESS FOR CORRESPONDENCE
Mark Cole
Head of Learning and Development
Education Centre
Queen Elizabeth Hospital
Station Road Woolwich
London SE18 4DH
UK
Tel: +44 (0)208 836 6793
Email: markcole10@gmail.com
Received January 2007
Accepted January 2007
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