Metaphor and medicine: narrative in clinical practice.

For decades it seems that the art has been slipping away from medicine. Like the ancient Greeks, who lamented the passing of the Golden Age, contemporary physicians, educators, the general public, and especially the sick mourn the loss of the human dimension of medical practice. Fragmentation, subspecialization, lack of continuity, technological demands, burgeoning patient volume, institutional stress, and, most recently, managed care appear to have caused recent generations of physicians to devalue relationship-based medicine in favor of procedures and machines [1, 2]. Commentators have responded to this unfavorable diagnosis with various prescriptions. One the earliest was the "biopsychosocial model," which George Engel put forth as a new paradigm to replace the reductionistic, disease-oriented "biomedical model" with a more holistic, illnesscentered perspective [3]. The competencybased initiative for medical education sponsored by the American Association of Medical Colleges and the American Council for Graduate Medical Education is the most recent proposed therapy [4, 5]. This innovative regimen parses the art of medicine into a series of topics and competencies in humanism, professionalism, communication, evidence-based practice, and social responsibility, and it requires medical schools and residencies to develop curricula that teach these competencies. Dehumanization can best be stated in narrative terms; i.e. nowadays medicine tends to ignore or minimize the role of narrative in illness and healing. Narrative medicine is "medicine practiced with the narrative competency to recognize, interpret, and be moved to action by the predicaments of others" [6]. Medicine is largely about storytelling and interpretation, and narrative, metaphor, and symbol are fundamental tools of the trade [7-9]. Ill persons experience meaning in their illnesses, they see themselves as characters in a life narrative, and they approach medicine as a vast network of healing symbols. Patients understand their illnesses in a narrative way whether their physicians realize it or not. If this is so, and if physicians ignore or devalue narrative, then health care is bound to suffer. From the patients' perspective, narrative incompetence causes widespread dissatisfaction, distrust, and failed expectations. Within the profession, it leads to the persistent