Originally posted by Dr. Schubiner on March 21, 2011 This blog was written by a friend and writer, Jared Egol. He writes eloquently about the patient’s history as “story” and the concept of “narrative medicine,” i.e. seeing the patient’s story as critical to healing. When the person with Mind Body Syndrome sees that they are, in fact, the “hero” of the story, they will be much farther on the road to recovery. To your health, Howard Schubiner, MD The Hero’s Journey as Story: The Irreducible Diagnostic Criterion by Jared Egol The patient, in present times, faces chronic, painful and dismissively mistreated and misappropriated syndromes of stalled emotional progress. Despite seeking to function at our service against pain and a variety of illness, medicine is traipsing feet-first into a biologic-centric approach to the treatment of our stories. Stories are completed, edited, examined, shared and propagated. And, most importantly, they are added to. They are not treated. Any treatment becomes a subscript to the through-line of how our life proceeds postscript. Health, like being human, is raconteurism. It wishes to be resolved and triumphant. While the scientific community begins to trumpet the mind-body connection as a wellspring for treatment possibility, it seems to passively disconfirm the blunt fullness of what mind-body awareness can be, greater than the sum of its words on paper: that the qualitative first step to treatment starts pre-diagnosis and pre-medicine, at the human condition, which in and of itself is idiopathic. If the mind-body paradigm is to someday be championed as a keystone of accepted treatment in the 32nd century, it must concede that the human condition’s only unit of perceivable measure by outside meters can be its stories, just as atmospheric pressure cannot be interpreted in kilojoules. By dimensional analysis, if spoken words are the sub-units of those stories, then the feelings evoked, hugs had, nods afforded and change experienced by the recipients of them are the units of their transfer: lessons. I believe that the doctors who rise above the ranks will be those identified as narratorial asides in the stories of the hero –the patient– who takes and imparts lessons in equal measure to the physician. Even the word-bare, thought and action-heavy field of intensive care, which my father occupied himself with for almost three decades, will one day evolve to contain the parameters of narrative in its protocol, even if I don’t know how it will look. Today, books on the subject of mind-body infrangibility in healing try to elucidate our likenesses as cauldrons of two differentially conjoined substrates: a self-contained, phenomenal interaction of tangible organic measurements with intangible outputs we’ve labeled incompletely as thoughts and feelings. As they ebb and flow in the images of our days, months and years, the horizon between the two becomes incomprehensibly blurred, and they are ultimately able to be dismissed as the same. An emotion, such as anger, is sometimes pigeonholed by New-Age health progressivists as a quantity extractable through some physical or psychic manipulation, no different than if it was two milliliters of fluid drained from a pilonidal cyst into a syringe. This floppy conclusion has more of what is intended by making boldface the narrative of the patient unto the doctor, but it still lords over the experience by reducing who we are to what we are, which cannot be done. Yet such acknowledgments are very positive steps towards the unification of a truly medical protocol that I whisper for so unsubtly. The faster that the diagnosis of dismissal– where medicine here has operated for too long by calling a cyst a cyst, and generally eschewing the patient’s hopes and dreams around and about the cyst in eight minutes or less–is hastened toward its place in medical archaeology, the more hope can be secured to a day when each patient can see a physician who abides by a readiness to confer the storytelling power to the patient, and understand how that concession coupled with his hard-fought knowledge of the body can transform a patient’s medical visit from symptoms into lessons for both. The phrase “medicine as an art” has become hackneyed, unfocused refuse in the bargain bin of good-sounding written idioms. But art interacts with souls, making it all performance art. Doctors, by injecting story into their practice of humans who seek to be sated by it, can indemnify the cliche by making it true. The supple difference lies with defining who the artist is. It is harder to see in simple cases, such as the man who comes to the office to have a cut stitched and disinfected. The overt lessons — be mindful of where your hands are, slow down when cutting vegetables, etc– make this example tepid at best. But it is the complex cases involving pernicious chronicity, such as fibromyalgia, where the true narrative elements emerge, and the story becomes not only the process, but sometimes the cure for the symptoms. All stories have their beginning, their middle and their end. Basely, the beginning wraps the elements of the narrative (the hero, the setting, the stakes) around the story recipient, hopefully giving context and orientation to what is happening. The middle is little more than the opposing elements that rankle the hero’s progress toward whatever end he or she has desired. The end, the third act, puts the hero into the driver’s seat of the story, making him an active participant. Naturally, but usually unconsciously, we seek to feel the change the hero is about to make, the lesson about to be or continue to be learned. By becoming active in the third act, when things are at their gravest, the hero truly is heroic, because he has adapted and solved the nature of his current problem by solving himself in a way amenable to victory. He has made a connection, learned, or recoiled against forces averse to his success. The patient who went to the doctor to have his lacerated finger assessed and treated has very little (if any) adversity to galvanizing his position as a hero of that story. Yet when medicine presents conditions like fibromyalgia, chronic fatigue syndrome and various others as constellation symptomatologies, diagnoses of exclusion, incurable or psychosomatic, it is only burgeoning forward with its old ways, with the single enlightenment coming from the acknowledgment that it has failed as a machine. As the psychosomatic, or mind-body diagnosis makes headway, the terrible truth is that it stands not only as baseless but destructive to most people suffering from a fibromyalgia diagnosis. But if contextualized as a story, the power to be healed from the pain and fatigue through the recognition that the worsening pain and worsening fatigue can be considered the third act, when things are irrefutably at their worst. For these patients, the third act has gone on for years and sometimes decades, exhausting them of tangible and intangible outputs alike. There is a label for this that does not work. Victim. These people are derisively positioned as victims. They are seen as defective, whiny, angry and annoying. Even worse, they’re called liars. But they contain in them the elements of change that every human has, the natural right and obligation to stories. If they have stories, then those stories have heroes. Upon being saturated by pharmaceutical and biologic subterfuge, which stands to divert possibility for self-healing and placing it in the hands of drugs marketed as heroes by the milligram, the ability of these suffering human beings to be heroes unto and for themselves is destroyed. And as the trend descends them farther down a funnel, they begin to see any humanistic, non-drug suggestions for success as vituperative, “all-in-their-head” nocebos designed to guard them against their potential. What got them to fibromyalgia was bad enough, and are the things that need acknowledgment and confirmation by the physicians of the future. Patients need to listen to their stories, and have explained convincing science by convincing hearts about the very condition of unbelief they’ve had beaten into them. Through the hardest of things to do, examining what in them needs to change and doing it, the third act of them at this time can be closed and celebrated vivaciously, for they then will become the heroes that their body has pleaded for them to become. I am an example of this, and continue to be. Cancer patients speak about how being diagnosed did great things for their lives. Cancer is an inverse of greatness, but it hastens the clock of self-evaluation by sparking the reality of imminence. Even when dead, by facing the forces of their disease and calling themselves to action by living through, living from it and inspiring others to be conscious of whatever lessons they discovered, cancer patients are labeled heroes with ease and gusto. Along the spectrum of disease are daunting voids of ignorance for what is both observable and treatable, and not everyone will get the chance to break free from theirs. But the compassion to have a story heard, discussed and reciprocated with positive power from a physician who knows why the journey through it has been eagerly made since he was a child, is a tool of inexhaustible medical power that, when coincided with the proven mind-body afflictions, can even revert the course of disease, as long as the patient is demonstrated a chance to revert back into the hero of their tale.