Can you explain Narrative Medicine and speak to your introduction to the field?
Narrative Medicine is looking at the intersection of medicine, science and art. It started around 1999, when Rita Charon, a doctor here at Columbia, had the vision for understanding the way that people experience illness as not just as a set of symptoms, as a set of facts about pathologies they experience, but in their own story. And this philosophy says that the patient’s story is a valid and important part of how we should understand illness and understand our patients. It’s really grown and taken off throughout the country and throughout the world. There are other programs along the same wavelength, outside of Narrative Medicine, that are united in looking at the more humanistic side of medicine. I personally was drawn into the field as a medical student. I was taking a required elective in it, which is funny because yesterday I just started teaching one of those for the new semester. Med students at Columbia have to take a course in Narrative Medicine and it’s an elective in some sort of artistic discipline, or something related to the arts. There’s a short story course, a photography course, poetry, one where you go to some of the great museums in New York and get guided tours of the artwork. So
I TOOK A LIFE DRAWING CLASS, WHICH WAS SOME OF THE BEST TIME I SPENT IN MEDICAL SCHOOL.
For me it was actually just a relief to sit down and draw, and it was interesting to do that in the context of coming from an anatomy lab, where you’re learning about the muscles in the body in a totally different way. How did your respective interests in drawing and medicine take shape? I was always drawing. It’s one of those things where I literally don’t remember when I wasn’t doodling or sketching. I always liked cartoons and comics, and when everyone else grew out of that stuff, I didn’t. And, I guess with medicine it was separate, but it was always present, too. My interest started from the fact that my father was and is a doctor, and I always looked up to him; I still look up to him. It just seemed like a fulfilling job and an interesting job. My father wasn’t and isn’t the type who is super happy or optimistic about medicine all the time, but that was actually part of what drew me to medicine. I would see how hard he would work and how rough it could be and yet he was still doing it every day and still eager to do it every day, and I knew there had to be something to that.
Did you feel a tension between medicine and drawing as your interests developed?
Yes, definitely. I had sort of these dueling career paths all growing up. I started college as a premed and I thought the classes were interesting, but I didn’t know if I was so into it that it was definitely what I wanted to be doing. So I stopped taking the premed classes and I got really engaged in the college newspaper, a humor newspaper, and I was making cartoons. I really liked that, but then as college was starting to end I realized I was still going to exist after college and that I should probably figure something out to do. And I had no clue how I would actually continue on the cartooning path. I thought, well, I know how to apply to medical school, and that seems like a reasonable job for me. So I ended up cramming the rest of the premed curriculum at the end of college and going that way. And the whole time in medical school, I found myself thinking this is really interesting and I understand the appeal of this but I don’t think I’m where I want to be. I do feel like I am neglecting this other part of me, and this other part is very important to me.
You know, if you’re not doing what you want to do, even if someone from a more objective standpoint can say that you’re doing good work, you’re not going to feel that. And I was feeling that about medicine. I could see that I was part of a team that’s helping people feel better, extending their lives, but I didn’t feel like I was doing anything. I just felt like I was a middleman between the patient and the medication. That wasn’t the case, but it is to say that I wasn’t in the right place.
How did you ultimately contend with that?
By the time I finally made the decision to leave medicine, I was feeling pretty unfulfilled and not particularly happy. I wasn’t really like, “Here’s my plan: I’m going to be here in a year, and here in two years.” It was more like, “I’m recognizing that I’m trading unhappiness for uncertainty,” and I was okay with that.
I started my residency, so I was doing my internship, where you’re func- tioning as a doctor but you’re still in training. I had my own panel of clinic patients, but I was in that in-between where you have the MD but you’re not really a doctor yet. But sort of close enough that I knew what I was giving up.
PART OF ME WAS SORT OF DECIDED EVEN BEFORE I FINISHED MEDICAL SCHOOL THAT I DIDN’T THINK I WAS GOING TO STAY ON THAT PATH
but I also thought it would be silly to quit being a doctor before I ever got to try being a doctor. So I got my license, which is the practical side of me too. I had no illusions that I would instantly make it as a cartoonist. I knew that there was a very real possibility that I would try it and then say, “Hey, you know what? I think I’ll finish that residency up.”
One of the very first things I did was take a night class at SVA to get back in the habit of drawing, because I hadn’t had much of an opportunity to do that for the previous several years, and I had lost touch with my own artistic style, which is kind of weird but it was an interesting creative exercise to build that up again. And then it’s not that interesting of a story; I worked freelance, I drew greeting cards for a little bit. I don’t even remember the timing, but at some point I did get back in touch with the medical world, with someone I knew here at Columbia in the Department of Ophthalmology, trying to make a textbook about the eye for medical students, which was a fun project. And then I found The New Yorker and that’s when I really started to find my groove.
How did your involvement with The New Yorker start?
That started in 2011. I learned that they had an open submission policy, and in fact, if you’re in New York, you can go up to the editor’s office on Tuesdays and present him your cartoons in person. The reason for the open-door policy is that the editor, Bob Mankoff, realized that he had a lot of great cartoonists, but those cartoonists were getting older instead of younger and if he didn’t add to the group of cartoonists, the art form would start disappearing. So he started this open-office-hour thing, and I started going, not as a lark, but with no expectation that it would ever lead to anything. You know, just to get feedback from the editor of The New Yorker, which sounded amazing. This was not long after leaving medicine, and really trying in earnest to start my career as an artist. So I would just put together my cartoons every week and I would present them to him. The first time, I sat down, and he said, “Well, you can draw.” Which he meant not particularly as a compliment, but it was the most positive reinforcement I’d received. It was the first time I’d gotten any validating external feedback from someone in the trenches as a cartoonist. You know, it’s nice when my mom says she likes my drawings, but to hear him say you can draw was a tremendous confidence booster. And then he said, “Come back next week,” which was also a huge confidence booster. I didn’t sell anything that week, and I didn’t sell anything the next week, or the week after that, or for the next six months. But eventually I broke through and here we are.
How do you feel your medical background has informed your cartooning?
In terms of what I get from the medical side that I bring to the artwork, well, I think they consider a lot of the same things, and I think that’s why they overlap. As a doctor you are thinking, how am I breaking down this complicated case, all of this information I have and making sense of it. I have to take the story from the patient, which means something different to them than it does to me, and make it meaningful as someone trying to treat this particular illness that they’re dealing with. I think that kind of information management has been very helpful to what I do, particularly with the gag cartoon, the short-form cartooning. Because the challenge with that is I have one box and one line of dialogue to sort of tell a story. And you have to do that very efficiently and very clearly. Any little bit of confusion, anything that’s going to take that joke an extra half-second to process, is totally going to derail it. So I think that efficient storytelling is something I’ve been able to take with me to the artistic side.
I think of a joke as a very simple story, but it makes more sense being told in two panels—you know, a setup and a punchline. With The New Yorker-style cartoon you have to balance it between the words and pictures. So sometimes your picture functions as your straight man and the punchline is all in the words, sometimes it’s the opposite, sometimes they carry their weight a little more equally.
So much of what we’re talking about is dynamics, and how you manage that.
It’s the type of thing where the doctor part of me says, you know, we should do more rigorous research on this before we talk too much about it, but the artist side of me says yes, there’s definitely something there.
THERE IS A BACK-AND-FORTH TO BOTH PRACTICING MEDICINE AND CARTOONING.
I don’t know what the scientific evidence behind this is, but I don’t feel personally like it’s a stretch to say that I use some of the same mental muscles when it comes to the rapid shifting of perspectives that’s required of both sides. What I mean by that is with both medicine and with cartooning, you’re constantly juggling these two information streams. With cartooning it’s what information is in the artwork and what information is in the words. How do they play off each other, how do they complement each other? And with medicine it’s a similar thing. You’re always trying to think, “What is my patient thinking? What are their concerns? What is their understanding of the situation?” And then, “What are my concerns? What is my understanding of the situation as the doctor?” You know when you’re a kid and you do the sort of Camera 1 and Camera 2 thing? [Dr. Schwartz covers his right eye, then uncovers it and covers his left eye. Back and forth.] Camera 1. Camera 2. In both worlds you’re constantly doing that. Looking back and forth from different perspectives.
So how does this study of perspective and the arts inform practicing doctors?
I think it helps in several ways. Above all, making artwork, writing, all of these artistic pursuits give doctors and med students an opportunity to stop, think, and process. They get to reflect. Which is something I think should be a part of all of our lives, but doctors are very busy people and, as sad as it may sound, they just simply don’t have the time. I mean, what a blur. We talk about all the years of training a doctor has to spend going through, but it goes by really fast because you’re so busy. And sometimes you don’t have a chance to process, to think how different you are from where you started. And that includes something I prompt my students to think about: think just how differently you’re speaking in terms of language. In a very concrete, literal way, through the time spent in med school, your vocabulary is different and you have become immersed in a very unique medical culture.
You know, I’m an idiot, I don’t speak any other languages, but I have friends who grew up in bilingual families and you see that moment when they’re talking and they slip into their other language and don’t even realize it. That’s what doctors do all the time when talking to their patients. They use words that are commonplace to them but it doesn’t even occur to them that “Oh, heart attack means something in this context, but myocardial infarction doesn’t.” So I think being mindful of that is a huge thing.
Which speaks to another thing about Narrative Medicine, which is understanding perspective, understanding if you’re telling a story, you have to understand who you’re telling it to and you have to put yourself in their shoes. One of the things we do in my class, because it’s visual, is make that connection in a very direct way. We draw a picture from one position in the class versus another, and the students are always going to see different elements of the object they’re drawing, and depending on what the object is, they might be minor differences, or, it might be major. For example, it’s a kind of gimmicky thing I do in my classes, but I’ll have a statue in the middle of the class, and it’s a statue of a very serious-looking doctor, but on the back I’ve taped a little “kick me” sign. And if you aren’t positioned to see the back you wouldn’t see the sign; it wouldn’t affect the way you view this character.
And that gets at this other huge thing, related to empathy. Even if you’re speaking the same language as your patient, you need to be finding the common ground. You need to be imagining the questions the patient needs answers to, because they are not going to be the same ones at the forefront of a doctor’s mind.
How did you find your way into the teaching world, and what has that experience been like for you?
It feels like ancient history, but I think it was right around 2011 also. I had reconnected with Rita Charon, and she wanted to bolster the visual arts representation in Columbia’s Narrative Medicine curriculum and thought that I would be a good fit for it. And I don’t think she was explicit about this, but I think she felt it would be good for the students to have contact with someone who hadn’t gone down the traditional medical path. Especially at large academic medical centers, as a student, you can think that’s there’s only one way to be a doctor.
And I love teaching. I love meeting the new class of med students every year. This is so cliché, but I love what they teach me. It’s really rewarding, and it speaks to the artistic ego, but I feel like when I’m teaching the class, whatever the value of the class is, it’s mine. I’m giving them my particular perspective, which lets me feel ownership and pride in what I’m doing. I also know and tell them
IT’S PROBABLY THE WEIRDEST CLASS THEY’LL TAKE IN MEDICAL SCHOOL.
It seems like the traditional medical school model can have the side effect of distancing doctors from the more altruistic reasons that drove them to pursue medicine in the first place. Does Narrative Medicine have a role to play in changing this experience for doctors?
I think there’s a lot of truth to that. I don’t think med school drills that out of you, you know, it’s not some sort of military-style “We’re drilling this out of you because it makes you weak” or something. Med school is just so focused on the other element of being a doctor—the science, the diagnosis. That’s obviously a really important element, so of course you’re going to be focused on it. But when you’re spending day in and day out looking at an individual as not a person, but as answers to questions like “Are the pupils dilated or constricted? How’s the breathing? What’s the heart rate?” When you turn a person into bits of information and then reconstruct them, not to look like a person, but as a case of pneumonia or whatever, that’s dehumanizing. Thinking that way helps you as a clinician, in the sense that it helps you determine the treatment for that person, but you probably lose sight of the person themselves in the process.
It’s not like doctors are unfeeling jerks or anything; I think doctors have viewed these concepts as deeply important for a long, long time. These nuanced aspects of being a doctor are the type of thing that gets referred to as the art of medicine, but I think it was treated as something you had to pick up along the way, instead of being treated as something we can actually focus on, and give direct attention to, and even teach. And I think that’s the real change of philosophy that Narrative Medicine and programs like that have brought about.
Before Narrative Medicine and other similar areas of study came about, how did this idea of bedside manner and how a doctor might foster it get taught?
I think it was more of a hidden curriculum. I shouldn’t speak too knowledgeably about the history of medical education, but I think certainly it wasn’t as holistically baked into the curriculum as it is in the Narrative Medicine curriculum. There’s a difference between one hourlong lecture where we talk about what it means to be in the role of doctors. It’s good to have something like that but that’s not the same as saying “Okay, we’re going to take that element of being a doctor and put it on equal footing with the study of anatomy, and physiology, and pathophysiology, so we’re going to have that woven into the curriculum throughout med school, because it’s going be important to any career after med school.”
I think previously it was more a kind of imparted wisdom. Less classroom-based learning, and more apprentice-based learning. Hopefully, you got a great role model who showed you that you have to be thoughtful toward what the patient is thinking, but if you didn’t, well… you were expected to figure it out on your own.
Sometimes it can feel silly teaching these Narrative Medicine courses because it can reduce down to almost kindergarten lessons: Be thoughtful. Be considerate. Think about others. But sometimes it’s worth saying these things, instead of just assuming we all know this. You know, this is really important. So, let’s talk about it, let’s give it time.
What kind of experience might a patient who is being treated by a doctor trained in Narrative Medicine have?
I would hope that there’s just more listening on the doctor’s part. Just generally more empathy, more willingness not to simply drive you in the direction of what they need out of you. I’m sure you’ve had this experience if you’ve been in a doctor’s office and the doctor is clearly under time pressure, and they’re asking you fairly rapid-fire questions and cutting you off to get to the next question once they’ve taken what they need from the answer. Again, not because they’re bad people—they’re just trying to do a particular thing, under particular time constraints. A doctor who has been trained in the narrative method also has those time constraints but hopefully they’ll give more space to the patient who is telling their story in a way that matters to them.
It’s the scientific method to focus on outcome, but the path you take to get there matters, too. In fact, it might matter more to people going through illness and tough times. You can have a treatment and it might extend your life, but if you’re miserable during that time, that might not be the optimal outcome. And Narrative Medicine considers that.
What do you think the future of Narrative Medicine looks like?
I think it will become more widespread. If not Narrative Medicine, things on a similar wavelength. It’s becoming more and more of a cultural value to us: that creativity matters, that art matters. I think it also lines up with where medicine is moving in terms of patient empowerment.
I THINK MORE AND MORE PATIENTS ARE GOING TO BE LOOKING TOWARD THEIR DOCTOR AS MORE OF A PARTNER THAN AN AUTHORITY FIGURE.
I think that’s a good thing, because that means patients will likely also be more engaged with their own health care. But to have a partnership you also have to have a real understanding between one another. And I think that’s where the narrative component comes in; you can help both sides find the common ground.
Are there medical communities outside the U.S. that you think might have a better conception of the practice of medicine?
I have no doubt that there are interesting and enlightening things coming from other communities. In fact, I know there are but I can’t really speak to them. I’m sure that getting more of that perspective in Western medicine, even if it’s not agreeing with it, but just addressing it, would be helpful. Alternative medicine is something in medical school that you get one lecture on, but that’s a shame because whether you’re into it or not, you’re going to have patients whom it matters to.
Do you consider your own cartooning a form of personal therapy?
[Laughs.] Yeah, I guess that’s fair. It makes me happy! [Shrugs.]