PART III: CASE STUDIES IN NARRATIVES ETHICS: CHAPTER 12: OF SYMBOLS AND SILENCE: USING NARRATIVE AND ITS INTERPRETATION TO FOSTER PHYSICIAN UNDERSTANDING.

This article discusses why narrative competence is integral to the doctor's knowing both patient and self. Ethical ways of being and doctoring depend on knowledge of human particularity that the physician is always acquiring through attentive observation and reflection. Knowledge so gained--about the patient, to be sure, but also about the doctor--is just as crucial to the physician's clinical excellence as his or her fund of medical knowledge, and, together with this medical knowledge, it becomes the basis for the physician's understanding, for action, and for care. The practice of ethics in the context of clinical medicine is fundamentally a matter of attention and interpretation. In a narrative model of medicine, the patient-physician relationship is cast as an ongoing, constructive conversation leading first and most immediately to diagnosis, prognosis, and treatment. The physician is the critical reader, highly skilled both in eliciting and interpreting the patient's story, which encompasses all that the patient says, how he or she says it, and the myriad nonverbal cues that accompany this telling. The physician's responsibility is to listen to the patient in a close, careful, and nuanced way in order to elucidate and then explain the patient's narrative, bring out and reflect its coherence and meaning, and finally translate what the patient has said and enacted into the formulaic tale--the case presentation--with which clinical medicine works. In a narrative model of medicine, the ongoing patient-physician relationship itself becomes a means of continuing the physician's education.