How would you like to lower your blood pressure by listening to a story? As improbable as it may sound, that is exactly what happened in a study reported in the January 18, 2011 issue of Annals of Internal Medicine (Houston TK, et al. Culturally appropriate storytelling to improve blood pressure. A randomized trial. Ann Intern Med. 2011; 154:77-84).

I have previously written of a category of medical instruction known as narrative medicine. Integral to the field of narrative medicine is the idea that while a disease can be understood through the process of empiric research and publication (left brain activity), illness—defined as the fully expressed human response to disease, as manifested by its emotional, spiritual, financial, and physical aspects—is best understood in story form, i.e. the narrative (a right brain activity).

Stories have a multi-layered, intuitive meaning that purely rational expression does not. Literary fiction, for instance, has the capacity to present characters so completely rendered we begin to understand ourselves—and others—more profoundly simply by identifying with such characters. Fully drawn fictional characters have much in common with patients. Identifying deeply with a fictional character—shivering when a character is cold, feeling sorrow when a character is sad, or becoming angry when a character is wronged—stimulates the same neuronal connections that allow physicians to feel empathy for patients#mce_temp_url#. Experiencing the world from a fictional character’s point of view is not so very different than experiencing the world from a patient’s point of view—a critical skill for doctors to have.

But what about our patients? Might they benefit from the unique virtues of storytelling too?

The authors of the Annals article sought the answer to this question by performing a randomized, controlled study to determine if viewing culturally appropriate videos had a beneficial effect on blood pressure control. 147 patients watched a series of 3 hypertension DVDs given at baseline, three months, and six months; a control group of 152 patients witnessed DVDs unrelated to hypertension control. The hypertension DVDs involved personal stories of blood pressure control as related by patients drawn from the same African American population in Birmingham, Alabama as the control patients.

Results of the trial showed that patients with uncontrolled blood pressure who viewed hypertension-treatment stories of cultural peers experienced an 11-point greater fall in systolic blood pressure than did similar patients in the control group. The authors speculate that such video storytelling changes behavior—in this case compliance with diet and medication—by breaking down cognitive resistance, perhaps by identifying with and mimicking the behavior of a particular story character.

This study is unique in that it applied left brain scientific method in an effort to document benefits of a right brain, intuitive form of treatment. The authors’ conclusion?

Storytelling not only changes lives, it can help save them, too.

It has been reported that up to 60% of doctors suffer from symptoms of psychological job-exhaustion, or physician burnout, leading to diminished career satisfaction, substance abuse, divorce, quitting the profession, and suicide.

An article in this week’s Journal of the American Medical Association attributes much of this psychosocial carnage to the loss of an “empathic connection” between doctors and their patients (Riess, Helen. Empathy in Medicine—A Neurobiological Perspective. JAMA. 2010; 304(14): 1604-1605).

The author summarizes a number of studies positing that empathy resides in specific areas and structures of the brain, such as the anterior cingulate cortex and amygdala. In one report, 17 experimental subjects viewed images of patients experiencing intense pain; simultaneous magnetic resonance imaging (MRI) of the study subjects’ brains revealed heightened neuronal activity in the purported empathy centers.

It also appears that the amount of empathy one is capable of mustering from these locations—which can be measured by psychotherapy tools like the Empathic Understanding Scale—is not static, and can be modulated up or down by external circumstances. The article describes the phenomenon of “empathy erosion” documented in third-year medical students—caused, perhaps, by a reflexive, self-protecting down-regulation of empathic neural circuits in order to keep the students from being overwhelmed by their exposure to so much pain and suffering.

But too much of this self-protective down-regulation by physicians can give rise to a permanent empathy deficit. They become hardened to human misery, and rupture the vital empathic connection between doctor and patient that is the cornerstone of all medical care. Patients who bond emotionally with their physicians have better outcomes, and physicians who are emotionally engaged with their patients are happier and more satisfied with their jobs—and less likely to suffer from the destructive malady of physician burnout. Dr. Riess, a Harvard psychiatrist, advocates education and the use of certain acquired behavioral skills to help prevent the erosion of physician empathy.

So what does the crippling syndrome of physician burnout have to do with Quasimodo? Regular readers of this blog know the answer lies at the nexus of literature and medical science, in the realm of the discipline known as narrative medicine.

Victor Hugo’s hunch-backed bell-ringer of Notre-Dame Cathedral is one of the most sympathetic characters in all of Western literature. Only someone possessing the heart of one of the gargoyles crouched atop the roof of the Cathedral could remain unmoved by this deformed, grotesque foundling who, at the same time, is the very soul of innocence and purity. We pity him for his deafness—caused by the loudness of the bells that are his greatest love—even as we share the bewitching Esmeralda’s disgust at his desire for her.

The act of identifying deeply with a complex literary character such as Quasimodo cannot help but result in the beneficial stimulation of the brain’s empathy centers that Dr. Riess advocates. Her failure to mention the reading of literary fiction as a time-tested means of increasing empathy is my one criticism of her article.

It is an effortless, natural way of healing hearts and souls one book at a time.

One of my colleagues recently told me he doesn’t read fiction because he doesn’t see the point in wasting time on something that isn’t real and doesn’t matter. He learns more from non-fiction, he said.

Oh my.

The awarding of the 2010 Nobel Prize in literature yesterday to Mario Vargas Llosa of Peru for ten million Swedish Kronors—or, in our increasingly worthless American currency, 1.5 million dollars—is a powerful reminder that fiction, for society in general and for our little niche of narrative medicine in particular, does indeed matter.

To those who believe the reading of fiction to be of no practical value, like viewing an action movie or a cops-and-robbers TV show, we need look no further than Mr. Vargas Llosa’s oeuvre for rebuttal. In his youth a prototypical Latin American leftist, Vargas Llosa later became a powerful advocate of free-market capitalism and liberal democracy. His fiction concerns itself with the dehumanizing effects of autocracy and the virtues of individual empowerment. Born in 1936, he came of age in the 1950s, a period during which Peru suffered greatly from a corrupt dictatorship. His personal experience with tyranny and his enormous compassion for victims of statist oppression led him to become a controversial and vocal supporter of the American-led liberation of Iraq and the effort to depose Saddam Hussein. He was awarded the Nobel, in the words of the Swedish Academy, “for his cartography of the structures of power and his trenchant images of the individual’s resistance, revolt and defeat.”

So what does the literary success of an apostate Marxist have to do with a blog on literature and medicine?

Well, everything. Because, in the words of Vargas Llosa himself, as reported today by Emily Parker in the Opinion section of The Wall Street Journal, “Through writing, one can change history…Nothing better protects a human being against the stupidity of prejudice, racism, religious or political sectarianism, and exclusivist nationalism than this truth that invariably appears in great literature: that men and women of all nations and places are essentially equal.”

And so it is with literary fiction and medicine. Through stories, one can change lives. The meaning of illness is revealed and the suffering of others deeply and personally experienced. Reading, reflecting on, and discussing great fiction increases the empathy of caregivers (Anyone out there whose doctor seems cold and unemotional?) and helps patients understand the universal question: Why? Why me? What does my illness mean?

The answer is different for each that asks, but the journey (of understanding illness) is not—just as citizens in a free society share in common their quest for liberty, though their expression of it is individually unique.

For those who take the time to enjoy it, literary fiction, whether dealing with matters of tyranny and liberty, as do the novels of Nobel Prize winner Mario Varga Llosa, or in dealing with human illness, as does this blog and the field of narrative medicine, is transformative.

Sorry, my doctor’s lounge companion, but fiction matters.

Welcome to The Literary Doctor’s inaugural “prescription,” a moving short story by T. C. Boyle called Sin Dolor –Without Pain.

I can think of no finer writer to begin a narrative medicine blog with than T. C. Boyle, a luminary of American literature. He is a graduate of the University of Iowa Writers’ Workshop and a Distinguished Professor of English at USC. In 2009 he was inducted into The American Academy of Arts and Letters, considered the highest formal recognition of artistic merit in the United States. He is the author of twenty-one—and counting—works of fiction. Sin Dolor comes from a collection of short stories entitled Wild Child and Other Stories, published in 2009. If you are unfamiliar with this author, do yourself a favor and read one of his thirteen novels.

What would it be like to never experience pain? Sin Dolor is T.C. Boyle’s discomfiting exploration of this very question.

Mercedes Fumes brings her four-year-old son Dámaso to the town doctor—who is the first person narrator of the story—for burns on his hands. But these aren’t just any burns; these are black, oozing eschars on his palms that came, his mother insists, from snatching hot coals off the brazier she uses to cook the indigestible tacos she and her husband Francisco hawk on the street. The doctor doubts her story and wonders about child abuse.

No one, not even the fakirs of India (and they are fakers), could hold onto a burning coal long enough to suffer third-degree burns.

She answers his skepticism with the unlikeliest of explanations. “He’s not normal, Doctor. He doesn’t feel pain the way others do.”

She urges him to prick her son with a needle. The doctor doesn’t hesitate. He swabs Dámaso’s arm and takes a syringe from the cabinet.

The boy never flinched. Never gave any indication that anything was happening at all…

“We call him Sin Dolor, Doctor…The Painless One.”

The next time the doctor sees the boy, now eight, he is with his father, Francisco. Dámaso comes in limping, favoring his right leg, which the doctor discovers is broken, a fractured tibia. That he walked in on. Without the slightest whimper. The doctor again suspects child abuse, but Francisco Fumes tells him Dámaso did it by jumping off the roof of a shed. The doctor realizes he has stumbled onto an unprecedented medical marvel.

I felt the boy’s gaze on me. He was absolutely calm, his eyes like the motionless pools of the rill that brought water down out of the mountains…For the first time it occurred to me that something extraordinary was going on here, a kind of medical miracle…

He is seized by ambition, an intense desire to claim credit for discovering what must be…a mutation in his genes, a positive mutation, superior, progressive…He befriends Dámaso in hopes of spectacular medical fame.

If that mutation could be isolated—if the genetic sequence could be discovered—then the boon for our poor suffering species would be immeasurable. Imagine a pain-free old age. Painless childbirth, surgery, dentistry…What an insuperable coup over the afflictions that twist and maim us and haunt us to the grave!

He encourages Dámaso to spend time at his clinic and to come to his home for dinner. At the same time, he contacts a geneticist he knows from medical school in Guadalajara, who implores him to send scrapings from the inside of Dámaso’s mouth for analysis. But Francisco Fumes becomes jealous of the attention lavished on his son—and of Dámaso’s response to the attention. He forbids all contact between Dámaso and the doctor, destroying the doctor’s ambitions and his son’s only chance to escape his circumstances…the stew of misinformation and illiteracy into which he’d been born…

Five or six years pass before the doctor sees Dámaso again…Though I heard the rumors—we all did—that his father was forcing him to travel from town to town like a freak in a sideshow, shamelessly exploiting his gift for the benefit of every gaping rube with a peso in his pocket.

Finally they meet again, Dámaso now thirteen or so, no longer in school and supporting his family by performing cheap carnival tricks that weren’t tricks, burning and slicing and maiming himself for the crowd without a hint of pain. After witnessing one such performance, the doctor observes that Dámaso has changed.

He seemed to walk more deliberately than he had in the past, as if the years had weighed on him in some unfathomable way…

Later, he learns the price Dámaso has paid for being a medical freak.

“I have no friends, Doctor, not a single one. Even my brothers and sisters look at me like I’m a stranger. And the boys all over the district, in the smallest towns, they try to imitate me.”

He tells the doctor that he does what his family asks of him—exploiting his painlessness, profiting from his miracle in the most vulgar of ways—out of a sense of duty to them.

“But what they’ll never understand, what you don’t understand, is that I do hurt, I do feel it, I do.” And then he taps himself over his heart. “Here,” he says. “Here’s where I hurt.”

He dies a week later, after leaping off a three-story building to satisfy the little sycophants who idolize him. “Jump!” they shout. “Sin Dolor! Sin Dolor!” He dies without a twinge of pain.

The story concludes with the doctor treating a small girl who has stepped on a sea urchin.

As delicately as I could, I held her miniature heel in my hand, took hold of the slick black fragment with the grip of my forceps and pulled it cleanly from the flesh, and I have to tell you, that little girl shrieked till the very glass in the windows rattled, shrieked as if there were no other pain in the world.

The last twenty years have seen the rise of an entirely new medical field: the specialty of Pain Medicine, or Algiatry, a discipline devoted to the prevention of pain. At first blush a noble endeavor, relief from the myriad cancers, fractures, nerve impingements, torsions, and infarctions we human beings suffer long overdue. But having practiced medicine during this time, I have witnessed firsthand a troubling and proportional surge in prescription drug addiction, patient after patient hooked on Vicodin, Norco, Percocet, Xanax, Oxycontin and countless other “mother’s little helpers,” as the eponymous song by the Rolling Stones goes. Perhaps, as T.C. Boyle so poignantly suggests, a certain amount of pain—I know, not childbirth and Oh God, please not kidney stones—is necessary to the human condition. Perhaps the complete elimination of pain is not without consequences.

Tell us what you think about the quest to eliminate pain, both from the perspective of a doctor seeking to relieve it, and from the perspective of a patient—of a human being—who suffers from it.