Fictional realities

Mark Cole BA (Hons) PGCEHead of Learning and Development, Education Centre, Queen Elizabeth Hospital,London, UK

In 12th Century Japan, a notorious bandit ambushes a samurai and his wife,killing the man and raping the woman. He is arrested for the crimes and put ontrial, where four separate and differing accounts of the events are offered: that ofthe bandit, the recollection of the wife, the supernatural testimony from beyondthe grave of the samurai, and the statement of a woodcutter who claims to havewitnessed the ghastly events.

The plot of Akira Kurosawa’s film Rashomon (1950) can be seen to be areflection on the question of truth. The work is a portmanteau that offersrepresentations of each of the witness statements. It is clear very early on thatnone of them are going to tally. In consequence, the viewer gains little or noinsight into the event itself; instead, we gain understanding of the characterbehind each recollection. In the structure of the film, what actually happenedcedes the foreground to a more complex exploration of perception, understand-ing and social interconnectedness.

Any particular event in our professional and personal lives is susceptible tomyriad interpretations – by others and indeed by ourselves. But Kurosawa’s filmattests to the validity of each of the four remembrances of the same event, despitetheir diverging nature. Each narrative of the same experience – the bandit’s attackon the couple – is taken not as an interpretation but as an expression of a truth,the very specific truth of each of the narrators. In a prescient anticipation of post-modern theories, the filmmaker guides us to a conclusion that our recollection ofa particular real event is, in truth, a fiction.

This observation does not in any way shake the foundations of reality, nor doesit render us all unreliable witnesses to our own lives, although it does raise com-plex technical issues around the question of how knowledge derived from narra-tive is to be understood (an interesting discussion of this – and the way in whichnarrative does not distinguish between fictive and non-fictive stories – is to befound in reference 1).1 It merely underscores the fact that our perceptions arecoloured and shaped by our experience and our understanding at any given time.In fact, Kurosawa’s example – a work of fiction that explores the constant fiction-alisation of reality – is a salutary reminder to the thoughtful person to ensure a

Work Based Learning in Primary Care 2007;5:xx–xx © 2007 Radcliffe Publishing

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high degree of reflexivity. By this I mean a sense of self in the act of recollectingthat recognises the way in which we influence and comprehend events – and theway in which they influence us.

Hence, as reflective practitioners, it is important to recognise the way in whichwe structure and understand the events on which we reflect. We need to bemindful of the fictionalisation that we engage in when reviewing and analysing aparticular event in our professional practice – both in our minds and on the page.In accessing memory of an event, we inevitably express it as a story – and thatnarrative structuring is as susceptible to reflection and understanding as our roleand actions in the event itself.

If the recollections on which we reflect are fictions, then there would appear tobe virtue in using authentic fiction as a means by which to undertake widerreflection. After all, the fictions in which we trade as a society – particularly thosethat maintain their currency over time – are those that deal with universallyrecognisable themes or capture the spirit of a particular time or event.

This has the potential to work at a number of levels. For example, medicineand its practice appear in a wide range of literary accounts, providing invaluablehistorical, social and clinical insight. A superb anthology on this theme, featuringan extensive selection of aphorisms, fictional writing, poetry and journal entries,appeared just a few years ago – and, in consequence, provides an excellent startingpoint for this type of analysis.2 Furthermore, at least one small-scale study, whichlooked at medical students undertaking a medicine and literature module as partof their undergraduate curriculum, saw very positive results in terms of insightinto illness and experience of treatment.3

There are also many fictional pieces that, while not being about medicine as aprofessional activity, have a strong ‘medical’ theme. To take just one example,Richard Matheson’s 1954 science fiction novel, in which a global outbreak ofvampirism is explained on the basis of bacterial infection, is a text that provokesthe reader to consider the relationship between disease, myth and the role ofmodern medicine.4 Less explicitly, of course, Franz Kafka’s curious novella, tellingthe story of a man who awakes to find himself transformed into a giant insect,can usefully be read as an allegory for disease and the reaction to it of bothpatients and their significant others.5 However, there are countless texts that makeno direct or indirect reference to medicine or disease but which enrich thereader’s understanding of life.

Interestingly, it is not simply the literary artefacts that help us to developunderstanding in this fashion. The practice of studying stories provides a meansof analysing all manner of narratives, from our own reflective accounts to the(hi)stories that patients and clients provide. In an interesting coincidence,narratologists – those who study narratives in a very formalised fashion – makethe distinction between an ‘act’ and a ‘happening’; the former entails someone inthe narrative actually doing something (‘she administered the drug’), while thelatter is something in the story that merely occurs (‘the waiting room was busy’).The person doing something in a narrative is called an agent, while someone not

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engaging in an act – interestingly enough – is called a patient. It is explained that,‘Whereas patients are affected by certain processes, agents initiate these processesand, more specifically, influence the patients, modify their situation (improvingor worsening it), or maintain it (for the good or the bad)’.6

This parallel between terms used in narratological analysis and in medicine canbe seen to show how a great deal of human practice is shaped and structured bytraditions of story telling. It reinforces the view that it is not simply fictions thatprovide us with the potential for personal insight in general – and professionalunderstanding in particular. The ways in which those fictions might be analysedalso help us to critically engage with stories – personal, organisational or clinical– in a meaningful way. It serves to remind the reader that it is not merely the textthat is significant: there is the issue of its provenance, its context and the structurewithin its content, all of which need to be taken into account when trying to makesense of a text – and how that text might speak very directly in terms of our ownlives.

With all the above in mind, I was asked to review three titles that form part ofa larger series, entitled Case Studies in Contemporary Criticism. Each volumeprovides a text to read – in this instance, Wuthering Heights,7 A Portrait of theArtist as a Young Man,8 and Tess of the D’Urbervilles9 – alongside a range of criticalexplorations. As such, the books under consideration here are comprehensive andfully rounded literary packages, providing an excellent opportunity to engagewith a text and to access quality commentary from expert academics.

A cursory reading of these three texts – or a passing acquaintance with theirrespective premises – encourages us to acknowledge that, at the broadest level,there are a number of shared and important themes here. Matters of class, ofgender and of human potential are to the forefront. Each story provides a veryspecific historical prism through which to view these important social trends. Thecharacters of both Tess Durbeyfield and Catherine Earnshaw are located in timesof great change, and their respective stories, to an extent, hinge around matters ofwider shifts in standing and status.

The texts, then, provide us with an understanding of wider social events oftheir times. They also allow for the reader to explore the motivations and actionsof the range of characters. How do we feel about the young Stephen Dedalus in APortrait of the Artist as a Young Man, as he wrestles with a strong desire for self-actualisation that sits uncomfortably with the strictures of family, nation andreligion? What view do we take of Heathcliff lending money to the tragic figureof Hindley in Wuthering Heights? How should we see Angel Clare’s abandonmentof Tess after their wedding in Tess of the D’Urbervilles? To consider each of thesequestions is, of course, an act of reflection, hopefully giving us thoughtful insightinto past and potential behaviour of others and ourselves.

The beauty of novels such as these – and the reason that they are able totranscend time and seem alive to us today – is that they deal with dilemmas andthemes that recur in the human condition. As such, they enrich our under-standing of what it is to be a person in the here and now, despite the fact that they

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refer to fictionalised events from another time and place. A reading of Shakespeare’sHamlet, for example, although set centuries ago and in Denmark, yields theageless themes of religion, madness, love, revenge, corruption and disease.10 Suchmatters have as much currency in the contemporary age as they did at the time.

So, there is much to be gained from reflectively reading fictional works such asthese. They give us a sense of past times and allow us to use characters as mediathrough which to think through circumstances and situations in a way thatencourages our own personal growth and development. However, as I intimatedearlier in this piece, the titles being reviewed here include a range of critical essaysthat will help the reflexive reader to apply narrative analysis to a wide range oftexts – including the range of stories that exist within our own working milieus.

For example, in the volume relating to Tess of the D’Urbervilles, there is an essayby JP Riquelme, at that time on the English faculty of Boston University, thatprovides a superb introduction to the theory and practice of literary deconstruc-tion, the technique that is closely associated with the notoriously impenetrableFrench writer Jacques Derrida.11 This lucid and useful chapter is in two parts:there is a preamble (written by the series editor, Ross C Murfin) that provides anoverall editorial introduction to deconstruction and to the analysis that follows,while the main essay sees Riquelme apply those techniques to Hardy’s novel.

Being able to see deconstruction in contextual use like this clarifies what theapproach means and how it actually works. It brings alive a technique that seesthe reading of any text as something characterised by uncertainty and ‘… as anact performed with the full knowledge of the fact that all texts are ultimatelyunreadable (if reading means reducing the text to a single homogeneous mean-ing)’.12 In bald terms like this, I notice that the casual reader of this review mightreasonably be left scratching their head ponderously; in conjunction with Riquelme’sanalysis, however, it seems less – how shall I put it? – continental.

For Wuthering Heights, the issue of psychoanalytic criticism – among otherapproaches – is explored.13 Using the same format, an introductory segmentprecedes a detailed item of textual analysis of the novel in question, opting toexplore the story from the perspective of the concept of the absent mother.Meanwhile, the title looking at A Portrait of the Artist as a Young Man has bothdeconstructive and psychoanalytic interrogations of Joyce’s story.

These are nice titles – attractively produced, cleanly printed and wiselycompiled – that provide a copy of well-known literary texts alongside detailedcritical essays. The latter provide a useful introduction to approaches in literarytheory while, at the same time, illuminating the fictional writing that they accom-pany. The series from which they are drawn is aimed at US college students,although the volumes serve as useful introductions for a wider reading public.And they serve as an excellent reminder of the fact that narrative – whether it isa genuinely fictional tale, an account of our own practice or an organisational storyfrom our wider workplace – is susceptible to the sort of analyses being applied here.

In health care, it is vital for all involved to recognise the centrality of storytelling to practice. Whether we look at stories drawn from the wider culture – in

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terms of literature, cinema or the arts in general – or at the narratives that giveshape to the work that we do, such as patient histories, medical notes, journalarticles, and reflective writings, it needs to be acknowledged that engagingcritically with such artefacts has an enormous potential to inform the way inwhich we work as practitioners – if, of course, we allow it so to do.

This edition of the journal carries four excellent clinical case studies, rich indetail, reflection and observations in respect of learning. Each of them serves toremind us of the remark of the French writer and semiotician Roland Barthes,who describes narrative thus:

‘Able to be carried through articulated language, spoken or written, fixed or movingimages, gestures, and the ordered mixture of all of those substances; narrative ispresent in myth, legend, fable, tale, novella, epic, history, tragedy, drama, comedy,mime, painting … , stained glass windows, cinema, comics, news items, conversations… Caring nothing for the division between good and bad literature, narrative isinternational, transhistorical, trancultural: it is simply there, like life itself ’.14

The case studies herein are clear examples of narrative. From my perspective, Ifeel that they underscore the fact that story telling is the main means by which wemake sense of, and engage with, the world. As Barthes intimates, the medium bywhich these stories are conveyed is largely unimportant: a scientific report, a casestudy, a reflective account, a work-related anecdote told to a colleague on passingthem in the corridor, all these are vessels by which a story can be conveyed. But itis the story – the setting, the characters, and, most importantly in terms of storytelling, the plot – that is vital to the wider understanding of both the narrator andthe listener or reader.

In consequence, these cases studies can – and should – be read as narrativesand analysed as such. When it is observed that a single mother, after a con-sultation with a paediatrician, ‘… felt helpless and neurotic and she wished shehad the funds for a private consultation’,15 the story gives the reader insight intothe negative impact that healthcare practice can have psychosocially on those whoare subject to it. Moreover, the character of the single mother becomes morethree-dimensional as we consider her feelings and wishes so pithily expressed.Lastly, we catch a glimmer of the social standing of the single parent, desperatelyconcerned about the well-being of her child but lacking resources to pursue herconcerns in the way she would wish.

The case study by Sara McMullen contains high drama at one point, when thewriter says, ‘Having administered the benzyl penicillin, his [the young patient’s]father has suddenly remembered that he was unable to have a certain medicinebut did not know which one’.16 I suspect that this is a narrative that Sara wouldlike to rewrite; storytelling and reflection allow the reflexive practitioner to dojust that, of course, and to learn from that rewriting.

She also gives us insight into the way in which storytelling can be used in termsof gathering information. Instead of taking history, a practitioner can gather

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stories. For example, Sara – in discussing her learning from the event – looks atthe issue of allergy status in children and suggests that ‘An option would be to askif they have had antibiotics in the past and when’.17 As an alternative, I thoughtthat it might be appropriate to call on story to access this vital information byasking ‘Can you think of any times in the past when your child has had a strangeor bad reaction to a drug or other treatment?’. This is an invitation to retell afamily story, rather than a bald request for clinical detail.

In the case study by David Bossano, we see how storytelling can allow us to talkfrankly about our reactions and feelings towards key events in a plot. Davidallows himself the observation that he ‘… was uncomfortable because I felt I hadbroached the subject of weight and lifestyle perhaps too insensitively’.18 As ahealthcare practitioner, to allow these feelings to surface in the text is both toacknowledge them and to discharge them. But they also enrich the learning thatthe clinician can derive from such circumstances because of the level ofpersonalisation involved.

David also observes that ‘The greatest impact on me was seeing the degree towhich Mrs Hughes’s condition affected her, expressed in writing. For example,Mrs Hughes indicated … that “she felt bad about herself … nearly every day”’.19

This reminds us of the value of inscription, the way in which committing eventsand thoughts to paper somehow makes them more potent and susceptible tocareful examination. (It is for this reason that reflective practitioners are advisedto reflect-on- as well as reflect-in-action, to get their reflections down on paperso that they can look at them closely, engage in meta-reflection and hence committhemselves to action arising from their reflection.)20

But, in fact, it is David’s strong reaction to the micro-story that Mrs Hughesincludes in her questionnaire response that is truly important here. In eightwords, she tells a plaintive story of her life that is extremely poignant for thereader: she felt bad about herself … nearly every day. If you read that line overseveral times, if you say it aloud, if you recite it to another human being, then youbegin to sense the story of Mrs Hughes and her condition at that time unfolding.To reflect on that eight-word story of someone’s life is to gain a greater and moreempathic understanding of his or her situation.

In an echo of the example of Rashomon with which this paper opened, HelenHalpern and Martin Abbas in effect tell their own distinctive stories of the sameevent, namely a mentoring session.21 The sharing of those stories by these twonarrators gives each an insight into the understanding of the other. Neitheraccount has an overwhelming claim on truth in respect to the events that actuallyoccurred. As I intimated earlier, this narrative approach is premised on a viewthat we have transitive knowledge of an intransitive reality. However, each storyclearly provides a means by which the authors can access greater mutualunderstanding of their positions.

Through the comparison and interpretation of their two stories, we see howthe authors are able to articulate their deeper attitudes and feelings towards this

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specific experience of mentoring – and, most significantly, of mentoring ingeneral. To that extent, it is possible to see how this insight might be used to alterand improve the way in which their specific mentoring occurs. It might also besaid to be a means by which these two people can enrich and deepen the qualityof the mentoring relationship that exists between them.

Let me conclude this exposition on narrative, then, on a lighter note, using an example in this regard that I confess amuses me greatly but which patently has serious implications for thought and action. Back in December 1998, theCanadian Medical Association Journal carried an article by two doctors thatlooked at the representation of medicine in the animated TV series TheSimpsons.22 They compared the two medical characters – Drs Julius Hibbert andNick Riviera – that appear in the show, in order to decide which was a better rolemodel for the profession. At first appearance, Hibbert is the better doctor: he is aconscientious, affable and trusted. Meanwhile, Riviera is a poorly qualified andvenal practitioner.

However, the paper concluded (with the authors’ tongues firmly in theircheeks) that

‘As a profession, we must shed the dark past embodied by Dr Hibbert – a wasteful,paternalistic and politically incorrect physician. Instead, the physician of the futuremust cut corners to cut costs, accede to the patient’s every whim and always strive toavoid the coroner. All hail Dr Nick Riviera, the very model of a 21st-century healer’.23

Elsewhere in the same edition, however, a solicited editorial took another viewand presented an alternative role model for physicians in Canada: it was Dr BonesMcCoy from the original Star Trek series.24

Although these were frivolous pieces for the pre-Christmas edition of thejournal, they demonstrate how serious professional issues – in terms of both thetechnical rationality of professional activity and the swampy terrain of profes-sional practice – can be explored using fictional characters. In fact, behind thequestion of who represents a better role model for medicine is a more seriousissue for exploration: what do the two cultural representations of modernmedicine in The Simpsons tell us about the social standing of the profession andthe popular appreciation of medical science?

All ‘fictions’ – whether they be our own recollection and retelling of particularevents or artistic creations, such as novels – provide the reflective and reflexivepractitioner with material through which to develop personally and profes-sionally. The titles reviewed here provide a text on which to work and a range oftechnical perspectives by which to achieve greater narrative clarity as a reader.They provide excellent guides to expanding our reflective potential and, as such,they are particularly welcome. Moreover, the case studies appearing in thisedition underscore the role that narrative plays in clinical practice – and hencehopefully provide an excellent bridge between the ideas I have discussed hereinand the day-to-day experience of clinicians.

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REFERENCES

1 Kreiswerth M. Merely telling stories? Narrative and knowledge in the human sciences.Poetics Today 2000;21:293–318.

2 Bamforth I (ed). The Body in the Library: a literary anthology of modern medicine.London: Verso, 2003.

3 Hampshire AJ and Avery AJ. What can students learn from studying medicine inliterature? Medical Education 2001;35:687–90.

4 Matheson R. I am Legend. London: Gollancz, 2006.5 Kafka F. Metamorphosis and other Stories. Harmondsworth: Penguin, 1916/1961.6 Prince G. A Dictionary of Narratology. Aldershot: Scolar Press, 1991.7 Peterson LH (ed). Wuthering Heights, by Emily Bronte (2e). Boston, MA: Bedford/

St Martin’s, 2003.8 Kershner RB (ed). A Portrait of the Artist as a Young Man, by James Joyce. Boston, MA:

Bedford/St Martin’s, 1993.9 Riquelme JP (ed). Tess of the D’Urbervilles, by Thomas Hardy. Boston, MA: Bedford/St

Martin’s, 1998.10 www.rsc.org.uk/hamlet/learning/themes.html#themes (accessed 4 April 2007).11 Riquelme JP. Deconstruction and ‘Tess of the D’Urbervilles’. In: Riquelme JP (ed).

Tess of the D’Urbervilles, by Thomas Hardy. Boston, MA: Bedford/St Martin’s, 1998,pp. 484–520.

12 Ibid, p. 492.13 Peterson LH (ed). Wuthering Heights, by Emily Bronte (2e). Boston, MA: Bedford/

St Martin’s, 2003, pp. 348–78.14 Barthes R (1977/1966) Introduction to the structural analysis of narratives. In: Heath

S (ed). Image Music Text. London: Fontana, pp. 79–124.15 G. Case study: anxious mother, unwell baby. Work Based Learning in Primary Care

2007;5:xx–xx.16 McMullen S. Case study: a child with a rash. Work Based Learning in Primary Care

2007;5:xx–xx.17 Ibid p.xx.18 Bossano D. Empathy and effectiveness. Work Based Learning in Primary Care 2007;

5:xx–xx.19 Ibid p. xx.20 Cole M. Reflection in healthcare practice: why is it useful and how might it be done?

Work Based Learning in Primary Care 2005;3:13–22.21 Halpern H and Abbas M. Baggage. Work Based Learning in Primary Care 2007;

5:xx–xx.22 Patterson R and Weijer C. D’oh! An analysis of the medical care provided to the family

of Homer J Simpson. Canadian Medical Association Journal 1998;159:1480–1.23 Ibid, p. 1481.24 Yeo M. To boldly go: we have to look beyond The Simpsons for a true medical hero.

Canadian Medical Association Journal 1998;159:1476–7.

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ADDRESS FOR CORRESPONDENCE

Mark ColeHead of Learning and DevelopmentEducation CentreQueen Elizabeth HospitalStation Road WoolwichLondon SE18 4DHUKTel: +44 (0)208 836 6793Email: markcole10@gmail.com

Received January 2007Accepted January 2007

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