We live in a post-modern society where a technocratic approach to medicine is no longer considered sufficient or desirable. Twenty-first century patients are looking for person-centred care: they want to be listened to and to have a dialogue with their doctor, to be healed rather than cured [1, 2]. The once-forgotten quality of empathy has been re-discovered as a desirable quality in doctors, and although it has been suggested that there are situations where objectivity may be more important [3, 4], empathy has been shown to be associated with improved patient satisfaction and better clinical outcomes [5–8].
What is empathy?
Although most people would claim to be able to recognise empathy, there is no agreed definition. One definition is “psychological processes that make an individual have feelings that are more congruent with another’s situation than with his or her own” . Most definitions include the ability to understand and share others’ feelings, and are sometimes divided into two components, affective and cognitive. Cognitive empathy, also referred to as perspective-taking, is the ability to understand how another person feels and what they might be thinking. The second component of empathy, affective empathy, includes experiencing the emotions that the other person is feeling . Some observers add an intention to help . A related concept is affinity, our natural attraction to others. Larson and Yao have commented on the tendency we have to empathise with people who are like us, and to not empathise with people who are seen as “other” or different from us [11, 12].
Neurobiological correlates of empathy have been demonstrated. A meta-analysis of neuro-imaging research on empathy found that the dorsal part of the left anterior midcingulate cortex was found to be activated more frequently in the cognitive- evaluative form of empathy, while the right anterior insula was activated only in the affective-perceptive form of empathy . Recent, though disputed research, suggests that “mirror neurons” may be “the neural basis of our empathic capacities” [14, 15].
A number of approaches using the medical humanities have been advocated for teaching empathy to medical studentsx . This paper describes a new approach using the medium of creative writing and a new narrative genre: “clinical realism”.
What is clinical realism?
Clinical realism has its roots in the realism movement in art and literature in the nineteenth century. Realism, notes Morris, is “a literary form that has been associated with an insistence that art cannot turn away from the more sordid and harsh aspects of human existence” . Modernism aimed to render a full report of human experience through the use of details, and was portrayed by George Eliot as “old women scraping carrots with their work-worn hands” but also extended the subject matter of novels to incorporate class, gender, sexuality, and social reality [17, 18]. Although it was not seen as a separate movement at the time, a number of novelists such as Balzac, Flaubert, Eliot and Zola included realistic medical content in their novels. Rothfield analysed a selection of British and French medical realist novels, and noted that although realism is often equated with representation, the connection between medicine and realism varied with the purpose and period of the author. For example, he notes that the smallpox contracted by Mme. de Merteuil in Les Liasions Dangerouses serves as a metaphor which offers moral, social and narrative closure: “her disease had turned her round and… now her soul is in her face.” We are told that she has been disfigured and has lost an eye, but there is no more detail about the disease. In contrast, Zola goes into graphic detail to discuss the smallpox which has killed his heroine in Nana, and which also perhaps, serves as a metaphor for the degeneration of an entire society: “the pustules had invaded the whole face, so that one pock touched the next. Withered and shrunken, they had taken on the greyish colour of mud…” Rothfield argues that medicine provided novelists with narrative strategies, epistemological assumptions and models of professional authority, and early medical realist novels in particular tended to portray illness as “either a fundamental ontological predicament or a punctual sign of innate moral inadequacy” .
Realism was replaced by other movements, including anti-realism, naturalism, detective fiction, modernism and post-modernism. In 1926, Virginia Woolf wrote an essay “On being ill”, commenting: “Considering how common illness is...... it becomes strange indeed that illness has not taken its place with love, battle and jealousy among the prime themes of literature” . As Jurecic notes, the paucity of writing about illness seems even more remarkable when it is set against the fact that five per cent of the world's population had died in the flu epidemic of 1918/19, less than a decade before Woolf wrote her essay .
Frank has commented on the rise of modernism, when “the medical chart became the official story of the illness”. He suggests that in post-modern time, people reclaimed the capacity for telling their own story . Jurecic notes the flood of illness narratives that appeared in response to the emergence of HIV/AIDs in the late twentieth century, and the establishment of illness/disability narratives as a literary genre at around this time, albeit one that is not taken very seriously by critics . The last decade has seen a similar explosion of graphic medicine accounts of illness. Graphic medicine explores the interaction between the medium of comics and the discourse of healthcare, and is allied to the graphic novel movement, which has produced “serious” comic books, aimed at adults. There are now numerous graphic medicine novels and autobiographies which recount illness narratives in cartoon form [22, 23]. There remains, however, very little representation of physical health problems in literary fiction. ONS statistics for 2014 show that over 11 million people in the UK have a limiting long-term illness, impairment or disability  QoF (Quality and Outcomes Framework) statistics from GP practices for 2012/13 show that 13.7 % of registered patients have hypertension, 6.2 % have diabetes, 5.9 % have asthma, 4 % have chronic kidney disease, 3.3 % have coronary heart disease, 1.8 % have chronic obstructive pulmonary disease, 1.7 % have had a stroke or TIA and 1.6 % have atrial fibrillation . And yet people with chronic physical health problems are almost invisible in contemporary fiction - we rarely see anyone adjusting their dose of insulin, having side-effects from their medication, or plotting the route of an outing by the proximity of available toilets.
Illness and disability can profoundly affect an individual's life opportunities and personal identity . Goffman has written about how people with stigmatising conditions, including many health conditions, have to manage their “spoiled identity” . Sontag notes how diseases such as cancer, TB and syphilis are seen “as punishment”, betraying a character flaw, while the names of these diseases themselves have become adjectival, being used as a metaphor for evil . Kleinman comments: “The trajectory of chronic illness assimilates to a life course, contributing so intimately to the development of a particular life that illness becomes inseparable from life history” . And yet in contemporary fiction we may hear about a character's appearance, class, ethnicity, education, job, politics, sexual proclivities, taste in music and even the contents of their handbag, but the day -to -day experience of living with a health problem is rarely represented.
For the purposes of this course, one of the authors (PM) created a new genre, clinical realism. This is defined as “Fictional writing where health problems are systematically represented, not as a metaphor, not as a plot point, and not as the central topic of the writing, but as a part of a character's personal identity and day to -day experience”.