Health Affairs, 27, no. 4 (2008): 1148-1153 doi: 10.1377/hlthaff.27.4.1148 © 2008 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Narrative Matters

Stories Beyond The Box

PREFACE: Twenty-five percent of the physicians, 10 percent of the nurses, and uncounted numbers of home health workers and nurse aides in the United States are immigrants. This is a huge but largely silent factor in American health care; despite the numbers, the voices of these health care workers are seldom heard in narrative or policy writing. What does this massive migration of talent mean for America and for the countries left behind? How does the legacy of the old country live on—and what about stigma, language, pride of accomplishment, and guilt of departure? What is it like to be an immigrant care-giver? In these essays, two physician-writers with immigrant roots ponder their experiences. Transplant surgeon Pauline Chen retells the folk tale of Urashima Taro and reflects on how it has bound three generations of her Taiwanese family together in their migration to America and her entrance into medicine. Then, in oncologist Alok Khorana’s essay, personal, cultural, and medical values jostle one another as he tells the story of his first night on call at a hospital in New York State after arriving from India three weeks into the start of his residency.

UP UNTIL ABOUT A YEAR AGO, the greatest challenge when driving was not battling traffic but keeping my twin pre-schoolers occupied. One morning, when I was about to play yet another children’s music CD, I heard my father’s voice. Beyond the highway, in my mind’s eye, I saw him leaning back, eyes closed, and speaking in a tone as deep as the pitch of a heartbeat. I heard each of his words; but then, as always happened, he disappeared, his voice hanging for a moment in the air, then evaporating like smoke into the sky. Dark waves rolled in, and thick salty air filled my nostrils.

I began telling my daughters the tale of Urashima Taro.

The Fisherman’s Tale

 
URASHIMA TARO WAS A poor Japanese fisherman who one day reeled in the largest and most beautiful fish he had ever seen. To his surprise, the fish spoke and begged the fisherman for his life. Urashima Taro let the fish go.

In return, this fish, a Fish Prince, brought Urashima Taro down to his castle under the sea and arranged a magnificent banquet in his honor. After three days, Urashima Taro began to worry about his wife. Before sending the fisherman back to his home, the Fish Prince presented him with a tamatebako, a magical gift box, and asked the fisherman never to open it.

When Urashima Taro returned to his village, he could not recognize any of the streets or buildings. He knocked on the door of a house that stood where his home once had been. A strange woman answered. "Urashima Taro? No one here by that name, but there’s a story about a Urashima Taro who went to sea and never returned. His wife died years ago, an old and broken woman."

Grief-stricken, Urashima Taro ran back to the water’s edge with the tamatebako. He pried open the box, hoping to retrace his steps and perhaps even regain his wife.

A great cloud of white smoke escaped from the box. In the reflection of the sea, Urashima Taro saw his hair grow white, his beard long, and his skin wrinkled.

He had aged 300 years.

The Power Of The Box

Top The Fisherman's Tale The Power Of The... Stories And White Smoke Telling My Own Stories Having Experiences Live On The Power Of Stories The Legacy

 
MY FATHER FIRST TOLD ME THE TALE OF URASHIMA TARO when I was a couple years older than my daughters are now. I begged him dozens of times thereafter to tell me the story; and every time my father recounted the tale, I believed that I had the chance to stop Urashima Taro from opening the tamatebako. I believed that I could make the story continue, give everlasting life to Urashima Taro’s dreams, and perhaps even stop time.

I had hoped for so many years that I eventually forgot the ending of the story. When I told Urashima Taro’s story to my children that very first time, I found myself fudging the details. My tamatebako held a lifetime’s worth of gold for the reunited couple. It was in this way that I believed Urashima Taro’s world would never end.

But I was wrong. Although Urashima Taro had aged 300 years in an instant, his world never did end. Every time my father recounted the tale, Urashima Taro would spring to life, the Fish Prince would be saved, the tamatebako would recapture that white smoke. And every time I told the tale to my children, the pieces would fall back together again, creating a tableau as vivid as ever.

The tamatebako did not hold time; it carried the power of story. And that power was something my father understood better than anyone.

Stories And White Smoke

Top The Fisherman's Tale The Power Of The... Stories And White Smoke Telling My Own Stories Having Experiences Live On The Power Of Stories The Legacy

 
THAT MY TAIWANESE FATHER HAD RAISED ME with a Japanese story is not extraordinary. He was born in 1932, when Taiwan was still a Japanese colony and Japan’s influence extended to every nook of the island. Miles of dirt roads and acres of rice fields separated my father’s village from the nearest city; nonetheless, he spoke Japanese as fluently as Taiwanese; delighted as a child in sweet mochi cakes; and grew up in a house with a shallow-pitched, red-tile roof, sliding rice-paper doors, and tatami mat flooring.

My father was, in the beginning, the fourth child and second son, a place well suited for his shy, bookish personality. But the drowning death of his older brother thrust my father, still in grade school, into the role of eldest son. He was now responsible for leading my grandparents’ stubborn, hot-tempered brood of seven.

It was then, I believe, that my father, who was endowed with neither physical power nor an aggressive nature, began to tell stories. And he soon discovered that with them, he could quell the cries of his younger siblings.

Those cries had to be silenced when the air raid sirens screamed through the air. Their wailing had to be hushed when the Nationalist troops of Chiang Kai-shek shot teachers and community leaders one by one, executioner style, then dumped the bodies into the river behind my father’s house. My father and his brothers and sisters watched the river turn red and later saw blood rolling down the steps of the village temple. My father can still hear the dying crying for water. "People become thirsty," my father told me in my first lesson in physiology, "when they bleed to death."

My father soothed his siblings with stories about the Peach Boy, the Crane Maiden, Monkey Face, the brilliant Cao Cao, and, of course, Urashima Taro. But as he grew older, my father began to bring his own stories out, first to his siblings and then to his own children. There were stories of the places he had visited—the big city just beyond the fields, the capital city up north, and then, the cities halfway across the world. There were stories of landing in one of those faraway cities with nothing but pocket change and walking into a restaurant only to discover that these pale strangers ate dogs, hot dogs; stories of struggling with a language whose musicality encompassed not single words but strings of words and that had a grammar full of exceptions to the rule; and stories of a home and family that, except for during these moments, became more and more distant.

Each time, my father would lean back and close his eyes. He would lower his voice until you felt it reverberating in your own chest. At first, you could hear his rhythmic breathing and the sounds of each word spinning off his lips. But then, those words would disappear, like a stream of white smoke, leaving you in a world so vivid and so real that you had to hold your breath, for fear that the slightest noise might startle the characters, causing them to vanish.

Telling My Own Stories

Top The Fisherman's Tale The Power Of The... Stories And White Smoke Telling My Own Stories Having Experiences Live On The Power Of Stories The Legacy

 
WHEN I COULD AT LAST TELL MY OWN STORIES, my father became my most avid listener. I read my English assignments, my college essays, almost everything to my father. I thought he did this to help me, but later, on visits home from college and medical school, I would find copies of my writing on his nightstand.

Never did I anticipate doing anything more. Stories, after all, were simply the language of my home, a language that accommodated the broken English, broken Taiwanese, broken Mandarin Chinese, and bits of Japanese that were my family’s way of communicating. Besides, what seemed so powerful to me in stories—my father’s words—always felt a bit ridiculous outside of our home. My father stuttered on the phone, his business letters were full of grammatical errors, he mispronounced names, including those of my favorite non-Asian professors, in ways I could not predict: Dr. Kleinman became Dr. Ku-line; Dr. Counter, Dr. Count-two. And as embarrassed as I might have been in front of others with my father, I knew that I, raised in such a language mishmash, could just as easily do the same.

"How did that acute abdomen go?" a surgical colleague might ask me.

"Oh, that?" I would respond. "It was a slice of pie!"

So I stopped telling stories and concentrated instead on becoming a doctor.

After finishing my training as a transplant surgeon, I found myself drawn back again to the stories. I wrote them in my office, on my computer, and in my lab. I dreamed about them on plane rides to procure organs from cadaveric donors. This story writing was becoming, I worried, an obsession, and I decided to take a couple of writing courses at UCLA to curb my impulses.

Midway through one of the courses, I wrote a one-page piece about a woman who, through the familiar act of digging a hole in the earth of her garden, recaptures memories of one she had loved and lost. I read the piece aloud to my class and began crying, crying so hard that I forgot who I thought I was (the linguistically confused child of immigrants), why I thought I was there (to control a compulsion to write), and where I thought I was (in front of twenty complete strangers).

But it was one of those strangers, the teacher, who gave me the courage to write my stories and made me believe that I indeed had stories worth telling.

Having Experiences Live On

Top The Fisherman's Tale The Power Of The... Stories And White Smoke Telling My Own Stories Having Experiences Live On The Power Of Stories The Legacy

 
SOON AFTERWARD, I DECIDED TO BECOME A WRITER. And I wanted to do what any dutiful Taiwanese daughter does: tell my parents. But I didn’t want to wait to go back home to tell my father, so I called him from my office.

"Are you crazy?" he said to me, his voice rising. "Every English major in America wants to write a book. What makes you think you have a story that will mean anything to people?"

"Dad," I said, "I’d like to try. My teacher thinks I have something to say." I twisted the cord of my office phone until it coiled up into a hopelessly tight knot and I had to bow my head down to talk into the receiver.

I could hear him sigh. "We work so hard so you can have everything and now you want to throw it away. Medicine is good. You don’t need perfect English. But to publish you need more than perfect English—you need the best English."

"I’m not quitting medicine," I answered. "I just want to write."

I had opened the tamatebako, but it was empty.

That conversation took place six years ago. I went on to publish a book about my experiences with dying patients. After that book came out, complete strangers came up to me and told me how different parts of the book had affected them. They talked about Dutch, Frank, Sam, and even my cadaver. They recounted events not as if they had read about them but as if they had been there as well.

My stories had gone on to have a life of their own.

Telling, writing, and publishing those stories have allowed these experiences to live in a way I never would have dreamed possible. They have made caring well for the terminally ill more pressing to people far beyond my own circle of family and friends. They have made end-of-life care a more real issue for those who have thumbed through my book’s pages. And, I would like to believe, these stories—pulsating with a life of their own—might one day help to make the need for good palliative care so personal that policy reform becomes inevitable.

But for several years I could not talk about stories with my father. In fact, after that phone conversation in my office, I did not mention writing again until I had signed with my publisher. After that, my parents heard and saw nothing until I handed a completed manuscript in to my agent and editor a year later.

I wasn’t there when my father read the manuscript for the first time, but I heard from my mother that he wept. Then he took the 200-plus loose pages to the local Kinko’s, had them bound up in the most secure binding possible, read through the manuscript once more, and wept again.

The Power Of Stories

Top The Fisherman's Tale The Power Of The... Stories And White Smoke Telling My Own Stories Having Experiences Live On The Power Of Stories The Legacy

 
STORIES OR NARRATIVES SEEM ANTITHETICAL TO today’s emphasis on evidence-based clinical practice. They offer no statistical power, no data to repeat and confirm. But what narratives have, over all other forms of research, is the ability to get to the heart of the experience.

A single narrative is as powerful as any health care intervention; it is the one language that all of us—health care worker and lay person—share. And just as a patient with a certain disease will always bring to memory patients past and how we could have done differently, a single narrative can change the way we live our lives, practice our art, and even reform our policies. When we don’t tell our stories, our experiences, like the years of life in the tamatebako, can disappear forever. So can the possibility of a more relevant and meaningful kind of health care.

Each of us has stories to tell that can change our world for the better. But the only way to begin that change is to believe in the inherent worth of our stories.

We need to write them down.

We need to release them from the tamatebako within.

The Legacy

Top The Fisherman's Tale The Power Of The... Stories And White Smoke Telling My Own Stories Having Experiences Live On The Power Of Stories The Legacy

 
A FEW MONTHS AGO OVER BREAKFAST, I asked my father to tell my daughters the story of Urashima Taro. I stood away from the table, watching my daughters take the story in and listening myself for all the forgotten details I had fibbed my way through. My father sat back, closed his eyes, and the hills and valleys of his voice stretched and deepened until I could hear him no longer. And once more, I felt the familiar squeeze in my chest, that hope against the inevitable for the poor old fisherman.

But then, I began to see things beyond the sea—the small boy playing in the village home with tatami mats and rice-paper doors, scrambling between dying villagers who littered the temple floor, covering the ears of his youngest sisters as the bombers flew overhead. I sat down, overwhelmed by all that was around me. I heard my father’s voice and saw Urashima Taro running back to the water’s edge, about to pry open the box.

Before I could stop him this time, Urashima Taro released the smoke. And I was back in my parents’ home.

My father was silent; his eyes were still closed. As a child I used to think my father had put himself to sleep, but now I knew that he was, for a moment, still in Urashima Taro’s world, transported by the evanescent contents of the tamatebako.

After a few minutes, my father opened his eyes, smiled at my daughters, and then looked at me.

"So, Pauline," he asked, his voice back to normal. "How are we doing on that next book?"

Editor's Notes

 
Pauline Chen is a surgeon specializing in liver transplants and a widely published writer who lives near Boston, Massachusetts. She is the author of Final Exam: A Surgeon’s Reflections on Mortality (Alfred A. Knopf, 2007), which was a New York Times bestseller, has been translated into a number of languages, and is sold in almost a dozen countries around the world; Final Exam was chosen by New York Times book critic William Grimes as one of his ten favorite books of 2007. This essay is adapted from Chen’s keynote address at the Narrative Matters conference, "Health Workers on the Move: Stories Told and Untold," in September 2007.

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