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Chekhov and the chair: reflections on medical practice – Art and Culture

Talking with the patient not only relieves but can modify the physiological variables. Why prioritizing a good dialogue is therapeutic?

The remembered doctor Francisco “Paco” Maglio used to say: “The greatest advance in medicine is the chair.” Perhaps for this reason he came to say that “after looking at medicine with the eyes of a biologist (which in itself is not bad because it is necessary)”, he felt that he was missing the essentials to see the patient holistically, as a somato-pisco-social human.

In times when technological advances seem to be inversely proportional to consultation times, it is well worth calling for a dialogue between the doctor and the patient, in which even questions outside the clinical questionnaire can give clues to the real reasons for the which a person seeks help.

One of the promoters of the current called Narrative Medicine is the doctor Rita Charon who, from Columbia University, New York, tries to focus on the patient by asking “What happens?” or “what can I do for you?”. In other words, it seeks to provide conceptual tools and cognitive skills at the service of health agents.

As mentioned by Dr. Daniel Flichentrei in a course he gave for IntraMed, in the so-called Narrative Medicine it does not matter what the disease “is” –for which biology is sufficient by itself– but the only thing that takes into account is what the sick person “says it is” to convince others and, especially, to convince herself.

The thing is the disease is lived in three dimensions: the anatomical physiological (recognized by the doctor); the Social (found in the body of people) and the subjective (suffering of the person). And, in some cases, acting on the condition first can determine the success of the actions on the physiology. In other words, inviting the patient to talk about their own suffering is therapeutic.

What is not fully understood in a system mediated by short times is that the narrative coherence (which refers to the subjective dimension of the patient, such as the loss of a loved one) disturbs physiological variables. That is, a biographical disruption necessarily produces a biological disruption. And subjective homeostasis is narrative coherence.

Therefore, talking is useful and a lot. And the literature realizes it. An example is the story “Sadness” by Anton Chekhov, which, with scenes of snowy landscapes, tells the story of Yona, an elderly coachman who has just lost his son. He is plagued by poverty, but he raises clients for less than what he deserves so as not to be alone and verbalize his grief, hoping to ease his pain. But none of the travelers echoes. Chekhov writes: “Yona exhales a sigh. She experiences an imperious, irresistible need to talk about her misfortune.”. And continues: “What would he not give to find someone who would listen to him, shaking his head sympathetically, sighing, pitying him!”

In the absence of interlocutors, Yona tells his sorrows to the only companion who remains with him, his horse, who in the words of Chekhov “exhales a moist and warm breath.” A breath opposed to the coldness of the travelers and the environment, to the feeling of helplessness. What the coachman desperately seeks is recover narrative coherence, homeostasis.

Chekhov’s narration is justified from the neurosciences, with the concept of “social thermoregulation”which postulates that social exclusion leads to lower skin temperatures and that this is literal, not metaphorical. Therefore “fooling the fingers” by rubbing them with a cup of hot tea attenuates negative feelings.

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