Teaching close reading: an instructor’s reflective case study of a Contemporary English Literature course for EFL medical students

Introduction

Close reading, defined as “the detailed analysis of the complex interrelationships and ambiguities (multiple meanings) of the verbal and figurative components within a work” [1], is the literary device that has been valorized by scholars as the key element of literature in promoting ethical and humane medical practices since literature and medicine has been recognized as a proper subdiscipline of medical humanities in the 1970s [2]. During the narrative turn of literature and medicine in this century, close reading continues to be regarded as the cornerstone of narrative competence and is “applied in all areas and all at once” in clinical lives [3], as articulated by Rita Charon, the champion of narrative medicine as an indispensable discipline of medicine. Despite ongoing debates regarding the legitimacy of literature’s role in medicine, the centrality of close reading as a conduit for literary contributions to medical practice remains widely acknowledged [4]. The pedagogy of narrative medicine is thus predominantly underpinned by the teaching of close reading, showcasing its enduring significance in fostering empathy, critical thinking, and reflective practice among healthcare practitioners.

For the past and present decades, China has witnessed the rapid blossoming of narrative medicine since it was formally introduced to Chinese medical professionals in 2011 [5]. With the recognition of Chinese narrative medicine, there is an increasing consensus that narrative medicine needs to be introduced to medical students in as many classes and as early as possible [6]. This trend has found resonance in the teaching of College English, a foundational course in undergraduate medical education. A 2013 review has predicted that narrative medicine “brings a new era for the integration of English literature and medical education” [7]. In the subsequent decade, indeed, an increasing number of English literature instructors in medical schools have included narrative medicine in their classes by teaching students how to read closely a diverse array of texts ranging from textbooks to novels, films, artworks, and materials from real-life events [8]–12]. These instructors believe that the incorporation of narrative medicine as a vital component can equip future healthcare professionals with a more holistic understanding of medicine and care. This article contributes to the ongoing discussion by examining a Contemporary English Literature course for undergraduate medical students, with a specific focus on the integration of close reading in a fundamental foreign language class. Three interrelated questions are presented at the core of the following discussion: what, how and why to teach close reading. Admittedly, it is beyond a single paper’s capacity to answer these questions thoroughly; instead, this article aims to exhibit potentials and possibilities of a close reading pedagogy from an instructor’s perspective to demonstrate a possible approach for the integration of narrative medicine and fundamental medical courses.

Interest-first: what to teach

When I started my Contemporary English Literature course about six years ago, the core of this course is to prioritize student engagement and foster a genuine interest in reading. Existing research has noticed a lack of interest in reading among medical students; moreover, there is also a tendency of superficial reading or reading merely for entertainment [13], [14], [15]. Such deficiency in serious reading has greatly hindered students’ understanding of medicine as a humane art. Therefore, I designed the course to be of literature rather than narrative medicine to cultivate a stimulating environment that would encourage students to enjoy reading. Over the years I slip small portions of the quintessence of narrative medicine in my lectures, albeit refraining from overt references to the field. After several rounds of running this course on Contemporary English Literature, I still regard it fundamentally as a literature course tailored for medical students rather than a strict narrative medicine course. While the boundary between the two domains may be rather vague in the most general sense, the underlying principles guiding each approach are distinct. Narrative medicine, with the emphasis on medicine, expects clinical outcomes in the biomedical context whereas literature reading aims to foster an appreciation of stories and train students’ narrative competence [16]. Overemphasis on narrative medicine in the pre-clinical phase may not be the most judicious use of valuable class time. Conversely, a literature course needs to maintain students’ attention and keep them as involved as possible. It is therefore almost a natural development that “interest first” becomes the golden rule of this Contemporary English Literature course governing the structure and content of each class session.

The principle of “interest first” turns out to be crucial for the students I’m working with. The majority of them are sophomores and juniors who have never read any English novels in its original and unabridged forms. In the introductory session of the course, I routinely ask the enrolled students whether they have ever read any full-length English novels. Among the 50 students for each round the course, only a handful of them would give the positive answer. The students may have achieved extraordinary scores in the College Entrance Examination, but it is still understandable that they would feel intimidated to read English literary works. A recent study reveals that more than half of the surveyed students find it difficult to read English literary works, but over 90 % of them are interested in registering in a guided reading course in English literature [17]. Making the course engaging, less theoretical, and more aligning to the students’ reading habits becomes the course’s lifeline to keep the students reading and maintain their motivation, enthusiasm, and confidence in learning English. Some would argue that reading short stories may be an alternative. This is true in its own merits, but reading a literary fiction has been proved by empirical research to best improve the reader’s theory of mind [18]. Moreover, a novel, in its extensive prose shape, affords the revelation of character complexities, event intricacies, and choice dilemmas that mirror the intricacies of real-life medical encounters.

With the above-mentioned guidelines in mind, I wrote the following description for “Contemporary Novels in English”:

This course is for students interested in reading contemporary novels in English. As an introductory survey class, it aims to bring together novels of different contemporary genres (detective, dystopia, fantasy, graphic, memoir, adventure, Si-Fi, etc.) and by authors of different cultural lineages (American, African, British, Canadian, Chinese, Irish, Japanese, etc.). Central issues for discussion include but are not limited to the relationship between past and present, fiction and truth, contemporary adaptations of the classics, media and literature, science and humanity.

In the paragraph, the word “interest” appears early and is deliberately devised as the emphasis of the opening sentence, underscoring the course’s profound emphasis on cultivating a genuine passion for the subject matter. I also highlight this to students in the introductory session that the course is heavily interest-motivated. I even discourage students from formal registration by bringing all the required novels to the classroom to give them a physical view of how much they are expected to read. While some students may opt to withdraw, those who remain registered typically try their best to complete the reading task, and wonderful results of narrative competence gradually reveal. The next sentence in the description concerns text selection. As may be noticed from the paragraph, many of the books I choose for this course belong to the “genre fiction,” which, according to the succinct definition by Diana Tixier Herald, has at its core “a story in which something noticeable happens” [19]. The inherent allure of genre fiction, characterized by its gripping plots and captivating narratives, serves as a potent catalyst for sustained engagement. However, I’m also aware of the common criticisms against genre fiction for aesthetic thinness and lack of literariness. In response I select meticulously crafted works by esteemed authors such as Margret Atwood, Ted Chiang, J. M. Coetzee, Neil Gaiman, Kazuo Ishiguro, Maxine Hong Kingston, Colum McCann, and Art Spiegelman. Over the years, the list continues to expand to include authors from a diversity of cultures, regions, and ethnicities so to foster a rich tapestry of narratives that resonate with students on a profound and multifaceted level.

Finally, the issues for discussion are proposed in order to prompt students to approach the reading material with critical questions in mind, rather than just skimming through for the plot or worse, for the sake of “finishing the reading task.” Another advantage of reading novels lies in the fact that a novel is capable of covering a wide range of issues in great details so that students may explore and come up with observations that have been neglected even by the instructor. Thus, the classroom creates a mutually beneficial environment for students and teachers alike.

Competence-centered: process of teaching

Close reading needs to be taught. This is a simple but often overlooked situation in educational settings. Close reading is essential for developing narrative competence, yet it is often overshadowed by the desire to extract meaning, significance, or moral lessons from a text. This does not by all means suggest a discrepancy between close reading and reading for ethical or other purposes. Nevertheless, without close reading as the foundation, students may form shaky hypotheses or rely on emotional responses, respectively the intentional fallacy and the affective fallacy that close reading strives to avoid [20]. A student without proper training in close reading would make judgments based primarily on personal biases, ignoring motives, history, or forces that propel a character to make a certain choice. Negations frequent such students’ response to a text, for instance, “I don’t think” “I disagree” “I am not” “I think it is wrong to,” which manifests an unwillingness to approach the text closely, attentively, and empathetically.

To encourage students to understand comprehensively rather than reading intuitively, it is crucial for instructors to impart close reading to students and demonstrate that close reading is a fundamental reading skill that can benefit all students. Rita Charon and her colleagues at Columbia University exemplify the process first with “The College of Physicians and Surgeons of Columbia University Reading Guide for Reflective Practice” [21], and later with specific chapters in the two monographs of Narrative Medicine: Honoring the Stories of Illness [3] and The Principles and Practice of Narrative Medicine [22]. These works exhibit ready-to-use guidelines for beginners to engage in close reading. However, it is important to note that the Charonian approach is tailored towards native or near-native English speakers, which may not be suitable for students in an English as a Foreign Language (EFL) setting like “Contemporary Novels in English.” While the Charonian approach focuses on narratological, rhetorical, and contextual aspects of close reading, students learning EFL may require a different approach that also addresses linguistic and cultural nuances.

Based on the students’ EFL background and their developmental stage as undergraduate EFL learners, here is a close reading model provided throughout “Contemporary Novels of English”:

A general close reading model for Chinese EFL medical undergraduates

1. Linguistic Aspects

What does specific word choice imply? How do grammatical features (tense, voice, mood, number, person, gender, case, etc.) work in the text? What about the sentence structure (length, types, punctuation, etc.)?

1. Formal Aspects

What are the generic conventions and does the text follow these conventions? How is the text structured (beginning, development, ending)? What are the rhetorical effects of the style or medium of the text?

1. Contextual Aspects

Can you identify any culture-specific norms, for example, the proper names of people, places, objects? Does the reading material at hand allude to any particular texts, myths, histories, events, communities, etc.? How are these contextual clues related to the textual, historical, cultural, and/or social implications of the reading material?

In the following section, I will provide some teaching examples to demonstrate how this model works in class.

Student-centered: breeding a sense of achievement

Narrative empowers medicine and close reading empowers narrative. Empowerment takes place only when students have indeed invested time and attention in reading the texts and appreciating the details. Therefore, the focus of teaching close reading is not the instructor’s lecturing but the students’ involvement. An empowering close reading class will at least encourage students to turn the pages, to apply close reading skills, and to discover diversities and complexities from textual clues.

For these reasons the assignments and assessment of “Contemporary Novels in English” are designed to motivate students to read as much and as attentively as they can. A response paper serves as a reading journal that allows students to keep a record of their reading and as a channel via which students will have individual feedback from the instructor on their writing and reading. A group presentation task provides a forum where students can present, discuss, and share their readings with each other. A final paper invites students to take the reading experience as a whole and include as many reading materials as possible so to focus on the similarities, relations, and possibly the contexts that give birth to these texts. Students are also welcome to opt for the other creative track of rewiring a story as their final project, which aims to transform their reading in a more flexible but equally critical way. In-class activities, selected from a wide range of debate, group reading, multimedia comparison, theatrical performance, reflective writing, and creative writing, complement after-class assignments in the set of tasks that aim to empower the student further in the mastery of English, the enhancement of reading skills, and the confidence in sharing ideas.

For a course to be student-centered, the core marker should be that a sense of achievement has been acknowledged by those who have actually completed the course. In the last session of “Contemporary English Novels,” it has become customary for the students to take an anonymous questionnaire as a reflective summary of the semester’s reading experience and an overall evaluation of the course effects. Questions include prompt writing with keywords like “reading” “story” “literature and medicine”, a detailed examination of class arrangements from the syllabus to the assignments, an evaluation of the reading materials, and possible dividends of the course in general. The questions are designed to inspire reflection and long-term interest in reading. The anonymity of the questionnaire invites open, frank, and constructive feedback.

Students generally report a sincere joy in reading. Here is one comment from a student:

This semester I read five English novels with different themes. After reading these novels, I deeply realize the charm of literature. Literature is not only an artistic creation, but also a vehicle for people to express their emotions. Reading a novel is like going through a journey, experiencing the joys and sorrows of life with the action of the protagonist.

This sentiment is shared by many students who find this course very different from other English reading courses. Many remember the course for a complete reading experience by requiring them to read full-volume novels instead of excerpts. Some students may have doubts at the beginning on the seemingly behemoth task of finishing a whole English novel, but often end up with asking for a reading list to continue the reading experience even after the course wraps up. The recognition of being able to read original English novels boosts their confidence not only in mastering the English language but also in their understanding of literature and life, as the quotation amply suggests.

Another significant achievement is the acknowledgement of close reading. One feedback refers to this experience as “amazing” and “magical” as the student recalls the experience of deciphering the cultural implications from the proper names in Atwood’s novels. More students transform from reading only for the plot to reading attentively. Here is a student who uses close reading to explain the unique style of the graphic novel Maus:

The literal meaning of the text itself and the visual effect of the text combine with each other to produce a meaning beyond language itself. In graphic novel, the shape and size of the text are related to the author’s writing style. The text in Maus is handwritten by the author, and when it indicates surprise or emphasis, the text is bolded or the font size is adjusted accordingly. All these are different from the textual narrative of traditional novels. The text of graphic novels is more direct and vivid, and the emotions and feelings of the narrator can be better experienced from the word.

When students apply close reading, they discover textual aspects that even the instructor ignores. Details such as handwriting styles, typographical choices, and text dimensions are mentioned to appreciate the unique style of the graphic novel. Reading students’ writings turns out to be a valuable learning process for the instructor to once again marvels at the empowerment of close reading in reading and interpretation.

Lastly, which is also my personal favorite, one student says, “I forget that I am a medical student in this class.” For me this simple sentence perfectly exhibits literature’s potential of breaking barriers and bringing people together. One student has phrased the idea in the following passage:

Most literary works show humanistic care, and humanistic care is what our society needs now. Man is the unity of spirit and material. Literature can not only provide spiritual level, but also show a way of life. The humanistic care embodied in literature mainly lies in that literature provides readers with poetic artistic conception, warmth and happiness. In literary works, people can find the missing parts in rea life. Some literary works can also be regarded as people’s yearning and longing for a better life, surpassing the reality and bringing infinite reverie to readers.

Doctors, as everyone, read and write to understand their profession and the world they live in [34]. It is beyond the original design of this course to have such a far-reaching range into the explorations of humanity and life. How students can combine fiction with reality, literature with medicine, story with life is a true source of delight for any instructor in narrative medicine.

Conclusions

The previous parts discuss the background, the model and the effects of teaching close reading for EFL medical students. Consequently, the article uses “Contemporary Novels in English” as an example to show how to organize a narrative-oriented course in a medical undergraduate class. It is also a reassurance of close reading as the signature method of narrative medicine that is of great textual, ethical, cognitive, and pedagogical values. This course also demonstrates an integrating teaching model that combines close reading with other fundamental courses, which reveals how narrative proficiency is an integral part of medical competence and clinical capability. There is no need, finally, to mention the known fact that close reading pedagogy is never singular or fixed, as instructors of narrative medicine around the world continue to explore innovative pedagogical methods and transform existing ones. It is the hope of this article to contribute meaningfully to the ongoing discourse by showcasing the transformative potential inherent in the pedagogical approach witnessed in “Contemporary Novels in English.”