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Narative Medicine

What is Narrative Medicine?


• International movement to include
reflective reading and writing in physician
practice

• Poetry, stories, memoirs written by doctors,


other health care professionals, students
and patients
The medical history
• The medical history is the foundation of clinical
medical practice: the history of the present illness, or
illness narrative
• To “take a history” vs to “elicit a history” – we study,
practice, refine, teach (and too often unlearn) this
process throughout our careers (interview – “to see
between”)
• Barriers – clumsy teaching, poor modeling, easy
access to diagnostic technology, documentation
pressures, time pressures, concerns about
confidentiality (including HIPAA), others…
REFLECTION
a "crucial process in the transforming of
experience into knowledge, skills and
attitudes"
Robertson, K. Reflection in professional practice and education,
Australian Family Physician, 2005; 34(9), pp. 781-783.

a key step in both life-long learning and the


development of professionalism in practice.
Novack DM et al. Calibrating the Physician: Personal Awareness and
Effective Patient Care. JAMA. 1997; 278: 502-509.
Narrative Medicine provides a forum
for thoughtful self-reflection
Improves patient-centered care
Yamada, S.et al. Family narratives, culture, and
patient-centered medicine, Medical Student Education,
2003; 35(4), pp.279-283.

reduces practitioner stress


Brady, DWet al. "What's important to you?": The use of
narratives to promote self-reflection and to understand
the experiences of medical residents, Annals of Internal
Medicine, 2002; 137(3), pp. 220-223.
Narrative Medicine Skills
• Observation

• active listening

• ability to tell the patient’s story

Verghese A. The physician as storyteller. Ann Intern Med


2001;135:1012-7.
Narrative Medicine & empathy

students practice taking the view of


another person (a patient, family
member, other healthcare providers)

they see the patient as a person within


a family, community, and culture
Halpern J. From detached concern to empathy: humanizing medical
practice. New York: Oxford University Press, 2001.

Das Gupta S & Charon R. Personal Illness Narratives: Using


Reflective Writing to Teach Empathy. Acad Med. 2004;79:351–356.
Narrative Medicine & PIE
• UNM medical students between their first and
second years spend nine summer weeks living &
working in a rural clinical practice “Practical
Immersion Experience (PIE)”

• Self-selected students write reflectively once a


week to volunteer physician mentors on campus
in place of one H&P

• Mentors respond in kind via email


Narrative Medicine does not make
medical students into "writers,"
but makes them better doctors

• supporting their skills of observation

• encouraging their reflection in a clinical context

• showsibg the students that their thoughts,


feelings, and questions are heard hrough the
responses from the mentors.
Students say this writing helped
them to:
• perceive their clinical work in a thoughtful
way

• become more observant and analytical

• look for recurrent patterns

• respond better to patients.


Content analysis
Julie Reichert read one work by each
student. Major themes:

• Cultural challenges
• Ethical issues: truth telling
• Importance of active listening
Writing prompts – Infinite variety…
think about goals, setting, background of
attendees
• What did you give up to come here today?
• Describe a time when you were angry with
a patient.
• Write your own obituary.
• Describe your first experience with death.
• Describe how you healed a patient.
Initiation: first-time experiences

Many of the students' stories addressed


first-time experiences – witnessing birth
and impending death, trying hands-on
procedures
Identity

The students grappled with who they were


becoming as they began to take on the
role of being a physician

A student's pain as he meditates on how


his new medical knowledge and focus on
becoming a doctor is leading him away
from his working-class family and his roots.
Many students marveled at the sheer beauty
of patients and of the practice of medicine:

The "exhaustion filled with love" of a 74-


year old father taking care of a 45-year-old
developmentally disabled daughter
Frustration and disillusion

Some students wrote about problems with


preceptors, the limits of medicine, and other
difficult topics.

Noticing the contrast in a preceptor's negative


attitude in treating a suicide survivor
("voluntarily" ill) with attitude in caring for an
older, dying patient
Feeling helpless and angry regarding an aging
couple’s losing their independence
Questioning

Sometimes, students’ experience evoked


unexpected thoughts and questions about
medical practice.

Observing an interaction between mother/child and


physician, questioning how much of medical
education should be science, and how much
humanities
The paradox of finding sick children interesting and
well babies boring
Values

Students questioned themselves when


suddenly faced with difficult ethical
situations

Feeling ethically challenged in the face of a


dying patient who refuses care
CONCLUSION: A Narrative Medicine
experience can be:

• simple to set up
,
• requires a very modest investment in
student and faculty time

• rewards the effort with increased


reflection and satisfaction for both
students and faculty.