Principles and Practices in Narrative Medicine: An Exciting Cutting Edge Multidisciplinary Training

If you are aware of the upcoming CASAT workshop Principles and Practices in Narrative Medicine, being presented by: Adrian Matt Zytkoskee, PhD, you may be wondering what it is and whether it applies to you. The principles and practices of narrative medicine just may be the humanistic and multidisciplinary framework you are seeking to relate better to your patients as a physician, nurse, emergency responder, or behavioral health provider. Whether you are simply curious or still on the fence about attending the training, read on to learn more about how narrative medicine not only improves communication between you and  your patients, but also how it can empower you to better use your experiences and those of others to navigate your own personal and professional paths.

What is Narrative Medicine?

Narrative medicine is not therapy and healthcare providers are not therapists. The foundations of narrative medicine include “literature and medicine, narrative ethics, medical humanities, healthcare communication, and primary care medicine (Charon, 2017 P. 2). The focus is on providing better medical care and on integrating the experiences of health providers and their colleagues into their development as practitioners. The narrative medicine methodology was founded at Columbia University in the late 90s by physicians who believed that the narratives of patients – patient perspectives – should drive their health care. Narrative medicine begins during medical school by using the reading and discussion of creative narratives during all four years of medical school to change – and improve – the way those receiving healthcare are received by providers. Learning narrative medicine is considered by its proponents to be an important part of becoming a physician. In a methodology supported by literary studies, philosophy, and psychoanalytic thought, medical students examine poems, art, dance, and other story-telling methods, write briefly about them, and discuss them in groups. This mutually supportive group activity evolved during the earliest beginnings of the methodology and the three benefits that emerged include:

• Attention Skills that are developed for better patient care. Through the process of learning to focus on the words used by others and by themselves in describing their thoughts and experiences, medical students learn to become more attentive and more committed to listening to what their patients tell them.
• Representation development by writing for brief periods of time, such as 3-4 minutes, as an opportunity to learn to observe and make sense of their lives, experiences, and the world.
• And Affiliation, or development of relationships and the ability to be present in the moment to listen with respect and curiosity as others share their writing. This process of risk-taking through sharing of thoughts and observations is rewarded by development of trust and better relationships and bonding between patients and clinicians.

Creativity within the practice of medicine is also developed through this process, enabling physicians and other healthcare providers to tap into their creativity and alternative solutions in providing patient care. Narrative medicine has spread throughout the world and the techniques and training methods have begun to reach into many healthcare and behavioral health settings and even into other fields such as law, education, and corporations (Charon, 2017).

Outcomes of Training in Narrative Medicine

Research suggests that the goal of quality improvement in the delivery of healthcare is better met by those trained in narrative medicine. Some of the outcomes include:

Building community and promoting self-care – In one study, an interprofessional program in narrative medicine was developed without funding and without protected time for participants. The 18-month program was attended by 126 caregivers who dropped in to the one-hour experience at the end of or just prior to their shifts. The participants included medical students, residents, or fellows (32%), attending physicians (29%), nurses or nursing students (12%), social workers (10%), child life specialists (6%), with the remaining 11% consisting of chaplains, administrators, and teachers. The qualitative study was designed to capture interprofessional relationships that formed, and the value participants placed in their work individually and as members of teams of professionals with different levels of training. The results of the interviews found that engaging in the narrative activities through art, literature, and writing exercises enabled professionals at diverse levels of the medical hierarchy to relate more as equals. This promoted trust and mutual understanding that allowed community-building. Participants also revealed they had difficulty in expressing feelings in the work setting due to being on the clock, concerns about safety in sharing with others, and the stress of handling difficult emotions. The narrative medicine activities created a safe space for sharing emotionally where they could express their thoughts and feelings in relationships with others and grow personally. The process of connecting with others in this way alleviated a lot of the job-connected stress by helping them to focus on the meaningfulness and value of their work that made it fulfilling  (Small et al., 2017).

Increase in Empathy and Decrease in Burnout of Healthcare Providers – One review of the literature examined 401 abstracts looking for evidence that the use of poetry in a narrative medicine training setting positively  affected empathy and burnout among healthcare workers and concluded that although there are limited studies that focus on the exclusive use of poetry in narrative medicine training, there is some limited evidence that it may reduce burnout (Schoonover et al., 2019).

Increased Program Satisfaction and Skills Competence in Diverse Areas – A review of 1,569 published training programs for narrative medicine supported high rates of satisfaction with the programs by participants in training programs for medical, dental, health sciences, allied health professionals, faculty in medical, dental, and health sciences, and non-faculty physicians. The studies included in the review were examined for qualitative and quantitative data related to relationship-building, empathy, perspective-taking/reflection, resilience and burnout detection/mitigation, confidence/personal accomplishment, narrative competence, ethical inquiry, pedagogical skills, clinical skills, relevance to work, institutional impact, and cultural competence. The results of the review revealed “modest but positive varied benefits related to narrative-based education for health science professionals” and “potential for enhancing communication and team-building skills, encouraging perspective-taking and reflection, promoting empathic behaviour, detecting/mitigating burnout, cultivating narrative competence, augmenting pedagogical and clinical skills, and fostering ethical inquiry” (Remein et al., 2019). The review authors also suggested that future research is needed to explore the use of narrative medicine training in the areas of cultural competence, its use for scientists, for helping to detect and mitigate burnout, and for use in low-resource settings.

Benefits of Narrative Medicine Training in Practice

For those in health professions the benefits of narrative medicine are very well documented. From their own perspective, research shows that providers trained in narrative medicine are able to build better relationships with others at a variety of levels in the medical hierarchy, learn to express and hear difficult emotions and the literature and through writing, and reap the benefits of this growth in increased empathy, reduced stress, and increased self-care. They become more attentive listeners, improve competence in a variety of skills, and feel more fulfilled in their work. Narrative medicine is an attempt to fix what is broken in the provision of healthcare, if what is broken is correctly reflected in a recent study that found most clinicians interrupted patients in the explanation of their health concerns after just 11 seconds (Singh et al., 2020) and data that found most doctor visits ended in 15 minutes or less (National Ambulatory Medical Care Survey, 2010).

Narrative medicine is still an evolving area of medical training, yet its value for providers in health and other fields is becoming increasingly well documented around the world. Moreover, medical schools are providing narrative-based education and support for this training, practitioners are becoming more competent, and the needs of the patients are being heard by more attentive providers. All that is missing is research to support that the training and skills in narrative-based medicine translates into higher patient satisfaction and outcomes. At least one researcher holds that narrative-based medicine is not as widely practiced as it might be and that more is needed to convince practitioners to use it. While “the healing power of narrative is repeatedly attested to…the scientific evidence, however, with respect to NBM’s effectiveness, is sparse (Zaharias, 2018). “If NBM is to be incorporated more broadly in clinical practice, more research is needed to better define NBM’s role, understand the specific skills required for practice, and determine NBM’s outcomes with respect to illness and disease” (Zaharias, 2018).

Narrative medicine provides skills for health providers to better gather information from patients, engage in more productive relationships, and features the clinician/patient partnership as key in managing illness and promoting health and well-being. What it provides is a means to improve healthcare provision and “a means by which the art of medicine can be practiced” (Zaharias, 2018).

Professional Development Opportunity

This In-Person class is offered by CASAT Learning on Tuesday August 31, 2021, at the University of Nevada, Reno: Redfield Campus. In the Principles and Practices in Narrative Medicine workshop, participants will:

1. learn about the psychosocial issues within health care that led to the establishment of narrative medicine.
2. explore the ramifications of our current global crisis and consider how the use of narrative might provide growth and healing.
3. practice a range of reflective writing exercises designed to help the writer unburden challenging emotions, process uncertainty, and bear witness to the lives of others and self.
4. connect with professionals in mental health through the sharing of experiences.
5. analyze published narratives and other forms of art relating to mental health.
6. discuss approaches to healthy group-work dynamics and providing feedback.

For more information and to register for the class visit CASAT Learning.

For additional materials and links visit CASAT OnDemand Resources & Downloads.

References

Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA. 2001;286(15):1897–1902. doi:10.1001/jama.286.15.1897

Charon, R. (2017). The principles and practice of narrative medicine . Oxford University Press.

Chen, P.-J., Huang, C.-D., & Yeh, S.-J. (2017). Impact of a narrative medicine programme on healthcare providers’ empathy scores over time. BMC Medical Education, 17(1), 108–108. https://doi.org/10.1186/s12909-017-0952-x

Lijoi, A. F., & Tovar, A. D. (2020). Narrative medicine: Re-engaging and re-energizing ourselves through story. International Journal of Psychiatry in Medicine, 55(5), 321–330. https://doi.org/10.1177/0091217420951039

Remein, C. D., Childs, E., Pasco, J. C., Trinquart, L., Flynn, D. B., Wingerter, S. L., Bhasin, R. M., Demers, L. B., & Benjamin, E. J. (2020). Content and outcomes of narrative medicine programmes: a systematic review of the literature through 2019. BMJ Open, 10(1), e031568–e031568. https://doi.org/10.1136/bmjopen-2019-031568

Schoonover, K. L., Hall-Flavin, D., Whitford, K., Lussier, M., Essary, A., & Lapid, M. I. (2020). Impact of Poetry on Empathy and Professional Burnout of Health-Care Workers: A Systematic Review. Journal of Palliative Care, 35(2), 127–132. https://doi.org/10.1177/0825859719865545

Singh Ospina, N., Phillips, K. A., Rodriguez-Gutierrez, R., Castaneda-Guarderas, A., Gionfriddo, M. R., Branda, M. E., & Montori, V. M. (2019). Eliciting the Patient’s Agenda- Secondary Analysis of Recorded Clinical Encounters. Journal of General Internal Medicine : JGIM, 34(1), 36–40. https://doi.org/10.1007/s11606-018-4540-5

Small, L. C., Feldman, L. S., & Oldfield, B. J. (2017). Using Narrative Medicine to Build Community Across the Health Professions and Foster Self-Care. Journal of Radiology Nursing, 36(4), 224–227. https://doi.org/10.1016/j.jradnu.2017.10.002

Zaharias, G. (2018). What is narrative-based medicine? Narrative-based medicine 1. Canadian Family Physician, 64(3), 176–180.

Zaharias, G. (2018). Learning narrative-based medicine skills Narrative-based medicine 3. Canadian Family Physician, 64(5), 352–356.

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