An Introduction to Narrative Medicine

Tom Barber, MDAssociate Professor of Medicine

Learning Objectives To consider the role of narratives in the

practice of medicine.  To understand how a focus on narrative can

sharpen clinical skills.

To learn a model for using written narratives in medical education.

To practice writing and sharing a narrative about our work as educators.

My interest and experience in hearing, reading, & writing narratives Children’s stories Writing exercise listening to the Grand Canyon Suite,

Ferde Grofe’, 1931 (also called 5 pictures of the Grand Canyon), 4th grade

My own writing South Shore writers group Charles River poets Narrative Workshops x2, American Academy on

Communication in Health Care South Chatham Writers Workshop, 7/14 Leading various seminars and workshops at BUSM,

BMC and in the region on the medical history and narrative

Narrative Medicine Workshop 3/14, Columbia University

Thanks to a Dept of Med Faculty Development Grant!

3 day workshop Lectures: “Methods for improving clinical

effectiveness;” “Reconceptualizing empathy;” “Narrative ethics”

Seminars: “Close reading;” “Clinical cases;” “Training in attentive listening;” “Illness Narratives: the skills of bearing witness to the suffering of others”

Facilitated writing exercises

Columbia Narrative Medicine Created by Rita Charon, MD, PhD Objectives of the program (direct quotes)

To develop narrative competence to nourish empathic doctor-patient relationships

To learn narrative communication strategies for patient-centered and life-framed practice

To build habits of reflective practice that enhance professionalism and nurture clinical communities

To acquire pedagogic skills to teach NM To replace isolation w affiliation, cultivate

enduring collegial alliances, and reveal meaning in clinical practice

Center for Narrative Practice An offshoot of the Columbia Narrative

Medicine program, led by Scott Alderman Raising funds now, with plans to open in

2015 Wider focus than health care “Our goal is to establish a Center for

Narrative Practice in Cambridge in 2015. Join our movement. Together, we can change the world, one story at a time.” (!)

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…

Opportunities to teach narrative practice at BMC/BUSM Dept of Med Introduction to Clinical Medicine 1 Communications skills workshops, Ambulatory

Internal Med clerkship, BUSM Clinical Reasoning Exercises (CREX), Dept of

Med. Diagnostic and clinical reasoning are enhanced by developing narrative skills: hearing, questioning, clarifying, synthesizing, reporting, writing, understanding clinical information

Writing for Wellness workshops Visual Thinking Exercises (VTS): sharpens

observation and listening skills; integrating information towards a “visual narrative”

Narrative workshops Where/when: Recall goals of Columbia NM

program: to promote empathy, communication skills, professionalism, reflective practice, teaching skills, collegial relations; to reveal meaning…

Tools: pen or pencil and paper, some time, usually with a group of people

Format: small group, introduction and “centering,” ground rules, writing prompt, spontaneous writing for short interval (5-15 minutes), sharing writing product with a few attendees (+/- 2-6) with time for responses, closure.

Ground rules or norms Mutual respect Confidentiality Attendees are encouraged to participate, but can opt

out of writing, reading, and/or commenting on narratives

Listen and respond without judgment to how the narrative is written/told, what is told, from concrete to emotional content.

The exercise is not a kind of psychotherapy; note that this notion is absent from goals; facilitators must respond, support and redirect if needed.

Lower expectations about writing product: the exercise is not about writing for publication or for a wide audience, but only for this group

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.

Questions? Comments?

Writing prompt for today

Tell about a time when you learned something new or important from a student or trainee.

The Teacher, by Curtis James

Recommended reading Charon R, Hermann N. A sense of story, or why teach

reflective writing? Acad Med 2012; 87: 5-7 Charon R. At the membranes of care: stories in narrative

medicine. Acad Med 2012; 87: 1-6. Charon R. A model for empathy, reflection, profession, and

trust. JAMA 2001; 268; 1897-2002. Ensign Josephine. “Medical Margins” Blog: The ultimate

writing prompt. Aug 14, 2013. Wordpress.com. Greenhalgh T, Hurwtiz B, eds. Narrative based medicine:

dialogue and discourse in clinical practice. London, Eng: BMJ Books, 1998.

Naghshineh, et al. Formal art observation training improves medical students’ visual diagnostic skills. J Gen Intern Med. 2008; 23: 991-997.

Peterkin A. Practical strategies for practicing narrative-based medicine. Can Fam Phys 2012; 58: 63-64.