Does Narrative Medicine Have a Place at the Frontline of Medicine?

This guest blog post is by Liam Dwyer, a postgraduate medical student at Trinity College, Dublin, where medical training encompasses medicine and health as well as humanities, provoking students to conceptualise medicine differently; not simply as a clinical science, but with a more holistic perspective. Here he explores the role of narrative medicine, both in medical training and its practicality in a clinical setting.

While medicine has always encompassed a narrative form, it is only in the past two decades that the study of humanities has begun to eclipse medical training (1–5). It represents a means of developing a skill in interpretive, relational and reflective areas otherwise difficult to teach (6). As espoused by Dr. Rita Charon, it ‘enlarged the evidence available on which to base our clinical actions and the grounds for our therapeutic affiliation’ (7), yet whether its basis represents clinical idealism rather than clinical realism entails further inquiries into the nature of such skills.

It cannot be denied that narrative medicine is met with some opposition. It stems from realistic concerns about the management of time, especially in terms of accessibility for patients. In the current situation, even large university hospitals have systems of managing the multiply-injured patient comparing poorly to international standards (8). Morris et al. reports the rooted dubiety of clinicians about narrative medicine. ‘”What you say about narrative is very interesting,” He has heard repeatedly. “Thanks so much for coming. But I have seven minutes per patient.” End of story’ (9). Furthermore, many patients, especially those who are well-informed, prefer a ‘no-nonsense’ physician who holds the answer (9). Narrative infers an expurgation of professional distance and authority.  A clinician conveying such intimacy may step over the line between paternalism and patient-centred care (10).

A significant discussion surrounding narrative medicine was Dr. Charon’s 2001 article in JAMA, asserting that narrative medicine is a form of knowledge, in terms of being a source and an instrument (11). As a source, it represents something clinically relevant to numerical data of an arterial blood gas. As an instrument, requiring skillful technique for its implementation, like a scalpel (9). Dr. Charon wants certified professional competence and medical training in narrative, advocating ways of thinking about knowledge that are bound to inspire resistance. A biomedicine potentially reformed by narrative medicine is right to see its menacing identity and power. Unlike biomedicine, narrative medicine entirely depends on the concept of inter-subjectivity (9). For narrative medicine to warrant space in JAMA, it needs to accentuate its claim to knowledge, which in the last few years, it has achieved to some extent (12–16). Physicians are beginning to accept the value of what’s absent by the accredited biomedical narrative forms (12–16). Not only medicine but also nursing, law, religious studies, and government have recognized the value of narrative knowledge (11,17).

Medical narrative forms have been established for exploring novel styles of interactions with patients (18). Even clinical trials have begun to be formulated around narrative medicine (19). Numerous teaching programmes have recently been created to enhance narrative competency, such as those at Columbia or  King’s College London, with experts in the area of narratology demonstrating its therapeutic role for patients (9). Authors such as Bury proposed that illness of any kind is a disruption, an adjournment of an on-going life (20,21). When an individual faces an illness, they need to adapt their life story. In this milieu, narrative provides a voice to that disruption (20). Anatole Broyard, a prominent writer for the New York Times, delineated the story of his illness, affirming ‘storytelling seems to be a natural reaction to illness. People bleed stories, and I’ve become a blood bank of them’ (20,22).

Narrative medicine aids doctors in appreciating styles of thought and interaction in medicine that go beyond disease-framed, chronological history-taking (5,23,24). They have been shown to play a key role in making diagnostic assumptions and developing care pathways (25), especially in comprehending the story of those with cancer (26), acute coronary syndrome (ACS), and those with other chronic diseases (25,27). Recently, Gargiulo et al. investigated the psychosocial and organizational aspects of the patient’s journey whilst undergoing hematopoietic stem cell transplantation (HSCT) through various narrative interviews (25). Psychological issues (‘I met many people who are now dead, each person is unique… unfortunately that’s life…’), and clinical issues (‘you might get infected… you might have stomach ache, backache. I had to take many pills every day. I could not eat… I lost 22kg… ‘) were highlighted, leading to more effective care plans for the patients (25).

Yet for narrative medicine to be implemented at the frontline of medicine, its idealistic expectations must be re-evaluated. A number of problems relating to Charon’s way of thinking have been raised. Angela Wood’s essay contests the rationale of the concept of narrative self through her discussion and use of Galen Strawson’s seminal ‘Against Narrativity’ (28,29). It asserts that storytelling is not the sole or most valuable method by which to highlight an individual’s suffering. It calls for the reassessment of the role of the narratee in the narrative process permitting scholars to re-evaluate what it is we do with stories of illness (29).  Also, to think on methods in which narrative may be employed to understand illness and suffering in medical humanities contexts.  Narrativity should be broadened to encompass forms of expression as even non-verbal expression needs language and narrative ordering in the development of expression. In each effort made to elicit an expression of suffering, we demand a cognitive engagement that requires the ordering information into narrative (29). As eloquently put by McKechnie, ‘We seek out communication; we desire the transmission of an idea. This is narrativity and it takes a myriad of forms’ (29). Furthermore, Dr Charon’s development of the parallel chart (30) is a practical and essential part of medical training, designed to increase the student’s capacity for effective clinical work. However, to employ parallel charts in an acute clinical context is far from practical. This method asks doctors, in addition to maintaining traditional records on their patients’ progress, to monitor the emotional toll of the hospital experience. As the healthcare environment speeds up, practice will also speed up, and therefore inter-professional healthcare teams will need a more powerful framework to achieve empathetic and effective collaborative relationships.

Narrative medicine is a promising addition to the current training strategies to prepare medical students for effective performance as resident physicians and practising clinicians, but its effective implementation in an acute setting is a challenging feat. Indeed, resistance to narrative medicine does exist, both with patients and physicians, and will not dissipate. Narrative medicine has gained enough traction that the present time seems appropriate to confront its internal differences. This self-assessment assures not just clarification of its principles, but also of the benefits that extend beyond improved patient care for doctors.

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