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Provocations

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

30 May, 17 | by amcfarlane

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.

References

  1. Bell SK, Krupat E, Fazio SB, Roberts DH, Schwartzstein RM. ‘Longitudinal pedagogy: a successful response to the fragmentation of the third-year medical student clerkship experience’, Academic Medicine 2008; 83(5): 467–75.
  2. Krupat E, Pelletier S, Alexander EK, Hirsh D, Ogur B, Schwartzstein R. ‘Can changes in the principal clinical year prevent the erosion of students’ patient-centered beliefs?’ Academic Medicine 2009; 84(5): 582–6.
  3. Branch Jr. WT, Kern D, Haidet P, Weissmann P, Gracey CF, Mitchell G, et al. ‘Teaching the Human Dimensions of Care in Clinical Settings’. JAMA. 2001;286(9):1067–74.
  4. Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. ‘Medical students’ professionalism narratives: a window on the informal and hidden curriculum’. Academic Medicine 2010; 85(1): 124–33.
  5. Hurwitz B, Charon R. ‘A narrative future for health care‘. Lancet. 2015; 381(9881): 1886–7.
  6. Arntfield SL, Slesar K, Dickson J, Charon R. ‘Patient education and counseling: narrative medicine as a means of training medical students toward residency competencies’. Patient Education and Counseling. 2013; 91(3): 280–6.
  7. Charon R. ‘Narrative medicine in the international education of physicians’. La Presse Médicale. 2013; 42(1): 3–5.
  8. Medicine E. ‘An Integrated Trauma System for Ireland’. Irish Association for Emergency Medicine. 2014;(December).
  9. Morris DB. ‘Narrative medicines: challenge and resistance’. The Permanente Journal. 2008;12(1):88–96.
  10. Tauber AI. ‘Patient Autonomy and the Ethics of Responsibility’. New England Journal of Medicine. 2008; 36(1): 148–9.
  11. Charon R. Narrative medicine: A Model for Empathy, Reflection, Profession & Trust. JAMA. 2001;286(15):1897–902.
  12. Zachariae R, Pedersen CG, Jensen AB, Ehrnrooth E, Rossen PB, von der Maase H. ‘Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease’. British Journal of Cancer. 2003; 88(5): 658–65.
  13. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. ‘Physicians’ empathy and clinical outcomes for diabetic patients’. Academic Medicine. 2011; 86(3): 359–64.
  14. Soo S, Kaplowitz KS, Johnston M V. ‘The Effects of Physician Empathy on Patient Satisfaction and Compliance’. Evaluation and the Health Professions. 2004; 27(3): 237–51.
  15. Davies K. ‘The information-seeking behaviour of doctors: A review of the evidence’. Health Information and Libraries Journal. 2007;24(2):78–94.
  16. Charon R, Hermann N, Devlin MJ. ‘Close Reading and Creative Writing in Clinical Education: Teaching Attention, Representation, and Affiliation’. Academic Medicine. 2016; 91(3): 345–50.
  17. Swenson MM, Sims SL. ‘Toward a narrative-centered curriculum for nurse practitioners’. Journal of Nursing Education. 2000; 39(3): 109–15.
  18. Murphy JW. ‘Primary Health Care and Narrative Medicine’. The Permanente Journal. 2015; 19(4): 90–4.
  19. Robert Lawrence M. ‘Impact of Early Implementation of Narrative Medicine Techniques on Patient Centered Attitudes of Medical Students’. 2017. ClinicalTrials.gov Identifier: NCT03041571.
  20. Fioretti C, Mazzocco K, Riva S, Oliveri S, Masiero M, Pravettoni G. ‘Research studies on patients’ illness experience using the Narrative Medicine approach: a systematic review’. BMJ Open. 2016; 6(7):e011220.
  21. Bury M. ‘Chronic illness as biographical disruption’. Sociology of Health and Illness. 1982;4(2):167–82.
  22. Broyard A. ‘Intoxicated by my Illness’. Intoxicated By My Illness and Other Writings on Life and Death. 1990: 3–68.
  23. Loudon M. ‘Doctors’ stories: the narrative structure of medical knowledge’. Medical History. 1993: 211–2.
  24. Greenhalgh T. Narrative based medicine: narrative based medicine in an evidence based world. British Medical Journal. 1999; 318(7179): 323–5.
  25. Gargiulo G, Sansone V, Rea T, Artioli G, Botti S, Continisio GI, et al. ‘Narrative Based Medicine as a tool for needs assessment of patients undergoing hematopoietic stem cell transplantation’. 2017; 88(7): 18–24.
  26. Copelli P, Foà C, Devincenzi F, Fanfoni R, Prandi R, Puddu M, et al. ‘The degree of coincidence between the needs of cancer patients and the answers in the statutes of associations and dedicated health services’. Assistenza Infermieristica e Ricerca. 2011;30(1):24–33.
  27. Apostoleris NH. ‘Review of integrating narrative medicine and evidence-based medicine: The everyday social practice of healing’. Families, Systems, & Health. 2012; 30(1): 82–3.
  28. Strawson G. ‘Against Narrativity’. Ratio. 2004; XVII(December): 428–52.
  29. McKechnie CC. ‘Anxieties of communication: the limits of narrative in the medical humanities‘. BMJ Medical Humanities. 2014; 119–24.
  30. Weiss S, Midelfort L. ‘Narrative Medicine: Honoring the Stories of Illness’. JAMA. 2006; 296: 2622–3.

Widening the Lens: Guest Post by Brandy Schillace

11 Mar, 14 | by BMJ

Widening the Lens | Medical Humanities

Brandy Schillace

Author, Historian and Adventurer at the Intersection (http://brandyschillace.com)

 

Recently, I read and reviewed Identity and Difference: John Locke and the Invention of Consciousness by Etienne Balibar. One of the points brought up in the lengthy introduction by Stella Sanford is that the reception of the work in its first edition was hindered by transcontinental miscommunication. It is a point worth considering. Our cultural context deeply influences the way we perceive everything from philosophy to art—and so it should not be surprising that this same cultural frame of reference has impacted what we mean by medical humanities. It can even influence what “counts” in the discipline (and this notwithstanding our frequent disagreements about humanities themselves!)

 

In the US context, the medical humanities are often subsumed under medical education or bioethics initiatives. At the Cleveland Clinic Lerner College where I help to develop year two curriculum, medical humanities consists in history, ethics, literature and arts with the purpose of integrating “the human dimension into healthcare, medical education and research.”[1] The New York University School of Medicine defines medical humanities in a similar fashion, as “an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, and visual arts) and their application to medical education and practice.”[2] In both of these statements and countless others in the United States, a key focus is upon the humanities utility to the practice of medicine. It enriches the human perspective, but with only a few exceptions, the medical lens is still primary. This differs from perspectives in the UK where, for instance, the Centre of Medical Humanities at Durham considers medical humanities to be a field of enquiry where the humanities lens is brought to bear on the enterprise of medicine. The BMJ’s medical humanities are similarly situated, seeking to enhance the discussion of medicine in a forum that welcomes critical exploration in which the humanities are frequently privileged and primary.  On one hand, these two perspectives do not seem divergent. And yet, small differences do matter. We seek inclusivity—and medical humanities is a necessarily broad field—but certain perspectives still fall between stools.

 

Despite our aims at diversity, one aspect of the medical humanities easily overlooked is the one nearest to us—the same that influenced the reception of Locke and of Barber’s work about him—our cultural context. Nothing is so blinding as the screen of self; we cannot get outside our own heads to see with other eyes. Those most adept at translation are those most immersed in multiple worlds, which is why I so deeply value medical anthropology and social medicine as critical lenses. This is also why I value the historical perspective—anything that unmoors us so that we may look back at a distance and see more of the picture. To Victorians, animal magnetism, mesmerism, mediums, paramnesia, proamnesia and displaced memory were all more or less soundly scientific. Further into our history we find alchemists, and long before that, Greek philosophers experimenting with elements supposedly ruled by planets and by the gods. How much of what we believe today will be cast out in the future? And might not some of that past knowledge be resurrected? An oncologist friend of mine recently pointed out that humoural theory has begun to have a certain valence once again—“progress” is rarely linear, after all.

 

I will examine a case from the US context, and from my work at Culture, Medicine, and Psychiatry, an international journal of cross-cultural health research. Devon Hinton, of Harvard, works a great deal with Cambodians suffering PTSD after the Pol Pot period. What he discovered was that this group possesses a unique “bereavement ontology,” in which dreams of the dead play a crucial role.[3] In another work by Hinton a few years earlier, he similarly looked at somatic distress, and here, too, the findings were unique.

 

The Cambodians believe in a wind-like substance called khyâl; this “wind” is greatly feared and considered pathogenic; it may “surge upward in the body” to cause bodily catastrophes: neck soreness, rupture of vessels, dizziness  and weakness.[4] The psychiatrists understood these as post traumatic symptoms, but that does not make the khyâl less real, or the dreams of the dead less important. Cambodians frequently resort to coining and cupping as treatment—and just because therapists also want to use biomedical methods of treatment does not negate the positive benefits of these traditional healings. Their experiences are not less “true” because they are conceived of along different lines, because scientific and medical truth are relative to context and experience. Seeing the relevance of other cultures’ beliefs and practices is valuable to remembering that the truth we cling to is largely a product of our cultural underpinnings. Does coining work? Ask the Cambodians before you say no. It’s working for them.

 

How does this relate to the medical humanities? The connection I draw between medical anthropology and our shared discipline is bridged, in part, by social medicine. As yet one more useful lens, social medicine studies intersections of medicine and society, the ethical and social contexts of medicine’s larger enterprise. Taking these perspectives together, we may be able to re-see ourselves, stepping away long enough to recognize that health is intimately bound up with the human, knit together as close as the bodies that contain us. The useful distance of history and place should also force us to recognize that there is room enough for medical understanding and for personal truth. Lastly, the social dimension should remind us that there are consequences to all we do—including the boxes we draw around ourselves and others. Will that make us too broad? I can imagine the question being asked, but for me the answer is necessarily yes. In fact, medical humanities ought not only to be broad, it ought to facilitate breadth. Only in so doing will we remove obstacles and be truly interdisciplinary—and in fact international—in scope.

 

As with so many things, we always see more when we widen the lens.

 


[1] Martin Kohn, Director. Medical Humanities/ Information Page. Cleveland Clinic Lerner College. http://my.clevelandclinic.org/about-cleveland-clinic/ethics-humanities-care/medical-humanities.aspx

[2] Felice Aull. “Mission Statement” Medical Humanities New York University School of Medicine

[3] Devon Hinton, et al. “Normal Grief and Complicated Bereavement among Traumatized Cambodian Refugees: Cultural Context and the Central Role of Dreams of the Dead.” CMP (2013) Volume 37(3):427-464

[4] Devon Hinton, et al. PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians:

The Results of a Needs Assessment Survey.” Medical Anthropology Quarterly (2012) 26(3):383-407

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