Curriculum Areas
Integrative Elective
NARRATIVE MEDICINE IN CLINICAL PRACTICE
LOCATION: The course will be located at UTMCK and the University Cancer Institute. There will be at least one home visit required during this rotation.
FACULTY: Ronald H. Lands, MD
SCHEDULE: This rotation is only available to 3d year residents who are in good academic standing and who have prior approval from Dr. Mark Rasnake, Program Director. It will be limited to those times when Dr. Lands is assigned as attending to House Staff Medicine. The resident will not have primary patient responsibilities on this elective, but they will participate on rounds with the House Staff Medicine Team allowing an opportunity to be exposed to10-20 patients daily. Dr. Lands also has a benign hematology clinic that meets ½ day per week during this rotation, and the schedule averages 1-3returns and 1-3 new patients per session. There will be at least one home visit required during this rotation.
RELATED CONFERENCES/VENUES: The resident will follow the Department of Medicine Residency conference schedule including morning report, clinical-pathologic conferences, morbidity and mortality conference, safety and quality improvement, and the noon didactic lecture series. The resident will meet their scheduled continuity clinics in the Outpatient Medicine Clinic. At least one afternoon per week, there will be a focused discussion on assigned readings and narrative aspects of clinical medicine prompted by patient encounters in any of the required venues with the attending and other members of the house staff team who have time and wish to join.
GOALS:
Patient Care: Residents will learn to use reading and reflective writing to nurture compassion and empathy, and to better identify appropriate and effective care.
Medical Knowledge: Residents will use novels, short fiction and poetry to enhance their knowledge of biomedical, clinical, social, behavioral, and epidemiologic aspects of medicine.
Professionalism: Residents will read fiction and poetry illustrating ethical dilemmas, people of different cultures, religions and beliefs and become more aware of how their personal attitudes influences medical care.
Interpersonal and Communication Skills: Residents will become more effective communicators in writing, formal presentations and in patient encounters.
OBJECTIVES:
• Student participants will be assigned readings in current medical journals and books written by thought leaders in the field and become familiar with the philosophy of narrative medicine.
• Residents will complete assigned readings of short stories and poems depicting clinical situations and illnesses presented in art form and relate it to past personal experiences, current observations from inpatient or outpatient encounters or predictable future ones.
• Residents will complete selected readings of works written by physicians including but not limited to Anton Chekhov, William Carlos Williams, Oliver Sacks, Sherwin Nuland, and Richard Selzer and participate in focused discussion and reflective writing regarding selected topics. Examples of these works are attached to the end of this document.
• Residents will complete readings by non-physician writers illustrating a particular point such as loss, receiving bad news, and grief. These writers include, but are not limited to William Carver, Amy Hempel, and Susan Perabo. Each work will be the subject of a focused discussion, facilitated by the attending. Examples of these works are attached to the end of this document.
• By the end of this course, residents will have completed a reflective work; clinical vignette, short story or poem, worthy of submission for publication.
SUPPLEMENTAL REFERENCES: References are attached.
PROCEDURES: There are no internal medicine procedures required in this elective.
RESEARCH OPPORTUNITIES: Research in narrative medicine is beyond the scope of this elective.
METHOD OF EVALUATION:
• The attending physician will evaluate the student by direct and indirect observation.
• The attending physician will evaluate the student’s knowledge and proficiency in applying narrative medicine concepts by evaluation of writing samples, effort, engagement and participation in discussions.
METHOD OF CURRICULA AREA PROGRAM EVALUATION:
• Residents may feedback regarding concerns at any time to the attending, the Internal Medicine Resident Program Director or the Chairman of the Department of Medicine.
• Residents will complete an evaluation form using New Innovations at the end of the rotation.
• The Departmental Chair will give cumulative feedback to the attending faculty.
FEEDBACK:
• At the beginning of the course, the attending physician will review the goals and objectives and elicit the personal goals of the student.
• The attending physician will provide feedback to the student at the midpoint, and as needed during the rotation.
• The attending physician will provide written feedback at the end of the rotation.
OVERVIEW:
There are two stories that comprise the physician-patient interaction. The illness story is the patient’s, couched in hopes and fears and tinged with a worldview that is unique to that person. The biomedical story is the one the doctor hears. It is filtered through his/her worldview, and finally interpreted and packaged in the form of a diagnosis and treatment plan for the patient, or for presentation to other doctors.1 Bringing the two stories together is an interpretive act that requires the skill to listen to an illness story with its sometimes unpredictable narrator, and at once, translate it into biomedical concept, then organize the information into the framework of the medical history that doesn’t dehumanize or diminish the patient’s credibility.2 Evidence suggests that physicians who can focus on the patient as well as their disease obtain more accurate and thorough historical data, increase patient adherence and satisfaction and set the stage for more effective physician-patient relationships.3
The skills needed to absorb a patient’s story are the same as those needed to read and interpret literature.4,5 Just as in a critical reading of prose, the reading of the patient requires attention to context, point of view, reliability of the narrator, character analysis, metaphors and hidden meanings.6,7,8 We witness as a part of our profession, birth, suffering, and death. Great writers of prose and poetry describe these same things.9 There is, therefore, an opportunity for medical residents and residents to benefit from reading about the lives of sick people, reflecting on their patient's illness and contemplating their experiences in the care of sick and dying patients.10 Novels, short stories, poems, or patient narratives that illustrate patients and caregivers in various roles are relevant, enjoyable to read and facilitate professional growth of the physician. 11,12,13
In addition to reading literature, writing about patients as stories builds interpretive, communicative and empathic skills.14,15 Reading and writing may help doctors maintain or regain the healthy perspective that is continuously at risk because of constant exposure to pain and suffering. Several studies strongly suggest that there is a positive relationship between writing and speaking about difficult or emotional experiences and physical health.16
The final common denominator of narrative medicine may be the self-examination that it promotes. The process of reflection is often triggered by recognition of a mismatch in existing knowledge and a current experience that requires one to consider the meaning and the implications of an experience or action.17 Doctors who reflect on their own decision-making, feelings, and behaviors develop insight into their own educational needs and are better prepared to practice autonomously.18
Finally, narrative without clinical experience and medical science is pointless.19 This course will assume that medicine is a scientific discipline with narrative responsibilities. The faculty will teach it with attention to maintaining a safe and effective balance between compassion and competence, the story and the science.
Samples of Assigned Readings:
Poetry:
- “I’ve seen a dying eye,” Emily Dickinson
a. The student will first diagnose the clinical syndrome that the poet is describing.
b. Discussion of clinical findings of delirium will follow to include the Confusion Assessment Method 20 by Dr. Inouye.
- “What the Doctor Said” Raymond Carver
a. The student will identify the clinical situation
b. Discussion of methods to deliver bad news, the 8 point scenario
Short Fiction:
- “In the cemetery where Al Jolson was buried” by Amy Hempel
a. The student will identify the roles of the two main characters
b. Discussion regarding caregiver stress - “Brute,” by Richard Selzer, MD
a. The student will identify the central issue
b. Discussion regarding anger management and professionalism - “The Use of Force” by William Carlos Williams
a. The student will identify the central issue
b. Discussion regarding emotion and treating the unreasoning - “Explaining Death to the Dog,” Susan Perabo
a. The student will indentify the central issue
b. Discussion of grief - “A Small, Good Thing” Raymond Carver
a. The student will indentify the central issue
b. Discuss loss
1Hunter, KM: Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton” Princeton University Press; 1991, page 13.
2Haidet P, Paterniti DA. “Building a history rather than “taking one:” a perspective on information sharing during the medical interview. Arch Intern Med 2003; 163: 1134-40.
3Platt FW, Gaspar DL, et. al. “Tell me about yourself.” The Patient Centered Interview. Ann Intern Med 2001; 134: 1079-1085.
4Charon R. Narrative Medicine: Honoring the Stories of Illness. Oxford University Press, 2006.
5Charon R. Narrative and Medicine. N Engl J Med 350:9, 862-864.
6Coulehan J. Metaphor and Medicine: Narrative in Clinical Practice. Yale Journal of Biology and Medicine 76(2003) 87-95.
7Reisfield GM, Wilson GR. Use of Metaphor in the Discourse on Cancer. Journal of Clinical Oncology, Vol 22, No 19, 1 October 2004, 4024-4027.
8Penson RT, Schapira L, Daniels K, et. al. Cancer as Metaphor. The Oncologist 2004;9:708-716.
9Charon R. Literature and Medicine: Origins and Destinies. Acad Med. 2000 75:23-7.
10Charon R, Narrative Medicine: Form, Function Ethics. Annals of Internal Medicine, 2 Jan 2001, Vol 134, No 1, p83-87.
11Charon, R. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA 2001; 286: 1897-1902.
12Hempel A. In The Cemetery Where Al Jolson is Buried. Reasons to Live. 1985.
13Carver R, What the Doctor Said. A New Path to the Waterfall. Page 113. Atlantic Monthly Press, New York. 1989 ISBN 0-87113-374-1.
14Spiro H. What is Empathy and Can It Be Taught? Annals of Internal Medicine, 15 May 1992, Vol 116, No 10, 843-846.
15Frank A. the Wounded Storyteller: Body, Illness and Ethics. Chicago: University of Chicago Press, 1995.
16Pennebaker JW. Telling Stories: The Health Benefits of Narrative. Literature and Medicine 19, no. 1 (Spring 2000) 3–18.
17Robertson K. Reflection in professional practice and education. Australian Family Physician Vol 34, No9, September 2005 781-783.
18Alcauskas M, Charon R, Right Brain: Reading, writing and reflecting. Making a case for narrative medicine in neurology. Neurology 70 11 March 2008, 891-894.
19Kalitzkus V, Matthiessen PF. Narrative Based Medicine: Potential, Pitfalls, and Practice. The Permanente Journal, winter 2009, vol 13 no. 1, Page 80-86.
20Inouye S. Delirium in Older Persons. NEJM 2006; 354: 1157-1165.
Narrative Medicine is available in PDF form for printing.