Transcript Narrative Medicine

Narrative Medicine at UNM
IRCME Symposium
March 16, 2007
Ellen M. Cosgrove, MD FACP
Senior Associate Dean, Education
University of New Mexico
ACKNOWLEDGEMENT:
the people who did this work
Julie Reichert
Directs UNM’s Narrative Medicine program
author, independent filmmaker
Summers Kalishman, PhD
Directs the Office of Program Evaluation
Brian Solan, MD
Directs the summer preceptorship
Objectives
• Describe Narrative Medicine
• Link Narrative Medicine to Professionalism
• Share UNM’s Narrative Medicine results
• Consider JAPANESE cultural traditions &
narrative medicine
Is this a good use of your time?
What Japanese cultural traditions and
literary forms encourage reflection?
What do YOU want to learn from this
lecture?
Dedication
Kimitaka Kaga, MD PhD
TANKA of the DYING
What is Narrative Medicine?
• International movement to include
reflective reading and writing in physician
practice
• Poetry, stories, memoirs written by doctors,
other health care professionals, students
and patients
REFLECTION
a "crucial process in the transforming of
experience into knowledge, skills and
attitudes"
Robertson, K. Reflection in professional practice and education,
Australian Family Physician, 2005; 34(9), pp. 781-783.
a key step in both life-long learning and the
development of professionalism in practice.
Novack DM et al. Calibrating the Physician: Personal Awareness and
Effective Patient Care. JAMA. 1997; 278: 502-509.
Narrative Medicine provides a forum
for thoughtful self-reflection
Improves patient-centered care
Yamada, S.et al. Family narratives, culture, and
patient-centered medicine, Medical Student Education,
2003; 35(4), pp.279-283.
reduces practitioner stress
Brady, DWet al. "What's important to you?": The use of
narratives to promote self-reflection and to understand
the experiences of medical residents, Annals of Internal
Medicine, 2002; 137(3), pp. 220-223.
Narrative Medicine Skills
• Observation
• active listening
• ability to tell the patient’s story
Verghese A. The physician as storyteller. Ann Intern Med
2001;135:1012-7.
Narrative Medicine & empathy
students practice taking the view of
another person (a patient, family
member, other healthcare providers)
they see the patient as a person within
a family, community, and culture
Halpern J. From detached concern to empathy: humanizing medical
practice. New York: Oxford University Press, 2001.
Das Gupta S & Charon R. Personal Illness Narratives: Using
Reflective Writing to Teach Empathy. Acad Med. 2004;79:351–356.
Narrative Medicine & PIE
• UNM medical students between their first and
second years spend nine summer weeks living &
working in a rural clinical practice “Practical
Immersion Experience (PIE)”
• Self-selected students write reflectively once a
week to volunteer physician mentors on campus
in place of one H&P
• Mentors respond in kind via email
Narrative Medicine does not make
medical students into "writers,"
but makes them better doctors
• supporting their skills of observation
• encouraging their reflection in a clinical context
• showsibg the students that their thoughts,
feelings, and questions are heard hrough the
responses from the mentors.
Students say this writing helped
them to:
• perceive their clinical work in a thoughtful
way
• become more observant and analytical
• look for recurrent patterns
• respond better to patients.
Content analysis
Julie Reichert read one work by each
student. Major themes:
• Cultural challenges
• Ethical issues: truth telling
• Importance of active listening
Initiation: first-time experiences
Many of the students' stories addressed
first-time experiences – witnessing birth
and impending death, trying hands-on
procedures
Identity
The students grappled with who they were
becoming as they began to take on the
role of being a physician
A student's pain as he meditates on how
his new medical knowledge and focus on
becoming a doctor is leading him away
from his working-class family and his roots.
Awe
Many students marveled at the sheer beauty
of patients and of the practice of medicine:
The "exhaustion filled with love" of a 74year old father taking care of a 45-year-old
developmentally disabled daughter
Frustration and disillusion
Some students wrote about problems with
preceptors, the limits of medicine, and other
difficult topics.
Noticing the contrast in a preceptor's negative
attitude in treating a suicide survivor
("voluntarily" ill) with attitude in caring for an
older, dying patient
Feeling helpless and angry regarding an aging
couple’s losing their independence
Questioning
Sometimes, students’ experience evoked
unexpected thoughts and questions about
medical practice.
Observing an interaction between mother/child and
physician, questioning how much of medical
education should be science, and how much
humanities
The paradox of finding sick children interesting and
well babies boring
Values
Students questioned themselves when
suddenly faced with difficult ethical
situations
Feeling ethically challenged in the face of a
dying patient who refuses care
Community: Students observed the
often unfamiliar communities
Being unexpectedly welcomed to a special
dinner in the Zuni Pueblo community
Observing the continuity of care that the
preceptor physician has provided over the
many years of practice
Appreciating the qualities of the people
living in a rural community after observing
the stoicism and courage of a disabled
member of that community
Faculty comments:
responding to student's reflective writing
makes the mentor more reflective
• Helps keep me in touch with students at the
early stage of training
• I got a much better insight into how students
grow over time.
• It has made me look closer at my own behavior
as a teacher, mentor and clinician.
Faculty comments
• I was very unaware that the student would
be exposed to taking short cuts in their
workup and not even know that they were
doing same.
• I feel more involved in the educational
process and appreciate the struggles of
the contemporary student.
RESULTS: “time well spent”
• Students and mentors overwhelmingly positive
• Most mentors return
• Explosion of student interest:
From a class of 75 students:
9 took Narrative Medicine track in 2005
22 in 2006
54 in 2007
CONCLUSION: A Narrative Medicine
experience can be:
• simple to set up
,
• requires a very modest investment in
student and faculty time
• rewards the effort with increased
reflection and satisfaction for both
students and faculty.