Narrative Medicine at UNM IRCME Symposium

March 16, 2007

Ellen M. Cosgrove, MD FACPSenior Associate Dean, Education

University of New Mexico

ACKNOWLEDGEMENT: the people who did this work

Julie ReichertDirects UNM’s Narrative Medicine program

author, independent filmmaker

Summers Kalishman, PhDDirects the Office of Program Evaluation

Brian Solan, MDDirects 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 74-year 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.