Armed with an understanding of the important clinical goals reachable through the use of narrative methods, we turn to ways in which we have used narrative medicine methods in our teaching practice. The educational goals parallel the clinical goals. Here, we display the educational experiences in a developmental sequence, starting with the premedical student and ending with the senior resident, suggesting which movements and specific goals have been reached in each example.
CASE ILLUSTRATION 7: PRE-MEDICAL STUDENT—REPRESENTATION (WRITING AS DISCOVERY)
A premed student was asked to witness my office. She had been an art history major who was embarking on a Master’s degree in international health. She wrote witness notes (similar to field notes an anthropologist might write) after observing in clinic, and I could see that she was “getting” what was going on between my patients and me, attentive to aspects of the encounters that I had not noticed myself. Her first personal statement for medical school applications was a smart crisp statement about international health movements and health care reform. Then, after her month of writing about what she witnessed in the office, she totally revised her statement. Her exposure to what patients said about themselves and the narrative routines in my practice transformed her view of what sick people really need and what doctors can to do help them.
CASE ILLUSTRATION 8: FIRST-YEAR STUDENT— ATTENTION (SELF AWARENESS)
A student told a story [in class] last week about the experience of seeing a patient interviewed in front of the whole class. It sounded like an old-time “demonstrate the pathology” session, with the patient passive and seemingly clueless and the doctor all-powerful. The student cried when she related the story and the whole group resonated. When I ran into her on the subway yesterday, she told me she hadn’t realized how upset she was. But articulating the experience helped her to realize and think about why this was so disturbing.
CASE ILLUSTRATION 9: FIRST-YEAR STUDENT—AFFILIATION (WITH PEERS)
[A first year medical student] came into the standardized patient encounter eager and animated. She began well, introducing herself and setting the tone. The patient was quiet and depressed, yet the student was unable to change her tone to respond to the patient’s cues. She continued the interview, but her enthusiasm and energy pushed the patient further and further away.
The semester continued and her enthusiasm did not wane. She continues to grapple with managing her perky manner while interviewing with a patient who was quieter, depressed, or troubled. She told me that her outward demeanor was actually covering up extreme anxiety about the patient interaction, and that her often almost manic interviewing skills were a result of her protecting herself from falling apart during patient interviews.
She wrote about her patient encounters, and often shared to the class what she wrote. She wrote about accepting the anxiety, and learning to read the physical manifestations, the clammy palms, the racing heart. She wrote that she has learned to just feel these sensations and not let them overshadow what she needs to say to the patient or do for the patient. She wrote that she has learned to let go of the anxiety surrounding the patient interview and instead feel the excitement of caring for the patient.
Although she has been writing about how it feels to interview, her objective ability to interview a patient, in a more controlled, dignified, professional way, has improved dramatically. The enthusiasm is still palpable, yet the energy is more controlled. I believe her ability to use narrative writing to express her feelings regarding the interview has allowed her to see herself in a way that she never would have, even with her preceptor or her peers commenting on her interview skills numerous time. The self-reflection that came from the narrative allowed her to undergo a truly transformative experience that will benefit her future career as a doctor.
CASE ILLUSTRATION 10: SECOND-YEAR STUDENT —REPRESENTATION (WRITING AS DISCOVERY); ATTENTION (SELF-AWARENESS AND SELF-CARE)
After reading the paragraph from Art Frank’s book about the dying child, I invited my students to write about a story that is working on them. One student had not disclosed in the context of our seminar complex events of her childhood related to the serious illness and death of a sibling. Until given this opportunity to write, the student had not disclosed the challenging role she herself had been asked to play in obtaining health care for her family. How did she benefit from writing about this? The permission to write let her acknowledge that these events, and her role in this story, had created who she is, and are part of the reason she is in medicine in the first place.
CASE ILLUSTRATION 11: THIRD-YEAR STUDENT—ATTENTION (SELF-AWARENESS); AFFILIATION (WITH PEERS)
While precepting third-year students on their internal medicine rotation, I devote one session a week to writing in the Parallel Chart, where I invite students to write about aspects of their patients that are critical to their care but that do not belong in the hospital chart. One student bristled at the idea of writing as discovery, saying she hated to write and, instead, just took long runs and did her contemplation and self-examination in that way. I invited her simply to bring in to class lists of things that went through her mind as she ran across the George Washington Bridge. She did so, and she created luminous texts filled with fragments of images that cohered into fragile meaning. I told her she was writing poems. She started bringing poems into our sessions. When she brought Dylan Thomas’s “Do Not Go Gentle into That Good Night” and read it with her classmates, she made a breakthrough in the care of a dying patient in her care, able for the first time to leave her own perspective on his care and to comprehend his and his family’s continuing wish for aggressive care.
CASE ILLUSTRATION 12: FOURTH-YEAR STUDENT—ATTENTION (SELF-AWARENESS); AFFILIATION (WITH PATIENTS)
[During a fiction-writing workshop, I gave medical students a prompt to write of a complicated situation from a point of view other than their own.] One student said that imagining her patient as if she were he changed everything for her. He had made her cry, she said, this was years before, and she hadn’t been able to forget him and his hostility. But when she wrote from his point of view, suddenly she felt she could understand him—understand why he was rude to her—even if it were only her imagination of why. It was enough. She felt better. It wasn’t about her after all.
CASE ILLUSTRATION 13: HOUSE OFFICER—ATTENTION (TOWARD PATIENT, SELF-AWARENESS)
I try not to interrupt the harried resident who is getting paged back on the floor, who has papers to be signed, and whose patient just wants to see the GI doctor, no matter that she had a normal colonoscopy last year in the Dominican Republic. “Strange,” I say, after consciously not asking for clarifying details or asking for a differential diagnosis. “What do you think is going on here? Why is this 38-year-old woman so adamant about a referral?” The resident looks at me, lists the possibilities, appropriately including a concern for domestic violence or nonconsensual sex, and then stops and stares. “Why don’t you ask her what she is concerned about?” With a shrug, she gets up and returns a few minutes later, now glowing: “Aha! Her mother-in-law—mother-in-law had colon cancer, and she’s worried she could have it!” This patient-narrative approach does not discredit the physiologic or epidemiologic approach to diagnostic reasoning. It simply contextualizes it, and, I believe, saves a great deal of time and money. As a supervisor and teacher, if I use the same stance toward my learner, who indeed is telling me a story, allowing myself to be the receiver at first, not yet the coach, then perhaps I am modeling behavior I would hope they would adopt in their own clinical work.
Manet/The Old Musician. Open access image download. Please visit images.nga.gov for more information. A13252.jpg. Edouard Manet, French, 1832-1883, The Old Musician, 1862, oil on canvas.
We see a developmental sequence unfolding for learners in our school and teaching hospital. Since narrative work has been adopted as one of our teaching and practice methods, the students are exposed to it longitudinally while their own skills deepen and complicate. From the premedical and first-year students’ early experiences of “seeing” what goes on either in office hours or in some lecture in the amphitheater, the students progress to more consequential telling of the self and claiming for oneself the formative force of autobiographical truths. They discover their peers to be valuable witnesses and confirmers of their own experiences. Their skills as readers of texts and spoken language come to represent valuable resources for their lives as doctors and as persons. More seasoned students write their ways through the inevitable assaults and sadnesses of ward medicine. By turning their developing writing powers to face actual conflicts or dilemmas with patients, they start to use these techniques to establish genuine contact with patients and then to solve clinical problems.
What Is Narrative Medicine For?
A short poem by Philip Larkin gives us courage to ask, “What is narrative medicine for?”
What are days for?
Days are where we live.
They come, they wake us
Time and time over.
They are to be happy in:
Where can we live but days?
Ah, solving that question
Brings the priest and the doctor
In their long coats
Running over the fields.
These examples, whether from clinical practice or in classroom or ward teaching, demonstrate the utility and gifts of narrative routines in health care. We hope you can trace the similarity of our work with patients and peers and our work with students. We fuel our own teaching of these skills with the benefits that these skills have given to us in practice. Our own clinical-narrative experience gives us a place from which to continue to develop these skills, to research their outcomes for other groups, and to convey them to learners who have entrusted us with their educations.
Narrative medicine methods donate methods of teaching, methods of doing, and methods of studying what might have been accomplished. As this young field develops, a robust outcomes research agenda is unfolding. Using various methodological approaches, researchers are measuring and articulating the consequences for clinicians, students, and patients of rigorous narrative work in clinical settings. Already, researchers in narrative medicine have documented improvements in team cohesion, deepening of cultural sensitivity, improvements in individual practitioners’ ability to adopt patients’ perspectives, improvements in medical interviewing and relationship-building skills, decreases in burnout, and decreases in compassion fatigue.
The field of narrative medicine is continuing its search for insight, for contact, for affiliation. In days of health care reform, of now drastic movement toward accountable care organizations and medical homes, where the care will be delivered and funded on the basis of not just cost effectiveness but continuity, the health of teams and the inner health of individual practitioners will be critical. We think that narrative training will equip both seasoned and emerging clinicians with the wherewithal to come to know the self, to be permeable to peers and patients, to make that healing contact with patients and peers now so dangerously lacking in the care we give to our sick. We close with Henry James’s description of what the reader does:
To lend himself, to project himself and steep himself, to feel and feel till he understands and to understand so well that he can say, to have perception at the pitch of passion and expression as embracing as the air, to be infinitely curious and incorrigibly patient, and yet plastic and inflammable and determinable. . [T]hese are the fine chances for an active mind, chances to add the idea of independent beauty to the conception of success.