Close Reading and Creative Writing in Clinical Education: Teaching Attention, Representation, and Affiliation

The power of informal cancer caregivers' writings: results from a thematic and narrative analysis

Background

Cancer is a disease that disrupts not only the patient’s life, but that of the entire family as well, from a care, organizational, and emotional perspective. Patients share their experience of illness frequently with their informal caregiver (IC), a partner, son/daughter, friend, volunteer, or any other person in the family or social network who offers to support them during their clinical journey. The purpose of this study was to investigate ICs’ still unknown cancer experiences through the stories of IC participants in a Literary Artistic Competition the Centro di Riferimento Oncologico di Aviano (CRO) IRCSS organized, and understand the themes that emerged from their texts and hence, the power of expressive writing.

Materials and methods

A qualitative study was carried out on literary texts using Mishler’s three levels of narrative analysis: thematic (to detect themes and subthemes); structural (to support the thematic level), and performative (to understand the narratives’ meaning). In addition, the narratives were classified based on Kleinman and Frank’s models. A particular focus was placed on the language of the narratives to identify figures of speech, e.g., metaphors related to cancer.

Results

Seven main themes emerged from the 40 stories’ thematic analysis: perceptions of the disease; biographical breakdown; relationships; transformation of the sick body; IC’s role; encounter with death; and strength of memory. The ICs’ stories also highlighted the strengths and weaknesses of the patient’s clinical pathway. ICs are a resource not only for the patient, who, thanks to them, is assured of continuous assistance but also for the healthcare organization, above all because they serve a relational role as a “bridge” between patients and healthcare workers. ICs have important messages to offer to healthcare organizations. If involved adequately, they can provide a strategic strength in supporting patients and healthcare workers themselves. The in-depth analysis of the themes and subthemes in this study led the authors to hypothesize that expressive writing benefit ICs with respect to the possibility of sharing their experiences with others and giving evidence of their role. Their stories are a testimony that can help those who face a similar experience.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-020-05901-3.

Medical Students' Perspectives on Empathy: A Systematic Review and Metasynthesis

PURPOSE

Some evidence indicates that physician empathy declines during medical training, which has made it the subject of much research. Qualitative studies are relevant in this context, focusing as they do on how students themselves conceive and understand empathy during medical school. The aim of this study was to explore medical students' perspectives on empathy by conducting a metasynthesis, including a systematic review of the literature and analysis of included studies.

METHOD

The authors systematically searched 4 databases through June 17, 2019, for qualitative studies reporting medical students' perspectives on empathy in medical school. They assessed article quality using the Critical Appraisal Skills Program, and they applied thematic analysis to identify key themes and synthesize them.

RESULTS

The authors included 35 articles from 18 countries in their analysis. Four main themes emerged: (1) Defining empathy, with a lack of understanding of the concept; (2) Teaching empathy, with a focus on the hidden curriculum and clinical supervisors; (3) Willingness to be an empathetic doctor, with ambivalence expressed by some study participants; and (4) Evolution of empathy during medical school, specifically its decline.

CONCLUSIONS

Medical students are beset by theoretical confusion regarding the concept of empathy, and they express doubts about its utility and relevance. Instruction should focus on simpler concepts such as listening, and schools should leverage clinical supervisors' strong influence on students' empathy. Prioritizing certain types of knowledge (clinical facts) during medical education has a globally negative effect on medical students' empathy.

"Inform the Head, Give Dexterity to the Hand, Familiarise the Heart": Seeing and Using Digitised Eighteenth-Century Specimens in a Modern Medical Curriculum

Recent years have seen an explosion of interest in digitising museum collections. Among the objects of interest are anatomical and pathological specimens found in medical museums. As researchers increasingly produce digital replicas of these preparations, ways of integrating these resources into the medical curriculum must be explored. This article takes a medical humanities approach to this topical question, comparing the historic use of anatomical specimens to modern intentions, and exploring the potential for using digital anatomy to help integrate humanities into the curriculum. The use of anatomical specimens by William Hunter (1718-1783), whose collection is now kept at the Hunterian in the University of Glasgow, provides a key historic focus. The teaching intentions for his private courses of anatomy are examined, to investigate how specimens were used in an eighteenth-century "curriculum". The motivations behind digitisation and the use of digital anatomy in modern curriculums are then examined and compared. Many of these motivations are shared with Hunter's: the desire to maintain a unique anatomical resource, the need to provide multisensory engagement in learning, and a desire to attempt to show "natural" anatomy without the interference of human processes. The balance between fostering empathy and maintaining detachment is also key for both. Using digital replicas of historic specimens to teach anatomy also opens up a unique opportunity to educate students in the medical humanities in a fully integrated way. Understanding the full story of the specimens they use, as explored in the first half of the article, allows students to place themselves, their dissection subjects, and healthcare as a whole in a historical context. As well as fostering empathy in the dissection lab, the stories behind the specimens can be used to introduce key humanities topics, including ethics, institutional bias, and social aspects of health and disease. It is essential that this potential is explored now while digital anatomy is still a relatively young field, and therefore collaborations between anatomists and medical humanities practitioners can be built and included from the ground up.

Creating Reflective Space for Reflective and "Unreflective" Medical Students: Exploring Seminal Moments in a Large-Group Writing Session

PROBLEM

Reflection is a critical skill for all physicians, but some busy medical students describe themselves as "unreflective." The authors sought to provide all third-year medical students at the Medical College of Wisconsin (MCW) with opportunities to explore seminal clinical and personal moments through reflective writing during workshops on preparing a personal statement for the Electronic Residency Application Service.

APPROACH

The authors developed and facilitated semiannual 1.5- to 2-hour sessions (January and June) for MCW third-year medical students (about 200 per class), pairing information on personal statements with reflective writing and group reflection activities. Students wrote reflectively but were not required to share their writing with peers or faculty. They discussed insights gleaned during the writing process in small groups and with the class. They completed pre- and postsession questions on an anonymous questionnaire.

OUTCOMES

Eight all-class sessions were held between January 2015 and June 2018. Students completed 1,139 of 1,600 questionnaires (completion rate of approximately 71%). They misperceived their peers' views of reflective activities. Twice as many students agreed their peers felt writing, reflective, and narrative exercises were a waste of time as they themselves did (39% vs 19%). While 42% entered the session comfortable with creative writing, 57% were surprised by the amount, quality, and/or insight of their writing during the session and 77% agreed the session helped them think more clearly about clinical encounters. Students who believed reflective writing was a waste of time were more likely to believe their peers felt that also, and they were less likely to believe the session helped them reflect on clinical experiences. Most written comments were positive.

NEXT STEPS

To expose students to narrative medicine techniques, the authors added a close-reading exercise and shortened the reflective writing activity in 2019, hoping this would better equip all students for their journeys.

Using text mining to analyze reflective essays from Japanese medical students after rural community placement

BACKGROUND

Following community clinical placements, medical students use reflective writing to discover the story of their journey to becoming medical professionals. However, because of assessor bias analyzing these writings qualitatively to generalize learner experiences may be problematic. This study uses a process-oriented text mining approach to better understand meanings of learner experiences by connecting key concepts in extended student reflective essays.

METHODS

Text mining quantitative analysis is used on self-evaluative essays (n = 47, unique word count range 43-575) by fifth-year students at a regional quota-system university in Japan that specializes in training general practitioners for underserved communities. First, six highly-occurring key words were identified: patient, systemic treatment, locale, hospital, care, and training. Then, standardized keyword frequency analysis robust to overall essay length and keyword volume used individual keywords as "nodes" to calculate per-keyword values for each essay. Finally, Principle Components Analysis and regression were used to analyze key word relationships.

RESULTS

Component loadings were strongest for the keyword area, indicating most shared variance. Multiply regressing three of the remaining keywords hospital, systemic treatment, and training yielded R² = 0.45, considered high for this exploratory study. In contrast, direct patient experience for students was difficult to generalize.

CONCLUSIONS

Impressions of the practicing area environment were strongest in students, and these impressions were influenced by hospital workplace, treatment provision, and training. Text mining can extract information from larger samples of student essays in an efficient and objective manner, as well as identify patterns between learning situations to create models of the learning experience. Possible implications for community-based clinical learning may be greater understanding of student experiences for on-site precepts benefitting their roles as mentors.

Impact of narrative medicine program on improving reflective capacity and empathy of medical students in Iran

PURPOSE

Narrative medicine is expressing medical experiences and reflecting on narratives to create empathic communication with patients. Moreover, reflection on narratives causes self-awareness and recognition of the narrator's feelings or the main character of the story, and affect the audience. This study conducted to examine the impact of the narrative medicine program on improving the reflective capacity and empathy of medical students.

METHODS

A quasi-experimental study was performed in 2018-2019 at Isfahan University of Medical Sciences, Iran for 135 medical interns with two groups (control (n=66) and experiment (n=69)). We held seven two-hour reflective practice sessions for medical interns in the experiment group, and no educational intervention for the control group. Pre-test and post-test were held for both of the groups using two valid and reliable tools to assess reflective capacity and empathy. A comparison of mean scores of reflection and empathy was done in pre-test and post-test in one group and between groups using t-paired and t-test (p≤ 0.05).

RESULTS

The mean score of reflection and empathy in the experiment group had a significant increase before and after the educational intervention, but in the control group had not. Moreover, the comparison of the mean scores between the two groups in the post-test was significant. (p<0.001).

CONCLUSION

Narrative medicine is an effective teaching method that can improve reflective capacity and empathy, and ultimately promote professionalism as a core competency in medicine. Consideration of learning conditions and interdisciplinary teaching is necessary for implementing the narrative medicine program.

Integrating Storytelling into a Communication Skills Teaching Program for Medical Oncology Fellows

Oncology training focuses primarily on biomedical content rather than psychosocial content, which is not surprising in light of the enormous volume of technical information that oncology fellows assimilate in a short time. Nonetheless, the human connection, and specifically communication skills, remains as important as ever in caring for highly vulnerable patients with cancer. We previously described a year-long communication skills curriculum for oncology fellows that consisted of monthly 1-hour seminars with role play as the predominant teaching method (Epner and Baile, Acad Med. 89:578-84, 2014). Over several years, we adapted the curriculum based on learner feedback and reflection by faculty and teaching assistants and consolidated sessions into quarterly 3-4-hour workshops. We now describe integrating stories into the curriculum as a way of building empathy and warming fellows to the arduous task of dealing with highly emotional content, such as conversations with young patients about transitioning off disease-directed therapy. Learners read and discussed published, medically themed stories; discussed their own patient care stories; and completed brief writing reflections and discussions. They then worked in small groups facilitated by faculty and upper level fellows who functioned as teaching assistants to work on applying specific skills and strategies to scenarios that they chose. Fellows completed anonymous surveys on which they rated the curriculum highly for relevance, value, organization, content, and teaching methods, including storytelling aspects. We conclude that sharing stories can help highly technical learners build reflective ability, mindfulness, and empathy, which are all critical ingredients of the art of medicine.

Development of a checklist to validate the framework of a narrative medicine program based on Gagne's instructional design model in Iran through consensus of a multidisciplinary expert panel

PURPOSE

Narrative medicine is a patient-centered approach focusing on the development of narrative skills and self-awareness that incorporates "attending, representing, and affiliating" in clinical encounters. Acquiring narrative competency promotes clinical performance, and narratives can be used for teaching professionalism, empathy, multicultural education, and professional development. This study was conducted to develop a checklist to validate the framework of a narrative medicine program through consensus of a panel.

METHODS

This expert panel study was conducted from 2018 to 2019 at Isfahan University of Medical Sciences, Iran. It included 2 phases: developing a framework in 2 steps and forming an expert panel to validate the framework in 3 rounds. We adapted a 3-stage narrative medicine model with 9 training activities from Gagne's theory, developed a framework, and then produced a checklist to validate the framework in a multidisciplinary expert panel that consisted of 7 experts. The RAND/UCLA appropriateness method was used to assess the experts' agreement. The first-round opinions were received by email. Consensus was achieved in the second and third rounds through face-to-face meetings to facilitate interactions and discussion among the experts.

RESULTS

Sixteen valid indicators were approved and 100% agreement was obtained among experts (with median values in the range of 7-9 out of a maximum of 9, with no disagreement), and the framework was validated by the expert panel.

CONCLUSION

The 16 checklist indicators can be used to evaluate narrative medicine programs as a simple and practical guide to improve teaching effectiveness and promote life-long learning.

Encouraging perspective taking: Using narrative writing to induce empathy for others engaging in negative health behaviors

Societal expectations of self-care and responsible actions toward others may produce bias against those who engage in perceived self-harming behavior. This is especially true for health professionals, who have dedicated themselves to helping reduce the burden of illness and suffering. Research has shown that writing narratives can increase perspective taking and empathy toward other people, which may engender more positive attitudes. Two studies examined whether creating a fictional narrative about a woman who smokes cigarettes while pregnant could increase positive attitudes toward the woman who smokes and reduce the internal attributions made for her behavior. Across both experiments, the narrative writing intervention increased participants’ empathy and perspective taking, evoked more positive attitudes toward a woman who smokes cigarettes while pregnant, and increased external attributions for her behavior. This work supports our hypothesis that narrative writing would be an efficacious intervention promoting attitude change toward patients who engage in unhealthy, and often contentious, behaviors. This work also suggests that narrative writing could be a useful intervention for medical professionals and policy makers leading to more informed policy or treatment recommendations, encouraging empathy for patients, and engendering a stronger consideration of how external forces can play a role in someone’s seemingly irresponsible behavior.

[What is narrative medicine?]

Narrative medicine first entered China in 2011 and has developed rapidly since then. The patient-centered care, shared decision making and relational medicine in the medical sphere, together with patients narrating their illness and narratology contributed to the rise of narrative medicine. Through listening to patients' narratives, paying attention to their emotions, and representing their stories in various ways, clinicians can connect with patients and empathize with them. In this way, affiliation and mutual trust with patients can be established. Patients will feel good in the doctor-patient encounter because of such humane care, and clinicians may get satisfaction from their work. Narrative medicine courses characterized by close reading of literature and writing should be added to the curriculum of medical education as the major content of medical humanities, so as to train narrative competence for the future doctors.

Narrative medicine as a medical education tool: A systematic review

Aim: Narrative medicine has been promoted as an innovative and effective means of stimulating medical students' professional development by teaching them to approach their patients' experiences of illness with more understanding and compassion. This systematic literature review aims to answer the following question: what evidence of effect is available in the literature about models for teaching narrative medicine? Methods: We conducted a narrative review of 36 articles and used the Best Evidence in Medical Education (BEME) Global Scale and Kirkpatrick Scale for strength and importance of evidence to categorize reported assessment strategies and to evaluate the effectiveness of their narrative medicine programs. Results: We found evidence that narrative medicine is an effective pedagogic tool with a clear and replicable structure and methodology. We also determined that a positive impact could be measured when pertaining to participation and modification of attitudes, knowledge, and skills. However, unequivocal evidence of the effect of narrative medicine on students' behavior or ongoing interaction with colleagues and patients is still lacking. Conclusion: While many recent publications describe the goals and virtues of a narrative-based approach, more research is needed to determine whether or not there is an ideological consensus undergirding this approach. In addition, it is still unclear whether the long-term impact of narrative medicine classroom interventions are felt by patients, or whether such interventions positively impact patient care.

How do residents perceive and narrate stories about communication challenges in patient encounters? A narrative study

OBJECTIVE

This article investigated residents' narratives to gain their understandings of which patterns are challenging in doctor-patient conversations.

DESIGN

Qualitative narratological framework.

PARTICIPANTS

We analysed 259 narratives from 138 residents' oral recounts of communication with patients in which they had felt challenged.

RESULTS

The analysis identified an ideal narrative for the doctor-patient encounter with the resident as protagonist pursuing the object of helping the patient with his health problem. Disruptions of this ideal narrative were at play when challenges occurred. Regardless of medical setting, challenges were often related to the establishment of a common object, and the communication actants had to go through negotiations, disagreements or even battles when trying to reach a common object. Challenges also occurred when actants which in the ideal narrative should act as helpers become opponents. We find narratives where patients, relatives and colleagues become opponents.

CONCLUSIONS

Our study showed that communication challenges were the result of disruptions of the perceived ideal narrative. Residents found it especially challenging to establish a common object, and dealing with helpers turned opponents. Patient communication is thus a challenge in the transition phase from student to doctor, and doctor-patient communication is complex in nature and continuously perceived to be so by residents, despite pregraduate training.

Transforming Preprofessional Health Education Through Relationship-Centered Care and Narrative Medicine

ISSUE

The Institute of Medicine identified health care education reform as a key to improving the error prone, costly, and unsatisfying U.S. health care system. It called for health care education that no longer focuses exclusively on the mastery of technical skills but teaches students the human dimensions of care and develops their ability to collaborate with patients and colleagues to alleviate suffering and improve health. When should this educational reform begin, by what frameworks should it be guided, and which methods should it employ are important questions to explore.

EVIDENCE

There is increasing evidence that practitioners' relational skills, such as empathy and reflection, improve patients' health outcomes. Efforts to shift education toward patient-centered care in interprofessional teams have been made at the professional level, most notably in medical schools. However, reform must begin at the preprofessional level, to start cultivation of the habits that support humane care as early as possible and protect against empathic decline and the development of counterproductive attitudes to collaboration. The conceptual basis for reform is offered by relationship-centered care (RCC), a framework that goes beyond patient-centered care and interprofessional teamwork to focus on the reciprocal human interactions at the micro, mezzo, and macro levels of care. RCC identifies practitioners' relationships with patients, colleagues, community, and self as the critical interpersonal dimensions of healthcare and describes a foundation of values, knowledge, and skills required for teaching each dimension. The teaching of these foundations can be facilitated with techniques from narrative medicine, a compatible care model that conceptualizes health care as a context in which humans exchange stories and thus require narrative competence.

IMPLICATIONS

We suggest beginning the educational reform at the preprofessional level with the implementation of a formal curriculum based on the 4 RCC dimensions with students expected to gain beginner levels of competency on these dimensions in addition to evidence-based principles of health sciences. This requires interprofessional collaboration among health professions, social science, and liberal arts faculty and training of health professions faculty in narrative medicine. Next, we suggest engaging in incremental change in the organizational culture with professional development and team-building activities. Although we need systematic research on the efficacy of the components of the transformation, their impact on students' learning, and their costs, it is important to engage in efforts to prepare professionals who are able to respond to the complex health needs of individuals and society in the 21st century.

Education Research: An arts-based curriculum for neurology residents

OBJECTIVE

To determine the feasibility and educational value of an arts-based curriculum for neurology residents, with the following specific learning objectives: to enhance communication and observational skills, increase awareness of point of view, and deepen appreciation of the narrative content of illness.

METHODS

Narrative medicine and visual thinking exercises, adopted from the study of literature and art history, were offered as monthly sessions in the neurology residents' conference schedule. Participants completed an institutional review board-approved anonymous evaluation using a 5-point Likert scale to rate course effectiveness and perform a retrospective pre- and post-self-assessment of communication and visual observation skills. They also provided free text feedback on the course.

RESULTS

All participants rated the course highly and found the exercises effective in enhancing awareness of language and observational skills. Eighty percent of participants rated their listening and observation skills as above average after participation, which improved from 63% and 45%, respectively, before the sessions. Comments on the course cited the importance of reflection, focused attention, awareness of multiple perspectives, and appreciation of colleagues.

CONCLUSIONS

Arts-based graduate medical education is feasible and effective in teaching residents to listen and observe more closely. Narrative medicine and visual thinking exercises highlight these skills and promote professional growth, providing an opportunity to reflect and find meaning in clinical work.

Implementing an interprofessional narrative medicine program in academic clinics: Feasibility and program evaluation

Interprofessional education (IPE) is a critical component of medical education and is affected by the characteristics of the clinical teams in which students and residents train. However, clinical teams are often shaped by professional silos and hierarchies which may hinder interprofessional collaborative practice (IPCP). Narrative medicine, a branch of health humanities that focuses on close reading, reflective writing, and sharing in groups, could be an innovative approach for improving IPE and IPCP. In this report, we describe the structure, feasibility, and a process-oriented program evaluation of a narrative medicine program implemented in interprofessional team meetings in three academic primary care clinics. Program evaluation revealed that a year-long narrative medicine program with modest monthly exposure was feasible in academic clinical settings. Staff members expressed engagement and acceptability as well as support for ongoing implementation. Program success required administrative buy-in and sustainability may require staff training in narrative medicine.

Exploring the Use of Photo-Stories and Fiction Writing to Address HIV Stigma Among Health Professions Students

HIV/AIDS stigma exists in healthcare and is harmful to people living with HIV (PLWH). Few anti-stigma interventions target undergraduate health professions students, although evidence supports reaching providers early in their training. We developed two different arts-based interventions based on Intergroup Contact Theory: a Photovoice intervention in which they viewed photo-stories of PLWH and a fiction writing intervention in which they developed characters with HIV. We present the results of a qualitative analysis of the post-intervention interviews, to elaborate on what and how students learned from both interventions. Via theme analysis, we identified three similar patterns among both sets of intervention participants. Interventions helped students to understand PLWH as "people first," experience emotional responses to PLWH, and complicated their understanding of who was living with HIV. All three themes illustrate how Photovoice and fiction writing interrupted stereotypes about PLWH and humanized PLWH to health professions students.

Medical Students' Efforts to Integrate and/or Reclaim Authentic Identity: Insights from a Mask-Making Exercise

Medical students' mask-making can provide valuable insights into personal and professional identity formation and wellness. A subset of first- and second-year medical students attending a medical school wellness retreat participated in a mask-making workshop. Faculty-student teams examined student masks and explanatory narratives using visual and textual analysis techniques. A quantitative survey assessed student perceptions of the experience. We identified an overarching theme: "Reconciliation/reclamation of authentic identity." The combination of nonverbal mask-making and narrative offers rich insights into medical students' experience and thinking. This activity promoted reflection and self-care, while providing insight regarding personal and professional development.

Narrative medicine: A comparison of terminal cancer patients' stories from a Dutch hospice with those of Anatole Broyard and Christopher Hitchens

Not all physicians readily discuss death with their terminal patients. To explore whether physicians discuss dying with their terminal patients and to pursue an in-depth understanding of patients' perceptions of death, we interviewed terminal cancer patients in a Dutch hospice and compared their stories to quotes from two autobiographies on dying from cancer, Christopher Hitchens' Mortality and Anatole Broyard's Intoxicated by my illness. This narrative medicine study could potentially teach physicians they should discuss impending death to prevent the use of an invasive medical treatment that typically extends the quantity, but not the quality, of life.

A visit to The Doctor

This article was migrated. The article was marked as recommended. Whether the arts have any value in the medical curriculum continues to be debated. This article presents the author's views on the use of the arts, the principal contention being that the arts (the humanities) can teach us a lot about the art of medicine. In this article, Thomas Fildes' painting, The Doctor, and Randa Haines' film of the same name are referenced to demonstrate how the arts may be utilized in order to create broader awareness and understanding and ultimately, transformational learning and change, two quite powerful outcomes. How the arts should be incorporated into the medical curriculum and how they should be taught are definite issues. This article makes recommendations with respect to some of the difficulties associated with both.

Impact and educational outcomes of a small group self-directed teaching strategy in a clinical neuroscience curriculum

The complexity of the material being taught in clinical neuroscience within the medical school curriculum requires creative pedagogies to teach medical students effectively. Many clinical teaching strategies have been developed and are well described to address these challenges. However, only a few have been evaluated to determine their impact on the performance of students studying clinical neuroscience. Interactive, 2-hour, self-directed small-group interactive clinical case-based learning sessions were conducted weekly for 4 weeks to integrate concepts learned in the corresponding didactic lectures. Students in the small groups analyzed cases of patients suffering from neurological disease that were based on eight learning objectives that allowed them to evaluate neuroanatomical data and clinical findings before presenting their case analysis to the larger group. Students' performances on the formative quizzes and summative tests were compared to those of first-year medical students in the previous year for whom the self-directed, small-group interactive clinical sessions were not available. There was a significant improvement in the summative performance of first-year medical students with self-directed clinical case learning in the second year (Y2) of teaching clinical neuroscience (P < 0.05) when compared with first-year students in the first year (Y1) for whom the self-directed learning approach was not available. Student performance in the formative assessments between Y1 and Y2 was not significantly different (P = 0.803). A target of ≥70% student scoring above 80% in the final summative examination was met. The current study revealed evidence for the impact and educational outcomes of a self-directed, clinical teaching strategy in a clinical neuroscience curriculum for first-year medical students. Anat Sci Educ 11: 478-487. © 2017 American Association of Anatomists.

Does narrative medicine education improve nursing students' empathic abilities and academic achievement? A randomised controlled trial

Objective

To determine the effectiveness of a narrative medicine educational intervention on the empathic abilities and academic achievement of Chinese nursing students.

Methods

A cluster randomised controlled trial was conducted between January 2015 and July 2017. Six class clusters (two controls, four interventions) comprising 180 nursing students were included in this trial. After pre-tests to obtain baseline measurements, two control classes (Group 1) attended regular medical education courses, two intervention classes (Group 2) received theoretical narrative medicine education for 1 term, and two intervention classes (Group 3) received narrative medicine education that integrated theory with practice for 2 terms. The empathic ability and academic achievement of the groups were compared, and longitudinal changes in empathic ability were measured.

Results

Students in Group 3 showed higher empathic ability and academic achievement than students in Group 1. Empathic ability was measured at six time points and showed between-group differences. The empathy scores of students in Group 3 increased abruptly after the two-term intervention.

Conclusions

Narrative medicine education that combines theory with practice is an effective strategy for improving nursing students’ empathic ability and academic achievement.

Looking Back to Move Forward: First-Year Medical Students' Meta-Reflections on Their Narrative Portfolio Writings

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students' reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster "reflective spaces" wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students' "Signature Reflections," end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students' writings and interpret the data. The authors identified two overarching interpretive themes-recognition and grappling-and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors' analyses, the Signature Reflection seems to provide a structured framework that encourages students' reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students' acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.

Narrative medicine educational project to improve the care of patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterised by a progressive loss of pulmonary function. Often patients do not adhere to inhaled therapies and this leads clinicians to switch treatments in order to improve control of the symptoms. Narrative medicine is a useful approach that helps healthcare professionals to think over the doctor–patient relationship and how patients live with their disease. The aim of this training project was to teach pulmonologists the basics of narrative medicine: to carefully listen to patients and to practice reflective writing in their relationship with them.

Training on narrative medicine and parallel charts was provided through a webinar and a weekly newsletter.

Across 362 narratives, written by 74 Italian pulmonologists, 92% of patients had activity limitations at their first visit. The main factor influencing the effectiveness and adherence to therapy was a positive doctor–patient relationship; indeed, if such relationship is difficult, only 21% of patients are able to resume all their activities.

After learning the narrative approach, clinicians became aware of the need to spend more time listening to patients, to reflect through writing and to understand more deeply the motivations that lead people towards adherence to new therapies.

The experience of 79 Italian pulmonologists using the narrative medicine approach in COPDhttp://ow.ly/NfnY30jdEpS

Learning narrative-based medicine skills: Narrative-based medicine 3

OBJECTIVE

To raise awareness of narrative-based medicine (NBM) as a valuable approach to the consultation, which, if practised more widely by GPs, would convey considerable benefits to both patient and doctor.

SOURCES OF INFORMATION

While this article draws on the perspectives of 2 of NBM's key proponents, Rita Charon and John Launer, it also presents the author's perspective on the usefulness of the arts.

MAIN MESSAGE

This article presents some practical ways in which GPs can start using the skills of NBM and methods for developing those skills further. This will include methods for broadening awareness, learning to decipher meanings, and developing reflective skills. In particular, the arts are a powerful means for gaining these skills, in addition to stimulating the imagination and promoting creativity.

CONCLUSION

Technological advances in medicine give strength to the notion that medicine is primarily a science. In the face of this, it can be forgotten that medicine is also an art. Narrative-based medicine is the means by which the art of medicine can be practised.

What is narrative-based medicine? Narrative-based medicine 1

OBJECTIVE

To raise awareness of narrative-based medicine (NBM) as a valuable approach to the consultation, which, if practised more widely by GPs, would convey considerable benefits to both patients and physicians.

SOURCES OF INFORMATION

Principally, the perspectives of 2 of NBM's key proponents, Rita Charon and John Launer.

MAIN MESSAGE

This first in a series of 3 articles outlines what NBM is and its benefits. In holding the patient story as central, NBM shifts the doctor's focus from the need to problem solve to the need to understand. As a result, the patient-doctor relationship is strengthened and the patient's needs and concerns are addressed more effectively and with improved health outcomes.

CONCLUSION

The healing power of narrative is repeatedly attested to but the scientific evidence is sparse. If NBM is to be incorporated more broadly in clinical practice, more research is needed to better define NBM's role, understand the specific skills required for practice, and determine NBM's outcomes with respect to illness and disease.

The Educational Psychology of Clinical Training

Clinical training is paramount to the educational experience of learners, and the purpose of this training can be categorized into the following 4 categories of learning taxonomies: socialization, clinical reasoning, medical management of patient care and attitudinal change. This article investigates the educational psychology that provides the foundation of the categories of learning that take place in the clinical environment. Understanding this is critically important to create an opportunity for learners to activate their knowledge repertoire at the precise time of appropriate application.

Learning from patients: trainers' use of narratives for learning and teaching

Background

There is a growing interest in how doctors learn from narratives about individual cases, reflected, for example, in the use of e-portfolios.

Aim

This study aimed to evaluate how GP trainers conceptualised ‘learning from patients’, and what use they currently made of narrative recounts in training.

Design & setting

Thematic analysis (TA) and corpus-linguistic (CL) analysis, with data collected from a convenience sample of trainers in the UK, Ireland, and Spain.

Method

GP trainers in the three settings were contacted, and volunteers recruited (22 in UK, 24 in Ireland, and 16 in Spain). Volunteers were interviewed and asked to offer a narrative about ‘a patient you learned from’ and whether they used narratives as a training device.

Results

There were no differences between settings. Trainers described an engaged and personal relationship with patients. They described learning about themselves, the human condition, and about how to live and die well. Their narratives were structured in various ways. At times, they led to precise conclusions: at times, they were perceived as meaningful, but resisting analysis. As regards teaching through narrative, it was reported as commonly used, but present practice appears ad hoc rather than planned.

Discussion

The lack of difference between settings suggests a degree of commonality about how trainers perceive learning and teaching in the areas explored, but cannot be generalised further. The level of personal engagement was more than anticipated, and suggests the label ‘doctor–patient relationship’, as the term is used, may not be adequate to describe the nature of some interactions.

Medical education of attention: A qualitative study of learning to listen to sound

INTRODUCTION

There has been little qualitative research examining how physical examination skills are learned, particularly the sensory and subjective aspects of learning. The authors set out to study how medical students are taught and learn the skills of listening to sound.

METHODS

As part of an ethnographic study in Melbourne, 15 semi-structured in-depth interviews were conducted with students and teachers as a way to reflect explicitly on their learning and teaching.

RESULTS

From these interviews, we found that learning the skills of listening to lung sounds was frequently difficult for students, with many experiencing awkwardness, uncertainty, pressure, and intimidation. However not everyone found this process difficult. Often those who had studied music reported finding it easier to be attentive to the frequency and rhythm of body sounds and find ways to describe them.

CONCLUSIONS

By incorporating, distinctively in medical education, theoretical insights into "attentiveness" from anthropology and science and technology studies, the article suggests that musical education provides medical students with skills in sensory awareness. Training the senses is a critical aspect of diagnosis that needs to be better addressed in medical education. Practical approaches for improving students' education of attention are proposed.

Doctors as Makers

Traditional skills and expertise are not enough to prepare future physicians for the complexity, instability, and uncertainty of clinical practice. Responding and making meaning from ill-defined or unusual problems calls for, even demands, creativity. In this article, the author suggests expanding the traditional role of doctor as science-using, evidence-based practitioner to include that of doctor as a "maker" (creator) and artist. Such a reimagining requires a shift in how we view medical knowledge and patients' stories, as well as a new appreciation for "not-knowing" as a generative, creative space in medicine. Creative thinking deserves a central place in the training of doctors, driven by a reconceptualization of the traditional educational model to include medical disciplines, humanities scholars, artists, and designers.

The stories they tell: How third year medical students portray patients, family members, physicians, and themselves in difficult encounters

BACKGROUND

Physicians have long had patients whom they have labeled "difficult", but little is known about how medical students perceive difficult encounters with patients.

METHODS

In this study, we analyzed 134 third year medical students' reflective essays written over an 18-month period about difficult student-patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students' observations and reflections.

RESULTS

Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed "nonmedical" problems; fearful, worried, withdrawn, or "disinterested" in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in "standard" behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions.

CONCLUSIONS

These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.

Getting (Along) With the Guidelines: Reconciling Patient Autonomy and Quality Improvement Through Shared Decision Making

In past decades, stark differences in practice pattern, cost, and outcomes of care across regions with similar health demographics have prompted calls for reform. As health systems answer the growing call for accountability in the form of quality indices, while responding to increased scrutiny on practice variation in the form of pay for performance (P4P), a rift is widening between the system and individual patients. Currently, three areas are inadequately considered by P4P structures based largely on physician adherence to guidelines: diversity of patient values and preferences; time and financial burden of therapy in the context of multimorbidity; and narrow focus on quantitative measures that distract clinicians from providing optimal care. As health care reform efforts place greater emphasis on value-for-money of care delivered, they provide an opportunity to consider the other "value"-the values of each patient and care delivery that aligns with them.The inherent balance of risks and benefits in every treatment, especially those involving chronic conditions, calls for engagement of patients in decision-making processes, recognizing the diversity of preferences at the individual level. Shared decision making (SDM) is an attractive option and should be an essential component of quality health care rather than its adjunct. Four interwoven steps toward the meaningful implementation of SDM in clinical practice-embedding SDM as a health care quality measure, "real-world" evaluation of SDM effectiveness, pursuit of an SDM-favorable health system, and patient-centered medical education-are proposed to bring focus back to the beneficiary of health care accountability, the patient.

Manipulating the Placebo Response in Experimental Pain by Altering Doctor's Performance Style

Background: Performance is paramount in traditional healing rituals. From a Western perspective, such performative behavior can be understood principally as inducing patients’ faith in the performer’s supernatural healing powers and effecting positive changes through the same mechanisms attributed to the placebo response, which is defined as improvement of clinical outcome in individuals receiving inactive treatment. Here we examined the possibility of using theatrical performance tools, including stage directions and scripting, to reproducibly manipulate the style and content of a simulated doctor–patient encounter and influence the placebo response in experimental pain.

Methods: A total of 122 healthy volunteers (18–45 years, 76 men) exposed to experimental pain (the cold pressor test) were assessed for pain threshold and tolerance before and after receiving a placebo cream from a “doctor” impersonated by a trained actor. The actor alternated between two distinct scripts and stage directions, i.e., performance styles created by a theater director/playwright, one emulating a standard doctor–patient encounter (scenario A) and the other emphasizing attentiveness and strong suggestion, elements also present in ritual healing (scenario B). The placebo response size was calculated as the %difference in pain threshold and tolerance after exposure relative to baseline. In addition, subjects demonstrating a ≥30% increase in pain threshold or tolerance relative to baseline were defined as responders. Each encounter was videotaped in its entirety.

Results: Inspection of the videotapes confirmed the reproducibility and consistency of the distinct scenarios enacted by the “doctor”-performer. Furthermore, scenario B resulted in a significant increase in pain threshold relative to scenario A. Interestingly, this increase derived from the placebo responder subgroup; as shown by two-way analysis of variance (performance style, F = 4.30; p = 0.040; η² = 0.035; style × responder status interaction term, F = 5.21; p = 0.024) followed by post hoc analysis showing a ∼60% increase in pain threshold in responders exposed to scenario B (p = 0.020).

Conclusion: These results support the hypothesis that structured manipulation of physician’s verbal and non-verbal performance, designed to build rapport and increase faith in treatment, is feasible and may have a significant beneficial effect on the size of the response to placebo analgesia. They also demonstrate that subjects, who are not susceptible to placebo, are also not susceptible to performance style.