The Art of Medicine: Using Narrative and the Humanities in Medical Training ► NCI Cancer Bulletin for September 6, 2011 - National Cancer Institute

The Art of Medicine:
Using Narrative and the Humanities in Medical Training

“As physicians, we become involved in the stories of our patients’ lives, sometimes as witnesses telling the story through a medical chart. At other times, we become players in the story.”
—Dr. Abraham Verghese, author, physician, and professor

In a classroom at Children’s National Medical Center in Washington, DC, far from the atrium decorated with brightly colored models of hot-air balloons, a group of third-year medical students meets for an hour-long session with two of their professors. They are meeting not to learn the latest in pediatric medicine but to discuss a short story by William Carlos Williams, a family physician and author of short stories, essays, and poems.
The discussion of the story, “The Use of Force,” about a doctor’s encounter with a particularly recalcitrant young patient, is part of the medical humanities program at George Washington University (GWU). Broadly defined, the field of medical humanities applies the humanities, social science, and the arts to medical education and practice. A related discipline, known as narrative medicine, focuses more specifically on reflective writing in the context of medicine and the close reading of stories, including poetry, fiction, and memoir.

Listening carefully to a patient's story can provide important clinical information that helps the physician make a correct diagnosis.

Proponents of humanities- and narrative-based approaches to medical training argue that the study of literature and the arts helps develop and nurture skills of observation, analysis, empathy, and self-reflection, which are essential for more humane—and ultimately more effective—medical care.
Over the past 20 or so years, many medical schools in the United States and elsewhere have established programs in medical humanities, although not always by that name. Humanities- and narrative-based instruction has also been introduced in some residency programs and in at least one course for oncology fellows. These efforts offer a counterpoint to an increasingly technology-driven health care system that can be impersonal and dehumanizing.
The Power of Story
From time immemorial, humans have used stories to communicate and make sense of their experiences. In narrative-based medical instruction, stories are used to provide insight into the human condition and human interactions. These stories can include physicians’ and patients’ memoirs, fiction, and film.
“The stories become a text that people have in common, and this enables a conversation that you can’t have otherwise,” because students are unlikely to have seen the same medical cases, explained Dr. Linda Raphael, director of the Narrative Medicine/Medical Humanities program at GWU. Such conversations, she said, “allow a very positive sort of ambiguity, where there are different ways of seeing things, all or several of which have value, and there are no absolute answers.” Such ambiguity often arises in the practice of medicine, though it is rarely addressed in traditional medical education or clinical training, which emphasize factual knowledge and technical expertise.
Stories can also unlock the door to discussing thorny issues such as human pain and suffering, death and dying, and the emotional distress and burnout that physicians may experience in their work.
“Medical culture is so focused on making sure that our interactions with patients, at least in a professional environment, are as technical as possible,” said Dr. Alok Khorana, who co-developed a Narratives in Oncology course for oncology trainees at the University of Rochester. “So it’s hard to sit 10 or 11 fellows around the table and ask them to share their feelings. What the humanities piece allows us to do is to use the narratives as a starting point.”

Literary works like those of author and physician William Carlos Williams are now being used as teaching tools in medical education. (Courtesy of the University of Pennsylvania Archives)

In the classroom at Children’s National, Dr. Raphael and Dr. Terry Kind, director of Pediatric Medical Student Education at GWU, lead a discussion of Williams’ “The Use of Force,” which centers on a child who does not want to let a doctor take a throat culture. The doctor, who narrates the story, is ashamed because he realizes that he wanted to win over the child for the sake of winning, not only to make the diagnosis. Dr. Raphael asks whether the students have encountered similar situations, guiding the students into a discussion of the power relationship between doctors and patients and the significance of reflecting, as the doctor-narrator does, on one’s inner experience.
Dr. Raphael holds periodic narrative-based sessions with all third-year medical students as they do clinical rotations in seven medical specialties. Under her direction, GWU also offers elective courses in medical humanities for first-, second-, and fourth-year medical students. While she includes stories, poems, and films that are not specifically “doctor stories” in the elective courses, for the sessions that take place during the rotations she sticks to fiction and nonfiction narratives of doctors and patients that are specific to each specialty.
Narrative in Oncology
In their course for oncology trainees at the University of Rochester, which was added to the formal curriculum in 2009, Dr. Khorana and his colleagues, Drs. Michelle Shayne and David Korones, focus on narratives written by doctors and patients. The three recently published a paper in the Journal of Clinical Oncology about their experiences piloting the course. The paper includes an appendix with an annotated course curriculum.
“Oncology is a very difficult clinical science, because you are not dealing just with medical decision making, you are also dealing with a lot of difficult issues, especially end-of-life issues,” said Dr. Khorana. Those issues place a burden not only on patients and their families but also on medical providers, he noted, and “there’s no place for trainees to turn for those types of discussions.”
“The broad theme of the course,” he continued, “is to allow expression and training of providers in physician-patient communication, because that’s what it boils down to: understanding that patients have a story that they’re telling you and that you are privileged to hear.”
Dr. Rohit Sud, an oncologist in private practice and an attending physician in a hospital in Chandler, AZ, was among the first to participate in the 1-hour, monthly narrative-based sessions. “An important thing that I took from the narratives,” he said, “was the ability to relate to what the patients were actually feeling as they were going through the stages of acceptance of their cancer diagnosis.” Dr. Sud also stressed the importance of maintaining empathy in one’s conversations with patients.
“The medical curriculum is such that it diverts you into really focusing on the disease and the treatment, leaving the patient and the caring by the wayside,” added Dr. Sud. “By the time you become a real doctor you’ve been mechanized to do things, and I think it’s important to feel as you do things, and that’s what is lacking.”
For that reason, he said, “it would be a great thing if humanities-based training could be incorporated into the curriculum at a fellowship level or, even better, during residency,” rather than only being included in medical school at most institutions.
Dr. David Dougherty, an oncologist who recently joined the faculty at Rochester, is also an alumnus of the Narratives in Oncology course. One story that stood out for him was “The Median Isn’t the Message,” in which the author, Stephen Jay Gould, brings his scientific experience to bear on his diagnosis of mesothelioma, writing about how survival data and prognostic data are presented to patients and how they perceive this information.

In narrative-based medical instruction, physicians' and patients' memoirs, literature, and film are used to provide insight into the human condition and human interactions.

“To me that was interesting,” said Dr. Dougherty, “because this is information that patients ask us for all the time, but often we’re not aware of how we’re presenting that information or what it means to the individual patient.”
Dr. Dougherty found solace in being able to talk with others who could relate to what he was going through. He also found the course valuable because it provided a regular forum where fellows could learn from the perspectives of a wide range of people, including fellows in other subspecialties of oncology.
Responding to Skeptics
Both Dr. Sud and Dr. Dougherty said that they and their classmates were initially skeptical about the Narratives in Oncology course. They had preconceived notions about what the course would involve and were concerned that it would take time away from what they saw as more important training experiences—feelings often shared by their counterparts in medical school.
To those who remain skeptical of using a humanities-based approach in oncology training, Dr. Dougherty said, “I really think that it touches a place in all of us which draws us to oncology and cancer care. This type of experience can so improve our day-to-day patient interactions, because although oncology is so scientific, and we are so focused on data, we’re dealing with patients who are in very difficult circumstances and who have a lot of emotions, and we bring a lot of emotions to the situation.”
Yet because the area of medical humanities deals largely with subjective concepts, such as empathy, assessing the value of this approach may not lend itself to the usual objective ways of evaluating medical knowledge.
To Dr. Raphael, “the question wouldn’t be so much should you do this at all, but what readings, films, reflective writing, and discussions really work? Which ones have an impact over a long period of time?”
For her and others, the value of narrative-based medical training is evident. “I think it’s important to be enlightened about the nuances of emotions and moral issues,” she said. “People who haven’t talked about the many human issues that are involved in the practice of medicine, including professional ethics, relationships with patients and colleagues, and personal responses to situations, may resist opening up to these matters. This kind of education invites people to open up to those things, to have a greater understanding of them, and not to close off to them.”
—Elia Ben-Ari
NCI Cancer Bulletin for September 6, 2011 - National Cancer Institute: - Enviado mediante la barra Google