Narrative Medicine: The Power of Shared Stories to Enhance Inclusive Clinical Care, Clinician Well-Being, and Medical Education

Abstract

The COVID-19 pandemic exacerbated the problem of secondary trauma and moral injury for health care workers. This reality, together with the epidemic of social isolation and loneliness, has brought the mental health of health care practitioners and patients to the forefront of the national conversation. Narrative medicine is an accessible, diversity-honoring, low-cost, underutilized pedagogical framework with potentially revolutionary benefits for enhancing patient care, supporting the underserved, mitigating clinician burnout, and improving team dynamics. Herein, the authors review the literature on these benefits and then discuss methods for integrating narrative medicine into clinical care and medical education at the undergraduate and graduate levels as well as continuing medical education.

Narrative Medicine Defined

Narrative medicine is a pedagogical framework that acknowledges and honors individual and collective narratives in the clinical and academic contexts. In practice, it covers a broad scope of activities from engaging with poetry and prose to reflective writing and engagement with the visual and performing arts. Any medium that tells a story can be used. Narrative medicine aims to address the feelings and experiences that occur when caring for the ill. It validates and bears witness to the experience of the patient while encouraging creativity and self-reflection in the health care practitioner.

Narrative competence is the ability to acknowledge, absorb, interpret, and act on stories. With narrative competence, health care practitioners can reach and join their patients in illness, observe and articulate their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and initiate consequential discourse with the public about health care. ¹

Overview of the Current State of Medicine

Clinician well-being: trauma, secondary trauma, moral injury, and resilience

The effect of the COVID pandemic on the mental well-being of health care workers, including doctors-in-training, has highlighted the need for mitigating the effects of trauma, secondary trauma, and moral injury on health care practitioners’ health. Secondary trauma, also called vicarious trauma, is indirect exposure to trauma through a firsthand account or narrative of a traumatic event. This is a common experience during the provision of care to patients and their families in the context of critical care and other emotionally distressing situations. Resident debriefing sessions such as the “helping the helpers” model described by Vaithilingam et al are relatively scarce. ^2–5 Narrative medicine can catalyze clinician well-being, bolster staff resilience, and mitigate burnout in pediatric residents. Such a platform is sorely needed. Three years of national survey data on pediatric residents showed that more than 50% demonstrated burnout on the Maslach Burnout Inventory Human Services Survey. Notably, empathy, self-compassion, quality of life, and confidence in compassionate care—all of which can be supported by narrative medicine—were found to be protective against burnout. ⁶ Moreover, staff resilience in pediatric intensive care units has been linked to narrative connections forged one-on-one between staff members and to programs such as Schwartz Center rounds. ⁷ Narrative medicine offers practical tools to catalyze clinician well-being, bolster staff resilience, and mitigate burnout. ⁶

Patient need for empathetic, compassionate care

Social isolation and loneliness can be serious and life-threatening. A 2010 meta-analysis of studies measuring mortality as a function of social relationships found that people with stronger relationships had a 50% higher likelihood of survival than their counterparts with weaker relationships. In terms of mortality, loneliness and social isolation can be as harmful as smoking 15 cigarettes a day. ^8,9 Optimal patient care, then, must address multiple dimensions of health including the importance of human connection.

Empathy and compassionate care are valued cornerstones of the doctor–patient relationship. ¹⁰ Narrative medicine sessions with groups of patients, through generous sharing and listening in group settings, can support the development of empathy and compassion on the part of the clinician, in addition to improving doctor–patient communication and ultimately patient outcomes. ⁶ Such experiences also can assuage the isolation that might otherwise amplify a patient’s health concerns, anxiety, suffering, and trauma.

Role of Narrative Medicine in Enhancing Care

Narrative medicine, particularly in group settings, ¹¹ leverages the power of social connection for health, with benefits to patient care and clinician wellness. It also clears the way for productive discussion of challenging topics such as health equity, systemic racism, and bias within undergraduate and graduate medical education by emphasizing the power of words and social narratives. ^12,13 Key concepts and practical implementation tools applied to a wide variety of settings can revolutionize clinical care, clinician well-being, and medical education.

Research on Benefits to Patient Care

Patient–clinician connection

Narrative medicine can help build and support the doctor–patient relationship. Thoele et al studied the 3‑Minute Mental Makeover (3MMM), a brief narrative exercise conducted during an outpatient visit. During the 3MMM, both the patient and the practitioner simultaneously write responses to 3 prompts asking what they are grateful for, 3 wishes that they have, and a 6-word story of their lives. After writing, the practitioner invites the patient to join in sharing what they have written. After participating, patients reported feeling more comfortable and connected with their doctors and other health care staff, that is, they felt “like a real team,” and reported reduced stress levels compared to baseline (P < 0.001). Practitioners reported improved communication with patients and families after participating in the 3MMM, with median preactivity vs postactivity score increasing from 4 to 5 (P < 0.001). Eighty‑eight percent of patients and families reported that the 3MMM activity was “helpful to me,” even though only 35% had used writing or journaling in the past. ¹⁴

The reduced stress and changes in behavior (for example, continuing to use the 3MMM with patients and families) continued through a 12- to 18‑month follow-up period using a 14-question survey. Of participating patients and families from the neonatal and pediatric intensive care units, inpatient units, and outpatient clinics of a children’s hospital, 85% agreed that the 3MMM had been helpful. In addition, 59% reported using writing to help cope with stress at follow-up, compared to only 38% (23) at baseline (P = 0.005). ¹⁵

Narrative medicine has also been shown to support the patient–doctor relationship by engaging with empathy, self-reflection, concepts of professionalism, and trust. ^1,16,17 It places emphasis on deep and generous listening, ^18,19 along with patient-sensitive, inclusive care. For example, one pilot study used narrative medicine to engage medical students and overweight community members with the topic of weight bias and found that both groups reported benefiting from the experience through “depathologizing, humanizing, empathy-inducing, and power-leveling interactions.” ¹²

Improvement in patient symptoms and quality of life

Several studies of narrative medicine interventions have demonstrated improvement in symptoms and/or suffering among patients with asthma, rheumatoid arthritis, heart failure, advanced cancer, diabetes, overweight, pain, and psychogenic nonepileptic seizures. Outcome measures included quality of life, improved medication adherence, decreased emergency room visits, overcoming of social withdrawal and fear after a trauma, regaining of meaningful activity, and recovery of lost self-identity during illness and treatment. ^17,19–30

Emerging data that reflective writing, drawing, speaking, and even singing about meaningful experiences can improve health, reduce unwanted symptoms, ease emotional discomfort, release oxytocin, and deepen connections with others, which can ultimately improve quality of life. The stories we tell about ourselves and to ourselves can shift negative narratives through neural re-narrating, ^31,32 which allows the individual to gain a sense of agency and well-being. Participants who engage with storytelling learn to access deeply held but rarely conscious beliefs and emotions and explore what gives them meaning, joy, and a sense of wholeness. Storytelling can be undertaken alone, through journaling or creating fiction, poetry, or graphic medicine, or in a group setting.

Support of diverse populations, including the underserved

Narrative medicine and storytelling have played a central role in the work of Native American physician and psychologist Lewis Mehl-Madrona in a study of shared collaborative care and group storytelling in the Native American community. Shared collaborative care refers to a group visit by multiple patients with the same disease, in this case diabetes mellitus type 2, and their families and loved ones. During these encounters, patients and families gave accounts of self and shared their life stories, hopes, and challenges. This approach to diabetes care was shown to be significantly superior to both group medical care and standard diabetic health education combined with conventional care. ²⁴ The medical team reported, “We (the nurses and I) looked forward every week to ‘diabetes afternoon.’ We enjoyed the patients with DM [diabetes mellitus] so much more than we had when providing standard care. …In group care, I learned their stories. I learned about their families, their hopes and dreams, their fears. In addition to taking blood pressures, measuring glucose, and performing the other instrumental activities of medical care, we shared our lives.” Patients reported feeling more amenable to adhering to medical treatments. For example, one participant said, “Nick [the traditional healer who co-participated with other health care practitioners in the groups] said to keep taking my diabetes pills. I wanted to just throw them away. I like coming to the meetings because I've been lonely since my wife died. My kids come around, but I need old people my age too. Those kids just don't understand what we old people have been through. It’s good to have people here who will listen.” The same methodology was also linked to improved quality of life in a Canadian indigenous population. ²⁵

Research on benefits to the clinician

Health care practitioners are at high risk for burnout. Participation in narrative medicine group sessions, in which participants read and discuss a poem, piece of prose, or visual image and then write and share their reflections with one another, has been shown to reduce burnout and compassion fatigue. ³³ Narrative interventions have also been demonstrated to preserve empathy, enhance self-awareness and perspective taking, increase emotional regulation, facilitate grief processing, support trauma-informed care, and encourage teamwork. ^34,35 Successful applications to caregiver burnout have also been demonstrated. ³⁶

Benefits for the well-being of health care professionals have also been seen at an institutional level. One academic medical center’s longitudinal initiative that aimed at establishing an engaging practice environment included narrative medicine activities; over the study period, participants’ mean distress score on the Mayo Clinic Well-Being Index fell from above to below the national mean. ³⁷

Research on medical education

Exposure to narrative medicine can enhance trainee knowledge, skills, and attitudes. In a study by Zazulak et al, a visual arts-based narrative medicine program was found to bolster medical students’ empathic response, history taking and communication skills, and professional identity formation. ³⁸ In another study, medical students achieved higher objective structured clinical examination scores and improved consideration of the standardized patient’s options after a narrative medicine intervention. ³⁹ Students exposed to visual arts training were found to exhibit increased tolerance for ambiguity and capacity for reflection. ⁴⁰

Arntfield et al evaluated a one-month narrative medicine elective for medical students and found that participants perceived narrative medicine as an important and effective means of enhancing competencies in communication, collaboration, and professionalism as mandated by the Accreditation Council for Graduate Medical Education and Royal College of Physicians and Surgeons of Canada. The researchers did note, however, that some students believed their nonparticipating peers might describe the elective as “fluffy,” “unnecessary,” and “touchy-feely.” ⁴¹ Narrative medicine has also been used as a means toward interprofessional communication and collaboration in several primary care settings with medical students and residents. ⁴² Constructive feedback on students’ written reflections can be provided using the Brown Educational Guide to the Analysis of Narrative, or BEGAN. ⁴³

Integrating Narrative Medicine Into Clinical Care, Clinician Well-Being Efforts, and Medical Education

One-on-one patient care

Narrative medicine can be integrated into patient care in various ways. One group examined texts written by hospitalized pediatric patients and used the written work as “a starting point to situate caregivers into the pediatric writer’s world in a moment in time.” ⁴⁴ The not-for-profit organization Hear Your Song brings collaborative songwriting to children with mental and physical health conditions, ⁴⁵ and visual artists have successfully partnered with art therapists at an academic hospital to create work with pediatric gastroenterology patients. ⁴⁶

Group patient care

Narrative medicine has also been successfully implemented by means of shared medical appointments and group visits. ^11,24,25 Weill Cornell Medicine ¹¹ introduced an innovative pilot program using a “narrative medicine shared medical appointment,” completing 243 group visits from February 2022 through July 2023. During sessions, which are ongoing, participants engage in biweekly 1-hour group visits run by 2 physicians. They are led through a centering meditation and a short writing exercise initiated with a written, musical, or visual prompt. The participants are then invited to share their reflections. Between visits, participants receive a reflection theme to share at the next meeting. Attendance has varied between 1 and 13 patients each session, and some patients have attended more than once. Patients have reported (verbally during visits or through an online survey at the end of a cycle of 4 visits) that they would recommend the group to others and that sessions have helped them achieve their goals, for example, to address anxiety, fear, isolation, loneliness, irritability, and stress. They have noted positive changes in their lives, such as “being more invested in caring for my mind”; the ability to use reflective storytelling on their own; and the opportunity to explore what matters to them in a deep and meaningful way. Patients have reported feeling hopeful, empathetic, and safe even if vulnerable at the end of visits. The 2 clinician leaders reported increased empathy, personal well-being, and work satisfaction.

Clinician self-care

Narrative medicine can be a tool for clinician self-care as well. ⁴⁷ In 1 study, Abigail Ford Winkel described a curriculum for OB/GYN residents. Over the course of 2 years, 15 small-group reflective writing workshops met for an hour at a time. Sixty-nine percent of the participants felt that the sessions were relevant to their work. They reported that the most effective parts of the course were reading, writing, sharing their writing with colleagues, and having positive experiences with members of their community. ³³

In her doctoral dissertation, Nicole M Saint-Louis described developing a narrative intervention group for oncology professionals. From the first to the fourth month of the intervention, significant decreases were found in burnout, compassion fatigue, emotional exhaustion, and depersonalization as measured on the Maslach Burnout Inventory and the Professional Quality of Life Scale. ⁴⁸

As increasing numbers of medical centers have integrated narrative medicine and the health humanities into their curricula, more avenues for sharing reflection and artistic work have emerged. Writing by, for, and about health care workers can be found in journals and online forums such as the Bellevue Literary Review, The Intima, Pulse, ourbreakroom.org, The Nocturnist, and Snapdragon, to name a few. The Journal of the American Medical Association publishes poetry and “A Piece of My Mind,” its platform for reflective essays about the joys and challenges of practicing medicine. Similarly, Annals of Emergency Medicine publishes “Change of Shift,” and Academic Pediatrics publishes “In the Moment,” a forum for authors to relate their personal experiences in pediatrics. The New England Journal of Medicine publishes reflective writing, and it printed fiction for the first time in 2021 when it held its inaugural annual fiction writing contest.

Book clubs are another venue for sharing a love of story and for honing narrative skill. At the authors’ institution, book clubs are hosted by several departments, including emergency medicine, pediatrics, and radiology. Books read include The Immortal Life of Henrietta Lacks by Rebecca Skloot, What Doctors Feel by Danielle Ofri, The Fault in Our Stars by John Green, and Five Days at Memorial by Sheri Fink. The Liz Claiborne Center for Humanism in Medicine sponsors monthly narrative medicine rounds and has also sponsored writer’s workshops and museum visits.

Medical education

Graduate medical education

The medical humanities and narrative medicine were first integrated into medical training in 1952 by Case Western Medical School. The National Academies of Science, Engineering, and Medicine ⁴⁹ and the Association of American Medical Colleges ⁵⁰ have both strongly encouraged integration of the arts and humanities into curricula at all levels of medical education. Programs in narrative medicine and the medical humanities now exist at 70 medical and osteopathic schools across 31 states.

Chretien et al ⁵¹ developed a pilot narrative medicine curriculum for the medicine clerkship, involving storytelling and reflection. Students listened attentively as patients spoke about their illness, after which they composed a narrative and read it back to the patient. Reflecting on this experience, students and patients both found the curriculum to be feasible and acceptable; moreover, several were profoundly moved. Over the course of the curriculum, students were judged to have developed narrative competence, as assessed by comparing audio recordings of patient stories to written accounts by trainees, to see whether major themes were accurately identified.

At Weill Cornell Medicine, narrative medicine has been integrated into the Essential Principles of Medicine integrative medicine lecture (Loy) and the Reflective Practice and Humanities lecture (Kowalsky) for first-year medical students, as well as the LEAP (Longitudinal Educational Experience Advancing Patient Partnerships) program, a mandatory curriculum focused on patient perspectives, medical and health humanities, and the practice of medicine (Kowalsky). The LEAP program includes reflection pieces at the start of monthly small-group sessions to stimulate discussion about the topic for that month. Topics and reflection pieces have included:

1. Adherence to medication: “The Fugitive” by T Coraghessan Boyle

2. Caring for a medically complex child: Catastrophic Rupture by K Jane Lee

3. Trauma-informed care: “The Tsunami” by Abe Ryūsei

4. Chronic illness: The Wounded Deer by Frida Kahlo

5. Integrative medicine: Vodou Flags by Myrlande Constant

6. Health literacy: Excerpt from Middlesex by Jeffrey Eugenides

Narrative medicine has been vetted as a curricular platform for teaching professional and compassionate care in the Healer’s Art course, taught at more than 90 US medical schools, ⁵² and for teaching concepts in diversity, equity, inclusion, and belonging. ^38,53,54

Undergraduate and graduate medical education

Few formal narrative medicine or health humanities programs exist for residency and fellowship. This may be secondary to the rigorous nature of residency and/or the lack of faculty with narrative medicine training within academic departments. The Yale internal medicine residency has a writer’s workshop, and The John Hopkins department of emergency medicine offers a fellowship in the humanities. Winkel ³³ also described a writing workshop curriculum for OB/GYN residents.

Weill Cornell Medicine offers 2 series for residents: a narrative medicine series for pediatric residents and an academic practice track in the humanities for emergency medicine residents.

Narrative medicine series for pediatric residents

In 2015, a 4-session workshop in narrative medicine was added to the pediatric residents’ core curriculum at Weill Cornell Medicine. Topics are chosen to represent educational milestones that are abstract or have socioemotional aspects that make them difficult to teach using a traditional didactic approach, but that lend themselves easily to discussion using narrative medicine. Examples include the following:

1. What is a good mother?: Excerpt from The Bluest Eye by Toni Morrison

2. Becoming a parent: “Expecting” by Kevin Young

3. A “real doctor”: Excerpt from Cutting for Stone by Abraham Verghese

4. The body up close: Jamar Roberts’ choreography in Ode

5. Learning without a classroom: “What You Missed That Day You Were Absent from Fourth Grade” by Brad Aaron Modlin

6. Death of a child: “A Threshold,” by Don Paterson

Academic practice track in the humanities for emergency medicine residents

In 2020, the New York-Presbyterian emergency medicine residency introduced multiple academic practice tracks, including a track in the health humanities. This program includes monthly group events, asynchronous events (ie, alternatives for those that cannot be present because of a clinical shift), and longitudinal projects. Programming has included the following:

1. Chronic pain: All the Rage, documentary by David Beilinson

2. Representing substance use disorders in the electronic medical record and the arts: The First True Thing by Claire Needell, in discussion with Dr Timothy Brennan

3. Graphic medicine: Mom’s Cancer by Brian Fies, in discussion with Ed Charlie Kochman

4. Chaos narratives: Tornado of Life: A Doctor's Journey through Constraints and Creativity in the ER by Dr Jay Baruch

5. Loving us: Physician partners: Poets Scott Hightower and Cecily Parks

6. Palliative care: Oli Otya? Life and Loss in Rural Uganda, documentary by Lucy Bruell, in conversation with Drs Randi Diamond and Jemella Raymore

Clinician lifelong learning through continuing medical education

Multiple opportunities exist for continuing medical education and masters level work in narrative medicine. Columbia University offers a master’s degree and a certificate in narrative medicine. Other institutions offering master’s degrees in narrative medicine include the University of Southern California, the University of Washington, Bay Path University, and Temple University. For a shorter experience, Columbia offers a 3-day immersive workshop. Literary magazines such as the Bellevue Literary Review and Snapdragon also offer workshops and readings.

At Weill Cornell, the emergency medicine department’s Protected Airway Course (PAC) offers a novel platform. This multimodal, immersive course teaches difficult airway management and includes a storytelling station where participants tell stories and listen to others’ accounts of challenging situations. This station normalizes and humanizes the experience of anxiety, self-doubt, and fear that can accompany the experience of managing a difficult airway. ⁵⁵ In 2023, 60 learners attended PAC, of which 31 (50%) interacted with stories by means of QR codes and 9 (15%) recorded new stories. Of 26 participants responding to a post-PAC survey, 31% gained a deeper understanding of another person’s difficult experience and felt that they were more likely to share their own story, 27% felt they had gained knowledge to apply to future airway situations, and 16% felt that AirTime increased their comfort level for difficult airways.

Community and Public Health

Narrative medicine and the arts are known to support community health. They have been integrated into programs such as the New York City Health and Hospitals Consortium’s Arts in Medicine project; ⁵⁶ various artistic programs at University Settlement, a community center in New York City; ⁵⁷ and numerous museums with public outreach projects. ⁵⁸ Associated health benefits include reduced anxiety, stress, chronic pain, and depression symptoms.

Challenges and Facilitators

Although most people who participate in narrative medicine report benefits for themselves and their patients, narrative medicine does not appeal to every learner. Some participants find reflective writing to be burdensome or stressful. ⁵⁹ These feelings may be related to personal preference, but they could also be related to the discomfort with uncertainty that is often expressed by medical learners. Narrative medicine names and explores areas of uncertainty, finding much richness involved in curiosity and the apprehension of the unknown. However, biomedical pedagogy does not typically treat uncertainty as positive. Any doctor will tell you that they dread saying “I don’t know.”

One way to engage recalcitrant participants is to start narrative medicine sessions with ground rules, for example, establishing the group as a nonjudgmental space in which all viewpoints are honored, and uncertainty and ambiguity are embraced as conduits to learning more about our patients and ourselves. On a structural level, fostering positive relationships with clerkship and residency directors helps to secure time, space, and support for narrative medicine activities.

For those who plan to implement a narrative medicine program, it is helpful to start by identifying allies and creative partners within both the institution and the community. The Office of Student Affairs may be aware of faculty and students with an interest in the arts. Many communities offer poetry readings, plays, and museum visits that could easily be integrated into a narrative medicine program. Further, the Health Humanities Consortium houses a Health Humanities Syllabus Repository with a wealth of resources. ⁶⁰

Conclusion

Narrative medicine is an accessible, low-cost, underutilized modality with practical implementation tools that can be applied to a wide variety of settings and has the potential to revolutionize clinical care, clinician well-being, and medical education.