The Value of Narrative Medical Writing in Internal Medicine Residency

Abstract

Narrative medical writing can be utilized to help increase the value and patient-centeredness of health care. By supporting initiatives in areas such as population health management, quality improvement and health disparities, it provides benefits that are particularly relevant to physicians focused on health care improvement, reform and redesign. Graduate medical education (GME) represents a key time and opportunity for internists to learn and practice this form of writing. However, due to a number of local and systems factors, many have limited opportunities to engage in narrative medical writing compared to other non-clinical activities. By capitalizing on the momentum created by recent GME reform, several strategies can be utilized to overcome these barriers and establish narrative medical writing as a viable professional and communication skill.

Medical writing is a broad term defined as the discipline of writing scientific documents for a range of regulatory, academic and commercial purposes.¹ While some forms are irrelevant to clinicians, a value-driven approach to narrative medical writing—which uses reflection and critical thinking to educate and inform others about important issues in medicine through stories—can enable physicians’ efforts to improve individual and societal health.

Narrative medical writing supports physicians’ roles as clinicians and patient advocates. By encouraging doctors to examine their relationships with patients, peers and our society at large, narrative writing allows them to practice with greater empathy and perspective.² It is also an effective and accessible form of peer-to-peer and peer-to-public medical writing, which are important for improving key health outcomes, including patient satisfaction and health behaviors.³

To achieve these benefits, physicians should gain proficiency in these forms of writing early in their careers. Medical school educators have recognized the social and educational advantages of narrative writing, using it to elucidate the effectiveness of medical education⁴ and issues around bioethics⁵ and professionalism.⁶ Writing is also a key medium for self-reflection, which can improve communication skills among learners as part of a comprehensive educational approach.⁷

While certain forms of writing (e.g., research writing) command a strong presence in graduate medical education (GME), there are few organized efforts to encourage narrative medical writing in residency training. This is problematic not only because communication skills must be learned and practiced repeatedly,³ but because narrative writing also has the potential to enhance a number of professional interests, and residency is a critical period for learners to solidify those passions and attendant skill sets.

We believe that if emphasized in GME, narratives can both improve professional development (e.g., greater reflection, stronger communication skills) and enhance a number of ongoing health care efforts. As a part of the recent GME reform, the Clinical Learning Environment Review (CLER) Program represents a unique opportunity to integrate narrative medical writing into internal medicine residency training. Created by the Accreditation Council for Graduate Medical Education, this program provides assistance in determining institutional attributes that optimize clinical learning environments.⁸

BENEFITS OF NARRATIVE MEDICAL WRITING

Narrative medical writing provides a number of important benefits that are relevant to internists (Table 1). While research and policy generate data that inform changes in population health management and care delivery, narrative vehicles deliver knowledge and meaning to larger constituencies. Because stories are an essential component of how humans use evidence,⁹ utilizing them to discuss policy issues can improve the dissemination and uptake that are vital to the adoption of best practices. Leaders in systems redesign and policy have leveraged narrative work to tether the urgency of policy issues to the broader public consciousness.^10,11 A number of internists and trainees have published narrative accounts in academic journals that advance discussions about policy related to care delivery and population health.¹²

Table 1.

Benefits of Narrative Medical Writing (NMW)

Health care domain	Potential benefits of narrative medical writing
Health policy and care delivery	Disseminate policy knowledge; personalize abstract ideas and theories; address salient bioethical issues related to delivery redesign; increase public awareness of key issues in chronic disease management
Quality improvement and high-value care	Explain multifaceted aspects of quality and value; help shape local or national quality and cost agendas; fulfill graduate medical education requirements and professional competencies in quality improvement and value
Community outreach and social justice	Provide examples of patient-centered care; personalize issues in social justice and social determinants; fulfill graduate medical education requirements around health disparities

Medical narratives can also help increase awareness about issues related to quality improvement, value and resource utilization. Because these topics are complex and multi-faceted, physicians can utilize narrative platforms to clarify the issues at hand, an approach that can be more effective than data alone in overcoming biases and preconceived beliefs.⁹ Narratives have been used in clinical settings to educate patients and providers about evidence-based guidelines and in leadership settings to identify the appropriate national agendas involving quality and cost.^9,13 In line with calls for GME competencies in high-value care, internal medicine residents who compose narrative reflections of their clinical experiences have been able to address inappropriate resource utilization within their organizations.^14,15

Finally, because narratives increase the credibility of health information by making it relatable to recipients,¹⁶ narrative accounts can be instrumental in building connections between providers and surrounding communities. As internists assume important roles in increasing patient-centeredness and health parity, the retelling of individual experiences and impactful clinical situations can educate our society about important health topics and humanize discussions about social determinants. Patient-centered care also requires thoughtful exploration and reflection of experiences related to illness,^17,18 and writing is an important method for both displaying and improving upon the process of reflection.^19,20 As such, trainees who put their own experiences into writing may be better equipped to elucidate patient-centric issues that are most pertinent to their communities.

BARRIERS TO IMPLEMENTATION

While isolated writing experiences for residents exist (e.g., Yale School of Medicine’s annual course, ad hoc workshops at individual institutions), several systems-level barriers have prevented broader implementation within GME. First, due to national work hour mandates and the growing complexity of care delivery, residents must often compress more work into less time. This makes it difficult for trainees to find time to pursue non-clinical activities such as narrative medical writing.

Second, non-clinical time is increasingly hard to come by under the scrutiny of entitlement programs such as Medicare and funding environments created by across-the-board cuts from the Budget Control Act. Specific efforts to cut indirect medical education funding, which is linked to an institution’s inpatient volume, case mix and training program size, add additional pressure to prioritize clinical activities.

Local factors also contribute. Residents frequently have fewer opportunities to engage in narrative medical writing compared to available research, quality improvement and medical education activities that are supported through curricula, mentorship and scholarships. Existing career tracks and job markets further incentivize these activities, which hold implicit value that can be leveraged in applications and promotion.

In contrast, there are almost no dedicated structural or cultural efforts to promote narrative medical writing in internal medicine residency programs. Post-graduate careers that incorporate such writing can also be extremely challenging to find or finance. As a result of limited exposure and familiarity, some trainees may not understand the benefits of narrative medical writing or view it as a wise investment of professional energy.

POTENTIAL SOLUTIONS

First, narrative medical writing can be woven into existing residency activities. Limited didactic time, competing alternatives and financial mandates in GME make it unfeasible to require exclusive writing activities for all residents. Diverse career goals among residents also make writing requirements potentially undesirable. Instead, educators could integrate narrative elements into ongoing initiatives (e.g., leadership tracks, policy courses, social justice curricula) to meet learner needs and to advance discussions about issues in health policy, quality improvement and patient advocacy.

The CLER program provides a particularly compelling impetus for this kind of integration. Several CLER “pathways” focus on experiential resident engagement in community and institutional needs. For example, the use of narrative writing among residents to illuminate issues in medical overuse supports the CLER goal of engaging residents in the “consideration of underuse, overuse, and misuse in diagnosis or treatment of patients.”⁸ Similarly, narrative accounts of adverse events can support CLER priorities (e.g., resident engagement in planning for quality improvement) by shedding important light on key barriers and opportunities in quality improvement. Narrative medical writing could also help identify areas of need in self-care/fatigue management and could teach residents about other CLER focus areas, such as inter-professional teams and health disparities.

Integrating narratives into existing residency activities can also provide residents with valuable professional experiences. Efforts by general medicine faculty to highlight internal medicine residents’ stories about medical overuse have led to academic presentations, awards and academic publications.¹⁴ Educators can similarly guide residents with promising pieces towards professionally meaningful academic or popular press publishing opportunities.

Second, residency programs could advocate for professional tracks in narrative writing, similar to those offered for other extra-clinical academic pursuits (e.g., research, policy). Because CLER is intentionally designed to evolve based on lessons from program evaluations, future iterations may provide additional momentum for writing tracks if narratives are utilized successfully to meet competency goals. Professionally, the portfolios that could result from such longitudinal experiences would be powerful and formative.

Third, medicine departments could utilize surrounding resources to provide directed career guidance for interested residents. This might include inviting physician-writers to speak to house staff or serve as mentors within writing tracks. It could involve leveraging university affiliations or exploring local connections to press outlets via institutional media departments. By partnering with foundations to identify narrative medical writing that supports organizational missions (e.g., in high-value care, diagnostic error, patient-centered outcomes), educators could provide focused writing support and opportunities.

Finally, program leaders could consider partnerships with professional groups and medical journals, some of which offer writing and editorial fellowships that include a focus on mission-driven narrative writing.^21–23 Popular press experiences do exist,^24,25 and internal medicine faculty have recently set the precedent for novel programs focused on communication skills.³ A diversity of options can allow different individual interests and needs to be met while allowing residents to better understand career opportunities and trajectories for narrative medical writing.

CONCLUSIONS

As health care transformation continues, narrative medical writing should be recognized as an important activity for physicians. While more work is needed to identify best practices and evaluation tools for integrating narrative writing into graduate medical education, recent educational reform provides a framework and impetus for institutions to pursue this change.

In order to realize its potential to amplify a range of important health care efforts—including health policy, health care quality and value, and patient-centered care—we must value narrative writing during residency training and utilize momentum from recent GME reform to support it as a viable professional skill.