The Art of Healing through Narrative Medicine in Clinical Practice: A Reflection

Abstract

The art of medicine has roots that lie deep in developing the biopsychosocial connection. Understanding a human body (both its physiology and pathology) along with components of emotional and spiritual cores can lead to provision of excellent medical care and better outcomes. The harmonization of psychosocial consequences of a biological disease is helpful not just for health care professionals but also for patients. Where it keeps the empathy and compassion alive and results in greater patient satisfaction, it also helps boost the physician’s morale.

Our objective is to reflect on the impact of narrative medicine on physician-patient dynamics for health care professionals in a clinical setting. This article was written after synthesizing the findings of evidence-based literature, retrieved from different sources, along with our own reflections on our encounters with patients.

One could infer from the evidence-based research that the practice of narrative medicine improves one’s concern and understanding toward the patient. This requires more time from the clinician, but medical care without compassion and humaneness causes high rates of dissatisfaction among both patients and health care practitioners, along with the risk of recurrent ailments. Our own patient encounters provide a testimony to this inference. The biopsychosocial model carries the same holistic approach toward patients. The mainstay of treatment in any domain of medicine should contain thoughtfulness for the sufferer rather than sole consideration of the suffering.

INTRODUCTION

The art of medicine has roots that lie deep in developing the biopsychosocial connection. Understanding a human body (both its physiology and pathology) along with components of emotional and spiritual cores can lead to provision of excellent medical care and better outcomes. The harmonization of psychosocial consequences of a biological disease is helpful not just for health care professionals but also for patients. Where it keeps empathy and compassion alive and results in greater patient satisfaction, it also helps boost the physician’s morale.

There is a new spectrum of interest among medical educators to help physicians-in-training develop core features of professionalism along with high ethical and moral standards by reflective exercises and writing patient experiences. A constellation of these reflective exercises is known as narrative medicine.

What is Narrative Medicine?

Narrative medicine has been defined by Charon¹ as “medicine practiced with narrative skills of recognizing, absorbing, interpreting and being moved by stories of illness.” Narrative medicine uses a patient-centered approach to understand suffering, disability, ailment, and personhood in the practice of medicine.

Narrative medicine is an effective tool to strengthen the physician-patient kinship and care. This provides the physician a deeper understanding of the patient’s disease from a broader aspect that includes his/her emotions, as well as the biological, cultural, familial, and existential situation. It aids the physician in establishing a therapeutic coalition to generate and to proceed to establish a differential diagnosis. It also helps to provide effective care to the patient, not only helping him/her heal, but also making the patient feel heard and understood by the health care professional.¹

When sociologists studied medicine in the 1960s, they described lack of feelings and empathy toward patients as “detached concern.”² This was meant to portray an encounter in which the physician focused on the disease but gave little thought to the patient’s circumstances. Today with the development of the newly emerging knowledge from narrative disciplines, physicians are reinventing themselves by bringing the power of storytelling, appreciation, and analysis into routines of scientific clinical work.

Our objective in this article is to reflect on the impact of narrative medicine on physician-patient dynamics for health care professionals in a clinical setting.

Dry Leaves: Is Compassion Dying in the Clinic?

Physician-ethicist Edmund Pellegrino³ suggests that writing one’s experience with patients, colleagues, or difficult parts of a duty can expand a physician’s awareness regarding meaning of illness and healing.

This article was written to consider the impact of narrative medicine on medical practice such as the reincarnation of the dying compassion in medical clinics.

A literature review was done and articles were collected on narrative medicine and humanism in medicine. The articles are reviewed here in light of our own experiences in the clinical setting. The benefits of narrative medicine for the physician were studied. A workshop was conducted at our university hospital regarding hands-on narrative medicine practice, and our work from the workshop is also a part of this piece.

LITERATURE REVIEW

Writer’s Block: Why Write?

We believe that reflective writing may be one tool in a multimodal collection to protect and to promote physician mental and physical health. We have identified the following three characteristics of well-being as likely to be positively affected by writing: Emotional equilibrium, self-healing, and building community/reducing isolation.

In the process of writing, learners usually step back from the actual situation, fears, and pressure (of training, duty, or demand) to halt and to reflect on a bigger picture to consider dos and don’ts of professionalism in a given situation. Naomi Goldberg⁴ calls the writing experience a “wild mind phenomenon” that is essential for students to cultivate reflective and meaningful imagination. This gives them the ability to express themselves metaphorically.

Dealing with Emotions: The Benefit to the Physician

Coulehan and Williams⁵ wrote that physicians must cultivate a balance between emotional steadiness (the ability not to be overwhelmed by the patient’s suffering) and emotional tenderness (the capacity always to be moved by that same suffering). A space to become familiar with physicians’ emotions and those of others can reduce isolation. One of the authors of this paper reflects how she uses writing as a medium to destress herself after a long day at work.⁶ According to her, this strategy is an ultimate mode of therapy that appears to work every time.

Downie⁷ has categorized possible outcomes of humanities-based interventions as transferable skills, humanistic perspective, situational coping, self-awareness, and joint investigation. The writing-reading-listening model can make useful contributions to these hard-to-teach clinical dimensions.

Pellegrino³ suggests that writing can be a hands-on, experiential method for increasing physician cognizance of the meaning of illness and of doctoring. Writing can be in the form of essays, short skits, plays, poetry, and critical incident essays.

The payback is not just for the writer of the story alone. Listening to the writing of colleagues offers learners a chance to sympathetically release their own helplessness and fears. Exposing learners to this position of reciprocity and equality offers them an alternative to the normally perceived role of physicians as unilateral and hierarchical.

The general hypothesis is made on this basis that it might be a “transfer effect”⁸ in which skills practiced in these sessions generalize to other aspects of doctoring. Three dimensions that may be influenced by the writing process are narrative competence, empathy, and insights into the process of patient care itself.

Therapeutic Aura: The Benefit to the Patient

The writing itself holds a therapeutic effect for a sufferer.¹ Writing one’s own story and being heard by peers can help learners clarify standards and rediscover their own ethical scope. It ignites the resolution pathway in the brain to take its action to resolve a matter or provide valid and rational explanation for a condition or emotion. The role of physicians is culturally considered as hierarchically superior and unilateral. The emotional reflection gives the patient a stable footing in the therapeutic alliance with the physician.¹ The writing can serve as a means of catharsis, and the emotions can be channeled into writing.

Not only does this benefit the sufferer, but others in the same situation may find relief in reading others’ pieces. This can help form a strong tie between them, which can lead to mutual collaboration and support.

Psychological Theories and Narrative Medicine

Proto-Narrative Nucleuses

A study conducted in children in a hospital in Italy states how every autobiographical and fictional event told by a person is derived from “inner proto-narrative nucleuses.”⁹ This means that the pieces of prospective tales told by a person are gathered in a person’s psychic archive. This is linked to his/her experiences and interpersonal relationships. These “inner proto-narrative nucleuses” are also derived from what the subject deciphers from all that s/he sees or hears around himself/herself.

In a person’s psychic archive, then, are connections between the autobiographical and nonautobiographical stories. These result from the two intersecting dimensions that influence each other and affect how the person views his/her story in context of all that goes on around him/her. This has implications for a physician-patient relationship as the writer’s (physician or patient) viewpoint may be influenced by what s/he has experienced before. An oncologist’s approach toward a patient may, for example, harbor the influence of his/her experience with other patients. In a way, these “proto-narrative nucleuses” affect how we interact with the world around us and are thus of immense significance, not just in narrative medicine but also in the physician-patient relationship.

Theory of Uncanny

Freud’s theory states that “uncanny is anything we experience in adulthood that reminds us of earlier psychic stages, of aspects of our unconscious life, or of the primitive experiences of human species.”¹⁰ The “uncanny” is when something in present life serves as a reminder of what has been long forgotten in our past. Storytelling can, hence, be one means to integrate our present with our past, our medical practice with our childhood experiences.¹⁰ Or, if you integrate this with the “proto-narrative nucleuses,” it serves as a means to place our present experience with those of the past and look at them in a holistic light.

Both these models/theories imply that whenever we tell a story, we put ourselves as one of the characters, either active or passive, and foretell the event from a personal situation that may have happened to us or someone else. We alter it and narrate it from our aspect of what could have occurred or should have been the cause or conclusion.

DISCUSSION: THE AUTHORS’ TAKE ON NARRATIVE MEDICINE

Three pieces are presented here as examples of narrative medicine. The first one, a prose named “The Observer,” was written by NK to document her experience dealing with a patient the same age as herself. Initially she was methodical in dealing with the patient but soon realized that her own problems were miniscule compared with what the patient faced with her chronic diagnosis.

The second example of narrative medicine is artwork (Figure 1) that was drawn by HJ to portray a patient with borderline personality disorder who feared relationships (R) penetrating her world/self (S) and had much difficulty separating the two. This caused problems in her life, which led to her seeking psychiatric help.

Figure 1.

Artwork as example of narrative medicine by Hena Jawaid, MBBS, FCPS.

R = relationships; S = self.

The third example is a poem, “Black and White,” written by AM about a patient who gets married, experiences “swaying” emotions, and feels that she can no longer accept her husband as her true love.

The Observer: By Natasha Khalid, MBBS.

The shift ends and I am writing the postdialysis weights of the patients as I ask them their names. My eyes are more focused on the weighing machine, rather than on the human being standing on it. “How much is my weight, again?” The question breaks my reverie about my envisioned optimal job, while writing down the weights of the patients in the log book. The girl standing on the weighing scale, the log book tells me, is the same age as me: 27. She’s a pleasant-looking young woman wearing lovely eyeliner and a nicely styled Abaya (a veil usually worn by [a Muslim] woman as a symbol of religious/cultural beliefs). I wonder of all the other 27-year-olds, myself included, and their routine struggles, this one’s issues take on a different dimension altogether given her almost daily dialysis routine. In a mere instant, I glance back at all my problems in life that presumably begin and end with the USMLEs [US Medical Licensing Examination]—problems I have chosen for myself. How every doctor I know in my age bracket is worried about the USMLE exam; how our day begins and ends with the thought of the number of hours we are able to study; how much we will score; how many publications and international electives we have under our belt; above all, whether we will match or not; how, if we don’t match, our life is going to end. I realize every day we are stressed about the future—to the point that we fail to enjoy the present.⁶

CONCLUSION: THE PHYSICIAN’S ART

Narrative medicine is an important and integral part of medical practice. The benefits are varied and reach out not just to the patient or the physician involved but also to listeners and readers of the narrative. This helps build empathy in the physician-patient relationship and can be of use as the patients feel themselves heard and understood while physicians get a chance to recognize their hopes and to confront their fears. It leads to the phenomenon of “transfer effect” whereby, through narrative medicine, a physician’s practice can be modified. The benefits are available not only to a physician’s practice but also to other health care professionals. Narrative medicine, then, is a powerful tool that we, as health care professionals, should hold onto to rejuvenate the components of care, integrity, empathy, and expertise within and without.

Black and White: By Aeman Muneeb.

When they stay around me,
It’s all fun and games,
My existence, so beautiful.
My world perfect with these
Relationships.

A mere penetrance,
Into what is called self,
And all that ceases to hold
True.

When I saw you first,
Never for a moment,
Did doubt overshadow,
This emotion called love.

I feel on the edge,
Two days into our union,
I oscillate between,
Desperation and elation.

All appears ugly,
As I became your wife,
My meaning so distorted,
Darkness surrounds my life.

I want to run away,
Before my feelings again sway,
Truth be told, I no longer want thee,
“Borderline” is what they call me.