Learning narrative-based medicine skills

Abstract

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.

It never occurred to anyone to say, “Tell us!”

Milan Kundera¹

For the GP who is new to narrative-based medicine (NBM), the first step in practising NBM is, invariably, listening to and exploring the narrative and empathizing with the patient. Narrative skills will evolve from here because, as more complex narratives present, the need will arise to make sense of these stories and to uncover hidden meanings. Reflection on the consultation and discussion² will assist with deciphering the stories, deepening the understanding of the patient, and developing insight into the dynamics of the interaction.² This is where the GP will need to learn new skills and might therefore consider undertaking courses in advanced communication skills, counseling skills, or psychodynamic principles for GPs. Alternatively, participating regularly in a Balint group^3,4 or in small group activities that focus on discussing challenging and complex presentations and managing uncertainty^5,6 can also be very useful for developing insight and reflective skills.

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

Listening, exploring, deciphering, and reflecting are tasks with the common aim of understanding, ultimately leading to the creation of a new narrative that enables and facilitates management. As the arts stimulate the imagination and foster creativity, they are a means for physicians to develop the skills required for NBM, so that they can incorporate these tasks in practice.

Listening and exploring

Listening to the patient narrative, drawing it out, and exploring it more deeply might appear daunting to a GP who is new to narrative.⁷ It is not a difficult task, however, and it could be compared to painting a picture.⁸ A painting is not always completed in one sitting. In fact, it might never be completed. It will certainly be revisited and it might need to be retouched or even started all over again. For the novice, a few simple yet practical strategies for exploring the narrative are helpful (Box 1).² Examples of the kind of questions to ask were presented in the first article⁹ in this series,^9,10 as were Charon’s “4 divides,”² which should always be kept in mind.

Box 1. Practical strategies for the novice in narrative-based medicine.

The following are some practical approaches to getting started:

• Show interest in the patient. Find out about him or her. The patient should not have to apologize for “talking too much” or “taking up your time”

• Listen attentively

• Do not interrupt, especially at the beginning of the consultation. Always let the patient finish his or her train of thought

• Ask open-ended questions

• Silences are good. Resist the impulse to ask a question. Wait for the patient to break the silence. Whatever he or she has to say will probably have more value than the response to any intended question

• Listen for cues and follow them

• Observe the patient’s body language

• If for whatever reason the narrative must be stopped, ensure that it is continued at the next opportunity

• View noncompliance as a blocked narrative, not as the product of a difficult patient

• Do not make assumptions

• Do not be judgmental

• Do not be in a hurry to manage the problem

• Be mindful of Charon’s “4 divides” (relation to mortality; context of illness; beliefs about disease causality; shame, blame, and fear)²

• When it is not very clear why the patient has presented, ask yourself, “Why has this patient presented at this moment with this problem?” Reflect this question back to the patient. Ask for the patient’s opinion

Deciphering

When a painting is incomplete, or when it does not portray a clear narrative, its meaning can be obscure. This also occurs with patient narratives. Obtaining more information can be helpful, but not always. More-developed narrative skills are required here in order to uncover hidden meanings and connections that will shed light on the situation. These skills can be gained from particular courses or small group activities.^5,6,11 In the first instance, however, discussing the dilemma with someone more experienced can provide interesting insights for opening up the narrative.

Reflecting

To be appreciated, a painting requires the observer to spend time looking at it and thinking about it. Similarly, reflection leads to a better understanding of the narrative. Some people, however, reflect more easily than others. There are several ways in which GPs can develop reflective skills. One way is by joining small groups in which challenging and complex presentations and the management of uncertainty are discussed. Having an experienced leader, one who is trained in narrative, is advantageous.^5,6,11,12 An experienced leader can challenge assumptions, creating greater awareness so that discussion will be suitably focused and more productive. Adherence to a few simple rules improves the group’s functioning, namely mutual respect; a focus on understanding, not problem solving; and not instructing.

Another way of developing reflective skills is to engage in creative writing classes,¹³ where ideas are shared and participants become inspired and motivated to be imaginative. Creative writing broadens the mind, conferring benefits to clinical practice.¹³ Author David Malouf, in examining what it means to be a writer, articulates this process in describing the “imaginative writer”:

The writer I have been evoking is what we loosely call the imaginative writer … whose business, as he would see it is with discovery; not with the articulation of some previously held view but the groping through words towards something only vaguely grasped and which he will recognize only when words have set it down on the page.¹⁴

Engaging in reflective writing is yet another way to develop reflective skills. Reflective writing is different from creative writing.¹⁵ As, Malouf describes,

There is, of course, another kind of writing … it is the product of consciousness that is very active and alert and it needs these qualities to do what it must do, which is to challenge, question, turn received ideas on their heads.¹⁴

The power of reflective writing is well documented.¹⁵ Rita Charon uses “parallel charts”¹ to teach narrative to health professionals. A parallel chart is a reflective piece written soon after a clinical encounter and generally on an encounter that has caused a degree of discomfort. There are no specific guidelines for what to write, only that it should be about the thoughts, feelings, reactions, and questions that were engendered by the encounter—the things, in other words, that cannot be written in the traditional chart. In form it can be creative: prose, poetry, or random thoughts. Its purpose is to be reflective. Group members then meet regularly with a trained leader to read and discuss their writing and to reflect on the patient narratives, their meaning, and the emotions engendered. The skills of narrative are therefore developed via the process of listening, recording, reflecting, discussing, and reflecting again.¹⁶ With practice, participants become more attentive to the patient story and more understanding of the patient. Insight and powers of reflection improve, not only with respect to the patient, but also for participants themselves and the way that they interact with patients and cope in difficult situations.^2,16 There are others^17–19 who, like Charon, conduct programs using creative and reflective writing for teaching narrative skills. These programs repeatedly attest to the benefits of NBM.

What has been described so far is reflection “on action”—in other words, after the patient encounter. With the parallel charts exercise, participants learn to reflect on their own feelings and reactions. Reflexivity—self-referencing to gain insight into someone else’s experience²⁰—is also a useful exercise, although it is important to understand countertransference in order to use it appropriately. Experiences might be similar but not exactly the same, and the doctor’s understanding can only be an approximation of the patient’s reality.^6,11 Balint groups and small group discussions around challenging problems will invariably discuss the patient’s and the doctor’s role in the consultation, as well as the doctor’s feelings, emotions, and reactions. In time, with guidance and practice, this increased awareness of the patient, the self, and the interaction will gradually change from being an awareness of each as separate entities into an ability to consider all of them at once. This is reflection “in action”²¹ at its most developed and it is a powerful skill. The ability to consider the 3 elements as a dynamic entity—to consider how one thing that the patient says or the doctor does changes the narrative—puts the doctor in a position to respond in the moment and in a way that might be more effective than something the doctor might do later on. This ability to reflect in action certainly comes with experience and is facilitated by having a broader awareness and a sense for complexity and interconnectivity. A powerful way of broadening awareness is to engage with the arts.

The arts

In the 19th and early 20th centuries, the arts were considered essential to a good education.²² This is not considered important today, possibly because the educational background of most doctors is either exclusively or predominantly in the sciences and because medicine’s scientific and technological base has been steadily increasing, driven by the search for precision and certainty.²² Periodically, however, there are calls for medicine’s humanity to return and the focus to come back to the patient.^23–25 Narrative-based medicine, having its origins in the arts, is about that humanity—sensitivity toward the human condition with genuine empathic connection. It is for these reasons that medical humanities programs have been established in medical schools^26–28 (Box 2).^23,29–32 The arts promote narrative skills by broadening the mind, developing insight and reflective capabilities, and creating deeper understanding.^26–30,33 Literature and drama generally have a narrative structure that relates to the real world. Novels and short stories that deal with relationships and the human condition provide a broader perspective and understanding, as well as a host of narratives. The subject matter does not have to be medical. Charon believes that the reading and analysis of literature² is a powerful way of learning narrative skills, and her parallel charts are a logical extension of this. The principles of literary analysis are extended to the analysis of patient and doctor narratives¹⁶ to achieve better understanding and to strengthen the patient-doctor relationship.

Box 2. Benefits of using the arts in medical education.

The arts enhance the ability to ...

• reflect on experiences (one’s own and those of others)

• interpret messages in different forms (eg, symbol, metaphor, subtext)

• use language precisely

• develop and extend a logical argument

• understand the subjective experience of others

• consider different ways of perceiving and understanding

• find meaning

• think independently

• consider why, not just how

• distinguish between objective and subjective, disease and illness, cure and healing

• acquire skills of high-level reasoning, tolerance to ambiguity, creativity, and imagination

• tap into and respond to feelings and emotional responses

Data from Moore,²³ Gordon and Evans,²⁹ Powley and Higson,³⁰ Alexander et al,³¹ and Macnaughton.³²

Images (painting, drawings, photographs) are an excellent format for discussing differing perspectives and interpretations.³⁴ Music and dance readily evoke feelings and emotions, and the symbols and metaphors that are used invite interpretation. Of the arts, film^31,35 is the most accessible. It is also a form that encompasses several elements (narrative, language, sound, music, image) from which much can be learned. As always, it is the reflection, and particularly the discourse, on the encounter with the arts—be it novel, poem, painting, or film—that leads to the discovery of new ideas and perspectives and, ultimately, greater awareness and understanding. It is not enough to ask, “What happened?” but also, “Why did it happen?” and “What does it mean?” and “How does it make you feel?” These questions encompass what NBM is about.

The arts and creative and reflective writing also stimulate the imagination and foster creativity. Imagination enables doctors to put themselves in their patients’ shoes (empathic imagination).^28,36 Creativity can assist with making connections and inferences, making sense out of what might appear fragmented or disconnected.²⁸ Clinical practice is fraught with many difficulties such as language barriers, cultural differences, conflicting goals and expectations, and comorbidity. Different ways of thinking are required³⁷ to navigate through the various challenges, and creative skills might be helpful,²⁸ given the many benefits of NBM (Box 3).^{2,11,12,32,33}

Box 3. Benefits of practising narrative-based medicine.

The benefits of narrative-based medicine include the following:

• improving communication

• improving medical information (accuracy of patient history)

• understanding how evidence can be interpreted in different ways (medicolegal understanding)

• exposing prejudices and fears in the clinician (self-reflection)

• improving and enriching the doctor-patient relationship (enhancing trust and empathy)

• fostering shared decision making (co-construction)

• understanding how medical errors are made and how they can be avoided

• understanding the transience of medical knowledge and the importance of keeping up to date

• improving relationships with colleagues and the effectiveness of the health team

• enhancing work satisfaction and decreasing clinician burnout (self-awareness, attention to self-care, development of resilience)

Data from Charon,² Launer,¹¹ Kalitzkus and Matthiessen,¹² Macnaughton,³² and Divinsky.³³

Conclusion

Life is short; and the art long; and the right time an instant; and treatment precarious; and the crisis grievous. It is necessary for the physician not only to provide the needed treatment but to provide for the patient himself and for those beside him.

Hippocrates

Learning narrative skills starts with listening to and exploring the patient’s story. It requires a willingness to hear that story and a willingness to understand. As more narratives are listened to, and with experience, many GPs will naturally look to improve their narrative skills further and gain, as Charon² terms it, narrative competence—the ability to practise NBM effectively. This takes time¹²—years in fact—time that could be shortened if narrative skills were taught more widely to undergraduates and clinicians generally.³⁸ There are already courses and programs for teaching narrative skills or that incorporate the arts into their teaching.^{2,11,16–19,27,28} More are needed.

The ever increasing and often astounding scientific and 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. The arts, however, speak to us of the art of medicine—how important and relevant this art is still. Narrative-based medicine is the means by which the art can be practised—for framing the patient’s and the doctor’s narrative within the context of a broader picture, for connecting empathically with the patient, for finding meaning and purpose within the detritus created by illness and disease, and for lighting the path toward healing.

Editor’s key points

• ▸ For those who are new to narrative-based medicine (NBM), the first step in practising NBM is listening to and exploring the narrative and empathizing with the patient. Listening, exploring, deciphering, and reflecting are tasks with the common aim of understanding, ultimately leading to the creation of a new narrative that enables and facilitates management.

• ▸ Development of narrative competence takes time and experience. The skills necessary to practise NBM can be strengthened through participation in narrative skills courses, Balint groups, or small group discussions, as well as through creative and reflective writing, literary analysis, and reflective engagement with film, theatre, and visual art.

Points de repère du rédacteur

• ▸ Les novices en médecine narrative doivent savoir que la première étape pour la pratiquer se situe dans l’écoute et l’exploration de la narration du patient, puis dans l’empathie. L’écoute, l’exploration, le décodage et la réflexion sont des tâches qui ont toutes pour but commun de bien comprendre et, en définitive, de mener à la création d’une nouvelle narration qui permet et facilite la prise en charge.

• ▸ Il faut du temps et de l’expérience pour perfectionner les compétences en narration. Il est possible de renforcer les compétences nécessaires pour pratiquer la médecine narrative en participant à des cours en compétences narratives, à des groupes Balint ou à des discussions en petits groupes, de même que par la rédaction créative et réflective, l’analyse littéraire, et une participation réflective aux arts visuels, au cinéma et au théâtre.