Tell Me Your Story: A Pilot Narrative Medicine Curriculum During the Medicine Clerkship
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Narrative medicine educational interventions may enhance patient-centered care, yet most educational interventions do not involve actual patient–provider interactions, nor do they assess narrative competence, a key skill for its practice. An experiential narrative medicine curriculum for medical students was developed and piloted.
The purpose of the study was to develop narrative competence, practice attentive listening, and stimulate reflection.
Participants were third-year medicine clerkship students.
The curriculum involved 1) an introductory session, 2) a patient storytelling activity, and 3) a group reflection session. For the storytelling activity, students elicited illness narratives in storytelling form from patients, listened attentively, wrote their versions of the story, and then read them back to patients.
Five student focus groups were conducted between July 2011 and March 2012 (n = 31; 66 %) to explore students’ experiences, student–patient dynamics, challenges, and what they learned. Patient interviews (n = 17) on their experience were conducted in January 2013. Thematic analysis of the audiotaped stories of ten patients and corresponding student-written stories helped gauge narrative competence.
The curriculum was found to be feasible and acceptable to both patients and students. Some patients and students were profoundly moved. Ongoing focus groups resulted in continual process improvement. Students’ stories showed attainment of narrative competence.
KEY WORDShumanism empathy patient communication medical education
Stories in medicine can benefit patients and physicians in therapeutic and deeply meaningful ways.1, 2, 3 The practice of narrative medicine has been proposed as a model for empathy, reflection, professionalism, and trust.4 It rests on narrative competence: “the ability to acknowledge, absorb, interpret, and act on the stories and plights of others.”4 Methods such as reflective writing, storytelling, and literary analysis can be used to practice narrative medicine and to develop narrative competence.2,4,5
Educators have used narrative medicine approaches such as illness narrative-writing exercises as a method to teach empathy, patient-centeredness, and humanism.5, 6, 7, 8, 9 Most published educational interventions have occurred during the preclinical years of medical school, outside actual patient–provider interactions. Furthermore, we are not aware of any studies that have addressed narrative competence skills. We sought to incorporate a brief experiential narrative medicine curriculum within a third-year medicine clerkship, with the goals of developing narrative competence, practicing attentive listening,10 and stimulating reflection, while providing patient-centered care for hospitalized patients.
SETTING AND PARTICIPANTS
The program involved third-year medical students during a 4-week inpatient medicine clerkship rotation.
A pilot experiential narrative medicine curriculum was launched in July 2011, informed by narrative medicine training completed by faculty and by adult learning principles of active learning and reflection.11,12 Components included an introductory session, a patient storytelling activity and a reflection session at the end of the rotation.
During the introductory hour-long session, students were introduced to the concepts of narrative medicine and attentive listening. They practiced storytelling and attentive listening in pairs (Appendix). Faculty shared examples of illness narratives written by past students and faculty.
The storytelling activity involved the following: eliciting an illness narrative from a patient (optional script, Appendix); practicing attentive listening during the storytelling; writing the story, incorporating what was said and how it was said; and reading the story back to the patient.
During the group reflection session, students wrote to the prompt, “Write about your experience doing the narrative medicine activity with your patient. What stood out for you?” Faculty participants moderated the sharing and discussion, including how students might incorporate aspects of the activity into their future practice.
We evaluated the pilot curriculum by conducting student focus groups and patient interviews, and by comparing a sample of student-written narratives to the corresponding audiotaped patient stories.
Five student focus groups were conducted between July 2011 and March 2012. Students were invited to attend via e-mail from the group moderator (BY); no incentives were offered other than the promise of baked goods. Researchers involved in evaluating students (RS, KC) did not know who participated. A semi-structured moderator interview guide explored students’ experiences, the student–patient dynamic, challenges, and what they learned (Appendix). At the conclusion of each focus group, the moderator summarized the main themes as a form of member-checking. An external service transcribed the focus group recordings. Two researchers (RS, KC) independently read and coded each focus group transcript, meeting periodically to compare codes and to construct/revise a master codebook.13 They resolved disagreements through discussion. Focus groups continued until saturation (no new themes being heard) was reached. The Washington D.C. VA Medical Center (VAMC) Institutional Review Board approved this study.
Thirty-one students (of a possible 47; 66 %) participated in five focus groups, lasting from 55 to 75 minutes. From the analysis, four major domains emerged: patient experience, student experience (with a sub-domain of student learning), student–patient dynamic, and challenges.
“…he said, ‘Well, the biggest story of my life is the story of my cancer,’ and just started [to] let it all out, started crying.” (FG5)
“…he was pointing and being, like, ‘yes…that’s totally what it feels like right now.’” (FG5)
“By the end of the activity he really seemed… a different person because he…had more understanding and willingness to cooperate.” (FG3)
“Like he’s been in and out of hospitals for 30 years and he felt like this hospital, we were doing something else—although we were really close…there was still something that made us closer than without it.” (FG2)
“…it was very therapeutic… by the end of the session he said that he would start taking the meds again.” (FG5)
“I was so glad it happened after. I remember just walking out being like: Wow you know, I feel like I know that patient better than a patient I had at [other hospital] for a whole month… we shared something that he really probably hasn’t shared with many people.” (FG2)
"I was completely just taken aback by what he shared with me having never met me before.” (FG3)
The activity offered students a break in their day and an opportunity to interact with new patients, to practice listening, and to see the human side of medicine. A couple of students were asked whether they could be their patients’ primary care physician.
“I…expected…all this emotion about his illness and we were going to connect … instead I kind of felt pushed away, and he wasn’t even actually able to engage in a story about his illness.” (FG5)
“I was completely just taken aback by what he shared with me, having never met me before, as a complete stranger. It was—there were some very personal details of his life that he opened up to me about and I was… pretty amazed the whole time.” (FG3)
Students’ perceptions of learning during the narrative medicine activity: themes and representative quotes
Patients are more than their disease.
“…sometimes we need to take a moment to just sit with someone and just listen…and make them feel like you know they’re a person once again, that they’re not an illness and that this isn’t the end of their life … I really got this feeling that this patient had lost this sense of hope and somehow by telling his own story it was renewed.” (FG1)
Be open to opportunities to slow down and listen.
“just don’t be afraid to ask and talk to your patients, because sometimes you have the feeling of you don’t want to be too intrusive or too personal with someone, but I guess just be willing to ask…and willing to listen—so you don’t miss the opportunity when someone is willing to share.” (FG1)
Stories give new insights into patients.
“I felt like I actually got a better picture of how he views his illness and everything else just by…the story he chose." (FG2)
Stories can affect patient care.
“he was able to open up about an experience…that recently happened that our team didn’t actually know about…we might never have known about this event that was actually pertinent to his care.” (FG3)
Patients as individuals
“I learned a lesson of just because they’re in a hospital doesn’t mean that they’re pessimistic or it doesn’t mean that they want to be… involved, and so I think just letting the patient guide that was a big lesson in general that I got out of this.” (FG1)
“As I listened to his story, I myself started to get outraged with the story. I was getting upset for him. I was like ‘this is ridiculous!’…And I think we kind of shared the emotions that were captured in the story” (FG1).
“I think my patient trusted me a lot more, and he’s a patient who didn’t trust anybody.” (FG4)
“I definitely felt like it broke down a lot of barriers.” (FG3)
A couple of students did not feel their student–patient relationship had changed. One student mentioned that she felt distant to her patient during the exercise, but this normalized the next day.
“It ended up improving his care later on because I was able to sort of level with him on things to get him the appropriate care he needed.” (FG5)
For students, selecting a patient was sometimes difficult, since they hoped to find someone that was expressive and needing to be heard. Other challenges were finding the time to do the activity, writing the story, and changing their way of interacting with patients.
“…it really is a struggle, unrealistic, in a real-world setting to have the time to do this, but I mean it is a great activity if you do have time.” (FG3)
Patient interview categories of responses and representative quotes
“She wrote a little thing about me…it really touched me, deep, you know, and I can’t think of anybody, at least in a couple decades, who has helped me with such high esteem. You know, when I’m here and I’m not in my best of shape or anything…that didn’t matter to her, she saw me as an individual and saw me as having self-worth [tears up].”
“It sounded alright. She read back what I told her…”
To assess narrative competence, we compared real-time audio-recorded stories of ten patients with the corresponding stories that were written by students immediately afterwards. Two investigators independently listened to recordings and abstracted major themes (e.g., redemption, identity loss); another investigator analyzed written stories for themes. The three investigators discussed their findings for degree of agreement on expressed themes. There was high or full agreement in eight of ten themes. However, two of the ten student-written stories missed major themes expressed in the recording. Both of these stories were written in a more list-like fashion than a true narrative.
A brief experiential pilot narrative medicine curriculum was found to be feasible and acceptable to students and patients. Our qualitative findings highlight the richness of the experience that students and patients derived from these interactions. Patients perceived that they were attended to and heard; students gained a deeper appreciation of the human side of medicine and felt deeper connections with their patients. After 2 years of experience and over 200 students participating, no student–patient relationships were known to be impaired due to the activity, although some were perceived to have no change.
A strength of this educational intervention was its direct involvement with patients in the clinical setting—one that had the ability to impact subsequent patient care. To our knowledge, it is also the first attempt to measure narrative competence within such an intervention. Students who wrote a true narrative versus a bulleted list were able to capture the essence of the stories they had heard. Indeed, the writing piece was pivotal. Students became co-creators of patients’ stories 14.
The study had several limitations. Feasibility limited the number of stories we could audio-record in real time and the number of patients interviewed. This was a single-institution study, and there were no patient outcome measures beyond satisfaction. Another limitation was that students who participated in focus groups were self-selected.
We do not know whether this curriculum had any lasting impact on students’ practice. This could be the focus of a future study. Anecdotally, former students who are now residents have written to us to say that their practice has been enriched by this approach. Given concerns about future time constraints, we emphasized in the reflection session how aspects of the approach could be used and how faculty have incorporated it into practice, and impressed upon them the unlimited opportunities available to witness patients’ stories, with all of the rewards that it can bring. Future studies could look at the development of narrative competence over time as well as patient outcomes.
This work was not funded. The work was presented as oral presentations for Innovations in Medical Education at the 2014 Mid-Atlantic Regional Society of General Internal Medicine (SGIM) Meeting, New York, NY, and at the 2014 SGIM Annual Meeting, San Diego, CA.
Conflicts of Interest
The authors declare no conflicts of interest.
- 11.Schon D. Educating the Reflective Practitioner. San Francisco: Jossey-Bass; 1987:100–118.Google Scholar
- 12.Knowles MS, Holton EF, Swanson RA. The Adult Learner. New York: Elsevier; 2005:140–164.Google Scholar
- 13.Crabtree, B., Miller, W. in Doing qualitative research. Newbury Park, CA: Sage, 93–109.Google Scholar