INTRODUCTION

Stories in medicine can benefit patients and physicians in therapeutic and deeply meaningful ways.1–3 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.5–9 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.

PROGRAM DESCRIPTION

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.

PROGRAM EVALUATION

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.

Focus Groups

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.

Patient Experience

Overall, students felt that their patients enjoyed the activity and valued the chance to talk freely, some feeling empowered by the experience. Many patients became emotional during the activity.

“…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)

As the stories were read back to the patients, students perceived that patients felt that they were understood, and that the students interpreted their stories accurately.

“…he was pointing and being, like, ‘yes…that’s totally what it feels like right now.’” (FG5)

Some students experienced a transformation in their patients after the activity.

“By the end of the activity he really seemed… a different person because he…had more understanding and willingness to cooperate.” (FG3)

Students felt that the activity was an opportunity for patients to have a break from routine, to have time to talk, reflect, and process what was going on in their hospitalization, to vent, to be heard and understood, and to feel that something different was happening.

“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)

Several students mentioned the word “therapeutic” when talking about the activity.

“…it was very therapeutic… by the end of the session he said that he would start taking the meds again.” (FG5)

Student Experience

For students, the activity was enjoyable, rewarding, and meaningful, sometimes surprisingly so. It led to new insights about their patients and allowed students to see patients as more than an illness.

“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.

Some students expressed feeling nervous during the activity, particularly during the reading back of the story. Other students had expectations that were not met.

“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)

Students were surprised by many aspects of the activity, including the story their patient chose to tell, the insights gleaned from their patients, and how emotional, enjoyable, and meaningful it was.

“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 their learning included the following themes: 1) patients are more than their disease, 2) be open to opportunities to slow down and listen, 3) stories give new insights into patients, 4) stories can affect patient care, and 5) patients as individuals (Table 1).

Table 1 Students’ perceptions of learning during the narrative medicine activity: themes and representative quotes
Full size table

Student–Patient Dynamic

The interaction between patient and student was often a shared, reciprocal experience that enriched the relationship.

“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).

After the activity, many students felt they knew their patients better and had a better relationship with them, with a greater sense of closeness and trust.

“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.

As a result of the interaction, some students felt a heightened sense of responsibility towards their patients, some shared insights with their teams, and some approached their patients differently. Some felt that subsequent patient care improved.

“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)

Challenges

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.

Several students anticipated difficulties in applying the activity in the future, given time constraints.

“…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 Interviews

In January 2013, members of the research team (KC, RS, RJ) approached 17 patients and one family member, selected based only on team member and patient availability, to undergo brief interviews on their experience with the activity. All patients (100 %) who were approached agreed to participate and provided written consent to be recorded. Responses were categorized as positive (12/17, 71 %) or indifferent (3/17, 18 %). None were negative. Two patients (2/17, 12 %) could not recall the event. See Table  2 for representative quotes for the categories.

Table 2 Patient interview categories of responses and representative quotes
Full size table

Narrative Competence

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.

DISCUSSION

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.