Narrative Medicine WorkshopVancouver 2010

Welcome and Introductions1. Introduction2. 45 minute interactive small group sessions

a) Writingb) Readingc) Reflection

3. Applications of narrative medicine4. Wrap up

What is narrative medicine?A clinical practice informed by reading,

writing, telling and receiving storiesNarrative skills include: active listening,

close reading, reflective writing and bearing witness

The development of these skills will create more effective cliniciansRita Charon

Narrative medicine in practiceMedicine is fundamentally narrative. Daily practice is filled with stories

Patient stories, “war stories”, hallway consultations, stories we tell ourselves

Patients ’ histories and physical findings can be read, studied and interpreted as if they were a text

KM Hunter 1991 Doctors’ Stories

Patients in turn must listen to and interpret the physician’s summary of their illness and advice. They may add this to their own story or not.

Narrative versus StoryStory:  a sequence of actions or events

independent of the actual text.Another way of thinking about this is the events as they happened in the real world.

Narrative:  the embodiment of the story in the discourse of a text.This could be a paper text, film, video, or even oral, as in the case of native healing ceremonies.

Role of stories • Convey information• Share experiences; connect with others• Entertain• Make sense of experience• Validate emotional realities• Link theory to practice• Reveal multiple perspectives, complexities• Encourage reflection and self-review

-Alterio

Clinical narrative• Created by clinicians• Usually “objective” unemotional• The patient experience is edited, encoded in

medical language, eliminating “irrelevancies”• Highlights details that point to diagnosis; to

treatment plan• All but unreadable to the untutored eye• When patients reads these, their story seems

flattened, unrecognizable to them• -KM Hunter 1991 Doctors’ Stories

Illness NarrativeLived experience of diseaseArthur Frank characterized common types

Restitution narrativeChaos narrativeQuest narratives

Close reading of patientsClose reading starts with attention: being

fully presentEntering into the reality of the otherConsider what is the purpose of their story,

the plot, the characters and the type of language used

Start with the same language or framework as the patient during explanations

Narrative ParadigmPatient Physician

WritesOwnsRevise narrative together

Patient tells story

Physician probes story

Illness Story/Narrative (typically unwritten)

ClinicalNarrative

Reflection

Reflection

Magic Mirror Story

ReflectionReflection : A process in which we witness

and present the patient’s story to ourselves and back to them

We present what we see and hear in writing and telling

The story can become altered in this process e.g. it can be stripped of elements of the patient’s illness experience, become merely a diagnostic and treatment summary

but it also can become a story meaningful in other ways –which the patient can chose to use or not

Instruction for Reflection ExercisePair offTell a story about a recent incident that you

found disturbing or wondered about (5 min)The listener will write your story down, ask

clarifying questions, but not problem solve or interpret (active listening)

Switch rolesReturn to main group; tell each other’s story

QuestionsHow did it feel to have your story told by

another?Did the listener capture the important

aspects in your opinion?Was it difficult to just listen and clarify the

story?Did you have any insights by doing this

exercise?

Application of Narrative medicineStrengthen the provider-patient relationshipTo ameliorate the patient’s condition

thorough new understanding of an old story or creation of new story

Provide for self reflectionDevelopment of professionalismIncrease sensitivity and insight into other

cultures

How and when to use Narrative MedicineHow do you currently use narrative medicine

in your practice?

Will you use narrative medicine in the future?

How and when to use narrative in practice• Selectively• When it is appropriate• When there is a signal that there is more or a

story to clinical presentation• At the beginning• “I will be your doctor and so I have to learn at

great deal about your body, and your health and your life. Please tell me what you think I should know about your situation.” - Rita Charon

Narrative in practiceCaveats

You can provide opportunities but the patient has to want to share the story

Boundary issues: It is the patient’s story, are you a player in this story? Is it appropriate?

Time management

Questions

ReferencesNarrative medicine Honouring the stories of

illness Rita CharonNarrative in Health Care John D Engel et al.Doctors’ StoriesThe structure of medical knowledge Kathryn

Montgomery Hunter

ReferencesThe Wounded story teller. Arthur FrankNarrative Primary Care: a practical guide.

John LaunerNarrative Based Health Care: Sharing stories

a multidisciplinary workbook. Trisha Greenhalgh & Anna Collard.

Story Re-visions Narrative Therapy in Postmodern world. Alan Parry & Robert Doan