Rita Charon

Personal illness narratives: using reflective writing to teach empathy.

Reflective writing is one established method for teaching medical students empathetic interactions with patients. Most such exercises rely on students’ reflecting upon clinical experiences. To effectively elicit, interpret, and translate the patients story, however, a reflective practitioner must also be self-aware, personally and professionally. Race, gender, and other embodied sources of identity of practitioners and patients have been shown to influence the nature of clinical communication. Yet, although medical practice is dedicated to examining, diagnosing, and treating bodies, the relationship of physicians to their own physicality is vexed. Medical training creates a dichotomy whereby patients are identified by their bodies while physicians’ bodies are secondary to physicians’ minds. As a result, little opportunity is afforded to physicians to deal with personal illness experiences, be they their own or those of loved ones. This article describes a reflective writing exercise conducted in a second-year medical student humanities seminar. The “personal illness narrative” exercise created a medium for students to elicit, interpret, and translate their personal illness experiences while witnessing their colleagues’ stories. Qualitative analysis of students’ evaluation comments indicated that the exercise, although emotionally challenging, was well received and highly recommended for other students and residents. The reflective writing exercise may be incorporated into medical curricula aimed at increasing trainees’ empathy. Affording students and residents an opportunity to describe and share their illness experiences may counteract the traditional distancing of physicians’ minds from their bodies and lead to more empathic and self-aware practice.

Older patient satisfaction with communication during an initial medical encounter

There has been extensive research on the factors associated with patient satisfaction with communication during medical encounters, however, little attention has been paid to satisfaction among subgroups of patients, including the elderly. It is inappropriate to assume that all patients have the same physician-patient relationship needs, and thus, they will all be satisfied with the same communication approaches during medical visits. In this study, we examine the interactional correlates of older patient satisfaction with an initial visit with a general internist. A multidisciplinary team composed of social scientists and physicians used the Multi-dimensional Interaction Analysis system to code audiotapes. Patients and physicians completed post-visit satisfaction questionnaires. Older patient satisfaction was positively correlated with the following variables: physician questioning and supportiveness on patient-raised topics; patient information-giving on patient-raised topics; the length of the visit; the physicians use of questions worded in the negative; shared laughter between the physician and the patient; and physician satisfaction. These findings suggest that older patients prefer encounters in which: (1) there is physician supportiveness and shared laughter; (2) they are questioned about and given an opportunity to provide information on their own agenda items; and (3) physicians provide some structure for the first meeting through their use of questions worded in the negative. The authors caution that although this sample of older patients appears to be satisfied with a communication style usually considered characteristic of the traditional model of the physician-patient relationship (i.e. a warm interpersonal style and physician-generated structure for the visit), older patients in other settings and future cohorts of elderly patients may prefer other communication approaches. It is also suggested that aspects of communication which provide satisfaction to patients in first visits may be different than aspects of communication associated with patient satisfaction in follow-up visits.

Hypertension in Women: What is Really Known?: The Women's Caucus, Working Group on Women's Health of the Society of General Internal Medicine

PURPOSE To determine whether there is sufficient information in the medical literature to guide appropriate treatment of hypertensive women. DATA IDENTIFICATION Epidemiologic surveys of hypertension, clinical trials of antihypertensive therapy, and studies of selected adverse effects of antihypertensive agents were identified through a computerized search using MEDLINE and by identifying all studies cited in current medical textbooks as supporting evidence for the guidelines for the treatment of hypertensive individuals. All epidemiologic studies selected were cross-sectional or longitudinal, multicenter, population-based surveys. All clinical trials were large, randomized studies comparing one or more antihypertensive agents with a placebo or nonplacebo control group. Epidemiologic studies and clinical trials were reviewed to assess the quantity and quality of information available regarding important aspects of hypertension in women. Data pertaining to epidemiology, natural history, results of treatment, and two significant side effects of antihypertensive treatment were examined. RESULTS OF DATA ANALYSIS The prevalence of hypertension is greater in black women than in black men and is about equal in white women and men. Because women outnumber men in the population, there are more hypertensive women than men. The attributable risk percent (the proportion of end points that could be eliminated by removing hypertension) for cardiovascular complications of hypertension is higher for women than men. Clinical trials show clear benefit of therapy for black women but no clear benefit for white women; some studies suggest that treatment of white women is harmful. Lipid profiles and their relation to ischemic heart disease differ for women and men; there is currently no information on the effects of antihypertensive agents on serum lipids in women. Few data have been published on the frequency of sexual dysfunction in treated hypertensive women. CONCLUSIONS Hypertension in women and its related cardiovascular outcomes are a major public health problem. Clinical trials of antihypertensive therapy do not fully support current guidelines for the treatment of hypertensive women. Research concerning adverse effects of antihypertensive agents has largely excluded women from consideration; further studies are required to guide appropriate treatment.

Narrative evidence based medicine

Henry Jamess story The Middle Years represents a writer, Dencombe, in the prime of his writing life but the decline of his physical life. Seriously ill as the reader meets him, he meets up with Dr Hugh, a brilliant physician and a skilled reader who has fallen head over heels for Dencombes novels. Dr Hugh is, narratologically, Dencombes “ideal reader”, schooled in, and sympathetic to, the writers project. In the epigraph above, Dencombe articulates his credo as he embraces, in the waning hours of life, his stilling love affair with the mystery of lifes questions. The “rest” that constitutes the madness of art is that which lies beyond doubt, namely, certainty. By placing the certain in the realm of art—and of madness— James tells us a great deal about his own aesthetic experience, his path toward knowledge, his sources of light, and the realms of his doubt.

Literature and medicine: origins and destinies.

Literature and medicine is a flourishing subdiscipline of literary studies that examines the many relations between literary acts and texts and medical acts and texts. The author examines the historical connections between these two fields and suggests that the growth and decline in medicines attentiveness to the power of words can be used as a marker for medicines degree of attentiveness to the individual patients predicament. The recent explosive growth in medicines interest in literature and narrative is taken as evidence that medicines swing toward the reductionist and away from the narrative has ended. Patients and doctors have reason to await the return swing of the pendulum—if not the turn of the spiral—toward a medicine that is both technologically and narratively competent.

Multi-dimensional interaction analysis: A collaborative approach to the study of medical discourse

This paper reviews the conceptual frameworks of several research approaches to the study of medical interactions. Two methods are discussed: process analysis and microanalysis. Adapted from Robert Baless study of the behavior of small groups, process analysis sorts and tallies such interviewing processes as questioning and informing, achieving analysis of large numbers of interviews at the expense of attention to the content or context of the interview. When used in medical interaction research, process analysis seeks correlation between processes documented in the interview and outcomes of the interview. The methods of conversation analysts and discourse analysts, microanalyses subject medical conversations to close linguistic study and contextualization. This review focuses on the underlying assumptions, generalizability of findings, and the types of subjective judgment applied by the methods. It then describes the Multi-Dimensional Interaction Analysis (MDIA) system, a linguistic analytic instrument that combines features of process analysis and microanalysis to capture content, process, and context of medical conversations. The MDIAs validity and reliability are reported and implications for future research are outlined.

Narrative medicine as a means of training medical students toward residency competencies

OBJECTIVE This study sought to explore the perceived influence of narrative medicine training on clinical skill development of fourth-year medical students, focusing on competencies mandated by ACGME and the RCPSC in areas of communication, collaboration, and professionalism. METHODS Using grounded-theory, three methods of data collection were used to query twelve medical students participating in a one-month narrative medicine elective regarding the process of training and the influence on clinical skills. Iterative thematic analysis and data triangulation occurred. RESULTS Response rate was 91% (survey), 50% (focus group) and 25% (follow-up). Five major findings emerged. Students perceive that they: develop and improve specific communication skills; enhance their capacity to collaborate, empathize, and be patient-centered; develop personally and professionally through reflection. They report that the pedagogical approach used in narrative training is critical to its dividends but misunderstood and perceived as counter-culture. CONCLUSION/PRACTICE IMPLICATIONS: Participating medical students reported that they perceived narrative medicine to be an important, effective, but counter-culture means of enhancing communication, collaboration, and professional development. The authors contend that these skills are integral to medical practice, consistent with core competencies mandated by the ACGME/RCPSC, and difficult to teach. Future research must explore sequelae of training on actual clinical performance.

Sounding narrative medicine: studying students' professional identity development at Columbia University College of Physicians and Surgeons.

Purpose To learn what medical students derive from training in humanities, social sciences, and the arts in a narrative medicine curriculum and to explore narrative medicine’s framework as it relates to students’ professional development. Method On completion of required intensive, half-semester narrative medicine seminars in 2010, 130 second-year medical students at Columbia University College of Physicians and Surgeons participated in focus group discussions of their experiences. Focus group transcriptions were submitted to close iterative reading by a team who performed a grounded-theory-guided content analysis, generating a list of codes into which statements were sorted to develop overarching themes. Provisional interpretations emerged from the close and repeated readings, suggesting a fresh conceptual understanding of how and through what avenues such education achieves its goals in clinical training. Results Students’ comments articulated the known features of narrative medicine—attention, representation, and affiliation—and endorsed all three as being valuable to professional identity development. They spoke of the salience of their work in narrative medicine to medicine and medical education and its dividends of critical thinking, reflection, and pleasure. Critiques constituted a small percentage of the statements in each category. Conclusions Students report that narrative medicine seminars support complex interior, interpersonal, perceptual, and expressive capacities. Students’ lived experiences confirm some expectations of narrative medicine curricular planners while exposing fresh effects of such work to view.

The Content of Physician and Elderly Patient Interaction in the Medical Primary Care Encounter

To examine the content of physician-elderly patient medical primary care encounters, audiotapes of 66 routine follow-up general medical visits were analyzed. Using the Multi-dimensional Interaction Analysis system, coders determined which content areas were discussed, which interactive participant initiated the discussion, and the quality of physician responsiveness in the different content areas. As hypothesized, physicians initiated discussion of the majority of subjects. Both physicians and patients were most likely to initiate discussion of medical topics. Physicians were more responsive to those topics that they initiated compared to the topics that older patients initiated. Implications of the research for physicians and elderly patients are discussed.

Commentary: calculating the contributions of humanities to medical practice-motives, methods, and metrics.

The inclusion of humanities in medical school curriculum has generated much pedagogic experimentation and assessment. Publications in medical journals in the past decade reflect the experience of teaching humanities in medical schools and the motives for which they are taught. As Ousager and Johannessen demonstrate elsewhere in this issue, short- and medium-range outcomes are available for examination, but the author of this commentary argues that the long view of change in clinical practice will not be available for another decade or more as the undergraduate student slowly becomes a full-fledged clinician. Rather than beg off the need to measure these teaching efforts, teachers in the humanities can embrace the demanding task of delineating how medicine changes when fortified by narrative competence and humanities-derived skills. To do so requires an examination of the institutional cultures in which patients and clinicians together try to address problems of the sick.