PAKISTAN ARMED FORCES
MEDICAL JOURNAL (Category Y)

A Journal of Army Medical & Dental Corps

Being published since 1956

ISSN (online) 2411-8842
ISSN (print) 0030-9648

VOL 67, No. 5, OCTOBER 2017

NARRATIVE BASED MEDICINE

Editorial

We are living in times when the social contract between medicine and society is being renegotiated. Most of the time patients expect personalized care. Holistic, patient-centered, relationship-based medical practice rejects a myopic focus on patient symptoms only. It stresses upon professionalism, empathy, reflection and trustworthiness. It understands that every patient is different and has specialized needs. Modern times have changed the perspective of society about medicine. Patients no seek personalized attention and care. The balance has shifted from a myopic focus on patients’ symptoms only to a more holistic, patients
centered and relationship based intervention and treatment1.
Narrative Medicine
Narrative based medicine (NBM) or narrative medicine is an approach to clinical practice medicine that seeks to promote empathy, reflection, professionalism and trustworthiness. It is grounded in the physician’s narrative competence which in turn is defined as the set of skills required to absorb, interpret, and respond to illness narratives2. It therefore enables healthcare providers to empathize with patient stories and integrate them into the patients’ overall care plan hence understanding not only the disease, but also the patients3. By amalgamating the narrative history of the patient with evidence-based clinical practice, it improves the quality of care delivered4. Patient encounter begins with a story and like all stories; there is a plot, subplots, form, sequence, imagery and silences. Healthcare professionals are witnesses of these ‘told’, ‘untold’ and ‘not told’ stories. Attunement to patients’ individuality, sensitivity to their emotions, cognizance of the cultural dimensions of care are desired5. As obligatory story tellers, they must not understand what to say to the patient and how to say it.
Narrative Medicine Program Narrative medicine program was founded by Dr Rita Charon in 2001 at Columbia University Medical Center. Since 2009, Columbia University is offering a 38-credit Master of Science (MS) program in narrative medicine. It is mostly taught in workshops and/ or seminars. The attendees are mostly doctors, nurses, social workers, clergy, educators, intellectuals, artists
and students planning to attend medical colleges. The discipline aims to foster the acts of listening and  narrating within clinical care settings. Students collectively reflect upon the meaning and structure of literary or artistic works. The discussions on poems, excerpts from novels, works of art, performance pieces etc are lightly guided by a facilitator. Writing prompts are given and are followed by voluntary sharing6. Elements
The elements of NBM include:- 

  • Attention – Listening to the patients’ narratives, attending to their non-verbal behaviors (like pauses, silences, gestures, expressions, body positions, tones of voice) as well as making note of what was left unsaid.
  •  Representation – Narrating the results of the discussions with the patient and reflectively telling or writing them as a story.
  • Affiliation – Building relationship with the patients and the people important to them as well as other healthcare professionals, promoting mutual understanding and providing care keeping the patients’ expectations in full view7.

Advantages
It is said that most visits to a doctor’s clinic by the patients are for an audience. At times simply telling their story works. With more spontaneous talk time, patient and family satisfaction improves, they feel validated and their trust in the profession is reinstated. This has special place in treating geriatric diseases, chronic conditions, multiple morbidities and noncompliance. To the healthcare professionals, NBM translates into better doctor-patient relationship and burgeoning confidence, rapport, morale, idealism and practice. They are now better able to explain to their patients their condition and how it fits into their lives in cognizance with their educational background and culture. The strategy to reduce healthcare costs while improving patient outcomes is benefitted much by NBM. Since patients’ information is processed better, the chances of reaching a more accurate diagnosis the first time are increased and repeat appointments and  e-admissions are averted. It also lowers the healthcare budget by reducing the number of expensive, unnecessary tests and increasing patient adherence to health promotion and disease prevention measures. Challenges
The challenges to practicing NBM include  doing away with paternalistic ‘we-know-best’ attitude, ‘non-touch technique’, ‘OPD mukao’ culture, ‘someone-else-will-take-care’ approach and adhocism. Due to the increased time it may take with new patients, busy healthcare professionals may equate it with an  increase in their already hard-to-grapple workload. It may also be seen as an infringement of burgeoning
private practices. Dearth of human resource may exert undue pressure and demand on the healthcare system. No prior training may also be thwarted as an excuse for not practicing NBM. The possibility of incongruence between the patient’s story and the disease trajectory and recommended service pathway especially in the wake of patient illiteracy cannot be ruled out. Although patient stories are the main focus of
NBM, but stories in medicine are incomplete without the stories of healthcare professionals.
Way Forward

  • Medical, nursing and other health professionals must be trained in skills like attentive listening  lose reading, reflective writing and storytelling in simulated patient encounters.
  • Electives in medical humanities should be offered.
  • Much emphasis needs to be placed onunderstanding patients from differentcultures and

CONCLUSION
Although healthcare professionals’ time and attention are fast becoming a scant resource, their role is not limited to fixing faulty parts. They need to place emphasis on the non-mechanistic aspects of care as well. Strengthening the narrative competence of doctors provides hope to achieve humanism and professionalism by providing them with skills in adopting patients’ points of view, imagining what they endure, deducing what they need and processing their own emotions while caring for patients.

Reference

1. Childress MD From Doctors’ Stories to Doctors’ Stories, and Back Again. AMA Journal of Ethics 2017; (3): 272-80.
2. Charon, R. Narrative medicine: A model for empathy, reflection, profession, and trust. J Am Med Assoc 2001; 286 (15): 1897-1902.
3. Harter LM, Bochner AP Healing through stories: A special issue on narrative medicine. J Appl Commun Res 2009; 37 (2): 113-17.
4. Charon R. Narrative and Medicine. N Engl J Med 2004; 9 : 862-64.
5. Coaccioli S. Narrative medicine: the modern communication between patient and doctor. Clin Ter 2011; 162 (2): 91-2.
6. http: //sps. columbia. edu/ narrative-medicine/curriculum accessed on 20 May 2017. 7. Charon R. Narrative Medicine: Attention, Representation, Affiliation. Narrative 2005; 13 (3): 261–70.



Creative Commons License
This is an Open Access article distributed under the terms of the Creative Commons Attribution License Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.