2. Welcome and Introductions 1. Introduction 2. 45 minute interactive small group sessions a) Writing b) Reading c) Reflection 3. Applications of narrative medicine 4. Wrap up

3. What is narrative medicine? A clinical practice informed by reading, writing, telling and receiving stories Narrative skills include: active listening, close reading, reflective writing and bearing witness The development of these skills will create more effective clinicians Rita Charon

4. Narrative medicine in practice Medicine 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 physicians summary of their illness and advice. They may add this to their own story or not.

5. Narrative versus Story Story: 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.

6. 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

7. 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

8. Illness Narrative Lived experience of disease Arthur Frank characterized common types Restitution narrative Chaos narrative Quest narratives

10. Close reading of patients Close reading starts with attention: being fully present Entering into the reality of the other Consider 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

12. Reflection

13. Magic Mirror Story

14. Reflection Reflection : A process in which we witness and present the patients 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 patients 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

15. Instruction for Reflection Exercise Pair off Tell 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 roles Return to main group; tell each others story

16. Questions How 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?

17. Application of Narrative medicine Strengthen the provider-patient relationship To ameliorate the patients condition thorough new understanding of an old story or creation of new story Provide for self reflection Development of professionalism Increase sensitivity and insight into other cultures

18. How and when to use Narrative Medicine How do you currently use narrative medicine in your practice? Will you use narrative medicine in the future?

19. 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

20. Narrative in practice Caveats You can provide opportunities but the patient has to want to share the story Boundary issues: It is the patients story, are you a player in this story? Is it appropriate? Time management

21. Questions

22. References Narrative medicine Honouring the stories of illness Rita Charon Narrative in Health Care John D Engel et al. Doctors Stories The structure of medical knowledge Kathryn Montgomery Hunter

23. References The Wounded story teller. Arthur Frank Narrative Primary Care: a practical guide. John Launer Narrative Based Health Care: Sharing stories a multidisciplinary workbook. Trisha Greenhalgh & Anna Collard. Story Re-visions Narrative Therapy in Postmodern world. Alan Parry & Robert Doan