1. An Introduction to Narrative Medicine Tom Barber, MD Associate Professor of Medicine

2. Learning Objectives  To consider the role of narratives in the practice of medicine.  To understand how a focus on narrative can sharpen clinical skills.  To learn a model for using written narratives in medical education.  To practice writing and sharing a narrative about our work as educators.

3. My interest and experience in hearing, reading, & writing narratives  Children’s stories  Writing exercise listening to the Grand Canyon Suite, Ferde Grofe’, 1931 (also called 5 pictures of the Grand Canyon), 4 th grade  My own writing  South Shore writers group  Charles River poets  Narrative Workshops x2, American Academy on Communication in Health Care  South Chatham Writers Workshop, 7/14  Leading various seminars and workshops at BUSM, BMC and in the region on the medical history and narrative

4. Narrative Medicine Workshop 3/14, Columbia University  Thanks to a Dept of Med Faculty Development Grant!  3 day workshop Lectures: “Methods for improving clinical effectiveness;” “Reconceptualizing empathy;” “Narrative ethics” Seminars: “Close reading;” “Clinical cases;” “Training in attentive listening;” “Illness Narratives: the skills of bearing witness to the suffering of others” Facilitated writing exercises

5. Columbia Narrative Medicine  Created by Rita Charon, MD, PhD  Objectives of the program (direct quotes) To develop narrative competence to nourish empathic doctor-patient relationships To learn narrative communication strategies for patient-centered and life-framed practice To build habits of reflective practice that enhance professionalism and nurture clinical communities To acquire pedagogic skills to teach NM To replace isolation w affiliation, cultivate enduring collegial alliances, and reveal meaning in clinical practice

6. Center for Narrative Practice  An offshoot of the Columbia Narrative Medicine program, led by Scott Alderman  Raising funds now, with plans to open in 2015  Wider focus than health care  “Our goal is to establish a Center for Narrative Practice in Cambridge in 2015. Join our movement. Together, we can change the world, one story at a time.” (!)

7. The medical history  The medical history is the foundation of clinical medical practice: the history of the present illness, or illness narrative  To “take a history” vs to “elicit a history” – we study, practice, refine, teach (and too often unlearn) this process throughout our careers (interview – “to see between”)  Barriers – clumsy teaching, poor modeling, easy access to diagnostic technology, documentation pressures, time pressures, concerns about confidentiality (including HIPAA), others…

8. Opportunities to teach narrative practice at BMC/BUSM Dept of Med  Introduction to Clinical Medicine 1  Communications skills workshops, Ambulatory Internal Med clerkship, BUSM  Clinical Reasoning Exercises (CREX), Dept of Med. Diagnostic and clinical reasoning are enhanced by developing narrative skills: hearing, questioning, clarifying, synthesizing, reporting, writing, understanding clinical information  Writing for Wellness workshops  Visual Thinking Exercises (VTS): sharpens observation and listening skills; integrating information towards a “visual narrative”

10. Narrative workshops  Where/when: Recall goals of Columbia NM program: to promote empathy, communication skills, professionalism, reflective practice, teaching skills, collegial relations; to reveal meaning…  Tools: pen or pencil and paper, some time, usually with a group of people  Format: small group, introduction and “centering,” ground rules, writing prompt, spontaneous writing for short interval (5-15 minutes), sharing writing product with a few attendees (+/- 2-6) with time for responses, closure.

11. Ground rules or norms  Mutual respect  Confidentiality  Attendees are encouraged to participate, but can opt out of writing, reading, and/or commenting on narratives  Listen and respond without judgment to how the narrative is written/told, what is told, from concrete to emotional content.  The exercise is not a kind of psychotherapy; note that this notion is absent from goals; facilitators must respond, support and redirect if needed.  Lower expectations about writing product: the exercise is not about writing for publication or for a wide audience, but only for this group

12. Writing prompts – Infinite variety… think about goals, setting, background of attendees  What did you give up to come here today?  Describe a time when you were angry with a patient.  Write your own obituary.  Describe your first experience with death.  Describe how you healed a patient.

13. Questions? Comments?

14. Writing prompt for today Tell about a time when you learned something new or important from a student or trainee.

15. The Teacher, by Curtis James

16. Recommended reading  Charon R, Hermann N. A sense of story, or why teach reflective writing? Acad Med 2012; 87: 5-7  Charon R. At the membranes of care: stories in narrative medicine. Acad Med 2012; 87: 1-6.  Charon R. A model for empathy, reflection, profession, and trust. JAMA 2001; 268; 1897-2002.  Ensign Josephine. “Medical Margins” Blog: The ultimate writing prompt. Aug 14, 2013. Wordpress.com.  Greenhalgh T, Hurwtiz B, eds. Narrative based medicine: dialogue and discourse in clinical practice. London, Eng: BMJ Books, 1998.  Naghshineh, et al. Formal art observation training improves medical students’ visual diagnostic skills. J Gen Intern Med. 2008; 23: 991-997.  Peterkin A. Practical strategies for practicing narrative- based medicine. Can Fam Phys 2012; 58: 63-64.