Clinical teachers' toolbox article: Harnessing narrative medicine to learn from underserved populations

Abstract

Story telling is a fundamental part of human nature. Yet in health care education, there is often a focus on students learning to condense a person's rich, sometimes messy story about their life, into a flat, aseptic, clinical account of a patient's symptoms.¹ While this approach may help learners handle the complexity of symptomatology, it risks losing sight of the story's central character, as the person is transmogrified into ‘the patient’. Excessive focus on fact-gathering diminishes the ability to communicate,² and adopting this mind-set risks shifting the emphasis of a consultation from relationship to transaction. Engraining a transactional approach to patient interaction may underpin the attrition in empathy seen during undergraduate medical programmes.³

Stories, be they written, visual or spoken, are a powerful way to learn. Rita Charon, general internist, literary scholar and originator of the field of narrative medicine,⁴ described it as ‘a commitment to understanding patients' lives, caring for the caregivers and giving voice to the suffering’.⁵ The purpose of narrative medicine is threefold: it can reveal patients' perspectives, facilitate self-reflection among learners and provide emotional support to learners.⁶

We contend that narrative medicine can be a particularly potent catalyst for meaningful learning about underserved populations and health inequality, be it racism, ageism, gender bias and sexism, hetero-normism, colonialism or stigmatised medical conditions. We believe that narrative medicine can add value to the education of all health care professionals—this is of particular relevance when considering underserved communities, since a multidisciplinary approach is recognised as being central to good care for these groups.⁷ In this toolbox article, we outline relevant educational theory, offer a structure for teaching using narratives, signpost and showcase recommended resources, outline potential barriers to implementation and offer strategies to mitigate against these.

Humans are story telling animals who were teaching and learning through stories long before there was any concept of educational theory—despite this it is useful to consider how this activity can be theorised. Our intention and experience with narrative medicine is that it can foster ‘light-bulb moments’, in which the learner's perspective can be expanded irrevocably. This aligns with TL theory which we will now consider.

TL has been defined by Mezirow, as ‘the process by which we transform our taken-for-granted frames of reference to make them more inclusive, discriminating, open, emotionally capable of change …’⁸ p.8. TL recognises that we all carry preconceptions and assumptions (frames of reference) that influence how we perceive and act within the world. TL seeks to go beyond teaching for knowledge and skills acquisition and instead aspires to challenge and ultimately change these frames of reference. As Kumagai eloquently writes, ‘In transformative learning, it is not just what one knows that changes; rather, it is how one knows something, how one sees oneself and others, and how one exists and acts in the world’⁹ p.650.

The events that provide the potential stimulus to change are termed disorientating dilemmas and are traditionally events that stir emotions.¹⁰ As an example, we signpost readers to novel work by Thompson et al.¹¹ that describes a course for medical students that aimed to develop their awareness of disability. Students spent 1 week at sea on a tall ship, working alongside a ‘buddy’ with a disability, in a challenging maritime environment.

Such an experience prompts learners to reflect critically on their established frames of reference, yet this alone does not guarantee that transformation will occur. TL contends that transformation is a collective, rather than an individual, experience. The opportunity to discuss, debate and share perspectives with peers, within the setting of a challenging, yet supportive group, provides the climate needed for transformation to occur.

Milota et al.¹² conducted a systematic review of narrative medicine as a medical education tool. They identified that the majority of included articles (22 of 36) employed a pedagogic process that consisted of three-steps. In Figure 1, we present a synthesis of this three-step approach, which we commend to educators planning to teach using narratives, along with a worked example of how this might be implemented in practice. Integrated into Figure 1 are links to the key tenets of TL theory described above. There is also a reference to the concept of ‘close reading’ within step 2 of Figure 1. Close reading has been described as the signature method of narrative medicine and involves training learners to ‘search for aspects of a written text—like sensory detail, perspective, genre, time, voice, metaphor, and plot—that may harbor meaning for both writer and reader’¹³ p.348.

There are a variety of different types of narratives that can be employed in such teaching; these include patients' narratives, relatives' or care-giver's narratives, clinician's narratives or fictional narratives. There is also great potential variety in the medium through which the narratives are presented to learners—written media (books, magazines, newspapers, poetry), visual media (film, video, television, theatre, art) and audio content (music, podcasts, interviews). Powley and Higson² p.25 describe how narratives ‘engage the imagination to release perceptive and creative responses’. We would encourage clinical teachers to embrace this sentiment and to employ similar imagination and creativity when selecting resources to use within teaching using narrative approaches.

For the purposes of this article, we have organised the suggested resources into three categories—so-called ‘big picture’ stories, multimedia resources and ‘local’ resources. We acknowledge that there is overlap between these groups but contend that this categorisation may help clinical teachers to identify potential resources and to plan delivery of sessions.

We acknowledge that while it is not yet clear whether narrative medicine can produce a long-term positive impact on patient care, it is proven to help learners develop more nuanced understanding of patients' perspectives and to enhance their capacity to self-reflect.¹² For the educator seeking to evaluate the impact of their session, we would suggest employing methods that enable learners to demonstrate the extent to which they have achieved these goals. Established evaluation methods that are congruent with both TL and narrative medicine include personal reflective essays or other forms of creative reflection such as art.

We recognise that for a multitude of reasons, educators may be reticent to trial this method of teaching in their institution. Informed by our own teaching experiences, which include many missteps and some successes, we provide within Table 3 further discussion of the potential barriers to teaching using narratives, along with strategies to mitigate against these.

Lastly, we contend that successful implementation of narrative medicine requires a deliberate faculty development strategy. Educators will need to grasp the theory that underlies this approach to teaching and understands the types of resources likely to prompt a disorientating dilemma. Peer discussion forms an important part of TL and narrative medicine, and thus, small-group teaching (SGT), where learner–learner interaction is the goal, naturally aligns. Yet SGT is challenging to deliver; for example, the tendency for teachers to talk too much within SGT is well-recognised, particularly for less experienced educators.¹⁸ Thus, faculty development initiatives that allow educators to hone their facilitatory skills¹⁹ are crucial to successful implementation of narrative medicine.

We offer this toolbox in the hope that it will aid teachers and students in developing what Charon terms ‘narrative competence’: the competence to use, absorb, interpret and respond to stories.⁴ By working from the global to the local, we aim to foster a sense of comfort in the hearing of, and responding to, narratives from the public domain, such that we are sensitised to the narratives that surround us in our clinical practice, including our personal stories. Through offering suggestions, we aim to encourage an imaginative search for teaching resources with the power to engender collaborative learning. We encourage teachers to find fresh, richer approaches to learning from patients, connecting teacher, learners and patients in anathema to the ‘detached concern’ commended to us in the past.²⁰

James Fisher: Conceptualization; writing—original draft; writing—review and editing; resources. Nony G. Mordi: Conceptualization; writing—original draft; writing—review and editing; resources. Richard Thomson: Conceptualization; writing— original draft; writing—review and editing; resources.

The authors have no conflict of interest to disclose.

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