NARRATIVE MEDICINE...norma baru?

seribulan

Perubatan bersastera- read between the lines

Narrative medicine: Connecting literature with medicine        





Dr Christopher Travis, an intern (houseman) in obstetrics-gynaecology, has cared for patients with Covid-19 and performed surgery on women suspected of having the coronavirus.

  But the patient who arrived for a routine prenatal visit in two masks and gloves had a problem that wasn’t physiological.
  “She told me, ‘I’m terrified I’m going to get this virus that’s spreading all over the world’,” and worried it would hurt her baby, he says of the March (2020) encounter.

  Dr Travis, who practises at the Los Angeles County + University of Southern California (USC) Medical Center in the United States, told the woman that he knew she was scared and tried to assure her that she was safe and could trust him.
  By asking many questions and carefully listening to the answers, he was exercising the craft of narrative medicine, a discipline in which clinicians use the principles of art and literature to better understand and incorporate patients’ stories into their practices.
  “How do we do that really difficult work during the pandemic without it consuming us so we can come out ‘whole’ on the other end?” he asks.
  Narrative medicine, which he studied at Columbia University, has helped him be aware of his own feelings, reflect more before reacting, and view challenging situations calmly, he says.

  The first graduate programme in narrative medicine was created at Columbia University in 2009 by Dr Rita Charon.
  The practice has gained wide influence since as evidenced by the dozens of narrative medicine essays published in the Journal of the American Medical Association and its sister journals.

  Learning to be storytellers also helps clinicians communicate better with non-professionals, says writer and geriatrician Dr Louise Aronson, who directs the medical humanities programme at the University of California, San Francisco.
  It may be useful to reassure patients or to motivate them to follow public health recommendations.
  “Tell them a story about having to intubate a previously healthy 22-year-old who’s going to die and leave behind his first child and new wife, then you have their attention.

  “At the same time, telling that story can help the health professional process their own trauma and get the support they need to keep going,” she says.
  This fall (2020), USC’s Keck School of Medicine of USC will offer the country’s second master’s programme in narrative medicine.
  The subject will also be part of the curriculum in the new Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California, which opens its doors July 27 (2020) with its first class of 48 students.

  Learning about living
  

Poetry reading is part of the narrative medicine course as it can help doctors better understand the varied experiences of living. — Photos: Filepic

Narrative medicine trains physicians to care about patients’ singular, lived experiences – how illness is really affecting them, says Dr Deepthiman Gowda, assistant dean for medical education at the new Kaiser Permanente school.

  The training may entail a close group reading of creative works such as poetry or literature, or watching dance or a film, or listening to music.
  He says there’s also “real, intrinsic value” for patients because a doctor isn’t only being trained to care about the body and medications.
  “Literature in its nature is a dive into the experience of living – the triumphs, the joys, the suffering, the anxieties, the tragedies, the confusions, the guilt, the ecstasies of being human, of being alive,” he says.

  “This is the training our students need if they wish to care for persons and not diseases.”
  Dr Andre Lijoi, a geriatrician at WellSpan York Hospital in Pennsylvania, recently led a virtual session for 20 frontline nurse practitioners who work in nursing homes.

  Two volunteers recited Mary Oliver’s 1986 poem Wild Geese, which reads “Tell me about despair, yours, and I will tell you mine. Meanwhile the world goes on.”
  Sharing the poet’s words helped the nurses relieve their pent-up tensions, enabling them to express their feelings about life and work under Covid-19, he says.

  One participant wrote, “As the world goes on around me, I mourn seeing my ageing parents, planning my daughter’s wedding and missing my great niece’s baptism.
  “I wonder, when will life be ‘normal’ again?”

  Dissecting metaphor

  Dr Naomi Rosenberg, an emergency room physician at Temple University Hospital in Philadelphia, studied narrative medicine at Columbia and teaches it at Temple’s Lewis Katz School of Medicine.
  The discipline helps her “metabolise” what she takes in while caring for Covid-19 patients, including the fear that comes with having to enter patients’ rooms alone in protective gear, she says.
  The training helped her counsel a worried woman who couldn’t visit her sister because the hospital, like others around the country, wasn’t allowing relatives to visit Covid-19 patients.

  “I’d read stories of Baldwin, Hemingway and Steinbeck about what it feels like to be afraid for someone you love, and recalling those helped me communicate with her with more clarity and compassion,” she says. (After a four-day crisis, the sister recovered.)
  Close readings can also help students understand the various ways metaphor is used in the medical profession, for good or ill, says Dr Pamela Schaff, who directs the Keck School’s new master’s programme in narrative medicine.

  Recently, she led third-year medical students through a critical examination of a journal article that described medicine as a battlefield.
  The analysis helped student Andrew Tran understand that describing physicians as “warriors” could “promote unrealistic expectations and even depersonalisation of us as human beings,” he says.
  Something similar happens in the militarised language used to describe cancer, he adds: “We say, ‘You’ve got to fight’, which implies that if you die, you’re somehow a failure.”

  Listening longer
  

Aside from improving communication with patients, narrative medicine can also help doctors process their own stress, grief and trauma.

In the real world, doctors are often focused narrowly, devoting most of their attention to a patient’s chief complaint.
  They listen to patients on average for only 11 seconds before interrupting them, according to a 2018 study in the Journal of General Internal Medicine.
  Narrative medicine seeks to change that.




@ipes2 per requested, please highlight

adila39

Good one TT

Saya dah highlight.

seribulan

Patient Care

Narrative Medicine: Every Patient Has a Story

Kim Krisberg , special to AAMCNews

March 28, 2017



Every patient has a story that goes beyond the symptoms they bring into the doctor’s office.

Those stories can illuminate how a person became ill, the tipping point that compelled them to seek help, and, perhaps most importantly, the social challenges they face in getting better. Stories can offer the kind of contextual richness that promotes and nourishes empathy, prompting a provider to switch from asking “How can I treat this disease?” to “How can I help my patient?” The difference may seem subtle at first, but knowing how to get patients to share their stories can be transformative in improving patient care, say proponents of this approach called “narrative medicine.”

Indu Voruganti, MS, now a third-year medical student at Brown University Warren Alpert Medical School, had just that type of realization. Voruganti had originally planned to head straight to medical school after completing her bachelor’s studies in biology. After taking an undergraduate creative writing class, however, she decided to take a slight detour.

“I immediately felt [creative writing] exercised a unique part of my brain that seemed to offer a different lens [with which] to view health care,” said Voruganti. “Then I learned there’s a whole world of physicians out there who are also writers.”

That lightbulb moment led Voruganti to enroll in the Program in Narrative Medicine at Columbia University College of Physicians and Surgeons, an interdisciplinary master’s program that seeks to improve clinical care through narratives. In a nutshell, narrative medicine draws on the study of art and literature to enhance students’ listening and observation skills and to expand their view of patients to encompass more than just medical histories.

    “[Narrative medicine] is a commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.”

    Rita Charon, MD, PhD
    Columbia University College of Physicians and Surgeons

“Narrative medicine can help us deliver more humanistic health care,” said Voruganti, who went on to create and teach an Art and the Medical Narrative elective course for first- and second-year medical students at Brown in 2015.
Learning to empathize

Rita Charon, MD, PhD, executive director of Columbia’s Program in Narrative Medicine, is widely recognized as the originator of the field. “The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others,” Charon wrote in a 2001 article in JAMA.

“It’s not a stretch to say we need help to look at our own processes or to see and appreciate what patients are telling us. For me, it became a way for patients to feel heard and noticed,” Charon said of her early experiences integrating narrative skills into her clinical practice. “It’s a commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.”

A core component of narrative medicine education is “close reading,” or learning how to thoughtfully and critically analyze a text. This approach helps students develop empathetic listening skills to better understand and connect with patients. Today, all Columbia medical students are exposed to narrative medicine in their first years, when they’re required to take one of 14 seminars on topics ranging from memoir writing to visual arts to medical journalism. The medical school also offers a fourth-year elective for medical students, as well as a scholarly track in Narrative and Social Medicine that Charon also directs.

While Columbia University is the only school with a graduate degree in narrative medicine, many medical schools have followed its lead, offering a variety of courses and seminars.

At the University of Nevada, Reno (UNR) School of Medicine, medical students can take narrative medicine as a scholarly concentration or as a fourth-year elective. Assignments include 10,000 words of reflective writing on clinical encounters that students must submit to a medical humanities publication. Susan Palwick, PhD, who teaches narrative medicine at UNR, said most students are drawn to write personal essays, though many try their hand at fiction and poetry as well.

    “It’s easy for patients to get reduced to a specific illness. Narrative medicine is a way of integrating everything back together; it’s a way of staying curious about people.”

    Susan Palwick, PhD
    University of Nevada, Reno School of Medicine

“It’s easy for patients to get reduced to a specific illness,” said Palwick, an associate professor of English and adjunct professor in UNR’s Office of Medical Education. “Narrative medicine is a way of integrating everything back together; it’s a way of staying curious about people. Ultimately, it’s a form of love.”

She said the experience can help students unpack their biases, too. For instance, Palwick said a student who was feeling particularly judgmental of patients undergoing bariatric surgery decided to write a series of vignettes imagining why such patients struggle with their weight and why they can’t lose it without the help of surgery. The process, Palwick discovered, “helps you stay empathetic and sympathetic."

Reflective writing also provides a “safe space” for students to discuss the stresses of medical school and their professional fears, she added.

Jake Measom, a fourth-year medical student at UNR, said that participating in the narrative medicine scholarly concentration has pushed him to be more creative in his approach to patient care. He also sees narrative medicine as a “remedy to burnout,” noting that while the practice of medicine can sometimes feel monotonous, narrative medicine reminds him that “there’s a story to be had everywhere.”

“It not only makes me a better physician in the sense of being able to listen better and be more compassionate,” he said, “it also helps you gain a better understanding of who you are as a person.”
Storytelling as a means of coping

“First you get your coat. I don’t care if you don’t remember where you left it, you find it. If there was a lot of blood, you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother’s name and you use her child’s name. You may not adjust this part in any way.”

That’s an excerpt from “How to Tell a Mother Her Child Is Dead,” which was published last September in the New York Times in the Sunday Review Opinion section. Authored by Naomi Rosenberg, MD, a physician at Temple University Hospital, the piece is a heart-wrenching example of how narrative medicine can serve as an outlet for coping with the harrowing experiences that providers regularly encounter.

Pulitzer Prize-winning journalist Michael Vitez encouraged Rosenberg to submit the piece in his new role as director of narrative medicine at Temple University Lewis Katz School of Medicine. After retiring from a 30-year career as a reporter at the Philadelphia Inquirer, Vitez approached the school’s dean about using his skills to help students, faculty, and patients translate their experiences into words. The idea morphed into Temple’s new Narrative Medicine Program, which launched in 2016.

Currently, the Temple program is fairly unstructured, with students and faculty working one-on-one with Vitez on their narrative pieces. For example, Vitez said a third-year medical student recently sent him a poem she wrote after an especially difficult day in her psychiatric rotation: “It helped her process her emotions and turn a really bad day into something really valuable,” he noted. Eventually, Temple hopes to offer a certificate and master’s degree in narrative medicine.

“I believe that stories have an incredible power,” said Vitez. “Understanding what a good story is and learning how to interview and ask questions will help you connect with your patients, understand them, and build relationships with them.”

Jay Baruch, MD, associate professor of emergency medicine at Brown’s Warren Alpert Medical School and faculty advisor to the narrative medicine course there, likewise maintains that the type of creative thinking often associated with the arts and humanities—and that narrative medicine often promotes—deserves a more central role in medical education.

“[Students and physicians] need to know the anatomy of a patient’s story just as much as the anatomy of the human body,” he said.

ipes2

semua doctors rasanya ingin sahaja spend alot of times dengan pesakit mereka, tetapi actually time sangat2 terhad.

seribulan

ipes2 replied at 2-7-2020 12:36 AM
semua doctors rasanya ingin sahaja spend alot of times dengan pesakit mereka, tetapi actually time s ...

So it's not possible to implement it in reality due to time constraint

seribulan

Fwd-

Narrative medicine is a promising addition to the current training strategies to prepare medical students for effective performance as resident physicians and practising clinicians, but its effective implementation in an acute setting is a challenging feat. Indeed, resistance to narrative medicine does exist, both with patients and physicians, and will not dissipate. Narrative medicine has gained enough traction that the present time seems appropriate to confront its internal differences.

adila39

ipes2 replied at 2-7-2020 01:36 AM
semua doctors rasanya ingin sahaja spend alot of times dengan pesakit mereka, tetapi actually time s ...

thats why in most hospitals and even here in Malaysia ada je support system - Psikology and Counseling department diwujudkan. Doctors akan refer patients tu jika depa rasa need more consultation. So, doctors also play big role on this, if time constraint is an issue. Awareness in patients pun kena improve if disini, sebut psikologi diingat gila which is so wrong.

Afteral, doctors are human too, a pep on shoulder will definitely helps too.

seribulan

One of the core principles of narrative medicine is that receiving patients' stories helps to build empathy in physicians and, in turn, improves the quality of care. Indeed, a number of recent studies have shown that higher levels of physician empathy may be associated with more positive outcomes in patients.

https://www.verywellhealth.com › n...
Narrative Medicine - Benefits,

zranger

seribulan replied at 2-7-2020 08:17 AM
So it's not possible to implement it in reality due to time constraint

Maybe kat private boleh kot..tp hospital/kkinik kerajaan memang tak la, unless psychiatry clinic/ward. Psy clinic kerajaan pon time follow up biasa je untuk sorang doktor tengok 20 patients dari 9am-1 or 2pm (4-5 jam), around 15min/patient. Nak menyembang lama lagi mmg tak mampu kang patients lain mengamuk la tumbuk tingkap la komplen la..

seribulan

zranger replied at 2-7-2020 05:10 PM
Maybe kat private boleh kot..tp hospital/kkinik kerajaan memang tak la, unless psychiatry clinic/w ...

Good insight I read somewhere example of this narrative way of approaching...hopefully can get it back and share here...it's just the way a doc approach needs to have the narrative element

seribulan

Found it, just above -

Modern electronic health records, with their templates and prefilled sections, can hamper a doctor’s ability to create meaningful notes, Dr Gowda says.

But doctors can counter that by writing notes in language that makes the patient’s struggles come alive, he says.

The school’s curriculum will incorporate a different patient story each week to frame students’ learning.

“Instead of, ‘This week, you will learn about stomach cancer’, we say, ‘This week, we want you to meet Mr Cardenas’,” he says.

“We learn about who he is, his family, his situation, his symptoms, his concerns.

“We want students to connect medical knowledge with the complexity, and sometimes, messiness of people’s stories and contexts.”

ipes2

seribulan replied at 1-7-2020 10:24 AM
Patient Care

Narrative Medicine: Every Patient Has a Story

hmm
i dont know.. im not convinced.
its just too heavy on time
most docs will have tonnes of duties and work to do
my paperwork alone is probnably 30-36 months behind
[i can spend 10 to 30 mins in forum daily as i trully do not go out, hang out with friends or watch tv; if i reply to people's ws.. its mostly likely from the toilet or while stuck in heavy traffick; i'll be honest: i dont even have enough time to spend my money]
i would nt have time to spend on narrations and i dont think im alone in this regards
or did i get it all wrong (in terms of what narrative medicine is)?

ipes2

seribulan replied at 2-7-2020 08:17 AM
So it's not possible to implement it in reality due to time constraint

i feel so, yes.
ion theory its cool and comfortable especially to read on; but to practice it out is a different matter altogether

ipes2

seribulan replied at 2-7-2020 06:51 PM
Found it, just above -

Modern electronic health records, with their templates and prefilled se ...

i must say i agree with dr Gowda's take on pre-filled forms etc.

ipes2

adila39 replied at 2-7-2020 11:27 AM
thats why in most hospitals and even here in Malaysia ada je support system - Psikology and Counse ...

yes support in this area will be useful but i must say that most docs remain in their scientifically-orientated world; plenty to highlight on the improtance of communication but again, communication needs time also

seribulan

ipes2 replied at 3-7-2020 03:46 AM
hmm
i dont know.. im not convinced.
its just too heavy on time

Toilet

Nope.. you are right track

seribulan

ipes2 replied at 4-7-2020 02:52 AM
i feel so, yes.
ion theory its cool and comfortable especially to read on; but to practice it out ...

Yup, on theory anything possible...not so in reality

adila39

ipes2 replied at 4-7-2020 03:56 AM
yes support in this area will be useful but i must say that most docs remain in their scientifical ...

what about narrative in point of view of patients tu? anyway ur doing just good here and over there. Tq for all the good feeds!

seribulan

ipes2 replied at 4-7-2020 02:54 AM
i must say i agree with dr Gowda's take on pre-filled forms etc.

Isn't it it is better for the pre treatment stage...but I did read a research done on the while treatment stage...will put it here...it's on cancer patients..quite enlightening

seribulan

Fwd- The outcomes of our analysis highlight the ways in which a five-point narrative competence framework widens the clinical gaze. Taking time, space, voice, metaphor and genre into account when thinking about a patient’s story navigates healthcare providers directly into the patient-centred point of view that enriches the quality, safety and relevance of clinical assessment and overall care.