Implementing a Narrative Medicine Curriculum During the Internship Year: An Internal Medicine Residency Program Experience

Implementing a Narrative Medicine Curriculum During the Internship Year: An Internal Medicine Residency Program Experience

 

Tiffany Wesley, MD; Diana Hamer, PhD; George Karam, MD

Perm J 2018;22:17-187 [Full Citation]

https://doi.org/10.7812/TPP/17-187
E-pub: 04/18/2018

ABSTRACT

Introduction: Narrative medicine develops professional and communication skills that align with Accreditation Council for Graduate Medical Education competencies. However, little is known about a narrative medicine curriculum’s impact on physicians in training during residency. Implementing a narrative medicine curriculum during residency can be challenging because of time constraints and limited opportunity for nonclinical education.
Methods: Six sessions were implemented throughout one academic year to expose first-year internal medicine residents (interns) to narrative medicine. Attendance and participation were documented. At the end of the year, interns completed an open-ended survey to gauge their perception of their experience with the sessions.
Results: In total, 17 interns attended at least 1 narrative medicine session, and each session averaged 5.4 attendees. Thirteen eligible interns completed the survey. Thematic analysis identified 3 predominant themes: Mindfulness, physician well-being, and professionalism.
Discussion: Overall, the narrative medicine sessions were well attended and the curriculum was well received. This intervention demonstrates the value of a narrative medicine curriculum during medical resident training. Large prospective studies are necessary to identify the long-term benefits of such a curriculum.

INTRODUCTION

In 2001, Rita Charon defined narrative medicine as listening, reflecting, and responding to patient stories to promote healing.1 The use of narrative techniques in medicine, however, is not novel. Medicine is saturated with storytelling.2,3 Today’s rigorous medical school curriculum focuses on seven areas ranging from biomedical sciences to interprofessional collaborative skills, leaving little room to teach medical humanities.4 The assumption that medicine is an objective science based on technical skills and the perception that the humanities lack clinical relevance further hinder the inclusion of humanities in the curriculum.5 Narrative medicine does not propose a completely new practice, but rather a new framework within which to conduct current medical practice.1 A narrative medicine curriculum was first developed at Columbia University College of Physicians and Surgeons in 2000.6 Since then, other medical schools have introduced narrative components into their curricula,7-9 recognizing value in developing professionalism skills. Narrative medicine also can help medical students meet Accreditation Council for Graduate Medical Education competencies, including interpersonal and communication skills and professionalism.10,11 

Medical students respond favorably to narrative medicine curricula.6,10 However, little is known about the benefits of a narrative medicine curriculum during residency training and thereafter.12 Few structured efforts encouraging narrative medicine during residency training exist even though narrative skills are essential to ensure effective physician-patient and physician-physician communication.13,14 Single-center and multicenter studies demonstrate the increased risk for burnout attributable to emotional exhaustion and depersonalization during the internal medicine internship year of residency.15,16 A narrative component to medical education can help foster a professional identity on the basis of affiliation, representation, and attention, which are needed in graduate medical education to balance the confusion, depression, and frustration often experienced during residency.

It is a challenge to implement a narrative medicine or other humanities curriculum during residency. Liao and associates14 highlighted four barriers to implementation: The increased complexity of care delivery and duty hours limit activities in nonclinical education; the Budget Control Act cut indirect medical education funding, prioritizing clinical activities; most residency programs do not have the structure or culture necessary to support a narrative medicine curriculum; and nonclinical activities focus on research, quality improvement, and other medical education valued in fellowship and job applications. A 2013 study discussed resistance among faculty and residents who were unfamiliar with narrative medicine and cited this lack of knowledge as a barrier to implementation.10 Nevertheless, opportunities exist within training to provide residents with the opportunity to engage in narrative and reflection activities. These opportunities include implementing activities during residents’ protected time (morning report or noon conference), using in-house resources (building space, library, and art displays), and encouraging residents to participate in unfamiliar activities. In an effort to stimulate and encourage writing and reflection in medicine, the Louisiana State University Health Sciences Center (LSUHSC) Internal Medicine Residency Program in Baton Rouge implemented a narrative medicine curriculum for first-year house officers (interns). The benefits of this pilot program are discussed here.

METHODS

During the 2015-2016 academic year at the LSUHSC Internal Medicine Program in Baton Rouge, incoming interns were invited to participate in a series of reflective sessions based on a narrative medicine curriculum. Each of 6 sessions was offered twice, for a total of 12 sessions throughout the academic year. To increase participation, the first occurrence of each session took place during the evening, and the next occurrence of the same session took place the next month during noon conference. Noon conference is part of a resident’s protected time for didactic activities, so the ability to make use of this time every other month ensured that interested interns could attend a session. One week before the session, we Emailed reminders to all interns with time and place information. Participation was voluntary, and interns were encouraged to attend at least 4 sessions throughout the year.

Each session consisted of a 30-minute discussion of a short essay, poem, article, or movie, followed by a 5-minute narrative exercise and a 10-minute wrap-up conversation. Narrative exercises included prompts that encouraged interns to briefly write and subsequently read aloud to the group. A discussion that followed the writing exercise allowed participants to reflect on their experiences with the group. Interns were allowed to keep their written narrations to protect confidentiality and encourage honest writing practices. The sessions took place in 2 areas of the LSUHSC Medical Education and Innovation Center that were designed with the value of medical education in mind: The Reconciliation Room, which is designed to encourage constructive feedback and foster feelings of completion, lack of hierarchy, wholeness, and unity (participants sit at a large round table to eliminate the sense of hierarchy), and the Teaching Terrace, which is an open outdoor space designed to foster humanism attributes in trainees.17 

After the last sessions, we surveyed the interns using an anonymous, open-ended questionnaire to assess their perception of the narrative medicine sessions attended during their intern year. The survey consisted of 6 questions previously developed by Arntfield and associates.10 Four additional questions captured the interns’ time and location preferences (see Sidebar: Ten-Item Narrative Medicine Sessions Survey). The final 10-item paper-based survey was completed 1 week after the last narrative medicine session of the internship year in June 2016. Survey responses were entered into a database, and thematic analysis was performed for each question. Responses had to be categorized into the same theme by at least 2 readers for inclusion. Survey procedures were approved by the LSUHSC New Orleans institutional review board (IRB 9410).

Implementing a Narrative Medicine Curriculum During the Internship Year: An Internal Medicine Residency Program Experience

RESULTS

Among 18 interns, 17 attended at least 1 session; 6 were preliminary and 8 were categorical interns, and 12 were men and 5 were women. On average, participants attended 3.8 sessions, with each session averaging 5.4 attendees. Thirteen interns completed the survey at the conclusion of the year. Course feedback was overwhelmingly positive, with 3 consistent themes emerging in the responses: Mindfulness, physician wellness, and professionalism. Interns defined mindfulness as increased personal reflection and awareness of patient feelings; physician wellness as good health and the ability to share difficult experiences to promote emotional well-being; and professionalism as strengthening of peer comradery, humanism, and public speaking skills. These themes are further discussed below.

Mindfulness

The interns stated that the sessions they attended gave them an avenue for personal reflection and encouraged them to be more thoughtful, both personally and professionally. Respondents stated that personal reflection led to increased awareness of emotions, insight into experiences encountered during their intern year, and a better understanding of the things that truly are significant in the fast-paced world of medicine. Moreover, reflection challenged them to be mindful of patient feelings and patient experiences. Most responses included statements on patient empathy acquired through awareness and reflection. Interns also revealed heightened empathy toward each other and their peers in the medical profession:

I enjoyed the sessions. I felt as though they helped me take a step back and evaluate my views and attitudes. I think it helped me to refocus on patient care and let go of the frustrations of intern year.

[The sessions were] a wonderful opportunity to reflect on our experiences and relate to one another. I now know that more people have the same feelings and struggles as me than I initially thought. It will help me to better understand colleagues. This course also helped me better empathize with my patients.

Physician Wellness

Many sessions led to discussions about the role of a physician in modern society. Interns reported feeling stressed and overwhelmed by the daily requirements of internship training, which leave little time for reflective or emotional outlets. There was a general consensus that the internship year can lead to compassion fatigue. The interns said the sessions had a positive impact on their emotional health and that narrative medicine was one of the only nonmedical outlets they had encountered throughout their medical education:

Talking about compassion fatigue is something that really struck me. Discussing this subject allowed me better insight into how I feel at times and how others may be feeling.

Unlike other avenues for dealing with stress and fatigue, I felt that the abilities to discuss things with peers provided a uniquely cathartic way to air out feelings. I left every session feeling more at peace than when it started.

Professionalism

Throughout the narrative medicine sessions, multiple recurring topics that involve the Accreditation Council for Graduate Medical Education definition of professionalism were discussed. Respondents indicated that participating in the sessions led to an increase in peer camaraderie, which strengthened their sense of affiliation to each other and to the institution. Peer-to-peer bonding was possible through the sharing of difficult experiences and emotions encountered during medical training. Interprofessional communication is an essential component of professionalism according to Accreditation Council for Graduate Medical Education standards. Residents reported that these discussions strengthened their communication skills by improving their ability to listen and encouraging public discussion about difficult topics. Respondents also revealed there was no other venue in which they could discuss these difficult topics, and that such conversations are not encouraged in medicine.

I thought it was a great opportunity to bond with my classmates and talk about our experiences … it allowed me to learn the importance of discussing your opinions and thoughts with others, which can be invaluable to help improve stress and anxiety.

The sessions did help to push us to open up and share things that otherwise may not have been discussed de novo amongst us.

When asked about the structure of the narrative medicine sessions, respondents said their attendance at noon or evening sessions was dependent on their clinical schedule. Respondents were split regarding their preference for an indoor or outdoor venue, yet most recommended including off-campus sessions. Suggestions on ways to improve the sessions included more variety in the format (use of different multimedia), more prompts, and offering the sessions to participants from other medical and health care disciplines.

DISCUSSION

Here we demonstrate the successful implementation of a narrative medicine curriculum during internship year and summarize the reported benefits to participants in an internal medicine residency program. The intern year is touted as the most difficult year in a physician’s life. It is characterized by numerous pressures from patients, attending physicians, other residents, and interns’ families; an exponential learning curve; and a lack of time to eat or sleep. The most common barriers to implementation of extracurricular activity during residency are time constraints and a lack of structural and cultural support.14 Yet the narrative medicine sessions were well attended. We attribute this success to two factors. First, the sessions took advantage of the residents’ protected didactic time (such as noon conference) or sessions took place at the end of clinical time. If an intern could not attend a session, a repeat session was offered the following month to ensure that both sessions did not fall on the same clinical rotation month. Attendance was not mandatory, but participation was encouraged through morning report and Email announcements. Second, program support was essential to ensure intern participation. The narrative medicine initiative was promoted by the Program Director, who teaches medicine with a focus on the art of medicine and humanism.

The high survey response rate captured interns’ perspectives on narrative medicine. Respondents highlighted a lack of alternative outlets for stress during residency training. The narrative medicine sessions provided a forum in which they could talk about topics they usually did not discuss in their personal or professional relationships. Internship year in internal medicine is characterized as relearning medicine as an applied science and the pressure of acting as a physician for the very first time, which can cause burnout.15,16 Providing structured time for reflective writing can help residents deal with the clinical demands of the intern year.

Today’s medical training is shifting from listening to patient narratives toward a more mechanical approach to care that is focused on quick information assessment. Such an approach eliminates consideration of a patient’s experience from physician training. Narrative medicine involves listening to the intricacies of patients’ stories as they unfold and “translating” subjective words into objective information to gain a better understanding of an illness. Moreover, storytelling often is therapeutic for patients and has demonstrated healing effects.3 Storytelling also can transform a medical encounter into a more empathetic and understanding experience between patients and physicians, which enhances the quality of care.14 This type of practice helps physicians improve their personal awareness and avoid succumbing to the confusion, loneliness, depression, and frustration that can be associated with caring for critically ill patients.10,18 The mindfulness, physician well-being, and professionalism themes support previous findings that including narrative practice in medical training can result in the availability of physicians who listen to their patients, reflect on their own experiences, and become well-rounded professionals as they improve patient-physician, physician-self, and physician-colleague relationships.

This residency program’s small sample size was a study limitation. Selection bias also was an issue because the interns who attended the most sessions were more interested in the value of the curriculum. Future research endeavors will focus on metrics that evaluate the curriculum’s impact on residents’ approach to patient care. Larger, prospective, and multicenter studies in residency programs are needed to measure the value of narrative medicine in graduate medical education.

CONCLUSION

An enthusiastic response following participation in a narrative medicine curriculum supported our endeavor. These results strengthen our belief that narrative medicine, acknowledged as beneficial to residents training in this program, will continue to gain momentum in the academic medicine community.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Brenda Moss Feinberg, ELS, provided editorial assistance.

How to Cite this Article

Wesley T, Hamer D, Karam G. Implementing a narrative medicine curriculum during the internship year: An internal medicine residency program experience. Perm J 2018;22:17-187. DOI: https://doi.org/10.7812/TPP/17-187

References
1.    Charon R. The patient-physician relationship. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA 2001 Oct 17;286(15):1897-902. DOI: https://doi.org/10.1001/jama.286.15.1897.
    2.    Mehl-Madrona L. The nature of narrative medicine. Perm J 2007 Summer;11(3):83-6. DOI: https://doi.org/10.7812/TPP/07-052.
    3.    Morris DB. Narrative medicines: Challenge and resistance. Perm J 2008 Winter;12(1):88-96. DOI: https://doi.org/10.7812/TPP/07-088.
    4.    LCME. Standards: Functions and structure of a medical school—(contains the LCME standards) [Internet]. Washington, DC: Liaison Committee on Medical Education; 2018 Mar [cited 2018 March 8]. Available from: http://lcme.org/wp-content/uploads/filebase/standards/2019-20_Functions-and-Structure_2018-03-05.docx.
    5.    Shapiro J, Coulehan J, Wear D, Montello M. Medical humanities and their discontents: Definitions, critiques, and implications. Acad Med 2009 Feb;84(2):192-8. DOI: https://doi.org/10.1097/acm.0b013e3181938bca.
    6.    Miller E, Balmer D, Hermann N, Graham G, Charon R. Sounding narrative medicine: Studying students’ professional identity development at Columbia University College of Physicians and Surgeons. Acad Med 2014 Feb;89(2):335-42. DOI: https://doi.org/10.1097/acm.0000000000000098.
    7.    Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: What can we learn from third-year medical student narrative reflections? Acad Med 2010 Nov;85(11):1709-16. DOI: https://doi.org/10.1097/acm.0b013e3181f57899.
    8.    Cohn FG, Shapiro J, Lie DA, Boker J, Stephens F, Leung LA. Interpreting values conflicts experienced by obstetrics-gynecology clerkship students using reflective writing. Acad Med 2009 May;84(5):587-96. DOI: https://doi.org/10.1097/acm.0b013e31819f6ecc.
    9.    Braun UK, Gill AC, Teal CR, Morrison LJ. The utility of reflective writing after a palliative care experience: Can we assess medical students’ professionalism? J Palliat Med 2013 Nov;16(11):1342-9. DOI: https://doi.org/10.1089/jpm.2012.0462.
    10.    Arntfield SL, Slesar K, Dickson J, Charon R. Narrative medicine as a means of training medical students toward residency competencies. Patient Educ Couns 2013 Jun;91(3):280-6. DOI: https://doi.org/10.1016/j.pec.2013.01.014.
    11.    Coulehan J. Viewpoint: Today’s professionalism: Engaging the mind but not the heart. Acad Med 2005 Oct;80(10):892-8. DOI: https://doi.org/10.1097/00001888-200510000-00004.
    12.    Johna S, Woodward B, Patel S. What can we learn from narratives in medical education? Perm J 2014 Spring;18(2):92-4. DOI: https://doi.org/10.7812/TPP/13-166.
    13.    Drazen JM, Shields HM, Loscalzo J. A division of medical communications in an academic medical center’s department of medicine. Acad Med 2014 Dec;89(12):1623-9. DOI: https://doi.org/10.1097/acm.0000000000000472.
    14.    Liao JM, Secemsky BJ. The value of narrative medical writing in internal medicine residency. J Gen Intern Med 2015 Nov;30(11):1707-10. DOI: https://doi.org/10.1007/s11606-015-3460-x.
    15.    Campbell J, Prochazka AV, Yamashita T, Gopal R. Predictors of persistent burnout in internal medicine residents: A prospective cohort study. Acad Med 2010 Oct;85(10):1630-4. DOI: https://doi.org/10.1097/acm.0b013e3181f0c4e7.
    16.    Ripp J, Babyatsky M, Fallar R, et al. The incidence and predictors of job burnout in first-year internal medicine residents: A five-institution study. Acad Med 2011 Oct;86(10):1304-10. DOI: https://doi.org/10.1097/acm.0b013e31822c1236.
    17.    Karam GH. Teaching values in medicine via awareness created through art. Trans Am Clin Climatol Assoc 2016;127:98-117.
    18.    Devlin MJ, Richards BF, Cunningham H, et al. “Where does the circle end?”: Representation as a critical aspect of reflection in teaching social and behavioral sciences in medicine. Acad Psychiatry 2015 Dec;39(6):669-77. DOI: https://doi.org/10.1007/s40596-014-0222-8.

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