Initiating Narrative Medicine at a Medical College in Pakistan: Achievements, Challenges, and Opportunities



 

Huma Baqir, MD1; Kanwal Nayani, MD2; Ayesha Mian, MD3; Asad I Mian, MD, PhD2,4

Perm J 2019;24:18.194 [Full Citation]

https://doi.org/10.7812/TPP/18.194
E-pub: 11/08/2019

ABSTRACT

Writing has always been a part of medicine, but it was largely used as a means to disseminate objective data. With changing times, qualitative writing in the form of narrative medicine (NM) is fast coming to the forefront. Data in the field from high-income countries have shown an enhancement in empathy and professionalism alike, for both patients and health care practitioners. Studies also elucidate the benefits of incorporating NM into medical curricula. However, there is scant literature from low-income to middle-income countries concerning NM. In this brief report, we discuss NM in the context of  low- to middle-income regions like ours,  describing how a workshop on NM-based reflective writing was developed and executed at Aga Khan University, Karachi, Pakistan. This workshop, titled “Narrative Medicine: Where Every Patient’s Story Matters,” was conducted in January 2016 and was attended by medical students, residents, and physicians as well as professionals from nonmedical backgrounds. The workshop served as an introduction to NM, and there are plans to further develop it at Aga Khan University. This development includes creating a digital library of narratives, releasing an annual NM newsletter, incorporating NM into the undergraduate curriculum, and conducting studies to assess the impact of our intervention.

INTRODUCTION

A narrative is a spoken or written account of an event or events,1 with the “narrative turn in medicine” being described decades ago by prominent thinkers such as Polkinghorne.2 More recently, according to Charon,3 narrative medicine (NM) is “medicine practiced with narrative competence … the competence that human beings use to absorb, interpret, and respond to stories,” which makes for “a model for humane and effective medical practice.” True to its nature, NM is a tool that can cater to the expression of patient encounters across various media, such as reflective writing and even visual or performance arts. It provides a compassionate, well-rounded angle to the practice of medicine, helping it reach its target audience more effectively.4 NM can be classified into genres such as patients’ stories, physicians’ stories, stories about physician-patient encounters, and even metanarratives: The interpretation of stories in a broad sociocultural setting.5

Along with scientific knowledge, physicians depend on the ability to listen to the narratives of their patients and interpret the nuances behind them, to be able to advocate most effectively for their patients.4 Although physicians have long written about their patients and their ailments (disease and treatment, success and failure rates, etc), the platform, being largely reliant on quantitative outcomes, was primarily used as a means to disseminate objective information across generations. In recent times, however, qualitative writing in medicine (in the form of NM) has emerged as another variant of medical writing and as a helpful adjunct to medicine itself.5

NM can take several forms, but reflective writing remains a key component. Reflective or personal essays are short essays exploring the emotive aspect of practice,6 and they help the writer better process and understand his/her experience. This act of reflection has been shown to affect personal and professional growth. By reflecting and writing about patient care experiences, health care practitioners may improve their humanistic skills and become better caregivers.6 Despite the fruits of reflective writing, low- to middle-income countries have not displayed much interest in initiating the practice or furthering its cause. We believe that this lack of interest may be tied to a lack of awareness regarding the mechanics of NM, reservations regarding the profound nature of its impact, or the challenges posed by it.

In this brief article, we attempt to demystify the concept of NM, in particular, reflective writing, for our part of the world. We also describe how a workshop on NM-based reflective writing was developed and executed at our institution, Aga Khan University (AKU) Medical College in Karachi, Pakistan, one of the largest medical universities in the region. We also discuss the consequences of our initiative and its role in eventually incorporating NM into undergraduate and postgraduate curricula.

IMPORTANCE OF NARRATIVE MEDICINE IN MEDICAL EDUCATION

The healing power of writing one’s own narratives—as well as listening to others’ narratives—is backed by evidence. According to certain clinical studies,  major changes are observed in physiologic parameters (eg, improvement of lung function in asthmatic patients7 or decline of disease activity in patients with rheumatoid arthritis) when patients write intimately about their struggle.

Additionally, if the patient’s narrative is not heard fully, the possibility of diagnostic and therapeutic error may increase.8 Without this expression, a decline in empathy may result, with the patient and physician being unable to connect and explore their relationship fully. Although the exchange of narratives remains a challenging task, with mindfulness (moment-to-moment, nonjudgmental awareness), one can become more sensitive to the patient’s story. Such a practice chisels the physician’s focus and offers the possibility for meaningful physician-patient relationships.8,9

Narratives can be used as a means of communication not only between physicians and patients but also among physicians themselves. They can tell the story from the physicians’ perspective; hence, patients can use these to understand the thoughts and feelings of their caregivers. Physicians can also read their colleagues’ narratives and reflect on what they would have done in a particular situation or relate them to an experience they are currently facing.10

Often, physicians find themselves facing a challenging, complex variety of patients. Because this can take an emotional toll, penning down one’s thoughts and feelings, or narratives, on paper can prove to be therapeutic. Health care practitioners can look back at the situation, gauge how they reacted, and reflect on what could have been done differently. This also helps them grow personally and professionally and, concomitantly, ensures quality health care for the patient.10

Finally, NM helps enrich the linear standard medical history (chief complaint, history of present and past illness, family history, review of systems, etc), with the nonlinear patient story. This emerges as a vital step in the journey of healing and allows medical students to actively “make a history” rather than just “take a history.”10 The process of personal transformation, as conceived by story writing, is an important consequence of NM.

IMPLEMENTATION OF NARRATIVE MEDICINE INTERNATIONALLY

NM, alongside patient-centered and relationship-centered care, aims to underscore the patient’s voice in medicine.11 Reflective writing is an established method of teaching medical students about empathetic interactions with patients, and it demands a critical analysis of one’s clinical experiences.12 Because this requires the practitioner to exhibit a high degree of emotional intelligence, being self-aware, both personally and professionally, becomes essential. DasGupta and Charon12 conducted a study in reflective writing and qualitatively analyzed the results, as part of a second-year medical humanities seminar. Because many physicians are known to have a difficult time grappling with personal illness experiences,13 this exercise was aimed at affording participants the opportunity to reflect on their own stories or the stories of their loved ones. Although the exercise was initially deemed challenging, it led to an increase in empathy among the participants. It was also highly recommended for incorporation into the medical curricula of both students and residents.12

In a similar vein, Chretien et al13 piloted an NM curriculum for third-year medical students. The storytelling component of the exercise—amid other dimensions of the activity—enabled students to elicit illness narratives from patients, write their versions of the story, and then read them back to the patients. On analysis, the curriculum was found to be feasible and acceptable by all stakeholders, with some patients and students being particularly impressed.13

Another creative writing exercise was introduced by Hatem and Ferrara14 at the University of Massachusetts, Worcester. Once again, students found the course pertinent to their development and evaluated it favorably. The themes explored felt relevant across various strata—from second-year medical students to practicing physicians—which emphasizes the role of writing in the professional development of physicians and physicians-to-be.14 According to Chen et al,15 at a teaching hospital in Taiwan, exposure to an NM program increased empathy among health care practitioners, as measured via the Jefferson Scale of Empathy, Health Professions Version.

Contrary to popular belief, NM has also succeeded in finding a place in surgical education. Pearson and team16 discovered the potential of a narrative-based approach in surgical resident education, where it enhanced both practice and professionalism, without being time-intensive.16

In the wake of the academic importance of the patient’s narrative, Columbia University in New York City, NY, has set another luminous example. All first-year medical students at Columbia are required to engage in half a semester’s worth of seminars in humanities (literary studies, narrative writing, history of medicine, ethics, visual arts, religious studies, and alternative medicine). Additionally, it offers a month-long, fourth-year elective in NM, which involves close reading, writing fiction, and reflective writing, all of which develop narrative and literary skills that augment clinical effectiveness.17

To study the efficacy of its initiative, Columbia University enrolled and assessed 12 students as part of the elective, with competencies in areas of communication, collaboration, and professionalism being measured. On thematic analysis, it was revealed that the elective had helped foster students’ communication skills and professional growth. The NM elective also enabled their approach to be more empathetic and patient-centered, and it advanced their capacity to collaborate with one another. Interestingly, narrative training was deemed by the students as an essential exercise, yet “misunderstood and perceived as counter-culture.”18

Columbia University has also launched a 1-year master’s program to further the cause at the graduate level. The core curriculum of this pioneering degree in NM combines intensive exposure to narrative writing and close reading skills, literary and philosophical analysis, and experiential work.18

Despite real interest in and serious work related to NM in high-income countries, it remains a largely unaddressed practice in low- to middle-income regions.

IMPLEMENTATION OF NARRATIVE MEDICINE AT AGA KHAN UNIVERSITY

The Critical Creative Innovative Thinking (CCIT) forum was founded in 2013 at AKU, with the aim of enhancing the creative and innovative aspects of biomedicine and health care.19

Considering the impact of reflective writing as evidenced in the international literature, AKU CCIT leaders decided to introduce the concept and practice of NM among students, trainees, and faculty at our institution. Although there is considerable academic push toward traditional research and clinical teaching around signs and symptoms at the university hospital, a group of faculty realized that students and residents were finding it hard to engage their learning around issues of empathy, compassion, professionalism, and humanism. Because humanism in medicine is an aspect imperative to quality health care,9 the group decided to introduce the practice of reflective writing, a concept known to encourage empathy, improve patient satisfaction, and reduce physician burnout.20

Workshop Participants and Components

At AKU, the first NM workshop, titled “Narrative Medicine: Where Every Patient’s Story Matters,” was held in January 2016 as a joint venture of CCIT and the Departments of Psychiatry and Emergency Medicine. The goal of the workshop was to recognize the value of narrating patients’ stories in clinical practice, medical education, and research as well as to project reflective writing as a unique learning experience. The workshop involved 30 participants at various levels of training, including nursing students, medical students, and residents, as well as faculty; all participants were either health care professionals or those working in health care settings.

The workshop comprised 2 sections. The first (part A) used experiential exercises in large-group setting to introduce participants to NM and its reflective writing component. In the second (which comprised parts B and C), participants were divided into smaller groups and encouraged to share their writing. While creating these small groups, it was ensured that each included a combination of faculty members, residents, medical and nursing students, and individuals from nonmedical backgrounds (but with an interest in health care), to ensure a diversity of perspectives.

Evaluation

After the workshop, each participant was asked to fill out a postworkshop evaluation form designed to obtain feedback about the logistics and content of the workshop. The first section (part A) of the feedback form listed statements, such as “I feel inspired after attending the session,” “I felt the presentations were at my level of understanding,” and “I felt confident/understood how I would like to write a piece.” Each participant had to give each statement a score on the Likert scale, with 5 representing the highest measure of agreement (strongly agree). There was also space where participants could write their own feedback and suggestions for future workshops.

The latter section of the workshop (parts B and C) was particularly well received by the participants, as they got an opportunity to discuss their most riveting experiences with their peers and mentors. At the same time, they experienced the art of developing empathy and compassion, and the need to incorporate it into their practice, qualities essential to being a holistic health care professional. Prewritten work was reviewed by peers and faculty mentors, and suggestions for improvement were made. Comments from the postworkshop evaluation form were mostly positive, with participants describing that the latter section was “the best part of the workshop” and that it “provoked a lot of personal feelings and perspective.” They also noted that the discussion “brought about an insight into others’ lives.” The section also brought various narratives to the forefront, including battling with a terminal illness, moral and ethical dilemmas encountered by physicians and physician-writers, and the changing sex-based roles in medicine. It also probed into patients’ perceptions of their health care practitioners. Many participants reported in the postworkshop feedback form that they would like to spend more time on reflective exercises and be part of similar workshops in the future. Overall, participants found the workshop useful and applicable to their daily lives in the medical profession.

In the postworkshop evaluation form, most participants agreed that they “realized the potential of NM and reflective writing to improve clinical practice”; this particular component received an average score of 4.52 of 5. Another high-scoring statement included “Listening to others and ideas and pieces were inspiring,” which received a score of 4.45. The statement “I was able to discuss my ideas openly/nonjudgmentally” received a score of 4.34. Lower-scoring items were related to logistical issues, such as the appropriateness of the venue (mean = 3.79), and time management (3.43 for part A and a combined 3.69 for parts B and C of the workshop). Suggestions for improvement also included encouragement of a bilingual and multilingual approach to NM.

ACHIEVEMENTS AFTER THE WORKSHOP

The NM workshop initiative not only gave participants a better understanding of the importance of NM, and the ethical boundaries enmeshed in it but also gave reluctant writers and listeners a sense of liberation. Participants stated that they felt inspired and that the workshop “provided a great platform for sharing ideas and narrative pieces with a larger audience.” In this regard, it was an effort aimed at nudging them into starting their own blog, getting their pieces published in biomedical journals19 or newspapers, or having them write their first book. As summarized in Figure 1, the success of the workshop paved the way for various future activities. For example, a similar workshop was conducted by CCIT at Liberty Books, Karachi, one of Pakistan’s largest, oldest, and most popular English-language bookstores. This workshop reached out to a more diverse audience, particularly those who were not professionally associated with medicine. This diversity was also true for age, as we were also able to involve teenaged students—and their malleable minds—in our journey of reflection, empathy, and communication.

Stories compiled from the workshop, and entries submitted directly, were published in an online blog with the consent of the writers. More than 26 narratives have so far been collected, with half of them being written by faculty members. Roughly, one-third of these were composed by medical students and recent medical graduates, and encompassed their struggles and experiences as trainees. Each narrative represented a unique observation in a clinical setting that had helped shape and nurture physicians’ attitudes toward their patients. Interestingly, a few of the pieces were contributed by people from nonmedical backgrounds, who showcased their own good and bad experiences as patients. It is important to emphasize that such narratives may be used as a learning tool for physicians, because these provide a patient’s perspective on what a physician should do and how they should act.

More recently, in October 2017, CCIT was invited to host a workshop at AKU, as part of the Scholarship of Teaching and Learning Conference. The workshop was attended by faculty from both the medical college and the Institute of Educational Development at AKU. Although it numbered fewer participants than our first NM workshop in 2016, it was cofacilitated by medical students and was well received.

FUTURE DIRECTIONS

Digital NM is a future offshoot of our interest in the subject. In this pursuit, as shown in Figure 1, we hope to formulate a local database of narratives that would allow readers worldwide to search their desired narratives (including poetry, videos, and audiorecordings) via keywords. This database would also afford users the opportunity to listen to narratives, as opposed to only reading them, making the stories more personal, emotive, and firsthand. This would also encourage artists, videographers, and speakers to practice the art of reflexivity alongside writers and physician-writers.

Our second initiative would be an orientation session or a 6-week selective course in NM in the first year of medical school. The primary objective of the course would be to teach the skill of reflective writing, elicit a sense of appreciation for it, and make students cognizant of empathy long before the onset of patient interaction. It would also serve to encourage them to attend NM and reflective writing workshops in the future. To gauge the impact made by this course, we plan to develop a questionnaire and to administer it before and after the completion of the selective. The tool would provide an estimate of how successful the selective course had been in inculcating empathy and compassion among the students, and whether such attempts should continue in future.

Finally, we hope to document our NM-based activities, as well as our most popular narratives, as part of an annual newsletter. Our plan is to circulate this newsletter among both students and faculty at AKU and to make it available as a soft copy as well as in print, for those who wish to learn more about NM.

CHALLENGES AND OPPORTUNITIES

Although reflective writing in NM may be a familiar concept internationally, it is a phenomenon largely unheard of in Pakistan. Therefore, AKU becomes the first university in the country, and perhaps even the South Asian region, to initiate and sustain the effort. By introducing the concept of reflective writing, AKU has taken a promising step toward addressing the dearth of creativity in medical education.

However, the initiative must be structured on a large scale and commands that the outcomes be scientifically, sequentially, and consistently measured. It also poses several other challenges: NM—reflective writing or otherwise—takes time and effort to adapt to,5 which may make it appear as a cumbersome and unnecessary inclusion in medical education. Second, it may not appeal to everyone, especially if the individual does not enjoy the process of writing. Third, it may appear to both dilute and to devalue the science of medicine.5 To quote prior literature, “The biggest challenge in taking a narrative approach is knowing when to stop. Disease, disability, deprivation, and death are not stories. They are facts. Professionals, who get carried away by narrative ideas to the point where they forget this, are not safe.”5 It may also become difficult to elicit stories from patients who may not be interested in opening up to the physician. Finally, not every topic raised in a consultation can call for detailed narrative exploration,5 demanding that writers be selective and intelligent about their approach.

At AKU, circumventing challenges like these remains a difficult task, given the limitations of time and resources, despite sustained interest in the cause. However, thanks to the overall positive reception of the university’s reflective writing model, we hope to eventually bypass these obstacles at our institute.

In making a case for NM, we wish to call our readers to action: To take the practice forward (as shown in Figure 1) and to eventually incorporate NM into their respective medical education curricula, as we hope to do at our university in the future. At AKU, we wish to create a large-scale model of reflective writing in medicine, with the aim of assisting our faculty and students in their journey of conscious humanism, academic innovation, and clinical excellence.

18.194

Disclosure Statement

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

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

How to Cite this Article

Baqir H, Nayani K, Mian A, Mian AI. Initiating narrative medicine at a medical college in pakistan: Achievements, challenges, and opportunities. Perm J 2020;24:18.194. DOI: https://doi.org/100.7812/TPP:18.194

Author Affiliations

1 Aga Khan University, Karachi, Pakistan

2 Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan

3 Department of Psychiatry, Aga Khan University, Karachi, Pakistan

4 Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan

Corresponding Author

Asad I Mian, MD, PhD ()

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Keywords: burnout, curriculum, doctors, empathy, medicine, narrative medicine, Pakistan, physician, reflection, reflective writing, students, writing

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