Narrating the Cycle of Life



 

Tatiana Valverde da Conceição, MD, PhD1; Gabriel Graça de Oliveira, MD, PhD2

Perm J 2020;24:19.139

https://doi.org/10.7812/TPP/19.139
E-pub: 05/13/2020

ABSTRACT

Narrative medicine (NM) is an approach that values the patient’s narrative about his/her disease as central to the clinical encounter and helps doctors to be more attentive to their patients’ perspectives in the diagnostic and therapeutic process. A curricular change enabled a greater insertion of the humanities in the curriculum of the Faculty of Medicine of the University of Brasília in Brasília, Brazil. In this context, NM was incorporated into one of the disciplines of the third semester. During the semester, students are encouraged to write, in small groups, a narrative combining fictional and real aspects of the history of life (and disease) of one patient. In the present article, the authors describe the educational experience of the insertion of NM in the medical curriculum and share personal impressions about the multiple possibilities of this approach.

The first “A Narrative Future for Health Care” conference, co-sponsored by the Centre for the Humanities and Health at King’s College London in London, UK; the Program in Narrative Medicine, Columbia University, New York, New York; and the Wellcome Trust in London, UK, took place at the King College Guy’s Hospital Campus in London, UK, from June 19 to 21, 2013. That conference had important influence on the 2016 medical curricular reform at the University of Brasília Medical School, Brasília, Brazil. Given the need to adapt the curriculum to the new priorities in the training of physicians listed in Brazil’s 2014 National Curricular Guidelines for the Undergraduate Course in Medicine1 and to optimize the acquisition of attitudinal skills, it was necessary to develop new educational approaches. These approaches needed to be oriented to interdisciplinarity, empathy, and care of one’s own physical and mental health, as well as attitudes necessary for a good doctor-patient relationship.

Among the different learning axes of the new curriculum, a new axis called “Knowledge of Self and of the Other” was created. This longitudinal axis is in the curricular matrix from the first to the eighth semesters of the medical curriculum, being divided into 8 disciplines. Among its objectives are the growth of the affective dimension of the medical student and the development of interpersonal skills and attitudes that favor the therapeutic relationship. The University’s Laboratory of Psychiatry and Humanities was responsible for the organization of the disciplines. However, in view of the interdisciplinary nature of the content, researchers from other disciplines, such as psychology, education, and sociology, also have participated in discussions with students in small groups inspired by active learning methods.

In the third semester of the axis, the content includes human development throughout the life cycle, with a focus on its emotional domain and the complex connections there are between the multiple and reciprocally influencing factors (environmental, genetic, and social), as well as the specifics of the doctor-patient relationship in each phase (pregnancy, childhood, adolescence, adulthood, senescense and death). The knowledge of these various stages and their potential crises is a useful tool in understanding the emotional experiences of the human being and also the possible suffering of the patient. We asked ourselves as teachers how to make the study of the life cycle interesting for students who are aged 18 to 19 years and who have not yet experienced many of those phases. We know that we are not alone in this belief that teaching human development is a great challenge,2 especially if we want students to understand major developmental theories and not just memorize developmental milestones. We believe that studying human development is to study how we all become who we are, to understand not only the generalizations of theories but also that every human being has his/her own unique trajectory of life. In short, it takes a good deal of creativity and innovation to create stimulating ways to teach human development.3

Considering that challenge, in this discipline, we chose to use narrative medicine as a didactic resource, in addition to chapters from books on human development, articles that discuss risk and protection factors, and films that illustrate several developmental stages from gestation to death. Narrative medicine is, in Dr Charon’s4 words, “a medicine practiced with narrative competence … the competence that human beings use to absorb, interpret, and respond to stories.” Thus, in addition to the theoretical discussions on the various stages of the life cycle, we ask students to write, in a small group of 5 students, a narrative about some patient whose clinical encounter influenced or marked them.

We stimulate them to combine truthful data from clinical history with fictional elements, and to imagine how their patient/character is or may be at the most diverse stages since childhood. We observe that the theoretical study of developmental theories helps them to imagine possibilities of life trajectories and to write a coherent narrative. Among the various themes that emerge in the narratives are, for example, the difficult situation experienced by war refugees, the indigenous population, feminism, and even suicide among medical students. In the process of elaborating the narrative, the students do much research on the themes that arise, including medical subjects that they have not yet studied, suggesting a possibility of vertical integration with other subjects of the coursework. In the end, the group makes a presentation of its narrative to the whole class and the teachers, and frequently professors and students of other disciplines also attend these presentations. In some cases the group makes a short enactment of the narrative. During class discussions of developmental themes in small groups, we realize that the students make immediate connections between their personal experiences and the topics discussed. Often they talk to family members to explore and understand aspects of their own past.

According to the students’ reports, this approach to narrative medicine has contributed to the understanding of developmental themes that are sometimes not yet lived or are distant for them, and to the way they think about the doctor-patient relationship, broadening their listening. There have been poster presentations written about the theme with an increasing interest in research on the subject among teachers and students.

For the teachers of the discipline, this has been an enriching and rewarding experience as we observe the development of our students as people and doctors in formation. We believe that narrative medicine is a powerful tool for teaching human development and that it holds the potential to aid in building empathic ability, self-reflection, and formation of identity.5 All these are fundamental skills for physicians in training.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.
A review by the institutional review board was deemed not necessary because of the nature of this article, which does not contain any research project-related material.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copyedit.

Author Affiliations

1 Department of Psychiatry, Faculty of Medicine, Queen’s University, Kingston, ON, Canada
2 Department of Psychiatry, University of Brasília, Brasília, DF, Brazil

Corresponding Author

Tatiana Valverde da Conceição, MD, PhD ()

Author Contributions

Tatiana Valverde da Conceição, MD,PhD and Gabriel Graça de Oliveira, MD, PhD participated in the manuscript intellectual concept and its preparation and review. The Corresponding Author has given final approval of the manuscript.

References
1.    Diretrizes Curriculares Nacionais para o curso de graduação em Medicina em 2014- Resolução CNE/CES no 3, de 20 de junho de 2014. (National Curricular Guidelines for the Undergraduate Course in Medicine). Available from: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
2.    Fox G, Katz D, Eddins-Folesbee F, Folesbee R. Teaching development in undergraduate and graduate medical education. Child Adolesc Psychiatric Clin N Am. 2007; 16: 67-94.
3.    Prager L. Appreciating “normal” development: How did we get here? J Am Acad Child Adolesc Psychiatry. 2013; 11: 1121-23.
4.    Charon R. Narrative medicine: A model for empathy, reflection, profession and trust. JAMA. 2001; 286(15): 1897-1902.
5.    Batt-Rawden S, Chisolm M, Anton B, Flickinger T. Teaching empathy to medical students: An updated, systematic review. Acad Med. 2013; 88:1171-77.

Keywords: education, human development, mental health, narrative medicine, teaching

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