Hello, stranger: building a healing narrative that includes everyone

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

Creating Alignment: How the Humanities Can Help Heal Physicians and Patients

The medical humanities, an umbrella term for the fields of ethics, social science, and fine arts, are increasingly recognized as an important component of medical education. Since the Flexner report, the primacy of science and evidence-based medicine has replaced subjectivity and nuance. While this has been critical for standardization of care and patient safety, an exclusive emphasis on science in undergraduate medical education can devalue more humanistic pursuits. Modern medicine is now plagued with burnout, pandemics, and societal ills that permeate into medicine. Addressing these requires a thoughtful, holistic approach where we extend our sights beyond strict evidence-based medicine.

Thriving in Neurology Residency: An Appreciative Inquiry Approach

BACKGROUND AND OBJECTIVES

Enhancing resident well-being has become a top priority for medical educators as awareness of physician burnout continues to grow. Though significant effort has been made to understand contributors to resident burnout and develop effective interventions, relatively little is known about what characterizes the opposite of burnout, i.e., thriving in medical training. This phenomenological qualitative study applies Appreciative Inquiry as an interview technique with the aim of characterizing self-identified experiences of thriving among residents in the Yale Neurology program.

METHODS

Eight residents across all years of training in a single neurology residency participated in semi-structured appreciative interviews to identify experiences of thriving during neurology training. These interviews were transcribed and qualitatively analyzed with a phenomenologic perspective for common themes.

RESULTS

Numerous themes emerged spanning personal, interpersonal, and organizational domains. While some of these themes were congruent with established foundations of well-being and adult learning theory, others revealed the crucial contributions of stress and challenge to thriving. One of the strongest emergent themes was the tendency of residents to thrive during autonomous, high-challenge, high-stress situations, provided that adequate support was present and psychological safety was ensured.

DISCUSSION

These findings resonate with phenomena studied in positive psychology that are not currently being widely applied in medical education. To the degree conclusions are transferable to other training contexts, this study suggests an opportunity for medical educators to harness the positive aspects of stress and challenge in a supportive way that facilitates trainee well-being through experiences of thriving.

From competencies to human interests: ways of knowing and understanding in medical education

When considering the teaching and learning of topics of social relevance in medicine, such as professionalism, medical ethics, the doctor-patient relationship, and issues of diversity and social justice, one is tempted to ask, are the ways of knowing in these fields different from that in the biomedical and clinical sciences? Furthermore, given that the competency approach is dominant in medical education, one might also ask, is the competency model truly appropriate for all of the types of knowledge necessary to become a good physician? These questions are not merely academic, for they are at the core of how these subjects are taught, learned, and assessed.The goal of this article is threefold: first, to explore the nature of knowing and the educational goals in different areas of medicine and, in particular, those areas that have social relevance; second, to critically review the concept of competencies when applied to education in these areas; and third, to explore alternative strategies for teaching, learning, and assessment. This discussion reflects a view that the goal of education in areas of social relevance in medicine should be the enhancement of an understanding of-a deep and abiding connection with-the social responsibilities of the physician. Moving beyond competencies, this approach aspires toward the development of practical wisdom (phronesis) which, when embodied in the physician, links the knowledge and skills of the biomedical and clinical sciences with a moral orientation and call to action that addresses human interests in the practice of medicine.

Beyond cultural competence: critical consciousness, social justice, and multicultural education

In response to the Liaison Committee on Medical Education mandate that medical education must address both the needs of an increasingly diverse society and disparities in health care, medical schools have implemented a wide variety of programs in cultural competency. The authors critically analyze the concept of cultural competency and propose that multicultural education must go beyond the traditional notions of "competency" (i.e., knowledge, skills, and attitudes). It must involve the fostering of a critical awareness--a critical consciousness--of the self, others, and the world and a commitment to addressing issues of societal relevance in health care. They describe critical consciousness and posit that it is different from, albeit complementary to, critical thinking, and suggest that both are essential in the training of physicians. The authors also propose that the object of knowledge involved in critical consciousness and in learning about areas of medicine with social relevance--multicultural education, professionalism, medical ethics, etc.--is fundamentally different from that acquired in the biomedical sciences. They discuss how aspects of multicultural education are addressed at the University of Michigan Medical School. Central to the fostering of critical consciousness are engaging dialogue in a safe environment, a change in the traditional relationship between teachers and students, faculty development, and critical assessment of individual development and programmatic goals. Such an orientation will lead to the training of physicians equally skilled in the biomedical aspects of medicine and in the role medicine plays in ensuring social justice and meeting human needs.

A conceptual framework for the use of illness narratives in medical education

The use of narratives, including physicians' and patients' stories, literature, and film, is increasingly popular in medical education. There is, however, a need for an overarching conceptual framework to guide these efforts, which are often dismissed as "soft" and placed at the margins of medical school curricula. The purpose of this article is to describe the conceptual basis for an approach to patient-centered medical education and narrative medicine initiated at the University of Michigan Medical School in the fall of 2003. This approach, the Family Centered Experience, involves home visits and conversations between beginning medical students and patient volunteers and their families and is aimed at fostering humanism in medicine. The program incorporates developmental and learning theory, longitudinal interactions with individuals with chronic illness, reflective learning, and small-group discussions to explore the experience of illness and its care. The author describes a grounding of this approach in theories of empathy and moral development and clarifies the educational value that narratives bring to medical education. Specific pedagogical considerations, including use of activities to create "cognitive disequilibrium" and the concept of transformative learning, are also discussed and may be applied to narrative medicine, professionalism, multicultural education, medical ethics, and other subject areas in medical education that address individuals and their health care needs in society.

Learning what matters for patients: qualitative evaluation of a health promotion program for those with serious mental illness

Sedentary lifestyle, poor dietary behaviors and metabolic alterations associated with psychiatric medications contribute to poor health and high rates of obesity among individuals with serious mental illness (SMI). Interventions that increase engagement in physical exercise, dietary modifications, lifestyle changes and preventive health care can provide health benefits across the lifespan. These interventions have led to substantial physical improvements in some persons with SMI, while others have not improved or have experienced worsening physical health. We set out to identify characteristics of a health promotion program that persons with SMI associated with physical health improvements. Interviews were conducted with eight participants from the In SHAPE health-promotion program who lost at least 10 pounds or diminished their waist circumference by at least 10 cm. Interviews aimed to determine which aspects of the program were perceived to be most helpful in promoting physical health improvement. Among successful participants, three themes emerged, highlighting the importance of: (i) individualized interventions promoting engagement in the program; (ii) relationships with health-promotion program employees and (iii) self-confidence resulting from program participation. Health-promotion programs that target these areas may have better success in achieving health benefits for persons with SMI.

Walking a mile in their patients' shoes: empathy and othering in medical students' education

One of the major tasks of medical educators is to help maintain and increase trainee empathy for patients. Yet research suggests that during the course of medical training, empathy in medical students and residents decreases. Various exercises and more comprehensive paradigms have been introduced to promote empathy and other humanistic values, but with inadequate success. This paper argues that the potential for medical education to promote empathy is not easy for two reasons: a) Medical students and residents have complex and mostly unresolved emotional responses to the universal human vulnerability to illness, disability, decay, and ultimately death that they must confront in the process of rendering patient care b) Modernist assumptions about the capacity to protect, control, and restore run deep in institutional cultures of mainstream biomedicine and can create barriers to empathic relationships. In the absence of appropriate discourses about how to emotionally manage distressing aspects of the human condition, it is likely that trainees will resort to coping mechanisms that result in distance and detachment. This paper suggests the need for an epistemological paradigm that helps trainees develop a tolerance for imperfection in self and others; and acceptance of shared emotional vulnerability and suffering while simultaneously honoring the existence of difference. Reducing the sense of anxiety and threat that are now reinforced by the dominant medical discourse in the presence of illness will enable trainees to learn to emotionally contain the suffering of their patients and themselves, thus providing a psychologically sound foundation for the development of true empathy.

Students learning from patients: let's get real in medical education

Medical students must be prepared for working in inter-professional and multi-disciplinary clinical teams centred on a patient's care pathway. While there has been a good deal of rhetoric surrounding patient-centred medical education, there has been little attempt to conceptualise such a practice beyond the level of describing education of communication skills and empathy within a broad 'professionalism' framework. Paradoxically, while aiming to strengthen patient-student interactions, this approach tends to refocus on the role modelling of the physician, and opportunities for potentially deep collaborative working relationships between students and patients are missed. A radical overhaul of conventional doctor-led medical education may be necessary, that also challenges the orthodoxies of individualistic student-centred approaches, leading to an authentic patient-centred model that shifts the locus of learning from the relationship between doctor as educator and student to the relationship between patient and student, with expert doctor as resource. Drawing on contemporary poststructuralist theory of text and identity construction, and on innovative models of work-based learning, the potential quality of relationship between student and patient is articulated in terms of collaborative knowledge production, involving close reading with the patient as text, through dialogue. Here, a medical 'education' displaces traditional forms of medical 'training' that typically involve individual information reproduction. Students may, paradoxically, improve clinical acumen through consideration of silences, gaps, and contradictions in patients as texts, rather than treating communication as transparent. Such paradoxical effects have been systematically occluded or denied in traditional medical education.

Viewpoint: the importance of worldviews for medical education

The culture of academic medicine holds implicit and explicit assumptions about what is important in life, including assumptions about health and the practice of medicine. This philosophy of life constitutes a worldview from which medicine is practiced. Medical educators should introduce medical students to the benefits and limitations of this worldview, and to important alternative worldviews, early in medical school. The authors describe the concept of worldview, discuss the biomedical worldview that is dominant in Western medicine, compare it with other life philosophies (including non-Western and spiritual perspectives), and propose teaching about biomedical and other worldviews within the existing structure of preclinical medical education. The authors propose beginning medical school with a Foundations of Healing course that would introduce students to the concept of worldviews, place the biomedical worldview in a larger context with other worldviews, and explore the beneficial and adverse elements of the biomedical worldview. To maintain the awareness of worldviews after the course described above, the authors propose humanistic "horizontal strands." These would be structural elements of a longitudinal curriculum that intentionally interweave patient vignettes and case discussions into basic science lectures to highlight the variety of worldviews operating in healthcare contexts. By exposing students to the concept of worldview early in their training, educators can better meet professionalism mandates related to bias and self-awareness, immunize students against the adverse effects of the hidden curriculum, and bolster the status of the social and behavioral sciences in medical education.

Professionalism and evolving concepts of quality

For much of the twentieth century, quality of care was defined specifically in terms of physician characteristics and behaviors. High-quality physicians were well trained, knowledgeable, skillful, and compassionate. More recently, quality of care has been defined in terms of systems of care. High-quality organizations develop and adopt practices to reduce adverse events and optimize outcomes. This essay discusses this transformation from physician-based to organization-based concepts of quality and the consequences for patient care and medical professionalism.