The practice of medicine is a beautiful confluence of art and science, where we interpret a patient’s clinical data within the context of their personal narrative and use all of the information to provide the best care possible. That sounds nice, but most residents hear that and laugh at the thought of having enough time to connect for so long with one patient. With increasing requirements for efficiency, a devastating diagnosis for a family turns into a one-liner. Let’s say you have a three-year-old patient named Jack whose favorite color is blue, who loves police cars and playing in the mud, and whose parents are crushed by his diagnosis of leukemia. You admit him, and for efficiency’s sake, your signout on him reads something like this: “3yo previously healthy M who presents with new onset leukemia, WBC 400k, high risk for tumor lysis syndrome so q6h labs, allopurinol, 1.5xMIVF, sedated LP, bone marrow biopsy, and port placement scheduled for today.” Your team knows exactly what to do about the leukemia, but they know nothing about Jack or his family.
In a practical sense, if you are just covering an inpatient service overnight, this doesn’t necessarily matter. In our hospital, you could be managing 30-40 patients, many of them tenuous (especially during the winter for pediatrics residents #thanksRSV), and your job is, to put it bluntly, to make sure they don’t die. But what if something bad does happen? What if the child is transferred to the PICU, what if they go into renal failure from tumor lysis and need dialysis, what if your infant with bronchiolitis goes into respiratory failure? Not only do you need to have a discussion with the family and help them process what is going on, but you also need to be able to cope with difficult circumstances as a human being. In addition, as human beings, the depersonalization we apply to increase efficiency promotes burnout and limits both the patient’s healing and our own1.
Residency programs at Children’s Hospital of Philadelphia2, Columbia University3, Louisiana State University4, Temple University5, University of Virginia6, Kaiser Vontana Medical Center1, and Vanderbilt University7 have looked at incorporating narrative medicine into clinical training in order to promote resident wellness as well as effectiveness. They have worked with pediatric, surgical, neurology, and internal medicine residents as well as others. These initiatives have ranged from one to two one-hour sessions to a 12-session series throughout the year. Most of them follow the general narrative medicine framework that involves reading a short piece, reflecting on it personally and as a group, and then writing a self-reflective piece. Others have incorporated long writing exercises even culminating in essay contests.
Success of the programs depended on making them available for residents to participate in, as in they took place during protected time, it wasn’t a significant time commitment, and while a few were mandatory, many were simply encouraged with support from the residency program director. Generally, from survey results, residents derived the following benefits from their sessions:
- Connecting with the patient allowed them to gather more information and generate fresh hypotheses, therefore improving patient care3,8
- They had a safe space to self-reflect and explore with peers, building camaraderie and professional connections2-5
- They had a creative outlet as well as an outlet for their stress and a way to express it that they did not have before3-5
- They improved communication skills, especially listening skills4,6-8
- They were better able to appreciate and accept ambiguity in medicine2,6
- They were able to reflect on their own behavior and that of others to identify negative and positive role models and be more intentional about their personal growth1,8
- They were able to find meaning in the patients’ narratives as well as their own by reflecting on their own illness experiences2,7
Almost all of this data has been collected via qualitative surveys in small groups (with a maximum of a few dozen study participants), so there is still much to be done to further investigate the effects of narrative medicine and having an outlet to write on the wellness and effectiveness of residents. However, it is promising to see that it is possible to make time for creative expression within a busy residency program, and both the trainees and patients benefit.
References
- Johna S, Dehal A. The power of reflective writing: narrative medicine and medical education. Perm J. 2013;17(4):84–85. doi:10.7812/TPP/13-043.
- Diorio C, Nowaczyk M. Half As Sad: A Plea for Narrative Medicine in Pediatric Residency Training. Pediatrics. 2019;143(1): e20183109. DOI: https://doi.org/10.1542/peds.2018-3109.
- Charon R, Hermann N, Devlin MJ. Close Reading and Creative Writing in Clinical Education. Academic Medicine. 2016;91(3):345–350. doi: 10.1097/ACM.0000000000000827.
- 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:10.7812/TPP/17-187.
- Rosenberg N, Vitez M. Jamaica Kincaid’s “Girl” and the Challenge of Growing Up in Medical Training. JAMA.2019;322(13):1238–1239. doi:https://doi.org/10.1001/jama.2019.14003.
- Harrison MB, Chiota-McCollum N. Education Research: An arts-based curriculum for neurology residents. Neurology. 2019;92(8):e879-e883. doi: 10.1212/WNL.0000000000006961.
- Pearson AP, McTigue MP, Tarpley JL. Narrative medicine in surgical education. J Surg Educ. 2008;65(2):99-100. doi: 10.1016/j.jsurg.2007.11.008.
- Koo K. The Value of Reflection in Urological Trianing: An Introduction to the AUA Residents and Fellows Committee Essay Contest. J Urol. 2018;200(2):253. doi: 10.1016/j.juro.2018.03.114.
Writing for Wellness 