Medical Education
Narrative medicine as a means of training medical students toward residency competencies

https://doi.org/10.1016/j.pec.2013.01.014Get rights and content

Abstract

Objective

This study sought to explore the perceived influence of narrative medicine training on clinical skill development of fourth-year medical students, focusing on competencies mandated by ACGME and the RCPSC in areas of communication, collaboration, and professionalism.

Methods

Using grounded-theory, three methods of data collection were used to query twelve medical students participating in a one-month narrative medicine elective regarding the process of training and the influence on clinical skills. Iterative thematic analysis and data triangulation occurred.

Results

Response rate was 91% (survey), 50% (focus group) and 25% (follow-up). Five major findings emerged. Students perceive that they: develop and improve specific communication skills; enhance their capacity to collaborate, empathize, and be patient-centered; develop personally and professionally through reflection. They report that the pedagogical approach used in narrative training is critical to its dividends but misunderstood and perceived as counter-culture.

Conclusion/Practice implications

Participating medical students reported that they perceived narrative medicine to be an important, effective, but counter-culture means of enhancing communication, collaboration, and professional development. The authors contend that these skills are integral to medical practice, consistent with core competencies mandated by the ACGME/RCPSC, and difficult to teach. Future research must explore sequelae of training on actual clinical performance.

Introduction

The Accreditation Council for Graduate Medical Education (ACGME) of the United States and the Royal College of Physicians and Surgeons of Canada (RCPSC-CanMEDS) have created an institutional mandate across North America to achieve competency in such areas as communication, collaboration, and professionalism [1], [2], [3]. Medical educators and students recognize that the formal medical school curriculum, at least in its traditional form, cannot on its own convey to students these essential skills [4], [5], [6], [7], [8]. Intuitively, development of these ACGME/CanMED competencies requires training both in medical expertise as well as in interpersonal, ethical, interpretive, and reflective capacities. The informal and hidden curricula, established in the literature to be one of the most powerful influences on student learning, may help teach some of these capacities [9], [10], [11], [12]. Unfortunately, these curricula may also diminish students’ empathy, promote cynicism, and enable moral stagnation or erosion [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]. Currently, many medical schools rely on role-modeling, mentoring, and clinical simulations to convey and provide practice in ACGME/CanMED competencies [11], [23], [24], [25], [26]. However, these methods may create a false sense of measurement when applied to nuanced, context-based behaviors, and may encourage students to ‘perform’ exterior actions rather than function through critically examined internal attitudes [12], [19], [25], [27], [28], [29], [30], [31], [32], [33], [34]. There remains a need for a dependable means of training and assessing skills within the ACGME- and CanMEDS-mandated domains of medical practice.

The study of the humanities — literature, creative writing, history, philosophy, visual arts, and anthropology — has emerged in medical training as a means of conveying skill in the interpretive, relational, and reflective areas otherwise hard to teach. Numerous innovative programs have been described in the past two decades [14], [15], [16], [17], [35], [36], [37], [38], [39], [40], [41]. Included among the teaching methods to emerge is the field of narrative medicine. Narrative medicine is an offspring of literature-and-medicine and patient-centered care, defined by Charon as “medicine practiced with… narrative skills of recognizing, absorbing, interpreting, and being moved by the stories of illness.” [42] Narrative medicine uses an interdisciplinary, process-based approach to examine suffering, illness, disability, personhood, therapeutic relationships, and meaning in health care. Narrative medicine methods have demonstrated improvements in team cohesion and perception of others’ perspectives while decreasing burn-out and compassion fatigue [43], [44], [45].

Although there has been a rapid uptake of narrative medicine and reflective writing teaching methods in several US and Canadian medical schools, there is no clear statement available from learners themselves regarding the utility of the methods or the changes experienced as a result of the training. The importance of this deficit is revealed in the recent review by Shapiro et al. which indicates that many educational initiatives rooted in the humanities are limited in their capacity to succeed due to significant resistance posed by both students and faculty [46].

This study sought to explore the perceived influence of narrative medicine training on clinical skill development for medical students who were within months of starting internship. Using qualitative methods rooted in grounded theory [47], we asked students to report the perceived effectiveness of training in several categories of interest, focusing on those capacities that are singled out by ACGME and CanMEDS as critical to effective professional work. Specifically, we aimed to understand how medical students participating in a one-month narrative medicine elective during their fourth year of medical school would perceive its influence on their ability to communicate with patients and colleagues, to collaborate with patients and health care team members, and to develop professionally. Perhaps most importantly, we provided students with opportunities to reflect openly on unintended or unexpected consequences of their experience.

Section snippets

Narrative training method

The College of Physicians and Surgeons of Columbia University (P&S) offers an intensive month-long narrative medicine elective for fourth-year students. Twelve students (10 P&S students and 2 from outside P and S) enrolled in the elective. The students had completed undergraduate degrees in science (6), English (2), Sociology (1), History (1), Literature (1) and Economics (1). They had successfully applied for residencies in orthopedic surgery (3), emergency medicine (1), internal medicine (3),

Participation

There was a 91% response rate for the weekly survey (180 out of a possible 192 questions were answered). Six students elected to participate in the focus group, which ran for 1.5 h. Within the one-month period given for follow-up responses posed one and a half years after the elective, three participants (25%) responded.

Overall, students expressed that the process of training in narrative medicine was enjoyable and that the outcome was transformative. Many students described the experience as

Discussion

This project provides consensual evidence from a group of 12 fourth-year medical students about the benefits of narrative medicine training through a grounded theory approach regarding the process, content, and experiences of learning narrative medicine. What emerged from the students is a clear statement of (1) their assertion that narrative medicine training helps equip them for ACGME and CanMEDS-required competencies specific to communication, collaboration, and professional development (2)

Funding

Dr. Charon's time, and a portion of Dr Dickson's time, was supported in part by National Heart, Lung, Blood Institute (K07 HLB082628).

Other disclosures

None.

Ethical approval

Ethical approval was granted (IRB # AAAI1336) and the work was carried out in accordance with the Declaration of Helsinki.

Disclaimer

None.

Previous presentations

Oral presentation of the abstract was give in April 2012 in the “Creating Spaces” component of the Canadian Conference for Medical Education (CCME) in Banff, Alberta, Canada.

Acknowledgements

The authors wish to thank Aubrie Swan (Ph.D, M. Ed) for conducting the Focus Group and Lorelei Lingard (Ph.D), Nancy Angoff (M.D.) and Phil Gruppuso (M.D.) for editorial suggestions.

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