Many medical students, even those with a background in the liberal arts, may have a hard time conceptualizing the role that the humanities–in particular, the art of the narrative–may have to play in clinical practice. However, a relatively new theory and practice of medicine, called narrative medicine, is beginning to take root and contains elements of both medical and language arts.
What is Narrative Medicine?
The phrase “narrative medicine” was coined by Dr. Rita Charon, one of the founders of this movement, which began to develop in the 1990’s in response to the perception of detachment and over-professionalism in medical practice. Dr. Charon wanted to explore new ways that medical practice could become more humanized and emotive– and lead to greater satisfaction with the clinical relationship for both doctors and their patients. In her definitive article, entitled “Narrative Medicine: a Model for Empathy, Reflection, Profession and Trust” which appeared in JAMA in 2001, Charon introduces her readers to this new concept by noting that “adopting methods such as close reading of literature and reflective writing allows narrative medicine to examine and illuminate four of medicine’s critical narrative situations: the physician and patient, physician and self, physician and colleagues and physician and society…By bridging the divide that separates physicians from patients, themselves, colleagues and society, narrative medicine offers fresh approaches for reflective, empathic and nourishing medical care.”
Kalitzkus and Matthiesen further explored this issue in their own paper, “Narrative-Based Medicine: Potential, Pitfalls and Practice” and begin their paper by noting that “narratives have always been a vital part of medicine”. Narrative medicine is based on the use of stories–fiction and nonfiction–in a clinical setting. The authors note that these stories tend to fall into one of four categories: patient stories, physician stories, stories about interactions between patients and physicians and meta-stories or meta-narratives. These stories can be used in different ways in this clinical setting: they can serve as a therapeutic or educative tool, aid in patient-doctor communication and aid in research on patient experiences with illness and disease.Since these articles were written, narrative medicine has slowly been growing within mainstream medical practice, particularly for vulnerable patient populations like children and ethnic minorities, and clinical researchers are beginning to explore the power of the narrative and the ways in which it can be applied to affect clinical outcomes.
The Application of Narrative Medicine in Clinical Practice
Narrative medicine sounds great in theory–but many student doctors may have reservations about it until they see how it can be put into clinical practice. In fact, there are many instances in which stories–both fiction and nonfiction–can be used to convey difficult medical concepts, strengthen the bond between patient and doctor, ease communication and make it easier to teach the patient about lifestyle choices which will help them to manage their condition.
The cases below are academic studies dealing with the role of narrative medicine in three different vulnerable patient populations: African Americans, Native Americans and children whose parents are hesitant to have them vaccinated.
Case #1: African Americans and Smoking Cessation
African Americans have been a traditionally underserved community and one which may have fewer resources to assist with smoking cessation than other members of the population. The ACCE project sought to study the efficacy of using narratives to reach out to African American smokers in addition to customary treatments (e.g. medications, nicotine replacement therapy and behavior modification). To this end, DVDs were made in which real-life smokers told their stories of addiction and of how they conquered that addiction in their own words. These DVDs were given to half of the patients in the study, all of whom received traditional therapy as well. The study found that the intervention group who had watched the videos expressed a stronger commitment to smoking cessation than the control group–and even had a marginally higher rate of actual cessation.
Researchers, in their conclusion, noted that “Narrative communication via storytelling… among African Americans in the South is one method to promote smoking cessation.”
Case #2: Native Alaskans and Cancer Awareness
Native Alaskans, like Native Americans in general, have been another underserved and impoverished (and thus vulnerable) patient population–and one with high rates of cancer. In this study, entitled “Digital Storytelling: a Tool for Health Promotion and Cancer Awareness in Rural Alaskan Communities,” authors wanted to look at the effect that storying telling could have on health care perception and outcomes. To that end, they produced a DVD of local, native Alaskan women between the ages of 24 and 54, relating their experiences with cancer. Authors of the study noted that “viewers reported the digitalized stories as an acceptable, emotionally engaging way to increase cancer awareness and to begin conversations. Those conversations often serve as a springboard for reflection, insight and cancer-prevention and risk-reduction activities.”
Case #3: Parents Hesitating to Vaccinate their Children
The modern reluctance of many parents to vaccinate their children has become a cause of concern for organizations like the Center for Disease Control–and for doctors across the country. Two studies have come out in recent years looking at whether or not this problem can helped by the application of narrative medicine.
In the first study, entitled “Storytelling in the Context of Vaccine Refusal: A Strategy to Improve Communication and Immunization,” the authors note that the recent outbreak of measles in California among a population of largely unvaccinated children underscores the serious nature of this disease, and also the serious consequences of vaccine refusal. Moreover, the authors point out that refusal is a complex and multifaceted issue–and that when doctors try to persuade hesitant parents with statistics and evidence-based medicine that “there is reason to believe that this is not the most effective style for communicating to all groups of parents.” The authors go on to advance the use of stories and storytelling to help overcome these parental doubts.
The authors of the second study, “Story and Science: How Providers and Parents can Utilize Storytelling to Combat Vaccine Information,” the authors take a more stringent approach, stating bluntly that “with little or no evidence-based information to back up claims of vaccine danger, anti-vaccine advocates have relied on the power of storytelling to infect an entire generation of parents with the fear of and doubt about vaccines.” The authors go on to advocate the utilizations of similar strategies for pro-vaccine education–only to combine the emotional power of stories with actual facts. They point out that there is some use of this already, such as the website Moms Who Vax, a website filled with information about the dangers of vaccine-preventable diseases, the uneventful vaccine appointment (i.e., children who receive their vaccines without the deadly reactions that anti-vaccine sites warn of), and what the authors call “anti-vax to pro-vax conversion”, where parents who used to be against vaccines change their minds in favor of them, usually after their child dies or nearly dies from a vaccine-preventable disease. Mention is also made of the Dr. Wendy Swanson, a pediatrician whose blog, Seattle Mama Doc, talks about her approval of vaccines both as a doctor and as a parent.
In short, narrative medicine, though an admittedly an unconventional approach in healthcare, is proving nonetheless to be an effective means of communicating with and educating patients, particularly those in vulnerable populations. Student doctors should consider weaving this technique into future clinical practice, particularly if they are planning on working with vulnerable patient populations.
Cawkwell, PB and Oshinsky, D. Storytelling in the Context of Vaccine Refusal: A Strategy to Improve Communication and Immunization. Medical Humanities. Published online October 5, 2015. PMID: 26438615
Charon, R. Narrative Medicine: a for Empathy, Reflection, Profession and Trust. Journal of the American Medical Association. 2001. 286(15) 1897-1902
Cherrington, A. et. al. Narrative to Enhance Smoking Cessation Interventions Among African American Smokers: the ACCE Project. BMC Residential Notes. 2015. 8(1) 567
Cueva, M. et. al. Digital Storytelling: a Tool for Health Promotion and Cancer Awareness Among
Rural Alaskan Communities. International Journal of Circumpolar Health. 2015.
Kalitzkus, V. and Matthiesen, P. Narrative-Based Medicine: Potential, Pitfalls and Practice.
Permanente Journal. 2009. 13(1) 80-86.
Shelly, A. and Ernst, K. Story and Science: How Providers can Utilize Storytelling to Combat Anti-Vaccination Information. Human Vaccines and Immunotherapeutics. 2013 9(8) 1795-1801
Brian Wu, MD, Ph.D., MNM, graduated from the University of Maryland with a Bachelor’s of Science in Physiology and Neurobiology, and graduated from the Keck School of Medicine (University of Southern California) with an MD with a focus on holistic care and treatment. He currently holds a Ph.D. in integrative biology and disease for his research in exercise physiology and rehabilitation.