Implementing a Narrative Medicine Curriculum During the Internship Year: An Internal Medicine Residency Program Experience (2024)

Abstract

INTRODUCTION

In 2001, Rita Charon defined narrative medicine as listening, reflecting, and responding to patient stories to promote healing.¹ The use of narrative techniques in medicine, however, is not novel. Medicine is saturated with storytelling.^2,3 Today’s rigorous medical school curriculum focuses on seven areas ranging from biomedical sciences to interprofessional collaborative skills, leaving little room to teach medical humanities.⁴ The assumption that medicine is an objective science based on technical skills and the perception that the humanities lack clinical relevance further hinder the inclusion of humanities in the curriculum.⁵ Narrative medicine does not propose a completely new practice, but rather a new framework within which to conduct current medical practice.¹ A narrative medicine curriculum was first developed at Columbia University College of Physicians and Surgeons in 2000.⁶ Since then, other medical schools have introduced narrative components into their curricula,^7–9 recognizing value in developing professionalism skills. Narrative medicine also can help medical students meet Accreditation Council for Graduate Medical Education competencies, including interpersonal and communication skills and professionalism.^10,11

Medical students respond favorably to narrative medicine curricula.^6,10 However, little is known about the benefits of a narrative medicine curriculum during residency training and thereafter.¹² Few structured efforts encouraging narrative medicine during residency training exist even though narrative skills are essential to ensure effective physician-patient and physician-physician communication.^13,14 Single-center and multicenter studies demonstrate the increased risk for burnout attributable to emotional exhaustion and depersonalization during the internal medicine internship year of residency.^15,16 A narrative component to medical education can help foster a professional identity on the basis of affiliation, representation, and attention, which are needed in graduate medical education to balance the confusion, depression, and frustration often experienced during residency.

It is a challenge to implement a narrative medicine or other humanities curriculum during residency. Liao and associates¹⁴ highlighted four barriers to implementation: The increased complexity of care delivery and duty hours limit activities in nonclinical education; the Budget Control Act cut indirect medical education funding, prioritizing clinical activities; most residency programs do not have the structure or culture necessary to support a narrative medicine curriculum; and nonclinical activities focus on research, quality improvement, and other medical education valued in fellowship and job applications. A 2013 study discussed resistance among faculty and residents who were unfamiliar with narrative medicine and cited this lack of knowledge as a barrier to implementation.¹⁰ Nevertheless, opportunities exist within training to provide residents with the opportunity to engage in narrative and reflection activities. These opportunities include implementing activities during residents’ protected time (morning report or noon conference), using in-house resources (building space, library, and art displays), and encouraging residents to participate in unfamiliar activities. In an effort to stimulate and encourage writing and reflection in medicine, the Louisiana State University Health Sciences Center (LSUHSC) Internal Medicine Residency Program in Baton Rouge implemented a narrative medicine curriculum for first-year house officers (interns). The benefits of this pilot program are discussed here.

METHODS

During the 2015–2016 academic year at the LSUHSC Internal Medicine Program in Baton Rouge, incoming interns were invited to participate in a series of reflective sessions based on a narrative medicine curriculum. Each of 6 sessions was offered twice, for a total of 12 sessions throughout the academic year. To increase participation, the first occurrence of each session took place during the evening, and the next occurrence of the same session took place the next month during noon conference. Noon conference is part of a resident’s protected time for didactic activities, so the ability to make use of this time every other month ensured that interested interns could attend a session. One week before the session, we e-mailed reminders to all interns with time and place information. Participation was voluntary, and interns were encouraged to attend at least 4 sessions throughout the year.

Each session consisted of a 30-minute discussion of a short essay, poem, article, or movie, followed by a 5-minute narrative exercise and a 10-minute wrap-up conversation. Narrative exercises included prompts that encouraged interns to briefly write and subsequently read aloud to the group. A discussion that followed the writing exercise allowed participants to reflect on their experiences with the group. Interns were allowed to keep their written narrations to protect confidentiality and encourage honest writing practices. The sessions took place in 2 areas of the LSUHSC Medical Education and Innovation Center that were designed with the value of medical education in mind: The Reconciliation Room, which is designed to encourage constructive feedback and foster feelings of completion, lack of hierarchy, wholeness, and unity (participants sit at a large round table to eliminate the sense of hierarchy), and the Teaching Terrace, which is an open outdoor space designed to foster humanism attributes in trainees.¹⁷

After the last sessions, we surveyed the interns using an anonymous, open-ended questionnaire to assess their perception of the narrative medicine sessions attended during their intern year. The survey consisted of 6 questions previously developed by Arntfield and associates.¹⁰ Four additional questions captured the interns’ time and location preferences (see Sidebar: Ten-Item Narrative Medicine Sessions Survey). The final 10-item paper-based survey was completed 1 week after the last narrative medicine session of the internship year in June 2016. Survey responses were entered into a database, and thematic analysis was performed for each question. Responses had to be categorized into the same theme by at least 2 readers for inclusion. Survey procedures were approved by the LSUHSC New Orleans institutional review board (IRB 9410).

RESULTS

Among 18 interns, 17 attended at least 1 session; 6 were preliminary and 8 were categorical interns, and 12 were men and 5 were women. On average, participants attended 3.8 sessions, with each session averaging 5.4 attendees. Thirteen interns completed the survey at the conclusion of the year. Course feedback was overwhelmingly positive, with 3 consistent themes emerging in the responses: Mindfulness, physician wellness, and professionalism. Interns defined mindfulness as increased personal reflection and awareness of patient feelings; physician wellness as good health and the ability to share difficult experiences to promote emotional well-being; and professionalism as strengthening of peer comradery, humanism, and public speaking skills. These themes are further discussed below.

DISCUSSION

Here we demonstrate the successful implementation of a narrative medicine curriculum during internship year and summarize the reported benefits to participants in an internal medicine residency program. The intern year is touted as the most difficult year in a physician’s life. It is characterized by numerous pressures from patients, attending physicians, other residents, and interns’ families; an exponential learning curve; and a lack of time to eat or sleep. The most common barriers to implementation of extracurricular activity during residency are time constraints and a lack of structural and cultural support.¹⁴ Yet the narrative medicine sessions were well attended. We attribute this success to two factors. First, the sessions took advantage of the residents’ protected didactic time (such as noon conference) or sessions took place at the end of clinical time. If an intern could not attend a session, a repeat session was offered the following month to ensure that both sessions did not fall on the same clinical rotation month. Attendance was not mandatory, but participation was encouraged through morning report and e-mail announcements. Second, program support was essential to ensure intern participation. The narrative medicine initiative was promoted by the Program Director, who teaches medicine with a focus on the art of medicine and humanism.

The high survey response rate captured interns’ perspectives on narrative medicine. Respondents highlighted a lack of alternative outlets for stress during residency training. The narrative medicine sessions provided a forum in which they could talk about topics they usually did not discuss in their personal or professional relationships. Internship year in internal medicine is characterized as relearning medicine as an applied science and the pressure of acting as a physician for the very first time, which can cause burnout.^15,16 Providing structured time for reflective writing can help residents deal with the clinical demands of the intern year.

Today’s medical training is shifting from listening to patient narratives toward a more mechanical approach to care that is focused on quick information assessment. Such an approach eliminates consideration of a patient’s experience from physician training. Narrative medicine involves listening to the intricacies of patients’ stories as they unfold and “translating” subjective words into objective information to gain a better understanding of an illness. Moreover, storytelling often is therapeutic for patients and has demonstrated healing effects.³ Storytelling also can transform a medical encounter into a more empathetic and understanding experience between patients and physicians, which enhances the quality of care.¹⁴ This type of practice helps physicians improve their personal awareness and avoid succumbing to the confusion, loneliness, depression, and frustration that can be associated with caring for critically ill patients.^10,18 The mindfulness, physician well-being, and professionalism themes support previous findings that including narrative practice in medical training can result in the availability of physicians who listen to their patients, reflect on their own experiences, and become well-rounded professionals as they improve patient-physician, physician-self, and physician-colleague relationships.

This residency program’s small sample size was a study limitation. Selection bias also was an issue because the interns who attended the most sessions were more interested in the value of the curriculum. Future research endeavors will focus on metrics that evaluate the curriculum’s impact on residents’ approach to patient care. Larger, prospective, and multicenter studies in residency programs are needed to measure the value of narrative medicine in graduate medical education.

CONCLUSION

An enthusiastic response following participation in a narrative medicine curriculum supported our endeavor. These results strengthen our belief that narrative medicine, acknowledged as beneficial to residents training in this program, will continue to gain momentum in the academic medicine community.

Linking

The greatest enterprise of the mind always has been and always will be the attempt to link the sciences and the humanities.

— Edward O Wilson, b 1929, American biologist, researcher, theorist, naturalist, and author

Acknowledgment

Brenda Moss Feinberg, ELS, provided editorial assistance.

Footnotes

References