Narrative Medicine: What Patient Stories Can Tell Us

WASHINGTON, D.C.—Many physicians have dreams of becoming physician-writers—to see their work published in The Journal of the American Medical Association’s A Piece of My Mind column or in The New York Times—but few feel confident they have the skills and knowledge to pursue these goals. At the ACR Convergence 2024 session The Fundamentals of Narrative Medicine, two outstanding speakers regaled the audience with stories and practical tips on this very subject.

Origins of Narrative Medicine

Catherine Rogers

The first speaker was Catherine Rogers, MFA, MS, associate director and lecturer, Program in Narrative Medicine, Columbia University and Columbia University Vagelos College of Physicians and Surgeons, New York. Rogers draws on her background as a performer and playwright—her plays have been staged in New York and Athens, Greece, as she works with medical trainees and practicing physicians on developing their skills in narrative medicine.

The origins of narrative medicine come from the work of Rita Charon, MD, PhD, professor of medicine and chair, Department of Medical Humanities and Ethics, Columbia University Vagelos College of Physicians and Surgeons. Dr. Charon is a general internist who realized that, when working with patients and asking them questions solely about their symptoms, something was missing.

Dr. Charon recognized that patients come to the clinic as people with stories, yet medical school had not taught her to uncover and analyze these stories. Thus, she sought out learning with a literary scholar and pursued her PhD in English. In doing so, she saw that the skills used in literary analysis—understanding narrative through lines, interpreting stories—were highly relevant to medicine and could make doctors better in their professional activities. Thus, she brought together literary scholars, philosophers, actors, art historians and others to develop systems meant to increase the skills of paying attention, representing stories, writing about patients and developing therapeutic relationships.

Benefits of Narrative Medicine

Soon, Dr. Charon and others were able to develop a narrative medicine curriculum for first-year medical students at Columbia. Through these electives, students work, for example, with an art historian and use visits to museums and guided observation of artwork to inform their skills of clinical observation. Other students work with a dancer from the Mark Morris Dance Company and are allowed the opportunity to choreograph pieces that reflect on and represent the experiences of their patients. Rogers leads a class in which, over the span of six weeks, students write a one-act play and are invited to perform these works in public. When students are asked what they have gained from this experience, they respond that playwriting allows them to step into another person’s shoes, to imagine and explore a world different than their own, to gain a respite from the daily stresses of medical training and to grow comfortable with assuming their new role as a doctor (which, to many students, feels like taking on the role of a new character).

A growing body of literature is looking at the objective benefits of participating in narrative medicine programs, and these include improvements in teamwork skills, reduction of burnout, enhanced interprofessional communication and collaboration, and a sense of restoring meaning in medical practice.¹ Other skills associated with narrative medicine training include building the ability to tolerate ambiguity, improving reflective practice and introspection, and picking up on details and clues in stories that may otherwise be missed.

Journalism Skills

Stephen Fried

The second speaker was Stephen Fried, BA, director, Columbia Narrative Medicine Journalism Workshop, New York, and lecturer, University of Pennsylvania Center for Programs in Contemporary Writing, Philadelphia. Mr. Fried, an award-winning journalist and The New York Times best-selling author, was precisely the right person to provide guidance to audience members hoping to be the next Atul Gawande or Siddhartha Mukherjee. Mr. Fried explained that narrative medicine journalism places an emphasis on that last word—journalism—and requires doctors to learn skills and acquire habits that may initially feel foreign or counterintuitive to them. Physicians must commit to true reporting, which includes the gathering of background/explanatory information and being aware of what is currently in the news that is relevant to the subject they are writing about. Mr. Fried cautioned that, even if doctors are leaders in their fields, they must still do the hard work of reporting to best be able to tell readers what they need to know.

Aspiring physician-journalists must also recognize the difference between writing for oneself to become a better clinician and writing/narrating on the same subject for a lay readership. Physicians must understand their own voice as a writer, develop this voice and know when to use—or not use—this voice in their writing. They must also be able to access and use the voices of others, which typically requires interviewing patients and others, rather than just writing based on what they remember happening. A skilled medical journalist can observe and re-create actual scenes, and this may mean going back to the place where an event took place.

Truly great medical journalists are continually asking themselves: What is going to be the next big thing? This question may apply both to improving a specific piece by exploring uncharted territory as well as developing ideas for future pieces. (Mr. Fried recommends that doctors keep a running list of the Big 5 items that they want to write about next.) A key concept in general is writing in a way that is personal to the reader rather than just personal to the physician writing the piece.

Approaching Patients

One significant topic of discussion was how to approach patients and obtain permission to write about their stories. Whereas physicians are used to submitting cases to medical journals with patients de-identified, medical reporting relies on talking about real people, using their real names and providing objective details that can be fact-checked. Mr. Fried said the doctors he works with in his workshop are often uncomfortable with the idea of being so explicit in asking for a patient’s permission, but that patients frequently are more than willing to share their stories. Mr. Fried also observed that the doctor who emails a patient to ask permission and does not receive an immediate reply typically assumes this means the patient is not interested in speaking with them. However, other explanations may exist—the patient may have been busy or sick or traveling—and, while being respectful of boundaries, the doctor ought to send a follow-up email and explore the conversation further.

In Sum

The session was tremendously engaging and even included an interactive writing exercise led by Rogers and Mr. Fried. With so many great stories in medicine, the audience clearly regarded the talk as well worth their time in helping them discover their passion for narrative medicine and grow into the writers they hope to be.

Jason Liebowitz, MD, is an assistant professor of medicine in the Division of Rheumatology at Columbia University Vagelos College of Physicians and Surgeons, New York.

Reference

1. Gowda D, Curran T, Khedagi A, et al. Implementing an interprofessional narrative medicine program in academic clinics: Feasibility and program evaluation. Perspect Med Educ. 2019 Feb;8(1):52–59.