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Editorial: What is Narrative Medicine, and Why Should We Use it in Orthopaedic Practice?

Leopold, Seth S., MD

Clinical Orthopaedics and Related Research®: November 2018 - Volume 476 - Issue 11 - p 2105–2107
doi: 10.1097/CORR.0000000000000504
REGULAR FEATURES

S. S. Leopold, Editor-In-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA

S.S. Leopold MD, Clinical Orthopaedics and Related Research®, 1600 Spruce Street, Philadelphia, PA, 19013 USA, Email: sleopold@clinorthop.org

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Received August 21, 2018

Accepted August 30, 2018

Emily Post advises those who care about etiquette never to arrive early to a party [25]. By that standard, orthopaedic surgery does pretty well. Evidence-based medicine had been thoughtfully defined by the early 1990s in internal medicine [8] after having already been practiced for decades [5], but the first evidence-based “Users Guides” did not hit an orthopaedic journal until 2001 [1]. If evidence-based medicine is the Yang, its Yin is narrative medicine, which was well characterized in English by Rita Charon more than 15 years ago [3] (and perhaps before that in Norwegian [15]). This is a transformative concept, but one that has yet to be addressed in depth in orthopaedic surgery. Late to the party again.

Well, better late than never. The concept of narrative medicine holds that by becoming more-insightful consumers of the stories we hear and see—through the written word, the stage, visual art, or other sources—we become more-empathic listeners to the stories our patients tell, and, by extension, more reflective, trustworthy, and effective practitioners of our profession. Although other specialties’ training programs and medical schools have been teaching this for a decade or more [21, 26] narrative-medicine offerings in orthopaedics (at least those available outside Clinical Orthopaedics and Related Research®) remain rather scant, though some have been quite compelling [9].

Here at CORR®, we believe deeply in the power of individuals’ stories to change clinicians’ perspectives, and numerous columnists here have used narrative medicine in the form of the written word to do just that [7, 13, 22]; in my own way, on this page, I have tried to do so, as well [18]. But one pair of columnists here—Linda and Gary Friedlaender—does this on a regular basis, using words but also compelling, unforgettable images, in our Art in Science column. I look forward to their contributions, because by opening my eyes, they open my mind. It was in fact through one of their columns [12] that I first learned of Rita Charon’s pioneering work in narrative medicine, a concept that I was familiar with but until I read the Friedlaenders’ column, I did not know it had a name.

By reading and looking for deeper meanings in art, good writing, drama, and music, we touch what it means to be human. Although I came to great fiction, great music, and transformative visual art later in the game than some, those art forms have completely changed the way I think about and listen to my patients. Narrative medicine teaches that we can refine our active-looking and active-listening skills by consuming outside narratives in art with intention, and the skills we develop then accompany us into each exam room. And the benefits of this so-called narrative competence [3] go beyond creating deeper connections with our patients. Numerous studies have shown that increased provider empathy improves the health of the patients we care for [2, 16, 20, 24], and I believe it also can improve our health as well. Others agree [6, 17].

Don’t like fiction? Get “museum legs” at art exhibitions? No problem. There are a number of wonderful nonfiction writers who traffic in medical narratives, and the lessons in those books aren’t hidden in symbols; their messages are explicit, and often delivered in gripping prose. Apart from the usual suspects, as good as they are—Atul Gawande, Oliver Sacks, Abraham Vergese, Pauline Chen—consider Dan Shapiro’s work (especially Delivering Doctor Amelia), or Perri Klass’s A Not Entirely Benign Procedure. Go back in time a bit and read (or re-read) anything by Lewis Thomas. And whatever you do, if you have not seen the ways that the Friedlaender duo connects empathy to art to medicine in their CORR columns [10, 11] by all means seek them out.

The best of what has been written about what narrative medicine is [4] and how to practice it [23] has appeared in family medicine and internal medicine journals, but we should not consider narrative medicine an “internist thing.” More than in many areas of medicine, orthopaedic patients’ stories are about what they can and can no longer do. And to many people, what they do is essential to who they are. Triathlete, longshoreman, artist, surgeon. As much as I try to separate what I do from who I am, I cannot completely do so. Perhaps you feel likewise. By hearing our patients out on these key existential issues, we unlock metaphors that can guide our care, and perhaps come to find that “noncompliance” (a term I so dislike that I feel compelled to place in quotes) may more often be an obstructed narrative than a form of patient stubbornness [23].

Keeping patients’ stories at arm’s length unquestionably is easier than engaging with them. Intimacy is always difficult, and practicing narrative medicine unquestionably is an intimate gesture. The rewards for trying, though, are tremendous, both for patients and their doctors. And one may reasonably say that in contrast to evidence-based medicine, which is built on level-of-evidence hierarchies and complex methodologies to quantify effect sizes [19], narrative medicine seems hopelessly subjective. Which texts should guide our empathy-development? If we can’t read and agree upon the conclusions to draw from a randomized trial (as sometimes happens), how will we ever agree on the interpretation of whether the protagonist finds redemption at the end of a Cormac McCarthy novel? I believe the specific interpretations matter less than does the very act of exposing ourselves to narratives. Consuming those narratives with care helps us see what can be gained by coming to know a story’s deeper meaning. I would add that a good practitioner of narrative medicine is better able to practice evidence-based medicine because a listener with narrative competence generates trust in the hearts of those telling the stories: Patients.

Proponents have suggested that precisely because physicians have less time to spend with each patient, somehow sitting still and listening longer is more important [3]. I confess that I cannot work the math out on this suggestion. But I do believe we must cultivate skills in narrative medicine despite the time pressures we face because of the benefits it offers both to us and to our patients. In that same essay [3], the author who (in my opinion) has best articulated the concepts of narrative medicine suggests that everything we do in our profession derives from narrative. As much as I admire her contributions, and as big a fan as I am of narrative medicine, I don’t believe this is true, either. Sometimes, to do what we need to do, coldhearted, technologically assisted precision, and emotional distance are called for. But that does not diminish the importance of gaining narrative competence, to use when circumstances allow us to, both for our own wholeness and wellness [6, 19], and also to improve the health of our patients [2, 16, 20, 24].

As any reader of CORR knows I wouldn’t suggest narrative medicine if it came at any cost to the evidence-based kind. And this is no appeal to abandon the hand-eye skills or the clinical judgment we take years to develop. While there may be areas of medicine where a provider can focus most or all of his or her attention on narrative, orthopaedic surgery is not one of them. Some 50 years ago, novelist John Barth recommended that whether in art or lovemaking, one should seek passionate virtuosity [14], a perfect balance of heart, hands, and head. Orthopaedic surgeons need to define and seek out our own brand of passionate virtuosity, by balancing technical excellence with deep and well-cultivated empathy. Exploring narrative medicine, whether in visual art, the written word, drama, or music, can help us to do just that.

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References

1. Bhandari M, Guyatt GH, Swiontkowski MF. User's guide to the orthopaedic literature: How to use an article about a surgical therapy. J Bone Joint Surg Am. 2001;83:916–926.
2. Brown MT, Bussell J, Dutta S, Davis K, Strong S, Matthew S. Medication adherence: Truth and consequences. Am J Med Sci. 2016;351:387–399.
3. Charon R. Narrative medicine. A model for empathy, reflection, profession, and trust. JAMA. 2001;286:1897–1902.
4. Charon R. Narrative medicine: Form, function, and ethics. Ann Int Med. 2001;134:83–87.
5. Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre. How to read clinical journals: I, Why to read them and how to start reading them critically. Can Med Assoc J. 1981;124:555–558.
6. Divinsky M. Stories for Life: Introduction to narrative medicine. Can Fam Physician. 2007;53:203–205.
7. Donegan DJ, Pasternack BG, Kelly JD IV. Your best life: Dealing with loss. Clin Orthop Relat Res. 2017;475:592–594.
8. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268:2420–2425.
9. Farrar E. What’s important: Lessons on life, death, and disability. J Bone Joint Surg Am. 2017;99:797–798.
10. Friedlaender GE, Friedlaender LK. Art in science: Enhancing observational skills. Clin Orthop Relat Res. 2013;471:2065–2067.
11. Friedlaender GE, Friedlaender LK. Art in science: The Doctor by Luke Fildes: Putting the patient first. Clin Orthop Relat Res. 2015;473:3355–3359.
12. Friedlaender GE, Friedlaender LK. Edvard Munch and The Scream: A cry for help. Clin Orthop Relat Res. 2018;476:200–202.
13. Friedman LGM. Residency Diary: Big lessons in small moments. Clin Orthop Relat Res. 2017;475:2861–2863.
14. Harris CB. Passionate Virtuosity: The Fiction of John Barth. Champaign, IL: University of Illinois Press; 1983.
15. Heskestad S, Tjemsland L. The story of suffering. On the traces of narrative medicine. Tidsskr Nor Laegeforen. 1996;116:1092–1094.
16. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86:359–364.
17. Johna S, Rahman S. Humanity before science: Narrative medicine, clinical practice, and medical education. Perm J. 2011;15:92–94.
18. Leopold SS. Editorial: Giving at the office. Clin Orthop Relat Res. 2017;475:1929–1931.
19. Maltenfort M, Días-Ledezma C. Statistics in brief: Minimum clinically important difference—Availability of reliable estimates. Clin Orthop Relat Res. 2017;475:933–946.
20. Mercer SW, Jani BD, Maxwell M, Wong SYS, Watt GCM. Patient enablement requires physician empathy: A cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland. BMC Fam Pract. 2012;13:6.
21. Nicholas B, Gillett G. Doctors’ stories, patients’ stories: A narrative approach to teaching medical ethics. J Med Ethics. 1997;23:295–299.
22. Page AE. Gendered innovations in orthopaedic science: Can we talk? Clin Orthop Relat Res. 2018;476:1417–1419.
23. Peterkin A. Practical strategies for practicing narrative-based medicine. Can Fam Physician. 2012;58:63–64.
24. Steinhausen S, Ommen O, Thüm S, Lefering R, Koehler T, Neugebauer E, Pfaff H. Physician empathy and subjective evaluation of medical treatment outcome in trauma surgery patients. Patient Educ Couns. 2014;95:53–60.
25. The Emily Post Institute. Party etiquette tips for hosts and guests. Available at http://emilypost.com/advice/party-etiquette-tips-for-hosts-and-guests/. Accessed on August 2, 2018.
26. Yamada S, Maskarinec GG, Greene GA, Bauman KA. Family narratives, culture, and patient-centered medicine. Fam Med. 2003;35:279–283.
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