Article In Brief
Narrative medicine programs, which involve reading and writing literary texts about illness and disability, are helping some neurologists stave off a sense of malaise and depersonalization. Neurologists discuss how the programs have helped them reconnect to their patients and mission as physicians.
Sneha Mantri, MD, MS, assistant professor of neurology at Duke University School of Medicine, was a third-year medical student when she first became disillusioned with medical practice.
Working with very ill HIV/AIDS patients on a medicine rotation, she and the other clinicians she worked with recognized that one of the patients was dying. But the patient didn't know it and, as a medical student, she felt powerless and distressed that no one else was informing the patient. When she shared her concern with a classmate, he told her she needed to “get over it” if she was going to be a good doctor.
“I thought ‘I don't want to get over this to be a good doctor; I have to be able to engage with this to be a good doctor,’” she said.
That conversation prompted Dr. Mantri to pause her clinical studies for a year and reconsider her options. She decided to pursue Columbia University's master's degree in narrative medicine.
As part of the program, Dr. Mantri took courses in illness and disability narratives, and learned to read and write in response to these and other scenarios from her own perspectives and experiences, as well the experiences of others. This skill helps a clinician to become a more attentive listener to patients and others, see multiple perspectives, and understand his or her role in a patient's story, she said.
When she returned to clinical rotations, Dr. Mantri felt grounded in her ability to keep the challenges of medical practice in perspective, understanding both the limits and the power of a clinician's interaction with a patient. She also was able to view medical training and medical practice with a more analytical eye.
“The narrative medicine program helped me personally get a better understanding of what was happening to me as a young medical student about to go into residency,” she said. “That helped me think about things like stressors and drivers of burnout that you see as a medical student.”
Narrative Medicine Defined
The concept of narrative medicine was developed by Rita Charon, MD, PhD, professor in the Division of General Medicine at Columbia University College of Physicians and Surgeons. She envisioned it as a vehicle to introduce medical students to literary texts about illness and reflective writing so that they could practice interpreting patients' stories and write about the experiences of both the patient and the clinician.
In a 2008 article in Neurology, Dr. Charon and her co-author, Megan Alcauskas, MD, a neurologist now based in Nashville, described narrative medicine as a way to help the clinician focus on “appreciating and reflecting on the patient's experience and the patient-physician relationship in order to improve both by building trust, developing empathy and fostering a sense of shared responsibility in a patient's health.”
Many medical schools and residency programs have added narrative medicine courses into their curricula since Dr. Charon introduced the concept.
“No one was talking about clinician burnout at that time. But, as narrative medicine programs began to spread across the country, some physicians trained in its principles began to see how it can protect clinicians from feeling a sense of depersonalization and other symptoms of burnout,” Dr. Charon told Neurology Today in an interview.
While narrative medicine was not developed specifically as a burnout antidote, it has served that purpose for Dr. Mantri. “What brought me into narrative medicine formally was burnout,” she said. “And I've continued with that as a theme throughout the work that I am doing.”
As a neurology resident, for example, Dr. Mantri led workshops for medical students during their neurology rotation. In one exercise, students read a selection from a neurology textbook about migraine symptoms and the changes in the brain when a person experiences a migraine. They then read Joan Didion's essay, “In Bed,” in which she describes her personal experience with migraine.
Students compared the two readings and discussed what each perspective offered to the other. Then the students re-wrote one of their own medical notes from the point of view of the patient.
That type of exercise helped students step away from the burnout-inducing frustration of treating chronically ill patients with difficult-to-manage symptoms to gain a new level of empathy for a patient's experience. It also served as reminder that knowing medical facts is just one part of caring for a patient.
Now a movement disorders specialist at Duke, Dr. Mantri has helped to develop a certificate program in medical humanities at the university that will guide undergraduate students as they explore what it means to be a health care professional.
“We'll be using disability stories, illness stories, and narrative medicine to help students understand that there's a lot more to medicine than biochemistry,” said Dr. Mantri, who serves on the faculty of Duke's Trent Center for Bioethics, Humanities, and History of Medicine, is a member of Duke's Narrative Medicine Colloquium, and frequently contributes to Synapsis, an online health humanities journal.
“The narrative medicine program helped me personally get a better understanding of what was happening to me as a young medical student about to go into residency. That helped me think about things like stressors and drivers of burnout that you see as a medical student.”
—DR. SNEHA MANTRI
The certificate program at Duke is one of dozens of other narrative medicine training initiatives that have emerged in the past two decades. In addition to the master's program at Columbia, there are formal programs at Lewis Katz School of Medicine at Temple University, Ohio State University, and other academic medical centers, as well as workshops, conferences, and seminars across the country.
An Antidote to Moral Injury
Narrative medicine training programs vary in content, structure, and focus. Columbia's Division of Narrative Medicine offers a three-day basic workshop to introduce the methods and skills of narrative medicine to physicians, nurses, social workers, and others. In March, the workshop addressed clinician distress head-on in a themed workshop entitled “Burnout in Healthcare: The Need for Narrative.”
“Because more and more people, elsewhere as well as at Columbia, are using our methods in efforts to counter burnout, we chose a theme of moral injury and burnout,” Dr. Charon said.
Moral injury is the damage an individual sustains when he or she sees or does something against his or her own moral beliefs or values, Dr. Charon explained. The term is often used to describe the psychological wounds that soldiers suffer; more recently, it has been used to describe how clinicians are harmed when insurance, regulatory, administrative, or other barriers prevent them from providing the best care for their patients.
The workshop included faculty presentations about concepts such as creativity, ethics, bearing witness, and empathy. Workshop participants convened in small groups to practice close reading, creative writing, and responding to the writings of others.
“It opens up a new way of approaching the care of patients, with some unusual concepts and tools from the world of the humanities, from literary theory and creative work and visual artists,” Dr. Charon said.
Participants are grouped in teams of eight for the entire weekend, and sharing the experience is part of its value. Many people who attend the workshops, she said, arrive emotionally exhausted by their work, and they are surprised by their ability to connect deeply with strangers so easily.
“They come because they're looking for nourishment, and they're looking for ways to reinvest themselves in what they do,” she said. “And they experience this sudden, unexpected, personal bonding with seven other people with whom they've been just assigned. We have learned to leave the small groups alone for the last session, because there is always weeping and hugging.”
Gaining More from Patient Encounters
Gayatri Devi, MD, MS FAAN, director of Park Avenue Neurology in New York, enrolled and completed the master's program in narrative medicine in a year. She said the training re-energized her commitment to write more about her patient encounters than technically required.
Dr. Devi recognized the importance of forging a personal connection with her patients before she learned the term “narrative medicine.” But after practicing for nearly 20 years, her career satisfaction had flagged to the point she was considering a change.
“I finally realized the reason I was burning out,” she said. “My practice had gotten very busy, so I was seeing patients one after the other. I was doing a lot of medical and neurologic work with them, but I really wasn't getting to chat with them as people.”
She felt she had no time to know her patients personally or let them know her. To address that, she began scheduling an extra five minutes of time with each patient, so she could choose to stay in the room and chat if she wanted to.
“And just that little extra time, which translates into about 40-50 minutes in a day, transformed my practice from my perspective,” Dr. Devi said. “Suddenly, it just all became a lot more meaningful once again.”
“I've always felt like some of the things patients say are pearls of wisdom, or funny, or just profound in some way,” she said. “After the narrative medicine program, I became more deliberate about writing those things down.”
She cited, for example, the notes she easily retrieved from a conversation she shared with a 95-year-old woman she had been seeing for more than a decade. She had started to write more than a medical history or progress notes, Dr. Devi said, focusing more on writing about the whole person. For example, she described one patient, a 95-year-old woman, “as being full of vim and bustling with happiness. Everyone at my office adores her and looks forward to her visits. Asked to describe herself, she said: ‘I am a very happy person, I like to laugh, I like to sing, I like to dance; I don't sit and bite my nails and make a tragedy of everything. I can be a comedian at times. I like people. I say hello to everyone, even to strangers on the street....’” The narrative medicine training program helped her see that knowing her patients' stories helped foster a deeper connection to her patients and her own well-being.
“I finally realized the reason I was burning out. My practice had gotten very busy, so I was seeing patients one after the other. I was doing a lot of medical and neurologic work with them, but I really wasn't getting to chat with them as people.”
—DR. GAYATRI DEVI
“As a doctor, sometimes you feel like a machine, especially in neurology, where you work with chronic illnesses and oftentimes there is no cure,” she said. “Narrative medicine gives you a framework within which to humanize the patient, and in the process, also humanize yourself.”