Tools for Applying Medical Knowledge

Storytelling and Written Reflection: Tools to Foster Meaning and Connection in Graduate Medical Education Settings.

Listening to the story of medicine

Philosophy, ethics, medicine and health care: the urgent need for critical practice

Reader in Applied Philosophy, Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK and Visiting Professor of Philosophy as Applied to Medicine, University of Buckingham, Uk Assistant Professor, Department of Philosophy and Religious Studies, Old Dominion University, Norfolk, VA, USA Associate Professor, Department of General Practice, University of Auckland, Auckland, New Zealand Director, University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada Assistant Professor, Department of Philosophy, University of Guelph, Guelph, ON, Canada Assistant Professor, Department of Philosophy, Dalhousie University, Halifax, NS, Canada Professor of Values in Health Care, Associate Director, Social Dimensions of Health Institute, University of Dundee, Dundee, UK

Review: <i>Narrative Medicine in Hospice Care: Identity, Practice, and Ethics through the Lens of Paul Ricoeur</i>, by Tara Flanagan

Rich experience of clinical diagnosis and treatment has been accumulated in the developmental history of Chinese medicine, and the efficacy has been increasingly accepted by the public. However, the evaluation of clinical efficacy is currently based more on scientific evidence instead of merely the changes of patient symptoms. In Chinese medicine, the changes of major disease indicators, patient symptoms, and pathogenesis are the major criteria for the evaluation of clinical efficacy. The lack of well-accepted and uniform criteria and the uncertainty of subjective evaluation limit the development of clinical Chinese medicine. Evidence-based medicine combines clinical skills with the current best evidence. Narrative medicine, utilizing people's narratives in clinical practice, emphasizes patient feelings, willingness, and value orientation. The introduction of both evidence-based medicine and narrative medicine into the evaluation of clinical efficacy refers to the construction of the clinical efficacy evaluation system in a paradigm of participatory diagnosis and treatment. It can fully reflect the characteristics of Chinese medicine, respect the values of patients, and achieve universal clinical evidence. Therefore, it helps to improve the diagnosis and treatment, the relationship between doctors and patients, patients' life quality and decision-making awareness, and finally the new evaluation model of clinical efficacy of Chinese medicine.

Notes on Contributors

At the heart of narrative medicine as conceived and practiced at the Columbia University Program in Narrative Medicine lies the desire to maintain contact, the move toward intersubjective encounter, reader and writer, doctor and patient, colleague and colleague. Whereas narrative medicine is most commonly described as arming medical professionals with narrative tools to develop more effective relationships in health care, the human consequences and ethical implications for literature scholars in this interdisciplinary practice are equally profound. “Ethics” can be an unfashionable word in contemporary literary circles. Today’s scientific community, by contrast, regularly tackles issues of empathy and “meaning.” Contact, engagement, and affiliation are at the heart of both the literary and the medical act, and by extension, the ethical act. Post-workshop reflections from the Aristotle University Thessaloniki School of English narrative medicine seminar “Understanding Illness and Trauma through Narrative” (2013) indicate that narrative medicine calls readers and writers toward conscious engagement with the complexity of the other. Around the narrative medicine table, when physicians, writers, and literary scholars alike look and look again at a text, they are called to act, to engage with the real-world implications of those texts, and so to understand literary practice as real-world endeavor.

There is a contemporary dialectic concerning the status of evidence-based medicine, criticising it for being ‘scientistic’, epistemologically inconsistent, rigid and dismissive of non-numerical sources of knowledge. A host of alternative frameworks has been proposed, including values-based medicine, narrative medicine, patient-centered care and personcentered medicine. Person-centered medicine is amongst the most persuasive and well-argued models. Miles and Mezzich [1] have argued in a major article that person-centered medicine employs theories of personhood to elaborate and justify its epistemology and praxis. At the same time, they claim that person-centered medicine is an ‘emergent’ concept that needs no base or foundation to justify it. We believe, however, that without some foundational values to underpin the status claimed for personhood, the arguments for person-centered medicine are incomplete. We therefore propose a set of foundational values – survival, security and flourishing – that underpin individual and social functioning transculturally. While these values are the same in all cultures, their expressions differ from culture to culture. Importantly, our notion of values is only modestly foundational. Modest foundationalism recognises that foundational propositions are only ‘warrantable assertions’ that may very well change in time and place. Foundational values in this sense are pragmatic and heuristic in kind and not normative. We enter a plea for their recognition in the form of the values-based medicine we describe.

Evidence base medicine (EBM) is based on objective evidence, which provides best available knowledge for physicians to scientifically make medical and therapeutic decisions for the care of all individual patients in order to improve the effectiveness of treatment and to prolong the life of patients. EBM has made a significant progress in clinical practice. But medical therapies cannot always bring a better life quality and clinically, patients' preference should be always taken into account. Value-based medicine medicine (VBM) is the practice of medicine that emphasizes the value received from an intervention. It takes evidence-based data to a higher level by combining the parameters of patient-perceived value with the cost of an intervention. The fundamental instrument of VBM is cost-utility analysis. VBM will provide a better practice model to evaluate the therapeutic package and cost effectiveness for individual and general health care.

Medicine in the twenty-first century faces an 'identity crisis,' as it grapples with the emergence of various 'ways of knowing,' from evidence-based and translational medicine, to narrative-based and personalized medicine. While each of these approaches has uniquely contributed to the advancement of patient care, this pluralism is not without tension. Evidence-based medicine is not necessary individualized; personalized medicine may be individualized but is not necessarily person-centered. As novel technologies and big data continue to proliferate today, the focus of medical practice is shifting away from the dialogic encounter between doctor and patient, threatening the loss of humanism that many view as integral to medicine's identity. As medical trainees, we struggle to synthesize medicine's diverse and evolving 'ways of knowing' and to create a vision of doctoring that integrates new forms of medical knowledge into the provision of person-centered care. In search of answers, we turned to twentieth-century philosopher Hans-Georg Gadamer, whose unique outlook on "health" and "healing," we believe, offers a way forward in navigating medicine's 'messy pluralism.' Drawing inspiration from Gadamer's emphasis on dialogue and 'practical wisdom' (phronesis), we initiated a dialogue with the dean of our medical school to address the question of how medical trainees and practicing clinicians alike can work to create a more harmonious pluralism in medicine today. We propose that implementing a pluralistic approach ultimately entails 'bridging' the current divide between scientific theory and the practical art of healing, and involves an iterative and dialogic process of asking questions and seeking answers.

Literature helps: listening to the narrative of medicine

Background Narrative medicine has been applied as a model for humane medical practice in many countries. However, it was not introduced in China until 2011 and there has been no standardized assessment of Chinese medical personnel regarding their perception and application of narrative medicine-related theories. This study is aimed at investigating Chinese medical personnel's knowledge, attitude, and practice regarding narrative medicine and the factors that influence it. Methods An online questionnaire based on the knowledge, attitude, and practice model was distributed among Chinese medical personnel from December 2021 to March 2022. All in-service medical personnel across China who had access to the Internet were eligible. Two independent samples t-tests, one-way analysis of variance, Pearson's correlation analysis, and multivariate linear regression were conducted for data analyses. Results The participants' scoring rates for knowledge, attitude, and practice were 49.62%, 47.18%, and 41.43%, respectively. Significant influencing factors for knowledge were education level, religious belief, professional role, title, working years, and institution categories; those for attitude were education level, religious belief, professional role, and working years; and those for practice were professional title, religious belief, working years, and institution categories. Conclusions Chinese medical personnel have generally good knowledge of, attitudes towards, and practice of narrative medicine; however, there remain deficiencies in their understanding of certain important concepts, their attitude towards narrative medicine, and the application of narrative skills in their daily work. Thus, to improve narrative medicine practice in China, the application of strategies based on theoretical, educational, and institutional aspects is warranted.

ARDEO: Chronicling the Lived Experience of Injury from Patient to Physician to Public Jules Odendahl-James (bio) Narrative medicine posits that a healthcare professional’s medical knowledge and practice are enriched by their study of and investment in narrative theory and practice.1 While the specifics of this claim are still being studied, debated, codified, and challenged, it has become a widely accepted truism among narrative medicine proponents that the patient’s experiences, conveyed via stories, anecdotes, or other means of self-portraiture, provide key, credible evidence of a medical condition’s appearance, treatment, recovery, and endurance. Rather than a text to be read, studied, and categorized, the patient in the narrative medicine view is a dynamic force who shapes the form, content, and reception of what becomes a shared story of an injury or illness with a collective protagonist, whether patient, caregiver, or healthcare professional. Narrative medicine embraces the personal, the subjective. Such a position is not without risk; clinical standards for healthcare and practice are rigorously maintained and regulated for good reason. In search of remedy or relief, we want scientific certainty, not doubt. Narrative medicine, however, argues that the turn to story, to personal experience, does not exist in opposition to scientific rigor, but rather is another domain of attention that provides both patient and physician a fuller picture of what illness or injury is based on its lived conditions. Rita Charon, one of the leading authors, proponents, and instructors of narrative medicine practices, argues that educating physicians about narrative through literary coursework and writing exercises, including those that might comprise the medical record, helps them “follow the patient’s narrative thread, identify the metaphors or images used in the telling, tolerate ambiguity and uncertainty as the story unfold[s], identify the unspoken subtexts, and hear one story in the light of others” (2008, 4). Expanding on this idea, Claire Charlotte McKechnie notes that narrative medicine is wise to consider “narrativity” broadly, with particular attention on elements of non-verbal communication important to theatre/performance practitioners: non-verbal expression requires language and narrative ordering in the construction of expression and in the process of meaning-making. Each time we make an effort to produce an expression of suffering, we demand a cognitive engagement that requires the ordering [of ] information into narrative. We seek out communication; we desire the transmission of an idea. This is narrativity and it takes a myriad of forms. (123) If diagnosis teaches a physician anything, it is how much individual variance of expression exists within a standard set of symptoms. Diagnosis also illuminates the difficulty of communicating and deciphering the often incomplete and inconsistent experiences of those symptoms. Popular culture, by contrast, teaches very different lessons about scientific reasoning. The “people lie, evidence doesn’t” mottos of shows like House, M.D. and Crime Scene Investigation depict a world in which infallible experts use clinical precision, emotional detachment, and high-tech instruments to expose patients’ and suspects’ deceptions (whether intentional or not). Narrative medicine seeks to bridge this false divide between certainty and ambiguity, thus relieving the physician from God-like omniscience and authority and empowering the patient to assert their personal experiences as central pieces of evidence on par with the givens of a diagnostic chart. [End Page E-5] Jacqueline Lawton’s ARDEO is a short play rooted in these principles of narrative medicine. While it demonstrates elements of documentary theatre—dialogue built from interviews and historical and disciplinary research—it is a poetic rendering of the flow of action in which patients, caregivers, and healthcare providers move at the North Carolina Jaycee Burn Center. Actors embody the sights and sounds of the unit, as well as the individual patients, caregivers, and medical personnel. We look into individual faces as they tell of heartbreak, terror, and courage, and then they morph into a backdrop of activity that crackles with the pressure of medical assessment and treatment. Such a pressurized environment then shifts into the patients experiencing the slower, difficult pace of recovery, only to stir and drive forward again with conflict over new complications and new realities post-injury. Theatre, unlike other long-form narrative structures, allows Lawton to give...

The process of thinking about stories forms the foundation of literary scholarship, particularly for narrative theorists, whose primary academic endeavour is to contemplate and theorise about the multitudinous forms and functions of narratives. The systematic analysis of narratives has also been promoted within the field of medical education as a means of stimulating medical students’ professional development by teaching them to approach their patients’ stories with more understanding and compassion. Arthur Frank – doctor, cancer survivor, and writer – makes the argument that we can do this by first helping our medical students gain more practical wisdom, or phronesis. This chapter intends to explore the ways in which narratives can contribute to phronetic growth by examining both a literary text and its reported impact on readers. It will begin with a brief overview of how the overlapping academic fields of narrative ethics and narrative medicine can contribute to our understanding of an ethics of and while reading. These theoretical clarifications will, in turn, inform a brief analysis of Paul Kalanithi’s memoir When Breath Becomes Air (2016). In order to illustrate just how Kalanithi’s illness narrative can impact and transform aspiring medical practitioners’ practical wisdom and developing ethos, this chapter will close with a brief analysis of Dutch medical students’ discussion of the narrative during a graduate-level reading seminar.