An introduction to narrative medicine

Communication is an integral part of the journey to build trust in a patient-provider relationship as well as an essential skill in providing effective care. Studies of patient-provider relationships have shown a direct correlation between improved communication and several desirable health outcomes: increased medication compliance, improved cardiovascular outcomes, heightened patient satisfaction, and overall health status improvement.[1,2,3] However, as the medical system becomes more complex, and physicians are increasingly burdened with its nuances, the communication gap between physicians and patients may widen.[4] While physicians are knowledgeable about disease processes, they may have an emotional disconnect toward the impact of the disease on the patient.[5] This may lead to a rift within the patient-provider relationship and ultimately hurt patient care. Patients may also fail to realize the impact of the disease on the physician or healthcare provider. When faced with an incurable illness, physicians may feel powerless with limited treatment options.[6] However, in the past decade, there emerged a new focus on how the disease may affect the human psyche. Narrative medicine provides a meaningful way to not only highlight the scientific but also the psychosocial impact of human disease. Ultimately, narrative medicine enables healthcare to bridge the disconnect between patients and physicians.[7] In that sense, narratives can be understood as the bridge between the evidence of large scale randomized - controlled studies and the medical art of applying this knowledge to a single case. Evidence based medicine (EBM) and narrative based medicine (NBM) thus must be understood in complementary terms.[8] Narratives have been used to tell stories, record history, and provide education since ancient times. In The Republic, Plato describes the development of an educational curriculum for warriors, which is focused on the use of stories. In the context of education, narratives in medicine are relatively new.[9] There exist various interpretations, with no universally accepted definition.[5] Originally, as well was first used to refer to patient narratives, but more recently has been used to describe multiple kinds of narratives as well [Table 1]. Narrative medicine was first introduced by Dr. Rita Charon in a 2001 JAMA article, and later expanded on in her original book, Narrative Medicine: Honoring the Stories of Illness.[5,10] In the book, Charon emphasizes the importance of listening to patient narratives to improve patient care.[11] Narrative medicine is an integrative approach that enables medical students, for example, to reflect on their particular experiences with patients, further allowing them to engage with their patients more personally and to reflect on the impact of the disease.[11] From a patient perspective, telling one's story enables a person to describe the impact of their disease to the physician, leading to individualization and confirmation of the patient's self-reflection.[12] Since Dr. Charon and her colleagues introduced the concept, narrative medicine has garnered an increasing level of support, with a number of conferences and formal education programs now offered. Programs in narrative medicine are Columbia University at major university programs, including Lewis Katz School of Medicine at Temple University, Albert Einstein College of Medicine, and the University of Western Ontario, among others.Table 1: Types of narrativesNarrative medicine has grown to include several specific aspects that distinguish it as a separate discipline.[13] First, instead of data collection to form a diagnosis, the emphasis is placed on a more humanistic approach. By making the illness a story, the patient can better describe the impact of the illness on their life.[14] This involves active listening by the provider, letting the patient describe the effect of their illness, and in the process of listening, enabling the physician to both develop and demonstrate empathy toward the patient.[14] Narrative medicine also places emphasis on reflection.[7] Reflection allows the physician to describe their experiences with the patient, thus permitting them to better improve future interactions with patients and develop themselves professionally and personally.[7] Finally, narrative medicine fosters creativity. By utilizing listening as a diagnostic tool, it allows the listener to create their own inferences about the patient's story, and how the disease has impacted them. The provider can take an active role in the patient's care beyond just objective data gathering.[15] While narrative medicine has demonstrated a significant impact in various studies, its implementation into routine clinical medicine has not yet occurred.[16] This is likely due to time constraints, lack of understanding regarding the discipline of narrative medicine, and a lack of exposure to the topic. In this special issue, we wish to highlight the utility of narrative medicine, especially during the ongoing pandemic of COVID-19. Several clinical scholars have submitted narratives in this special issue, bringing to light the impact that patients' stories have had on their personal and professional experiences. The authors' level of training, specialty, and geographic location are as diverse as their stories. A team of clinicians watching over the same patient will often tell a different story; but in their individual telling, we may read similar phrases uttered, questions raised, and common themes woven across the pages of their different stories, such as emotional stress, fear, isolation, hopelessness, self-sacrifice. Their personal narratives remind us that our individual encounters in healthcare are often a product of our shared experiences. The stories are a reflection of our humanity and our need to connect during an isolating time. This issue hopes to coalesce healthcare and storytelling to give us insight into the human condition of both patients and medical providers – something the study of health humanities has been promoting and teaching since the 1930s.[17] This issue also allows us to gain insight about the pandemic through self-reflection. The articles highlight how COVID-19 has blurred the lines between personal and professional, life and death, hero and victim, right and wrong. These stories not only explore providers experiences with patients, but also their experiences as parents, spouses, friends, and family members. These “clinician” stories are not separate from their personal stories; even when we try to separate the personal from the professional, the balance we strive for is rarely achieved. The authors' work-home identities have become rather fluid and ever-changing during this pandemic, and the authors acknowledge that the demarcation between personal-professional boundaries is not so easily fixed. The authors' identities frequently bleed into one another, and the structured relationship between who is labeled “provider” and who is labeled “patient” is broken. Ultimately, we want our readers to become aware that narrative medicine is not about what it means to be a clinician, but ultimately, what it means to be human.