Narrative medicine

Rita Charon first used the phrase “narrative medicine” in 2000 to refer to clinical practice fortified by narrative competence [7]. Narrative medicine is medicine performed with narrative skill and offered as a model for humanism and effective medical practice, illuminating medicine’s crucial narrative relations: physician and patient, physician and self, physician and colleagues, and physicians and society [6, 8]. Such narrative skill can be developed through engaging in one’s own narrative reading and writing episodes, particularly through expressive writing: “Building a narrative, then, may be critical in reaching understanding or knowledge” [9]. The development of narrative skill can also include listening to stories of patients, self- reflection, and reflection on the profession as a whole, or even on society as a whole [8, 10].

For physicians, narrative medicine is therefore thought to be a good way to understand the personal connections between themselves and their patients [6]. It is believed to help physicians recognize, interpret, and be moved to action by the problems of others and develop confidence and competence while identifying the conflicts they face [6]. Narrative medicine practitioners assert that physicians are able to link to their patients with narrative competence; further understanding their own personal journeys through medicine; recognise empathy with, and responsibilities toward, other health care professionals; and engaging in meaningful discussions with the public about health care [11]. By connecting physicians to patients, colleagues and society, narrative medicine is thought to provide new opportunities for respectful, empathic, and nourishing medical care [12–14].

Medical students’ reactions to narrative medicine

Research suggests that there is a benefit for physicians-in-training and surgical residents to engage patients, to elicit their story in the context of illness and to undertake reflection through narrative writing [15, 16]. Furthermore, medical students believe narrative medicine to be an important, effective, and counter-cultural means of enhancing their communication, collaboration, and professional development by supporting complex interior, interpersonal, perceptual and expressive capacities [17, 18]. Indeed, an experiential narrative medicine curriculum for medical students involving patient storytelling and group reflection was found to be feasible and acceptable to both patients and students, with some patients and students being profoundly moved by the experience [19]. However, studies examining the impact of narrative medicine training have predominantly been conducted within a Western medicine perspective, even when the research context itself comprises a non-Western setting [20]. Furthermore, even research that includes a mixture of students studying Western and Chinese medicine has failed to examine differences between these two groups [21]. As such we do not know whether the concept of narrative medicine will be equally well received across these different medical cultural contexts.

Differences between Western and traditional Chinese medicine

Western medicine uses a reductive and analytical approach, while Chinese medicine uses an inductive and synthetic approach. Chinese medicine, however, lacks proper diagnostic tools, whereas Western medicines’ strength is its powerful diagnostic ability [22]. Thus, Western medicine is based on standards and evidence, with Chinese medicine relying on experience over time through numerous trials and clinical observations [22, 23]. In short, while Western medicine is a standardized and evidence-based science, Chinese medicine is experience-based and more of a healing art [22].

Traditional features of Chinese medicine

The ancient medical scientists within traditional Chinese medicine explain the phenomenology of human physiology, pathology-based Yin and Yang and summarize the medical experience. Chinese medicine has taken the human body as a whole, from the key concepts of “qi, blood, yin-yang, viscera (Zang-Fu), and meridian and channel”, rather than a single cell or a particular organ [23]. In Chinese medicine, disease is not viewed as something that a patient has, but something that the patient is. Disease is considered as an imbalance in the patient’s being. There is only a whole person whose body functions may be balanced or imbalanced, harmonious or disharmonious. Thus, understanding the nature of the imbalance is the goal of diagnosis, while restoring balance is the focus of treatment [22]. This suggests that people studying Chinese medicine might therefore have a different world-view than those studying medicine within a Western framework, and this world-view might impact on how they engage with different aspects of their curricular, including narrative medicine activities.

This study aims to fill the gap in current literature by comparing Western and Chinese Medicine students’ perceptions of narrative medicine as an approach to learning empathy and professionalism. We specifically asked the following research question: Are there any differences in the perception of a narrative medicine programme between Western and Chinese Medicine students during a pre-doctor clerkship?

Context

The context of this study is a large teaching hospital in Taiwan. Western medical students (MS) have a 7-year undergraduate programme [24]. During the first 2 years, they not only have fundamental courses that provide an introduction to medicine, but they also have courses related to general education, such as information technology, art and literature. In the following 2 years, they have the opportunity to learn further medical skills and knowledge. From Year 5, students have an opportunity to apply the knowledge they have gained in practice: each student completes a 2-year clerkship and a 1-year internship in hospitals so they can master all the required techniques and know-how of patient care.

Traditional Chinese medical students (TCMS) have an 8-year undergraduate programme. The characteristic of the Department of Traditional Chinese Medicine is the teaching of both Chinese and Western medicine. The courses offered include Basic Education, General Education, Basic Education of Chinese and Western Medicine, Clinical Education of Chinese and Western Medicine, Practice of Western Medicine (7th year), and Practice of Chinese Medicine (8th year). In order to develop the students’ life-long learning ability, problem oriented teaching is added to the courses in coordination with the General Education. This course focuses on the nurture of personalities with the aim of developing excellent doctors with ability and moral integrity in a combination of both Chinese and Western medicine. Thus, when they are in a practice environment, they are more aware of the health attitudes of their patients from different ethnic backgrounds, leading to a better patient-doctor relationship and better adherence with treatment [25].

The narrative medicine model was introduced into the clerkship program of 5th-year clerks, for both MSs and TCMSs. Using a narrative approach, clerks write about daily clinical events and encounters, their struggles and their accomplishments without the critical eye of the preceptor, the attending or their seniors.

Study methods and participants

A three-cohort cross-sectional questionnaire study design was used. The questionnaire comprised a 10-item survey instrument administered using a 5-point Likert scale (strongly disagree to strongly agree). Ethical approval was obtained from the Chang Gung Memorial Hospital and Chang Gung University Institutional Review Boards (IRB No. 102-4138B, No.103-1755B, 105-2716C, 106-1287C) and participation in the study was voluntary.

Three factors identified: Personal attitude, self-development/reflection, emotional benefit

On the basis of the characteristics of the items that constituted each factor, the first factor was interpreted as “personal attitude” (4 items), the second as “self-development/reflection” (3 items) and the third as “emotional benefit” (2 items). Students’ responses to this 9-item questionnaire yielded a Cronbach alpha measure of reliability equal to 0.934. Cronbach’s alpha coefficients for each subscale were 0.92, 0.85, and 0.72 respectively.

For the three-factor model, the mean and standard deviation scores of subscales personal attitude, self-development/reflection, and emotional benefit were 3.35 ± 0.995, 3.82 ± 0.871, and 3.19 ± 1.056 respectively.

Western versus Chinese medical student differences

Strengths and weaknesses of the study

This study, recruiting clerks from different training programs (MSs and TCMSs), obtained a high response rate and analyzed data collected at the end of a 13-week long study employing prompted narrative medicine. The current study is unique, being the first to examine the perceptions of narrative medicine between two different groups of medical students: MSs and TCMSs.

There are some limitations to this study. First, the study was surveyed in an internal medicine rotation only, but not in pediatrics, or surgical systems such as surgery or gynecology. Although this work was carried out in two separate groups of clerks, caution should be taken in generalizing the findings to other medical trainees apart from the Department of Traditional Chinese Medical. Secondly, our MSs or TCMSs followed a prospective-based program on clerkship narrative medicine, however they could not be randomized. For the purposes of data analysis, we did not hypothesize that their choice of specialization would be a significant contributing factor. Nevertheless, this is unlikely to be an important factor as the students were from two different groups. Thirdly, as previously mentioned, there is the possibility that the two programs of medical education may attract different kinds of students: Chinese medicine might seem more suitable for holistic thinkers who could be more open to the humanities. As such this could be a possible contributor to the differential impact of the narrative medicine course. Finally, narrative medicine as a teaching practice has been criticized as being too naïve a use of ‘reflective practice’ in pedagogy [39, 40]. Indeed, the key issues that underpin how such practices can be valuable are far more complex than could be captured in this single study. Thus further studies are needed to better understand the differences between MS and TCMS groups of students in their engagement with, and reactions towards, narrative medicine.

Suggestions for practice

The act of narrative writing involves thinking explicitly about a thought, experience, or action and has profound implications for medical education [41, 42]. Thus, educators may consider incorporating narrative writing into their curriculum to promote humanism since it may be difficult for young pre-doctors to feel, understand, and think about humanistic situations. For medical students, narrative medicine may be a good complement to the philosophies of a bio-psychosocial approach and patient-centered practice and could be brought in at an earlier point in the curriculum for Western medicine students as an ‘antidote’.

The most important aspect of narrative writing is to review one’s assumptions or beliefs to enhance self-awareness. A medical student’s journey through the healthcare system is often difficult and accompanied with self-doubts and frustration. Although we have not found our narrative medicine course to be best at relieving their own grief or pressure, our hope is that by having the clerks begin writing about their experiences, they will gain a sense of themselves through reflection over time and, through the sharing of stories, see that others feel the same or similar to themselves.

Suggestions for future research

In this study, three factors were extracted: personal attitude, self-development/reflection, and emotional benefit. We also found that the perceptions of narrative medicine were significantly higher in the TCMS than the MS group. However, definitions and actualisations of narrative or narrative medicine are often broad. Indeed, what lies within the ‘black box’ of narrative medicine needs to be better explored [43–45]. Despite the different learning cultures of medical education in which these student groups engage can partially explain our results, we do not fully understand what it is about narrative medicine that works, for whom, and why across different learning culture contexts, As such, the impact of learning cultures deserves to be further studied in order to explore the complex interactions and to develop a transferable theoretical model of what works, for whom and why [46]. In this way, not only will we understand similarities and differences between Chinese and Western medical students learning with narrative medicine processes, we will also be able to tailor educational strategies to promote narrative medicine into early pre-doctoral medical education for specific groups and further enhance reflection and humanism.