Exploring perception and usage of narrative medicine by physician specialty: a qualitative analysis.

BACKGROUND: Narrative medicine is a well-recognized and respected approach to care. It is now found in medical school curricula and widely implemented in practice. However, there has been no analysis of the perception and usage of narrative medicine across different medical specialties and whether there may be unique recommendations for implementation based upon specialty. The aims of this study were to explore these gaps in research. METHODS: Fifteen senior physicians who specialize in internal medicine, pediatrics, or surgery (5 physicians from each specialty) were interviewed in a semi-structured format about the utilization, benefits, drawbacks (i.e., negative consequences), and roles pertaining to narrative medicine. Qualitative content analysis of each interview was then performed. RESULTS: Three themes emerged from our analysis: roles, practice, and outcomes. Through these themes we examined the importance, utilization, barriers, benefits, and drawbacks of narrative medicine. There was consensus that narrative medicine is an important tool in primary care. Primary care physicians (general internists and general pediatricians) also believed that narrative medicine is not as important for non-primary care providers. However, non-primary care providers (surgeons) generally believed narrative medicine is valuable in their practice as well. Within specialties, providers' choice of language varied when trying to obtain patients' narratives, but choice in when to practice narrative medicine did not differ greatly. Among specialties, there was more variability regarding when to practice narrative medicine and what barriers were present. Primary care physicians primarily described barriers to eliciting a patient's narrative to involve trust and emotional readiness, while surgeons primarily described factors involving logistics and patient data as barriers to obtaining patients' narratives. There was broad agreement among specialties regarding the benefits and drawbacks of narrative medicine. CONCLUSIONS: This study sheds light on the shared and unique beliefs in different specialties about narrative medicine. It prompts important discussion around topics such as the stereotypes physicians may hold about their peers and concerns about time management. These data provide some possible ideas for crafting narrative medicine education specific to specialties as well as future directions of study.

Comprehensive and Equitable Care for Vulnerable Veterans With Integrated Palliative, Psychology, and Oncology Care.

OBJECTIVE: Veterans who live with cancer need comprehensive care. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer guidelines recommend evaluating distress and providing appropriate follow-up to all patients with cancer. METHODS: We created patient-centered, collaborative clinics to screen for and address cancer-related distress. Medical oncologists received education about available supportive services and instructions on how to make referrals. Participants completed the Coleman Supportive Oncology Collaborative screening questions. RESULTS: Patients in this outpatient US Department of Veterans Affairs medical oncology clinic were primarily older, African American men. Most veterans screened positive for ≥ 1 type of cancer-related distress. Patients screened for high levels of distress received in-person clinical follow-up for further evaluation and to make immediate referrals to supportive care services. CONCLUSIONS: We evaluated patients' needs, made referrals as needed, and helped bring care directly into the oncology clinic. Using a screening tool for cancer-related distress and managing distress with integrated psychosocial providers could improve care coordination and enhance patient-centered supportive oncology care, especially for high-risk patients. A full-time social worker was integrated into the medical oncology clinics based on our program's success.

Goal-Concordant Care in the Era of Advanced Stroke Therapies.

Stroke is a leading cause of disability and mortality worldwide. Recent advances in stroke care now enable patients with severe ischemic stroke owing to large vessel occlusion to safely undergo endovascular thrombectomy (EVT) up to 24 hours since their time of last known well, with the goal of improving functional outcomes by recanalization of the occluded vessel and reperfusion of downstream ischemic brain tissue. The objective of this analysis is to highlight clinical and ethical challenges related to ensuring goal-concordant care in this era of unprecedented advances in acute stroke care. Specifically, there is a salient challenge of whether advanced therapies such as EVT may be justifiably considered comfort focused, given their potential to preempt accumulated neurologic disability and suffering at the end of life. Through the lens of a patient case, we discuss key challenges, lessons learned, and suggestions for future care and research endeavors at the intersection of acute stroke care and palliative care principles. Although therapies such as thrombolysis and EVT may be considered aggressive prima facie, their potential to ameliorate additional disability and potential suffering at the end of life prompt close consideration of the proper role of these therapies on a case-by-case basis in the context of comfort-focused care. Modification to the workflow for EVT evaluations may facilitate goal-concordant care and timely resource allocation, especially for cases that involve hospital-to-hospital transfers for advanced stroke care.

Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs.

Objective: To describe museum-based education (MBE) as an emerging pedagogy in our four hospice and palliative medicine (HPM) training programs. Background: MBE is a pedagogy that uses art and the museum space to promote a variety of skills, including reflective practice, self-awareness, and interprofessional teamwork. While MBE has been extensively applied and studied in undergraduate medical education, it is not a common educational strategy in HPM education. Methods: We summarize the characteristics of MBE initiatives in our institutions, including makeup of fellowship class, MBE site, facilitators, exercises, number of sessions, number of years using MBE, and expenses and funding to support MBE in our training programs. Results: To date, we have used MBE to train 104 HPM fellows. Evaluations from MBE have been overwhelmingly positive. Conclusion: MBE holds great promise as a pedagogic strategy to improve metacognition, tolerance of uncertainty, appreciation of multiple perspectives, and teamwork among hospice and palliative care professionals. Further research is needed to identify best practices for MBE across HPM training programs.

Lost in transition: the ethics of the palliative care handoff.

In the palliative care setting, patients and families may experience transitions of care between home and different care facilities. These handoffs between care teams and settings are opportunities for miscommunication about many aspects of care. Specifically, clear, concise, and accurate information about patients' preferences and goals may not be a part of these transitions. This article presents a case where preferences were unclear and unclearly communicated and the patient received care that was likely contrary to his goals. Suggestions are made for mechanisms that may increase the likelihood that information about goals of care and preferences is clearly communicated during these transitions.