Contrasting epistemologies: Biomedicine, narrative medicine and indigenous story medicine.

BACKGROUND: Narrative Medicine (NM) and Indigenous Story Medicine both use narrative to understand and effect health, but their respective conceptualizations of narrative differ. AIMS: I contrast the concept of narrative in NM with that of Indigenous Story Medicine. MATERIALS AND METHODS: The article relies Western narrative theorists as well as Indigenous epistemologists to frame a discussion-by-contrast of the Judeo-Christian creation myth with a Haundenosaunee Creation Story. RESULTS: I demonstrate that the deficiencies of Narrative Medicine exist because the latter's use of narrative is a mere application in an otherwise reductive field, whereas Indigenous epistemologies rely on story as medicine itself. DISCUSSION: OMIT. CONCLUSION: I call for more scholars to take up different narratives to further investigate the ethical space between NM and Indigenous Story Medicine.

As 'synapses' become 'protoplasmic kisses': Symmetry across clinical reasoning and poetry.

CONTEXT: We argue that biomedicine at root is not primarily instrumental, but shares aesthetic, ethical and political values with poetry. Yet an instrumentalist bias in medical pedagogy can lead to frustration of biomedicine's potential. Such unfulfilled potential is exposed when making a comparison with poetry, a knowledge system that expressly engages a range of value systems. How then to recover biomedical language's riches for medical education's gain? METHODS: We combine scientific and artistic approaches by positing a common frame to which both medicine and poetry can aspire: the 'high-water mark' of language. Poetry's language is complex, intensive and connotative-concerned with mood, ambiguity, metaphor and embodiment. Biomedicine potentially engages with such linguistic complexities, particularly in metaphor production, yet persistently falls away from this high-water mark of language, reducing connotative language to denotation or literal meanings. We describe such instances of frustrated potential as 'trying to accelerate with the brake on'. This paradoxical state has become habitual in medical education. The resultant lack of productive metaphor insulates pedagogy from mood, separating it from the vernacular as a specialist tongue that ensures identification with the medical community of practice. Such language can alienate both patients and poets for the same reason: it is less human than technical. CONCLUSIONS: Using the example of clinical reasoning and attendant diagnostic work, we show that reductions from the connotative to the denotative not only mask but also contradict the complexity of implicit, embedded and distributed cognitive structures, creating a tension that medical education consistently fails to either resolve or draw upon as a resource. Further, poetry too has a complex set of implicit rules and formative structures that shape composition. These structures show symmetry, correspondence or even isomorphism with medical cognition, where both can aspire to activity that is aesthetically rich, intense and cognitively elegant.

Physicians' perspectives on processes for emergency mental health transfers from university health clinics to hospitals in Ontario, Canada: a qualitative analysis.

BACKGROUND: In Ontario, Canada, there is variability in how students experiencing a mental health crisis are transferred from university health clinics to hospital for emergent psychiatric assessment, particularly regarding police involvement and physical restraint use. We sought to understand existing processes for these transfers, and barriers to and facilitators of change. METHODS: Between July 2018 and January 2019, we conducted semistructured qualitative interviews by telephone or in person with physicians working at Ontario university health clinics. We developed the interview guide by integrating an extensive literature review, and the expertise of stakeholders and people with lived experience. We analyzed the interview transcripts thematically. Analysis was informed by participant responses to a questionnaire exploring their perspectives about crisis transfer processes. We requested institutional policy and process documents to support analysis and generate a policy summary. RESULTS: Eleven physicians (9 family physicians and 2 psychiatrists) from 9 university health clinics were interviewed. Ten of the 11 completed questionnaires. Policy and process documents were obtained from 5 clinics. There was variation in processes for emergency mental health transfers and in clinicians' experiences with and beliefs about these processes. Police were commonly involved in transfers from 7 of the 11 clinics, and in nearly all or all transfers from 5 of the 11 clinics. Handcuffs were always or almost always used during transfer at 2 clinics. Three major themes were identified: police involvement and restraint use can cause harm; clinical considerations are used to justify police involvement and restraint use; and pragmatic, nonclinical factors often inform transfer practices. INTERPRETATION: The involvement of police and use of restraints in crisis mental health transfers to hospital were related to pragmatic, extramedical factors in some university health clinics in Ontario. Exploring existing variability and the factors that sustain potentially harmful practices can facilitate standard implementation of less invasive and traumatizing transfer processes.

A logical development: biomedicine's fingerprints are on the instrument of close reading in Charonian Narrative Medicine.

Narrative Medicine as originated by Rita Charon began as an attempt to redress the unopposed biomedicalisation of the medical profession. Although the movement has been self-positioned as a corrective to deliver an ideal of care, it began within the rhetorical framework of biomedicine and not outside of it. Thus, Narrative Medicine justifies itself in biomedical terms, invoking instrumental rationales for its use. This seeming 'scientification' of narrative is only half of the biomedicine-indebted Narrative Medicine story. An equally important but as-yet unmentioned debt is the quasi-scientific origin story of Narrative Medicine's signature method of close reading. Thus, there is an inherent paradox at the heart of the Narrative Medicine movement: designed to resist a reductive biomedicine, it exists in a dependent relationship on biomedicine at the level of justification and at the level of praxis. Thus, it is an open question if the Narrative Medicine movement is the proper vehicle for a rebalancing of humanities and biomedicine.

The politics of the surgical mask: Challenging the biomedical episteme during a pandemic.

COVID-19 has seen politicians use a selective 'science' to justify restrictions on mobility and association, to mandate the wearing of face masks, and to close public infrastructure. There seems to be no role for health humanities scholars as yet, but perhaps there should be. This paper considers the fate of a health humanities article on surgical mask use that was published in a biomedical journal in 2016. This article, which did not operate from within the biomedical episteme but which was in conversation with the episteme, was misappropriated on both sides of the political spectrum to justify personal beliefs around mask use in the pandemic. This mistaken misappropriation is not only evidence of the utility of the common ground shared between biomedicine and the health humanities, it is also evidence of the possibilities inherent in a future interdisciplinary involving biomedicine and the health humanities.

Understanding moral empathy: A verbatim-theatre supported phenomenological exploration of the empathy imperative.

OBJECTIVES: Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training. METHODS: Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences. Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy. RESULTS: The findings suggest that a resident's sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training. Importantly, these factors are rarely experienced as having a direct deleterious impact on residents' moral empathy but rather are experienced as challenges to their ability to act on their moral empathy. CONCLUSIONS: The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education.

Policies and procedures for patient transfers from community clinics to emergency departments under the mental health act: Review and policy scan.

OBJECTIVE: The objective of this commentary is to summarize the few findings from the scientific literature pertaining to humane mental health transfer practices in the province of Ontario as well as the broader Canadian and international context. These findings are juxtaposed with a policing policy scan concerning the Ontario and Canadian contexts. The practice of default restraint use during transfers is surprisingly widespread practice, despite advocacy to the contrary, and is presented as the consequence of stigma and the lack of codified restriction of restraint use by police in their policy guidelines. METHODS: (1) Literature search to discover relevant articles which were summarized using narrative review due to the lack of high-quality studies available in this area, and (2) Scan of publicly available policy documents in use by Ontario police agencies in March and April of 2018, as well as contacting several police agencies and community resources to review policies and procedures. RESULTS: We review the available evidence on the use and impact of restraints in patient transfer to emergency departments from police settings, highlight police practices in four Ontario jurisdictions, and summarize recommendations from police and mental health advocates regarding mental health transfers. DISCUSSION: Synthesizing the available evidence, policies, and procedures, we illustrate that the Ontario-wide variability in both who transfers PMI on a Form 1 to hospital and whether restraints are utilized reflect systemic failures to utilize least restrictive means of transfer. We offer a look at future areas of research and advocacy to improve practices in Canada.