"An invitation to think differently": a narrative medicine intervention using books and films to stimulate medical students' reflection and patient-centeredness.

BACKGROUND: Narrative medicine purports to improve medical students' communication skills, self-reflection, empathy and professional development. These interpersonal skills and attitudes can facilitate more patient-centered care and positively impact patients' treatment outcomes. However, current studies report mainly on small study populations, leaving the efficacy of narrative medicine in larger study groups unknown. Therefore, this study aimed to evaluate a mandatory narrative medicine lesson in a large sample of medical students. We assessed if this narrative medicine lesson stimulated meaningful self-reflection on patient-centeredness in medical students. METHODS: All fourth-year medical students of a Dutch medical school participated in this mandatory narrative medicine lesson. The four-step activity consisted of an introductory lecture, close reading and watching of a book and film, a discussion group and a short reflective writing exercise. Students were divided over three thematic pairings (or book and film combinations): 'The doctor as a patient,' 'The mysterious brain,' and 'Until death do us part.' A mixed-methods design was used. First, we qualitatively analyzed the content of 203 essays from the reflective writing exercise. A quantitative analysis of the reflective quality was conducted using a scoring-system based on the REFLECT rubric. RESULTS: Students demonstrated reflection on a professional level and connected this to future intentions as medical practitioners, for example to use specific communication strategies or to deliver healthcare in a broader sense. They also reflected on a personal level by questioning their own worldview or beliefs. Furthermore, they stressed the importance of individual patient stories to gain understaning of patients' perspectives. Approximately half of the students showed an in-depth and authentic reflection, according to the REFLECT rubric. Additionally, reflection levels differed between book and film pairings. CONCLUSIONS: This study supports the value of narrative medicine in the medical curriculum by validating its outcomes in a larger study population and in a mandatory course. Students reflected on themes related to the principles of patient-centeredness, namely personal attitudes towards patients and the uniqueness of patient stories. In additon, the majority of students demonstrated higher levels of reflection, which suggests that this exercise contributes to self-awareness and self-reflection, important qualities for delivering patient-centered healthcare.

Fostering patient-centredness by following patients outside the clinical setting: an interview study.

BACKGROUND: Patient-centredness is considered a core competency for health professionals. To support faculty in designing courses focused on patient-centredness, an understanding of how educational interventions lead to patient-centredness is required. This study aims to show how learning mechanisms, which potentially contribute to patient-centredness, are triggered. METHODS: Thirty-five third-year medical students at the UMC Utrecht followed four different patients for two years. The intervention took place in an out-of-hospital setting. Students visited patients in their home circumstances and accompanied them to clinical events. Twelve students were interviewed. The realist approach was used to construct configurations which relate components of the intervention to the context and learning mechanisms. RESULTS: Following patients in their home circumstances for a prolonged period supported the development of meaningful relationships between students and patients and provided continuity. In the context of a meaningful relationship and continuity, mechanisms contributing to learning patient-centredness were triggered. The most important learning mechanisms found in this study were: reflecting, contextualising disease in a real persons' life, broadening perspectives and engaging with the patients. CONCLUSIONS: Learning mechanisms are triggered by continuity and by meaningful student-patient relationships. These can be enhanced by an out-of-hospital setting and longitudinal contact. Thus, a relationship between students and patients is an important enabler for the development of patient-centredness.

Clinical characteristics and genetic analyses of 187 patients with undefined autoinflammatory diseases.

OBJECTIVES: To describe the clinical characteristics, treatment response and genetic findings in a large cohort of patients with undefined systemic autoinflammatory diseases (SAIDs). METHODS: Clinical and genetic data from patients with undefined SAIDs were extracted from the Eurofever registry, an international web-based registry that retrospectively collects clinical information on patients with autoinflammatory diseases. RESULTS: This study included 187 patients. Seven patients had a chronic disease course, 180 patients had a recurrent disease course. The median age at disease onset was 4.3 years. Patients had a median of 12 episodes per year, with a median duration of 4 days. Most commonly reported symptoms were arthralgia (n=113), myalgia (n=86), abdominal pain (n=89), fatigue (n=111), malaise (n=104) and mucocutaneous manifestations (n=128). In 24 patients, relatives were affected as well. In 15 patients, genetic variants were found in autoinflammatory genes. Patients with genetic variants more often had affected relatives compared with patients without genetic variants (p=0.005). Most patients responded well to non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, colchicine and anakinra. Complete remission was rarely achieved with NSAIDs alone. Notable patterns were found in patients with distinctive symptoms. Patients with pericarditis (n=11) were older at disease onset (33.8 years) and had fewer episodes per year (3.0/year) compared with other patients. Patients with an intellectual impairment (n=8) were younger at disease onset (2.2 years) and often had relatives affected (28.6%). CONCLUSION: This study describes the clinical characteristics of a large cohort of patients with undefined SAIDs. Among these, patients with pericarditis and intellectual impairment appear to comprise distinct subsets.

Twelve tips for patient involvement in health professions education.

Moving towards person-centered care, with equal partnership between healthcare professionals and patients, requires a solid role for the patient in the education of students and professionals. Patients can be involved as teachers, assessors, curriculum developers, and policy-makers. Yet, many of the initiatives with patients are isolated, small events for targeted groups and there is a lack of patient involvement at the institutional level. To support educators in involving patients, both at the institutional level and at single educational encounters, we offer twelve practical tips. This paper came about through an innovative collaboration between healthcare professionals, educators, teachers, and patients. These tips can be used as a tool to start or reinforce patient involvement in health professions education and provide guidance on how to make it a sustainable part of the curriculum. The article involves organizational conditions for success, tips for sustainable partnerships, ideas for curriculum design and proposes concrete teaching strategies. Finally, besides practical tips, we stress that involving patients in education is not business as usual, and paradoxically this needs to be acknowledged before it can become business as usual.