Disability and narrative medicine: Challenges and opportunities.

Despite decades of international entreaties for improvement, education about and provision of healthcare for people with disabilities remains harmfully inferior to that of the non-disabled population. Many obstacles confound efforts to ameliorate this inequity, perhaps the most pernicious of which is negative bias on the part of providers. Narrative medicine offers a means to address healthcare attitudes towards people with disabilities, in particular negative attitudes based on 'ableism'. Through absorbing, writing, and sharing of diverse perspectives, narrative medicine kindles imagination and empathy, promoting self-reflection. This approach enriches the students' capacity to absorb what their patients are trying to say, and to appreciate, respect, and hopefully meet the healthcare needs of people with disability. WHAT THIS PAPER ADDS: Narrative medicine is a pedagogical tool to help providers listen and reflect on patients with disabilities.

COVID 19: Ethical dilemmas in human lives.

On 7 May 2020, Columbia University Global Centers hosted an online international symposium on ethical dilemmas during the COVID-19 pandemic. This interdisciplinary engagement between philosophers and Covid medical professionals reports the challenges as well as the discrepancies between ethical guidelines and reality. This collection of presentations identifies four key ethical dilemmas regarding responsibility, fairness, dignity and honouring death. In looking into accountability and consistency in medical humanities, it examines whether the contextuality of coronavirus across countries and cultures affected the ethical decision-making processes. This work aims to provide a seminal resource for the development of a high-quality roadmap in medical ethics for future health crises.

Reading the Self: Medical Students' Experience of Reflecting on Their Writing Over Time.

PURPOSE: To investigate students' experience (over time) with meta-reflection writing exercises, called Signature Reflections. These exercises were used to strengthen reflective capacity, as part of a 4-year reflective writing portfolio curriculum that builds on a recognized strategy for reflection (narrative medicine) and employs longitudinal faculty-mentors. METHOD: In 2018, the authors conducted 5 focus groups with 18 third-year students from the Columbia University Vagelos College of Physicians and Surgeons class of 2019 to examine students' experience with Signature Reflections. Using an iterative, thematic approach, they developed codes to reflect common patterns in the transcripts, distilled conceptually similar codes, and assembled the code categories into themes. RESULTS: Three core themes (safe space, narrative experience, mirror of self) and 1 overarching theme (moving through time) were identified. Students frequently experienced relief at having a safe reflective space that promoted grappling with their fears or vulnerabilities and highlighted contextual factors (e.g., trusted faculty-mentors, protected time) that fostered a safe space for reflection and exploration. They often emphasized the value of tangible documentation of their medical school journey (narrative experience) and reported using Signature Reflections to examine their emerging identity (mirror of self). Overlapping with the core themes was a deep appreciation for the temporal perspective facilitated by the Signature Reflections (moving through time). CONCLUSIONS: A longitudinal narrative medicine-based portfolio curriculum with pauses for meta-reflection allowed students, with faculty support, to observe their trajectory through medical school, explore fears and vulnerabilities, and narrate their own growth. Findings suggest that narrative medicine curricula should be required and sufficiently longitudinal to facilitate opportunities to practice the skill of writing for insight, foster relationships with faculty, and strengthen students' temporal perspectives of their development.

Implementing an interprofessional narrative medicine program in academic clinics: Feasibility and program evaluation.

Interprofessional education (IPE) is a critical component of medical education and is affected by the characteristics of the clinical teams in which students and residents train. However, clinical teams are often shaped by professional silos and hierarchies which may hinder interprofessional collaborative practice (IPCP). Narrative medicine, a branch of health humanities that focuses on close reading, reflective writing, and sharing in groups, could be an innovative approach for improving IPE and IPCP. In this report, we describe the structure, feasibility, and a process-oriented program evaluation of a narrative medicine program implemented in interprofessional team meetings in three academic primary care clinics. Program evaluation revealed that a year-long narrative medicine program with modest monthly exposure was feasible in academic clinical settings. Staff members expressed engagement and acceptability as well as support for ongoing implementation. Program success required administrative buy-in and sustainability may require staff training in narrative medicine.

Looking Back to Move Forward: First-Year Medical Students' Meta-Reflections on Their Narrative Portfolio Writings.

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students' reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster "reflective spaces" wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students' "Signature Reflections," end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students' writings and interpret the data. The authors identified two overarching interpretive themes-recognition and grappling-and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors' analyses, the Signature Reflection seems to provide a structured framework that encourages students' reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students' acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.

To See the Suffering.

The author notes the impressive growth in medical humanities programs, scholarly journals, textbooks, and national and international conferences as well as the convening of two recent national forums or boards addressing the potential of the humanities and the arts to improve medical practice. She also notes that the field of medical humanities seems to have shifted from addressing topics on the margins of medical education to equipping students with the foundational skills required for effective doctoring. This Invited Commentary proposes a number of personal, relational, and interpretive consequences to rigorous training in the humanities or the arts that might lead to improvement in the skills of doctoring. Where else but in hospitals with very ill patients and very young doctors who care for them are such skills needed the most? The author suggests that to see the suffering might be what the humanities in medicine are for, and that those who become capable of seeing the suffering around them in medical practice both experience the cost of countenancing the full burden of illness and death and, simultaneously, comprehend with clarity the worth of this thing, this life.

Close Reading and Creative Writing in Clinical Education: Teaching Attention, Representation, and Affiliation.

Medical educators increasingly have embraced literary and narrative means of pedagogy, such as the use of learning portfolios, reading works of literature, reflective writing, and creative writing, to teach interpersonal and reflective aspects of medicine. Outcomes studies of such pedagogies support the hypotheses that narrative training can deepen the clinician's attention to a patient and can help to establish the clinician's affiliation with patients, colleagues, teachers, and the self. In this article, the authors propose that creative writing in particular is useful in the making of the physician. Of the conceptual frameworks that explain why narrative training is helpful for clinicians, the authors focus on aesthetic theories to articulate the mechanisms through which creative and reflective writing may have dividends in medical training. These theories propose that accurate perception requires representation and that representation requires reception, providing a rationale for teaching clinicians and trainees how to represent what they perceive in their clinical work and how to read one another's writings. The authors then describe the narrative pedagogy used at the College of Physicians and Surgeons of Columbia University. Because faculty must read what their students write, they receive robust training in close reading. From this training emerged the Reading Guide for Reflective Writing, which has been useful to clinicians as they develop their skills as close readers. This institution-wide effort to teach close reading and creative writing aims to equip students and faculty with the prerequisites to provide attentive, empathic clinical care.

"Where Does the Circle End?": Representation as a Critical Aspect of Reflection in Teaching Social and Behavioral Sciences in Medicine.

OBJECTIVE: This paper describes a reflective learning program within a larger curriculum on behavioral and social science that makes use of close reading, written representation of experience, discussion, and textual response. This response may in turn lead to further reflection, representation, and response in a circular pattern. A unique feature of this program is that it pays attention to the representation itself as the pivotal activity within reflective learning. Using the narrative methods that are the hallmark of this program, faculty writings were analyzed to characterize the essential benefits that derive from these practices. METHODS: In the context of a faculty development seminar on the teaching of behavioral and social sciences in medical curricula, a group of 15 faculty members wrote brief narratives of reflective learning experiences in which they had made use of the methods described above. Their responses were submitted to iterative close reading and discussion, and potential themes were identified. RESULTS: Four themes emerged: writing as attention to self, writing as attention to other, writing as reader/writer contract, and writing as discovery. In each instance, writing provides a new or deepened perspective, and in each case, the dividends for the writer are amplified by the narrative skills of those who read, listen, and respond. CONCLUSIONS: The narrative pedagogy described and modeled herein provides a potentially promising approach to teaching the social, cultural, behavioral, and interpersonal aspects of medical education and practice. Future research will deepen our understanding of the benefits and limitations of this pedagogy and expand our appreciation of its applications.

Sounding narrative medicine: studying students' professional identity development at Columbia University College of Physicians and Surgeons.

PURPOSE: To learn what medical students derive from training in humanities, social sciences, and the arts in a narrative medicine curriculum and to explore narrative medicine's framework as it relates to students' professional development. METHOD: On completion of required intensive, half-semester narrative medicine seminars in 2010, 130 second-year medical students at Columbia University College of Physicians and Surgeons participated in focus group discussions of their experiences. Focus group transcriptions were submitted to close iterative reading by a team who performed a grounded-theory-guided content analysis, generating a list of codes into which statements were sorted to develop overarching themes. Provisional interpretations emerged from the close and repeated readings, suggesting a fresh conceptual understanding of how and through what avenues such education achieves its goals in clinical training. RESULTS: Students' comments articulated the known features of narrative medicine--attention, representation, and affiliation--and endorsed all three as being valuable to professional identity development. They spoke of the salience of their work in narrative medicine to medicine and medical education and its dividends of critical thinking, reflection, and pleasure. Critiques constituted a small percentage of the statements in each category. CONCLUSIONS: Students report that narrative medicine seminars support complex interior, interpersonal, perceptual, and expressive capacities. Students' lived experiences confirm some expectations of narrative medicine curricular planners while exposing fresh effects of such work to view.

Narrative medicine as a means of training medical students toward residency competencies.

OBJECTIVE: This study sought to explore the perceived influence of narrative medicine training on clinical skill development of fourth-year medical students, focusing on competencies mandated by ACGME and the RCPSC in areas of communication, collaboration, and professionalism. METHODS: Using grounded-theory, three methods of data collection were used to query twelve medical students participating in a one-month narrative medicine elective regarding the process of training and the influence on clinical skills. Iterative thematic analysis and data triangulation occurred. RESULTS: Response rate was 91% (survey), 50% (focus group) and 25% (follow-up). Five major findings emerged. Students perceive that they: develop and improve specific communication skills; enhance their capacity to collaborate, empathize, and be patient-centered; develop personally and professionally through reflection. They report that the pedagogical approach used in narrative training is critical to its dividends but misunderstood and perceived as counter-culture. CONCLUSION/PRACTICE IMPLICATIONS: Participating medical students reported that they perceived narrative medicine to be an important, effective, but counter-culture means of enhancing communication, collaboration, and professional development. The authors contend that these skills are integral to medical practice, consistent with core competencies mandated by the ACGME/RCPSC, and difficult to teach. Future research must explore sequelae of training on actual clinical performance.