1. Narrative Medicine: Encouraging Patient Resilience and Hope
Rob Slocum, D. Min., Ph.D.
Narrative Medicine Program Coordinator
UKHealthCare

2. Agenda Narrative Medicine Video Introduction to Narrative Medicine
Narrative Scenarios – Videos with Stories
Journal Workshop

3. Learning Objectives
Describe basic principles and methods of Narrative Medicine 
Apply basic principles and methods of Narrative Medicine in interactions with patients
Identify appropriate cases for referral to a Narrative Medicine facilitator

4. Financial Disclosure
The presenter has no relevant financial relationships to disclose

5. Narrative Medicine Video
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6. Narrative Medicine Introduction

7. Narrative Medicine as an Expression of Medical Humanities
Medical Humanities as applying disciplines, perspectives, ways of knowing, insights from the humanities to medical practice and education.
Epistemology in terms of ways of knowing—not just one way, no single way of knowing is most effective in all contexts.
Different ways of knowing, like different instruments or tools, serve best in different situations (don’t fish with tennis racket, identify music with a microscope).
Don’t try to identify one way of knowing as most appropriate in all contexts.

8. Narrative Medicine as an Expression of Medical Humanities
Identify narratives already active in patients’ lives and stories.
Identify characters, plot, motivations and obstacles, conflicts and resolutions in patient’s narrative.
Draw out role of patient as central character in own story.
Affirm significance of patient’s thoughts and feelings.  

9. Narrative Medicine as an Expression of Medical Humanities
Identify unfolding plot of patient’s own story, in narrative world of patient’s experience of illness and treatment, taking into account symbols and meanings expressed in the patient’s narrative.
Listen (pay attention) to verbal and nonverbal expressions.
Discern and encourage role of unfolding narrative in expression and formation of patient’s identity during illness and treatment.
Help patient claim and articulate personal meanings and sense of self as expressed through narrative.

11. Narrative Medicine is…
Patient Centered
Listen!
Respect!
See the whole person
Interactive & Dynamic
Expect the unexpected!
Collaborative
Share information and insights with treatment team members!

12. Use of Self: Hearing and Healing
“The self is the physician’s most important therapeutic tool, for the healing that comes from sitting by a patient, leaning forward and listening fully—without interruption or ready judgment—often goes beyond any cure. While listening for the nuances of a patient’s story, to what the body—and the person—are saying, a relationship of authenticity and trust begins.”
-Mary T. Shannon, “Giving Pain a Voice: Narrative Medicine and the Doctor-Patient Relationship”

13. Engaging Patients’ Stories
Patients may…
Perceive their illness, treatment, & entire lives in terms of stories
Recover or rediscover meaning & identity in terms of stories
Reframe their self-understanding with a new story
Claim the role of central character in their own story (Rosenblatt)
Types of patient stories: restitution, chaos, quest (Arthur Frank)

14. Core Questions What brings you here? What helps you the most?
Do you see anything differently?
What comes next?

15. Will to Live
Patients bring with them (and may change) their own attitudes concerning…
Illness
Treatment
Living

16. Pain and Suffering Physical pain without suffering
Child birth
Athletics
Suffering without physical pain
Loss of meaning
Demeaning events

17. Humanize or Dehumanize
Identity
Dignity
Autonomy
Relationships
Respect
Meaning

18. What brings you here? Story Symptoms Diagnosis Getting to treatment
“Underdiagnosis”/“Overdiagnosis”
Getting to treatment
Prognosis
Treatment plan

19. What helps you the most? Observe Identify or discover values
Frequent answers
Faith
Family
Friends
Personal strength
Favorite activities
Staff & outstanding facility

20. Do you see anything differently?
Different perspectives?
Different priorities?
Has anything changed?
Frequent answers
Don’t take things for granted
Thankful attitude
Some things that seemed important are not important
Give time to things that matter most
Don’t put off or defer important things
Acknowledge limitations

21. What comes next? What do you look forward to? (Frankl)
What do you want to do with the rest of your life?
What will you do first when you get home?
Frequent answers
Deferred dreams, goals, adventures
Family milestones
Complete projects, plans
Favorite work or recreational activities

22. Levels of Visits Discussions may move between levels
Basic visit– introduction and explanation, core questions, beginning discussion, inquire and listen, draw out story, support
Follow up visit– developing story in detail, unfolding story shared by patient, sustaining through changes
Patient engages a concern or issue to talk through in context of story, patient explores understanding and discovers insight through sharing story
Discussions may move between levels

23. Additional Possibilities
Follow-up visits
Life review
Journal writing
Journal workshop

24. Journal Workshop

25. Overview and Summary of Studies
Quantitative Studies
Qualitative Studies
Reflections

26. Narrative Ethics Factual scenarios as stories
Characters, conflict, possible resolutions
Does the story “make sense” of the facts presented? 
Is something “missing”? 
Does a different story make better sense of the facts presented?

27. Narrative & Patient Identity
Patient’s essential identity – who the patient is – understood in terms of each patient’s story
Patient’s illness as “biographical disruption” (Lossignol)
Impact of symptoms understood relative to identity
Patient may reclaim or rediscover identity during treatment – exploring story to renegotiate identity

28. Narrative Medicine Case Notes
Haven’t lost everything. Patient reframes understanding of situation when reminded of family support.
Accept vulnerability, let daughter visit. Let in help.
Riding the tractor. Used to being active. Victory lap. Claustrophobic in house. Team questioned informed consent but story clarified.
Traumatic post-op in restraints. Open the discussion. Able to sleep, eager to talk.
Turtle time. Find new reference points, ways to recognize contexts. Find humor in situation.

29. Narrative Medicine Case Notes
Attending talked over me, didn’t listen, made a decision about what was wrong and got impatient if I seemed to disagree. Patient can find self, concerns, choices when listened to.
Nothing helps. Adult daughter right there. See sources of support and resources available.
Combat veteran avoids crowds, loud noises, keeps war stories inside until he’s ready to talk with someone he trusts. Opening up just a little changes everything.

30. Narrative Medicine Case Notes
PNES patient aggravated by stressors, experiences spells, explores ways to manage and deflect stress, experiences fewer spells. Reflection seems to externalize the problem, separate pt from problem, making it manageable
Neuro-oncology patient initiates unnecessary lifestyle changes that make life less satisfying—running, mowing the grass—assumes this is needed by condition and treatment, isn’t, returned to favorite activities.
PNES heart patient goes through multiple life crises with frequent spells, talks through situation, lives through situation so crises sort out one by one, decreased spells.

31. Narrative Medicine Case Notes
VAD implant patient with long recovery, nurse unfamiliar with case questions why still seeking curative measures, long perspective on patient’s story shows slow but steady improvement, patient strongly committed to recover.
Cancer patient receiving chemo with high anxiety. Conversation discloses pt isn’t especially anxious about cancer or chemo. Pt is still dealing with traumatic accident in which close relative died, he survived.

32. Narrative Medicine Case Notes
Go to patient’s story. Infusion clinic patient not worried about cancer or first chemo but actively grieving sudden death of husband six months before, shares her grief
Cancer patient failing to thrive after transplant. Medically ok. Story and observation and family report discloses eating disorder
Patient was ambivalent about potentially life-saving surgery. After discussion patient had the surgery.

33. Narrative Medicine Scenarios
Videos with a story
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34. Journal Exercise