Thursday Review: “Integrating Narrative Medicine into Clinical Care”

This week’s review centers around a brief but meaningful summary of a 2016 pilot to integrate Narrative Medicine into medical students’ clinical rotations.

So far, most Thursday Reviews have tried to discover how the authors’ findings support and expand the use of storytelling in medicine. This week, I’d like to do something a little different. I’d like to work through the paper and ask questions along the way.

Narrative Medicine is a huge step forward in trying to deliberately rediscover the human act of caring within systems which are increasingly dehumanizing. It’s also based primarily in the written word. My personal background is based on performance. Because of that, I’m sure I view the literary focus of Narrative Medicine a little differently than most. If the Medical Humanities are going to be effective, I wonder if there aren’t questions we can ask to make their implementation even better and more immediate. This brief write-up about exposing medical students to Narrative Medicine is an opportunity I’ll take to ask some of them.

Why is literature and writing the primary mode of analysis and expression?

At Baylor College of Medicine, we piloted a 1-month clinical NM elective that purposefully integrates medical students’ care of hospitalised patients with literary analysis and creative writing.

Once upon a time, culture was primarily oral. We as a species invented written communication to make speech more permanent and portable.

Written communication has a lot of advantages over oral communication. As mentioned, it’s permanent and portable. Oral communication, or at least conversation, is extemporaneous in a way that written communication isn’t. As I sit here and write this, I can choose very specific words, and if I choose the wrong one, I can simply delete it, and choose a better one.

Written communication is also standardized in a way that oral communication isn’t. Everyone in a college or medical school course studies the same text, because teaching from different texts is cumbersome. For all these reasons, European and American culture has always preferred written text as the object of study and creation. A speech or performance disappears as soon as it’s made. This doesn’t make it impossible to study, it just makes it much more difficult.

Why is the time devoted to clinical care divorced from the time devoted to narrative?

In this elective, students devoted 25 hours per week to clinical care and 15 hours per week to NM activities.

This seems like a stupid question, I admit. The elective offered is about Narrative Medicine. Every med student on rotation gets clinical experience. The difference is the work in Narrative Medicine.

One of the interesting things, though, about literature as the preferred medium of Medical Humanities is that it is separate from the clinic.

I’m the last person to say that writing isn’t useful as a mode of examining, analyzing, and learning. (Why else would I write this?) One of the things painfully obvious in our current system of medical care, though, is that no provider needs one more thing on their to-do list.

There is a solitary element to the act of writing, even when done collaboratively. The efforts of Medical Humanities are aimed at better communication, better performance, and better care. Is there a way these things can be done, can be learned, and be analyzed in the presence of the patient? Would it be more powerful?

To frame this in the context of written vs. oral communication, written communication grew out of oral communication. Why not go back to where it all began?

One of the positive outcomes of this pilot elective was the following:

…one student described an encounter with a patient who was non-compliant with medications. I knew there had to be a back story, so I started asking questions … in the process, I learned he had more than 14 medications to keep track of and he just couldn’t do it, so we worked toward a better solution.

I certainly don’t want a group of med students and residents surrounding a patient, prodding them with questions until finally, it’s revealed that the patient is having a hard time keeping track of their medications. What I wonder, though, is what would happen if a portion of the fifteen hours per week were spent arming students with analytical and theoretical tools, and after that, they were told, “Use what you’ve learned. Go talk to your patients. Talk to them a lot!”

There’s absolutely a need for physicians and other healthcare providers to process and reflect on their experiences apart from patients. If Medical Humanities aim to improve healthcare, though, it aims to improve a communication event. Shouldn’t that be where it all begins?

Could younger medical students and more experienced physicians benefit from this instruction? What other health professions, e.g., nurse, social worker, chaplain, could have benefited?

The medical team consisted of three internal medicine residents, four medical students (in their final year of training) and an internal medicine attending physician, who has published multiple works of fiction and provides clinical service at the county hospital. The NM team consisted of the same internal medicine attending physician and an instructor in English literature at a nearby university.

The program described was a pilot, and surely, the practical answer is, “This was the minimum viable group that we needed to run the pilot in a clinical setting.”

The focus on narrative in literature is certainly applicable to all professions in healthcare. The wonderful and contrasting thing about storytelling is that everyone already does it in some way. Leveraging the power that stories have not only helps make the physician-patient relationship better, but makes the communication between professions more effective, too.

What about the final exam?

…students were expected to submit one original piece of writing for review and critique in the writing workshops.

What would’ve happened if, on the last day of this elective, the students were asked without warning or time to prepare, “Tell the group something amazing that happened to you in this elective”?


The article reviewed: Balmer, Dorene, Anne Gill, and Ricardo Nuila. “Integrating Narrative Medicine into Clinical Care.” Medical Education 50, no. 5 (2016): 581–82.

Featured Image: “No Substitute”, by flickr user Patrick Feller, used under a CC BY 2.0 license.