Do Tell
THE CASE FOR NARRATIVE-BASED MEDICINE.
As a consultant in palliative medicine, Dr. Miriam Colleran places a high value on humanity, caring, and sensitive communication. It comes with the territory for someone who works with people facing the end of life. To navigate such delicate relationships, Dr. Colleran has come to lean on a concept called narrative-based medicine (NBM).
“Narrative-based medicine helps us to be more compassionate. It’s really about re-humanizing medicine and helping us see the patient as a person,” she told Mind Over Matter® from her home in the Irish town of Naas, southwest of Dublin.
In part, NBM involves deep, attentive listening to what a patient has to say about their situation.
Earlier in her career, when she practiced in hospital and in family medicine, Dr. Colleran found that she interrupted patients more, pushing to get the point of an office visit, a habit that is unfortunately common in health care.
“NBM helped me focus more on the person, to be a better listener, letting them speak more, while obviously keeping in the mind the other necessary questions. If we give the patient room to speak, they feel welcome to explain what’s concerning them and what their wishes are for their care so we can help them.
“It makes us better people and better doctors.”
Dr. Colleran started with NBM during the pandemic when she came upon a virtual weekend workshop run out of Columbia University. Hooked, she followed up with a four-month foundational course at the University of Toronto’s Narrative-Based Medicine Lab (narrativebasedmedicine.ca), where she interacted with other professionals in what she describes as a nurturing, supportive environment.
Dr. Colleran recently completed the Advanced Certificate in narrative-based medicine at the NBM Lab. She said it emphasized how close reading of literature can help to simulate the experience of the characters and connect emotionally with them, which aids empathy and tolerance toward others. She also learned about the importance of writing about her own experiences.
“NBM is a very broad area. There’s no single accepted definition,” said Dr. Karen Gold, the Curriculum Lead for the Lab.
“It’s really understanding the role of story or storytelling and the application of narrative ideas and methods in the experience of illness and in health care.”
IS NARRATIVE-BASED MEDICINE JUST FOR DOCTORS?
Dr. Gold, who was a clinical social worker for 29 years, says the courses are not only for physicians. Participants include other healthcare practitioners such as nurses and physical therapists, but also social workers, researchers, artists, and patient advocates.
“Writing allows them the space to step back and reflect. There aren’t many opportunities to do that in today’s healthcare system. It’s a space where we come together, to share experiences and listen to the experiences of others,” she told Mind Over Matter®.
The Lab’s co-founder, Dr. Allan Peterkin, said NBM helps practitioners cope with the stresses of their jobs and risks of burnout. Among the professionals he mentored was Dr. Colleran.
“There’s a wellness aspect to it for doctors. The idea that every story is new is a remedy for feeling the monotony of the work or the depersonalization of the work.”
What we’re hearing from the people we train is that there’s a sense of renewal,” continued Dr. Peterkin.
“As I say to my students, if you’re a family doctor, you’re going to treat 1,000 cases of congestive heart failure. But each patient has only one heart. So, the experience of finding out what’s unique to each person’s experience of illness is very interesting. And it makes the patient feel seen and heard.”
HOW LISTENING HELPS
One of NBM’s pioneers is Dr. Rita Charon of Columbia University, author of several books and dozens of papers on the subject. She teaches it via three “movements”.
The first is paying “deep, profound attention” to what the patient is telling you. The second she describes as “representation,” which is advising the practitioner to capture what they are seeing and perceiving in words or image. And the third is “affiliation,” which she illustrated through her own technique in dealing with new patients.
“I follow my own drill. I don’t write or type. I just put my hands in my lap, and I say, ‘Please tell me what you think I should know about your situation?’ And I don’t interrupt,” she said in an interview with Mind Over Matter® from her New York City office.
“My colleagues say: ‘Rita, who can do that? You must have all the time in the world,’” she noted. “I say, if you’re good at it, it doesn’t take very long, and I learn things I never would have learned. It boils down to: What do you need? Not long ago I had a patient who said to me, ‘You know what I really need? I need a new set of teeth!’ She was a diabetic and I had no idea that teeth were the prominent thing on her mind. So that’s where we started.”
Dr. Charon said that, while there have not been large-scale clinical studies on the effectiveness of NBM, there is compelling evidence of real benefits. She cited the example of oncology teams who participated in sessions in NBM at Columbia, sessions where tears flowed freely as practitioners spoke frankly about dealing with dying cancer patients. They reported afterwards that the cohesion of their team improved.
“They do their job better and they develop skills of listening to one another and knowing how to take in the perspective of another. Which is an essential and difficult task. These smaller trials are showing significant changes.”
Dr. Charon has also noticed differences between the sexes. More than three-quarters of the people who enrol in either the master’s program or in the intensive sessions at Columbia are women, although she has seen the numbers of men slowly grow.
Dr. Chase McMurren, a Toronto-based physician, has heard Dr. Charon speak and admires her approach. He said he weaves NBM techniques into his psychotherapy practice with artists.
“We have to be slow, reverential, and respectful of people. It’s important to slow down and respect that people are doing the best they can,” Dr. McMurren said in an interview with Mind Over Matter®. He noted the concept of NBM resonates with his Indigenous ancestry.
“It’s an interesting fusion of Indigenous and non-Indigenous traditions. The stories themselves are medicine.”
While Dr. Colleran has found NBM to be helpful in her palliative care practice, there have also been personal benefits. She writes poetry, sometimes drawn from work experiences, but also about her own life. Her work includes a poem about the death of her father, who passed away some time after her mother, both of whom had a rare form of cancer. Titled “Differently,” it reads in part:
I think of you when I cook dinner
and remember the meals we shared—
when I need your wisdom, your support, your love,
I remember you and hear you say,
“There’s no such thing as a worry
That’s stupid to the person who has it.”
I feel your absence,
I miss you both, yourself and Mam,
Just differently.
Said Dr. Colleran: “Reflective writing has been a huge way of coping with grief for myself, but also with supporting the grief of others. I have to say that that’s one of the big things narrative-based medicine did for me.”
Source: Mind Over Matter V19