Clinical teachers' toolbox article: Harnessing narrative medicine to learn from underserved populations

Story telling is a fundamental part of human nature. Yet in health care education, there is often a focus on students learning to condense a person's rich, sometimes messy story about their life, into a flat, aseptic, clinical account of a patient's symptoms.1 While this approach may help learners handle the complexity of symptomatology, it risks losing sight of the story's central character, as the person is transmogrified into 'the patient'. Excessive focus on fact-gathering diminishes the ability to communicate,2 and adopting this mind-set risks shifting the emphasis of a consultation from relationship to transaction. Engraining a transactional approach to patient interaction may underpin the attrition in empathy seen during undergraduate medical programmes.3 Stories, be they written, visual or spoken, are a powerful way to learn. Rita Charon, general internist, literary scholar and originator of the field of narrative medicine,4 described it as 'a commitment to understanding patients' lives, caring for the caregivers and giving voice to the suffering'.5 The purpose of narrative medicine is threefold: it can reveal patients' perspectives, facilitate self-reflection among learners and provide emotional support to learners.6 We contend that narrative medicine can be a particularly potent catalyst for meaningful learning about underserved populations and health inequality, be it racism, ageism, gender bias and sexism, hetero-normism, colonialism or stigmatised medical conditions. We believe that narrative medicine can add value to the education of all health care professionals—this is of particular relevance when considering underserved communities, since a multidisciplinary approach is recognised as being central to good care for these groups.7 In this toolbox article, we outline relevant educational theory, offer a structure for teaching using narratives, signpost and showcase recommended resources, outline potential barriers to implementation and offer strategies to mitigate against these. Narrative medicine can be a particularly potent catalyst for meaningful learning about underserved populations and health inequality Humans are story telling animals who were teaching and learning through stories long before there was any concept of educational theory—despite this it is useful to consider how this activity can be theorised. Our intention and experience with narrative medicine is that it can foster 'light-bulb moments', in which the learner's perspective can be expanded irrevocably. This aligns with TL theory which we will now consider. TL has been defined by Mezirow, as 'the process by which we transform our taken-for-granted frames of reference to make them more inclusive, discriminating, open, emotionally capable of change …'8 p.8. TL recognises that we all carry preconceptions and assumptions (frames of reference) that influence how we perceive and act within the world. TL seeks to go beyond teaching for knowledge and skills acquisition and instead aspires to challenge and ultimately change these frames of reference. As Kumagai eloquently writes, 'In transformative learning, it is not just what one knows that changes; rather, it is how one knows something, how one sees oneself and others, and how one exists and acts in the world'9 p.650. The events that provide the potential stimulus to change are termed disorientating dilemmas and are traditionally events that stir emotions.10 As an example, we signpost readers to novel work by Thompson et al.11 that describes a course for medical students that aimed to develop their awareness of disability. Students spent 1 week at sea on a tall ship, working alongside a 'buddy' with a disability, in a challenging maritime environment. Such an experience prompts learners to reflect critically on their established frames of reference, yet this alone does not guarantee that transformation will occur. TL contends that transformation is a collective, rather than an individual, experience. The opportunity to discuss, debate and share perspectives with peers, within the setting of a challenging, yet supportive group, provides the climate needed for transformation to occur. The opportunity to discuss, debate and share perspectives with peers provides the climate needed for transformation to occur. Milota et al.12 conducted a systematic review of narrative medicine as a medical education tool. They identified that the majority of included articles (22 of 36) employed a pedagogic process that consisted of three-steps. In Figure 1, we present a synthesis of this three-step approach, which we commend to educators planning to teach using narratives, along with a worked example of how this might be implemented in practice. Integrated into Figure 1 are links to the key tenets of TL theory described above. There is also a reference to the concept of 'close reading' within step 2 of Figure 1. Close reading has been described as the signature method of narrative medicine and involves training learners to 'search for aspects of a written text—like sensory detail, perspective, genre, time, voice, metaphor, and plot—that may harbor meaning for both writer and reader'13 p.348. There are a variety of different types of narratives that can be employed in such teaching; these include patients' narratives, relatives' or care-giver's narratives, clinician's narratives or fictional narratives. There is also great potential variety in the medium through which the narratives are presented to learners—written media (books, magazines, newspapers, poetry), visual media (film, video, television, theatre, art) and audio content (music, podcasts, interviews). Powley and Higson2 p.25 describe how narratives 'engage the imagination to release perceptive and creative responses'. We would encourage clinical teachers to embrace this sentiment and to employ similar imagination and creativity when selecting resources to use within teaching using narrative approaches. For the purposes of this article, we have organised the suggested resources into three categories—so-called 'big picture' stories, multimedia resources and 'local' resources. We acknowledge that there is overlap between these groups but contend that this categorisation may help clinical teachers to identify potential resources and to plan delivery of sessions. We consider 'big picture' stories to be those of global significance. Some of these may be widely known, others may not, but the essence of these 'big picture' stories is that they carry headline messages that may be shocking, challenging or disrupting to one's understanding or world view. The global context of these stories is important, as they offer a vehicle to help normalise diversity, to embed concepts of social justice and accountability within curricula and to produce graduates who are culturally competent and better able to understand and serve the needs of the diverse populations they serve.14 Furthermore, it is recognised that teaching using narrative medicine can 'reveal worlds that are otherwise closed to us'15 p.818. In Table 1 below, we present five suggested stories. For each, we outline the story, the context and the topics that could be taught using the narrative. Henrietta Lacks was an African American woman who died of cervical cancer in 1951. Unbeknownst to her, cancerous cells obtained while treating her condition were taken for research. The cells proved to have an incredible capacity for survival in a laboratory. The cell line, so-called HeLa, has since been used widely in medical research and underpins many modern medical discoveries, including most recently, research into vaccines for COVID-19. John E Fryer was an American psychiatrist and gay rights activist. At the 1972 American Psychiatric Association annual conference, wearing a mask and assuming the pseudonym Dr Henry Anonymous, he gave a speech about his sexuality. At the time, homosexuality was listed as a mental illness within the Diagnostic and Statistical Manual of Mental Disorders (DSM). His speech and the ensuing protests were a key factor in the removal of homosexuality from the DSM. In this section, we provide an assortment of potential resources that could be drawn on to teach using narratives. These suggested resources are presented in Table 2 below, where they are categorised by resource type. There is increasing recognition that medical schools ought to engage with, partner with and respond to the needs of their communities.17 Through this process, the hope is that graduates will qualify with a more nuanced appreciation of the health needs of their local population. Narrative medicine has the potential to be used as a vehicle to achieve this. Stories from the geographical areas within which students are training offer a potentially rich resource for learning. Such narratives may be unique to a particular region and, when used judiciously, may open a window into a person's life that allows a student, from a differing background, to better understand the psycho-social context that underpins that person's lived experience. To illustrate the power of such local narratives, we present two examples from our own clinical experiences. Stories from the geographical areas within which students are training offer a potentially rich resource for learning. The first example is drawn from the author RT's local practice in Ashington, a town in the North East England. Image 1 shows 'Bedside', a painting produced by George Maclean, one of the 'Pitmen Painters'. 'George Maclean was a member of the Ashington Group, which began in the early 1930s, as an evening class of Northumbrian pitmen keen to learn about art. Within weeks they were producing their own work and within a few years their paintings amounted to a complete record of life in a mining community: clocking in, work at the coalface, the pithead baths, Saturday night at the Club etc. Their paintings ring true, transcending the usual limitations of amateur art. I came to Ashington as a physician in 2000, more than a decade after the last pit had closed. It is a close-knit, robust but warm-hearted and generous community that suffered immense post-industrial deprivation. This painting captures bereavement, emptiness, a lonely future; it resonates with the struggles I have witnessed in widowed miners. We sense the physical legacy of hard and dangerous work, strong hands and stooped frame, but also the hopelessness that comes with loss of companionship and role. I worry how this man fared and how his health needs were met'. The second example is drawn from the author NM's local practice in Fife, Scotland, and links with Image 2, Homeless life by Franco Folini. 'One story told by students rotating to Fife is that there is a lot of 'great pathology'. 'Great pathology' is often a symptom of poverty and associated issues such as addiction. My story begins with 'John', a 42-year-old man who attended hospital with pain from leg ulceration at a previous heroin injection site. It had been present for a year but had become increasingly painful over a few weeks. On reviewing John's medical notes, I created a story even before setting eyes on him. My body tensed up. I have noticed when looking after patients with addiction that sometimes I practise from a place of prejudice and thus consultations are short and subsequently lacking compassion. Admitting this brings feelings of shame, particularly because I am aware that occasionally people approach 'people like me' (a woman of African heritage) in the same way. However, I met John at a point in my life when health equity and social justice were at the forefront of my mind. So, I got respectfully curious. 'Why don't you see your practice nurse for regular sterile dressings?' I asked. 'Well, I use toilet paper for that because I don't have a GP. I'm homeless so I can't register'. John's story expanded my narrative, and I use these 'bedside stories' to reflect on bigger topics such as what it means for the NHS to be 'free at the point of access'; the difference between equality and equity in practice; how we challenge our own prejudices and use our privileges to advocate daily'. We acknowledge that while it is not yet clear whether narrative medicine can produce a long-term positive impact on patient care, it is proven to help learners develop more nuanced understanding of patients' perspectives and to enhance their capacity to self-reflect.12 For the educator seeking to evaluate the impact of their session, we would suggest employing methods that enable learners to demonstrate the extent to which they have achieved these goals. Established evaluation methods that are congruent with both TL and narrative medicine include personal reflective essays or other forms of creative reflection such as art. Narrative medicine is proven to help learners develop more nuanced understanding of patients' perspectives and to enhance their capacity to self-reflect. We recognise that for a multitude of reasons, educators may be reticent to trial this method of teaching in their institution. Informed by our own teaching experiences, which include many missteps and some successes, we provide within Table 3 further discussion of the potential barriers to teaching using narratives, along with strategies to mitigate against these. Lastly, we contend that successful implementation of narrative medicine requires a deliberate faculty development strategy. Educators will need to grasp the theory that underlies this approach to teaching and understands the types of resources likely to prompt a disorientating dilemma. Peer discussion forms an important part of TL and narrative medicine, and thus, small-group teaching (SGT), where learner–learner interaction is the goal, naturally aligns. Yet SGT is challenging to deliver; for example, the tendency for teachers to talk too much within SGT is well-recognised, particularly for less experienced educators.18 Thus, faculty development initiatives that allow educators to hone their facilitatory skills19 are crucial to successful implementation of narrative medicine. Successful implementation of narrative medicine requires a deliberate faculty development strategy We offer this toolbox in the hope that it will aid teachers and students in developing what Charon terms 'narrative competence': the competence to use, absorb, interpret and respond to stories.4 By working from the global to the local, we aim to foster a sense of comfort in the hearing of, and responding to, narratives from the public domain, such that we are sensitised to the narratives that surround us in our clinical practice, including our personal stories. Through offering suggestions, we aim to encourage an imaginative search for teaching resources with the power to engender collaborative learning. We encourage teachers to find fresh, richer approaches to learning from patients, connecting teacher, learners and patients in anathema to the 'detached concern' commended to us in the past.20 James Fisher: Conceptualization; writing—original draft; writing—review and editing; resources. Nony G. Mordi: Conceptualization; writing—original draft; writing—review and editing; resources. Richard Thomson: Conceptualization; writing— original draft; writing—review and editing; resources. We would like to thank the Ashington Group Trustees, Woodhorn Museum, Ashington, U.K. for granting permission to reproduce 'Bedside' by George Maclean. The authors have no conflict of interest to disclose. Not required.