UAB Synopsis, Vol. 24, No. 23, June 20, 2005
Emphasizing the humanness of physician-patient relationship
Early in his medical training, an attending physician told Fred Griffin, MD, to "cut out the editorializing" and stick strictly to clinical facts when describing a patient's case. This admonition to ignore less obvious aspects of patients' lives and illnesses did not hold much appeal for Dr. Griffin, who thought important diagnostic information could be overlooked with a totally objective approach.
He also came to believe that reducing patients' illnesses to the bare details of their physical and laboratory findings can deprive physicians of the human connection in clinical work — the very aspect that draws many to medicine. This lack of "humanness" in day-to-day practice can lead to physician frustration and burn out, he says.
Dr. Griffin, who recently joined UAB as associate professor of psychiatry, is now introducing the university community to narrative medicine, a term coined by Columbia University internist Rita Charon MD, PhD, who suggests that practicing medicine with narrative competence, which she defines as the ability to acknowledge, absorb, interpret, and act on the stories and plights of others, can lead to more effective and satisfying medical care (JAMA. 2001; 286:1897-1902).
"Narrative medicine has to do with creating stories from what patients tell us and letting that information impact us," Dr. Griffin explains. "Listening in this way, with empathy and acknowledgment of what a patient is feeling, provides a sense of the biopsychosocial totality of a human being and helps physicians grasp the context in which patients' illnesses arise.
"The physician-patient relationship is at the heart of medicine, but some aspects of modern medicine — including medical training, managed care directives, and the spread of subspecialization and biomedical technologies — can fractionate individuals into organ systems or abnormal test results, diminishing that relationship and making it less satisfying and effective," Dr. Griffin says. "If physicians don't understand the context in which a person lives, for example, they may prescribe treatment that is theoretically correct but irrelevant because of the patient's family situation, cultural background, or personality style. Being able to put yourself in your patient's place — to imagine what it would be like to be the patient — multiplies diagnostic and therapeutic skills."
Self-reflection and Insight
To develop narrative competence, physicians must not only read patients' emotional and social clues, but reflect on how patients' stories affect them, Dr. Griffin says.
"Making medical decisions requires a certain amount of detachment, but if physicians become too removed from their emotions, they may no longer understand what patients are feeling. Being attuned to one's emotional responses creates a self-reflective space that literally provides 'in-sight' into the situation," he says.
Narrative medicine offers a combination of tools to help create self-reflective space. Imaginative literature is one such device that can inform clinical work. "Reading literary works and noting how they affect us can spur our imaginations and jar us out of habitual responses to patients," says Dr. Griffin, who has used the short stories of physician-writer William Carlos Williams in narrative medicine courses and to help resolve a therapeutic impasse with a patient.
"The capacity to recognize and reflect on what happens in the physician-patient relationship is further developed when doctors experiment with writing vignettes about patient interactions," Dr. Griffin adds. "Sometimes, when you're under a lot of stress with a patient, you become locked in two-dimensional roles — noncompliant patient and unhappy doctor, for example. Literature can help clarify our emotional reactions and bring some resolution to these seemingly insolvable situations."
Taking a narrative moment — sharing one's thoughts with colleagues or writing them down — can also create insight. With the help of Dr. Griffin, pulmonologist Waid Shelton, MD, is putting narrative medicine into practice on the pulmonary units to help ease the stress that inevitably accompanies caring for patients with chronic and serious illnesses.
"Narrative medicine gives us the opportunity to focus on the doctor-patient relationship," Dr. Shelton says. "We ask our interns and residents to write a few sentences about their patients and discuss responses in our daily meeting. People seem to appreciate talking about the emotional aspects of patient interactions that rarely come up in more usual data-driven discussions. These exchanges take only a few minutes but give us an opportunity to reflect and add a little extra energy to the day."
During a recent pulmonary grand rounds, Drs. Griffin and Shelton presented their experiences with narrative medicine to a receptive audience — when they opened the floor to discussion, many in the room seemed eager to talk about their own experiences.
"Sometimes, being a doctor can be alienating and lonely, and it's clear that talking about these events has great value," says Dr. Griffin, who looks forward to collaborating with colleagues on both the medical and academic sides of campus. He recently led a Scholar's Week course for UAB medical students called "Doctor Stories: An Introduction to Narrative Medicine." During the course, students wrote short narratives about their clinical experiences and read published pieces written by physicians and patients. Dr. Griffin also hopes to introduce the emerging field of narrative medicine to residents and fellows, as well as to faculty and community physicians. "I hope other faculty will have the kind of courage and intellectual curiosity that led Waid Shelton to create narrative medicine rounds on the pulmonary unit," he says.
Conversations with Physicians
Before coming to Birmingham, Dr. Griffin conducted several series of guided readings of the works of John Berger and William Carlos Williams for practicing physicians that he called "Conversations with Physicians," and would like to direct a similar series at UAB. Eventually, he plans to incorporate these experiences into a book that will serve as a guide for integrating narrative medicine into medical practice.
"I came to UAB because of the opportunity to teach psychotherapy in an environment that would also foster the interdisciplinary work I'm interested in," he says. "Through my writing, I hope to offer a new perspective to the literature on narrative medicine; most people writing in the field approach it from studies of literature and medicine or from the discipline of literary studies. Over the years, I've had the privilege of learning so much from my patients and teachers about the importance of the human connection between physician and patient. It's this experience from clinical psychotherapy and psychoanalysis — where the doctor-patient interaction is central to the work — that I would like to translate and pass on to physicians working in other areas of medicine."
Dr. Griffin welcomes inquires from those interested in learning more about narrative medicine. Please contact him at flgriffin@uabmc.edu.
Narrative Medicine Suggested Readings
Berger, John, and Mohr, Jean. A Fortunate Man: The Story of a Country Doctor. New York: Holt, Rinehart and Winston; 1967. Reprint, New York: Vintage Books; 1997.
Charon, Rita, Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA. 2001;286:1897-1902. Available at: http://jama.ama-assn.org/cgi/content/full/286/15/1897.
Williams, William Carlos, The Doctor Stories, Coles, Robert, ed. New York: New Directions, 1984.
Griffin, Fred. The Fortunate Physician: Learning from Our Patients. Literature and Medicine. 2004;23.(2):280-303. Available at: http://muse.jhu.edu/journals/literature_and_medicine/v023/23.2griffin.html.
Horowitz, C. et al. What Do Doctors Find Meaningful about Their Work? Ann Int Med. 2003;138:772-776.