Narrative Medicine 敘事醫學 胸腔科黃建達 2011-4-7 7:30 – 8:30

多一點故事，少一點理論 Robert Coles: 當他開始用聽故事的方式了解病人時 他邀請病人共同編寫有關於自己疾病的故事 發現自己彷彿配備了另一雙耳朵 不再僅僅專注於收集有助診斷的「症狀」，套入各種疾病的「模型」，然後安排適當的「治療」 他邀請病人共同編寫有關於自己疾病的故事 擴大為生命的故事 豐富了對病人的理解與關懷。 讓生命訴說自己的故事：敘事與醫學 http://tw.myblog.yahoo.com/mental-shelter/article?mid=173&sc=1

What is Narrative Medicine? 敘事醫學 哥倫比亞大學Rita Charon醫師 2000 提出了「Narrative medicine」 International movement to include reflective reading and writing in physician practice Poetry, stories, memoirs written by doctors, other health care professionals, students and patients

醫學知識應分為兩組 Rita Charon 第一組是客觀的「logical-scientific knowledge」 是對疾病的遺傳、病理基礎的了解與治療。 第二組則是主觀的「narrative knowledge」 是在病人的理解與故事中，疾病所扮演的角色，所象徵的意義，所帶來的變化與所隱含的功能，這些細節應該由醫師與病人共同編寫、探索。 Rita Charon

Narrative Medicine 敘事醫學鼓勵每個人書寫、分享、重新建構自己的故事 對醫師、病人 傳統病歷的書寫從收集症狀、建立因果關係、診斷排序下手，是一種「reductionist」的簡化、歸納手段， 敘事醫學鼓勵每個人書寫、分享、重新建構自己的故事 對醫師、病人 敘事則邀請更多可能性、更多細節來豐富理解 可能必須花上更多時間 值不值得？ 讓生命訴說自己的故事：敘事與醫學 http://tw.myblog.yahoo.com/mental-shelter/article?mid=173&sc=1

「只有聽得懂他人的故事我們才能開始思考如何解除他人的苦痛」 美國許多醫學院 --- 在訓練課程中加入了文學賞析 「只有聽得懂他人的故事我們才能開始思考如何解除他人的苦痛」 --- 醫學的初衷 Charon醫師在紐約哥倫比亞大學 --- 開了一門「Narrative Medicine」碩士班 讓生命訴說自己的故事：敘事與醫學 http://tw.myblog.yahoo.com/mental-shelter/article?mid=173&sc=1

敘事醫學與六大核心能力 Physician and Patient, Self, Family  Patient Care Physician and Self, Patient  Medical Knowledge Physician and Self, Patient, Colleagues, Society  Practice-Based Learning and Improvement Physician and Patient, Colleagues, Society  Systems-Based Practice All Situations  Interpersonal and Communication Skills Professionalism

敘事醫學與療傷 For Patient For Provider Coping strategy; facilitates adjustment/ adaptation Process feelings and reactions Expression and communication Promote healing, improved health outcomes For Provider Process reactions to difficult situations/grief Protection against burnout Reduce practitioner stress Improves patient-centered care Yamada, S.et al. Family narratives, culture, and patient-centered medicine, Medical Student Education, 2003; 35(4), pp.279-283. Reduces practitioner stress Brady, DWet al. "What's important to you?": The use of narratives to promote self-reflection and to understand the experiences of medical residents, Annals of Internal Medicine, 2002; 137(3), pp. 220-223. Yamada, S.et al. Medical Student Education, 2003; 35(4), pp.279-283. Brady, DWet al. Annals of Internal Medicine, 2002; 137(3), pp. 220-223.

敘事醫學與同理心 Empathy 同理心 students practice taking the view of another person (a patient, family member, other healthcare providers) they see the patient as a person within a family, community, and culture Halpern J. From detached concern to empathy: humanizing medical practice. New York: Oxford University Press, 2001. Das Gupta S & Charon R. Personal Illness Narratives: Using Reflective Writing to Teach Empathy. Acad Med. 2004;79:351–356.

supporting their skills of observation Narrative Medicine does not make medical students into "writers," but makes them better doctors supporting their skills of observation encouraging their reflection in a clinical context showing the students that their thoughts, feelings, and questions are heard through the responses from the mentors. Narrative Medicine at UNM IRCME Symposium, March 16, 2007

內容分析 Initiation: first-time experiences Identity Awe Frustration and disillusion Questioning Values Narrative Medicine at UNM IRCME Symposium, March 16, 2007

Students say this writing helped them to perceive their clinical work in a thoughtful way become more observant and analytical look for recurrent patterns respond better to patients. Narrative Medicine at UNM IRCME Symposium, March 16, 2007

Faculty comments: responding to student's reflective writing makes the mentor more reflective Helps keep me in touch with students at the early stage of training I got a much better insight into how students grow over time. It has made me look closer at my own behavior as a teacher, mentor and clinician. Narrative Medicine at UNM IRCME Symposium, March 16, 2007 Reflective

RESULTS: “time well spent” Students and mentors overwhelmingly positive Most mentors return Explosion of student interest: From a class of 75 students: 9 took Narrative Medicine track in 2005 22 in 2006 54 in 2007 Narrative Medicine at UNM IRCME Symposium, March 16, 2007

CONCLUSION: A Narrative Medicine experience can be: simple to set up requires a very modest investment in student and faculty time rewards the effort with increased reflection and satisfaction for both students and faculty. Narrative Medicine at UNM IRCME Symposium, March 16, 2007

“I write the story. The story writes me.” 發展敘事醫學能力 “I write the story. The story writes me.” ~Watts “It turns out, as I wrote deeper and deeper into my subject, I revealed more and more about myself. That, I guess, is what literature does. Makes us set aside inhibitions. Makes us find a pathway to the interior.

推動敘事醫學的目的 反省 溝通 教育 高雄醫學大學呼吸治療學系 林慧如助理教授

TRAINING MODEL KNOWLEDGE KNOWLEDGE ACQUISITION APPLICATION (Novice) (Beginner) STORIES = TOOLS TO ASSESS & IMPROVE (Competent) Lawrence & Viken (2004). RAP

Narrative Medicine Skills Observation Active listening Ability to tell the patient’s story 感動別人 Verghese A. The physician as storyteller. Ann Intern Med 2001;135:1012-7.

敘事學的兩種型式 1.簡單敘述 由一位具體的敘述者所講述的故事 2.模仿敘述 由全知而無實體的存在角度岀發講述故事 敘事者身份隱藏

案例試寫 臨床上曾有什麼困擾你的倫理事件嗎？ 對這事件印象最深的一個「場景」 回想此場景，直接浮現的3-4個「印象點」「關鍵對話」 以這3-4個「印象點」描繪一個簡短的故事 請給它一個最適當的簡短標題 不要套用術語儘量還原到原初情境 高雄醫學大學呼吸治療學系 林慧如助理教授

孩子還給我 “Twenty-four year-old, 28 weeks pregnant. Small abruption, dilated to 4 or 5, s/p mag. Signed out AMA to smoke. Down. Abrupted. Bled. Came up baby dead. Positive cocaine. Stupidity. Irritated.” Howis could also do “Mr. White” Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family Medicine September 2006

還原情境 還原情境的第一步驟：不套用術語 其次：為故事命名 範例： 孩子還給我 機器人女孩 大象男孩 父親的害怕

醫學敘事文學創作徵文比賽file://localhost/Users/cdhuang/Desktop/Narrative Medicine/醫學倫理文學創作徵.doc - narrative medicine

How to Get Started… Critical Components Curriculum Integration Application Assessment Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family Medicine September 2006

Critical Components Resident champion/facilitator “Safe” faculty member Education about narrative competence, narrative medicine, and core competencies Motivation Noon conference credit & food Opportunities to practice & experiment with writing Acceptance, comfort level Willingness to share, model for others Literature, literature, literature Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family Medicine September 2006

Integrating Narrative Medicine into the Curriculum Use during orientation to help residents get to know one another Include writing exercises in required didactics and seminars Narrative Medicine Rounds Read orientation intro’s Critical incidents/experiences Opportunities for reflection on learning and development Improved understanding of specific competencies Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family Medicine September 2006

Narrative Medicine Rounds

Narrative Medicine Rounds Requirements Complete pre- and post- self-assessment questionnaires Attend and participate in at least 50% of scheduled Narrative Medicine Rounds Keep a personal journal Have fun! Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family Medicine September 2006

Narrative Medicine Rounds Session Format Brief 5 to 10 minute didactic Reading of the day Time to write Reaction to reading Guided writing Personal reflection Time to share Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family Medicine September 2006

Ｎarrative medicine round Plan 敘事文章書寫一篇 優秀文章選拔與研讀 Ｎarrative medicine round

References Howis Y. Toler, M.D., Julie Wood-Warner, Ph.D. Research Medical Center Family Medicine Residency, Kansas City, MO The 27th Forum for Behavioral Sciences in Family Medicine September 2006 Ellen M. Cosgrove, MD FACP Senior Associate Dean, Education, University of New Mexico. Narrative Medicine at UNM IRCME Symposium March 16, 2007 讓生命訴說自己的故事：敘事與醫學 http://tw.myblog.yahoo.com/mental-shelter/article?mid=173&sc=1 臨床敘事倫理 高雄醫學大學呼吸治療學系 林慧如助理教授 敘事醫學與醫療專業 長庚兒童氣喘過敏風濕科副教授林思偕 長庚醫訊２９卷０７期

「只有聽得懂他人的故事,我們才能開始思考如何解除他人的苦痛」 Take HoME Messages Narrative Medicine does not make medical students into "writers," but makes them better doctors 「只有聽得懂他人的故事,我們才能開始思考如何解除他人的苦痛」

Thank You!