1 Recognizing, Absorbing, Interpreting, and Responding to Stories of Illness Julie M. Aultman, Ph.D Family and Community Medicine
2 Workshop Overview Hour 1: Understanding the Narrative Approach in Medicine Value of Narrative Medicine Types of Narratives of Illness Narrative Elements Reflective Practice Hour 2: Reflective Practice Exercise Interpreting and Responding to Stories of Illness Role of Facilitator Healthcare Professional as Writer
3 Part I.
4 Our lives are ceaselessly intertwined with narrative, with the stories that we tell and hear told, those we dream or imagine or would like to tell, all of which are reworked in that story of our own lives that we narrate to ourselves in an episodic, sometimes semi-conscious, but virtually uninterrupted monologue. We live immersed in narrative. Peter Brooks, Reading for the Plot
5 The Value of Narrative Narrative opens up the life world of oneself and others, particularly the experience of being sick. Narrative can prompt one to recognize and reflect on one s own values Narrative competence allows one to recognize, interpret, and be moved to action by the predicaments of others (Charon, 83) Engaged reading reading with openness, a willingness to learn from the text promotes solidarity with others Reading literature in medical settings may help ward off selective reality, or the belief that your vision of the world is the most accurate, most complete, most true.
6 Narrative can develop and strengthen the following skills critical for clinical work: Moral imagination Overall critical and reflective thinking Communication (writing) skills Commitment to decision-making Conflict awareness and resolution Reasoning for alternative approaches Organization skills Ethical and moral knowledge
7 Consciousness Narrative theorists argue that narratives can be categorized by the way consciousness is presented in a story: A third-person narrator can look into a character s mind (the narrator is the perceiver and the character s mind is perceived) or, Look through the character s mind (the character is the perceiver and the world is perceived) ( e.g., Story -Playing God ) Todd Chambers, The Fiction of Bioethics, p. 11.
8 The Use of Stories Stories as cases for teaching principle based medical ethics Narratives as moral guides for living a good life Narratives of witness Narratives to help healthcare professionals examine their ethical practices Jones, 1999
9 Physician as Writer The more I wrote about my patients and myself, the more confident I became that the act of narrative writing granted me access to knowledge about the patient and about myself that would otherwise have remained out of reach. I also realized that writing about patients changed my relationships with them. I became more invested in them, more curious, more engaged, more on their side. Rita Charon, 2001, Annals of Internal Medicine
10 An example The principle of autonomy may tell us to respect patient s autonomy, but it may not tell us what it means to respect the autonomy of Mr. Smith in room 1303 Howard Brody, p. 151, Stories Matter
11 Different types of Medical Narratives Medical interview Medical history Patient s story Family s story Healthcare professional s story Ethics consultation and case; ethicist s point of view Legal case; lawyer s point of view
13 The Illness Narrative Arthur Frank (1995) sees illness as itself a call for stories in two ways: becoming ill demands that one re-create one s selfstory, and, ill persons are asked to engage in storytelling by those who surround them (e.g., healthcare professionals, family, friends, employers, and so on). His narrative ethic focuses on thinking with stories which entails allowing one s own thoughts to adopt the story s immanent logic of causality, its temporality, and its narrative tensions. His focus is on the re-telling.
14 Restitution narrative This is the story most people tell: Yesterday I was healthy, today I m sick, but tomorrow I want to be well again... back to normal. Rests on the broken down metaphor of the body that must be repaired.
15 David At the end of the day what I am doing is I am buying time, I am buying time by concentrating on good health, no alcohol, low fat, high fiber, and exercise in order to buy time so the medicos of the world can come up with the panacea that addresses, resolves and extinguishes my hepatitis C So in answer to your question, would I go back on treatment, well I d go back on treatment if it is going to buy me time.
16 Chaos narrative No movement toward remedy or cure Feelings of futility and impotence Lack of control
17 Sarah Well today I am sick. I was going to clean up the house and move, but I am too sick to do it, I can t do it, I don t have the nerve to do it, I don t have enough nervous stamina to get through. The more I think, I think it s your fault, and then I think back and I have actually got no clothes, I am sitting here with my pajama jacket on and trousers with holes in them, I ve got two pairs of socks and an old pair of shoes, a pair of stockings that need replacing There is no money for clothes or haircuts or anything like that. There is nothing.
18 Quest narrative Yesterday I was healthy, today I m sick, but I have been so transformed by my illness that I can never go back. Desire to use one s suffering to move themselves and others to deeper levels of living Often involves testimonials, memoirs, activism A narrative of self-discovery; illness becomes accepted.
19 Laura Back then when I was using if you had told me I could have got a disease it wouldn t have mattered, I still would have done it, I had no self respect, and today I have learnt, I have become a better person because of it, a sick person, but a better person. I ve learnt so much about myself because of this.
20 Narrative Elements Character Desire Conflict
21 Reading literature helps healthcare professionals think narratively, in terms of stories Plot and Theme Point of View Setting Tone
22 PLOT AND THEME Plot is movement, events in time. It is what an author does to the simple narrative account to make it a story, to give it a purpose or meaning. The Theme is the central or dominant idea expressed by a piece of writing or a spoken story.
23 POINT OF VIEW First person - narrator tells story from his/her point of view (as a character in story) Third person - narrator is not a character in the story Omniscient - sees all minds, all characters, all actions Limited omniscient - sees only through one (or sometimes more) character's mind or experiences Objective - sees no minds, but all characters, all actions
24 SETTING The setting is the physical, geographical, historical, cultural, and/or temporal location(s) in which a story takes place. Tends to influence the interpretation of actions and events Can establish a mood or feeling about the characters or action
25 TONE Tone is the atmosphere or mood expressed by the writing. Tone refers to the author s (or storyteller s) attitude toward his or her subject or audience. By the selection of incidents an author chooses to focus on, or to omit, he or she establishes a tone. It may indicate contemptuous, respectful, or other attitudes toward his or her audience/listeners.
26 Part II
27 Reflective Practice Objectives Recognize/resolve personal and professional issues/dilemmas as they relate to life in medicine; Engage in collective discussions aimed to promote respectful and trusting relationships with colleagues and a sense of community; Develop a broadened appreciation for and understanding of a wider range of human experiences; Clearly recognize and be fully conscious of the forces intrinsic to their own professional identity development and socialization in medicine; and Develop a broader understanding of the commitments and obligations that attend the privilege of service in medicine.
28 Short story Read the following short story. Answer a set of questions (next slide) and write a short reflective paragraph on how the story resonates with you. Discuss in small group Michael A. LaComb, M.D. Playing God
29 Reflective Practice Who is the narrator? Identify the characters, and interpret the meaning as to why these particular characters are in the story Identify the elements: plot and theme, point of view, setting, and tone (e.g., how would the story be different if the setting were here?) Identify the type of the (illness) narrative What may be the desire? (e.g., to get better) What may be the conflict? (social, financial, moral, clinical) How might there be resolution? If there was resolution, would you act differently? In what ways? How does the story personally resonate with you? What feelings does this story elicit? Were you reminded of your own past personal encounters (patients, others)? Is this story a work of fiction or non-fiction does it matter?
30 I would continue medicine, for I am determined to be a poet; only medicine, a job I enjoyed, would make it possible for me to live and write as I wanted to. I would live: that first, and write, by God, as I wanted to if it took me all eternity to accomplish my design William Carlos Williams, Poet, Physician, Scholar
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