NARRATIVE MEDICINE: HONORING THE STORIES OF ILLNESS Rita Charon, MD, PhD New York: Oxford University Press, 2006, 288 pp., $39.95 (hardcover). The good physician knows his patients through and through, and his knowledge is dearly bought. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is in caring for the patient. (Francis W. Peabody, 1927, "The Care of the Patient," Journal of the American Medical Association, 88, 877-882) I listen not only for the content of his narrative, but for its form-its temporal course, its images, its associated subplots, its silences, where he chooses to begin in telling of himself. (Rita Charon, 2004, "Narrative and Medicine," New England Journal of Medicine, 350, 862-864) Rita Charon is a highly experienced physician internist with a PhD in English. In this book, she combines these two demanding intellectual disciplines to define a new field, narrative medicine. Most of the material in the 288 pages of this work constitutes a veritable course in narrative theory. Casual readers may be overwhelmed by the subject matter unless they are able to sustain the required intense concentration upon a text that is uncompromising in its demands. It requires sustained focus to grasp the critical points. Yes, it's worth the effort. NARRATIVE MEDICINE Narrative medicine is most simply defined and understood through Charon's point that narrative knowledge is distinguished from scientific knowledge. Diagnostic efforts in this field therefore must join "2 contradictory impulses at once." These are to observe the defining, perhaps unusual, characteristics of the patient's disorder and also at the same moment to categorize this information to make it "readable," or useful. A symptom or disease is indeed an event befalling a character, sometimes caused by something identifiable, within a specified time and setting that has to be told by one to another from a particular point of view. (p. 41) The central recognition of narrative medicine is "the power of language in illness and health" (p. 91). This recognition allows us to meld "the instrumental and the reflective" in our work and as well in the lives of our patients; and to do so demands "new narrative forms . . . to contain, reflect and discover these perceptions." If, indeed, increasing doctors' skills to represent that which is seen and heard contributes to more effective affiliations between doctor and patient, there is an imperative to put these narrative practices into routine use. (p. 191) The patient's history must be received, not taken. By writing down the patient's narrative ("representing" it), we learn to comprehend it. We can see it, grasp it, understand it from all sides because it has been "formed." NARRATIVE THEORY AND PRACTICE Charon's explication of narrative theory is offered in all its complexity, and its precise language. The average physician reader (if I may so describe myself ) must pay full attention, remain alert at all times, and be prepared to suffer in order to gather the rewards of studying and comprehending this work. The author's intention is to define a field-that of narrative medicine-with the purpose of infusing medicine with narrative competence. A medicine practiced with narrative competence will more ably recognize patients and diseases, convey knowledge and regard, join humbly with colleagues, and accompany patients and their families through the ordeals of illness. These capacities will lead to more humane, more ethical, and perhaps more effective care. (p. vii, preface) One may well ask, how does this relate to the actuality of patient care? …

Narrative Medicine: Honoring the Stories of Illness

In The Five Dysfunctions of a Team, renowned author Patrick Lencioni turns his keen intellect and storytelling power to the fascinating, complex world of teams. Using his familiar writing style of incorporating fables, Lencioni tells the story of Kathryn Petersen, DecisionTech’s CEO, who faces the ultimate leadership crisis: How to unite a team that is in such disarray that it threatens to bring down the entire company. Will she succeed? Will she be fired? Lencioni’s tale serves as a timeless reminder that leadership requires courage and insight. As difficult as it is to build a cohesive team, it is not complicated. In fact, keeping it simple is critical, whether you run the executive staff of a multinational company, a small department within a larger organization, or even if you are merely a member of a team that needs improvement. Lencioni reveals the five dysfunctions that are at the very heart of why teams — even the best ones — often struggle. He outlines a powerful model and actionable steps that can be used to overcome these common hurdles and build a cohesive, effective team. Lencioni’s compelling fable offers a deceptively simple yet powerful message for all those who strive to be exceptional team leaders.

The Five Dysfunctions of a Team: A Leadership Fable

Professionals in healthcare are increasingly encouraged to work together. This has acted as a catalyst for research on interprofessional collaboration. Authors suggest developing interprofessional collaboration is not just the job of managers and policy makers; it also requires active contributions of professionals. Empirical understanding of whether professionals make such contributions and if so, how and why, remains fragmented. This systematic review of 64 studies from the past 20 years shows there is considerable evidence for professionals actively contributing to interprofessional collaboration. Although the evidence is limited, we can show they do so in three distinct ways: by bridging professional, social, physical and task-related gaps, by negotiating overlaps in roles and tasks, and by creating spaces to be able to do so. Professionals from different professions seem to make different contributions. Moreover, differences exist between collaborative settings and healthcare subsectors. We conclude by proposing a research agenda to advance our understanding of these contributions in theoretical, methodological and empirical ways.

https://www.tandfonline.com/doi/pdf/10.1080/13561820.2019.1636007

Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration

Objectives This article presents the findings from a scoping review which explored the nature of interprofessional online learning in primary healthcare. The review was informed by the following questions: What is the nature of evidence on online postgraduate education for primary healthcare interprofessional teams? What learning approaches and study methods are used in this context? What is the range of reported outcomes for primary healthcare learners, their organisations and the care they deliver to patients/clients? Setting The review explored the global literature on interprofessional online learning in primary healthcare settings. Results The review found that the 23 included studies employed a range of different e-learning methods with contrasting course durations, use of theory, participant mix, approaches to accreditation and assessment of learning. Most of the included studies reported outcomes associated with learner reactions and positive changes in participant attitudes/perceptions and improvement in knowledge/skills as a result of engagement in an e-learning course. In contrast, fewer studies reported changes in participant behaviours, changes in organisational practice and improvements to patients/clients. Conclusions A number of educational, methodological and outcome implications are be offered. E-learning can enhance an education experience, support development, ease time constraints, overcome geographic limitations and can offer greater flexibility. However, it can also contribute to the isolation of learners and its benefits can be negated by technical problems.

https://bmjopen.bmj.com/content/bmjopen/7/8/e016872.full.pdf

Interprofessional online learning for primary healthcare: findings from a scoping review.

__Aims and objectives__ To describe how nurse practitioners enact their role in outpatient consultations, and how this compares to their perception of their responsibility for patients with chronic conditions. 
__Background__ Nurse practitioners working with patients with chronic conditions seek to support them in self-managing their diseases. 
__Design__ An ethnographic study. 
__Methods__ Episodic participant observations (in total 48 hours) were carried out combined with formal interviews. The study population consisted of a purposive sample of nurse practitioners working in five outpatient clinics related to chronic care in one university medical centre in the Netherlands. Two different types of clinics were selected, namely (1) for patients with episodic flare-ups and (2) for patients with diseases requiring life-saving procedures. 
__Results__ The nurse practitioners perceived the monitoring of patients’ treatment as their main professional responsibility. Four monitoring strategies could be distinguished: ‘assessing health conditions’, ‘connecting with patients’, ‘prioritising treatment in daily living’ and ‘educating patients’. 
__Conclusion__ While nurse practitioners considered building a relationship with their patients of utmost importance, their consultations were mostly based on a conventional medical model of medical history taking. Little attention was paid to the social, psychological and behavioural dimensions of illness. Nurse practitioners in this study seemed quite successful in their extension into medical territory, but moving patients’ illness perceptions to the background was not conducive to self-management support. 
__Relevance to clinical practice__ By their medical subspecialty expertise, nurse practitioners have a major role in the longitudinal process of the management of chronic diseases’ treatment. Supporting patients to reduce the impact of the disease and its complications requires nurse practitioners to develop new coaching strategies designed to meet patients’ individual needs.

Rhetoric or reality? What nurse practitioners do to provide self-management support in outpatient clinics: an ethnographic study.

Individuals living with chronic kidney disease (CKD) must be mindful of their diet and exercise, take multiple medications, and deal with other compounding illnesses. We observed renal patients’ encounters with health professionals at a renal clinic for tensions and gaps in patients’ and health professionals’ understandings of “living well” with CKD. We found that the renal patients at the clinic become emotionally invested in the fluctuations in the numbers on their blood work. Narrative practices of health professionals greatly affect how patients emotionally deal with the possibility of dialysis, transplant, death, or aging. Expectations to “live well” can become a moral burden to be a “good” patient. The gaps between the priorities of patients, their caregivers, and health professionals complicate the notion of “living well” with CKD. Trust, rapport and the practice of listening appear to have the greatest impact in addressing these gaps.

Feeling Well and Having Good Numbers Renal Patients’ Encounter With Clinical Uncertainties and the Responsibility to “Live Well”

This study aims to explore how health care professionals in a multidisciplinary chronic kidney disease clinic interact with one another, patients, families, and caregivers to expand understanding of how this increasingly common form of chronic disease management functions in situ. Nonparticipatory observations were conducted of 64 consultations between patients and health care professionals and end-of-day rounds at a multidisciplinary chronic kidney disease clinic. Key themes in our findings revolved around the question of boundaries between the health professions that were expected to work cooperatively within the clinic, between medical specialties in the management of complex patients, and between caregivers and patients. Understanding the importance of various professional roles and how they are allocated, either formally as part of care design or organically as a clinical routine, may help us understand how multidisciplinary care teams function in real life and help us identify gaps in practice. This study highlights two areas for further study and reflection: the effect of discrepancies in health information and the role of caregivers in patient care.

/pdf/boundaries-gaps-and-overlaps-defining-roles-in-a-2c92d4h72d.pdf

Boundaries, gaps, and overlaps: defining roles in a multidisciplinary nephrology clinic.

Primary care providers need continuing professional development (CPD) in order to improve their knowledge and confidence in the care of patients with chronic conditions. We developed an intensive modular CPD program in the chronic disease management of HIV for primary care providers. The program combines self-directed learning, interactive tutorials with experts, small group discussions, case studies, clinical training, one-on-one mentoring and individualized learning objectives. We trained 27 family physicians and 7 nurse practitioners between 2011 and 2013. The trainees reported high levels of satisfaction with the program. There was a 136.76% increase in the number of distinct HIV-positive patients receiving HIV-related medication refills that were prescribed by the trainees.

Helen Kang

Papers

Feeling Well and Having Good Numbers Renal Patients’ Encounter With Clinical Uncertainties and the Responsibility to “Live Well”

Boundaries, gaps, and overlaps: defining roles in a multidisciplinary nephrology clinic.

Continuing professional development in HIV chronic disease management for primary care providers