http://science.sciencemag.org/content/sci/201/4359/899.2.full.pdf

Phenomenology of perception.

Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango)

ContextCurrent assessment formats for physicians and trainees reliably test
core knowledge and basic skills. However, they may underemphasize some important
domains of professional medical practice, including interpersonal skills,
lifelong learning, professionalism, and integration of core knowledge into
clinical practice.ObjectivesTo propose a definition of professional competence, to review current
means for assessing it, and to suggest new approaches to assessment.Data SourcesWe searched the MEDLINE database from 1966 to 2001 and reference lists
of relevant articles for English-language studies of reliability or validity
of measures of competence of physicians, medical students, and residents.Study SelectionWe excluded articles of a purely descriptive nature, duplicate reports,
reviews, and opinions and position statements, which yielded 195 relevant
citations.Data ExtractionData were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion
were broad, given the heterogeneity of interventions, complexity of outcome
measures, and paucity of randomized or longitudinal study designs.Data SynthesisWe generated an inclusive definition of competence: the habitual and
judicious use of communication, knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served. Aside from protecting the public
and limiting access to advanced training, assessments should foster habits
of learning and self-reflection and drive institutional change. Subjective,
multiple-choice, and standardized patient assessments, although reliable,
underemphasize important domains of professional competence: integration of
knowledge and skills, context of care, information management, teamwork, health
systems, and patient-physician relationships. Few assessments observe trainees
in real-life situations, incorporate the perspectives of peers and patients,
or use measures that predict clinical outcomes.ConclusionsIn addition to assessments of basic skills, new formats that assess
clinical reasoning, expert judgment, management of ambiguity, professionalism,
time management, learning strategies, and teamwork promise a multidimensional
assessment while maintaining adequate reliability and validity. Institutional
support, reflection, and mentoring must accompany the development of assessment
programs.

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Defining and Assessing Professional Competence

The physician's degree of resourcefulness, i.e., the ability to deal skillfully and promptly with new situations, is important for changing the health behaviors of patients within the constraints of a brief office visit. This quality, however, was in short supply among 15 primary care physicians selected for their interest in preventive medicine. The physicians tended to rely on a single approach for changing specific health behaviors of patients, restricted referrals to community services and other health specialists, relied almost exclusively on fear for motivating patients and expressed considerable pessimism about changing the health behaviors of older patients. The physicians uniformly reported that their inadequate education and the lack of reimbursement influenced how they counseled their patients. A good place to begin to rectify this situation is the required reading of the Guide to Clinical Preventive Services for medical students and residents, and continuing education opportunities for practic...

Guide to clinical preventive services: a challenge to physician resourcefulness

The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence, called narrative medicine, is proposed as a model for humane and effective medical practice. Adopting methods such as close reading of literature and reflective writing allows narrative medicine to examine and illuminate 4 of medicine's central narrative situations: physician and patient, physician and self, physician and colleagues, and physicians and society. With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. By bridging the divides that separate physicians from patients, themselves, colleagues, and society, narrative medicine offers fresh opportunities for respectful, empathic, and nourishing medical care.

/pdf/narrative-medicine-a-model-for-empathy-reflection-profession-4n1xbk2y8w.pdf

Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust

I: WHAT IS NARRATIVE MEDICINE 1. The source of Narrative Medicine 2. Bridging Health Care's Divides 3. Narrative Features of Medicine II: NARRATIVES OF ILLNESS 4. Telling One's Life 5. The Patient, the Body, and the Self II: DEVELOPING NARRATIVE COMPETENCE 6. Close Reading 7. Attention, Represenation, and Affiliation 8. The Parallel Chart III: DIVIDENDS OF NARRATIVE MEDICINE 9. Bearing Witness 10. The Bioethics of Narrative Medicine 11. A Narrative Vision for Health Care

Narrative Medicine: Honoring the Stories of Illness

Reflective writing is one established method for teaching medical students empathetic interactions with patients. Most such exercises rely on students' reflecting upon clinical experiences. To effectively elicit, interpret, and translate the patient's story, however, a reflective practitioner must also be self-aware, personally and professionally. Race, gender, and other embodied sources of identity of practitioners and patients have been shown to influence the nature of clinical communication. Yet, although medical practice is dedicated to examining, diagnosing, and treating bodies, the relationship of physicians to their own physicality is vexed. Medical training creates a dichotomy whereby patients are identified by their bodies while physicians' bodies are secondary to physicians' minds. As a result, little opportunity is afforded to physicians to deal with personal illness experiences, be they their own or those of loved ones. This article describes a reflective writing exercise conducted in a second-year medical student humanities seminar. The "personal illness narrative" exercise created a medium for students to elicit, interpret, and translate their personal illness experiences while witnessing their colleagues' stories. Qualitative analysis of students' evaluation comments indicated that the exercise, although emotionally challenging, was well received and highly recommended for other students and residents. The reflective writing exercise may be incorporated into medical curricula aimed at increasing trainees' empathy. Affording students and residents an opportunity to describe and share their illness experiences may counteract the traditional distancing of physicians' minds from their bodies and lead to more empathic and self-aware practice.

Personal illness narratives: using reflective writing to teach empathy.

A 36-year-old Dominican man with a chief symptom of back pain comes to see me for the first time. As his new internist, I tell him, I have to learn as much as I can about his health. Could he tell me whatever he thinks I should know about his situation? And then I do my best not to say a word, not to write in his chart, but to absorb all that he emits about his life and his health. I listen not only for the content of his narrative, but for its form — its temporal course, its . . .

Narrative and Medicine

Acknowledgements Introduction: Memory and Anticipation: The Practice of Narrative Ethics, Rita Charon and Martha M. Montello Part I: Narrative Knowledge 1. Narratives of Human Plight: A Conversation with Jerome Bruner, Jerome Bruner 2. The Ethics of Medicine, as Revealed in Literature, Wayne Booth 3. Like an Open Book: Reliability, Intersubjectivity, and Textuality in Bioethics, Laurie Zoloth and Rita Charon Part II: Narrative Components of Bioethics 4. Context: Backward, Sideways, and Forward, Hilde Lindemann Nelson 5. Voice in the Medical Narrative, Suzanne Poirer 6. Time and Ethics, Rita Charon 7. The Idea and Character, Anne Hunsaker Hawkins 8. Plot: Framing Contingency and Choice in Bioethics, Tod Chambers and Kathryn Montgomery 9. The Reader's Response and Why It Matters in Biomedical Ethics, Charles M. Anderson and Martha Montello Part III: Case Studies in Narrative Ethics 10. The Narrative of Rescue in Pediatric Practice, Walter Robinson 11. Beyond the Authoritative Voice: Casting a Wide Net in Ethics Consultation, Susan Rubin 12. Of Symbols and Silence: Using Narrative and Its Interpretation to Foster Physician Understanding, Marcia Day Childress 13. Narrative Understanding and Methods in Psychiatry and Behavioral Health, Richard Martinez 14. In the Abscence of Narrative, Julie Connelly Part IV: Consequences of Using Narrative Methods 15. Narrative Ethics and Institutional Impact, Howard Brody 16. Reconsidering Action: Day-to-Day Ethics in the Work of Medicine, John Lantos17. The Color of the Wallpaper: Training for Narrative Ethics, Anne Hudson JonesPart V: The Narrative Future of Ethics Practice 18. The Hyphenated Space: Liminality in the Doctor-Patient Relationship, Ronald Carson 19. Narrative Ethics, Gene Stories, and the Hermeneutics of Consent Forms, Larry Churchill 20. Narrative, Ethics, and Pain: Thinking with Stories, David Morries 21. The Story Inside, Joanne Trautmann Banks Notes on Contributors Permissions Index

Rita Charon

Papers

Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust

Narrative Medicine: Honoring the Stories of Illness

Personal illness narratives: using reflective writing to teach empathy.

Narrative and Medicine

Stories Matter: The Role of Narrative in Medical Ethics