The Power of Stories to Teach and Inspire

ACE Seminar, 12/9/14 Daniel Epner, MD Department of Palliative Care and Rehabilitation Medicine

A Perplexing Question

Epner DE, Journal of Clinical Oncology 2014

Stories with a teller, a listener, a time course, a plot, and a point.

Narratives Charon, Narrative medicine: honoring the stories of illness, 2006

Stories told by: Patients, families Doctors and other providers

Stories received Oral Written Filmed

Finding meaning Experiencing emotion Being inspired Educating

What is narrative medicine?

Attention: focused concentration on a person, text, or work of art that enables perception without distraction.

Representation: conferring of linguistic or visual form onto an experience so that it is perceived and communicated to self and others.

Affiliation: development of a shared commitment to the well-being of the patient, achieved through meaningful contact

Bring patients and clinicians into authentic contact as a prelude to action.

3 Foundational Movements of Clinical Practice Acad. Med 2014, Miller et al

Competence to absorb, interpret and respond to stories.

Enables the provider to practice with empathy, reflection, professionalism, and trustworthiness

Meaning is derived collaboratively, by the teller and listener, reader and writer, observer and observed, patient and physician.

Narrative competence: receiving story Charon, NEJM 2004

It takes 2 to tango Patient and provider share a story, experience it

and derive meaning from it in their own ways Stories are inspired by other stories Stories become part of our lived experience.

Intersubjectivity

What you say about narrative is very interesting, I hear repeatedly. Thanks so much for coming. But I have seven minutes per patient. End of story.

So, lets make the most of those 7 minutes

Standard Biomedical Practice as Narrative Morris, DB, The Permanente Journal/ Winter 2008

Like any instrument, narrative must be cost-effective.

However, costs must be calculated fairly, with an awareness of total costs. Litigation Error Unneeded diagnostic procedures Harmful end of-life intervention.

Fairly calculated, an ounce or two of narrative prevention pays big dividends.

Cost Effectiveness of NM Morris, DB, The Permanente Journal/ Winter 2008

Narrative acts sharpen the teller/writers perception and mobilize his or her imagination

Narratives trigger changes of many kinds in both the teller and the listener, yielding meanings that are reciprocally produced by each teller listener dyad.

Value of telling stories Charon, Acad Med 2012

Empathic witnessing (Kleinman) Build an illness narrative with a sick person that

will make sense of and give value to the experience

That sick person and the provider can be one and the same person.

Giving students and residents an opportunity to describe and share their illness experiences (or imagined ones) leads to more empathic practice.

Using Reflective Writing to Teach Empathy DasGupta and Charon, Acad Med 2014

The key point is that narratives, like personal identities or postmodern cities, dont just exist or arise: they are constructed.

Narratives are constructed. Morris, DB, The Permanente Journal/ Winter 2008

Writing about traumatic experience provides measurable health benefits.

Physicians and other providers not only treat trauma but also experience it as caregivers

We realized that the people who benefited from writing were constructing stories.

Writing is therapeutic Pennebaker JW, Seagal JD. J Clin Psychol 1999.

Receiving Great fiction novels Poems Thought provoking

movies Songs with lyrics Short stories

Telling / writing

Building Narrative Competence

Using reflective skills developed in practice

Listen to patients story

What does he mean when he says I hurt?

Why does she show up to clinic late?

Why does he talk so much?

Applying Narrative Competence Charon, Acad Med 2012

Active process Requires reflection

What does the author (patient) mean? How does this experience make me feel? How can I put my thoughts and feelings into

action? Inspires Educates

Close reading

A Perplexing Question

Epner DE, Journal of Clinical Oncology 2014

Relive the ancient customs of their ancestors.

sleep on luxurious comforters like those used by countless ancestors.

luxurious Bedouin tents with fluffy bedding, wool carpets, rich tapestries, and Old World grace.

Timelessness Connection to all of humanity

Close reading of A Perplexing Question Epner, JCO 2014

She described how happy she feels hearing her children laugh and squeal as they race up and down sand dunes, chase lizards, and fly kites.

She explained how safe and secure she feels sleeping on the floor of the tent among her children and husband.

calming fussy little boys and girls The power of a family's love Universality of human needs

Close reading of A Perplexing Question Epner, JCO 2014

I could imagine the indescribable beauty and vastness of the starry desert sky at night.

I imagined a desert night, with its warm sensuous breezes drifting through the tent

The sacred, spiritual, and mysterious power of nature and our connection to it

Our place in the Universe

Close reading of A Perplexing Question Epner, JCO 2014

I fondly recalled the many hikes with no particular destination, savoring life in every breath (Bushido)

Intersubjectivity of Stories

I moved the chair back into position by her bed and contemplated how much I would miss our daily conversations.

When he woke in the woods in the dark and the cold of the night hed reach out to touch the child sleeping beside him. Nights dark beyond darkness and days more gray each one than what had gone before. Like the onset of some cold glaucoma dimming away the world. His hand rose and fell softly with each precious breath. He pushed away the plastic tarpaulin and raised himself in the stinking robes and blankets and looked toward the east for any light but there was none

The Road Cormac McCarthy, Pulitzer Prize winner

Masahiro Motoki: Daigo Unemployed cellist Moves to childhood

home Accidentally becomes a

mortician Shunned by wife and

others due to stigma around death

Departures Winner of 2009 Academy Award for best foreign film

First Job: 32:55-36:01 Daigo sees the light: 1:21-

1:24:06

Affirmation of life: 1:24:06-1:30:25

Departures Winner of 2009 Academy Award for best foreign film

I have seen how the seemingly smallest gestures often provide the most immense comfort. Paradoxically, it is perhaps in those moments that we have the greatest power to heal.

The Watchman Weinberg RB, Annals of IM 2012

Tentative September 2015 Doctors, nurses, social workers, chaplains,

writers, others Co-sponsored by MDACC, BCM, UTHSCH Plenary sessions and small groups Participants share stories Reflective writing

Proposed Narrative Medicine Conference

In the practice of our art we are each like a solar system, our patients revolving around us like planets around a sun. Some whirl furiously in close orbits, seeking our warmth; others circle more lazily at a distance; and others, like comets, streak through our reach only once in a lifetime. What keeps them all from spinning off into the cold and lonely vacuum of space is the gravity of our love.

First Love Weinberg, RB, Annals of IM 1997

The Power of Stories to Teach and InspireEpner DE, Journal of Clinical Oncology 2014NarrativesCharon, Narrative medicine: honoring the stories of illness, 2006What is narrative medicine?3 Foundational Movements of Clinical PracticeAcad. Med 2014, Miller et alNarrative competence: receiving storyCharon, NEJM 2004IntersubjectivityStandard Biomedical Practice as NarrativeMorris, DB, The Permanente Journal/ Winter 2008Cost Effectiveness of NMMorris, DB, The Permanente Journal/ Winter 2008Value of telling storiesCharon, Acad Med 2012Using Reflective Writing to Teach EmpathyDasGupta and Charon, Acad Med 2014Narratives are constructed.Morris, DB, The Permanente Journal/ Winter 2008Writing is therapeuticPennebaker JW, Seagal JD. J Clin Psychol 1999.Building Narrative CompetenceApplying Narrative CompetenceCharon, Acad Med 2012Close readingEpner DE, Journal of Clinical Oncology 2014Close reading of A Perplexing QuestionEpner, JCO 2014Close reading of A Perplexing QuestionEpner, JCO 2014Close reading of A Perplexing QuestionEpner, JCO 2014Intersubjectivity of StoriesThe RoadCormac McCarthy, Pulitzer Prize winnerDeparturesWinner of 2009 Academy Award for best foreign filmDeparturesWinner of 2009 Academy Award for best foreign filmThe WatchmanWeinberg RB, Annals of IM 2012Proposed Narrative Medicine ConferenceFirst LoveWeinberg, RB, Annals of IM 1997