Narrative medicine as a medical education tool: A systematic review

Figures & data

Table

Practice points

Narrative medicine interventions in the medical school setting consistently employ close reading, creative reflection, and group discussion as a pedagogic strategy. A variety of qualitative and quantitative tools have been employed to measure the outcomes of narrative medicine classroom interventions with the most common being surveys, observation, pre- and post-tests, and focus groups. Studies that have attempted to assess the short-term outcomes of a narrative medicine intervention report positive changes in attitudes, perceptions, attainment of new knowledge and skills as well as positive changes in behavior in subsequent settings. Studies that attempted to assess long-term changes in organizational practice or patient interaction reported an improved awareness of patients’ perspectives and better collegial collaboration.

Figure 1. PRISMA flow diagram of literature search.

Table 1. Best Evidence Medical Education (BEME) coding scheme for strength of evidence and Kirkpatrick-based outcomes.

BEME strength of evidence scale
1	No clear conclusions can be drawn—results based on testimonial evidence of authors
2	Ambiguous results, there may be a trend—tool(s) for analysis exhibit insufficient power, small sample size, other intervening factors
3	Conclusions can probably be based on the results—tool(s) used for analysis have sufficient power to assess the outcome
4	Results are clear and very likely to be true—multiple tools for analysis with sufficient power and explicit triangulation of results
5	Results are unequivocal
Kirkpatrick-based outcome levels
Level 1	PARTICIPATION Affective reactions and feedback by students (for example: learning experience, course organization, materials, quality of instruction, feelings of pleasure or enjoyment) Instruments—surveys, questionnaires, comment forms
Level 2a	MODIFICATION OF ATTITUDES OR PERCEPTIONS Changes in attitudes towards intervention (for example, sense of personal or professional growth, increase in empathy, new sense of affiliation or connectedness) Instruments—observation, pre- and post-tests, interviews, focus groups
Level 2b	MODIFICATION OF KNOWLEDGE AND SKILLS For knowledge: acquisition of concepts, procedures, or principles. For skills: acquisition of thinking an problem-solving. Instruments—observation, pre- and post-tests, interviews, focus groups, course writing samples
Level 3	BEHAVIORAL CHANGE Evidence that knowledge and skills learned in course have been applied in subsequent contexts Instruments—creative final product (papers, projects, portfolios), surveys, observation
Level 4a	CHANGE IN ORGANIZATIONAL PRACTICE Attributable changes in organization or delivery of care Instruments—alumni surveys, patient and/or employee feedback
Level 4b	BENEFITS TO PATIENTS AND CLIENTS Improvement in health and well-being of patients as a direct result of classroom intervention Instruments—patient feedback

Table 2. Data extraction from included articles (N = 36).

	Author		Country	Course level	Type of course	Course duration	# and duration of sessions	# of participants	NM intervention: (1) close reading; (2) Writing; (3) Discussion	Kirkpatrick outcomes	Strength of evidence
		Description of nm course, pedagogy, or pedagogic tool
1	Charon, Hermann, et al. 2016		US: Columbia University	Medical school physicians and surgeons	Required	4 Years of medical school	Not stated	Not stated	1 2 3	NA		1
2	DasGupta 2003		US: Columbia University	Second-year medical students	Elective	6 Weeks	Not stated	Not stated	1 2 3	NA		1
3	Devlin 2015		US: Columbia University	Faculty development seminar	Faculty	Ongoing	Weekly	15	1 2 3	NA		1
4	Graham 2009		US: Brighton, Michigan	Residents	Required	3 Years	Unspecified; part of “resident wellness” curriculum	Not stated	2 3	NA		1
5	Grossman 2015		Brazil: University of the State of Rio de Janiro	Medical school: adolescent health care	Elective in virtual learning environment	Not stated	2 sessions per unit, # of units not specified	Not stated	1 2 3	NA		1
6	Hellerstein 2015		US: Columbia University	Preclinical students	Elective option in required nm curriculum	6 Weeks	Weekly 3-h sessions	12	1 2 3	NA		1
7	Kissler 2016		US: Baylor College of Medicine	First-year medical students	Required	Single session	1-h session	17	1 2 3	NA		1
8	Pearson 2008		US: Vanderbilt	Third year surgical clerkship students	Required	Single session	Not stated	33	2 3	NA		1
9	Wald et al. 2010		US: Brown University	First and second year medical students	Required	2 years	Weekly sessions	Not stated	2 3	NA		1
10	Wald 2011		US: Brown University	First and second year medical students	Required	2 Years	Not stated	Not stated	2 3	NA		1
11	Wear and Aultman 2005		US: Northeastern Ohio University	Fourth year medical students	Elective	Not stated	Not stated	Not stated	1 2 3	NA		1
12	Weiss and Swede 2016		US: Indiana University	Undergraduate and graduate students	Required	Not stated	Not stated	Not stated	1 2 3	NA		1
13	Wittenberg 2017		US: trainees from 50 states and 88 countries	Professional development	Elective	Not stated	Not stated	Not stated	2 3	NA		1
		Assessment of nm course with qualitative, quantitative, or mixed-methods analysis
14	Balmer and Richards 2012		US: Columbia University	Continuing professional development	Faculty	Ongoing	Weekly 90-min sessions	8	1 2 3	2a; 2b; 3; 4a		2
15	DasGupta 2004		US: Columbia University	Second-year medical students	Elective	6 Weeks	6 sessions	16	1 2 3	1; 2a		2
16	DasGupta 2006		US: Columbia University	Second-year residents	Unclear	14 Months	Thirteen 1–1.5 h sessions	40	1 3	1; 2a		2
17	Feigelson and Muller 2005		US: Mount Sinai	Second-year medical students	Elective	21 Weeks	Seven 2-h sessions	8	1 2 3	1; 2a		2
18	Garrison 2011		US: University of Rochester	Third-year medical clerkship students	Required	Half semester	One session	44	2 3	1		2
19	Liben 2012		Canada: McGill University	Faculty development seminar	Faculty	Single session	Half-day	10	1 2 3	1; 2b		2
20	Liu 2016		US: Yale	Third year medical students	Required	Single session	1 h	25	2 3	1; 2a		2
21	Maurer 2006		US: Columbia University	Medical interns	Rotation	1 month	Five half-day sessions	60	2 3	2a; 2b;		2
22	McDonald 2015		England: Manchester Medical School	Third-year medical students	Elective	4 Weeks	Weekly workshops	6	2 3	2a		2
23	Miller 2014		US: Columbia University	Medical students: physicians and surgeons	Required	Half-semester	“Intensive” seminars: specific number not stated	130	1 2 3	2a; 2b		2
24	Ross 2014		US-Yale	Residents	Not stated	3 Months	12 sessions	12	1 3	1; 2b		2
25	Tsai and Ho 2012		Taiwan-National Taiwan University Hospital	Residents	Random sample	Single session	Not specified	15	2 3	2b		2
26	Vannatta 2013		US-University of Oklahoma	Senior medical students from the honors college	Elective	Not stated	3-h sessions		1 2 3	2a; 2b		2
27	Welch and Harrison 2016		US: Florida State University	Fourth year medical students	Elective	4 Weeks	Weekly 1-h sessions	13	1 2 3	1		2
28	Wesley 2018		US: Louisiana State University	First year residents	Elective	Academic year	Twelve 45-min sessions	13	1 2 3	1; 2a		2
29	Winkel 2010		US: Columbia University	Residents	Required	Unclear	6 1-h sessions at 6 week intervals	18	1 2 3	1; 2a		2
30	Winkel et al. 2016		US: NYU, University of Chicago, University of Vermont	Residents	Required	Unclear	15 1-h sessions at 4–8 week intervals	43	1 2 3	2a; 2b		2
31	Al-Imari et al. 2016		Canada: Ontario	Continuing professional development	Elective	6 Months	3 1-h sessions	8	2 3	1; 2b		3
32	Bhavaraju and Miller 2014		US: Phoenix Children’s Hospital	Continuing professional development	Faculty	1 Year	Monthly sessions	12	1 2 3	2a; 2b; 3		3
33	Chretien 2015		US: Washington DC	Third-year medical clerkship students	Pilot study	4 Weeks	Three sessions	31	1 2 3	1; 2a; 2b;		3
34	Cunningham 2018		US: Columbia University	First year medical students	Required	1 Semester	Not stated	97	1 2 3	2b		3
35	Sands 2008		US: Columbia University	Continuing professional development	Faculty	6 Weeks	Weekly seminars	19	2 3	2a; 2b		3
36	Arntfield et al. 2013		US: Columbia University	Undergraduate	Elective	1 Month	“Intensive” course load	12	1 2 3	1; 2a; 2b; 3; 4a		4

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