Assessing a faculty development workshop in narrative medicine

Abstract

Background: Narrative medicine is increasingly popular in undergraduate medical curricula. Moreover, although faculty are expected to use narrative approaches in teaching, few faculty development learning activities have been described. In addition, data on the impact of faculty development initiatives designed to teach narrative are limited, and there is a paucity of tools to assess their impact.

Aims: To assess the impact and outcomes of a faculty development workshop on narrative medicine.

Methods: Two groups of clinical teachers were studied; one group had already attended a half-day narrative medicine workshop (N = 10) while the other had not yet attended (N = 9). Both groups were interviewed about their uses of narrative in teaching and practice. Additionally, the understanding of a set of narrative skills was assessed by first viewing a video of a narrative-based teaching session followed by completion of an 18-item assessment tool.

Results: Both groups reported that they used narrative in both their teaching and clinical practice. Those who had attended the workshop articulated a more nuanced understanding of narrative terms compared to those who had not yet attended.

Conclusion: This study is one of the first to describe measureable impacts of a faculty development workshop on narrative medicine.

Introduction

The field of narrative medicine has emerged (Donald 1998; Greenhalgh 1999; Charon 2004; Thernstrom 2004; Carr et al. 2005; Charon 2006; Divinsky 2007; Langellier 2009) as one way to improve healthcare provider responses to both the suffering of patients (manifesting as a caring and compassionate attitude) and to their own suffering (related to burnout and depression) (Charon 2001). One definition of narrative medicine refers to the ability to “acknowledge, absorb, interpret, and act on the stories and plights of others” (Charon 2001). While there is a paucity of data in the literature on how to assess narrative medicine teaching and learning, and on the more difficult issue of assessing its impact on the clinical practice of physicians (Ousager & Johannessen, 2010), it is nonetheless being taught in many medical schools. At McGill University, a half-day faculty development workshop on narrative medicine has been offered for the past seven years (Appendix 1). This study was designed to assess the learning impact of this narrative medicine faculty development workshop.

In our context, a four-year longitudinal mentorship course entitled “Physician Apprenticeship” has the primary responsibility of facilitating medical students’ transition from layperson to physician (Steinert et al. 2010). The Physician Apprenticeship groups consist of six students, one clinical teacher/mentor (called an “Osler Fellow”) and, occasionally, one or two senior medical students. The groups meet regularly throughout the four years of medical school. Osler Fellows are faculty members in the Faculty of Medicine of McGill University, who are selected based on their availability and reputation for excellent teaching. There are currently 180 Osler Fellows teaching the approximately 600 medical students in the four-year undergraduate curriculum. Osler Fellows are invited to participate in a series of faculty development workshops with the goal of preparing them to fulfill their roles as mentors. One such half day workshop, entitled “Introduction to Narrative Medicine”, begins with a didactic session followed by small group reading and writing exercises (Appendix 1).

Table

Practice points

Clinical teachers are using narrative in both their teaching and clinical practice. It is possible to assess narrative skills after a faculty development workshop with the use of a trigger video (of small group narrative medicine teaching session) coupled with a narrative skill assessment tool. Clinical teachers that participate in a faculty development workshop in narrative medicine demonstrate enhanced use of narrative terminology.

The narrative medicine skills emphasized and practiced in the faculty development workshop are to recognize understand and appreciate tone, diction, genre, timing, metaphors, imagery, and first, second and third person viewpoint. Teaching narrative medicine to medical students and residents has thus far been conducted in a small group context wherein relevant literature is read and analyzed and where writing exercises are practiced. As such small group narrative skills teaching requires large numbers of clinical teaching faculty who themselves need training, we designed a faculty development workshop for Osler Fellows.

While there are some evidence in the literature of the impact of narrative medicine courses on medical students and residents (Radwany & Adelson, 1987; Calman et al., 1988; Marshall & O'Keefe, 1995), we were not able to find evidence on how learning was assessed following a faculty development intervention in the teaching of narrative-based skills. While many questions about narrative medicine remain unresolved (e.g. its exact definition; how and when to best to teach it; and its ultimate impact on improving medical care), this study focused on how to assess the learning impact of specific narrative skills after attending a faculty development narrative medicine workshop when compared with a control group that had not yet attended the workshop. Because there were no existing assessment tools appropriate for our needs, we developed a novel trigger video and a narrative skills assessment tool (NSAT) to assess the learning impact of the workshop. In order to have a baseline to contextualize the findings, we also examined the extent to which narrative medicine was already being used by clinical teachers in their teaching and clinical practice.

Methods

Research design

This qualitative study, approved by the McGill Institutional Review Board, examined and compared two groups of Osler Fellows. The first group attended the faculty development workshop within the previous one–three years, and is referred to as attendees. The second group had not yet attended the workshop and is referred to as non-attendees.

Participant recruitment

Letters of invitation explaining the study and offering a small stipend were sent out to the two groups of Osler Fellows as follows:

1. Workshop attendees: From 2007 (F = 6, M = 12), 2008 (F = 3, M = 15), 2009 (F = 7, M = 10) a total of 53 (F = 16 M = 37) Fellows attended the workshop. Out of the 53, 10 fellows from each year (2007 F = 4, M = 6; 2008 F = 2, M = 8; 2009 F = 5, M = 5) were randomly selected to receive letters of invitation. Of the 30 letters sent out, 10 fellows in total (F = 1, M = 9) responded positively, representing family medicine, internal medicine, biomedical ethics, geriatrics and surgery.

2. Workshop non-attendees: Out of the total of 26 new 2010 fellows (F = 8, M = 18) who had not yet attended the workshop but were scheduled to do so in the following year, 15 were randomly selected (F = 3, M = 12) to receive letters of invitation (F = 1, M = 8). Those who responded positively represented pediatrics, pathology, emergency medicine, internal medicine, neurology, and surgery.

Research tools

The following three research tools were developed:

1. Semi-Structured Interview – In order to examine Fellows’ use of narrative in undergraduate and postgraduate teaching and in professional practice, a semi-structured interview guide was developed (Appendix 2).

2. Video – In order to have a consistent tool to assess participants’ ability to evaluate narrative teaching and learning in action, a trigger video clip was developed. This video depicted a typical small group narrative teaching session between a Fellow and a group of students. Out of 153 third-year medical students who were invited, the first 12 to respond were accepted to participate. Two 60-minute sessions, structured as a teacher-led discussion based on a reflective writing exercise, were then conducted and videotaped, each led by two of the study authors who are themselves are experienced Osler Fellows. From the resulting 120 minutes of video, 15 concurrent minutes were chosen to be used as the trigger video for study participants. This 15-minute video clip demonstrated a small group discussion resulting from a student reading aloud her written narrative that focused on her thoughts and feelings of inadequacy and powerlessness in an emergency room situation.

3. Narrative Skills Assessment Tool (NSAT) (Table 1) – In order to assess how participants in both study groups rated the teacher's use of narrative in the video, a set of 18 written assessment criteria was developed for the Narrative Skills Assessment Tool (NSAT).

   Table 1.  Narrative skills assessment tool (NSAT)

   “The facilitator”	N/A	Not done		Done	Done well
   Relevant to close reading and creative writing
   1. Provides ground rules for conduct of the session and gives clear instructions to students (e.g., outlines session goals, confidentiality agreement, participation in sharing stories/opting out)
   2. Attends to students’ feelings and emotions as expressed verbally and non-verbally
   3. Demonstrates and role models effective listening skills (e.g., does not interrupt)
   4. Attends to structural elements of the text (e.g., author vs. narrator, metaphors, time sequence, genre, imagery)
   5. Attends to the narrative point of view chosen (e.g., first, second or third person)
   6. Explores aspects of the story that may have been omitted
   7. Seeks out different meanings and perspectives from all students
   8. Allows for ideas to emerge from the group
   9. Avoids direct confrontation in the face of controversial student text/comments, and instead raises questions to the group to address the issues
   10. Closes session by inviting student reflections on what transpired or what was learned
   Relevant to close reading
   11. Instructs students to first read the text quietly to themselves, and then asks to have it read aloud
   Relevant to creative writing
   12. Provides clear directions (e.g., gives a prompt, times and stops the writing)
   13. Ensures that the students’ stories remain the focus (i.e., does not dominate the session)
   14. Ensures that the author has priority and ultimate voice in interpreting their own text (i.e., is permitted to opt out of sharing their story and is invited to have the last word after group discussion)
   15. Redirects appropriately when students begin to paraphrase or overly interpret their writing (i.e., ensures that the emphasis is directly on students’ text)
   16. Directs questions to the author and to the listeners about the text (i.e., other group members)
   17. Involves students through invitation, rather than enforcing the sharing of stories
   18. Demonstrates appreciation of the students’ stories

NSAT development proceeded using an adapted Delphi process (Hasson et al. 2000) that took place in four iterations as follows.

Two authors (SL & DB) independently developed a list of narrative teaching skills thought to be the most salient, resulting in two initial lists of 42 and 25 items. The combined 67-item list was returned to these two authors to eliminate redundant items resulting in a new list of 37 items. All five authors then rated each of the 37 items as either less important, important, or very important along with brief explanations for each choice. The rated 37 item list was then circulated to all five authors and discussed in a face-to-face meeting that resulted in consensus of a newly refined 18 item list. The 18 item list was then sent for feedback to an external expert in narrative medicine and minor adjustments were made to the wording of the final NSAT.

Research protocol

One of the authors (KC) met with each research participant to explain the study and obtain participant written consent. Both workshop groups (attendees and non-attendees) then followed the same 90-minute research protocol as follows:

• First, we conducted a semi-structured interview to examine participants’ current use of narrative in their undergraduate and postgraduate teaching, and in their professional practice. The interviewer did not define the term “narrative” and interviewees were free to use their own definition in answering questions.

• Second, having completed the semi-structured interview, participants then watched the 15-minute trigger video.

• Third, after having watched the video, each participant was asked the open-ended question: “Having seen the video, and with respect to running a narrative based small group, what do you think the Osler Fellow did well and not so well?”

• Fourth, participants were then given the NSAT to complete.

• Fifth, in a post-NSAT interview participants were asked to explain the rationale they used for each of the 18 NSAT answers they provided.

Responses of participants from both study groups (attendees and non-attendees) were audio-recorded and transcribed for later analysis.

Data analysis

In order to establish a baseline context for clinical teachers’ use of narrative medicine in their teaching and professional practices, an initial analysis completed by one author (KC) involved reading the transcripts and creating initial themes. In the next step themes were discussed with the other four authors in a face-to-face meeting wherein areas of agreement and disagreement were discussed and consensus was achieved on final themes.

In order to assess learning after participating in the workshop responses to the 18-item NSAT and post NSAT, interviews were reviewed by all authors, first individually and then in a group meeting. Three NSAT items were selected for post-NSAT interview qualitative analysis based on their specificity to narrative medicine. These three narrative-specific items were: Item 4 (attends to structural elements of the text), Item 5 (attends to the narrative point of view chosen), and Item 6 (explores aspects of the story that may have been omitted). Analysis of possible differences between the two groups in the post NSAT interview responses to these three items was examined independently by three authors (DB,SL,KC) blinded to attendee or non-attendee group. Findings were then further discussed in a group meeting with all authors until consensus was reached.

Results

Clinical teachers’ use of narrative in teaching and clinical practice

Data from the semi-structured interviews revealed that the majority of clinical teachers used narrative in both their teaching and clinical practice: 17/19 in undergraduate teaching, 12/19 in postgraduate teaching, and 17/19 in professional practice. Most participants were able to easily answer the questions and gave concrete examples of how they used narrative. Their responses were also indicative of the particular way they themselves each defined what “using narrative” meant to them. A workshop participant described his use of narrative with undergraduates as follows:

I just asked them “write about when you got in [to medical school]” … , it floored me what they came back with. Some of them got in off the waiting list, some of them it was the biggest moment of their lives, some of them it was the biggest moment of their parent's lives, some of them said ‘Eh, it happened, and it passed’. And each person's reaction to their moment when they got in – everybody in the room was surprised. And, it brought them closer together as a group … A (attendee) 3

Another workshop participant described his use of narrative in professional practice:

A few patients who will, they will tell me, that they have trouble talking about some things that are difficult for them to talk about. And I will say, “Why don't you write them down? “And I have one or two patients who will come with a diary, and ask me to read it. And I say “Look, I'm going to read this and we'll talk about it next time.” You know, so, if someone really expresses to me the feeling that they have trouble saying things, that they can write things more easily, then I ask them to write it, bring it in, in a narrative form. A5

Those who had attended the workshop were able to explicitly and clearly articulate how they used a narrative approach. For example the workshop attendee below indicated that he assigns specific readings to his residents as a basis for a narrative teaching session:

… the book the ‘Bell Jar and the Butterfly’ so that's the story of the story of the French editor who has locked in syndrome. There was a movie that was made of it. Because we take care of patients on the wards who cannot express themselves and we often treat those people as less than human. … So by reading that book, or selections in that book and seeing that it has implications in the care of patients I think opens up their eyes to the fact that people that look as if they have no humanhood, in fact, do. A4

For those who did not attend the workshop, the use of narrative appeared to be more implicit than explicit as demonstrated by this participant who was unsure as to the exact definition of a narrative approach:

Like I usually tell a story when we talk about brain tumors about a guy who I was with who had a meningioma and before the diagnosis was made he had a vision of the Virgin Mary who told him he had to go preach and he did that for a year in Scotland and eventually he had a seizure and they took out the meningioma, but I tell the story about that to give sort of an experience for them of what it can do. So if that's narrative, the narrative approach, then I have used it … . NA (non-attendee) 5

Comparison of narrative understanding in workshop attendees compared to non-attendees

Analysis of the responses of the 18-item NSAT revealed no consistent differences in the frequency of the four possible responses to each item (Not applicable/Not done/Done/Done well) between those who attended and those who had not yet attended the workshop. However, qualitative analysis of items on the NSAT that were considered to be most highly specific to the understanding of narrative and less representative of generic small group facilitation revealed subtle differences between the attendees and non-attendees. Those who attended the workshop described what they saw on the video using a nuanced technical vocabulary, suggesting that they had acquired a more elaborated and enhanced understanding of narrative.

For NSAT item 4 (attends to structural elements of the text, e.g., author versus narrator, metaphors, time sequence, genre, imagery) attendees showed a trend to use more narrative-specific terms such as prose, poetry, tense, sequence, and imagery. For example, this attendee used specific terms related to temporality, imagery and genre;

I mean time sequence: it was a linear story over a very short period of time and the imagery was great. I mean, I don't think it was difficult for him because the narrative was very … it was almost poetic A3

Attendees were also specific about the narrative point of view they observed being addressed in the video:

 …  we can indicate the author's … whether they're first person, third person. Is this a past event? A future event … ? A9

While workshop non-attendees often did mention imagery, there was a tendency for this group to use more non-specific language and more colloquial terms compared to attendees. This non-attendee mentioned imagery and used more general non-specific language to describe what he saw:

The on-screen leader did a good job sort of prompting discussion around specific language that was used for example, you know, holding the head and he made … he was talking specifically about the point that she used, the term “earth” at one point or “ground” … holding to the ground so he did … it seemed to me that he paid, you know, quite good attention, and he brought up things about powerful imagery and I think he did … I think that was done very well. NA14

For item 5 (attends to the narrative point of view chosen) one attendee specifically highlighted the narrative point of view used in the video;

… this kind of thing people write in the third person and when it's written in the third person there is a natural, there's always the question of “the patient did this”. That's how we tend to write in the medical report. And that distances us from the patient … A4

Non attendees used less specific language to describe the narrative point of view in the video:

… the first narrative position is that of the patient but I’m not 100 percent sure about that, or is it the person who is recounting the story? That I don’t know. So I don’t know, there are probably definitions … NA18

For item 6 (explores aspects of the story that may have been omitted) there was a general consensus in both attendees and non-attendees that the teacher in the trigger video did not demonstrate this skill as thoroughly as they would have liked. Both groups of participants would have preferred the teacher to have explored additional aspects of the story, especially those related to patient experience and outcomes, in addition to the student's involvement in the story.

One non-attendee wanted to know more than what the student wrote about and said:

He really dealt only with what she had said and he didn’t get into other things like well, how would you have felt if she had died? Or, things that might have been part of her story, you know, did you get blood on your hands and how did that make you feel if you didn’t have gloves? NA5

Another participant appeared frustrated that what ultimately happened to the patient was not explored further by the teacher who:

Didn't really focus on what was omitted from [the patient's] story. And in the end, ‘well, the person survived’. That's a … He kind of didn't address it but, that's a big thing! The outcome: you’re in medical school not just to take care of people, you're in medical school to take care of people and not succeed or fail but, not having that in the story is interesting. Because, it almost didn't matter to the narrative if the woman did well or not. A2

Discussion

We originally developed a new narrative medicine faculty development workshop with the intention of having clinical teachers use some of the learned narrative skills with their groups of medical students in the Physician Apprenticeship course. This study was designed to assess whether the faculty development workshop was effective in introducing faculty teachers to specific skills in narrative medicine. Because we could not find existing narrative medicine assessment tools in the literature, exploring the learning impact of the workshop required the development of new ones in the form of the trigger video and NSAT.

In order to contextualize the results of the workshop intervention, we first set out to establish how narrative was already being used by this group of clinical teachers. Data from the semi-structured interview revealed that the majority of study participants already use a form of narrative in their teaching of undergraduate and postgraduate learners as well as with patients. When we looked for possible differences between those who did and did not attend the workshop, we found that those who attended displayed a more nuanced understanding of narrative as revealed by their (appropriate) use of specific narrative medicine descriptors. The group that had not yet attended the workshop demonstrated more implicit understanding of narrative and appeared to be less able to define narrative terms and to articulate how one can use narrative medicine with students and patients.

The two novel narrative assessment tools (the NSAT and the trigger video of a narrative small group teaching session) are “first generation” in that they were designed specifically for this study. The 15-minute trigger video of a small group discussion after a student read aloud her written narrative was chosen because of the perceived depth of material in the student's story and because it showed the teacher performing some tasks well and others less well. While the trigger video was useful in eliciting participants ability to evaluate another teacher “in action”, it remains to be proven what exact content, time-frame, and setting is most useful for a trigger video. An additional beneficial outcome of developing the video for this study is that the video can now be used as teaching tool in large group plenary sessions of the workshop to demonstrate narrative teaching and learning in action.

The novel 18-item NSAT used in this study was developed to identify and assess the different elements of narrative teaching. The NSAT incorporated questions related to both the assessment of specific narrative skills as well as generic small group facilitation skills. The teaching of narrative in a small group setting requires a safe environment for learning (and the sharing of potentially emotional stories), and as such small group skills are a requisite part of the NSAT. The list of individual NSAT items therefore included many skills that are non-narrative medicine specific. This list of non-narrative specific items became longer than the narrative specific skills as the NSAT was iteratively created. Future versions of the NSAT may benefit from further deconstruction of the current narrative-specific items. For example, future generations of the NSAT may expand upon the current version of item 4, that groups the structural elements of the text together (author vs. narrator, metaphors, time sequence, genre, imagery), into separate NSAT items for each element.

Comparing post-NSAT interview data between the two groups revealed that those who had participated in the workshop had a more nuanced understanding of different narrative skills when compared to those who had not yet attended the workshop. At the same time, although workshop attendees were better able to articulate narrative terminology, it remains to be shown whether this translates into more effective teaching. In addition, we did not control for how much previous narrative experience participants had, or for how much they may have incorporated such skills into their usual teaching. Such factors are likely have an influence on their ability to assess the kinds of narrative skills shown in the trigger video.

The trigger video elicited comments from both groups on a perceived lack of questioning (by the small group leader) of what actually happened to the patient who was the focus of the student's reflective writing. Several participants in both groups appeared frustrated that the patient's outcome in the student's story was not highlighted by the group leader in the video, even though it was not necessarily relevant to the learning objectives of the narrative session being portrayed. In comparison to the clinical setting where patient outcome is of paramount importance, when medical students are writing about what happened during a narrative workshop, what is more salient than patient outcome is the question of why this student decided to write about this incident. In other words, the patient in this instance is the subject of a student's story and is not currently requiring care. It is the motivations and significance of what the student's story is about that is important in such a writing exercise. Understanding this mismatch between the intentions of the writing exercise from the usual goals of clinical medicine can assist in narrative skills teaching. This potential misunderstanding of the goals of the writing exercise can be articulated and resolved in group discussion so that clinical teachers of narrative skills can then focus on the meaning of the written story as it is written, and less on patient outcomes that are not as relevant for this exercise. This finding has important implications for future faculty development workshops in narrative medicine and is one immediate outcome of this study.

The generalizability of the study findings are limited by the selection of study participants who, as Osler Fellows, are a group (n = 180) of clinical teachers selected for their willingness to teach and guide a group of medical students over four years. At the same time, it may be possible for other medical schools to select and support a similar group of faculty to teach and mentor their own medical students. Another limitation of the study is the larger number of men versus women who were both Osler Fellows and study participants. It remains unknown how gender impacts on the learning and use of narrative. Sample size limitations are that 10/30 attendees and 9/15 workshop non-attendees choose to participate and the results may have been different with a larger sample. It is encouraging to see the diverse range of disciplines of those who did choose to participate in the workshop (e.g., family medicine, geriatrics, internal medicine, and general surgery).

Conclusion

This article responds to a gap in the literature on how to assess faculty development initiatives on teaching narrative medicine. Using the NSAT and trigger video, specialized assessment tools developed for this study, allowed for a preliminary analysis of narrative learning after attending a faculty development workshop. Our study revealed that most clinical teachers already use narrative for teaching, that it is possible to assess some aspects of narrative medicine learning, and that there may be identifiable differences in narrative knowledge after a brief workshop intervention.

More research is required (1) to refine the NSAT by further deconstructing the narrative-specific skills (2) to assess whether repeated exposure (booster sessions) to faculty development initiatives in narrative medicine lead to increased narrative medicine learning, and (3) to better understand how and why clinicians use narrative medicine in their teaching and practice, and its impact on patient care and student learning.

Acknowledgements

We are grateful to Dr Rita Charon for her comments in the development of the NSAT and to Michaela Knot for her assistance in organizing the qualitative data. We would also like to acknowledge the Royal College of Physicians and Surgeons of Canada for the Medical Education Research Grant they provided for this project.

Declaration/Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Appendix 1: Introduction to narrative medicine: A half-day faculty development workshop

Plenary: Introduction to narrative medicine (90 minutes)

In addition to a large group lecture format, this session also includes two large group interactive exercises. The first is a close reading of a poem (“Coats” by Jane Kenyon). The second is a brief 5 minute writing exercise (“Write about your name”) with volunteers reading aloud what they wrote. During these activities the plenary speaker responds with questions and comments simulating what could happen in a small group teaching session with students.

Refreshment Break (15 minutes)

Small group practicum: Applying narrative medicine (60 minutes)

Groups of six–seven faculty members (Osler Fellows) are led by a faculty member experienced in small group facilitation and familiar in the use of narrative techniques. A handout is provided for each participant with a set of narrative group guidelines for both a close reading and a creative writing exercise. The facilitator explains that the current session is a model for how they may choose to run a narrative small group exercise with their own students. The first part of the session is a close reading of a short story (or poem) and subsequent discussion. The second part is a small group writing exercise on “a clinical encounter that involved suffering” that is followed by an open discussion and debriefing.

Incorporating narrative medicine into physician apprenticeship (45 minutes)

The large group is reconvened for a discussion on ways to incorporate what was learned into the Physician Apprenticeship small group meetings.

Appendix 2: Semi-structured interview template on narrative skills

1. Small group teaching with undergraduates

   • Have you used a “narrative” approach with your small group teaching with undergraduates? If so, how? Did you achieve your objectives? What were the outcomes? What were students’ reactions?

   • Do you have any other comments to share about using a narrative approach in this context?

2. Teaching postgraduates

   • Have you used a “narrative” approach with postgraduates? If so, how did you do so? Did you achieve your objectives? What were the outcomes? What were residents’ reactions?

   • Do you have any other comments to share about using a narrative approach in this context?

3. Professional practice

   • Have you used a “narrative” approach in your professional practice? If so, how did you do so? Did you achieve your objectives? What were the outcomes?

   • Do you have any other comments to share about using a narrative approach in this context?