Narrative medicine in clinical internship teaching practice

ABSTRACT

Objective: To explore the effect on empathy skills of integrating narrative medicine instruction into clinical internship undergraduate medical education.

Methods: One hundred clinical undergraduate students who were transferred to gynecology and obstetrics in 2016 were selected as subjects and divided into two groups. The control group adopted the traditional practice teaching mode, while the experimental group adopted a narrative medicine integrated with traditional teaching mode. The impact of the narrative medicine course was evaluated using the Davis Empathy Scale, and the students’ acceptance of the course was investigated using a self-developed questionnaire.

Results: After completion of the rotation, the empathy scores of the experimental group were higher than those of the control group (p < 0.05). Students in the experimental group rated the integration of narrative medicine into the internship class highly, and most students thought that the narrative medicine course was of great benefit with respect to the humanistic quality of medical teaching.

Conclusion: The application of narrative medicine teaching in the clinical practice teaching of obstetrics and gynecology promoted students to improve their empathy ability.

KEYWORDS:

• Narrative medicine
• obstetrics and gynecology
• clinical practice
• medical education
• medical humanities

Introduction

Development of empathy and related humanistic skills is a key component of learning to become a physician. The field of obstetrics and gynecology has been a source of advocacy for patient-centered and empathic care. In the process of diagnosis and treatment, patients often undergo sensitive or invasive exams, which makes it necessary for obstetricians and gynecologists to have good humanistic quality and to exhibit empathy for patients’ situation [1]. Medical students in the context of undergraduate education exhibit strong plasticity and these skills may be particularly necessary for medical students during their obstetrics and gynecology clinical rotations.

Narrative medicine(NM) was first proposed by Professor Rita Charon of Columbia University in 2001, believing that narrative ability is the ability to recognize, absorb, explain, and be moved by the stories of diseases [2]. NM emphasizes humanistic care and is a medicine practiced by clinical workers who have the ability. Its development is mainly through communication, understanding, and empathy with patients, helping medical practitioners understand the pain endured by patients in the disease [3]. It is an inevitable product of the development of modern medicine [4]. NM requires doctors and nurses to focus on patients’ real feelings of disease but not just data or image on the medical reports [2]. NM improves the empathy and reflective abilities of medical workers through specific training methods such as fine reading and reflective writing [5,6]. NM advocates that parallel medical record writing and reflective writing should be integrated into clinical teaching and practice to improve doctors’ attention to patients’ feelings of disease, as opposed to a situation in which doctors focus only on a number on their checklist [7,8]. Growing research into the efficacy of integrating NM education into clinical education has suggested that NM has indeed improved the empathy of medical students [9].

If the relevant theories and methods of NM can be integrated into medical education, this process may help medical students or clinical doctors provide better diagnoses and treatment experiences to female patients and increase patient cooperation [10]. However, the heavy workload of medical courses and the difficulty of medical exams are of crucial importance for the career of medical students [11], leading them to be more willing to focus on learning professional knowledge and underestimate the cultivation of medical humanities literacy [12].

The traditional clinical practice teaching mode mainly helps students consolidate their professional knowledge by combining theoretical knowledge with clinical practical cases. Owing to the long-term neglect of the cultivation of humanistic quality, medical students may not develop crucial qualities of empathy and patient-centeredness. The core purpose of NM is to cultivate an empathic understanding of patients’ experiences [3]. According to the characteristics of a variety of theories and methods associated with NM, this approach is very suitable for clinical interns. First, during this time, medical students are still developing their clinical skills, and are likely to be open to learning. Second, the clinical internship is a process in which theory and clinical practice intersect. With the help of instructors, medical students can gradually cultivate their empathy for patients by coming into contact with patients while they master theories.

To test the feasibility of this method, the Third Xiangya Hospital of Central South University took undergraduates who were engaged in practice in obstetrics and gynecology as its main research object to determine whether the integration of NM teaching into clinical practice in obstetrics and gynecology can help medical students improve their empathy regarding patients. In this study, the teaching method of NM is integrated into the undergraduate internship course and compared with the traditional teaching method to analyze the feasibility of integrating NM teaching into the development of humanistic quality in undergraduate medical education.

Method

Participants

Five-year clinical medicine senior undergraduate medical students were selected as the research subjects when they were engaged in practice in the Department of Obstetrics and Gynecology of the Third Xiangya Hospital of Central South University in 2019. In their pre-clinic and clerkship years, the development of humanistic skills was mainly taught by lectures based on ethics textbook in class. This study underwent institutional review board (IRB) review and received an exemption, and all students were provided with an information sheet detailing the purpose of the study and the ways in which they could opt out of participation. A total of 100 students were randomly divided into control group (n = 50, 24 females) and experimental group (n = 50, 28 females), which were taught by the same teacher.

Teaching method

Both the control group and the experimental group were taught by the same experienced teacher specializing in clinical education and humanistic quality education in the context of medicine. The control group received traditional teaching methods, which were guided by a combination of textbook professional knowledge with specific clinical cases, with the main purpose of teaching clinical professional knowledge. On the basis of teaching clinical professional knowledge, the experimental group integrated NM-related knowledge with practical methods, emphasizing the improvement of students’ humanistic quality in the process of engaging in medical activities. All training sessions, regardless of format, lasted for 2 hours.

The teaching contents of the experimental group mainly included eight courses: introducing relevant theories and research progress related to NM; introduction to NM-related literary works; appreciation of film and television works related to NM; introduction to parallel medical record writing; narrative ward round: listening to the patient’s story and completing parallel medical record writing; parallel medical record sharing and discussion; reflective writing; reporting and sharing learning experiences.

The teaching cases focused on the experiences of real patients as their main material. Students experienced the real lives of the patients behind the clinical data by listening to patients’ vivid stories. During their teaching rounds, the students were encouraged to listen to patients’ stories and to record their unique feelings using parallel medical records.

Implementation process

Before conducting the research, the investigators communicated with the lecturer fully regarding the research purpose, the specific implementation methods and the arrangement of theory and practice in the curriculum. Training and guidance regarding NM were provided to teachers to ensure uniform teaching methods and consistent classroom design. The Power Point course and task objectives were prepared one week prior to class. The class flow of the control group first featured an explanation of the relevant professional knowledge, which was followed by bringing the students to the ward to complete their teaching rounds; finally, 4–5 people were organized into a group to collect the patient’s medical history and write a complete medical record. The teaching process used for the experimental group first featured an explanation of the relevant professional knowledge, including NM-related knowledge, which was followed by the teaching ward round; finally, the students were encouraged to listen to the patient’s story and record it in the form of parallel medical records as part of the process of medical history collection. At the conclusion of the course, the students in the experimental group were surveyed using the course evaluation questionnaire.

Measures

The Davis empathy scale was first developed by Mark H. Davis in 1983 to evaluate empathy defined in terms of a multidimensional construct and is widely used for researching on the multidimensionality of the empathic process in the general population [13,14]. This scale was used to examine the effect of NM on students’ empathy ability in this study. The Davis empathy scale includes 28 questions, each of which is scored on a scale ranging from 1–5: very unqualified, somewhat unqualified, uncertain, somewhat qualified, and very qualified. These 28 questions ranged across four dimensions: the fantasy scale, the perspective-taking scale, the empathic concern scale and the personal distress scale [15]. According to the nature of the questions, they were associated with positive integers, i.e. plus points, and negative integers, i.e. minus points.

Data analysis

The empathy ability of all participants was measured before and after the course. All participants were included in the analysis. SPSS 20.0 software was used to conduct the statistical analysis. The measurement data were described by X ± s, and independent t tests and chi-square analyses were used to explore group differences in responses. The criterion of p < 0.05 was used to reject the null hypothesis.

Results

Comparison of self-perceptions of empathy between the two groups of medical students

According to the results of this survey, the differences between the two groups of medical students in terms of their self-perceptions of empathy scores were compared (Table 1). In the longitudinal comparison before and after the class, there were no significant differences between the control group and the experimental group (p > 0.05). In the horizontal comparison between the control group and experimental group at the same time point, there were no significant differences between the scores on the empathy scale exhibited by the experimental group and those exhibited by the control group before the course (p > 0.05), but after the course, the scores of the experimental group were significantly better than those of the control group (p = 0.0146) (Table 2 and Figure 1).

Figure 1. Bar chart showing the scores of each group. *= p < 0.05, ns = not significant.

Table 1. Davis empathy scale score.

group	Maximum	minimum	mean	SD
Pre-class control group	73	12	41.75	12.82
Pre-class experimental group	63	24	46.66	11.18
After class control group	76	25	42.31	10.23
After class experimental group	74	16	48.29	11.42

SD: standard deviation.

Table 2. Comparison of scores between experimental group and control group.

			P
Longitudinal comparison	Pre-class experimental group	After class experimental group	0.6153
	Pre-class control group	After class control group	0.9654
Horizontal comparison	Pre-class experimental group	Pre-class control group	0.1187
	After class experimental group	After class control group	0.0146(*)

Medical students’ understanding of NM and evaluation of the narrative course

After the course, the self-developed course evaluation questionnaire was distributed to students in the experimental group anonymously. Due to the integration of NM teaching into the internship course for obstetrics and gynecology, most medical students believed that they had a clear understanding (54%) or a deep understanding (30%) of NM. Regarding the necessity of continuing to provide NM-related courses in the future, 94% of the students believed that it was ‘necessary’ or ‘generally necessary, but more content and practical guidance are needed’. Seventy percent of the medical students reported that their overall impression of the course caused them to understand new medical concepts, and 24% of the students claimed they had made some gains. However, the teaching content of the course was too simple, and 6% of the students thought that the course was meaningless and a waste of time. In addition, 56% of the medical students thought that the NM course was rich in content and that it integrated various forms of teaching methods. Another 36% of the medical students thought that the curriculum arrangement was reasonable but that the content required further adjustment. Only 8% of the students thought that the curriculum arrangement was unreasonable and required large adjustments (Table 3).

Table 3. Overall evaluation of narrative medicine course.

evaluation of narrative medicine course	selections	n(%)
How much know about NM	With a superficial understanding	8(16.00)
	With a clear understanding	27(54.00)
	With a deep understanding	15(30.00)
carry out narrative medicine related courses	It is necessary to carry out	22(44.00)
	Generally necessary, but more contents and practical guidance need to be added	25(50)
	Unnecessary, waste of time	3(6.00)
Impression of the course	Get new concept	35(70.00)
	Some achievements, but the content is too shallow	12(24.00)
	No gain, waste of time	3(6.00)
Course design	The teaching plan is reasonable, the teaching content is rich, and various forms of teaching methods are integrated	28(56.00)
	Reasonable, needing to adjust the content	18(36.00)
	Unreasonable, requiring substantial adjustment	4(8.00)

The role of the NM curriculum

In the questionnaire concerning the role of NM in clinical medical work, medical students generally acknowledged the role of NM in medical education and medical practice. Fifty percent of the medical students thought that NM played a role in enhancing their doctor‒patient communication ability, 44% of the students thought that it was very useful, and only 6% of the students thought that it was not useful. Learning to listen is an important aspect of NM. Sixty-two percent of the medical students reported that listening was very important to the establishment of a relationship of harmonious communication, and an additional 36% of the medical students thought that listening was very important but that it may be difficult to implement in concrete situations. Sixty-two percent of the students noted that they often listened to patients’ stories during their internships, and 36% of the medical students listened occasionally. When asked whether NM could promote their reflection on their own behavior in medical practice, some students noted that they had taken action (24%) or were deeply touched (30%) or somewhat touched (38%) by NM, and only 8% of the students thought that it had little effect. Cultivating the empathy ability of medical students is a basic goal of NM. Ninety-six percent of the medical students thought that empathy ability could improve doctor‒patient communication, while 86% of the medical students thought that the NM teaching method was conducive to helping them develop empathy ability (Table 4).

Table 4. The role of narrative medicine curriculum.

The role of narrative medicine curriculum	group	n(%)
Enhancing students’ ability of doctor-patient communication	It seems to be of little use	3(6.00)
	It works	25(50)
	It is very useful	22(44.00)
The importance of listening for doctor-patient communication	Very important, listening is the key to a harmonious communication relationship	31 (62.00)
	Important, but the reality may not allow a lot of time to listen	18 (36.00)
	Not important, just listen to the key information	1(2.00)
Listen to the patient’s story during the consultation	Often	31(62.00)
	Occasionally	18(36.00)
	Only mastering the main information of the disease	1(2.00)
Promote self-reflection in medical practice	Little effect	4(8.00)
	There are some touches	19(38.00)
	Deeply touched	15(30.00)
	Has been put into action	12(24.00)
The necessity of empathy for doctors	It’s of little use. As long as the doctor can diagnose and treat	2(4.00)
	It works	10(20.00)
	Very useful to help us better communicate between doctors and patients	38(76.00)
Helping students understand empathy	It’s not very useful. Empathy is innate and difficult to cultivate	7(14.00)
	It works	15(30.00)
	It is very useful	28(56.00)

Discussion

The aim of the present study was to explore the effect of narrative medicine in clinical internship teaching practice, which may provide evidence for applying NM in clinical education. In this study, by comparing the scores of the two groups on the empathy scale, after completing the NM course, experimental group showed a higher level of empathy. Our results correspond to previous studies indicate that the integration of NM education into the clinical course has obvious advantages with respect to cultivating participants’ self-perceptions of empathy [16].

Previous reports about the doctor-patient relationship showed that patients are non-adherent with treatment when they are not fully understood the purpose of medical treatment and provided some strategies to establish better understanding between patients and doctors [17]. A recent study was conducted semi-structured interviews to explore the experience of doctors in communication with patients and further demonstrate that communication skills are absent during clinical practice [18]. However, the content of doctor-patient communication includes not only disease-related information but also emotional communication. Thus, as Jacynthe et al. suggest, narrative medicine can help students reflect their professional identity, developing good professional identity abilities, promoting self-reflection in healthcare practice and having insight into patients’ suffering [19], so that to have better understanding experience of patients, thereby promoting good doctor-patient communication.

The NM education is patient-oriented, while other medical curriculums are more technique-oriented [20]. Some studies have shown that NM improved patients’ illness experience and compliance, which almost established a consensus [21,22]. Although NM provide many methods to help improving doctor-patient relationship, it is still hard to play a role in clinical practice. For example, listening and reflection, as important skills emphasized by NM, play an important role in facilitating the doctor-patient relationship [2]. However, our results are consistent with Abigail’s study that, although most participants understand the importance of listening and reflection, they worry that these methods are difficult to implement in their practical work due to the heavy pressure associated with clinical work and then influenced their work with patients [23]. These evidences further proving that it is necessary to applying NM in medical education because of the difficulty in implementing in clinical work. Based on the results of the curriculum evaluation questionnaire, students’ perceptions of this new teaching model were objective and positive. Most students noted that they developed a comprehensive understanding of NM and a new understanding of the doctor-patient relationship as well as doctor-patient communication throughout the course. However, simultaneously, the students also objectively noted that the content of the teaching was too simple, indicating that we should add additional elements to the classroom teaching to attract students, which requires us to have a sufficient number of teachers and to enrich our teaching content and strengthen our teachers constantly. Integrating NM into the traditional classroom requires the lecturer to have a deep understanding of the relevant concepts and practical principles of NM. Therefore, it is necessary to improve the training of these teachers.

There are still many limitations in this research. Firstly, the samples only include undergraduate students of one grade. In future research, graduate students, clinical residents, etc. should be included in the research scope. Secondly, in our study, there were only 8 courses of narrative medicine integrated into the teaching method, and the number of courses and the richness of teaching content should be increased. However, this study also highlights the benefits of integrating NM into internship classes to cultivate the empathy ability of medical students and reflects the feasibility of NM teaching in contemporary medical teaching. It is believed that this teaching mode will play an increasingly important role following a process of continuous exploration, practice, reform and innovation.

Author contributions

Jing Yuan write and reviewed the first draft and analyzed the survey data. Xiangyang Zeng designed and distributed the questionnaires and drafted the original manuscript. Yan Cheng reviewed the manuscript. Hua Lan analyzed the data. Ke Cao re-analyses the data and led the writing team during article revision. Songshu Xiao conceptualized the paper and led the writing team. All authors approved the final draft.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding authors upon reasonable request.

Additional information

Funding

This study was supported by the Construction Project of the Graduate Teaching Case Base of Central South University (2022ALK032), the Graduate Education and Teaching Reform Project of Central South University (2022JGB064), the 14^th Five-year Plan of Educational Science in Hunan Province (ND213576), Hunan Postgraduate Teaching Platform Project (2019-39), Hunan Province Degree and Graduate Teaching Reform Research Project (Curriculum Ideological and Political Project) (2022JGSZ016), Central South University Graduate Course Ideological and Political Construction Project (2022YJSKS009), Central South University Education and TeachingReform Research Project (2023jy122).