Narrative and reflection

Day 2 of Narrative and Medicine

The first 2 presentations shifted the attention to the flip side of the narrative coin, reflection.

A narrative, in the context of a therapeutic relationship, demands a response. Morally we are duty-bound to act and the action begins with reflection. Reflection comes more naturally to some people than others, but, as the superb presentations this morning showed, reflection encompasses skills that can be taught, but to be of value must be practiced. This paper by Carmen Caeiro and Carla Pereira showed how a narrative reasoning course helped physiotherapists develop understanding of patients’ experiences and themselves as well as embedding reflective practices in clinical practice. I’ve highlighted the last bit because I think it’s of tremendous importance for medical education in general and medical ethics education in particular because reflective practice is embedded in most medical curricula with little evidence about what it’s doing or whether it continues into clinical practice. The power of the hidden curriculum, the culture that socialises professionals into ways of thinking and acting, is formidable. Reflective practices are subversive of culture because they equip professionals with the conceptual tools and deliberative practices that challenge established cultural norms. The presentation by Alan Weber about a narrative and reflective writing course in Qatar, bought this into a sharp perspective.The Qatari poet Mohamed Rashid al-Ajami was jailed in 2012 for 15 years for a piece of public reflection, a poem that criticised governments across the Gulf region in the wake of the Arab Spring uprisings. Alan’s students have grown up in a culture where personal reflection is discouraged and even to begin to teach the skills has been a huge challenge. By critically analysing safe subjects like arts and literature the students developed the confidence and critical skills which they were then able to turn on themselves, the practice of medicine and culture beyond. They chose to write reflectively about issues like virginity examinations, autonomy, sexuality and other taboo issues, some too dangerous to publish, though many of their essays have been published, albeit anonymously in three volumes. It’s easy for us to think about the Qatar students as being something ‘other’, we’re reflective they are not, we can write about controversial subjects, they can not but I was reminded of Rees and Monrouxe’s work with UK medical students’ professionalism dilemmas. They asked students write about unprofessional behaviour they witnessed, which included doctors inviting students to perform intimate examinations on anaesthetised patients without their consent and bullying of students and other professionals. Reports from Kirkup and Mid Staffs about dreadful, unprofessional behaviour should remind us that we have our own taboos which are being uncovered, but all too rarely discussed in a supportive, reflective setting, where something can be done before it’s too late. If we teach reflective skills and embed reflective practices – which as I argue in a forthcoming paper we should, it can help us challenge our own and others behaviour every day. It can undermine hierarchies and make professionals more sensitive to patients’ experiences. Reflective practices teach us humility and show us that there are multiple perspectives and help us reveal them, value them and judge them sensitively and seriously.

Teaching reflective skills is not easy. When I go to the annual tutors’ day at Barts and the London it’s very common for tutors to admit their lack of confidence. Careiro and Pereira have both undertaken post-graduate studies in medical humanities at the university in Lisbon and involve sociologists and psychologists in their teaching. Their students have an 8 week course and read challenging texts by Kafka and Nietzsche as well as watching films like One Flew Over the Cookoo’s Nest and The Diving Bell and The Butterfly before each small group tutorial. The course was introduced into a new curriculum with the support of their university. For those of us working in long-established medical schools without their skills, replicating their work will be difficult, but far from impossible.

From Dr Interpretive to Dr Discursive

In Emmanuel and Emmanuel’s classic paper about four models of the doctor-patient relationship they describe an evolution from Paternalistic, via Informative and interpretive to discursive. One of the problems about narrative and medicine is that there is a tendency to get stuck on the interpretive. There is a lot of fascinating theory about how to interpret narratives. In the afternoon sessions we heard about narrative’s interpretive limits in a paper given by A. Sile about the book Exploding Into Life by Dorothea Lynch and her photographer partner Eugene Richards. The book, about Lynch’s experiences with breast cancer is illustrated with Richards’ photographs. Neither narrative nor image stand alone, both are different representations of Lynch’s experiences. Later, Richards who was a professional documentary photographer, said that he wouldn’t trust a photograph without text, and one suspects, text without a picture. I was reminded of UK artist Emma Barnard’s fantastic photographic portraits of patients who have had head and neck surgery for her patient as paper project. The photographs are presented on X-Ray acetates and then the patients are invited to respond by writing and drawing on their portraits. What she shows, beautifully and simply, is that patients can be represented in multiple forms by others and by themselves.

Medicine is, of course an interpretive practice, we interpret a medical history, signs and symptoms, blood tests and scan results, response to treatment and so on. And the things we interpret are themselves representations of the ‘thing’ we are trying to diagnose. Layer upon layer of representation and interpretation. Medicine is not a science, or even an interpretive science, though it is informed by science. It is, among other thing an interpretive practice. Kathryn Monrgomery, another narrative medicine pioneer has written about this in her book, How Doctors Think.

In the last paper I heard today, Briege Casey, who teaches a medical humanities course to nursing students in Dublin, described how established pedagogic practices such as Imagework by Iain Edgar and Ekphrasis can equip educators with simple tools to teach students sophisticated interpretive skills. With these we can help to teach wisdom and intellectual curiosity.

She finished with a quote from one of her students that is of profound importance to anyone concerned with patient-centred care,

how would your patients choose to represent you?

Keynote by Rita Charon