Narrative Medicine and Emerging Clinical Practice

Through the stories, we hear who

we are. Leslie Marmon Silko¹

There in front of me lay a thin, almost translucent looking person. Her hands were warped with the ravages of rheumatoid arthritis and her hair was so thin I could see the age spots on her delicate little head. She was sleeping, soundly from the looks of it. Her oxygen tubing was wrapped around her head and the machine made a strange whirring sound reminiscent of a swamp cooler I once had in my apartment in college. I touched her hand, softly at first, then squeezed a little harder. "Mrs. G., Hi Mrs. G., are you awake?" Her eyes opened and she cracked a huge smile. Uh oh, I thought, she thinks this is funny already? "Mrs. G., I'm the medical student who was going to see you today, did your nurse tell you I was coming?" Her eyes closed again. "Oh sure! Betty told me this morning," she said in a barely audible voice. "I even had them bring me an extra chair for you!" Wow, she is completely cognizant. Both a sigh of relief and a wave of terror struck me at once. Now I had to play the doctor.

Many medical schools are exploring the uses of narrative writing to help students develop certain aspects of their training, primarily professionalism, patient care, and practitioner wellbeing. Writing is a means for expression and communication and a tool for learning and discovery. Current medical literature demonstrates the usefulness of expressive or reflective writing for gaining self-awareness,² improving patient-physician engagement through deepening physicians' understanding of the connections between their own lived and bodily experiences and those of their patients,³ enhancing the empathy necessary to patient-centered care,⁴ reducing practitioner stress,⁵ helping physicians integrate the personal with the professional to enhance patient care,⁶ and developing empathy and trust between patient and practitioner and between practitioner and practitioner.⁷

Other recent literature discusses the value of reflection as a "crucial process in the transforming of experience into knowledge, skills and attitudes,"⁸ a key step in both life-long learning and the development of professionalism in practice.

While reflective writing alone can be therapeutic for the writer⁹ and can foster understanding of others,¹⁰ receiving a response to that writing adds the extra dimension of audience, a sense of being heard. Murray and others note that response is essential to developing writers' craft.¹¹ When faculty respond to student writings, students gain the benefits of response and the benefits of mentorship. Mentorship, in this context, is "a dynamic, reciprocal relationship in a work environment between an advanced career incumbent (mentor) and a beginner (protégé) aimed at promoting the career development of both."¹²

This paper reports the development and evaluation of a mentored, reflective writing program for first-year medical students as they participate in their first concentrated clinical experience.

The Project

At the end of their first year of study, the medical students at the University of New Mexico's School of Medicine disperse throughout the state to engage in a community-based clinical preceptorship. During this eight-week summer Practical Immersion Experience (PIE), students live in a medically underserved rural or urban community and work under the guidance of a primary care physician preceptor at a local clinic. They see patients with their preceptor for three to five half-days per week and engage in a community project and a series of self-guided didactic experiences (learning issues in basic science, clinical topics, public health, and behavioral medicine) the rest of the time. This is the students' first sustained participation in patient care and clinical practice.

Typically, PIE students produce two clinical write-ups of patient encounters and two write-ups of learning issues per week, as well as a log of all patient encounters. They review the writings with their preceptors and with an on-campus faculty member (we call these faculty members "circuit riders"), whom they meet with once before moving to their community...