'Narrative medicine' may help stem doctor burnout

(Reuters Health) - - As reports of rising levels of physician burnout and suicide accumulate, two pediatricians urge medical programs to consider using “narrative medicine” to help humanize practice and begin to treat the heavy emotional toll many doctors experience.

Their appeal comes in an article titled, “Half As Sad: A Plea for Narrative Medicine in Pediatric Residency Training,” published in the journal Pediatrics.

Coauthor Dr. Caroline Diorio begins with her vivid remembrance of the loss of an 8-year-old patient and her struggle to deal with the sadness she felt as a third-year hospital resident. Diorio, a pediatric cancer specialist at McMaster Children’s Hospital in Hamilton, Canada, tells of a conversation with a colleague who told her how relieved he felt knowing he wasn’t the only one wrenched by the death. “He told me that he was feeling despair,” Diorio writes. “This was the first child he had cared for that had died. He had never felt such sadness before and felt guilty for feeling sad.”

The young doctor, it turns out, had been counseled by a senior physician to “never feel more than 50 percent as sad as the patient’s family.”

Diorio believes that narrative medicine, which teaches doctors to focus on patients’ stories rather than a cut-and-dried checklist of symptoms, can help improve care for patients because their whole story is being heard. It can also help doctors work through their emotions while at the same time enhancing their feelings of empathy.

As an example of how it can work, the article’s other author Dr. Malgorzata Nowaczyk told Reuters Health about her encounter with a pregnant patient with complaints other doctors had not been able to make sense of. “She told me, ‘that is not the way I look,’” said Nowaczyk, a pediatrician and clinical geneticist and a professor of molecular medicine and pathology and pediatrics at McMaster University. “I stopped and asked, ‘what do you mean?’”

The woman, it turned out, was distressed because her facial features had been coarsening. Along with that, she had been getting hairier and hairier and her voice kept getting deeper. “It turned out she had a hormonal imbalance that had coarsened her features,” Nowaczyk said. “Her voice was a baritone by the time I met her.”

Nowaczyk realized that the woman’s fetus had a condition that led to over-production of testosterone, which was leaking through the placenta and affecting the mother’s health.

Narrative medicine isn’t limited to listening to patients’ stories, it also includes writing about them, Nowaczyk said. The very act of writing can hone doctors’ observational skills and enhance the connection they feel with the patient, she added.

Beyond that, the exercise of writing can also work like therapy for doctors, Nowaczyk said. Writing about a patient’s death, for example, can help a doctor process the emotions she feels.

Diorio and Nowaczyk’s article “does a great job of explaining why narrative is so important,” said Dr. Douglas Reifler, a professor of medicine and associate dean for student affairs and medical humanities at the Lewis Katz School of Medicine at Temple University in Philadelphia. “It does a wonderful job demonstrating the problem of not having a chance to reflect on some of the powerful dimensions of the human experience that physicians encounter on a day to day basis.”

Reifler, who wasn’t involved in the article, points to the growing problem of physician suicides. “One of the important protective factors against that is having a sense of meaning in the work you’re doing,” he said. “Narrative allows physicians to develop a sense of meaning in their work. That can get lost in the day to day barrage, if things are not processed constructively.”

The approach may be especially helpful for doctors in training, Reifler said. “Medical students are having clinical experiences in the normal course of training or practice and then writing about them and about how those experiences impacted them,” he explained. “And then, sharing them with their peers.”

Reifler’s use of narrative medicine extends to his anatomy course that all first year medical students must take. “I ask them to write about their experiences dissecting cadavers,” he said. “This goes beyond the factual learning content, and extends to how the experience working with a dead person affects them. They are given a choice: one, to imagine based on any physical evidence they have, to write about who this person was, or two, to focus on the experience they are having as students, describing what it is like to cut into a dead person.”

The payback from this approach is realized by both physicians and patients, Reifler said. “For physicians, it makes them more healthy in their lives and practices,” he explained. “And from the patient standpoint, you want your doctors to be emotionally accessible and empathetic.”

SOURCE: Pediatrics, online December 6, 2018.