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EDUCATION AND DEBATE: Trisha Greenhalgh and Brian Hurwitz Narrative based medicine: Why study narrative? BMJ 1999; 318: 48-50 [Full text]

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The Lost Tradition

Ross Upshur   (6 January 1999)

A lesson told long ago

Matthias Löhr   (14 January 1999)

Narrative based medicine

Brian McMullen   (16 January 1999)

The black plastic bag of qualitative research

Robert Power   (30 January 1999)

Narrative based medicine

Louise Robinson   (15 February 1999)

Working narratively

Katherine R Clare   (21 February 2003)

Re: Working narratively

Lisa C Blakemore-Brown   (22 February 2003)

The Lost Tradition 6 January 1999
Ross Upshur, Assistant Professor Department of Family and Community Medicine Suunybrook Site, Sunnybrook and Women's College Health Science Centre, Toronto Ontario Send response to journal: Re: The Lost Tradition	Greenhalgh and Hurwitz are to be commended for bringing forth to the general medical audience the concepts of narrative and interpretation. This series is part of a growing recognition of the interpretive aspects of medical practice. A recent article by Richard Horton in the Canadian Medical Association Journal makes a similar argument for the need for physicians to be cognizant of the interpretive elements of medical practice.(1) Horton emphasizes the need for reasoning skills and attention to the importance of argumentation in medical practice. There is a unifying theme to these papers. Evidence based approaches are a necessary but not sufficient basis for the adequate training of physicians. The lost tradition alluded to by Greenhalgh and Hurwitz is not so deeply hidden. The skills of interpretation and careful conceptual reasoning are at the heart of humanities training and of philosophy in particular. Thus far, the contribution of philosophy to medicine has largely been confined to ethics. However, epistemology(or theory of knowledge), informal logic and argument analysis and hermeneutics (or theory of interpretation) have much to contribute to modern medical training. The tradition is lost largely because most physicians have little exposure to serious humanities scholarship either prior to medical school or in the medical curriculum itself. In so far as evidence based medicine is defined in terms of such virtues such as judiciousness, conscientiousness and explicitness it is clear that the time has come for a more robust dialogue on the relationship between philosophy and medicine. 1.) Horton R. The grammar of interpretive medicine. CMAJ 1998;159: 245-249
A lesson told long ago 14 January 1999
Matthias Löhr, Ass. Professor; Attending Physician Univ. of Rostock, Germany Send response to journal: Re: A lesson told long ago	Dres Greenhalgh and Hurwitz are to be congratulated to this excellent paper. It echos back what was known to our predesessors in medicine: listen to the patient, let him talk, and write it down the way (s)he expresses it. There is no doubt that lab tests and further imaging procedures produce an 'objective' picture of the illness of the patient; however, as nicely laid out in the case of the diabetic patient, one must listen carefully. In the old days, doctors had the time to sit down with patients and listen to them. Today, time is short, making it 'valuable'. I am collecting old textbooks of Medicine which sometimes give you a glimpse of this narrative approach - there was not that much to write on lab tests and other investigations. One could witness this loss in the East of Germany: after the unification, the elder doctors were quite proficient in art of taking a history with the narrative approach. With the advent of the 'modern' medicine, it is all gone...
Narrative based medicine 16 January 1999
Brian McMullen Send response to journal: Re: Narrative based medicine	I see the inclusion of your series on Narrative Based Medicine (1) as further evidence of the trend to balance the science of medicine with the arts and humanities and I congratulate you on this development. The importance of stories and myths has been debased in our culture and particularly in our profession to the point that myths are equated with falsehoods. Ironically this was demonstrated in the same issue of the BMJ in "sexual myths" in the series "ABC of sexual health" (2) Baum suggests that doctors are in danger of losing their humanitarian instincts to become mere technocrats (3) Literature and the arts can assist doctors to get outside their professional cocoon (4) and I hope that the series on stories will stimulate the debate on the role of the humanities in medical education. Brian McMullen 2 Burnside Kinloss Moray IV36 3XL 1 Greenhalgh T, Hurwitz B. Why study narrative. BMJ 1999;318:48-50 2 Butcher J, Female sexual problems. BMJ 1999;318:41-43 3 Baum M, Arts and Humanities for medical undergraduates - a Prospectus;1997:University Colege London 4 Calman K, Downie R. Why arts courses for medical curricula. The Lancet.1996.347:1499-1500
The black plastic bag of qualitative research 30 January 1999
Robert Power Send response to journal: Re: The black plastic bag of qualitative research	Dear Sir Your recent series on narrative based medicine [1] adds to the debate concerning qualitative methods in medical research [3]. However, this useful contribution belies the emerging paradigm in qualitative research which has elevated the status of the spoken word (be it self-report, focus group, narrative or interview). Participant observation and more direct ethnographic data collection methods data are rarely part of the modern qualitative researcher's repertoire [4]. Yet, direct observation and description of events by skilled researchers provide contextual data which augments our understanding of social phenomena. One prime example is that of AIDS and injecting drug use, where observation of injecting practices has fine-tuned health promotion and prevention interventions, contributing to reducing the spread of infection [4]. We need to ensure ethnography's unique contribution is not side-lined in favour of less direct methods of data collection. To illustrate these points I refer to the evaluation of an intervention run by Gay Men Fighting AIDS (GMFA). GMFA provided condoms and other health promotion materials to men using an open air public sex environment (PSE) in London. One practical problems was public complaints about the amount of "litter" created by men discarding used condoms and other materials. In response, regular "litter picnics" were held, where volunteers scoured the area, clearing the debris. Myself and another researcher participated in one of these events. Each volunteer was given a black plastic bag (and one rubber glove!). Previous participant observation sessions took place at night. But, in broad daylight, it became apparent that here was a rich source of data. After two hours rubbish collecting we randomly selected one of the ten bags and collated the contents. Table 1: Materials recovered from the litter bag used condoms as distributed by GMFA (n=47); torn GMFA condom packs (77); other used condom brands (4); other torn condom packs (45); GMFA lubricant packs (57); other lubricant packs (6); large quantities of GMFA "green" tissue paper; sundry items (including 6 used amyl nitrite bottles and items of clothing). These data, serendipitously collected during an observation session, strengthened the process evaluation, confirming and augmenting findings from self-reports and interviews. In this light, five conclusions were drawn. One, the "litter collection" data indicated sex was taking place in the area. Two, GMFA packs were being distributed and reaching the target group. Three, the identifiable contents of the GMFA packs (condoms, water- based lubricant, tissues) were being used in situ. Four, condoms and water -based lubricants were being used by men at the PSE. Five, men were not merely "relying" on GMFA provision, but were bringing to the area (and using) other brands of condoms and lubricants. A sixth, and more general, conclusion could be that there is more to qualitative research than the spoken and recorded word. [1] Greenhalgh T, Hurwitz B: Why study narrative? Brit Med J 1999, 318: 48-50. [2] Pope C, Mays N: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Brit Med J 1995, 311: 42-45. [3] Denzin N, Lincoln Y. Handbook of qualitative research. London: New Left Books; 1975. [4] Grund J, Kaplan C, Adriaans N, Blanken P: Drug sharing and HIV transmission risks: the practice of frontloading in the Dutch injecting drug user population. J Psych Drugs 1991, 23: 1-10. Yours faithfully Robert Power PhD Senior Lecturer in Medical Sociology Department of Sexually Transmitted Diseases Royal Free and University College Medical School The Mortimer Market Centre Mortimer Market London WC1E 6AU
Narrative based medicine 15 February 1999
Louise Robinson Send response to journal: Re: Narrative based medicine	General practitioners and other health professional colleagues constantly recount clinical anecdotes informally, for example during "coffee time" discussion, and formally, when reviewing case notes in vocational training. In the first article on narrative based medicine, Greenhalgh and Hurwitz stated that narrative "provides meaning, context and perspective for the patient's predicament, defining how, why and in what way he or she is ill" 1. They reviewed the study of narrative as qualitative research and as a method of reflective practice in undergraduate and postgraduate education. We have studied how the narrative of health professionals can be systematically captured in routine clinical practice in order to improve the quality of patient care. We have developed and tested a method (facilitated case discussion)2-4 for multidisciplinary teams to perform clinical audit around significant events in the care of patients. Using an external facilitator, and cases chosen from a primary care death register5, primary care teams are encouraged to "build up a picture" of the case by discussing the actual events, their feelings and concerns, and the reasons why they considered the case significant. We have audiotaped the discussions. Analysis of the narrative transforms the process into a method of qualitative research from which lessons for improving care can be drawn. Detailed guidelines on how facilitated case discussion can be performed by multidisciplinary teams have already been published3. In practice, discussion of one case takes between 30-60 minutes and can be performed by primary health care teams in place of their routine team meetings. Our findings have shown that teams consider facilitated case discussions practical, effective, motivating and enjoyable4. The focus on "real cases" and its encouragement of reflective practice is particularly appreciated for improvement in quality (Robinson L, unpublished data). Our form of narrative based medicine for practising clinicians, based on analysis of significant events, can be added to the "tool-box" for postgraduate education and audit and the improvement of clinical care. Louise Robinson, Lecturer Rosie Stacy, Lecturer in Medical Sociology John Spencer, Senior Lecturer Department of Primary Health Care School of Health Sciences Medical School Framlington Place Newcastle upon Tyne NE2 4HH Raj Bhopal, Professor of Epidemiology and Public Health Department of Epidemiology and Public Health School of Health Sciences Medical School Framlington Place Newcastle upon Tyne NE2 4HH References 1 Greenhalgh T, Hurwitz B. Narrative based medicine - why study narrative? British Medical Journal 1999;318:48-50. 2 Berlin A, Spencer JA, Bhopal RS, van Zwanenberg TD. Audit of deaths in general practice: pilot study of the critical incident technique. Quality in Health Care 1992;1:231-235. 3 Robinson L, Stacy R, Spencer J, Bhopal R. How to use facilitated case discussions for significant event auditing. British Medical Journal 1995;311:315-318. 4 Spencer JA, Stacy R, Robinson L, Berlin A, Bhopal RS. Audit of death in general practice. A report of a study into the development and evaluation of death registers and facilitated case discussions. University of Newcastle upon Tyne Department of Primary Health Care, 1995. 5 Stacy R, Robinson L, Bhopal R, Spencer J. Evaluation of death registers in general practice. British Journal of General Practice 1998;48:1739-1741.
Working narratively 21 February 2003
Katherine R Clare, family therapist and paediatric liaison specialist Child and Adolescent Mental Health Send response to journal: Re: Working narratively	I am a family therapist and work narratively with children, young people and their families as well as with larger systems. I visited this site for the first time and read with true interest the articles here. It is refreshing to know that narrative and medicine can begin to live alongsidfe each other. In the general hosptial where I work, there is no attention paid to the narratives of the patients or thier families....for example, in childhood epilepsy, I beleive that without attention to the narrative description of the episodes and effects on the family the treatment cannnot 'fit'. I'm told that the pressure of time doesn't allow for so much attention to listening and yet the families come back time and again to tell the same stories until they 'demand' to be listened to. Any suggetsions as to how to increase the chances of more narrative in British Medicine please? Competing interests:   None declared
Re: Working narratively 22 February 2003
Lisa C Blakemore-Brown, Psychologist UK Send response to journal: Re: Re: Working narratively	This Family Therapist wrote 'In the general hosptial where I work, there is no attention paid to the narratives of the patients or thier families....for example, in childhood epilepsy, I beleive that without attention to the narrative description of the episodes and effects on the family the treatment cannnot 'fit'. I'm told that the pressure of time doesn't allow for so much attention to listening' This respondent's perceptions and Trisha Greenhalgh's paper highlight issues of fundamental importance to successful reciprocal interactions and the future success of any relationship and the purpose of that relationship. The reasons for making contacts range from, for instance, reporting a crime, finding help for a medical problem with a doctor or a hospital to liaising about the Third World War. In each situation empathic LISTENING is key. The wise words of Dr Greenhalgh and those she quotes seem to have fallen on stony ground in most arenas in the last few years. In my work as a psychologist, I seek an audit trail of the history, use a framework of questions but interweave this with narrative. I always find that the clues to understanding the problem lie within the opportunities which allow the client/patient and/or their parent to share the story of their experiences. Without a doubt there are problems relating to time and how such information can be gleaned in the limited time frame available, for instance, to General Practitioners. However, as Dr Greenhalgh describes, certain types of training and thinking can lead us to ignore the obvious. Inevitably this will lead to errors of judgement, as given in the example of the patient with diabetes and the the examples of families with epilepsy. There is an urgent need for us to radically review training and the emergent modes of thinking about how we interact with and interpret the narratives of those we have a duty to support in all specialities. Only when we alter this thinking which blinds us to the obvious will we be able to deal with the comparative relatively simple task of time management. Our collective futures are surely at stake on this planet where we must all live together, ideally in harmony, unless we do. Competing interests:   None declared