Why study narrative?
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7175.48 (Published 02 January 1999) Cite this as: BMJ 1999;318:48All rapid responses
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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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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...
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests