Intended for healthcare professionals

Rapid response to:

Education And Debate Narrative based medicine

Why study narrative?

BMJ 1999; 318 doi: (Published 02 January 1999) Cite this as: BMJ 1999;318:48

Rapid Response:

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improvement in quality (Robinson L, unpublished data).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


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

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

Competing interests: No competing interests

15 February 1999
Louise Robinson