Microsoft Word - ABriefExerciseArticle.docx Published by University of Minnesota Libraries Publishing A Brief Exercise in Narrative Medicine for Preclinical Medical and Premedical Students: MY STORY Allison B. Engelbrecht, B.S.; Rebecca E. Higdon; Hannah M. Marshall; Sarah R. Parker, B.S.; Dimond A. Shelton; William J. Crump, M.D. DOI: https://doi.org/10.24926/jrmc.v2i5.2272 Journal of Regional Medical Campuses, Vol. 2, Issue 5 (2019) z.umn.edu/JRMC All work in JRMC is licensed under CC BY-NC Allison B. Engelbrecht, B.S.; M-2 Medical Student, ULSOM Trover Campus. Rebecca E. Higdon; College Rural Scholar, ULSOM Trover Campus Hannah M. Marshall;College Rural Scholar, ULSOM Trover Campus Sarah R. Parker, B.S.; M-2 Medical Student, ULSOM Trover Campus. Dimond A. Shelton; College Rural Scholar, ULSOM Trover Campus William J. Crump, M.D.; Associate Dean, University of Louisville School of Medicine Trover Campus at Baptist Health Madisonville. All work in JRMC is licensed under CC BY-NC Volume 2, Issue 5 (2019) Journal of Regional Medical Campuses Perspective A Brief Exercise in Narrative Medicine for Preclinical Medical and Premedical Students: MY STORY Allison B. Engelbrecht, B.S.; Rebecca E. Higdon; Hannah M. Marshall; Sarah R. Parker, B.S.; Dimond A. Shelton; William J. Crump, M.D. Abstract As part of a 3-week summer regional medical school campus rural immersion experience, preclinical medical and pre-medical students accompanied a rural Family Medicine residency inpatient team on bedside rounds. One theme of the summer program is the value of empathy and the importance of truly understanding what it is like to “walk a mile in the patient’s shoes.” A previously established brief narrative exercise was modified so that the learner spent an hour facilitating a hospitalized patient’s recall of their life and then produced a short summary that was edited by the patient and then provided to the team. The senior resident chose the patient for the exercise and introduced the student, who remained when the team left the bedside. The response from the patients was uniformly positive, and in an anonymous written evaluation, eight of 11 students completing the project rated it as positive, with 3 neutral, and none negative. Four gave it the highest rating possible in terms of meeting the goals of the program. Introduction In July each year for almost 20 years, the University of Louisville Trover Campus has hosted a group of pre-clinical and pre-medical students who spend three weeks in the host town of Madisonville, population 20,000, which also is home to the oldest family medicine residency in Kentucky.1-3 The students work in small groups to step through a clinical case in twice- weekly sessions facilitated by the regional dean to learn clinical reasoning. They also work together to provide free school and sports physicals to 12 year olds in adjoining underserved counties, supervised by a volunteer family physician. The college students receive some academic tutorials, and both groups shadow rural physicians. In the 2019 session, we provided an opportunity for each student to go along on bedside hospital rounds with the family medicine residency inpatient team, and we used a narrative medicine exercise to provide structure for these relatively inexperienced learners to connect with patients. As an introduction to compassion training and the importance of empathy, the group heard a presentation covering the professional identity curriculum used at the Trover Campus.4,5 The focus of the narrative exercise was provided by a quote: But often (third year histories) were not as good as first-year students in gaining an accurate and comprehensive view of what bothered the patient, or what living with the illness was like… The disparate behavior of first- and third-year medical students was the result of education. First-year students listened to the story of illness. Third-year medical students strove to write a story of disease. For them the disease was the thing: classification, or merging the current patient with preceding patients, was their objective.6 Methods When preparing for the summer program, Trover Campus staff became aware of the “My Life, My Story” effort in the Veteran’s Administration (VA) system.7 The authors contacted that group and adapted the My Life, My Story Interviewer Guide and Script for Consent for use with non-VA patients, along with prompt questions for the students (See Table 1). During program orientation, we described the narrative project as an opportunity to interview the patient in-depth without the time constraints that characterize everyday medical practice. While the VA project assumed that an “anchor identity” for all their patients would be the former service in the military, the students were encouraged to find the anchor identity for their “My story” patients. Students were introduced to semi-structured interviewing techniques in their initial program orientation. They interviewed the patient assigned to them after being introduced by the senior resident caring for the patient during bedside hospital rounds. The student told the patient they would write up a 1,000-word story and bring it back to them to read and make changes. Once the patient was satisfied with it, it would be given to the patient’s doctor and the patient would receive a copy. Patients were free to Journal of Regional Medical Campuses, Vol. 2, Issue 5 Perspective decline participation as well as to make any edits to their story they wished. The student interviewer also provided brief written feedback on their perspectives of the experience at the end of the program. Results What follows are brief anonymized excerpts from some “My Story” pieces written by the students, followed by their comments on the process. A country girl with a calling Mrs. M is former nurse and mother of four. She has three daughters and one son; her son, who she admits wanted her to go to the doctor sooner than she did, is currently living with her at her home. She says that she never knows just how sick she is; she always tells herself that she’s going to be alright, even when she isn’t feeling her best. She found out a few months ago that she has lung cancer, but it was actually pneumonia and a high fever that brought her into the hospital this time. Mrs. M started smoking at the age of 36 and has continued until her most recent admission to the hospital, at the age of 71. She smoked around a pack a day at first, and then cut back to about half a pack a day. She was married to her first husband at the age of 15. Her second husband died a few years ago from an aneurysm, although he had also been diagnosed with lung cancer before he died. She worked for both General Electric and a plastic factory, but her favorite job was at a local “rest home” where she worked as a nursing assistant. Mrs. M recalls her days as a nurse very fondly. She loved the group of people that she got to work with and remembers giving out many hugs during her time there. Her favorite part of her job was helping the residents get ready to leave by cleaning them and “getting them prettied up.” She loved helping them feel more confident about themselves, whether this involved their outward appearance or personality. Her career as a nurse was cut short when she was injured while on the job. As she was attempting to help a resident move around, Mrs. M made an awkward movement and seriously injured her back. She had to leave work immediately and ended up having a thirteen-and-a-half-hour surgery. After the surgery, she “laid in bed” for 3 months. She had a hard time walking again, saying that “my legs didn’t want to go,” but she had a house full of kids, so she had to keep going. Mrs. M has devoted her life to her kids and she’s been with them through thick and thin. They all live close to her, yet she sadly admits that after her husband died, her three daughters seemed to pull away from her. She feels like after years of her caring for them, giving them everything she could, they didn’t take it well when the roles were reversed, with her needing them more than they needed her. Luckily, her son remains by her side, being the one to bring her to and from the hospital when she becomes sick. Mrs. M is a country girl with a positive personality; she has a huge heart and a true passion for making others feel special. A mother with pain in her way I’m a Madisonville native, born and raised; my family has lived in the area for years and I’m proud to call it home. I moved to Nashville for a while to pursue a degree in business administration before returning home, where I now manage accounts for local government. While this may be what I do, it is only a small part of who I am. I am a wife and mother to six beautiful children who are my pride and joy. They range in age from thirteen to twenty, four girls and two boys. My husband and I have joked that they seemed to pair off along the way, each pair being inseparable, almost more like having three sets of twins than six individual children. As they get older, it is exciting to see who they are becoming as individuals. The second oldest will be moving away to start college this fall, and it’s starting to hit home that they will all be making their own way in the world soon. Journal of Regional Medical Campuses, Vol. 2, Issue 5 Perspective We like to spend time as a family enjoying the outdoors. You’ll find us fishing and kayaking near Clarksville, Tennessee. It’s beautiful out there, and if you ever get the chance to visit, I highly recommend it. I enjoy spending time with my children. They are strong willed and independent and they are my driving force. They keep me going and push me to stay healthy and be positive, even in situations like mine where it seems like the answers are never quite clear. My first hospitalization was a few years ago. I felt severe pain in my stomach and when it didn’t go away, I decided it was time to see a doctor. They said I had polycystic ovary syndrome and severe endometriosis. Between the two, I had to undergo numerous surgeries to remove cysts and suffered from many infections that frequently put me back in the hospital. It was then that I decided to undergo a hysterectomy and oophorectomy. It seemed like more of a means to an end, a necessary procedure that would end the need for surgeries and allow me to stay out of the hospital, return to work, and not keep me away from my family so often. Since then the pain has returned on several occasions. I have met with specialists, been through numerous imaging studies and a few more hospital stays, but the answer as to why this keeps happening isn’t clear. The financial burden of these repeated stays is growing, and at times, it feels like I may never get an answer. It’s during these times that I think about my family and keep pushing. The doctors here have been very kind and have listened to my concerns. I just hope to be able to return to my family and get back to enjoying the outdoors soon. Second-generation coal miner and competitive athlete Mr. G was born and raised in Madisonville, Kentucky, and has continued to stay and raise his children in the area. He is the only child of a coal miner father and a mother who was a proficient seamstress. He was just nine years old when the United States entered World War II, and his father was granted an exemption from the draft because he was a coal miner. Mr. G has memories of his family gathering coal that had fallen off the trains in order to heat their home before Madisonville had natural gas. Growing up in the era before television, everyone played outside and participated in sports. He remembers his neighbor from down the street, a legendary basketball player who made his way to the hall of fame after playing for the Boston Celtics. Mr. G vividly recalls that star’s father hanging up lights in the backyard so they could shoot hoops late into the night together. Mr. G himself was an athlete who earned 13 varsity letters among basketball, football, and baseball. The first time he laid hands on the leather of a football during a game, he scored a touchdown. In one game of baseball, he hit two homeruns. During a single basketball game, he racked up 25 points for his team. After high school, he went to a regional university to play basketball for the coach for whom the arena was eventually named. After playing basketball for a year, he transferred to another college to continue his sports career on a football scholarship. Mr. G later pursued a career in the mining industry and sold underground mining equipment to coal mines all over the nation. He recounted not only mining underground coal, but also the mining of salt in 16 different states. He has traveled the country and firmly believes that the United States of America is the greatest country on Earth and is the land of opportunity. He has two sons and a daughter. He boasted that all of his children graduated as high school valedictorians of their respective classes. His children have a wide range of talents that carried over into their careers: from playing multiple instruments to engineering mining equipment. Mr. G has four granddaughters, one grandson, and one great grandson. His family is a large part of his life, and he is a proud father, grandfather, and great grandfather. He enjoys trivia in his free time. A frequent participant in the local restaurant’s weekly trivia night, he excels in all topics of trivia. His general knowledge across all areas exceeds most competitors, he says. Proud of his willpower, he says as a former tobacco and alcohol user, he put down both of these habits, cold turkey, about 20 years ago. Mr. G was admitted for cellulitis, which has cleared up and healed well. He tries to remain as active as possible with his age. When asked about the care he has received, he had nothing but praise. The nurses and medical assistants were caring and would openly engage in conversations with him. His doctors were never afraid to reach out and shake his hand or touch his shoulder when discussing his future care options. Instead of having medical advice thrown at him and the doctors making all the decisions regarding his care, Mr. G felt he was included in these discussions and played a very active role in determining the care that best suited him and his needs. He insisted that our local hospital is ahead of the competitors when providing quality medical care. A lucky girl Suzy R is now on a regular nursing unit after first being admitted to the ICU for severe shortness of breath from her known COPD. She describes herself as a healthy person until a few years ago when several bouts of pneumonia resulted in several hospital admissions. She sees everything now in the light of her last big hospital scare when a wisdom tooth extraction caused her to develop jaw osteomyelitis. That Journal of Regional Medical Campuses, Vol. 2, Issue 5 Perspective hospitalization left her depressed and intermittently suicidal. She was very embarrassed and ashamed of her facial deformities at first and felt as though she had nothing to live for. However, it was for her two children that she turned her attitude around in spite of the long recovery road ahead of her. She now calls her facial deformities her “lucky scars” and she feels as though she became stronger because of this process, discovering what and who was really important to her. Suzy spent most of our conversation proudly bragging on her two children and describing the effect they have on her emotional wellbeing. Her daughter is going back to college with intentions to graduate. She was very proud that her daughter decided to continue her education. Also with pride, Mrs. R recounted that since that last scare, she permanently stopped smoking. She also appreciates the chance to share her experience with students and doctors so they can better recognize and treat jaw osteomyelitis. Her eyes lit up when she discussed her love of the outdoors and told of many happy hours spent fishing with her children. She carries her oxygen tank with her and strives to be as active and involved in life as she possibly can be. She then spoke sadly about her physical inability to work in her former role as a manager of a general store. She also worries about paying her share of costs of medicines and doctor’s visits. The smile returned when she talked about how lucky she is to have been adopted by her grandparents, and how fortunate she is to have survived all her close calls to continue to be in her children’s lives. She also expressed how pleased she is with her hospital care and feels comfortable returning here if needed. The favorite aunt Mrs. R is a 51-year-old African American woman who has just been diagnosed with diabetes after an episode of diabetic ketoacidosis for which she was hospitalized. One morning she woke up, walked outside, and noticed that everything was so blurry that she couldn’t recognize any of her family members. She stayed at home for two days and was incredibly fatigued and thirsty the entire time. She does not have any children, but her family is extremely important to her. Her young niece stayed with her the entire time and would not let her go to sleep, for fear that she would not wake up. She refers to her as “my little angel.” After two days at home, Mrs. R’s mother told her she would take her to get food and instead she sneakily took a “wrong turn” and made her get out at the ER. As a child, Mrs. R played center for the women’s high school basketball team. She likes watching baseball and tennis, playing PS4, and going out with her girlfriends to Applebee’s and other places around town. Her mother works for the water department and her father, who is deceased, was a coal miner. Mrs. R has lived alone for the past year in a house across the street from her mother. She was born and has lived her whole life in a town of 1700 in western Kentucky. She is the oldest child of four with three younger brothers. Some of her younger brother’s daughters live with Mrs. R’s mother across the street and they frequently spend time with her. The greatest joy in her life is spending time with her family—listening and comforting them is what she enjoys the most. She has no children herself and suffered a miscarriage a few years ago fathered by a man who is no longer in her life. She broke up with her last boyfriend a few months ago but keeps in close contact with him still. Currently, she has no job but has worked in the food service industry at a large number of restaurants around town. After a few months on the job, she often gets bored or finds some of the other staff hard to deal with, so she quits and moves on to something else. She would like to get a factory job in the future and someday have enough money to get her teeth fixed cosmetically. Faith is important to Mrs. R and she considers herself a Christian Baptist. She likes to “float” around to different churches and try them out. She is currently a member of a local Baptist church. In her opinion, a good church will send someone to check on you if you aren’t at the service on Sundays. As for her rating of the hospital, she says that “everything gets a 10.” She has no complaints about her or any of her family member’s treatment. Comments from students As a medical student, it is very easy to get caught up in the diagnosis and treatment portions of medicine. My Story allows you the opportunity to step away from the “what” and connect with the “who.” These interactions can help guide shared decision-making plans for treatment and can aid in building a better patient-physician relationship. As a college student, I thoroughly enjoyed talking to the patient about his life and what brought him to seek care at the hospital. I think it’s especially helpful for the patient more than we realize because it demonstrates that someone has interest in their background. As a college student, I gained a new perspective when it comes to treating patients. When interviewing my assigned patient, I realized the effects a diagnosis can have on a patient beyond their physical health. As physicians, we feel relieved when we finally, after months of back and forth, narrow down the cause of our patient’s symptoms. We often don’t realize that when we place the diagnosis on a patient, their acceptance and understanding is just beginning while ours is just ending. We close the book, and move on to Journal of Regional Medical Campuses, Vol. 2, Issue 5 Perspective another patient with more handfuls of complicated problems. I understand now how important it is to get to know your patients. This experience will change the way I practice medicine in the future, and I hope to be a better physician because of it. From my perspective as a college student, this exercise showed me what it is like to see a patient as more than just a patient- to see the whole person. I think anyone planning on going into healthcare should do a similar exercise. For me, it added fuel to my passion for helping people and gave me a new perspective on the patient. In the first two years of medical school, we learn about the intricate complexity of bodies we will take care of, but we rarely get to hear about the souls attached. In the 45 minutes I spent with my “My Story” patient, I learned about their past, the forces that move them every day, and how I could serve them best as a physician one day. These stories continue to drive me on my medical journey. Evaluation The response from the patients was uniformly positive, and in an anonymous written evaluation, eight of 11 students completing the project rated it positively, with three neutral, and none negative. Four gave it the highest rating possible in terms of meeting the goals of the program. Discussion We found the “My Story” narrative exercise to meet the needs of this rural summer program that included relatively inexperienced interviewers. The structure is easily learned, and patients accepted it well. It seemed that careful communication with the senior resident and faculty on the residency inpatient service was important in our success. The inpatient setting provides a less time-stressed environment than an office experience would, and has the additional benefit of allowing these preclinical learners to see confident family medicine role models on the acute hospital service. Feedback from the students was that this exercise was effective in providing an opportunity for reflection on the value of empathy, and we consider it as a first step of a compassion training effort. References 1. Crump WJ, Fricker RS, Ziegler CH, Wiegman DL. Increasing the Rural Physician Workforce: A Potential Role for Small Rural Medical School Campuses. The Journal of Rural Health. 2016; 32(3):254-259. 2. Crump WJ, Fisher SM, Fricker RS. Community Service as Learning Laboratory: A Report of Six Years of a Rural Community-Academic Partnership. Journal of the Kentucky Medical Association. 2014; 122: 131-136. 3. Whittington CP, Crump WJ, Fricker, RS. An invitation to walk a mile in their shoes: a rural immersion experience for college pre-medical students. Journal of Regional Medical School Campuses. 2019;1(5). doi:10.24926/jrmc.v1i5.1565. 4. Crump, B. Professional Identity Curriculum at the University of Louisville Trover Campus: Reflection and Meaning in Medical Education. The Journal of the Kentucky Academy of Family Physicians. Winter 2017;88:18. 5. Crump WJ, Ziegler CH, Fricker RS. A residency professional identity curriculum and a longitudinal measure of empathy in a community-based program. Journal of Regional Medical Campuses. 2018:1(4). doi: https://doi.org/10.24926/jrmc.v1i2.1292. 6. Reiser SJ. Science, Pedagogy, and Empathy. In Spiro H, Curnen MG, Peschel E, and St. James D (Ed). Empathy and the practice of medicine. Yale University Press. New Haven and London. 1993. p129. 7. 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