The power of reflective writing: narrative medicine and medical education.

There is no doubt that medicine is an art and a science. Today, practicing medicine as science is probably much easier than practicing medicine as art, in light of the dazzling advances in medical technology and informatics. Even before technology gained the upper hand, patients were healed by physicians when most of the remedies were useless if not harmful, and when remedies were driven by theories that did not stand the test of time. To some extent, the art of fostering the sacred physician-patient relationship might have played a major role in the dramatic healing process. The physician-patient relationship is not limited to a comprehensive history and physical examination, a diagnostic workup, and the final discussion about a plan for action. Medicine requires that the physician establish deep connections by which s/he can dive deep into the crying soul of the patient. Healing an ailment is a complex process that must address two domains: disease, which is the alteration in the biologic structure and/ or function of the body; and illness, which is the psychological and social aspect of the ailment. Proper healing starts with open communication between physicians and patients. Patients draw on physicians’ attributes of honesty, integrity, empathy, and compassion to share their stories as they strive to heal. Narrative medicine offers a unique framework to explore and manage the complexity of healing. Its impact extends beyond the physician-patient relationship and into the relationships between physician and self, physician and colleagues, and physician and society. It is no wonder that many medical schools and residency programs have incorporated narrative medicine in the form of reflective writing into their curricula. Our learners, students and residents, are encouraged to be engaged in reflective writing as they search to understand what medical practice means to them, their patients, their colleagues, and society at large. Learners meet with the first author (SJ) on a regular basis to discuss and analyze their short, open-ended narratives. They are frequently asked to reflect on events of their choice that had a lasting impact on them, negative or positive, at any institution where they rotated. We (SJ and AD) are mesmerized by the insight of the learners and depth of their reflective capacity in their quest for self-identity, ideals, and values as they enter the complex environment of medical practice. It is only fitting to share some excerpts from learners’ narratives about valuable lessons from rich experiences in which they found themselves deeply immersed. One learner ruminated over the discrepancy between what we preach and how we act. He described his negative experience tagging along with his attending physician in a busy outpatient clinic. He wrote: I saw a 45-year-old patient with an advanced hepatocellular carcinoma. He came with his wife to learn about the results of his liver biopsy performed with [computed-tomography] guidance. He had no clue what was wrong with him, much less his prognosis. He was smiling and engaged in a conversation with his wife as I walked into the room. I asked him how much he knew about his condition. “They told me I might have a tumor, but I was told that you will be telling me more.” I was in my second month of training and did not feel comfortable breaking the bad news to him. I decided to leave it to my attending. A few minutes later, my attending and I went into the room. After introducing himself to the patient, the attending asked me to bring the ultrasound machine because he wanted to examine the patient for ascites. After he was done, he told the patient that there was no fluid and all this abdominal distension was probably due to an enlarged liver and suggested that the patient [go] to radiology for palliative chemo-embolization. While he was standing next to the door that was half open, the attending asked the patient “So, do you know what is going on with you?” The patient did not say anything but his [facial] expressions were enough for us to tell that he was not aware of how serious his condition was. “You have a very bad cancer and you will die in six months,” the attending said. Surprisingly, just [a] few days before that, the same attending gave us a lecture for an hour about palliative therapy of terminal cancer [patients]. The whole lecture was centered around dealing with terminal cancer patients and breaking bad news. He talked about some personal experiences as well as some skills and strategies of how to build a relationship with your patient[s] and how to earn their trust. “Touching the patient, sitting close to them, smiling, and some other simple things make all the difference in the world for them,” the attending had said. After we left the room, I was thinking of how shocking and overwhelming that was to the patient. I was wondering if being busy can be an acceptable excuse for not showing empathy and