ERIC EJ1094967: Once upon a Time. . . at the Tenth SOBRAMFA International and Academic Meeting--S. Paulo--Brazil

2006·0.28 MB·English

by  ERIC

Title:
Once Upon a Time. . . At The Tenth SOBRAMFA International and Academic Meeting - S. Paulo
- Brazil
Journal Issue:
Journal for Learning through the Arts, 2(1)
Author:
De Benedetto, Maria Auxiliadora C., SOBRAMFA - Brazilian Society of Family Medicine
Blasco, Pablo G., SOBRAMFA - Brazilian Society of Family Medicine
de Castro, Ariane G., SOBRAMFA - Brazilian Society of Family Medicine
de Carvalho, Elsi, SOBRAMFA - Brazilian Society of Family Medicine
Publication Date:
2006
Permalink:
http://escholarship.org/uc/item/9p44s8qz
Acknowledgements:
Keywords:
Narratives, Family Medicine, Medical Education, Healing
Local Identifier:
class_lta_2536
Abstract:
In Brazil, medical practice and the predominant medical education model are based on
specialization. Methodologies such as patient-centered medicine and narrative medicine are either
unknown or not applied in a systematic way. In order to draw students’ and doctors’ attention to
these approaches during the TENTH SOBRAMFA INTERNATIONAL AND ACADEMIC MEETING,
an informal event called “Narrative Session” was presented. The meeting’s attendees were asked
to send patients’ stories in advance. The stories submitted were selected and classified according
to medical sociologist Arthur Frank’s description of three structures or skeletons of narrative –
restitution stories, chaos stories, and quest stories. A special ambiance – a setting evoking The
Tales of 1001 Nights– was created for the presentation. The narratives performed showed the
narratives’ healing and didactic potential for patients, doctors, and students.
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1.StoriesinMedicine:searchingforhumanisticroots
Medicineisaprofessionthatinvolvesrelationshipbetween atleasttwo
individuals–physicianandpatient.Tellingstories isanaturaltendencydeep-rootedin
thecoreofhumanbeings.Illpeoplealsoneedtotellthestoryoftheirillnessesandthe
storiestheythinkarerelatedtotheirsufferings. In theolddays, resourcesfordiagnosis
andtherapyweremuch morelimited,andlisteningtopatientswithempathywastheonly
toolapplicableinsome medicalsituations.Eveninthemodern era,when physicianshave
much greatertechnicalknowledge,patientsdon’t trustdoctorswhodonotpayattention
totheirstoriesandconsidertheirfeelings.Thepatient-doctorrelationship alwayswas,
andwillbe,thefoundationofagood medicalpractice.Thecoreofgood medicine
remainsthesame:awarenessofapowerfulandimportantbondbetweendoctorand
patient.Althoughthescienceofmedicinenowis vastlydifferentfromthat inprevious
centuries,theconnection betweenphysician andpatientisstill basedonthesame
principlesofhumannature.(1)
Nowadays, medicineis aworlddominatedbytechnological advances,inwhich
priorityis giventoincreasingreductivenessandspecialization.Physicians knowagreat
dealabouteverysegmentofthehumanbodyand mind; sometimesthispreoccupation
withthetechnicaldetails ofdiseasehamperstheperceptionofthewholenessrepresented
bythehumanbeing.Althoughthedominantmedicalmodeloffersinnumerable
advantages forpatients’ care,somethingis missing.Patientsanddoctorsaren’ttotally
satisfied,perhapsbecausethefragmentationofthehumanbeingandthehighlightingof
technologyhaveobscuredtheimportanceofagoodpatient-doctorrelationship.(2)
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Mostcurrentclinical activityisdrivenbytheprinciplesofevidence-based
medicine. “Usingthismodel,clinicianstrytoturnpatients’stories intoclinicalquestions
andthensearchforthebestrelevant evidenceto gettherightanswer.”(3) Scientific
evidencecomesfrom randomizedtrialsorcohortstudiesappliedtopopulations
accordingto mathematicalmodels.Theresults obtainedthroughthesestudies concern
populationsorgroupsofpatientssimilartothosestudied.
Thechallengeistherealanduniquepatientdoctors haveinfrontofthem. Allthe
textswrittenaboutphysiopathologyofdiabetes mellitusaresimilar,buteachindividual
whoisexperiencingtheillnesshasadistinctiveandirreplaceablestory. Itis also
necessaryforthephysicianstobeabletoreadand understandthistext.Goodmedical
practicerequires aproperapplicationofevidence-basedmedicineconcepts tothe
individualcontext.Itis uselesstoknowthebestmanagementforaparticulardisease,if
thepatientdoes nottakethemedicines,becauseheorsheis depressedorhasasystemof
beliefthatimpedeshisorheradherencetothetreatment.
Thedevelopmentofagoodpatient-doctorrelationshipisacrucialresourcefor
translatinggeneralizedscientificevidenceintotheparticularhumansituation. Thisuse
ofthedoctor-patientrelationshipisacornerstoneoffamilymedicine,which routinely
filterssciencethroughthelivedexperienceofthepatient.Patient-centered medicineand
narrativemedicineareusualmethodologiesforthis purpose.
Forimprovingtheclinical method,differentapproaches ofpatient-doctor
communicationhas been developedduringthelastdecades. “Clinicalmethodisan
interpretativeactwhichdrawsonnarrativeskillstointegratetheoverlappingstories told
bypatients,clinicians, andtest results.”(4)In1957,thephysician,Michael Balint,
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introducedtheterm“person-centered medicine”to refertoaclinical methodthathas
psychotherapeuticconnotations andis basedonphysicianself-awareness. Patient-
centeredmedicinebecameoneofthemostimportantpillars ofthespecialtyof family
medicine. Ian McWhinney,afoundingfatheroffamilymedicine,andhisdiscipleshave
guidedfamilyphysicians aroundtheworldindevelopinga methodologycomposedofsix
basiccomponents,whosefunctionistostrengthen andexpandthepatient-doctor
relationship.(5)Practicingpatient-centered medicineimpliestheprimacyof listeningto
thepatient.
Whenpatients meetdoctorsorhealthcareprofessionals whoarewillingtolisten
tothemwithempathy,theyeasilystarttellingstories–storiesoftheirlives and
sufferings,andstoriesrelatedtotheirbeliefs andlifephilosophy.Thepoint nowiswhat
todoandhowtodealwithpatients’stories,eventhosethatapparentlyhavenothingtodo
withtheirdiseases’clinicalstories.
2.Turningstoriesinto narratives:a healing methodology
Duringthelast decades, anew methodology–narrativemedicine, atermcreated
byRitaCharon(6),ornarrative-based medicine,as Britishauthorsprefer– hasbeen
constructedas apossibleresponsetotheabovequestion.Suchamethodologyinvolves
theuseofpatients’stories as atherapeutictool. Focusingonpatientnarratives,bringing
themtolight andconsideringalternativenarratives,allows patients toparticipateintheir
ownhealingprocess.(7)Patients’narratives aremorethan merestoriesin whichthefacts
aretoldoneafteranother inachronologicaland finitesequence. Theyalso gobeyondthe
familiarclinicalstoriesphysicians constructabout theirpatients. Inpatient narratives,the
feelingsbehindtheevents areoften moreimportantthantheconcreteeventsthemselves.
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Narrativesalwaysinvolveinterpretation.(8)Thesamestorycanbetoldandlistenedtoin
manydifferent ways. Moreand morehealthprofessionals agreeabout thehealingpower
ofthewordand recommendthattheirpatientsexpress,throughtalkingor writingin
proseorpoetry, feelings theyhavedifficultydealingwith.(9) Aspatientshavethe
chancetofreelyexpress theirfeelings,anxieties,fears,beliefsandthesad eventsoftheir
life’sstory,theyfrequentlyleavetheofficebetterthantheyarrived.Tofullyappreciate
patientstories,weneedtohavethenarrativeskills toapprehendvarious componentsof
thesechronicles,suchas structure,plot,voice,and character.As themedicalsociologist
Arthur W. Frankasserts, “Thesubtlesemanticsofnarrativesuggestastructure
underpinningthestory, andnarrativeanalysis locates structures thatstorytellersrelyon
butarenotfullyawareof”.(10)
Inordertopracticepatient-centered medicineinaproper manner,itis important
tounderstandthehuman beinginalldimensions – physical,emotional,cultural,social
andspiritual. Withtheintroductionofhumanities departmentsinvarious medicalschools
aroundtheworld,medicalstudentsanddoctorshavebeen advisedtoimprovetheir
knowledgeaboutinnerhumannaturebystudyingthehumanities–literature,philosophy
andarts-andincorporatinginsightsderivedfromthesedisciplinesintotheirpractice.
Studentsand youngdoctorscan,forexample,beintroducedtodifficultthemesrelatedto
life,death,pain,illness andsufferingthroughliterary,philosophicalandcinematicworks.
Insuchaway,theycanbepreparedtodealwiththesedifficultsubjectsbeforehavingto
facethemin reallife.
Butonemayalso enhancethisliteraryapprenticeshipinthedailypracticeof
medicinebyconsideringrealpatients’stories and howthesestoriesintersectwithand
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relatetotheirownpersonalandprofessional stories.Suchstoriesrepresent asourceof
teachingaboutthesubtletiesofhuman emotionandbehavior.Aslisteningtopatient
narrativesstimulatesreflection,doctorsandstudentsbegintolearnabout aspectsoftheir
patients’livesandtheirrelationshipswiththeirpatientsthat previouslywereinaccessible
oronlybarelysensed.Bysharingthesenarratives withcolleaguesandpromoting
reflectionanddebate,theknowledgeobtainedis expanded.Itispossiblethatone
patient’snarrativewillenlightenasimilarsituationlivedbyotherpatients. So,inmany
aspects,narrativesacquireanimportantdidacticroleinthepracticeandteachingof
medicine.
3.StoriesinMedicalEducation:the SOBRAMFAexperience
TheBrazilian SocietyofFamilyMedicine(SOBRAMFA)isan academicsociety
whoseaimistopromotefamilymedicineandtoestablishtheproperbasis andscientific
methodologyfor familypractice. SOBRAMFA runs aresidencyandothertraining
programsforstudents anddoctors,specialists and generalists.Theprinciples ofevidence-
basedmedicineareappliedtoimprovethetechnicalperformanceofits trainees.Beyond
that,humanisticresources areusedtoteachthephilosophyandpracticeoftheartof
medicine.
Onceuponatime, attheTenthAnnual SOBRAMFA InternationalandAcademic
Meeting, agroupofstudents anddoctors frommanyBrazilianstatesassembledtotell
andlistentostories intheopeningsessiondedicatedtonarratives.Each year,this
meetingopenswithasessionfocusingonnarrative,andthis yearwasnoexception.
Thesesessions areaninformal encounterwhoseaimistodrawtheattentionofstudents
anddoctorstotheimportanceofnarrativeinmedicalpractice.Accordingtothe
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predominantBrazilian medicaleducationmodel,studentsstudya greatdealabout
diseases,organs andsystems and verylittleaboutthehumanbeingstheywill havein
frontofthemthroughout theircareers.Althoughtheteachingofhumanitieshas been
introducedinsomeBrazilianmedicalschools,itsstudysuffers adichotomyinthatitis
rarelydirectlyconnected withclinicalpractice.Andnarrativemethodologyis practically
unknown. Studentsand youngdoctors longfora waytoacquiretoolsthatallowthemto
dealappropriatelywithhumanbeingsintheir completeness. Webelievethenarrative
sessionisastimulus tothinkaboutalltheseissues.
This year,inthe“callfor narratives”,theattendeesatthemeetingwereaskedto
sendinadvancepatients’storiesthathadbrought greatlearningorinsights forthemor
showedapalliativeor curativeeffect forpatients.Elevenofallnarrativessubmittedwere
selected,inaqualitativeway,forhavingfulfilled theconditionsrequiredinthecall.The
finalpresenterswereaskedtoeitherreador recitethesestoriesfrom memory.
Everyyear,aspecialambianceisprepared forthenarrativepresentations,a
settinginspiredbyaliteraryorcinematicworkin whichastorytellerplayedasignificant
role. In2006,asettingevokingTheTalesof1001Nights wascreated, and, onthe
“stage,”aSOBRAMFA second yeartraineeincarnatedthecharacterScheherazadeto
conductthesession.Afteranexplanationaboutnarrative methodologybyoneofthe
eventcoordinators,SOBRAMFA’s Scheherazadeopenedtheperformancewiththe
followingstory:
“Onceuponatimeacruelsultanlivedinavery,verydistantrealm.Becausehe
hadbeenbetrayedbyoneofhis wives,hebecameconvincedthat nowomanwas
trustworthy.So,hemadeapromisetohimself–hewouldnever bebetrayed
again.Inordertokeephispromise,eachtimehetookanew wife,hekilled heron
theirweddingnight.Thatwas thewayhefoundtoavoidpotentialbetrayal.Then,
hechoseScheherazade, aprincess ofaneighboringkingdom,as his wife.
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Scheherazadehadagift –sheknewhowtotellstories inawaythatmadepeople
fascinated.Andeachnight thesultankepther alivebecausehewantedtolistento
anewwonderfulstoryor toknow theendofanearlierone.Thestories told by
Scheherazadeoriginated TheTalesof1001Nights.”
Then,thetraineeexplainedthatthechoiceofscenariowasbasedonthefollowing
idea:knowinghowtotellstoriesmadethedifferencebetweenlifeanddeath for
Scheherazade.Similarly, inmedicine, aprofessionthatdeals withhuman relations,
knowinghowtolistento andtellstories alsocan makethedifferencebetweendeathand
life,diseaseandhealth,sadness andjoy,sufferingandtranscendence.
Next,Scheherazadecalledontheparticipantsinapredeterminedsequence
resultingfromaprevious categorizationoftheirstories.Thestories selectedwere
classifiedaccordingto Frank’s descriptionofthreestructuresorskeletons ofnarratives –
restitutionstories,chaos storiesandqueststories. Thisclassificationwaschosenbecause
ithas shownagreatapplicabilitytothedailypracticeoffamilymedicine, especiallyin
didacticpalliativecaresettings.Thefollowingtext,inwhich Frank’sinsightsabout
narrativewaspresentedandexplicated,was intermingledbetweenthenarrative
presentations.(11)
Frankconsiders thepatienttobeastorytellerandthetellingand receivingofthe
storyas agiftrelation,notaprofessionalexchange.Storytellingis arecursiveelaboration
oftherelationshipbetweenthosesharingthestory.Thereis astorytellingrelation,in
whichsomeonecanbespeaking,butstories aretoldwith–notonlyto–listeners whoare
partofthestory. Stories arenot materialtobeanalyzed,butrelationshipstobeentered.
Eachoneofthethreenarratives’skeletonsdescribedbyFrankmaybecomeapathway, a
wayofenteringrelationships. Thestructuresdescribedbytheauthorarenotrigid,but
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representapredominantpatterninthestory.Dependingonthe mannerin whichthestory
is toldandlistenedto,onecan changefromonepatterntoanotherinitsdevelopment.
Storiesallowfortheemergenceof meaninginrelationtoillnessandsuffering;
andtheidentificationofthemeaningbyitselfcan exertatherapeuticeffectonthepatient.
Andthisis truenotonlyforthepatients,butforphysicians andmedicalstudentsaswell.
Whentheseprofessionals telltheirstories,theyarenotmerelylookingforclinicaladvice.
Liketheirpatients,theytooarelookingformeaning,aclarificationoftheirrelationship
withpatients; andtheyaretryingtolearnhowtosuffer withpatients.
4.Illnessanddoctoringthroughstories:restitution,chaosandquestnarratives
Inthenarrativesession,restitutionstorieswerethefirstpresented.Thesestories
concern apersonwho getssick,receivescarefromadoctororhealthprofessional,and,
throughtreatment,his/herwellbeingisrestored.Duringtheevolutiontohealing,what
waswrongbecomes corrected,andthedoctorsometimes emergesas ahero. Insuch
narratives,thephysician orhealthprofessionalisthemainactororactressinthescene
andthediseaseisan enemytobeconquered.Themonologicaldiscourseoftheillperson
is torecountthatthetreatmentwasefficientandeffectiveoratleastis expectedtoleadto
healing.Restitutionstoriesareappropriateforthosepatientswith greatlikelihoodofcure
andareoftenrelatedwhenillness isinaninitialphase.TheyarewellillustratedbyFrank
asfollows: “Restitutionstories representthetriumphantoptimismofmedicalscience.”
Doctorswhoaresearchingforsuccessfulclinicaloutcomeandefficiencyareeasily
attractedtothis kindofnarrative. Inthesestories,thesubjectivityofthepatient,which
shouldbeanill person’s mostsignificantcharacteristic,vanishesalmostentirelyinthe
healthcareprofessional’s recountingofthepatient’sstory.Inourcountry,as aresultof
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fragmentedtraining, mostofdoctorsarenotusedtopayingattentiontopatients’stories,
andwheneventually,theydosobysomeinnerimpulse,theytendtowanttotell
restitutionstories.Certainly,illpeople’sfamilyandfriendsalsowanttohearthesekinds
ofnarratives,wherehealthandwell-beingarerestored.
Herearesomefragments ofrestitutionstories:
Ilearnedwithmypatients,forinstance,thatmanyofthemkeepinsideseedsof
healingandifsomeoneputwateronthesesseeds,theysproutinsurprisingways.
Shegazedatapointandtearspouredfromhereyes.Then,Ididsomething I
thoughtisforbiddenforadoctor–Iclosedthedoor,tookher hands,satdownon
herbedandaskedherto tellmewhatwas disturbingher.Andforthefirsttime,as
Icouldapprehend,shespokeabout herfeelings, suffering,andemotional painto
adoctor…Nodoctor haddiscussed hertreatmentandalthoughshethought she
couldbehealed,shehad alsomanydoubts.Aftertheclarification,shegotcalmer.
Therewasanunaccompanyinganother patient inanearbybed. WhenIsaid
good-bye,shewhispered tome:‘Youareyoung,butneverforgettositbytheside
ofyourpatients whentheyareinneed’.Thatpatientadheredandrespondedvery
welltothetreatmentandwentbackhomeinadifferentmood,withhercourage
pluckedup.
Unfortunately,itisnotunusualforhealthprofessionals tofacecircumstancesof
profoundsufferingandpainthathavenopossibilityofremissionorsolution.Incurable
diseases ortheimminent deathofafamilymemberaresituationsthatgeneratechaos
stories,inwhichthereis noapparentorderinthesequenceofevents.Chaosstoriesare
characterizedbyincompletesentences,periodsofsilenceandquestionswithnoanswers.
Sometimes,doctorsbecomeemotionallyimmobilizedinthesesituationswiththe
subsequentreactiontorunawayortoignoretheconditionsthatmakethemfeelimpotent.
Chaos storiesaretheones wedon’t wanttohear, becausestudents inmedicalschoolare
nottaughttodealwithfeelingsofpowerlessness,anddoctors usuallyseeksolutions,
eveninsituations wherethereisnosolution,exceptlistening. Itisdifficult toteach
medicalstudents tohavethatattitude,becausetheyaretaughtto giveanswersallthe
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