1、胸 腔 科 黃 建 達2 0 1 1 - 4 - 7 7 : 3 0 8 : 3 0NARRATIVE MEDICINE敘事醫學多一點故事，少一點理論Robert Coles:當他開始用聽故事的方式了解病人時 發現自己彷彿配備了另一雙耳朵 不再僅僅專注於收集有助診斷的症狀，套入各種疾病的模型，然後安排適當的治療他邀請病人共同編寫有關於自己疾病的故事 擴大為生命的故事 豐富了對病人的理解與關懷。讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/ IS NARRATIVE MEDICINE?敘事醫學 哥倫比亞大學Rita Charon醫師 2000 提出了Narrati
2、ve medicine 醫學知識應分為兩組 第一組是客觀的logical-scientific knowledge 是對疾病的遺傳、病理基礎的了解與治療。 第二組則是主觀的narrative knowledge 是在病人的理解與故事中，疾病所扮演的角色，所象徵的意義，所帶來的變化與所隱含的功能，這些細節應該由醫師與病人共同編寫、探索。Rita CharonNARRATIVE MEDICINE 傳統病歷的書寫從收集症狀、建立因果關係、診斷排序下手，是一種reductionist的簡化、歸納手段， 敘事醫學鼓勵每個人書寫、分享、重新建構自己的故事 對醫師、病人 敘事則邀請更多可能性、更多細節來豐富
3、理解 可能必須花上更多時間 值不值得？讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/ 美國許多醫學院 - 在訓練課程中加入了文學賞析 只有聽得懂他人的故事我們才能開始思考如何解除他人的苦痛 - 醫學的初衷 Charon醫師在紐約哥倫比亞大學 - 開了一門Narrative Medicine碩士班讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/ Physician and Patient, Self, Family Patient Care Physician and Self, Patient Medical Knowledge P
4、hysician and Self, Patient, Colleagues, Society Practice-Based Learning and Improvement Physician and Patient, Colleagues, Society Systems-Based Practice All Situations Interpersonal and Communication Skills All Situations Professionalism 敘事醫學與療傷 For Patient Coping strategy; facilitates adjustment/
5、adaptation Process feelings and reactions Expression and communication Promote healing, improved health outcomes For Provider Process reactions to difficult situations/grief Protection against burnout Reduce practitioner stressYamada, S.et al. Medical Student Education, 2003; 35(4), pp.279-283.Brady
6、, DWet al. Annals of Internal Medicine, 2002; 137(3), pp. 220-223.敘事醫學與同理心Empathystudents practice taking the view of another person (a patient, family member, other healthcare providers)they see the patient as a person within a family, community, and culture Halpern J. From detached concern to empa
7、thy: humanizing medical practice. New York: Oxford University Press, 2001. Das Gupta S & Charon R. Personal Illness Narratives: Using Reflective Writing to Teach Empathy. Acad Med. 2004;79:351356. 同理心NARRATIVE MEDICINE DOES NOT MAKE MEDICAL STUDENTS INTO WRITERS, BUT MAKES THEM BETTER DOCTORS suppor
8、ting their skills of observation encouraging their reflection in a clinical context showing the students that their thoughts, feelings, and questions are heard through the responses from the mentors. Narrative Medicine at UNM IRCME Symposium, March 16, 2007內容分析 Initiation: first-time experiences Ide
9、ntity Awe Frustration and disillusion Questioning ValuesNarrative Medicine at UNM IRCME Symposium, March 16, 2007STUDENTS SAY THIS WRITING HELPED THEM TO perceive their clinical work in a thoughtful way become more observant and analytical look for recurrent patterns respond better to patients. Narr
10、ative Medicine at UNM IRCME Symposium, March 16, 2007FACULTY COMMENTS: RESPONDING TO STUDENTS REFLECTIVE WRITING MAKES THE MENTOR MORE REFLECTIVE Helps keep me in touch with students at the early stage of training I got a much better insight into how students grow over time. It has made me look clos
11、er at my own behavior as a teacher, mentor and clinician.Narrative Medicine at UNM IRCME Symposium, March 16, 2007 ReflectiveRESULTS: “TIME WELL SPENT” Students and mentors overwhelmingly positive Most mentors return Explosion of student interest: From a class of 75 students: 9 took Narrative Medici
12、ne track in 2005 22 in 2006 54 in 2007Narrative Medicine at UNM IRCME Symposium, March 16, 2007CONCLUSION: A NARRATIVE MEDICINE EXPERIENCE CAN BE: simple to set up requires a very modest investment in student and faculty time rewards the effort with increased reflection and satisfaction for both stu
13、dents and faculty.Narrative Medicine at UNM IRCME Symposium, March 16, 2007發展敘事醫學能力“I write the story. The story writes me.” Watts 推動敘事醫學的目的反省溝通教育 高雄醫學大學呼吸治學系慧如助教授TRAINING MODELKNOWLEDGEACQUISITION (Novice)KNOWLEDGEAPPLICATION(Beginner) STORIES = TOOLS TO ASSESS &IMPROVE(Competent)Lawrence & Viken (
14、2004). RAP NARRATIVE MEDICINE SKILLS Observation Active listening Ability to tell the patients story感動別人Verghese A. The physician as storyteller. Ann Intern Med 2001;135:1012-7.敘事學的種型式1.簡單敘述由一位具體的敘述者所講述的故事2.模仿敘述由全知而無實體的存在角岀發講述故事敘事者身份隱藏案例試寫案例試寫 床上曾有麼困擾你的事件嗎？ 對這事件印象最深的一個場景 回想此場景，直接浮現的3-4個印象點關鍵對話 以這3-4
15、個印象點描繪一個簡短的故事 請給它一個最適當的簡短標題 要套用術語儘還原到原初情境高雄醫學大學呼吸治學系慧如助教授孩子還給我“Twenty-four year-old, 28 weeks pregnant.Small abruption, dilated to 4 or 5, s/p mag.Signed out AMA to smoke.Down. Abrupted. Bled. Came up baby dead. Positive cocaine.Stupidity.Irritated.”Howis Y. Toler, M.D. The 27th Forum for Behavioral
16、 Sciences in Family MedicineSeptember 2006還原情境 還原情境的第一步驟：套用術語 其次：為故事命名 範： 孩子還給我 機器人女孩 大象男孩 父親的害怕 醫學敘事文學創作徵文比賽file:/localhost/Users/cdhuang/Desktop/Narrative Medicine/醫學倫理文學創作徵.doc - narrative medicineHOW TO GET STARTED Critical Components Curriculum Integration Application AssessmentHowis Y. Toler,
17、M.D. The 27th Forum for Behavioral Sciences in Family MedicineSeptember 2006CRITICAL COMPONENTS Resident champion/facilitator “Safe” faculty member Education about narrative competence, narrative medicine, and core competencies Motivation Noon conference credit & food Opportunities to practice & exp
18、eriment with writing Acceptance, comfort level Willingness to share, model for others Literature, literature, literatureHowis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family MedicineSeptember 2006INTEGRATING NARRATIVE MEDICINE INTO THE CURRICULUM Use during orientation to help reside
19、nts get to know one another Include writing exercises in required didactics and seminars Narrative Medicine RoundsHowis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family MedicineSeptember 2006NARRATIVE MEDICINE ROUNDSNARRATIVE MEDICINE ROUNDSREQUIREMENTS Complete pre- and post- self-as
20、sessment questionnaires Attend and participate in at least 50% of scheduled Narrative Medicine Rounds Keep a personal journal Have fun!Howis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family MedicineSeptember 2006NARRATIVE MEDICINE ROUNDS SESSION FORMAT Brief 5 to 10 minute didactic Re
21、ading of the day Time to write Reaction to reading Guided writing Personal reflection Time to shareHowis Y. Toler, M.D. The 27th Forum for Behavioral Sciences in Family MedicineSeptember 2006PLAN敘事文章書寫一篇優秀文章選拔與研讀arrative medicine roundREFERENCES Howis Y. Toler, M.D., Julie Wood-Warner, Ph.D. Researc
22、h Medical Center Family Medicine Residency, Kansas City, MO The 27th Forum for Behavioral Sciences in Family MedicineSeptember 2006 Ellen M. Cosgrove, MD FACP Senior Associate Dean, Education, University of New Mexico. Narrative Medicine at UNM IRCME Symposium March 16, 2007 讓生命訴說自己的故事：敘事與醫學讓生命訴說自己的故事：敘事與醫學 http:/ 床敘事 高雄醫學大學呼吸治學系 慧如助教授 敘事醫學與醫療專業敘事醫學與醫療專業 長庚兒童氣喘過敏風濕科副教授林思偕長庚兒童氣喘過敏風濕科副教授林思偕 長庚醫訊卷期TAKE HOME MESSAGESNarrative Medicine does not make medical students into writers, but makes them better doctors只有聽得懂他人的故事,我們才能開始思考如何解除他人的苦痛THANK YOU!
