Recognizing and Maximizing the Nexus of Perioperative Medicine and Narrative Medicine 2023

“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

Francis W. Peabody, MD, Harvard Medical School (1927)^1,2

Perioperative medicine remains an evolving, interdisciplinary subspecialty, which encompasses the unique perspectives and incorporates the respective vital expertise of anesthesiology, internal medicine, surgery, nursing, physical therapy, occupational therapy, pharmacy, dietetics, and medical social work. Ideally, all these diverse perioperative medicine practitioners and stakeholders view patient care as essentially a collaborative effort, integrating the patient’s entire surgical journey from initial contemplation of surgery, often in the primary care setting, to postoperative recovery and rehabilitation.

This integrated model of perioperative medicine and care has a wide-ranging set of clinical, strategic, and operational goals. Among these various programmatic goals, a subset of 4 specific, interdependent goals include (1) enhancing patient-centered care, (2) embracing shared decision-making, (3) optimizing health literacy, and (4) avoiding futile surgery (Figure 1). Achieving and sustaining this subset of 4 goals requires continued innovative approaches to perioperative care. The burgeoning field of narrative medicine (Figure 2) represents one such innovative approach to perioperative care.

Narrative medicine is considered the most prominent recent development in the medical humanities. Its central tenet is that attention to narrative—in the form of the patient’s story, the clinician’s story, or a story constructed together by the patient and clinician—is essential for optimal patient care. This narrative or story contains information needed to treat the individual patient, and attention to this narrative or story can enhance the physician-patient interaction and relationship. Proponents assert that “narrative competence”—the ability to construct as well as deconstruct or understand stories—is a key element of comprehensive clinical expertise.

A recent article published in Anesthesia & Analgesia surveyed incorporating narrative medicine into medical education and residency training, and applying qualitative and mixed qualitative-quantitative methods in the evaluation of narrative medicine embedded in clinical programs and medical education curricula. This follow-on Special Article first discusses the current understanding and relevance of the aforementioned subset of 4 interdependent goals of perioperative medicine. This article then further explores the nature and landscape of narrative medicine. It, in turn, examines the practical applications of narrative medicine to achieve and to sustain each of these 4 fundamental goals of perioperative medicine. Finally, this present Special Article presents additional educational and research opportunities to apply narrative medicine in the perioperative medicine setting.

ENHANCING PATIENT-CENTERED CARE

A 2017 article in the NEJM Catalyst provided this more specific, practical definition: “patient- and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.”

In designing and managing such a customized and comprehensive care plan, patients partner with their health care providers, and these providers treat their patients not only clinically but also from emotional, mental, spiritual, social, and financial perspectives. This multidimensionality of patient-centered care reflects that it is not a monolithic entity—as many as 12 models of patient-centered care have been described.

Based on large-scale, focus group-based qualitative data, and in collaboration with the Commonwealth Fund, the Picker Institute has delineated 8 contemporary principles of patient-centered care (Figure 3). While the underpinnings of these Picker principles of patient-centered care date back to the early 1990s, they have been iteratively revised in response to the interim changing nature of health care.

Since its conception, patient-centered care has emphasized the importance of better understanding the experience of illness and of addressing patients’ needs in the face of an increasingly complex and fragmented health care delivery system. Successfully achieving these 8 contemporary principles of patient-centered care thus requires enlisting patients and families as allies in designing, implementing, and evaluating health care delivery systems.

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, patient-centered care has become even more paramount because, as poignantly articulated by Adrienne Boissy, Chief Experience Officer of the Cleveland Clinic Health System, reflecting on the long-term impact of the COVID-19 pandemic:

“Although the how of delivery has changed, the timeless and universal commitment to patient-centered care should not. We will keep patients safe, we will care for them as people, we will partner with them, and we will make it easier…We need to capture (or recapture) the humanity that is at the heart of health care. We need to design our operations to support true patient-centered care: operationalized empathy. Redesigning patient experience measurement and assessing our organizations’ readiness to deliver on the promise of patient centeredness, will empower us to deliver not just care, but actual caring.”

EMBRACING SHARED DECISION-MAKING

Shared decision-making has been described as the “pinnacle of patient-centered care.” Although several models of shared decision-making have been promulgated, most share 2 common elements: (1) shared decision-making is primarily focused on treatment choices and (2) the clinician is primarily responsible for providing options while the patient contributes values and preferences. It has been argued that these 2 common elements render shared decision-making suboptimal in clinical practice. Shared decision-making is instead better viewed as collaboration across all aspects of clinical care, with clinicians engaging in the patient’s entire experience of disease, illness, and treatment.

Shared decision-making can validly occur only within an ongoing partnership between clinician and patient, in which both respect the other as a person—not just as episodic players in a single, isolated encounter. Respect for the patient as a person goes beyond simply the clinician’s respect for their choice. The clinician must know the patient well enough to be able to answer the patient’s salient question: “What would you do if you were me?” This more comprehensive approach to shared decision-making acknowledges clinicians as persons and requires them to understand patients as persons.

High-quality surgical decision-making includes assuring the right operation, the right patient, the right provider, and the right place. High-quality surgical decision-making requires that “the patient should demonstrate a full understanding of risks, benefits, and alternatives, and there should be concordance between patient preferences and values and expected clinical outcomes.”

While widely touted and increasingly studied, much remains controversial, challenging, and unknown about shared decision-making. Two fundamental questions remain unanswered and warrant further health services research. Does shared decision-making work in practice? And, does the practice of shared decision-making has any impact on patient outcomes?

OPTIMIZING HEALTH LITERACY

A systematic review in 2012 identified 17 explicit definitions of health literacy. Of these definitions, those presented by the American Medical Association (AMA), the Institute of Medicine (IOM), and the World Health Organization (WHO) have been most frequently cited in the literature. The shared components of these abundant definitions are an individual’s skills and capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Within its definition of an individual having health literacy, the IOM included cultural and conceptual knowledge, listening, speaking, arithmetical, writing, and reading skills as the main components of health literacy.

AVOIDING FUTILE SURGERY

Surgical futility has been variously and sometimes poorly defined. However, there are patients with extremely high preoperative risk factors who still undergo surgery and experience early postoperative death, suggesting futile care. Surgery in critically ill or end-of-life patients thus often raises difficult questions about futility.

A broader perspective on futile surgery—beyond the critically ill or end-of-life patient—is considered in the current discussion. “Procedures that ultimately will not improve the patient’s well-being—as defined by the patients and their families—are futile. Treatments should only be considered non-futile if they have the potential to either improve quality of life or prolong life.” In this broader clinical context, 2 criteria can be used in defining surgical futility: (1) the clinician defines a successful outcome; and (2) the clinician determines the level of certainty or probability that this successful outcome will occur.

A successful outcome provides a clinical benefit and aligns with the patient’s self-defined goals of care. It cannot be overstated that these goals of care are determined principally by the patient. The more difficult aspect of defining surgical futility is determining how certain a clinician should be that a surgical procedure will achieve one of these goals.

Surgery has additional consequences—surgical procedures carry a significant risk to the patient of additional pain, disability, and suffering. Therefore, a major factor in determining futility should be the potential of doing patient harm. A high probability of causing significant pain, disability for the patient, and suffering, with a low probability of a successful outcome, should render a surgical procedure futile.

NATURE AND LANDSCAPE OF NARRATIVE MEDICINE

The principles and practice of narrative medicine can be derived from the individual and collective perspectives and work at Columbia University by Charon et al. Charon et al have broadly defined narrative medicine (Figure 2) as “a rigorous intellectual and clinical discipline to fortify healthcare with the capacity to skillfully receive the accounts persons give of themselves—to recognize, absorb, interpret, and be moved to action by the stories of others.” The Columbia University model of narrative medicine has 3 primary, guiding premises:

1. Contemporary medicine has overemphasized the biomedical and technological aspects of care at the expense of the person or human side of care.
2. Narrative medicine emphasizes development of a clinician’s narrative skills to provide them with the necessary narrative tools and competencies.
3. By applying these acquired narrative tools and competencies, clinicians can better understand the patient and thus put themselves in the patient’s point of view.

Charon has further noted that the phrase “narrative medicine” serves as “a unifying designation to signify a clinical practice informed by the theory and practice of reading, writing, telling, and receiving stories.” In essence, “narrative medicine is committed to developing deep and accurate attention to the accounts of self that are told and heard in the contexts of healthcare.”

Charon posited that “narrative medicine provides health care professionals with practical wisdom in comprehending what patients endure in illness and what they themselves undergo in the care of the sick.” Narrative medicine can thus have bidirectional therapeutic benefits for the patient and the clinician. This bidirectionality was echoed in a recent, thought-provoking opinion article titled, “A Physician’s Tale: Humanism and the Power of Narrative.”

TEACHING AND LEARNING NARRATIVE MEDICINE

The theoretical underpinning of narrative medicine, as promulgated by Charon et al at Columbia University, is the 3 constructs of attention, representation, and affiliation (Figure 4). These 3 constructs are manifested in a commitment to skilled listening, the power of representation to perceive another individual, and the use of partnerships resulting from narrative interaction. These 3 constructs also form the basis of the Columbia University narrative medicine curriculum.

Charon et al at Columbia University developed a pioneering in-residence Master of Science in Narrative Medicine and subsequently created an online certificate program in narrative medicine. An essential element of their teaching narrative medicine is experiential learning through repeated practice in instructor/facilitator-led, small group, single sessions or multisession workshops (Figure 5).

Attention is translated into the close reading of a piece of literary text, film, visual art, dance, or music—observing its details, noting its perspective, describing its form, hearing its voice, and sensing its mood. Representation follows as the close reading of the piece generates questions and discussion among the narrative medicine session or workshop participants. This discussion is followed by a short, open-ended writing prompt related to the subject of the chosen piece. The participants, along with the instructor/facilitator, have a brief time, typically 3 to 5 minutes, to write spontaneously to the prompt, without any concern about diction, punctuation, or grammar. The participants are encouraged but not required to share what they have written with the group—the instructor/facilitator may also do so. Affiliation naturally develops as the narrative medicine session or workshop participants come in closer contact and form a connection with one another (Figure 5).

In summary, this experiential narrative medicine training involves close, intentional reading of a nuanced literary or artistic piece, responsive telling, attentive and accurate listening to others, prompted reflective writing, openly receiving shared stories, and mindfully bearing witness to one’s own and other’s thoughts and emotions. These narrative medicine sessions and workshops are conducted in small groups in which clinicians can explore both the process and experience of patient care. The attendant self-reflections and group reflections often reframe and deepen the caregiving experience, allow participants to uncover biases and blind spots, and build camaraderie, while exploring ways in which one can derive greater meaning from work.

Of note, following the pioneering efforts and lead of Charon and colleagues at Columbia University, the Keck School of Medicine at the University of Southern California has launched a Master of Science in Narrative Medicine. This educational program of study “integrates narrative theory, practical experience, and research methods to focus on the ethical implications of storytelling for individuals, community wellness, and the health care system.”

PRACTICAL APPLICATIONS OF NARRATIVE MEDICINE

When asked, the majority of clinicians believe that they listen to their patients. However, when asked, many patients and their family members do not perceive that their clinicians listen to them—listen to their individual stories.^42–46 The signature method and foundational technique of narrative medicine are close reading. In one’s clinical practice, this close reading manifests in its progeny: attentive and accurate listening to what the patient conveys to the clinician—the story the patient as the teller tells. Applying Charon et al’s model of narrative medicine in the care of the surgical patient can facilitate achieving the 4 still-currently-relevant interdependent subset of perioperative medicine goals: (1) enhancing patient-centered care, (2) embracing shared decision-making, (3) optimizing health literacy, and (4) avoiding futile surgery (Figure 6).

Patient-Centered Care

A main goal of narrative medicine is to provide clinicians with the skills to strengthen their capacity “to reach, understand, and ally with the patient.” Narrative medicine also seeks to “rehumanize” the practice of medicine by empowering clinicians to focus on the whole human being they are caring for—and not just on their disease or the treatment of their disease. These goals are aligned with the current, broad trend in health care of refocusing care to put the patient back at the center of that care.

The more effective practice of perioperative medicine requires narrative competence: “the ability to acknowledge, absorb, interpret, and act on the stories and plights of others.” Narrative medicine and attendant narrative competence take advantage of the resources, perspectives, and information gained by inviting, telling, hearing, and reflecting the surgical patient’s shared narrative, thus delivering patient-centered care.

However, if the perioperative clinician cannot or does not undertake these intentional narrative efforts, the surgical patient might not tell their entire story, might not ask their most difficult and frightening questions, and might not feel heard. The resulting perioperative medicine evaluation is unfocused and possibly more complex and expensive than needed; important patient comorbidities are missed; perioperative care is hampered by patient noncompliance, and the therapeutic relationship remains perfunctory, superficial, and ineffective.

In contrast, if equipped with narrative competence, perioperative clinicians can take into account all the surgical patient’s personal and singular aspects and thus deliver patient-centered care. Narrative competence enables perioperative clinicians to invest themselves in their patient’s unique situation, to understand these particular aspects, and to implement a tailored plan of perioperative care.

Shared Decision-Making

The increasing emphasis on shared decision-making has been driven largely by the recognition that patients need adequate information to make informed choices regarding their health care. However, experience suggests that providing more information alone is not enough to address the greater issue: the need for the patient and clinician to jointly create, in partnership, a plan of care that is best for the individual patient and their family. “The larger need in evidence-informed shared decision-making is for a patient-clinician interaction that offers conversation, not just information, and care, not just choice.” Applying narrative medicine skills can foster these needed conversations and shared decisions about a personalized plan of care, including in the perioperative setting.

The perioperative clinician ideally knows the surgical patient well enough to be able to answer their patient’s essential question: “What would you do, if you were me?” Answering this question can be challenging, but in doing so, both clinician and patient are respected as persons within the therapeutic dyadic relationship. Only when the knowledge, experiences, values, and concerns of 2 persons are actively considered and incorporated, can perioperative decision-making actually be shared. This more comprehensive approach to perioperative shared decision-making acknowledges clinicians as persons and requires them to understand patients as persons. This symbiosis creates the further evolution into perioperative person-centered care.

Health Literacy

Even in developed, high-income countries with an extensive health care sector, most people have little interaction with the health care system, and they are generally unfamiliar with the prevention, diagnosis, and treatment of even common health conditions. When suffering from a chronic disease or undergoing a surgical procedure, the medical information typically provided by clinicians can be overwhelming for patients and their families, because of its complex language, unfamiliar terminology, and use of statistical data.

Understanding such vital information requires specific health literacy skills. Sufficient health literacy empowers individuals to exercise their autonomy and self-determination regarding health-related matters. Health care systems and their providers, including in the perioperative period, hence have an ethical obligation to provide patients and their families with medical information that is understandable.

Patient narratives, in the form of descriptive personal stories, about health and health care experiences can be used to improve communication and thus increase health literacy. Patient narratives can convey complex information in a more easily understood way.  Patient narratives can help health care administrators and policymakers understand the informational needs of their health care consumers and to identify crucial communication gaps. Health communication specialists are increasingly using narrative storytelling to convey health information.

In their captivating book, Storytelling in Medicine: How Narrative Can Improve Practice, Robertson and Clegg, disciples of Charon and practitioners of narrative medicine, highlight a clinician’s ability to use a narrative or story to solve or prevent many of these medical communication difficulties. Clinicians’ use of narrative storytelling enables them to convey and to explain concepts that would otherwise be difficult or impossible. Robertson and Clegg offer these practical points to optimize clinician communication and patient health literacy:

1. Speak slowly and clearly
2. Keep your sentences short
3. Use language and words that are fully understood by the patient
4. Use your body language and nonverbal communication to aid your techniques
5. Allow time for the message to “get through”

Perioperative medicine often uses the metaphor of integration of the entire continuum of the surgical patient’s journey—it hence seems apropos to use the power of guiding narrative and storytelling to help the patient understand and navigate along that perioperative pathway.

Futile Surgery

As discussed earlier, surgery is not dichotomous: useless (hence futile) versus useful, instead a spectrum of risk versus benefit to the patient, such that one avoids surgery where the risk outweighs the benefit to the patient, including not only harm but also long-term benefits and quality of life.

Charon identified “4 divides” that contribute to the disconnect that can occur between the clinician and the patient: (1) the relation to mortality; (2) the context of illness; (3) beliefs about disease causality; and (4) the emotions of shame, blame, and fear. Narrative medicine seeks to identify and to ameliorate these 4 contributors to the disconnect between the clinician and the patient. Bridging Charon’s 2 divides of the relation to mortality (understanding of mortality) and the context of illness (conceptions of illness) are important, in order for patient beliefs regarding death and dying, as well as desired/expected versus likely postoperative quality of life, to be integrated into patient and family counseling about futile surgery in nonlife-threatening settings, and especially under life-threatening circumstances.

Previous authors have reframed performing futile surgery as a failure of communication by the surgeon and/or an incomplete understanding by the patient and thus advocated for improving communication, thereby strengthening the patient‐physician relationship. However, nonoperative discussions and care planning require skilled communication with a humanistic approach. To this end, narrative medicine skills can facilitate explaining and understanding surgical futility by fostering communication and negotiation between the patient, family, and clinician, before undertaking high-risk surgery. Rigorous training in and the application of the principles of narrative medicine can foster a shared decision regarding surgery that is aligned with the patient’s culture, values, and preferences.

EDUCATIONAL AND RESEARCH OPPORTUNITIES TO APPLY NARRATIVE MEDICINE IN THE PERIOPERATIVE SETTING

As noted earlier, a recent article in Anesthesia & Analgesia explored incorporating narrative medicine into medical education and residency training. It also discussed applying qualitative and mixed qualitative-quantitative methods in the evaluation of the practice of narrative medicine embedded in clinical programs and medical education curricula.

In a commentary in Health Affairs, Dohan et al observe: “When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision-making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research.”

Dohan et al thus highlight: (1) how various narratives inform health and medical decision-making by patients and clinicians, and (2) why it is difficult but essential to integrate qualitative research on such narratives into the health sciences. These authors describe new tools and methodology to link qualitative research and quantitative findings in health science. Finally, they emphasize the benefits of more fully integrating qualitative research, including narrative analysis, into the corpus of medical evidence and hence into evidence-based medical practice.

A timely and informative systematic review of the literature through 2019 examined the content, outcomes, and evaluation methods of existing narrative medicine programs. The authors identified 55 unique narrative medicine programs, the majority of which had reported a qualitative or quantitative form of evaluation; however, evaluation methods lacked consistency. The identified programs overall demonstrated evidence of high participant satisfaction and pre- versus postimprovement in competencies like relationship-building, empathy, confidence, personal accomplishment, pedagogical skills, and clinical skills. These authors recommended these best practices and future directions for narrative medicine:

1. Enhance narrative medicine program evaluation methods
2. Focus on narrative writing skills
3. Implement narrative medicine for scientists
4. Apply narrative medicine for detecting/mitigating burnout and building resilience
5. Use narrative medicine to promote cultural competence
6. Adapt narrative medicine for low-resource settings

These specific recommendations represent fertile opportunities for narrative medicine program evolution and expansion, as well as topics for narrative medicine-related health services research—including in the realm of perioperative medicine.

Narrative medicine educational programs have primarily focused on medical students, residents, and fellows—training and empowering the next generation of physicians. Efforts need to continue to expand narrative medicine beyond the formative undergraduate medical education (UME) and graduate medical education (GME) populations.

Offering a narrative medicine session or multisession workshops at continuing medical education (CME) events at the interdepartmental, intradepartmental, institutional, and specialty society levels would enlist a broad spectrum of attending physicians, with their wellspring of experience and wisdom. This integration of UME, GME, and CME activities would promote narrative medicine as a partnership within the current multigenerational health care workforce—including in the realm of perioperative medicine.

Distilling and disseminating narrative medicine education, training, and skills into a busy clinic or hospital, and the realm of perioperative medicine, entails:

1. Endorsement by health care organizational leadership and management
2. At least 1 and preferably 2 or 3 narrative medicine facilitators
3. A meeting location that assures a private and safe space without interruptions
4. A dedicated block of time for each narrative medicine session: minimum of 45 minutes and maximum of 90 minutes
5. Single narrative medicine session or preferably a workshop comprised of 4 to 8 weekly or monthly sessions, with same cohort of participants, to establish greater group rapport and trust—thereby enhancing uptake
6. Based on initial needs’ assessment, narrative medicine participants from either a single discipline (specialty) or the multiple disciplines reflecting the care team, for example: group of perioperative advanced practice providers versus entire perioperative care team

As noted at the outset of this article, perioperative medicine encompasses the unique perspectives and incorporates the respective vital expertise of a wide array of practitioners. All these diverse perioperative medicine practitioners ideally view care of the surgical patient as a highly collaborative effort. As such, perioperative medicine can exemplify an interprofessional collaborative practice (IPCP) model. By demonstrating strong habits of communication and teamwork, the members of a robust perioperative IPCP serve as the foundation and role models for the interprofessional education (IPE) of trainees. Both IPCP and IPE represent another potential avenue and venue to apply narrative medicine, thereby culminating in an ideal interprofessional education and collaborative practice (IPECP) including in the realm of perioperative medicine.

CONCLUSIONS

In her defining book, Narrative Medicine: Honoring the Stories of Illness, Charon observed, “A medicine practiced without a genuine and obligating awareness of what patients go through may fulfill its technical goals, but it is an empty medicine, or, at best, half a medicine.”

In her seminal article, Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, Charon posited, “Along with scientific ability, physicians need the ability to listen to the narratives of the patient, grasp, and honor their meanings, and be moved to act on the patient’s behalf. This is narrative competence, that is, the competence that human beings use to absorb, interpret, and respond to stories.”

Nevertheless, humanities-based approaches like narrative medicine are at best thoughtful and expansive responses, but at worst reactionary responses, to the increased emphasis on and importance of evidence-based medicine and reductionist (genetic, neural, and biochemical) explanations of human disease and illness.

Advocates for narrative medicine express a familiar and widely shared desire to maintain the secular sanctity and integrity of the traditional physician-patient dyad as the core of the practice of medicine. However, there needs to be a pragmatic equipoise between the science and the art of medicine in clinical practice and clinical research—achieved by acknowledging each approach and listening to the perspectives of its respective and respected advocates.

To that end, there is a potential nexus between perioperative medicine and narrative medicine, which if capitalized on can maximize perioperative care. If we can view the health care experience through the patient’s eyes, we will become more responsive to patients’ needs and, thereby, better clinicians.