dr. T. Ibnu Alferraly, M.Ked.PA, SpPA, D.

Bioet

DEVISI BHMP – MEU

FAKULTAS KEDOKTERAN
What is narrative?
 Study of peoples’ stories that involves creating,
collecting, and analyzing written text
 Constitute text data that provide rich descriptions
of particular events, situations, and personal
histories
 It could be experience from the author past, recent
or ongoing experience, or experiences of others.
What is Narrative Medicine?
 International movement to include reflective reading
and writing in physician practice

 Poetry, stories, memoirs written by doctors, other

health care professionals, students and patients
REFLECTION
a "crucial process in the transforming of experience into
knowledge, skills and attitudes"
Robertson, K. Reflection in professional practice and education, Australian
Family Physician, 2005; 34(9), pp. 781-783.

a key step in both life-long learning and the

development of professionalism in practice.
Novack DM et al. Calibrating the Physician: Personal Awareness and Effective
Patient Care. JAMA. 1997; 278: 502-509.
Narrative Medicine provides a forum for
thoughtful self-reflection
improves patient-centered care
Yamada, S.et al. Family narratives, culture, and patient-centered
medicine, Medical Student Education, 2003; 35(4), pp.279-283.

reduces practitioner stress

Brady, DWet al. "What's important to you?": The use of narratives to
promote self-reflection and to understand the experiences of medical
residents, Annals of Internal Medicine, 2002; 137(3), pp. 220-223.
Narrative Medicine Skills
 Observation

 active listening

 ability to tell the patient’s story

Verghese A. The physician as storyteller. Ann Intern Med 2001;135:1012-7.

Narrative Medicine & empathy
students 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 empathy: 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;79:351–356.
Narrative Medicine does not make students
into "writers,"
but makes them better doctors

 supporting 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.
General characteristics
Include:  characterization
 plot structure  setting
 introduction  theme
 rising action  point of view
 climax  sequencing
 falling action  transitions

 resolution
 conflict
Narratives
 Study single individuals to develop a picture of the
beliefs and practices of a community through key
informant interviews or life histories or accounts of
specific experiences
 Narratives of entry into drug use
 Narratives of describing recent experiences in treating or
managing a health problem
Sources of narratives
 Involve human experiences which can be
constructed from variety of sources:
 key informant interviews
 Books, articles, scripts or written text
 Plays
 Court transcipts
 Film
 Videotapes
 Stage directions
Focus of narratives
 Knowledge, beliefs, and practices to study
 How people practice their professions
 How they learn to carry out tasks
 How they come to know about their world, etc.
Uses of narratives
 Highlight the experiences of people who have been
oppressed or marginalized where they live
 “giving voice’ to people whose experiences are not well
known in the mainstream of their society
 Present multiple perspectives in a given setting
Examples of narratives
 More or less chronological accounts of a person’s
life, career, or set of experiences
 Transcript of courtroom or other formal
proceedings
 Stories of people’s intention to do something or
explanation on why they acted as they did
 Series of episodes, fantasies, or philosophical
musings
Narratives
 Reflect the structure of what has been called
“grand narratives,” with plot, settings, characters,
conflict, conflict resolution, and a moral or
summing up
The individual and the social
 The interview situation may contribute to the illusion
that the story is individual rather than social

 The narrative may be seen as the social space for

experience that is expressed and negotiated not only
by the narrator but also by the audience and all others
involved
 Good’s focus
 The role of narrative in the constitution of illness and
illness experience

 Explore how illness narratives are structured in cultural

terms and how these reflect or give form to distinctive
modes of lived experience
Complexity in relation to narrative-lived
experience
 Experience transgresses story-telling
 Much experience is assigned little or no meaning,
whereas some experience take on much significance
in the story
 New questions are constantly raised in new
interpretations/versions
 Need to explore relationship between culture,
narrative and experience in order not to project own
experience onto others’ suffering
Inspiration from text theory (Ricœur)
 Narrative - story structure
 Plot – story line
 Desire – dynamic force that drives story line
 Emplotment - relation between plot and
audience
 Time – not chronological but condensed in
special moments of significance
 Subjunctivity – openness, undecidedness, room
for action
What is narrative in medical
setting?
 narrative medicine is medicine practiced with the
competence to recognize, absorb, interpret, and be
moved by the story of illness.

 in response to a health care system that places corporate

and bureaucratic concerns over the needs of the patients
and that leaves patients feeling abandoned and unheard
(Charon, 2006).
What is narrative in medical
setting?
 To understand the suffering of the patients, doctors
need to enter the worlds of their patients, even only
imaginatively, and to interpret these worlds from the
patients’ point of view (emic perspectives).
What doctors need in narrative
writing?
 the expertise to listen to their patients experiences
(illness),
 to honor the meanings of their patients narratives
of illness (sickness), and
 to understand as best they can the ordeals of illness
(etiology or explanatory model), and
 to be moved by what they behold so that they can
act on their patients’ behalf (therapy) (Charon, 2006;
Kleinman, 1988).
Explanatory model (eights questions—
Kleinman)
 What do you call your illness? What name does it
have?
 What do you think has caused the illness?
 Why and when did it start?
 What do you think the illness does? How does it
work?
Explanatory model (continued)
 How severe is it? Will it have a short or long
course?
 What kind of treatment do you think the patient
should receive? What are the most important
results you hope she receives from this
treatment?
 What are the chief problems the illness has
caused?
 What do you fear most about the illness?
Narrative Medicine Skills
 Observation
 Active listening
 Ability to tell the patient’s story

Verghese A. The physician as storyteller. Ann

Intern Med 2001;135:1012-7.
 “I write the story. The story writes me.”
~Watts

“It turns out, as I wrote deeper and deeper into my subject, I revealed more and more
about myself. That, I guess, is what literature does. Makes us set aside inhibitions.
Makes us find a pathway to the interior.
Narrative Story
 I have had in my practice for many years a now 79 year old woman with
hypertension, breast cancer, spinal stenosis, insomnia, and uncontrollable
anxiety. She lost her husband to congestive heart failure, her son to lung
cancer, a granddaughter to a hit-and-run accident. For years, she took
Librium for her nerves, unwilling to enter psychotherapy and unable to
really talk about the source of her anxiety. She has considered herself
sickly ever since she fell of a motorcycle as a little girl.

 For years I was baffled by her illness. Recently, she told me the core of her
sickness. She did not fall of a motorcycle as a 12-year-old girl. She had been
raped by a boy in the neighborhood. She knew at that time, young as she
was that she could not tell everyone about this. Her mother would not be
able to keep the secret from her father, and if her father knew, he would
have acted on his rage and would have died as a result. So for almost 70
years she kept his secret, disfiguring her heart with wreath and fear. It took
more than 10 years for me to become trustworthy enough to hear her tell
it. And once she told her secret, her health improved. She slept. Her back
pain got better. See stopped the Librium. Her heart had room to expand,
not being to in the grip of the untold.
Latihan
 Berpasangan (2 orang)

 Cerita dan tanya jawab tentang pasien yang berkesan

dan mempengaruhi praktek anda (bisa menggunakan
explanatory model)

 Buatlah “narrative” dari pasien tersebut. dengan

menggunakan cara Inspiration from text theory (Ricœur)
Recommended reading
 Ruth Picardie “Before I say goodbye: Recollections and
observations from one woman’s final year”

 John Diamond “because cowards get cancer too”

 Jean-Dominique Bauby “The diving bell and the

butterfly”

 Narrative based medicine BMJ 1999 – a series of five

articles
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31 Oktober 2014

Let The Story Writes You