If You had a Blank Slate, How Would You Integrate Narrative into Medical Education?

From the 6/18/2021 newsletter

Three Questions for Dr. Deepthiman Gowda

If You had a Blank Slate, How Would You Integrate Narrative into Medical Education?

Deepthiman Gowda, MD MPH MS, is a nationally recognized expert on Narrative Medicine and the founding Assistant Dean for Medical Education at the newly opened Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena CA. He spoke to Transformational Times editor, Bruce Campbell …

Transformational Times: In what ways is narrative integrated into the curriculum at the Kaiser Permanente Bernard J. Tyson School of Medicine? 

Dr. Gowda: The School of Medicine's curriculum was intentionally built on the three co-equal pillars of the Biomedical, Clinical, and Health Systems Sciences. By emphasizing the value of deep dives into health systems along with the other disciplines, students discover that organ dysfunction, illness, and suffering always occur within social and societal contexts, and that nuanced and effective “doctor-patient relationships” require students to understand and address often obscure, external forces. Through our “spiral” model of learning, students revisit these key areas and concepts repeatedly and with increasing sophistication throughout the four years. 

In addition, we identified core values we consider essential for meaningful participation in high-functioning healthcare and turned these into four reappearing curricular “threads.” These are: 

• Equity, Inclusion, and Diversity
• Health Promotion
• Interprofessional Collaboration 
• Advocacy and Leadership

Narrative Medicine and its pedagogical cousins fit nicely within this curricular approach.  For example, patients are often powerfully affected by the social determinants of health and experience their illnesses and healthcare interactions within larger narrative frameworks. These moments provide wonderful opportunities for our students to explore and respond to stories. On a personal level, providers benefit when they have guided, protected time to investigate their own narratives. Finally, interprofessional teams and interpersonal relationships function better when people understand each other’s stories. 

To enable these moments, we built many opportunities for narrative into our curriculum. We worked with the foundational scientists and clinicians to provide narrative opportunities at “moments of attention,” such as with cadaver dissection, pelvic and breast exam sessions, and challenging experiences. Over the four years, each student participates in regular REACH sessions (Reflection, Education, Assessment, Coaching, Health and Well-Being), that occur in one-week blocks, four times each in Years One and Two and three time each in Years Three and Four. REACH incorporates dedicated time to explore health, well-being, and resilience skills. Students participate in close reading, writing-to-a-prompt, and conversation, facilitated by trained faculty mentors who remain with the same groups of six students throughout the four years. The sessions also include goal setting, professional identity formation activities, and the creation of critical reflective essays. 

Transformational Times: How have the students taken to this emphasis on narrative in the curriculum? 

Dr. Gowda: Students these days expect curricula to address health systems issues in ways that were not explored in the past. There was great local and national engagement around the Black Lives Matter movement and how implicit bias is manifest in medicine. Our school is small, only about fifty students per class, but the learners are enthusiastic about narrative opportunities. About one-quarter are part of our Medical Humanities Interest Group, for example. The M2s will soon head to one of the local art museums. 

Student-led initiatives have been key. For example, the students organized StoryTime, a monthly storytelling event that is much like The Moth. Each event includes volunteer student, staff, and faculty storytellers and is built around a theme, such as Solidarity, Community, or Mental Health. These events provide a glue for our community. 

Transformational Times: What barriers are there to incorporating narrative meaningfully into the curriculum?

Dr. Gowda: Well, first of all, it is relatively simple to bring narrative to topics such as well-being, professional identity formation, and diversity & inclusion. Students understand the inherent value of reflecting on - and learning from - their own experiences and struggles. For these types of narrative experiences, they engage easily. 

Other areas of study can be more challenging. Employing narrative techniques to unwrap broader issues within health systems science are also valuable but can be difficult, particularly when trying to make sense of large, amorphous structures and bureaucracies. Finding ways to integrate narrative into foundational sciences can be the most difficult, requiring commitment and engagement by both faculty and students. But it can be done. 

All of us in the field struggle with metrics. In other words, how do we demonstrate the value of narrative in the curriculum? There are rubrics for scoring reflective activities, but we don’t always know if they are measuring what we think they are. We also worry that if students believe they are being “graded” on their reflections, that might suck the joy out of the process. Reflection fatigue is real, and students are smart enough to “write to the test,” even with reflective essays. 

We need to understand the students’ growth along the spectrum - as my colleague at Columbia University, Maura Spiegel, describes - between “thin” and “thick” narratives. In this sense, growth occurs when students demonstrate shifts from stories that focus on a single aspect of identity to stories that reflect multiple points of view and enriched contexts. The ability to create these “thickened narratives” might be important in understanding our learners’ narrative progress and competence. 

As they graduate, we need to make certain that our efforts have helped them become compassionate, team-based, and resilient physicians who possess narrative humility. We believe narrative is part of that, but we are still deciding how best to understand and measure progress in a competency-based system.

The transformation of medical education is a difficult but necessary challenge. I have been here at Kaiser Permanente for two years and have never worked harder in my career. It is a huge, exciting task and there is much left to do. 

 

Deepthiman Gowda, MD MPH MS, is the Assistant Dean for Medical Education and Associate Professor of Medicine at the Kaiser Permanente Bernard J. Tyson School of Medicine. He also serves at the Director of Clinical Practice of the Columbia University Irving Medical Center Division of Narrative Medicine.