A faculty development workshop in narrative-based reflective writing

Over the past three decades, narrative theory has become increasingly prominent in the health professions. This trend has coincided with a similar phenomenon in the humanities where it has been referred to as the ‘narrativist turn’ [1]. Narrative in the context of medicine has acquired diverse forms and functions. One of the earliest versions of continuing professional development grounded in story telling was the Balint groups [2]. First implemented in 1950, they were designed to support the doctor–patient relationship by focusing attention on physicians’ emotions arising out of clinical encounters, particularly those perceived as puzzling or unsettling. Although the Balint group method did not specifically revolve around an understanding of narrative as a genre, stories—in the guise of ‘cases’—were the indispensable ingredient [3]. A similar activity has been termed ‘reflective writing’ in that written stories serve as stimuli to and the subject matter for individual or group reflection. In the UK, reflective writing courses have been deployed for the on-going professional education of general practitioners [4]. Participants are urged to write about events or ideas in their personal and professional lives that are troubling or hard to resolve and to share these stories with peers in a supportive group setting.

In essence, ‘narrative’ is ‘a story and its telling’. We use the terms narrative and story interchangeably. Narrative is manifest in many forms in addition to the written. Stories constitute the basis of psychotherapeutic intervention and narrative has evolved as a stream within bioethics. Many health care professionals will recognize it as a specific methodology in qualitative research. In order to capture the breadth of expression of narrative within medicine, a taxonomy was recently constructed and published [5]. A notable entry in this taxonomy is ‘narrative medicine’. The term was coined and the subject given much of its character and appeal by the physician and literary scholar Rita Charon. She views it as a clinical method that makes explicit use of narrative skills and defines it as: ‘[a] medicine practiced with the narrative competence to recognize, interpret, and be moved to action by the predicaments of others’ [6]. That is a rather expansive conception of narrative within medicine. There are alternative notions in which narrative is considered less a defined clinical discipline and more a theoretical concept with instrumental possibilities. There is an expanding literature on the application of narrative strategies. For example, narrative-based programmes designed to promote ‘ethical mindfulness’ have been outlined in some detail [7, 8]. Despite these innovations, we are not aware of a description of an introductory faculty development workshop in narrative-based reflective writing that would be appropriate for clinical teachers.

The foundational premise for the use of contemplative writing in medical education is that the very act of putting one’s storied experiences down on paper, of selecting the precise manner in which to recount a tale (e.g. choosing which characters to include and which to leave out; deciding which of several constitutive events should serve as the beginning, middle and end; adopting a particular point of view; creating an emotional tone) activate introspection and critical reflection. An added benefit is that the written text, in comparison with a spoken monologue or colloquy, is enduring; it is a ‘thing’ that, having assumed a certain form is then available for subsequent review and analysis. It has been claimed that reflective writing can meet a variety of objectives: the list includes the nurturing of empathy [9], training for mindfulness [10], professional identity formation [11], and prevention of burnout [12]. Whether reflective writing actually accomplishes such laudable goals, and how it does so, are essentially unknown. It has been hypothesized that there is a ‘transfer effect’ whereby skills in story-writing, listening and recounting are generalizable to alliance building with patients [13]. One teacher who uses illness narratives to foster empathy suggests that they do their work by creating a state of emotional or cognitive disequilibrium [14]. The conceptual foundations of narratology and the theories on how writing comes to be in the service of reflection are beyond the scope of this essay.

Our aim is to describe the core elements of a faculty development workshop in narrative-based reflective writing. While we were guided by the needs of teachers in an undergraduate medical programme, our intent is not to propose a template that is narrowly focused on one particular audience. We believe there is a need for a template that is feasible, scalable, adaptable to the continuum of health professional education and respectful of the multiplicity of concepts attributable to narrative in medicine. We begin by describing a locally based programme and then expand the scope to a potentially larger audience by broaching issues integral to the design of any faculty development programmes of this nature.

The template we designed is based in a six-year experience (2005–2011) of conducting introductory workshops in narrative at McGill University’s Faculty of Medicine. More specifically, it arises from a retrospective critical review process of ‘meta-evaluation’ which, according to the 3rd edition of ‘Programme Evaluation Standards’ of the Joint Committee on Standards for Educational Evaluation, is a ‘self-awareness, pausing, openness to monitoring, scrutiny, and a changing of course’ [15]. This definition captures our longitudinal experience with these workshops and our resultant reflections. We benefited from the involvement of experts in the field, including Rita Charon who served as facilitator at our inaugural session. We modified the workshops iteratively based on participant feedback and developed new audiovisual materials as aids to learning.

The sessions were conducted over a half day and delivered to clinical teachers in a formal mentorship programme for medical students. This programme, entitled ‘Physician Apprenticeship,’ has two primary goals: (i) to assist students in their transition from laymanship to physicianship to become professionals and healers, patient-centred and reflective practitioners, and (ii) to provide a safe and supportive environment where students are encouraged to discuss issues arising out of professional socialization and their educational experience. The apprenticeship groups consist of six students, one or two senior medical students and a clinical teacher. These individuals (with the exception of the student co-leaders, who graduate approximately half-way through the programme) remain constituted as a group for the duration of the medical school curriculum of 4 years. They meet approximately five times per year. The clinical teachers, who are called Osler Fellows, are offered a targeted faculty development programme that aims to equip them to meet the objectives of the apprenticeship [16]. Three to four workshops are held annually; the series includes sessions on small group facilitation skills, mindfulness, cultural sensitivity training and narrative in medicine. The session on narrative serves three purposes: (i) to introduce basic narrative theory and precepts, (ii) to practice reflective writing using narrative as a frame for a shared dialogue and analysis, and (iii) to discuss strategies that Osler Fellows might consider using in integrating the reflective writing exercises within their apprenticeship groups. All three objectives are necessarily intertwined. Up to 2011, we welcomed 92 participants (approximately 16 per session) to our narrative medicine workshops. The template we describe stems from a long-standing tradition of effective small group facilitation, and was informed by the experience of two of the authors (AF, SL) in using narrative techniques in medical humanities electives.

There is a growing appreciation of the importance in the health professions of reflective practice. As the educational focus has shifted towards understanding and supporting professionalization and identity formation it has been paralleled by an expanding interest in strategies, such as narrative skills, which can provide an entry into the process. These developments are anchored in the idea, expressed so eloquently by neo-Aristotelian philosopher Alasdair MacIntyre that ‘the chief means of moral education is the telling of stories.’[24].

Health care professionals are very receptive to the belief that an acquisition of narrative skills can contribute to more effective and critical reflection and enhance communication with peers, patients and learners. Despite the centrality of stories to many of the tasks that clinicians perform it remains that explicit and formal teaching of knowledge and methods in narrative is relatively novel. The template we have presented for an introductory faculty development workshop is not intended to be comprehensive nor should it be received as a procrustean operational rule book. Rather, it is meant to provide a basic overview, anchored to reflective writing as one particular expression and use of narratives. It is clear to us that if this emerging discipline is to fulfil its various promises additional tools for faculty development as well as longitudinal programmes in evaluation will be required. The template we propose, based on a successful practice with clinical teachers engaged in a mentorship programme, is a modest contribution to that end.