Introduction

Long ago, people realized that well-communicated affliction leads to its proper treatment. It is enough to recall the Eleusynian inscriptions with the patients’ pleas to Asclepios giving them cure for their disabilities or the Hippocrataeum Corpus of texts testifying the engagement of ancient people into the development and transmission of the medical knowledge [1, 2]. Nowadays, considering the importance of narrative in medicine, understood as narrative-based communication ability and competence among physicians, it is ‘narrative medicine’ (NM) as discipline that facilitates enrichment of medical knowledge and improvement in general approach to a patient in educational and clinical settings. NM seems to exceed a mere communication skills training, since it extends this process to establishing the relational attitude between medical personnel and patients, and their families, between patients and medical staff, and finally, between doctors and their professional background. To understand and define the premises of NM, ‘medicine’s central narrative situations’ as defined by R. Charon could be taken into consideration [3]. On the basis of the Charon’s tenant of NM, it would be important to differentiate among the papers written on the matter. Charon categorizes ‘medicine’s central narrative situations’ into four groups as follows: (1) physician-patient, (2) physician and self, (3) physician and colleagues, and (4) physician and society. Each of the situations strictly entails storytelling as narrative basics in terms of message, its sender, and recipient in a specific social background. The review of literature on NM as an approach by Fioretti et al. (2016), which seems to be the first on the research studies on NM, has recently discussed Charon’s first category of the physician-patient relationship as requiring a special emphasis on the patient expressing their illness experiences in front of their caregivers [4].Footnote 1 Our review of literature instead considers Charon’s four categories as the most relevant to the topic of narrative medical education. Still, the authors of this paper believe that there is a seeming paucity of literature on the topic of the benefits and importance of NM in undergraduate medical training.

Objective

The objective of this review is an analysis of the available literature on the usage of narrative teaching methods in medical schools curricula worldwide. Hence, it is also aimed at answering questions whether, and how NM should be introduced into the medical curricula.

Material and Method

To find the most relevant articles for the literature review, we searched PubMed database without restriction of language, i.e., papers dating from 1986 to 2016. Regarding the vast amount of results, the assessment was made according to full texts or abstracts of the 443 selected papers that were provided on the basis of the keyword ‘narrative’ in their title. There were 52 articles with ‘narrative medicine’ in their title, abstract, or in the keywords. Twenty-five papers regarded NM as an approach and 27 concerned strictly NM in medical education. In October 2016, the same search was assessed under the Best Evidence in Medical Education (BEME) review protocol requirements.Footnote 2

Results

As a result of this query, it is possible to stipulate several domains with respect to NM. It can be consecutively related to stories of illnesses as medical cases, the first category of Charon’s classification and this is the majority of the papers under the entry NM (70% of 25, n = 18); stories answering questions about professional competence of physicians using the methodology of NM (20% of 25, n = 5); papers dealing with medical ethics, NM as social and cultural phenomenon, also commenting on the general theme of anthropology of narratives (9% of 25, n = 2). The papers concerning NM in medical education were scattered among different strands of topics and are estimated at about 0.2% of 443 assessed papers with ‘narrative’ in their titles or in the keywords. They represent material dedicated primarily to nursing students and some to medicine students, trainees, and residents. They also embrace the cases of description of particular curricula and training approaches using NM conducted mainly at American medical schools. The results are collected in the form of the following Table 1:

Table 1 NM in medical education worldwide
Full size table

Discussion

There are medical universities’ curricula offering classes on medical humanities in which there is an integrated course on NM. However, as such they are still in the minority [32, 33]. What can be observed is the specific reluctance of the responsible bodies toward introducing this approach into the general academic outline. The problem seems to be more understandable in the wider perspective even of a social character. This is connected with the issue of the dominating biomedical model of healthcare that has been questioned as no longer satisfactory [33,34,35]. Hence, what is most welcome is the turn to more holistic, humanistic approach in medicine [36] toward its mission which should be regarded as necessary not only in public healthcare system but also, and even primarily, into the medical education focused on developing and enriching professional identity formation (PIF) of medical students [37, 38]. Among the papers, there were interesting accounts of such conduct that brought statistically measured results. The staff of the College of Medicine in Ohio State University described how, thanks to the classes on literature which were standing for more critical approach to narrative inquiry in medical settings, they achieved the positive feedback on transgressing by students their resistance to difficult issues of violence and inequality they encountered in the selected study materials [39]. Next, Columbia University staff, responsible for introducing the NM approach into medical education and practice, also gave a report on what students extracted from training in humanities, social sciences, and arts in NM curriculum. The obtained results showed that students appreciated NM as a valuable tool in enriching their professional identity in three features of NM, i.e., in (1) attention, (2) representation, and (3) affiliation with their patients.Footnote 3 As for the training concerning the assessment of clinical performance with the use of NM, two brief reports prepared by the university staff from Taiwan and from Canada were retrieved. The first report was devoted to the topic of objective structured clinical examinations (OSCEs) comprising 12 stations: 2 history-taking stations, 2 physical examination stations, 2 communication stations, 2 clinical decision-making stations, and 4 procedural skill stations. The results were clear as for the better performance on two communication stations for the students’ group acquainted with the NM approach (‘the case group’) than for ‘the control group,’ which was not acquainted with NM approach [26]. In the pilot project run at the University of Alberta, an assumption was made that narrative reflective practice (NRP), understood as a ‘process that helps medical students become better listeners and physicians,’ may influence in a positive way the students’ achievements during the performance on multiple-choice question exams (MCQs), on OSCEs, and on subjective clinical evaluations (SCEs). The results were convincing at least with regard to MCQs exams. The students that underwent the NRP training scored 4.7% statistically higher than those who did not. The research group is positive about taking the NRP course in the future, because it can improve also the results of the OSCE and SCE exams [40]. The cited examples show systematic solutions for academic medical curricula in developing and including the NM course in them.

In the case of Poland as a country with a long tradition of medical education, there is a highly structured and organized system of medical studies. In order to meet the demands of the European Qualification Framework gathered in the Directive formulated by the Polish Ministry of Science and Higher Education (MSHE, 2012), from 2012 MSHE gradually implement deep reform of Polish medical schools curricula [41]. Till then, the educational process in Polish medical schools was based mainly on so-called ‘traditional’ approach to the learner-teacher relationship, having the teacher in the center of learning activity, i.e., the teaching lowest level [42], and weighting a biomedical model of medical studies in favor of holistic, humanized approach to the patient more compatible with society’s expectations. However, the situation is gradually changing into positive focus onto students’ practical engagement into medical training, having the students in the center of educational activities. This potential change is made thanks to the establishment of the educational institutions such as centers of medical simulations in which students are able to gain practical skills through practical training at, e.g., OSCE stations. In the light of the above achievements taken from abroad, authors of this review are convinced to make a specific request as for the importance of NM introduction into the medical teaching curricula. NM supports students in developing communicational skills with respect to personal communication, and, what is more, it deepens critical thinking and reflective practices. Hence, as it is proved by the aforementioned material, it will probably prepare them to achieve better outcomes at the practical exams such as OSCEs and later in the clinical setting, e.g., during their apprenticeship. A change in the medical education involves also changes within the conduct of clinical communication teaching. In many Polish medical universities, clinical communication is still taught with a large groups of students, and is based on lectures or seminars. In search of the best solution, Polish teachers participate into the discussion about the means of clinical communication teaching. There has been a debate about how to approach the teaching of communication between physicians and patients. There appear to be two very different and at first sight mutually exclusive viewpoints, which dominate the discussion—the skills and the attitude approach. The skills approach helps learners to acquire the numerous skills that have been shown by research and experience to support doctor-patient communication and to incorporate them into their own style. In contrast, according to the attitude approach, the difficulties do not lie primarily in poor skills but in a deeper level of attitudes and emotions, of self-awareness and reflection. The authors believe that the truth probably lies somewhere in between and physicians’ attitudes and skills tend to go together. NM based on its three primary features, i.e., attention, representation, and affiliation could be introduced into the curriculum to balance the skills approach, applying such educational tools as for example: general NM training course, narrative medical writing, especially that on individual experience on clinical physician-patient relation, NM lectures, and listening/reading exercises.

Limitations

Firstly, the authors did not find in the review any written example of adaptation of NM approach into the Central European setting but this does not mean it is not happening [43]. There is one article published already in Poland, but it is just a theoretical outline of the issues related to NM. Noteworthy, it was retrieved outside the PubMed database. Authors’ current work seems to be the first review on that topic coming from the Polish background. Secondly, this review does not embrace the results accomplished by the authors in that particular field. It was made to recognize the current status of NM that could be introduced into the Faculty Development Program and undergraduate students’ study program, since the authors do not acknowledge any disadvantages to using NM approach. Finally, due to the narrative nature of data, it was not possible to implement a meta-analysis of the selected studies.

Conclusions

The trend to accommodate NM approach into educational and clinical settings seems to be apparent and effective. Medical educators around the world using NM are focused on giving their students more than just biomedical ‘optics’ on their patients and fortifying them with self-aware, ethical, and relational dimensions of clinical practice. These dimensions embrace a capacity to reflect on one’s own clinical experience, to be prepared and respect different points of view of manifold events, to develop empathic attitudes and minimize uncertainties, and finally to recognize ethical and societal layers of healthcare. Nonetheless, this description may be more convincing only when it could be supported by more specific data as for learner’s group characteristics, evaluation of teaching methods effectiveness, curricular learning outcomes, and description of NM course. According to the authors’ recognition based on the collected data, there is no structured model of NM approach in the medical education but there is revealed a need toward the NM application into the medical curricula as such. Additionally, we assume that the lack of certain information can be caused by the state of the discipline that seems to be still developing. This growing interest in NM around the world still seems to be an opportunity for Central European medical schools, including Centre of Medical Education in Lublin, of taking lessons from what has been achieved in that field abroad. We consider the analysis made to be useful to prepare the best teaching template applicable in the Centre of Medical Simulation in Lublin. It could be applied especially for the improvement of Faculty members’ general humanistic attitude and communication skills, but it could be also dedicated to undergraduate students’ educational groups. A high rate of migration among physicians in Central Europe and frequent establishment of medical faculties distinguishing by their international character contribute to NM implementation into academic curriculum to improve the quality of education for the medical students and for the patients’ safety. This should be done in authors’ view reasonably and methodically, but dynamically enough to keep pace with recent changes in the healthcare system and academic curricula but still respecting their present status. Students should be also invited to benefit from this modern and encouraging discipline within the medicine understood as a science but also as an art.