The Power of Stories

to Teach and Inspire

ACE Seminar, 12/9/14
Daniel Epner, MD
Department of Palliative Care
and Rehabilitation Medicine

Epner DE, Journal of Clinical Oncology 2014

A Perplexing Question

Narratives
Charon, Narrative medicine: honoring the stories of illness, 2006

Stories with a teller, a listener, a time course, a

plot, and a point.

What is narrative medicine?

Stories told by:
Patients, families
Doctors and other providers

Stories received
Oral
Written
Filmed

Finding meaning
Experiencing emotion
Being inspired
Educating

3 Foundational Movements of Clinical Practice

Acad. Med 2014, Miller et al

Attention: focused concentration on a person, text,

or work of art that enables perception without
distraction.
Representation: conferring of linguistic or visual
form onto an experience so that it is perceived and
communicated to self and others.
Affiliation: development of a shared commitment
to the well-being of the patient, achieved through
meaningful contact
Bring patients and clinicians into authentic contact
as a prelude to action.

Narrative competence: receiving story

Charon, NEJM 2004

Competence to absorb, interpret and respond to

stories.
Enables the provider to practice with empathy,
reflection, professionalism, and trustworthiness
Meaning is derived collaboratively, by the teller
and listener, reader and writer, observer and
observed, patient and physician.

Intersubjectivity
It takes 2 to tango
Patient and provider share a story, experience it
and derive meaning from it in their own ways
Stories are inspired by other stories
Stories become part of our lived experience.

Standard Biomedical Practice as Narrative

Morris, DB, The Permanente Journal/ Winter 2008

What you say about narrative is very

interesting, I hear repeatedly. Thanks so

much for coming. But I have seven
minutes per patient. End of story.
So, lets make the most of those 7 minutes

Cost Effectiveness of NM
Morris, DB, The Permanente Journal/ Winter 2008

Like any instrument, narrative must be costeffective.

However, costs must be calculated fairly, with an
awareness of total costs.

Litigation
Error
Unneeded diagnostic procedures
Harmful end of-life intervention.

Fairly calculated, an ounce or two of narrative

prevention pays big dividends.

Value of telling stories

Charon, Acad Med 2012

Narrative acts sharpen the teller/writers

perception and mobilize his or her imagination
Narratives trigger changes of many kinds in both
the teller and the listener, yielding meanings that
are reciprocally produced by each teller listener
dyad.

Using Reflective Writing to Teach Empathy

DasGupta and Charon, Acad Med 2014

Empathic witnessing (Kleinman)

Build an illness narrative with a sick person that
will make sense of and give value to the
experience
That sick person and the provider can be one and
the same person.

Giving students and residents an opportunity to

describe and share their illness experiences (or
imagined ones) leads to more empathic practice.

Narratives are constructed.

Morris, DB, The Permanente Journal/ Winter 2008

The key point is that narratives, like

personal identities or postmodern
cities, dont just exist or arise: they are
constructed.

Writing is therapeutic
Pennebaker JW, Seagal JD. J Clin Psychol 1999.

Writing about traumatic experience

provides measurable health benefits.
Physicians and other providers not only
treat trauma but also experience it as
caregivers
We realized that the people who
benefited from writing were constructing
stories.

Building Narrative Competence

Receiving
Great fiction novels
Poems
Thought provoking
movies
Songs with lyrics
Short stories

Telling / writing

Applying Narrative Competence

Charon, Acad Med 2012

Using reflective skills

developed in practice
Listen to patients
story
What does he mean
when he says I
hurt?
Why does she show
up to clinic late?
Why does he talk so
much?

Close reading
Active process
Requires reflection
What does the author (patient) mean?
How does this experience make me feel?
How can I put my thoughts and feelings into
action?

Inspires
Educates

Epner DE, Journal of Clinical Oncology 2014

A Perplexing Question

Close reading of A Perplexing Question

Epner, JCO 2014

Relive the ancient customs of their

ancestors.
sleep on luxurious comforters like those used
by countless ancestors.
luxurious Bedouin tents with fluffy bedding, wool
carpets, rich tapestries, and Old World grace.
Timelessness
Connection to all of humanity

Close reading of A Perplexing Question

Epner, JCO 2014

She described how happy she feels hearing her

children laugh and squeal as they race up and
down sand dunes, chase lizards, and fly kites.
She explained how safe and secure she feels
sleeping on the floor of the tent among her
children and husband.
calming fussy little boys and girls
The power of a family's love
Universality of human needs

Close reading of A Perplexing Question

Epner, JCO 2014

I could imagine the indescribable beauty and

vastness of the starry desert sky at night.
I imagined a desert night, with its warm
sensuous breezes drifting through the tent
The sacred, spiritual, and mysterious power of
nature and our connection to it
Our place in the Universe

Intersubjectivity of Stories
I fondly recalled the many
hikes with no particular
destination, savoring life in
every breath (Bushido)
I moved the chair back into
position by her bed and
contemplated how much I
would miss our daily
conversations.

The Road
Cormac McCarthy, Pulitzer Prize winner
When he woke in the woods in the dark and the
cold of the night hed reach out to touch the child
sleeping beside him. Nights dark beyond
darkness and days more gray each one than
what had gone before. Like the onset of some
cold glaucoma dimming away the world. His
hand rose and fell softly with each precious
breath. He pushed away the plastic tarpaulin
and raised himself in the stinking robes and
blankets and looked toward the east for any light
but there was none

Departures
Winner of 2009 Academy Award for best foreign film

Masahiro Motoki: Daigo

Unemployed cellist
Moves to childhood
home
Accidentally becomes a
mortician
Shunned by wife and
others due to stigma
around death

Departures
Winner of 2009 Academy Award for best foreign film

First Job: 32:55-36:01

Daigo sees the light: 1:211:24:06

Affirmation of life:
1:30:25

1:24:06-

The Watchman
Weinberg RB, Annals of IM 2012

I have seen how the seemingly smallest

gestures often provide the most immense
comfort. Paradoxically, it is perhaps in those
moments that we have the greatest power to
heal.

Proposed Narrative Medicine Conference

Tentative September 2015
Doctors, nurses, social workers, chaplains,
writers, others
Co-sponsored by MDACC, BCM, UTHSCH
Plenary sessions and small groups
Participants share stories
Reflective writing

First Love
Weinberg, RB, Annals of IM 1997

In the practice of our art we are each like a solar

system, our patients revolving around us like planets
around a sun. Some whirl furiously in close orbits,
seeking our warmth; others circle more lazily at a
distance; and others, like comets, streak through our
reach only once in a lifetime. What keeps them all
from spinning off into the cold and lonely vacuum of
space is the gravity of our love.