叙事医学讲座-长庚大学医学系课件

胸腔科黃建達2011-4-77:30–8:30NarrativeMedicine

敘事醫學多一點故事，少一點理論RobertColes:當他開始用聽故事的方式了解病人時發現自己彷彿配備了另一雙耳朵不再僅僅專注於收集有助診斷的「症狀」，套入各種疾病的「模型」，然後安排適當的「治療」他邀請病人共同編寫有關於自己疾病的故事擴大為生命的故事豐富了對病人的理解與關懷。讓生命訴說自己的故事：敘事與醫學http:///mental-shelter/article?mid=173&sc=1WhatisNarrativeMedicine?

敘事醫學哥倫比亞大學RitaCharon醫師2000提出了「Narrativemedicine」醫學知識應分為兩組第一組是客觀的「logical-scientificknowledge」是對疾病的遺傳、病理基礎的了解與治療。第二組則是主觀的「narrativeknowledge」是在病人的理解與故事中，疾病所扮演的角色，所象徵的意義，所帶來的變化與所隱含的功能，這些細節應該由醫師與病人共同編寫、探索。RitaCharonNarrativeMedicine傳統病歷的書寫從收集症狀、建立因果關係、診斷排序下手，是一種「reductionist」的簡化、歸納手段，敘事醫學鼓勵每個人書寫、分享、重新建構自己的故事對醫師、病人敘事則邀請更多可能性、更多細節來豐富理解可能必須花上更多時間值不值得？讓生命訴說自己的故事：敘事與醫學http:///mental-shelter/article?mid=173&sc=1「只有聽得懂他人的故事我們才能開始思考如何解除他人的苦痛」美國許多醫學院---在訓練課程中加入了文學賞析「只有聽得懂他人的故事我們才能開始思考如何解除他人的苦痛」---醫學的初衷Charon醫師在紐約哥倫比亞大學---開了一門「NarrativeMedicine」碩士班讓生命訴說自己的故事：敘事與醫學http:///mental-shelter/article?mid=173&sc=1敘事醫學與六大核心能力PhysicianandPatient,Self,FamilyPatientCarePhysicianandSelf,PatientMedicalKnowledge

PhysicianandSelf,Patient,Colleagues,SocietyPractice-BasedLearningandImprovement

PhysicianandPatient,Colleagues,SocietySystems-BasedPracticeAllSituations

InterpersonalandCommunicationSkillsAllSituationsProfessionalism

敘事醫學與療傷ForPatientCopingstrategy;facilitatesadjustment/adaptationProcessfeelingsandreactionsExpressionandcommunicationPromotehealing,improvedhealthoutcomesForProviderProcessreactionstodifficultsituations/griefProtectionagainstburnoutReducepractitionerstressYamada,S.etal.MedicalStudentEducation,2003;35(4),pp.279-283.Brady,DWetal.Annals

ofInternalMedicine,2002;137(3),pp.220-223.敘事醫學與同理心Empathystudentspracticetakingtheviewofanotherperson(apatient,familymember,otherhealthcareproviders)theyseethepatientasapersonwithinafamily,community,andculture

HalpernJ.Fromdetachedconcerntoempathy:humanizingmedicalpractice.NewYork:OxfordUniversityPress,2001.DasGuptaS&CharonR.PersonalIllnessNarratives:UsingReflectiveWritingtoTeachEmpathy.AcadMed.2004;79:351–356.同理心NarrativeMedicinedoesnotmakemedicalstudentsinto"writers,"

butmakesthembetterdoctors

supportingtheirskillsofobservationencouragingtheirreflectioninaclinicalcontextshowingthestudentsthattheirthoughts,feelings,andquestionsareheardthroughtheresponsesfromthementors.NarrativeMedicineatUNMIRCMESymposium,March16,2007內容分析Initiation:first-timeexperiencesIdentityAweFrustrationanddisillusionQuestioningValues

NarrativeMedicineatUNMIRCMESymposium,March16,2007Studentssaythiswritinghelpedthemtoperceivetheirclinicalworkinathoughtfulwaybecomemoreobservantandanalyticallookforrecurrentpatternsrespondbettertopatients.NarrativeMedicineatUNMIRCMESymposium,March16,2007Facultycomments:

respondingtostudent'sreflectivewritingmakesthementormorereflective

HelpskeepmeintouchwithstudentsattheearlystageoftrainingIgotamuchbetterinsightintohowstudentsgrowovertime.Ithasmademelookcloseratmyownbehaviorasateacher,mentorandclinician.NarrativeMedicineatUNMIRCMESymposium,March16,2007ReflectiveRESULTS:“timewellspent”StudentsandmentorsoverwhelminglypositiveMostmentorsreturnExplosionofstudentinterest:

Fromaclassof75students:9tookNarrativeMedicinetrackin200522in200654in2007

NarrativeMedicineatUNMIRCMESymposium,March16,2007CONCLUSION:ANarrativeMedicineexperiencecanbe:simpletosetuprequiresaverymodestinvestmentinstudentandfacultytimerewardstheeffortwithincreasedreflectionandsatisfactionforbothstudentsandfaculty.NarrativeMedicineatUNMIRCMESymposium,March16,2007發展敘事醫學能力“Iwritethestory.Thestorywritesme.”

~Watts

推動敘事醫學的目的反省溝通教育

高雄醫學大學呼吸治療學系林慧如助理教授TRAININGMODELKNOWLEDGEACQUISITION(Novice)KNOWLEDGEAPPLICATION(Beginner)

STORIES=TOOLSTOASSESS&IMPROVE(Competent)Lawrence&Viken(2004).RAPNarrativeMedicineSkillsObservationActivelisteningAbilitytotellthepatient’sstory感動別人VergheseA.Thephysicianasstoryteller.AnnInternMed2001;135:1012-7.敘事學的兩種型式1.簡單敘述由一位具體的敘述者所講述的故事2.模仿敘述由全知而無實體的存在角度岀發講述故事敘事者身份隱藏案例試寫臨床上曾有什麼困擾你的倫理事件嗎？對這事件印象最深的一個「場景」回想此場景，直接浮現的3-4個「印象點」「關鍵對話」以這3-4個「印象點」描繪一個簡短的故事請給它一個最適當的簡短標題不要套用術語儘量還原到原初情境高雄醫學大學呼吸治療學系林慧如助理教授孩子還給我“Twenty-fouryear-old,28weekspregnant.Smallabruption,dilatedto4or5,s/pmag.SignedoutAMAtosmoke.Down.Abrupted.Bled.Cameupbabydead.Positivecocaine. Stupidity.Irritated.”HowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicine

September2006還原情境還原情境的第一步驟：不套用術語其次：為故事命名範例：孩子還給我機器人女孩大象男孩父親的害怕醫學敘事文學創作徵文比賽file://localhost/Users/cdhuang/Desktop/NarrativeMedicine/醫學倫理文學創作徵.doc-narrativemedicineHowtoGetStarted…CriticalComponentsCurriculumIntegrationApplicationAssessmentHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicine

September2006CriticalComponentsResidentchampion/facilitator“Safe”facultymemberEducationaboutnarrativecompetence,narrativemedicine,andcorecompetenciesMotivationNoonconferencecredit&foodOpportunitiestopractice&experimentwithwritingAcceptance,comfortlevelWillingnesstoshare,modelforothersLiterature,literature,literatureHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicine

September2006IntegratingNarrativeMedicine

intotheCurriculumUseduringorientationtohelpresidentsgettoknowoneanotherIncludewritingexercisesinrequireddidacticsandseminarsNarrativeMedicineRoundsHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicine

September2006NarrativeMedicineRoundsNarrativeMedicineRounds

RequirementsCompletepre-andpost-self-assessmentquestionnairesAttendandparticipateinatleast50%ofscheduledNarrativeMedicineRoundsKeepapersonaljournalHavefun!HowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicine

September2006NarrativeMedicineRounds

SessionFormatBrief5to10minutedidacticReadingofthedayTimetowriteReactiontoreadingGuidedwritingPersonalreflectionTimetoshareHowisY.Toler,M.D.The27thForumforBehavioralSciencesin