Introduction

Over the last 15 years the psychological approach known as narrative medicine has gained increasing consent in the medical world, mostly with very sick adult patients who are especially fragile and in need of help. In current practice, conflicting factors are dramatically increasing because sophisticated diagnostic and therapeutic techniques have taken on an important role in the relationship between patient and physician. Sick adolescents and their families want to have a better understanding of the meaning of tests and examinations, of their disease, and of treatment and prognosis. On the other hand,  physicians are busier and busier, ever more pressed by bureaucracy, technology, and studies, which means only being able to dedicate a short time to each patient and family. Problems linked to communication, listening ability, and dialog become important, and reach a new identity. Even more than any other type of approach, the narrative approach allows the physician to acquire a deeper knowledge of the patient. There are no questionnaires, no tests, no instruments, but only the communicative ability of the physician who becomes the true friend capable of listening and of helping  through comprehension and discussion.

The practice of medicine in the ancient ages, from the Egyptians to the Greeks, cared above all about communication, listening, and information with patients. In recent times sick people and their families require ever more attention from their physicians, who are  always too busy to spend time with them. This is  the reason for the birth of a new school, called narrative medicine, which can mainly be found in industrialized countries (1-4). Its aims are to teach important techniques of dialog and communication. The patient may be physically cured, but he/she still feels unhappy, in trouble, stressed by a lack of certainty, afraid of a relapse of the disease, of late effects, and he/she becomes extremely fragile and incapable of looking at the future optimistically. Therefore, through a real  patient-physician alliance, listening and dialog become the first steps towards complete and true cure.  During the last few years we have chosen to apply this simple method with our sick children, and especially with our adolescent patients (5,6). Since then, families and children have started seeking us out, not only because we are their physicians, but because they also recognize us as friends who are willing and able to help them. Applying the narrative approach takes time and requires a private office, which, whenever possible,  should not be inside the hospital itself.

Narrative and listening technique

The patient’s narrative capacity and the physician’s listening skills are the two hinges which guide this method applied to medicine. Patients wish to attract the full attention of their physicians, they want to be helped, to be cared for, to have the possibility to talk about their worries, their sufferings. They usually do not like any impersonal forms of investigation, such as questionnaires or structured interviews, but want to be understood, to receive answers to their questions and honest information about the disease, the diagnostic procedures and treatment, including shared, informed consent. We strongly believe that this technique should be studied both at Medical School and  during Residency. Nowadays, dialog with patients and their families is difficult even for young graduates, especially if there is bad news to be delivered  (7-9). In addition, few teachers at Medical Schools ask their pupils to write about their experience (10,11), in order to increase the value of this technique.

Drawings are the tale of the sick child

Graphic and pictorial communication holds great importance for sick children since this is an area they have easier access to, and that they cultivate through play. This type of activity fulfills their innate need to communicate with themselves and with others. Children express themselves through drawings, using them as a stage to dramatize their needs, wishes, anxieties, and joys. When in hospital, children are afraid, they feel embarrassed around strangers and even parents, especially when the parents are speaking with their caregivers. Children are afraid of making a poor impression and of being rejected by adults, of being considered inadequate and untruthful. Their need for truth and for communication unfolds through artistic expression, and this is the basis of art therapy. The opportunity to express themselves through drawings is what makes the ill child his/her own therapeutic agent through a self-healing mechanism. This may be further guided so as to lead to an increase in self-esteem, which in turn will lead to both enhancement of their full expressive possibilities and to positive feedback of their self image.

Narrative medicine and the scientific journals

Over the last few years, several outstanding journals have included a section on Narrative medicine, and have dealt with various areas of this topic. Many articles have described the clinical history of patients, others have shared the physicians' experience, thus providing new insight into teaching and into their relationship with ill persons and their families. These articles offer a look at new teaching methods in the Medical Schools, always considering the patient as a person suffering from several difficult problems. With regards to pediatric oncology, this would appear to be especially important in treating adolescents.

        Luisa M. Massimo, MD and Daniela Caprino, MD, PhD

        Department of Pediatric Hematology and Oncology

        G. Gaslini Children’s Research Hospital, Genova, Italy

References

1.  Wilkie V: Narrative based medicine essential in communication skill training. BMJ 1999,318:28.

2. Charon R: Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 2001,286:1897-1902.

3. Eggly S: Physician-patient co-construction of illness narratives in the medical interview. Health Commun 2002,14:339-360.

4. Donnelly WJ: Patients’ stories as narrative. JAMA 2002,287:447-448.

5. Caprino D, Wiley TJ, Massimo L: Childhood cancer survivors in the dark. JCO 2004,22:2748-2750.

6. Massimo LM, Wiley TJ: Randomization, Informed Consent and Physicians’ Communication Skills in Pediatric Oncology: a Delicate Balance. Electronic Journal of Oncology 2005,2:228-231.

7. Branch W, Pels RJ, Lawrence RS, Arky R: Critical-incident reports from third-year medical students. N Engl J Med 1933, 329:1130-1132.

8. Christakis DA, Feudtner C: Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993,68:249-253.

9. Charon R: Reading, writing, and doctoring: literature and medicine. Am J Med Sci 2000,319.285-291.

10.  Katz AM, Conant L, Inui T, Baron D, Bor D: A council of elders: creating a multi-voiced dialogue in a community of care. Soc Sci Med 2000,50:851-860

11.  Miller SZ, Schmidt HJ. The habit of humanism: a framework for making humanistic care a reflexive clinical skill. Acad Med 1999,74:800-803.