Narrative medicine for pediatric residents during neonatal and pediatric intensive care rotations

1 Introduction

Narrative medicine uses a patient-centered app-roach to understand human suffering, ailment, and subjectivity in the practice of medicine. The discipline was described by Rita Charon as “medicine practiced with narrative skills of recognizing, absorbing, interpreting and being moved by stories of illness” [1]. Physicians are taught reflection as a means to identify and understand their own emotional responses to their patients and make sense of their own life journeys thus providing effective care [1]. Narrative medicine can foster physician empathy [2] and facilitate self-consoling for physicians who bear witness to the suffering of patients [3]. By teaching reflection and instilling empathic understanding, narrative medicine also ameliorates physician burnout and compassion fatigue [4].

Few studies examine residents’ responses to narrative medicine. Narrative medicine curricula promote trainees’ empathic patient understanding with narrative competency as part of didactic education [5]. Reports from select residency programs in emergency medicine, internal medicine, obstetrics, and general surgery outline emerging narrative medicine exposure for their trainees [6–9]. A recent plea was made for a narrative medicine curriculum in Pediatric Residency education [10], however, this published narrative medicine curriculum provides no measures of efficacy. One pediatric narrative medicine curriculum, presented in an abstract, was able to foster relaxation and self-reflection and increased physician/patient engagement [11]. Narrative medicine techniques extend to palliative care teams [12], complex pediatric patients [13, 14], and perinatal patients [15], however, reports and studies do not yet encompass critical care or neonatology rotations.

Some of the more challenging rotations for pediatric trainees, NICU and PICU, combine a busy resident workflow with intellectually and emotionally challenging patient care, placing residents at risk for compassion fatigue, moral distress, and burnout [16]. Whether or not narrative medicine is useful for pediatric trainees working in intensive care units is unknown. Our goal was to examine how pediatric residents working in the NICU and PICU at St. Christopher’s Hospital for Children responded to a narrative medicine curriculum.

2 Methods

This study was conducted between July 2019 and August 2020 at St. Christopher’s Hospital for Children –an urban, academic children’s hospital serving a low-income, minority community. The hospital is a tertiary referral center for the north-northeast Philadelphia region and has a level IV NICU, the only pediatric burn center in the Philadelphia region, and is a level I trauma center. At the time of this study, St. Christopher’s Hospital for Children was not a transplant center. St. Christopher’s pediatric residency program had 75 residents at the time of this study. Sixty-one of these residents were female. Seventy-one residents received their medical degrees from American medical schools. Sixteen residents were D.O.s (Doctor of Osteopathic Medicine) and 59 were M.D.s (Doctor of Medicine).

All residents rotating in the NICU or PICU were eligible for participation in this study. Residents were assigned to these rotations by their chief residents based on requirements for pediatric training. Of the 75 residents in the residency program, 36 residents attended at least one session. Prior to beginning this study, it was approved by the institutional review board and discussed with the pediatric residency program leadership. The narrative medicine curriculum occurred every other block over the span of a year.

The narrative medicine sessions occurred twice during the pediatric residents’ 4-week rotation schedule. Sessions occurred during the regular, daily scheduled didactic slot at 8 o’clock in the morning and lasted one hour. Narrative medicine sessions in this study were not optional nor were they added on after-hours.

Narrative medicine sessions were facilitated by one or two of the authors of this manuscript who are all neonatologists. A consistent PICU attending came to many but not all sessions as well. All facilitators had training from the Director of Narrative Medicine at the Lewis Katz School of Medicine at Temple University. Three of the four authors also attended Columbia University’s Narrative Medicine Basic Workshop prior to facilitating these sessions.

Narrative medicine sessions were patterned off of narrative medicine sessions offered at both Temple and Columbia’s Narrative Medicine Basic Workshop. Each session began with examining a piece of provided literature, visual art, or audio recording. For written pieces, residents were asked initially to read to one’s self and then aloud as a group. The group then had the opportunity to discuss each selection. Residents were subsequently provided a prompt and given 10 minutes to write reflectively. Finally, residents then could share their writing and offer comments on one another’s reflections. Residents were not required to speak and were not forced to write or read their reflections.

At the beginning of their NICU or PICU rotation, pediatric residents were emailed with a description of the study. At the end of their rotation, they were emailed a request to participate anonymously in an open-ended survey. The survey was distributed through REDCap, a HIPAA compliant database. Residents were asked select questions previously developed to assess narrative medicine sessions [17]:

What is your overall impression of the narrative medicine sessions?

Additionally, residents who participated in the intervention group reported how many narrative medicine sessions they attended.

Survey responses were interpreted using NVivo 1.0, using the program’s algorithm for recurrent words or phrases which then created word clouds based on word recurrence and common words. Each question’s responses were analyzed separately within the program. Every response to each question was entered for analysis. Common articles such as “the” and “and” were removed from the analysis.

3 Results

Twenty-two of the 36 residents queried responded to our surveys at the end of their rotation. This was a 61% response rate. All of these residents attended at least one narrative medicine session. Figure 1 depicts the word clouds NVivo 1.0 generated for questions 1, 2, and 4. The larger the word in each cloud, the more commonly it was used by residents in their survey responses. Table 1 depicts all of the resident responses received. Residents did not respond sufficiently to question 3, so no cloud was generated. The few responses offered are included in Table 1.

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Fig. 1

Word Cloud Responses.

Facilitators selected diverse pieces; however, the most common and well-received selection was Rudyard Kipling’s poem If. Other selections included Lawrence Ferlinghetti’s I am waiting, Alan Bruce’s My First Breath, and Maya Angelou’s Still I Rise.

As evident in the word clouds and table, nearly all of the feedback was positive. Many residents were able to self-identify the sessions as worthwhile experiences for self-reflection and a professionally meaningful release of emotion. Residents identified empathic witnessing to each other as a strength of these sessions. Respondents noted value in “Listening to another person’s words at a deeper level,” and “liked hearing about other people’s feelings and experiences, some resonated.” They noted cohesion and bonding within these intensive car teams as an important aspect of these sessions, with one comment highlighting, “Listening to others speak about their experiences has been very beneficial.”

Resident suggestions for improvement were centered around timing of the sessions –some wanted to use informal afternoon sessions instead of given didactic teaching time in the mornings. Feedback also centered around not requiring post-call participation and about the difficulty of interruptions related to patient care during the sessions. Only one resident did not have a positive experience with these sessions.

Pediatric residents rotating in the NICU and PICU endorsed narrative medicine sessions as a fulfilling and meaningful forum for them to share their emotions and reflect on their own experiences as well as those of their colleagues. The process of reflective writing after close attention to a poem, work of art, or story, followed by discussion of these reflections, allowed the residents to feel seen, see each other, and better understand their patients as having viewpoints distinct from their own.

Residents noted that having dedicated time to reflect together while in the intensive care unit setting was important in helping them to realize their own emotional responses to the ICUs were collectively challenging and deeply felt. We received few responses to question 3, perhaps because this question was more challenging for residents to answer in an online survey format.

The positive experiences described by residents in this study were similar to that of obstetrical residents’ experience of narrative medicine [9]. This same obstetrical program elicited diminished burnout scores in residents after engagement with their narrative medicine curriculum [4]. Twenty-two studies report narrative medicine programs for residents [18], however few of these studies provide any assessment of these narrative medicine programs. None of these prior studies of residents were in pediatrics or neonatal intensive care settings [18].

One resident felt the sessions were not as helpful as learning pathophysiology in the context of intensive care unit didactic time. This viewpoint is not unique in medical training and medical culture in general. The fact that another resident noted this was the first time “we were finally sat down and were asked about how we were genuinely doing; not just as physicians, but also as human beings” is an important balancing comment. Both pathophysiology and humanism can have a place in medical training.

Facilitators from the Narrative Medicine program at the Lewis Katz School of Medicine at Temple University note “many residents voice their appreciation for the opportunity, on a regular basis, to visit different forms of creative expression . . . and to find how the writing relates to their world and that of patients seeking medical care” [5]. Residents in our study were similarly appreciative of these sessions, as evident in the themes emerging in the word cloud analysis of our survey responses.

Integrating narrative medicine into the resident workday underscored that these sessions were as important as those focused on pathophysiology. Residency education must adapt to recognize residents’ human responses to witnessed patient suffering. Discussion groups of any type, including narrative medicine groups, promote teamwork, collegiality, networking, and reignite meaning in work [19]. Trainees participating in narrative medicine sessions can experience a sense of community, a reduced feeling of isolation, promote self-reflection, and cultivate reflective imagination [17].

Using poems, paintings, recordings, and stories instead of clinical cases is a narrative medicine strategy that permits trainees to react, relate, and respond safely to the provocative narratives in those curated selections without the burden of responsibility that comes with patient care [20].

Limitations of this study are that it was conducted at a single children’s hospital. The responses and experiences of residents in a single training program may not translate to other pediatric residency programs. The qualitative nature of this study does not lend itself to measuring quantifiable changes in resident well-being nor was the study designed to measure direct impacts of residency narrative medicine sessions on patient care.

For residents to successfully see beyond their pa-tients’ symptoms to develop compassion and empathy for their patients’ illness stories, they must have a framework with which to understand their patients. Narrative medicine helps residents value their own emotional responses to their clinical work, underscoring the real and human responses trainees have to critically ill children. As pediatricians learn to effectively shepherd pediatric patients and their parents through critical illnesses, they must also learn to shepherd themselves.

Disclosure statement

The authors have no financial disclosures to declare.

Human research statement

Prior to beginning this study, it was approved by the Drexel University Institutional Review Board.

Funding

Not applicable.