Collaborative reflection and discussion using the narrative medicine approach: speech acts and physician identity

SA and frequency

Many characteristics can be seen in Table 4. Some SA appeared with high frequency in 24 CRD, which shows a distinct feature of the narrative medicine approach. For example, the SA of “focus on the time and speed of illness process (1)” appeared in 22 out of 24 discussions. SA with a percentage higher than 70% can be considered to be the most repeated parts of CRD, including “focus on the time and speed of illness process (1),” “analyze the patient’s physical changes (4),” “identify the different voices (6),” “know the attitude of the patient (13),” “understand the plot and situation deeply (15),” “increase the level of empathy (19),” “attention to details of illness and death, such as word choice (22),” “reflect on what kind of attitude doctors should have toward the patient (29),” and “think about communication and connection (32)”.

The frequency of SA varies widely, but it is not easy to distinguish which SA is necessary for students to use in CRD. One reason may be related to the contextual differences. If the narrative works provided the context in the first person of the patient, students need not “confirm that the patient is aware of the illness status (2)”; if there were no apparent conflicts in attitudes or interests, students need not “rank the wishes of the patient and others (14)”. The examples demonstrate that although some SA seems important, the narrative works do not guarantee the necessity to use them. The perspective of thinking also influences the choice of SA. For example, “give spatial information in a region (5)” and “identify the voices that influence the patient (10)” were usually not directly related to the medical knowledge that aroused students’ interest, but were often proposed by the teacher who guided the discussion. Students may choose SA that seems related to their major, or the one that is easier to identify from the elements of CRD. As a rough estimate, SA with a frequency of more than 60% (bold in Table 4) is necessary for CRD.

Physician identity

Based on the frequency of SA and the CRD corpus, we summarized the main physician identities as follows.

The spokesperson for the patient’s wishes

Students noticed that when patients did not clearly state their wishes for subjective or objective reasons, doctors should take the initiative to inquire and presume the patient’s wishes from the details. The identity of the spokesperson can be seen in confirming that the patient is aware of the illness status (2), presuming the patient’s wishes (11), knowing the attitude of the patient (13), ranking the wishes of the patient, and others (14), and being aware of the rights and interests of the patient (17). Students tried to analyze the patient’s wishes while taking notes of other people. Even when the patient did not express any wishes, the students speculated about his possible expression based on his educational background and life experience. When patients and doctors choose different medical options, students realize that they need to communicate with the patients (32), prioritize their wishes (14), and consider inviting their relatives regarded as people who know them best to participate in medical decisions (10).

Example 1a: The doctor’s objectivity and the patient’s suffering (CRD on How the Poor Die)

Student: Based on all we know about him (10), he would refuse cupping therapy (11). But his resistance had no effect (15), and he suffered too much (19).

Teacher: Did Orwell say anything? Why did you make this judgment?

Student: He knew he was seriously ill (2), but he didn’t want to be treated like the No. 57 patient (13) whose belly is the only valuable part to the doctor and interns (15). I think the doctor should ask for Orwell’s permission (32).

Student: Case teaching is inevitable, but the way the doctor performed was not beneficial for Orwell (17).

Teacher: What did he do for Orwell?

Student: Ask him to take fundamental drugs. But I’m afraid the doctor wanted to take him to the autopsy room after he died (14, 15).

Teacher: What did Orwell expect?

Student: His needs should come first (13, 14). If possible, any of his relatives or friends should also be there to help (10).

After closely reading How the Poor Die, the students identified that patients in free wards were treated with no dignity, and presumed Orwell’s wishes based on his life background and experience in public hospitals (11). After reviewing the details, they confirmed that he knew the illness status (2). The student perceived that the treatment chosen by the doctor or the medical institution did not necessarily correspond to the rights and interests of the patient (17). Therefore, after examining the doctor’s medical behavior in the story (15), they knew the patient’s attitudes by checking the medical context (13) and found that the wish of the patient was different from that of the doctor (14). The students were aware that, in diagnosis and treatment, the doctor should ask patients and their relatives about their wishes, putting the patient’s wish first in the ranking process (14).

The students found the hybrid identities of doctors challenging; they viewed the doctor as a scientist and researcher who should take a distant and objective attitude when communicating with the patient; on the other hand, they realized it was far from the patient-centered concept required by the clinical practice as it showed no respect for the patient. The students wrote in reflection (Example 1b): “This is a story told from the patient’s perspective as if to warn us what should be the first concern of a doctor (12,15)”; “Scientific descriptions and research are important, but ignoring the emotional demands of patients can lead to doctor-patient conflicts (9) and undermine doctors’ efforts to respect patients (17).” The students tried to understand complex expressions and the plot in the stories (12,15), coming to a consensus that, by inquiring and presuming the patient’s wishes, doctors not only prioritize the patient’s rights and interests (14,17) but also protect doctors’ safety by avoiding possible risks (29).

The guide for patients in the face of illness and death

Most students learned about different diseases and their consequences for the first time by reading a novel or watching a movie. They read detailed descriptions of the illness and tried to understand patients’ psychological states like emotions, perceptions, and expectations. Therefore, the physician identity as a guide was developed in CRD as the students learned how to help patients increase courage in the face of illness and death, and how to advise on possible arrangements as the disease got worse. It can be seen in focusing on the time and speed of illness development (1), examining how patients experience sick time (3), analyzing the patient’s physical changes (4), accepting and promoting the concept of palliative care (23), raising the issue of caring for patients (25), suggesting arrangements or activities (27), and paying attention to the patient’s hobbies or the final wishes (28).

Example 2a: Noticing, finding, and advising arrangements (CRD on Breathe)

Student: In just ten minutes of the film, Robin was infected with the polio virus and paralyzed (1), with only a slight head movement (3,4). It’s so sad (19).

Student: Without a ventilator, he would die in two minutes (1,4).

Teacher: So what is the narrative focus of Breath?

Student: It’s about how they faced the disease (12). It’s good for them to do everything they can, leaving no regrets (27). What the doctors can do is trying to keep death from coming too soon (25).

Student: But Robin was lucky (19). Diana took care of everything with the help of their friends (25). Relatives can do more than doctors (25).

Teacher: What happened then?

Student: He finally decided to say goodbye to the world (1,13) because relying on the ventilator for such a long time made his lungs extremely susceptible to infection (1,4).

Student: At least he saw his son growing up. It may be what he wanted most (13,28). The near-death stage should not be prolonged (23). If I were Robin, I would do the same (19).

In Example 2a, the elements of “time” and “space” (1,4) were discussed several times as students constantly found new details of the progression of the disease and the physical changes of the patient. The students empathized with the loss of the patient’s health (19), tried to know the best that the doctor and caregivers could do in different stages of illness (25), noticed the patient’s final wishes (28), and accepted and promoted the concept of palliative care (23). By directly observing the dynamic changes of the disease and the patient’s experience of illness, the students proposed the arrangement (27) concerning emotional care and finally accepted and respected the patient’s decision to say goodbye to the world (13). Students developed an understanding of the doctor’s responsibility as a guide for patients. In the CRD of reflective writings (Example 2b), students realized that doctors need to communicate with patients on the topic of illness and death (32), reflect on what kind of attitude doctors should have toward the patient (29), and guide patients to vent their feelings when they are in sickness:

Example 2b: Guide patients to think about illness and death

• I think what the author wants to say is that the meaning of death is letting life explode more brightly in an increasingly limited time (12,15). Death is not a negative existence; it’s a “good night.” If we convey such positive emotions to the patient (29,32), it is also a form of medical help and treatment (16). (CRD on Do Not Go Gentle into That Good Night)

• When the doctor informed the patient of the bad news, he encouraged the patient to face reality bravely rather than using technical terms (32). I was deeply impressed by his solicitude. A doctor’s verbal language can help a patient calm down and encourage him (16,29). (CRD on What the Doctor Said).

The students’ SA were often targeted, usually from doctors’ perspectives, such as informing diagnosis, body language, medical or life advice, and palliative care. Students can understand that the doctor should be with the patient in the face of illness or death as their guide during medical treatment.

The listener for multiple voices

The students often searched for medical knowledge related to the narrative works and briefly exchanged information with peers (33) to prepare for a better understanding of diverse voices. They identified different voices (6), confirmed the speaker’s rights and obligations (7), noticed the gap between the speaker and the listener (8), and observed the effects of the speaker’s encounter with the listener (9) to understand all the voices in the story. Through deeper reading and writing, they noticed the patient’s difficulties (26) and communication issues (32). Students were thus able to ensure that all voices were taken into account in the virtual medical context and realized that they should listen to multiple voices before taking responsibility for healthcare decisions.

Example 3a: An understanding of all voices (CRD on the Children Act)

Teacher: Adam’s parents were supposed to know Adam best (10). What choice did they make?

Student: They would refuse blood transfusion because of religious beliefs (6).

Teacher: So what choice did others make?

Student: The hospital filed a lawsuit, so Fiona decided to force blood transfusions (6).

Teacher: We seemed to ignore Adam’s wishes (11).

Student: He refused the treatment (13).

Teacher: What did he say? Why did you make this judgment?

Student: He would accept blood transfusion treatment (11) because Fiona had become his new faith (15). But when he wrote or talked to her, Fiona thought it was not her job (6,26), so he refused (13).

Student: Fiona did not listen to Adam’s story (8). She ignored Adam’s emotional needs (7). There’s a big gap between them (8,26).

Teacher: But she finally changed. Do you know why?

Student: Her conversation with her husband showed that she had changed (9). If she had changed earlier, the result might have been different (29,32).

The students discovered the hidden voices between the lines and the intricate background behind them. The student first pointed out that Adam had leukemia and briefly shared relevant medical knowledge, noting that it should be a recurrent case (33). After identifying the voices of Adam, his parents, the court, Fiona, and her husband (6), they pointed out that Fiona, as a professional, refused to listen to Adam (26), which prevented the patient’s voice from being heard, and that she did not fulfill her duty as a listener (7,8). As a result, the students shared an in-depth reflection on Adam’s refusal of blood transfusion (9), which prompted them to think about how to communicate and connect with others as doctors (32). One student shared his writing excerpts in the class (Example 3b): “When Adam wanted to talk to Fiona, what Fiona thought about was the proprieties and dignity of her professional identity (26,32). Children are vulnerable. In addition to the physical well-being, we must provide them with spiritual well-being (29)”.

Different voices that need to be heard by doctors also arise among students who presume they are doctors. In the 22nd CRD on You Don’t Know Jack, many students believed that Jack patiently listened to each patient’s words and understood their wishes and interests, so making euthanasia legal was acceptable. However, some expressed concern about the technical aspects of communicating with the patients and understanding their choices and wishes. They finally concluded that doctors should pay attention to all the voices, on which they could make prudent healthcare decisions.

The Empathizer who offers love and help

Some SA showed students’ empathy for patients’ emotions like pain and loneliness. Being an empathetic doctor who can offer love and help to patients was also what medical students realized when developing the awareness of physician identity. The identity of the empathizer can be seen in their new or changed knowledge to help the patient (16), their perception of the patient’s experience (18), an increased level of empathy (19), an increased understanding of the elderly and the seriously ill (20), and reflection on how to help the ill (24). The discourse in Example 4 came from the 3rd CRD about how people help each other to overcome difficulties together.

Example 4: Giving care, love, and empathy to patients (CRD on The Way We Live Now)

• There are no words warning visitors of the possibility of infection now. It’s hard to imagine what it was like for him to live in an environment of discrimination before such changes happened (19).

• During his hospitalization, he began to keep a diary, recording his feelings since he was diagnosed with AIDS, and writing down his regrets (3,15). Will it be of great help if we encourage patients to read or write poems or diaries to vent their feelings or get inspiration (16,24)?

• He may think he was alienated and isolated (18), but the doctor was kind, patient, and optimistic about his condition (15). Good qualities such as respect, compassion, and companionship are valuable for the patients (16,24).

The students analyzed from all perspectives: how “his” lover, friends, the hospital, and doctors were concerned about his illness in different ways. They focused on how to provide “him” with continual love and assistance. The above SA with strong empathy included open-ended questions (“What it was like for him to …?”) and more implied questions (“Is it of great help if …?”). Such emotional insights left room for reflection and reminded students to offer love and help to patients. “Good qualities … are valuable” is not only the affirmation of the doctor’s medical behavior but also an invitation for all future doctors to give care and empathy to the patients.

The reflective doctor who reinterprets the process

To develop the ability to describe the clinical process in non-technical language, the students learned to describe the causes and effects, disease progression, and the care process, reinterpreting and thinking reflectively based on “time and speed of illness process (1),” “spatial information (5),” “complex and metaphorical expression (12),” “the plot and contextual situation (15),” and “details of illness and death such as word choice (22).” The students explored the way they reinterpreted the process in the discussions, which may contribute to their reflection on illness, diagnosis, and death:

Example 5a: Reinterpretation of the story (CRD on The Masque of the Red Death)

• During the plague (1), the king welded the bolt and reveled inside the castle, leaving people to die outside (5,15). The strike of midnight (1) suggested his death (12). “Red” (12,22) is the color of blood from killing all people (12), but behind the masque was empty. Does it indicate that the king was not killed by the “Red Death” but by his ruthlessness and brutality (12)?

Through reflection and discussion, students noticed something they were unaware of and re-understood the complicated information. Sometimes, they invited their peers to pay attention and listen to their reflections (30), and they responded to the invitations (31). In this process (Example 5b), the students often examined their reinterpretations from a distance or from the point of view of another student to verify whether their perceptions were accurate and adequate:

Example 5b: The dilemma of oncologists (CRD on Wit)

• She reviewed her life in the hospital bed (3), talking to her father, first teacher, students, and “us” in the classroom (5). Passing away with the teacher reading her favorite childhood story (1,3) was the best send-off she could have imagined (28). I felt a deep sadness (19). I think oncologists love cancer cells more than patients because the former is the victor and the strong (15). Do you agree (30)?

• It’s true that doctors should be calm, objective, and rational, but most also have compassionate hearts. Sometimes, patients only need someone to be with them (16,19).

Some students took great pride in their reflective writings and were adept at capturing what they saw in narrative works and sharing it with others (30); some commented on their peers’ concerns and reinterpretation (31). They responded to the call of the suffering patients and tried to understand what the doctor should do to echo the call.