胸 腔 科 黃 建 達2 0 11 - 4 - 7 7 : 3 0 8 : 3 0NARRATIVEMEDICINE敘事醫學多一點故事，少一點理論Robert Coles: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。讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/tw.myblog.yahoo.com/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？讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/tw.myblog.yahoo.com/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碩士班讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/tw.myblog.yahoo.com/mental-shelter/article?mid=173&sc=1敘事醫學與六大核心能力Physician and Patient, Self, Family Patient CarePhysician and Self, Patient Medical Knowledge Physician and Self, Patient, Colleagues, Society Practice-Based Learning and ImprovementPhysician and Patient, Colleagues, Society Systems-Based PracticeAll Situations Interpersonal and Communication SkillsAll Situations Professionalism敘事醫學與療傷For PatientCopingstrategy;facilitatesadjustment/adaptationProcessfeelingsandreactionsExpressionandcommunicationPromotehealing,improvedhealthoutcomesFor ProviderProcessreactionstodifficultsituations/griefProtectionagainstburnoutReducepractitionerstressYamada,S.etal.Medical Student Education,2003;35(4),pp.279-283.Brady,DWetal.Annals of Internal Medicine,2002;137(3),pp.220-223.敘事醫學與同理心Empathystudentspracticetakingtheviewofanotherperson(apatient,familymember,otherhealthcareproviders)theyseethepatientasapersonwithinafamily,community,andcultureHalpernJ.Fromdetachedconcerntoempathy:humanizingmedicalpractice.NewYork:OxfordUniversityPress,2001.DasGuptaS&CharonR.PersonalIllnessNarratives:UsingReflectiveWritingtoTeachEmpathy. Acad Med. 2004;79:351356.同理心NARRATIVEMEDICINEDOESNOTMAKEMEDICALSTUDENTSINTOWRITERS,BUTMAKESTHEMBETTERDOCTORSsupportingtheirskillsofobservationencouragingtheirreflectioninaclinicalcontextshowingthestudentsthattheirthoughts,feelings,andquestionsareheardthroughtheresponsesfromthementors.NarrativeMedicineatUNMIRCMESymposium,March16,2007內容分析Initiation: first-time experiencesIdentityAweFrustration and disillusionQuestioningValuesNarrativeMedicineatUNMIRCMESymposium,March16,2007STUDENTSSAYTHISWRITINGHELPEDTHEMTOperceivetheirclinicalworkinathoughtfulwaybecomemoreobservantandanalyticallookforrecurrentpatternsrespondbettertopatients.NarrativeMedicineatUNMIRCMESymposium,March16,2007FACULTYCOMMENTS:RESPONDINGTOSTUDENTSREFLECTIVEWRITINGMAKESTHEMENTORMOREREFLECTIVEHelpskeepmeintouchwithstudentsattheearlystageoftrainingIgotamuchbetterinsightintohowstudentsgrowovertime.Ithasmademelookcloseratmyownbehaviorasateacher,mentorandclinician.NarrativeMedicineatUNMIRCMESymposium,March16,2007ReflectiveRESULTS:“TIMEWELLSPENT”StudentsandmentorsoverwhelminglypositiveMostmentorsreturnExplosionofstudentinterest:Fromaclassof75students:9tookNarrativeMedicinetrackin200522in200654in2007NarrativeMedicineatUNMIRCMESymposium,March16,2007CONCLUSION:ANARRATIVEMEDICINEEXPERIENCECANBE:simpletosetuprequiresaverymodestinvestmentinstudentandfacultytimerewardstheeffortwithincreasedreflectionandsatisfactionforbothstudentsandfaculty.NarrativeMedicineatUNMIRCMESymposium,March16,2007發展敘事醫學能力“I write the story. The story writes me.” 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學系慧如助教授TRAININGMODELKNOWLEDGEACQUISITION(Novice)KNOWLEDGEAPPLICATION(Beginner)STORIES=TOOLSTOASSESS&IMPROVE(Competent)Lawrence&Viken(2004).RAPNARRATIVEMEDICINESKILLSObservationActivelisteningAbilitytotellthepatientsstory感動別人VergheseA.Thephysicianasstoryteller.AnnInternMed2001;135:1012-7.敘事學的種型式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岀發講述故事敘事者身份隱藏案例試寫案例試寫床上曾有麼困擾你的事件嗎？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要套用術語儘還原到原初情境高雄醫學大學呼吸治學系慧如助教授孩子還給我“Twenty-fouryear-old,28weekspregnant.Smallabruption,dilatedto4or5,s/pmag.SignedoutAMAtosmoke.Down.Abrupted.Bled.Cameupbabydead.Positivecocaine.Stupidity.Irritated.”HowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicineSeptember2006還原情境還原情境的第一步驟：套用術語其次：為故事命名範：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/Narrative Medicine/醫學倫理文學創作徵.doc - narrative medicineHOWTOGETSTARTEDCriticalComponentsCurriculumIntegrationApplicationAssessmentHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicineSeptember2006CRITICALCOMPONENTSResidentchampion/facilitator“Safe”facultymemberEducationaboutnarrativecompetence,narrativemedicine,andcorecompetenciesMotivationNoonconferencecredit&foodOpportunitiestopractice&experimentwithwritingAcceptance,comfortlevelWillingnesstoshare,modelforothersLiterature,literature,literatureHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicineSeptember2006INTEGRATINGNARRATIVEMEDICINEINTOTHECURRICULUMUseduringorientationtohelpresidentsgettoknowoneanotherIncludewritingexercisesinrequireddidacticsandseminarsNarrativeMedicineRoundsHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicineSeptember2006NARRATIVEMEDICINEROUNDSNARRATIVEMEDICINEROUNDSREQUIREMENTSCompletepre-andpost-self-assessmentquestionnairesAttendandparticipateinatleast50%ofscheduledNarrativeMedicineRoundsKeepapersonaljournalHavefun!HowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicineSeptember2006NARRATIVEMEDICINEROUNDSSESSIONFORMATBrief5to10minutedidacticReadingofthedayTimetowriteReactiontoreadingGuidedwritingPersonalreflectionTimetoshareHowisY.Toler,M.D.The27thForumforBehavioralSciencesinFamilyMedicineSeptember2006PLAN敘事文章書寫一篇優秀文章選拔與研讀arrativemedicineroundREFERENCESHowisY.Toler,M.D.,JulieWood-Warner,Ph.D.ResearchMedicalCenterFamilyMedicineResidency,KansasCity,MOThe27thForumforBehavioralSciencesinFamilyMedicineSeptember2006EllenM.Cosgrove,MDFACPSeniorAssociateDean,Education,UniversityofNewMexico.NarrativeMedicineatUNMIRCMESymposiumMarch16,2007讓生命訴讓生命訴說說自己的故事：敘事與醫學自己的故事：敘事與醫學 http:/tw.myblog.yahoo.com/mental-shelter/article?mid=173&sc=1床敘事高雄醫學大學呼吸治學系慧如助教授敘事醫學與醫療專業敘事醫學與醫療專業 長庚兒童氣喘過敏風濕科副教授林思偕長庚兒童氣喘過敏風濕科副教授林思偕 長庚醫訊卷期TAKEHOMEMESSAGESNarrativeMedicinedoesnotmakemedicalstudentsintowriters,butmakesthembetterdoctors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THANKYOU!