Storytelling and Written Reflection: Tools to Foster Meaning and Connection in Graduate Medical Education Settings

The Accreditation Council for Graduate Medical Education (ACGME) Council of Review Committee Residents (CRCR) hosted a 1-hour session during the 2022 Annual Educational Conference to promote the inclusion of storytelling and narrative medicine in graduate medical education (GME). The purpose of the session was to foster community, well-being, and humanism through storytelling and narrative medicine, and to provide strategies for incorporating a topic-focused curriculum into GME programs regardless of specialty, duration, or program size.The ACGME Common Program Requirements for residency programs mandate training programs and their sponsoring institutions address trainee well-being, including “efforts to enhance the meaning that each resident finds in the experience of being a physician…and enhancing professional relationships.”1 Storytelling and narrative medicine have the potential to address both of these requirements. These contemplative practices allow for deeper engagement with several dimensions of the physician experience, including the 4 most common physician relationships—with themselves, patients, colleagues, and society.2 The opportunity to share written reflections creates and promotes trust and vulnerability in a GME community, which also strengthens professional relationships.The National Storytelling Network defines storytelling as “the interactive art of using words and actions to reveal the elements and images of a story while encouraging the listener's imagination.”3 Thus, storytelling is an engaging act shared among multiple individuals where language and gesture conjure an image of action. Because stories are entirely the teller's to communicate and the listener's to interpret, they are less about factual recounting and more a means of sharing and eliciting interpretations of reality. This tactic is commonplace in religious sermons and professorial lectures, and even in sales pitches and comedians' jokes. Impactful storytelling can have countless effects, from educating and motivating to connecting and reflecting.4 In medicine, storytelling commonly involves physicians describing a patient experience or patients sharing a health care experience. If used well, the practice can improve understanding of patient values and concerns, foster higher quality care, and derive meaning from work.Dr. Rita Charon, recognized as the founder of narrative medicine,5 states that the practice of narrative competence—being able to interact with the stories of others heard in medicine—is what defines narrative medicine. She described the benefits of narrative medicine through connecting deeply to patients, physicians reflecting on their journey, and starting important discussions with the public about health care. Through the practice of narrative medicine, we are offered “opportunities for respective, empathic, and nourishing medical care.”2A recent article noted that “stories can offer the kind of contextual richness that promotes and nourishes empathy, prompting a provider to switch from asking, ‘How can I treat this disease?' to ‘How can I help my patient?'”5 This reflective process encourages contextualization, exploration, open-mindedness, and a broader understanding of the practice of medicine.6 Although there is no single way to practice narrative medicine, the process begins with belief in the patient's story. The listener can then apply the principles of narrative competence. In this way, the physician empathizes with the patient. Action that ultimately helps the patient manage their situation now comes with a deeper understanding of the patient and their circumstances and how best to achieve intended outcomes.Narrative medicine programs designed specifically for GME trainees are not novel, and several sample models exist on MedEdPORTAL, ranging from a single event7 to longitudinal curriculum models that span years.8 Because the transition between undergraduate medical education and GME is viewed as a continuum rather than distinctly separate experiences, there is also an opportunity for written reflective exercises that support narrative medicine to be incorporated in undergraduate medical education.9During the session “Fostering Meaning and Connections Through Storytelling and Written Reflection” at the 2022 Annual Educational Conference, session attendees were invited to respond in real time to sample prompts provided throughout the ACGME CRCR's 1-hour session. A Google survey with free text spaces was distributed in the chat box during the semi-live session to compile the responses. Participation in the survey was voluntary, all responses were anonymous, and participants were informed about the use of their responses for future editorial publication. Given the nature of this project, institutional review board review was unnecessary, and participants provided informed consent by responding to survey questions.As an introduction to storytelling, based on Matthew Dick's principles, participants were first invited to share a meaningful moment or memory; this exercise was called “Homework for Life.”10 The next survey prompt encouraged participants to take the same meaningful moment or memory and “just start writing about it” using unfiltered stream of consciousness writing—this exercise was called “Crash and Burn.”10For the last part of the survey, participants were provided with a quote by Dr. Andrew Taylor Still, the founder of osteopathic medicine11: “To find health should be the object of the doctor. Anyone can find disease.”12 Participants were then asked to respond to 1 of 2 sets of follow-up questions. The first set of appreciative inquiry questions were written to engage meaningful reflection about the physician-patient relationship. Box 1 lists the follow-up questions for this exercise. Another set of questions was provided for session attendees who did not participate in clinical patient care and focused on self-reflection. Box 2 lists these follow-up questions.The exact number of people who attended the semi-live session is unknown because of limitations of the conference platform technology. However, there were 856 total views of the session, which included views during the semi-live presentation and later views of the recorded session. Overall, 14 individuals provided responses to the prompts during the semi-live session. All responses were reviewed, even if the participant provided only 1 response to a single prompt. Number of responses for each survey prompt were tabulated and common words and themes were identified.Ten participants responded to the first prompt about sharing a meaningful moment or memory. Responses were summarized into 3 broad themes: transitional moments (eg, goodbyes, time spent waiting), meaningful activities spent with other people, and appreciating visual or auditory naturescapes (eg, listening to the crash of waves). Over half of responses involved interactions with other people, highlighting the meaningfulness of human connection. The majority of responses to the second prompt built on this theme, and involved another person or group of people, including family or colleagues, or involved a group event, such as giving a presentation.Seven participants responded to the last prompt asking them to reflect on the physician-patient relationship in the context of focusing on health versus disease. Patient(s) or patient care was referred to in 5 of the responses. Two responses were provided by individuals who identified as nonphysicians. Four responses focused on the physician-patient relationship, highlighting health through “listening, respect, accountability,” “personal value and connection with others,” and supporting the workforce of the future.For the self-reflection-focused questions of the last prompt, 9 participants provided responses. Six responses discussed barriers to health and included words like “time,” “motivation,” “negative thoughts,” “energy,” “work-life balance,” “responsibilities to colleagues,” “physical pain,” and “stress.” Five responses included reflections about the healthiest person in their life, which typically identified friends, family, or colleagues.Incorporating storytelling and narrative medicine at multiple levels in medical education has the potential to improve the patient-physician relationship as well as physician and patient health. Only 14 attendees of this session to promote the inclusion of storytelling and narrative medicine in GME provided responses to the anonymous Google survey prompts. With such a small sample size and limited external validity, it is difficult to extrapolate conclusions that can be applied to the GME community. However, despite limitations to interpretation of participant responses, we believe that this single 1-hour session elicited insightful commentary and may impact future interactions of participants with their GME communities and patients.The overall purpose of the session was to provide tools to the GME community that would foster meaning and connection. Of the 4 prompts, the second prompt, called “Crash and Burn,”10 had a majority of responses related to connections with others. Further, all 9 responses to this prompt highlighted relationships, other people, a general sense of community, or togetherness. Through the responses shared, we believe that GME community members who participated in the session were able to apply the tools put forth in the presentation in real time. We hope this in turn means that respondents and session participants can expand the use of storytelling and narrative medicine within their local institutions.The prompts provided during the semi-live Annual Educational Conference session required participants to engage in introspection and self-reflection. Given the deeply personal nature of these assignments, the relatively low number of participants was not surprising. Even though written responses in the Google survey form were anonymous, session attendees may have been hesitant to share intimate memories and thoughts with others, resulting in our low response rate. The semi-live and large group setting was also not conducive to creating a safe space for vulnerable sharing. Therefore, when designing a storytelling or narrative medicine curriculum in a GME setting, medical educators should be aware of the potentially sensitive nature of the topics. For example, forcing GME trainees to share their writing may have unintended consequences such as feelings of discomfort, shame, or fear of retaliation. However, voluntary sharing of experiences in intimate settings may have the opposite effect and foster feelings of togetherness and community,13 which is a goal of narrative medicine.2Given the encouraging outcomes from this session, individual programs may be able to develop similar sessions about storytelling and narrative medicine. Further, such programs could use information gained from our session to address challenges related to sharing of personal experiences. Interestingly, sharing negative experiences may be yet another way to improve participation in these types of programs. In a study involving surgical residents, Lillemoe and Geevarghese14 found sharing personal details about adverse events seemed to mitigate the consequences of sharing sensitive details and even improved well-being. Although such data was not available from participants of our session, incorporating discussion of moral injury in storytelling and narrative medicine sessions of individual programs may improve outcomes for these programs.The ACGME is dedicated to developing opportunities that improve GME. Storytelling and narrative medicine are simple, relatively low-cost opportunities that can be leveraged to improve resident education and well-being and, ultimately, patient health. We hope that this Annual Educational Conference session serves as an example of ways that the GME community can take stock of opportunities presently available in individual programs.Establishing meaning in medicine and connecting with patients are vital skills in modern medical practice. These skills can be nurtured and developed during GME training through a variety of mechanisms, including storytelling and narrative medicine. Personal reflection is inherent to these contemplative practices, and professional relationships can be strengthened through sharing of deeply personal stories. Programs and institutions striving to promote trainee well-being, which is codified in the ACGME's Common Program Requirements, may consider this low-cost intervention that can be incorporated into the curriculum of any specialty.