Medical Student Education Qualitative Analysis of Medical Student Impressions of a Narrative Exercise in the Third-Year Psychiatry Clerkship David Garrison, MD, Jeffrey M. Lyness, MD, Julia B. Frank, MD, and Ronald M. Epstein, MD Abstract Purpose Clinical clerkship directors and faculty undertake the challenge of teaching patient-centered communication to students who face the enormous doctor- centered task of learning diagnostic medicine. The authors examined students’ written reactions to the narrative exercise, which, drawing from narrative medicine and narrative therapy, challenges students to be more patient- centered by writing a patient’s life story and sharing it with that patient. Method During one-half of an academic year (2008 –2009), the authors used qualitative methods to explore the range of medical student experiences with the narrative exercise in the psychiatry clerkship. Results During the study period, 46 medical students completed the exercise, and 44 (96%) submitted 367 comments for the research team to analyze. Four broad categories emerged: (1) communication, (2) insight, (3) hope, and (4) mixed or negative reactions. The most common theme was improved communication, which comprised the subcategories of enhanced active listening, opening up, and relationship building. Improved insights included student insights into their patients, as well as the facilitation of patient insights into themselves, especially regarding their own strengths and relationships. The exercise was well received by students: Only five comments were categorized as negative, and all of these related to difficulties selecting patients. Conclusions Students reported many examples of improved patient-centered communication facilitated by the exercise. The narrative exercise may also promote a greater understanding of patients as complete human beings rather than diagnostic entities. The approach may be useful in educational settings beyond the psychiatry clerkship. Students who operate in a health care system that is driven by the application of technology and severely constrained by time have limited opportunities to observe and master the art of patient- centered communication. Increasingly identified as an important clinical and educational objective, 1 patient-centered communication has been defined by four elements: eliciting the patient’s perspective, understanding the patient’s unique psychosocial context, reaching a common understanding, and enabling patients to participate more actively in their care. 2 Studies have demonstrated that improved communication is associated with better clinical outcomes and patient satisfaction. 3–6 A wide range of approaches for improving physicians’ communication skills exist, 7,8 and a growing but still limited body of empirical evidence supports practical teaching methods to guide educators in this process. 9,10 Of concern, though, is evidence suggesting that, too often, medical school education may promote values that undermine effective communication and even cause skills to deteriorate. 11–13 Our approach to this problem, the narrative exercise, explicitly fosters patient-centered communication by asking students first to elicit from their patients a life story and then to share it with those same patients in writing. Students’ knowledge that patients will read the assessment changes the patient–student transaction from the outset as students are challenged to generate a narrative that is not only accurate but empathic and hopeful as well. The exercise borrows from two different narrative approaches: narrative medicine 14 –17 and narrative therapy. 18,19 Narrative medicine challenges clinicians to strengthen their skills of empathic engagement through reading and writing about patients. Narrative therapy has a more therapeutic aim of working collaboratively with patients to reframe problem-saturated narratives with storylines that emphasize strengths and hope. Both approaches encourage students to go beyond the medical model to capture the patient’s perspective with both compassion for the reality of the patient’s condition and hope for the possibility of recovery. This analysis examines students’ experiences with the narrative exercise as implemented as a required activity in the third-year psychiatry clerkship. To explore the complexities of this interpersonal transaction, we used qualitative methods 20 to elucidate the Dr. Garrison is director of the psychiatry clerkship and assistant professor of psychiatry, University of Rochester Medical Center, Rochester, New York. Dr. Lyness is director of curriculum, associate chair for education, and professor of psychiatry, University of Rochester Medical Center, Rochester, New York. Dr. Frank is director of medical student education in psychiatry and associate professor of psychiatry and behavioral sciences, George Washington University School of Medicine and Health Sciences, Washington, DC. Dr. Epstein is director, Center for Communication and Disparities Research, and professor of family medicine, psychiatry, oncology, and nursing, University of Rochester Medical Center, Rochester, New York. Correspondence should be addressed to Dr. Garrison, University of Rochester Medical Center, Department of Psychiatry, 601 Elmwood Ave., Rochester, NY 14641; telephone: (585) 275-2512; e-mail: David_Garrison@urmc.rochester.edu. Acad Med. 2011;86:000 –000. First published online doi: 10.1097/ACM.0b013e3181ff7a63 balt1/zvk-acm/zvk-acm/zvk00111/zvk4686-11a angnes S4 10/29/10 3:06 Art: ACM202269 Input-afm Academic Medicine, Vol. 86, No. 1 / January 2011 1 <zdoi;10.1097/ACM.0b013e3181ff7a63> • <zjs;Medical Student Education> • <zjss;Medical Student Education>