Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-029588 on 2 August 2019. Downloaded from The influence of narrative medicine on medical students’ readiness for holistic care practice: a realist synthesis protocol Yufrica Huang, 1 Lynn V Monrouxe, 2 Chien-Da Huang1,3 To cite: Huang Y, Monrouxe LV, ABSTRACT Strengths and limitations of this study Huang C-D. The influence Introduction Holistic healthcare considers the whole of narrative medicine on person—their body, mind, spirit and emotions—and ► This study is one of the first to examine prepared- medical students’ readiness for has been associated with narrative medicine practice. holistic care practice: a realist ness for holistic care as an outcome to narrative Narrative medicine is medicine performed with narrative synthesis protocol. BMJ Open medicine interventions. skill and has been offered as a model for humanism 2019;9:e029588. doi:10.1136/ ► The use of a systematic approach to identifying the and effective medical practice. Narrative medicine bmjopen-2019-029588 literature around outcomes relating to holistic care interventions have been associated with physicians’ Prepublication history and arising from narrative medicine interventions is a ► increased empathy and more meaningful interactions with additional material for this study strength. patients about managing their illness and preventative paper are available online. To ► The application of a realist approach to under- medicine. However, while there is some evidence that view these files, please visit standing the contexts in which narrative medicine certain groups are more open to narrative practices the journal online (http:// dx. doi. prepares different types of students for holistic care (eg, traditional vs Western medical students), the org/ 10. 1136bmjopen- 2019- practice, and how, is another strength. 029588). extent to which narrative medicine interventions during ► One concern for this study is that there might be undergraduate medical education impacts on students’ a limited number of studies that have examined readiness for holistic care, as well as the underlying Received 01 February 2019 holistic care and its associated components as an reasons why, is unknown. Revised 11 July 2019 outcome to narrative medicine interventions. Methods and analysis Realist review is a theory-driven Accepted 12 July 2019 ► One further concern is that the reporting of narra- approach to evaluate complex interventions. It focuses on tive medicine intervention outcomes might predom- understanding how interventions and programmes work inately focus on reactions to the intervention rather (or not) in their contextual setting. This realist synthesis than provide deeper understanding of the mecha- aimed to formulate a theory around the influence of http://bmjopen.bmj.com/ nisms that might promote/inhibit holistic care. narrative medicine medical students’ readiness for holistic care practice. We will follow Pawson’s five steps: locate existing theories, search strategy, study selection, data extraction, data analysis and synthesis. We will use the synonymous with Engel’s biopsychosocial following electronic databases: Web of Science, Medline, model.3 The biopsychosocial approach Scopus and Embase. Articles between January 2008 and to illness comprises four systems within September 2018 will be included. Results will be written the person: the organs, the whole person, according to the RAMESES (Realist And Meta-narrative behaviour and social roles. There are also © Author(s) (or their on September 28, 2021 by guest. Protected copyright. Evidence Syntheses: Evolving Standards) standard for four contextual factors that influence these employer(s)) 2019. Re-use reporting realist syntheses. systems: personal factors, physical environ- permitted under CC BY-NC. No Ethics and dissemination Ethics approval was commercial re-use. See rights 2 obtained from the Chang Gung Memorial Hospital for ment, social environment and time. Holistic and permissions. Published by care asserts that the patient is a person, not a BMJ. the wider study. The findings of this review will provide disease. Thus, treatment involves treating the 1Chang Gung Medical Education useful information for academics and policymakers, who will be able to apply the findings in their context underlying cause of the condition rather than Research Center, Chang Gung 1 2 Memorial Hospital Linkou when deciding whether and how to introduce narrative just alleviating the symptoms. Branch, Taoyuan, Taiwan medicine programmes into medical students’ curricula. Recent research has identified individual 2Faculty of Health Sciences, The We will publish our findings in peer-reviewed journals and attributes of clinicians that are optimal for University of Sydney, Sydney, international conferences. providing holistic care. For example, key New South Wales, Australia PROSPERO registration number CRD42018115447. 3Medical Education and Thoracic personal attributes such as sociability, compas- Medicine of Chang Gung sion, respectfulness, patient centredness and Memorial Hospital, Chang Gung sensitivity are all thought to facilitate holistic University College of Medicine, BACKGROUND care provision.4 Furthermore, being able to Taoyuan, Taiwan Holistic healthcare is a form of healing identify and to satisfy patients’ needs has also Correspondence to that considers the whole person—body, been identified as a motivational factor that Dr Chien-Da Huang; mind, spirit and emotions—in the quest for enable healing relationships with patients cdhuang@ adm. cgmh. org. tw optimal health and wellness.1 2 It is essentially to develop, thereby encouraging an holistic Huang Y, et al. BMJ Open 2019;9:e029588. doi:10.1136/bmjopen-2019-029588 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029588 on 2 August 2019. Downloaded from care approach.4 Finally, having the foresight and ability systematic review of the literature on narrative medicine to facilitate autonomy and self-confidence in patients, has found the outcomes for patients to be efficacious in to support individuals in obtaining relevant information terms of decreasing pain; increasing well-being (related about their condition and to enhance effective communi- to illness), confidence and cooperation; and decreasing cation all contribute towards individuals’ sense of empow- stress and feelings of alienation.27 Additionally, narrative erment around making medical treatment decisions.5 6 As medicine educational interventions are not always effi- such, providing holistic care means understanding how cacious. Indeed, recent research has begun to unpack an illness affects the whole person and how to respond to the differential engagement and outcomes across study their specific needs.7 cohorts. For example, when considering the outcomes of However, the development of a holistic approach a narrative medicine course in Asia, students on a Chinese to care is not straightforward. For example, in recent medicine track reported greater emotional, reflective and years, medical schools across the world have become self-development outcomes in comparison with students increasingly concerned around the issue of empathy on a Western medicine track.28 decline in their students,8 9 especially during the clin- As we can see, despite the appearance of a link between ical years.10 This is possibly due to students’ reactions the desired outcomes of a narrative medicine course to so-called professionalism dilemmas: situations in which and requirements for holistic care practice, evidence is medical students witness or participate in something they inconclusive. Additionally, to date, no direct evidence believe to be unethical, unprofessional or ‘wrong’.11 12 unpacking the underlying processes for this potential link Common professionalism dilemma events for healthcare has been provided; thus, prior research draws on elements students that give rise to conflicts between their formal of holistic care to make their assertions (eg, empathy) professionalism learning and what they witness during without illuminating the contexts and mechanisms work-based placements include student abuse, patient through which this might have come about. Therefore, dignity and safety issues.12 13 While experiencing such understanding the underlying mechanisms that enhance situations may lead some students to strongly reject these such an outcome of narrative medicine programmes, negative role models, it can also lead to diminishing alongside the necessary conditions for them doing this, empathy and professional identity disruption.14 15 Thus, is crucial for curriculum designers (the beneficiaries of medical schools are seeking ways to design more effective this research). curricula to cultivate positive character development and To our knowledge, this is the first systematic review to professionalism in their students. Indeed, more broadly, focus on the impact of a narrative medicine interven- the medical humanities, which includes narrative medi- tion on medical students’ preparedness for holistic care, cine, has been heralded as a remedy to experiences of with the explicit aim of unpacking the ‘black box’ of the negative role modelling and has been thought to facili- intervention itself, by asking the following broad research http://bmjopen.bmj.com/ tate compassionate care.16–18 question: under what circumstances and for whom does a narrative medicine intervention in an undergraduate Narrative medicine and holistic care medical curriculum influence