narrative medicine
(Clockwise from left) Speech-language pathology student Brianna Guild is learning under therapist Sucheta Heble how to apply narrative medicine. It’s helping patients such as Stephanie Gaw identify and reach meaningful therapy goals. (Photo: UHN)

When Stephanie Gaw walked into her first therapy session at Toronto Rehab's Acquired Brain Injury Outpatient Program, she was feeling tired and anxious to get started.

She was tired from months of rehab that focused on her physical recovery from a cycling accident, which left her with a broken pelvis, wrist and elbow. And anxious to finally be able to address the less visible side-effects of her injury, which she'd been struggling with for so long.

"My physical injuries were initially prioritized, but I had also bumped my head, and I kept thinking there was something wrong," Stephanie recalls. "I was having trouble with memory, communication and understanding people.

"But it's hard to express or advocate for yourself, when you feel so vulnerable."

All it took was one question from speech-language pathology (SLP) student Brianna Guild to reassure Stephanie that she was in good hands, and finally on the road to recovery.

The narrative medicine approach

"When a patient first sits down with me, I've already read his or her chart and know why he or she is coming in. But my first question is still, 'what brought you to the outpatient program?'" says Brianna.

"It gives them an opportunity to tell their own story, instead of cutting right to the specific questions I have about their injury."

This approach, called narrative medicine, involves deep listening during a patient-led conversation. It can help a clinician understand the patient on a holistic level, identify meaningful rehab goals, and allow space for a patient to feel like a partner in their own care.

Tips for applying the narrative medicine approach

  1. Ask patients for their story, even though you've read their chart. Don't assume you have all the information.
  2. Be present in the moment. Clinicians are used to being the "fixers." Set that aside, listen and just be there for the patient – without feeling that you have to come up with all the answers.
  3. Listen for the purpose of learning and understanding, instead of listening to collect information.
  4. Be aware of your personal biases and judgments. Patients may be very different from you, but accept them for who they are and what their story is.

The approach also allows clinicians to glean important information, such as whether a patient fully understands details of their injury, and from an SLP practice, where language and communication gaps may exist.

"People who have experienced an illness or injury that has led them to be in a hospital are in a really vulnerable position," says Brianna.

"To be able to tell your own story, how it's affected you, and how you're feeling about it, is not the type of information your clinician is going to get from a chart. It creates a more complete picture that helps support recovery."

For example, as Stephanie was telling her story, and expressed frustration around her inability to focus on reading – a favourite pastime – it inspired the pair to identify reading as a rehab goal, and Brianna to start thinking about strategies to get there.

Beyond the first assessment, other open-ended questions such as, "what is important for you right now," or "tell me how your last few days have been," are equally important in guiding a therapy session, as they allow the clinician to gain insight into the patient's priorities.

"Knowing that a patient is feeling down, tired or sore allows me to modify the difficulty of the therapy I've prepared, to ensure our time together is used well," Brianna explains.

These conversations also help Brianna pick up on more subtle, but important cues.

"Brianna has learned that I love to talk," says Stephanie.

"So if she's explaining something and I'm suddenly quiet, she knows it means I don't understand, and she'll approach what she's teaching me differently."

Teaching students to put their agendas aside

At Toronto Rehab, the narrative medicine approach is introduced to all SLP students on the first day of their orientation.

"Our patients often come to us with fractured communication skills, and may have difficulty expressing themselves confidently," explains Sucheta Heble, SLP.

"Teaching students to really listen to their patients' stories and help them retell their stories in an authentic way may help get the students out of their own heads. The therapeutic process is ultimately strengthened by helping the patients create meaning from their own experiences."

To that end, students get an opportunity to integrate their deep listening into clinical practice with a narrative competency exercise. They're tasked with choosing a patient, and writing the patient's story from that person's point of view. Then, students present their stories to fellow students, SLP clinical educators and other SLPs at the end of their placement.

The goal is to increase empathy and compassion, build rapport, and help patients feel heard, valued, and acknowledged.

"I'm a person first, not a patient," says Stephanie.

"Working with a clinician like Brianna, who is making an effort to be engaging, and genuinely getting to know me, makes me feel relaxed, lowers my anxiety, and increases my chances of learning and improving.

"I know I'm in good hands and I'm going to be okay."

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