Background Narrative medicine is a well-recognized and respected approach to care. It is now found in medical school curricula and widely implemented in practice. However, there has been no analysis of the perception and usage of narrative medicine across different medical specialties and whether there may be unique recommendations for implementation based upon specialty. The aims of this study were to explore these gaps in research. Methods Fifteen senior physicians who specialize in internal medicine, pediatrics, or surgery (5 physicians from each specialty) were interviewed in a semi-structured format about the utilization, benefits, drawbacks (i.e., negative consequences), and roles pertaining to narrative medicine. Qualitative content analysis of each interview was then performed. Results Three themes emerged from our analysis: roles, practice, and outcomes. Through these themes we examined the importance, utilization, barriers, benefits, and drawbacks of narrative medicine. There was consensus that narrative medicine is an important tool in primary care. Primary care physicians (general internists and general pediatricians) also believed that narrative medicine is not as important for non-primary care providers. However, non-primary care providers (surgeons) generally believed narrative medicine is valuable in their practice as well. Within specialties, providers' choice of language varied when trying to obtain patients' narratives, but choice in when to practice narrative medicine did not differ greatly. Among specialties, there was more variability regarding when to practice narrative medicine and what barriers were present. Primary care physicians primarily described barriers to eliciting a patient's narrative to involve trust and emotional readiness, while surgeons primarily described factors involving logistics and patient data as barriers to obtaining patients' narratives. There was broad agreement among specialties regarding the benefits and drawbacks of narrative medicine. Conclusions This study sheds light on the shared and unique beliefs in different specialties about narrative medicine. It prompts important discussion around topics such as the stereotypes physicians may hold about their peers and concerns about time management. These data provide some possible ideas for crafting narrative medicine education specific to specialties as well as future directions of study.

Journal of Palliative MedicineVol. 24, No. 8 Personal ReflectionA Goal of CareDaniel A. FoxDaniel A. FoxAddress correspondence to: Daniel A. Fox, BS, Northwestern University Feinberg School of Medicine, 420 E Superior Street, Chicago, IL 60611, USA E-mail Address: daniel.fox@northwestern.eduNorthwestern University Feinberg School of Medicine, Chicago, Illinois, USA.Search for more papers by this authorPublished Online:16 Jul 2021https://doi.org/10.1089/jpm.2021.0005AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"A Goal of Care." Journal of Palliative Medicine, 24(8), pp. 1255–1256FiguresReferencesRelatedDetails Volume 24Issue 8Aug 2021 InformationCopyright 2021, Mary Ann Liebert, Inc., publishersTo cite this article:Daniel A. Fox.A Goal of Care.Journal of Palliative Medicine.Aug 2021.1255-1256.http://doi.org/10.1089/jpm.2021.0005Published in Volume: 24 Issue 8: July 16, 2021PDF download

Baggett, Nathan MD; Schulz, Kathryn DPhil, MPhil, BA; Buffington, Anne MPH; Marka, Nicholas MS; Zimmermann, Christopher MD; Tucholka, Jennifer BS; Kata, Anna MD; Fox, Daniel BA; Schwarze, Margaret MD, FACS Author Information

Background: Lack of awareness about the life-limiting nature of renal failure is a significant barrier to palliative care for older adults with end-stage renal disease. Objective: To train nephrologists to use the best case/worst case (BC/WC) communication tool to improve shared decision making about dialysis initiation for older patients with limited life expectancy. Design: This is a pre-/postinterventional pilot study. Setting/Subjects: There were 16 nephrologists and 30 patients of age 70 years and older with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73 m2 in outpatient nephrology clinics, in Madison, WI. Measurements: Performance of tool elements, content of communication about dialysis, shared decision making, acceptability of the intervention, decisions to pursue dialysis, and palliative care referrals were measured. Results: Fifteen of 16 nephrologists achieved competence performing the BC/WC tool with standardized patients, executing at least 14 of 19 items. Nine nephrologists met with 30 patients who consented to audio record their clinic visit. Before training, clinic visits focused on laboratory results and preparation for dialysis. After training, nephrologists noted that declining kidney function was "bad news," presented dialysis and "no dialysis" as treatment options, and elicited patient preferences. Observer-measured shared decision-making (OPTION 5) scores improved from a median of 20/100 (interquartile range [IQR] 15-35) before training to 58/100 (IQR 55-65). Patients whose nephrologist used the BC/WC tool were less likely to make a decision to initiate dialysis and were more likely to be referred to palliative care. Conclusions: Nephrologists can learn to use the BC/WC tool with older patients to improve shared decision making about dialysis, which may increase access to palliative care.

Importance Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict. Objective To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. Design, Setting, and Participants This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat. Interventions A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. Main Outcomes and Measures Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. Results Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal alpha = .01). Conclusions and Relevance The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly.

•Identify opportunities to improve patient engagement in decision making during visits with specialist providers.•Identify how the Best Case/Worst Case tool can help specialists improve patient engagement in conversations regarding life-sustaining treatments.•List key components of physician-patient conversations that promote patient engagement. Older adults who initiate dialysis often passively accept treatment without making an active choice to commit to life-supporting therapy. Interventional strategies that target the dialysis decision-making conversation between patients and their nephrologists may promote earlier access to palliative care, leading to better outcomes. To characterize communication about dialysis and evaluate the proof of concept of an intervention to change nephrologist communication. Pre/post-intervention study design. We recorded 16 outpatient conversations between nephrologists and patients age 70 and older with an eGFR≤20 mL/min/1.73 m2, not on dialysis. After recording the first 12 conversations, we trained seven nephrologists to use the Best Case/Worst Case (BC/WC) communication tool to describe treatment options and potential outcomes within the context of the patient's overall health. We used OPTION 5 and qualitative analysis to measure and characterize patient engagement in decision making before and after BC/WC training. Before training, OPTION 5 scores were low (median 20 out of 100 (IQR 15-35)), suggesting limited patient engagement in decision making. Nephrologists typically discussed lab values and considered when and how patients might receive dialysis. Few acknowledged the option of “no dialysis.” After training, nephrologists used BC/WC with fidelity and OPTION 5 scores increased (median 65 (IQR 50-76)). Using the BC/WC tool, nephrologists presented a choice between dialysis and supportive care without dialysis, described how dialysis and other health events might be experienced, provided prognostic information, and used phrases to elicit patients' goals. Currently nephrologists discuss the mode and timing of dialysis without disclosing prognosis or presenting dialysis as a choice. This leaves limited opportunity for patients to understand the role of supportive care or palliative care concurrent with dialysis. Interventions to support patient engagement in treatment decisions may improve access to palliative care.