在述說故事與醫學之間－談敘事醫學與醫療照護

Medicine and Storytelling-Lessons from a Symposium on Narrative Medicine and Patient Care

10.6145/jme.201103_15(1).0007

劉競明(Ching-Ming Liu)

敘事醫學 ； 理念建構 ； 見證筆記 ； 反省式寫作訓練 ； 醫療照護 ； narrative medicine ； conceptual framework ； witness notes ； reflective practice ； health care

Journal of Medical Education

15卷1期（2011 / 03 / 01）

60 - 68

繁體中文

敘事醫學被定義為：將臨床技巧或執業，靠著認知、吸收、代謝、詮釋遭受罹患疾病的故事而感動的敘事能力。這種根據敘事能力的醫療執業，即稱為「敘事醫學」為新近提出的人文及有效執業之模式。此模式讓醫師執業，能夠有同理心、反省、專業及信任。夏隆教授提出之理念建構的三種主要活動為：注意、表現性、聯盟性。敘事醫學鼓勵吾人當聆聽病患說話時，能夠「聽到」吾人內心的意念。敘事醫學亦可用之於教學，其為一種「反省式寫作訓練」，包括：描寫他們、做、演講展示、閱請他們、給予回應。敘事醫學有四大層次：從自我執業反思、經同儕專業互動、由醫病同理溝通，到最高層級之醫師與社會的公共信任。在實務上的應用，有許多詩歌與小說傳奇被放在討論課裏，從兩人小組的工作坊去閱讀、討論、體會與學習。總之，跨專科領域的整合式醫療照護、團隊組成及協同運作必須要靠著敘事醫學來提倡。關係導向的照護與敘事能力，將有助於明日的醫療照護體系，讓明天會更好。

Narrative medicine is defined as a clinical skill or practice that uses narrative competence and has the capacity to recognize, absorb, analyze, interpret, and be moved by stories of illness. Medicine practiced with narrative competence, called narrative medicine, has been proposed to have a place in any model for humane and effective practice. Such a model enables the physicians to practice medicine with empathy, reflection, professionalism, and trustworthiness. The conceptual framework of Dr. Charon's three cardinal movements of narrative medicine consists of ”Attention”, ”Representation”, and ”Affiliation”. The four interactive dimension of narrative medicine are made up of firstly, the physician and self linked with reflection in practice, secondly, the physician and colleagues linked with professionalism, thirdly, the physician and patients linked with empathic engagement and finally, the physician and society linked with public trust. Narrative medicine encourages us to listen to ourselves when we hear the patients speaking. It can also be used as a teaching tool by involving ”reflective writing”, which includes the physicians writing themselves, the physicians giving presentations, the physicians reading and the physicians responding to their patients. A great deal of poetry and fiction was read at the discussion forum and these were examined by pairs of participants during the workshop. The implementation of narrative medicine in Taiwan will involve persuading senior faculty members that it is useful approach and establishing an incentive mechanism. Physician fees, patients, and research projects that lead to publications are the three elements needed for survival when working in a tertiary hospital. There are no incentives in place to encourage teaching and this will make an implementation strategy for narrative medicine with its targeted objectives much harder to put in place. In summary, team-building and inter-professional integrated health care should be promoted by narrative medicine and in this context relationship-centered care and narrative competence ought to lead to better health care delivery in the future.

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