Weed’s clinical documentation efficiency system caught fire. However, similar to Flexner’s later second thoughts, Weed also cast doubt on the full effect of his recommendations. In a 2009 interview conducted by a former medical student of his, Weed revealed views that more closely resemble our current competency-based medical education and stress the value of interpersonal skills in patient care12:
- Computerization of the medical record—with its vast amount of information and physician-processing capacity—“inevitably” leads to dangerous cognitive shortcuts. Medical education seeks to instill “medical knowledge and clinical judgment,” giving students “misplaced faith in the completeness and accuracy of their own intellects and is the antithesis of a truly scientific education.”12
- Medical student recruitment and instruction have long emphasized memory and regurgitation of facts, while students should be selected for their hands-on and interpersonal skills. Medical school should be “teaching a core of behavior instead of a core of knowledge.”12 These are areas in which NM helps.
FLEXNER, WEED, AND NOW, CHARON
Medicine’s history is blemished by errors, some significant. Flexner neatly compartmentalized medical education, Weed digitized the clinician/patient interaction, and Charon revitalizes the reason clinicians chose a health care profession. Charon—as a practicing internist, as well as a professor in the Department of Medicine and Executive Director of the Program in Narrative Medicine at Columbia University’s Vagelos College of Physicians and Surgeons in New York City—is fully qualified to speak to the importance of NM in medical education and medical practice. Her 2006 book reminds us that sore throats are not always simple, boring, and routine; each one is as unique as the person housing that particular pharynx.13
How does NM drive clinicians to be better, countering cognitive errors while incorporating the patient’s cultural and philosophic background? According to Charon, the NM concept results from conversation among scholars and clinicians teaching and practicing at Columbia University in early 2000, fueled by decades of insight from literature, medical (health care) humanities, ethics, health care communication, and primary care medicine.3 NM supports patient-centric teaching and care, reminding us that it combines the historical doctor-at-bedside, who exhibited careful, empathetic questioning and listening, with the benefits of modern medical science.
Charon describes 3 main clinician-to-patient interactions, allowing us to regain some of what we have lost: attention, representation, and affiliation (Table 2). In addition to medical error reduction, these 3 interactive behaviors counter the aforementioned 3As (anchoring, availability, and attribution) of cognitive error.5Attention initiates the clinician’s heightened and committed listening to the patient.3 In our patient encounter, essential information is undisclosed, leading to a missed diagnosis and an incomplete representation in the written note. The clinician, due to insufficient attention, missed important clues such as the patient’s dress, accent, and profession, which limited the representation. This almost seems nonsensical; who would care about a patient’s dress or accent and, of practical concern today, where would one record it? And could another urgent care clinician or specialist find these notes? How might a more serious future medical outcome be averted? Affiliation results in a connection of careful listening and full documentation as the clinician becomes invested in the whole patient, not just the sore throat.3
PREPROFESSIONAL AND PROFESSIONAL EDUCATION
Preprofessional humanities education may result in stronger NM conceptualization. The Association of American Medical Colleges (AAMC) recognizes the value of arts and humanities in medical education in developing qualities of professionalism, communication skills, and emotional intelligence in physicians. The AAMC Curriculum Inventory and Reports (2015-2016) shows that 119 medical schools require humanities education, including
- Visual arts to improve observational skills
- History education to frame modern-day Ebola outbreaks (eg, using the framework of the Black Death),
- Literature and poetry to enhance insight into different ways of living and thinking, fostering critical thinking.14
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