Narrative Medicine from a Medical Director’s point of view: interview to Marco Triulzi
Marco Triulzi is Medical Director at “S. Maria Nascente” IRCCS Centre (Milan), care and scientific research centre with a multeplicity of services addressing healthcare, educational, formative, and social demands.
MT. For me is difficult using the term “Narrative Medicine” as translated from English: it can be misleading for who doesn’t know what it is. I would rather use the term “healing narrative”, that in Italian creates less misunderstandings: it indicates a healing narrative both for the patient – obviously – and for the staff in a medical and qualitative sense. Healing narrative is a more focused term: it is important to not misunderstand. After attending the Master in Applied Narrative Medicine of ISTUD Foundation, I wondered about why this healing narrative, in Italy and in Healthcare, struggle to spread out – although it is not difficult, once you understand, grasp the beneficial effects for the assisted person and the health care provider. In my opinion, among the causes of this situation there is – first of all – the fact that these activities are not included in the LEA (Essential Levels of Care), then in the required standards and in the national legislature’s choices within the National Health Service: in front a general situation that does not allow “excesses” with respect to a minimum to provide for costs, expenses, and so on, the tendency for the public and accredited private is to deviate little (or to not deviate) from what is provided in LEA. The controls are very pressing and frequent, not only in Lombardy: so, on the one hand we don’t exceed these measures, on the other hand – for economic and business survival – both public and private don’t permit anything more. And I say this sadly: it’s not a cultural and ethical neglect, it’s a matter of survival. My thought is that, if we should still be able to produce some effort, it is where the beneficial effect of healing narrative may seem more profitable. Maybe I say something assumed for those dealing with this issue: instead of insisting in acute care hospitals (also because of how hospitals are organized today, where the duration of treatment is cut down to the bone, and not only in Italy), we could focus on chronically ill people, who for the duration of the condition and for the living with it, the type of disease, and so on, can derive a greater benefit. So, we also talk about constitutional or become chronic disabled: severe physical and mental disabilities are another category, with other problems, and needs other instruments. I think this can be interesting in the hospital and outside, and also to the general practitioner, who should be the first physician in the system of the National Health Service, the figure that better knows the assisted and his/her living environment, family, work. Let’s think also to the RSA (Health Residences for the Elderly) or RSD (Health Residences for Disabled People), here the so-called Narrative Medicine can be particularly beneficial and feasible – or less problematically feasible. And at each age. There are extraordinary possibilities in the field of rehabilitation activities in which healing narrative can fit: they cannot be massive, even in rehabilitation institutions, but they can be qualifying. They cost time, preparation: and often need some clever sponsors. When there are these combinations, a scientific institution can start with pilot initiatives to test pragmatically if “the game is worth the candle”, and eventually if there is a positive outcome. After the pilot study, we can configure a quantitative testing, analyzing advantages and cost-effectiveness. And so there are occasions in which – if a little sponsored – even Narrative Medicine can give a contribution. Doctors treat disorders, diseases, but of course wellbeing counts too. So, you must be able to reach even what is not paid and not considered a priority in not so rich countries: finding a sponsor, or someone investing beyond the limited NHS, demonstrating the benefits of the so-called Narrative Medicine.
Q. Do you think that Narrative Medicine can be a support for National Healthcare System sustainability?
MT. Yes, it can be as regards chronically ill or chronic disabled (physical or psychophysical limited) people, but for trauma and acute diseases is likely to be very difficult. If anything, I highlight that, in an aging society like the Italian one, is raising the possibility that a considerable part of the population can benefit from the healing narrative. In any case it is right and justified spreading a culture, a precise and solid knowledge of the so-called Narrative Medicine: however, we cannot claim that this goes beyond the reasonable conditions for the application, otherwise we do a damage.
Q. Did you ever employed tools such as parallel charts, in your experience?
MT. Parallel charts in the traditional sense are a well-known fact since years, even with full legal value. They are not those of Narrative Medicine – first of all, in forming the clinical chart, we must pay attention to technical and professional, and descriptive for objectivity and actions, rigor. Clinical charts are also documents of public faith, untouchable and unchangeable, and are intended to record the truth of events. It is a priority and unavoidable achieving this important goal for all, for justice and for treatment. “Narrative Medicine” writings may be improper and risky, if they become part of the authentic “clinical chart”. We should think also to the notification of adverse events, errors, to facilitate evaluation and communication: these notifications are not the source of complaints or disciplinary measures. This doesn’t mean that we cannot operate separately, record, collate aspects relating to the so-called Narrative Medicine. I would save and safeguard them where planned, but I would keep them distinct. However, these are not my concluding thoughts, but first reflections on the attention should be paid on these aspects.
Q. Is Narrative Medicine (or healing narrative) important in medical education, according to you?
MT. Any contribution to a more comprehensive medical education, and of health personnel in general, on relationships between people, on not just biological aspects, is inescapable, but at the moment it is more or less lacking, and dependent by individual initiative. Obviously there are good examples, but I don’t know if this kind of education is already present in the normal course of medical studies. And I’m not referring only to Narrative Medicine, but to every authentic, refined attention to preparation and cooperation in a complex and relational medicine such as the hospital one: these aspects are important, because we cannot have a valid technician but incapable of entering into a complex organization. Not everyone can become an authentic leader, but all the doctors in complex structures must be able to relate properly with others. This is not the absolute reality, there are people who – beyond medical capabilities – are not properly inserted and included in the collaborative relationship, and this is not good for the individual and for the community. Since university, relational aspects and attention to the psychological and cultural care are unavoidable, even with colleagues and collaborators, primarily for doctors and nurses.