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Narrative Based Medicine as a Cultural Relativism in Medical Professionals and Patient Relationsps - Dr. Takuya Tsujiuchi
 

Narrative Based Medicine as a Cultural Relativism in Medical Professionals and Patient Relationsps - Dr. Takuya Tsujiuchi

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Narrative approach plays an epoch-making role in improving the level of medical care, clinical psychology and welfare area. ...

Narrative approach plays an epoch-making role in improving the level of medical care, clinical psychology and welfare area.
First, I introduce the process and meaning of the Narrative Based Medicine
Next, I dare to observe a negative aspect and risk in Narrative Approach to look for a new role of Narrative Approach.

The work was presented during the II Workshop on Medical Anthropology in Rome, October 14th - 15th 2011.

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  • 生活習慣病学( NBM 生活習慣病物語を読む) 2007

Narrative Based Medicine as a Cultural Relativism in Medical Professionals and Patient Relationsps - Dr. Takuya Tsujiuchi Narrative Based Medicine as a Cultural Relativism in Medical Professionals and Patient Relationsps - Dr. Takuya Tsujiuchi Presentation Transcript

  • Narrative Based Medicine as a Cultural Relativism in Medical Professionals and Patient Relationships Associate Prof. Takuya TSUJIUCHI MD, PhD. Department of Health Science & Social Welfare, Faculty of Human Sciences, WASEDA University
  • My Background
    • 1986-1992: Hamamatsu University School of Medicine
    • 1992-1994: Internal Medicine, Tokyo Metropolitan Hospital
    • 1994-1997: Kanto Medical Reformatory
    • 1996-1999: Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo
    • Ph.D.(Medicine)
    • 1999-2003: Graduate School of Social Sciences and Humanities Ph.D. Course, Chiba University (Regional Development of Societies, Health and Environment)
    • 2003 ~: Department of Health Science & Social Welfare, Faculty of Human Sciences, Waseda University
    • Medical Sciences, Psychology, and Anthropology grow together.
  • Introduction
    • Narrative approach plays an epoch-making role in improving the level of medical care, clinical psychology and welfare area.
    • First, I introduce the process and meaning of the Narrative Based Medicine
    • Next, I dare to observe a negative aspect and risk in Narrative Approach to look for a new role of Narrative Approach.
  • What is Narrative ?
  • What is “narrative” ?
    • Something that is told as a story. The art of telling a story . (LONGMAN Dictionary)
    • The act, process or skill of telling a story. (OXFORD Advanced Learner’s Dictionary)
    • “ Narrative” is the forward movement of description of actions and events, making possible the backward action of self reflection and self understanding.
    Trisha Greenhalgh & Brian Hurwitz, 1998
  • Characteristic of “narrative”1
    • First, “narrative” has a finite and longitudinal time sequence. – that is, it has a beginning, unfolding events, and ending.
    • Second, it presupposes both a narrator and a listener, whose different viewpoints are brought to bear on how the story is told.
    Trisha Greenhalgh,1998
    • Third, the narrative is concerned with individuals, as characters in the story.
    • Fourth, the narrative provides items of information that do not pertain simply or directly to the unfolding of events.
    • Finally, it engages the listener and invites an interpretation.
    Characteristic of “narrative”2 Trisha Greenhalgh,1998
  • Narrative Based Medicine
  • Aims of NBM
    • Narrative Based Medicine (NBM) aims to understand meanings of illness experiences by patients’ multi-vocal story telling.
    • According to the words of Greenhalgh and Hurwitz (1998) ,
    •  “ Narrative provides meaning, context, perspective for the patient’s predicament ”.
  • Interpretation by Medicine
    • Generally, the patients’ experience of symptoms is interpreted by medical professional’s knowledge, eventually leading to a diagnosis and respective therapeutic intervention.
    • Illness(patient’s) into Disease(medical words).
    • But NBM policy denied this interpretation.
  •       Medical Education   Clinical Experience Disease     Illness Experience Life Experience Illness Medical Paradigm -> interpretation-> Local Cultural Beliefs
  • The Process of NBM
    • The first approach in NBM is to recognize that there are different beliefs between medical professionals and patients.
    • Second, active listening to the narratives of patients is recommended to medical professionals.
  • The Process of NBM
    • Third, try to understand the context of narratives in order to clarify the socio-cultural background of patients.
    • Forth, active dialogic discussions are recommended.
  • Definition of NBM 1
    • “ Illness is considered a story being developed in a big story of a patient life,
    • Regarding a patient as a story teller and respecting him or her as a professional to have experienced the illness ,
    By Dr. Seiji Saito, 2003
  • Definition of NBM 2
    • On the other hand, a medical view of a disease and medical care should be considered a story by the medical doctor-side.
    • Furthermore, medical care is regarded as a process producing a new story by arbitrating both-side stories of the patient and the medical professions.”
    By Dr. Seiji Saito, 2003
  • Cultural Relativism in NBM
    • In order to perform NBM in clinical sessions, it is important for medical professionals to master inter-cultural communication , because there are apparent different cultures between medical professionals and patients.
    • In this respect, we can find out the concept of cultural relativism in NBM.
  • Illness   Disease Culture of Medical Professions     Medical Education   Clinical Experience Doctore’s Explanatory Model Culture of Patients     Illness Experience Life Experience Patient’s Explanatory Model CLASH ! Local Cultural Beliefs Medical Paradigm -> interpretation->
  • Cultural Relativism
    • Cultural relativism is the philosophical notion that all cultural beliefs are equally valid and that truth itself is relative, depending on the cultural environment.
    • This principle was established as axiomatic in anthropological research by Franz Boas (1858–1942) in the first few decades of the 20th century and later popularized by his students.
  • Difficulty in Practicing NBM
  • Strong power of established culture
    • The strong structural power of medical professionals is the established culture that is never given up.
    • Medical professionals are trained to view illness and human beings through a special theoretical lens established by their educations and long clinical experiences
    • Medical theory is authorized by the social system and generalized as a universal theory.
  • Difficulty to change the value system of medical professional
    • It is similar to change the operating system, rather than to install new software in the world of computer.
    • Cultural anthropologists learn cultural relativism through a field work like staying in the different culture.
    • It is hoped that medical professionals should also completely change their value system.
    • How can they do? How can we do?
  • Edger Rubin’s Vase http://topics.j-cast.com/keywords/ Make your side view to a wooden interior ! 900US$
  • Allegory of Edger Rubin’s vase and face
    • Let’s think about the situation that the figure is seen as a vase to me but as a face to a native in a different culture.
  • Generalization of ethnocentrism (own-culture centered principle)
    • “ They think that the vase is human faces, but that is wrong, it is really a vase.”
    • “ Those who argue that the vase is human faces will soon realize that it is a vase if they psychologically awake or learn an objective way of view.”
  • Ethno-centrism in Medicine
    • ‘ Medical professionals assume that a patient is suffering from heart disease, but will realize that it is an illness caused by stress if they learn recognition of themselves and illness.
  • Silence and hands-off in the name of cultural relativism
    • It is an extreme case of culture relativism.
    • “ Strangely enough, they see the vase as human faces, but let’s leave it, even if they think so because it is a result of cultural difference.”
    • -> To give up understanding different cultures.
    • -> To stop the effort of overcoming the cultural difference
    • -> To abandon a dialogue.
  • The attitude to drive for:
    • “ why do they view the vase as faces? Let’s try to understand their culture and value system underlying their way of viewing.”
    • “ If we change our way of viewing, we may see the vase as faces. We should try to understand so.”
    • -> Constant efforts to understand different culture
  • Case of trying NBM Brief introduction of my clinical case using Japanese herbal medicine, 2010
  • Ms. Yoko-san, 48 year-old
    • A stomach cancer was accidentally found during medical treatment of Guillan-Barre syndrome.
    • The tumors reached lymph node and she was already on the fourth stage of metastatic cancer of the lung.
    • The doctor in charge advised chemotherapy, but the patient wanted naturopathic method and visited my clinic for treatment by Japanese traditional herbal medicine.
  • Yoko-san’s value
    • From the standpoint of NBM, I tried to understand Yoko-san’s way of thinking of nature, universe, and life and death.
    • Yoko-san as well as her husband is intelligent engaged in research area.
    • They have been interested in classical Chinese medicine and naturopathy since they were young.
  • Yoko-san’s value
    • She adopted qi-gong (Chinese exercise), moxibustion using leaves of loquat, macrobiotic food therapy, and memorial service for ancestor.
    • Her sentimental thought for natural therapy seemed to be her selection of way of life in view of the world after her death.
  • How to practice NBM ?
    • It is not NBM to accept patient’s value system unconditionally.
    • That is silence and hands-off in the name of cultural relativism.
  • Progress Notes 1
    • I felt that her life is critical if only depending on naturopathy, in consideration of biomedical information from her doctor in charge.
    • I repeated discussions with her and her husband, and she decided to adopt chemotherapy (anticancer drug) as well as naturopathy.
    • For some months, her life force appeared to be improving.
  • Progress Notes 2
    • Towards the year-end, her coughing became severe, and she was hospitalized for emergency.
    • Her life is critical due to lung lymphedema and pericardial effusion.
    • The patient initially denied adoption of chemotherapy.
  • Progress Notes 3
    • I agreed with the doctor in charge that she will die in a few days without anticancer drug and strongly advised her to adopt chemotherapy.
    • She accepted usage of anticancer drug, saying ‘because it is advised by the doctor who really tries to save my life.’
    • However, she passed away in a week.
  • My reflection
    • I tried to listen to Yoko-san’s narrative most carefully, and repeated dialogues between my and her value systems.
    • NBM is really difficult.
    • I wonder if my strong culture invaded Yoko-san’s idea authoritatively.
    • Was my answer or treatment really called NBM ?
  • Progress Notes 3
    • After a month, her husband called on me to express his appreciation and said, ‘We are being tested for a certain kind of life. We have never lost our confidence in our doctors as they heartily thought of our life, and I believe she also thinks as I do.’
  • Conclusion
    • 1) NBM is a useful action to communicate between two different cultures of medical professionals and patients.
    • 2) Medical professionals should recognize their own strong power established by culture.
    • 3) Do not abuse “cultural relativism” for your silence or hands-off to patient’s culture.
    • 4) Constant efforts are important to understand different cultures.
  • Grazie ! per la vostra cortese attenzione. Takuya TSUJIUCHI MD, PhD.