Narrative Based Medicine as a Cultural Relativism in Medical Professionals and Patient Relationships Associate Prof. Takuy...
My Background <ul><li>1986-1992: Hamamatsu University School of Medicine </li></ul><ul><li>1992-1994: Internal Medicine, T...
<ul><li>2003 ~: Department of Health Science & Social Welfare, Faculty of Human Sciences, Waseda University </li></ul><ul>...
Introduction <ul><li>Narrative approach plays an epoch-making role in improving the level of medical care, clinical psycho...
What is Narrative ?
What is “narrative” ? <ul><li>Something that is told as a story. The art of telling a story .  (LONGMAN Dictionary) </li><...
Characteristic of “narrative”1 <ul><li>First, “narrative” has a finite and longitudinal time sequence. – that is, it has a...
<ul><li>Third, the narrative is concerned with individuals, as characters in the story. </li></ul><ul><li>Fourth, the narr...
Narrative Based Medicine
Aims of NBM <ul><li>Narrative Based Medicine (NBM) aims to understand meanings of illness experiences by patients’ multi-v...
Interpretation by Medicine <ul><li>Generally, the patients’ experience of symptoms is interpreted by medical professional’...
      Medical Education   Clinical Experience Disease     Illness Experience Life Experience Illness Medical Paradigm -> i...
The Process of NBM <ul><li>The first approach in NBM is to recognize that there are  different beliefs  between medical pr...
The Process of NBM <ul><li>Third, try to understand the  context of narratives  in order to clarify the socio-cultural bac...
Definition of NBM 1 <ul><li>“ Illness is considered a story being developed in a big story of a patient life,  </li></ul><...
Definition of NBM 2  <ul><li>On the other hand, a medical view of a disease and medical care should be considered a story ...
Cultural Relativism in NBM <ul><li>In order to perform NBM in clinical sessions, it is important for medical professionals...
Illness     Disease Culture of  Medical Professions     Medical Education   Clinical Experience Doctore’s Explanatory Mode...
Cultural Relativism <ul><li>Cultural relativism is the philosophical notion that  all cultural beliefs are equally valid  ...
Difficulty  in Practicing NBM
Strong power  of established culture <ul><li>The strong structural power of medical professionals is the established cultu...
Difficulty to change the value system of medical professional <ul><li>It is similar to change the operating system, rather...
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 <ul><li>Let’s think about the situation that the figure is seen as a vase to me b...
Generalization of ethnocentrism  (own-culture centered principle) <ul><li>“ They think that the vase is human faces, but t...
Ethno-centrism in Medicine <ul><li>‘ Medical professionals assume that a patient is suffering from heart disease, but will...
Silence and hands-off in the name of cultural relativism <ul><li>It is an extreme case of culture relativism. </li></ul><u...
The attitude to drive for: <ul><li>“ why do they view the vase as faces? Let’s try to understand their culture and value s...
Case of trying NBM Brief introduction of my clinical case using Japanese herbal medicine, 2010
Ms. Yoko-san, 48 year-old <ul><li>A stomach cancer was accidentally found during medical treatment of Guillan-Barre syndro...
Yoko-san’s value <ul><li>From the standpoint of NBM, I tried to understand Yoko-san’s way of thinking of nature, universe,...
Yoko-san’s value <ul><li>She adopted qi-gong (Chinese exercise), moxibustion using leaves of loquat, macrobiotic food ther...
How to practice NBM ? <ul><li>It is not NBM to accept patient’s value system unconditionally.  </li></ul><ul><li>That is s...
Progress Notes 1 <ul><li>I felt that her life is critical if only depending on naturopathy, in consideration of biomedical...
Progress Notes 2 <ul><li>Towards the year-end, her coughing became severe, and she was hospitalized for emergency. </li></...
Progress Notes 3 <ul><li>I agreed with the doctor in charge that she will die in a few days without anticancer drug and st...
My reflection <ul><li>I tried to listen to Yoko-san’s narrative most carefully, and repeated dialogues between my and her ...
Progress Notes 3 <ul><li>After a month, her husband called on me to express his appreciation and said, ‘We are being teste...
Conclusion <ul><li>1) NBM is a useful action to communicate between two different cultures of medical professionals and  p...
Grazie  ! per la vostra cortese attenzione. Takuya TSUJIUCHI MD, PhD.
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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.
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

    1. 1. 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
    2. 2. My Background <ul><li>1986-1992: Hamamatsu University School of Medicine </li></ul><ul><li>1992-1994: Internal Medicine, Tokyo Metropolitan Hospital </li></ul><ul><li>1994-1997: Kanto Medical Reformatory </li></ul><ul><li>1996-1999: Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo </li></ul><ul><li>Ph.D.(Medicine) </li></ul><ul><li>1999-2003: Graduate School of Social Sciences and Humanities Ph.D. Course, Chiba University (Regional Development of Societies, Health and Environment) </li></ul>
    3. 3. <ul><li>2003 ~: Department of Health Science & Social Welfare, Faculty of Human Sciences, Waseda University </li></ul><ul><li>Medical Sciences, Psychology, and Anthropology grow together. </li></ul>
    4. 4. Introduction <ul><li>Narrative approach plays an epoch-making role in improving the level of medical care, clinical psychology and welfare area. </li></ul><ul><li>First, I introduce the process and meaning of the Narrative Based Medicine </li></ul><ul><li>Next, I dare to observe a negative aspect and risk in Narrative Approach to look for a new role of Narrative Approach. </li></ul>
    5. 5. What is Narrative ?
    6. 6. What is “narrative” ? <ul><li>Something that is told as a story. The art of telling a story . (LONGMAN Dictionary) </li></ul><ul><li>The act, process or skill of telling a story. (OXFORD Advanced Learner’s Dictionary) </li></ul><ul><li>“ Narrative” is the forward movement of description of actions and events, making possible the backward action of self reflection and self understanding. </li></ul>Trisha Greenhalgh & Brian Hurwitz, 1998
    7. 7. Characteristic of “narrative”1 <ul><li>First, “narrative” has a finite and longitudinal time sequence. – that is, it has a beginning, unfolding events, and ending. </li></ul><ul><li>Second, it presupposes both a narrator and a listener, whose different viewpoints are brought to bear on how the story is told. </li></ul>Trisha Greenhalgh,1998
    8. 8. <ul><li>Third, the narrative is concerned with individuals, as characters in the story. </li></ul><ul><li>Fourth, the narrative provides items of information that do not pertain simply or directly to the unfolding of events. </li></ul><ul><li>Finally, it engages the listener and invites an interpretation. </li></ul>Characteristic of “narrative”2 Trisha Greenhalgh,1998
    9. 9. Narrative Based Medicine
    10. 10. Aims of NBM <ul><li>Narrative Based Medicine (NBM) aims to understand meanings of illness experiences by patients’ multi-vocal story telling. </li></ul><ul><li>According to the words of Greenhalgh and Hurwitz (1998) , </li></ul><ul><li> “ Narrative provides meaning, context, perspective for the patient’s predicament ”. </li></ul>
    11. 11. Interpretation by Medicine <ul><li>Generally, the patients’ experience of symptoms is interpreted by medical professional’s knowledge, eventually leading to a diagnosis and respective therapeutic intervention. </li></ul><ul><li>Illness(patient’s) into Disease(medical words). </li></ul><ul><li>But NBM policy denied this interpretation. </li></ul>
    12. 12.       Medical Education   Clinical Experience Disease     Illness Experience Life Experience Illness Medical Paradigm -> interpretation-> Local Cultural Beliefs
    13. 13. The Process of NBM <ul><li>The first approach in NBM is to recognize that there are different beliefs between medical professionals and patients. </li></ul><ul><li>Second, active listening to the narratives of patients is recommended to medical professionals. </li></ul>
    14. 14. The Process of NBM <ul><li>Third, try to understand the context of narratives in order to clarify the socio-cultural background of patients. </li></ul><ul><li>Forth, active dialogic discussions are recommended. </li></ul>
    15. 15. Definition of NBM 1 <ul><li>“ Illness is considered a story being developed in a big story of a patient life, </li></ul><ul><li>Regarding a patient as a story teller and respecting him or her as a professional to have experienced the illness , </li></ul>By Dr. Seiji Saito, 2003
    16. 16. Definition of NBM 2 <ul><li>On the other hand, a medical view of a disease and medical care should be considered a story by the medical doctor-side. </li></ul><ul><li>Furthermore, medical care is regarded as a process producing a new story by arbitrating both-side stories of the patient and the medical professions.” </li></ul>By Dr. Seiji Saito, 2003
    17. 17. Cultural Relativism in NBM <ul><li>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. </li></ul><ul><li>In this respect, we can find out the concept of cultural relativism in NBM. </li></ul>
    18. 18. 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->
    19. 19. Cultural Relativism <ul><li>Cultural relativism is the philosophical notion that all cultural beliefs are equally valid and that truth itself is relative, depending on the cultural environment. </li></ul><ul><li>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. </li></ul>
    20. 20. Difficulty in Practicing NBM
    21. 21. Strong power of established culture <ul><li>The strong structural power of medical professionals is the established culture that is never given up. </li></ul><ul><li>Medical professionals are trained to view illness and human beings through a special theoretical lens established by their educations and long clinical experiences </li></ul><ul><li>Medical theory is authorized by the social system and generalized as a universal theory. </li></ul>
    22. 22. Difficulty to change the value system of medical professional <ul><li>It is similar to change the operating system, rather than to install new software in the world of computer. </li></ul><ul><li>Cultural anthropologists learn cultural relativism through a field work like staying in the different culture. </li></ul><ul><li>It is hoped that medical professionals should also completely change their value system. </li></ul><ul><li>How can they do? How can we do? </li></ul>
    23. 23. Edger Rubin’s Vase http://topics.j-cast.com/keywords/ Make your side view to a wooden interior ! 900US$
    24. 24. Allegory of Edger Rubin’s vase and face <ul><li>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. </li></ul>
    25. 25. Generalization of ethnocentrism (own-culture centered principle) <ul><li>“ They think that the vase is human faces, but that is wrong, it is really a vase.” </li></ul><ul><li>“ 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.” </li></ul>
    26. 26. Ethno-centrism in Medicine <ul><li>‘ 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. </li></ul>
    27. 27. Silence and hands-off in the name of cultural relativism <ul><li>It is an extreme case of culture relativism. </li></ul><ul><li>“ 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.” </li></ul><ul><li>-> To give up understanding different cultures. </li></ul><ul><li>-> To stop the effort of overcoming the cultural difference </li></ul><ul><li>-> To abandon a dialogue. </li></ul>
    28. 28. The attitude to drive for: <ul><li>“ why do they view the vase as faces? Let’s try to understand their culture and value system underlying their way of viewing.” </li></ul><ul><li>“ If we change our way of viewing, we may see the vase as faces. We should try to understand so.” </li></ul><ul><li>-> Constant efforts to understand different culture </li></ul>
    29. 29. Case of trying NBM Brief introduction of my clinical case using Japanese herbal medicine, 2010
    30. 30. Ms. Yoko-san, 48 year-old <ul><li>A stomach cancer was accidentally found during medical treatment of Guillan-Barre syndrome. </li></ul><ul><li>The tumors reached lymph node and she was already on the fourth stage of metastatic cancer of the lung. </li></ul><ul><li>The doctor in charge advised chemotherapy, but the patient wanted naturopathic method and visited my clinic for treatment by Japanese traditional herbal medicine. </li></ul>
    31. 31. Yoko-san’s value <ul><li>From the standpoint of NBM, I tried to understand Yoko-san’s way of thinking of nature, universe, and life and death. </li></ul><ul><li>Yoko-san as well as her husband is intelligent engaged in research area. </li></ul><ul><li>They have been interested in classical Chinese medicine and naturopathy since they were young. </li></ul>
    32. 32. Yoko-san’s value <ul><li>She adopted qi-gong (Chinese exercise), moxibustion using leaves of loquat, macrobiotic food therapy, and memorial service for ancestor. </li></ul><ul><li>Her sentimental thought for natural therapy seemed to be her selection of way of life in view of the world after her death. </li></ul>
    33. 33. How to practice NBM ? <ul><li>It is not NBM to accept patient’s value system unconditionally. </li></ul><ul><li>That is silence and hands-off in the name of cultural relativism. </li></ul>
    34. 34. Progress Notes 1 <ul><li>I felt that her life is critical if only depending on naturopathy, in consideration of biomedical information from her doctor in charge. </li></ul><ul><li>I repeated discussions with her and her husband, and she decided to adopt chemotherapy (anticancer drug) as well as naturopathy. </li></ul><ul><li>For some months, her life force appeared to be improving. </li></ul>
    35. 35. Progress Notes 2 <ul><li>Towards the year-end, her coughing became severe, and she was hospitalized for emergency. </li></ul><ul><li>Her life is critical due to lung lymphedema and pericardial effusion. </li></ul><ul><li>The patient initially denied adoption of chemotherapy. </li></ul>
    36. 36. Progress Notes 3 <ul><li>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. </li></ul><ul><li>She accepted usage of anticancer drug, saying ‘because it is advised by the doctor who really tries to save my life.’ </li></ul><ul><li>However, she passed away in a week. </li></ul>
    37. 37. My reflection <ul><li>I tried to listen to Yoko-san’s narrative most carefully, and repeated dialogues between my and her value systems. </li></ul><ul><li>NBM is really difficult. </li></ul><ul><li>I wonder if my strong culture invaded Yoko-san’s idea authoritatively. </li></ul><ul><li>Was my answer or treatment really called NBM ? </li></ul>
    38. 38. Progress Notes 3 <ul><li>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.’ </li></ul>
    39. 39. Conclusion <ul><li>1) NBM is a useful action to communicate between two different cultures of medical professionals and patients. </li></ul><ul><li>2) Medical professionals should recognize their own strong power established by culture. </li></ul><ul><li>3) Do not abuse “cultural relativism” for your silence or hands-off to patient’s culture. </li></ul><ul><li>4) Constant efforts are important to understand different cultures. </li></ul>
    40. 40. Grazie ! per la vostra cortese attenzione. Takuya TSUJIUCHI MD, PhD.

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