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      Perspectives on narrative medicine

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          Dear editor We read the article on the relationship between narrative medicine and the positive outcomes reflected in COPD management, by Banfi et al1 with great interest. We were particularly intrigued by how the simple documentation of parallel charts could improve the patient–doctor relationship and patient adherence to treatment. It made us evaluate narrative medicine from different perspectives. The article1 highlights that narrative medicine improves the patient–doctor relationship and hence patient outcomes. Graffigna et al2 suggested a multidimensional association between the patient–doctor relationship, patient engagement, and medical adherence for patients with chronic conditions. All of which are critical elements in determining outcomes of COPD patients. Banfi et al1 briefly explored ways narrative medicine can benefit doctors, allowing them to reflect upon their emotions, in addition to those of their patients. We were interested to find further evidence of this outside the realm of COPD. Nowaczyk3 explained that, when used by clinical geneticists, reflective narrative writing allowed patient encounters to be explored far beyond medical diagnosis, a much greater story that often allows physicians to relieve emotional unrest they face during practice. Moreover, Meier et al4 state possible consequences when physicians’ emotions remain unassessed, including, compromised patient care, physician disengagement, depression, and burnout. Hence, this further evidences the benefits of narrative practice, given it can safeguard physicians from such complications amongst others. To us as medical students, the importance of empathy is never understated. However, we are all witness to doctors who are at best indifferent, to the emotional state of patients, which can impede good patient care. Interestingly, Banfi et al1 found the terms within parallel charts to be most commonly disease-specific and that younger physicians struggled more to relate to their patients; what was not explored was the development of language of individual physicians within their parallel charts. It would be intriguing to see if evidence of emotion and empathy increased within later parallel charts of individual doctors over time. However, within the original article1 the number of parallel charts completed by each physician was quite limited, thus, a further study where each doctor completes several parallel charts, would be needed to assess this thought. Although parallel charts strengthened the patient–doctor relationship,1 their use with all patients is not feasible given the time constraints imposed upon the profession by increasing patient numbers. Esch et al5 explored another approach to break down barriers between patients and doctors. One in which patients are given and actively encouraged to read their medical notes, consequently, patients commonly stated an improvement in the relationship with their doctor. A less time-consuming method for physicians, while still compelling them to be more thoughtful when writing notes. Many chronic conditions, including COPD, exist whereby a patient’s own choices directly impacts their health outcomes. Therefore, a relationship of trust between doctors and patients is paramount. The emotional aspects of chronic conditions make this difficult, however narrative medicine and similar techniques may positively influence both sides of this relationship.

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          The inner life of physicians and care of the seriously ill.

           Diane E Meier (2001)
          Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differential diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.
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            Engaging patients through open notes: an evaluation using mixed methods

            Objectives (A) To gain insights into the experiences of patients invited to view their doctors’ visit notes, with a focus on those who review multiple notes; (B) to examine the relationships among fully transparent electronic medical records and quality of care, the patient-doctor relationship, patient engagement, self-care, self-management skills and clinical outcomes. Design Mixed methods qualitative study: analyses of survey data, including content analysis of free-text answers, and quantitative-descriptive measures combined with semistructured individual interviews, patient activation measures, and member checks. Setting Greater Boston, USA. Participants Patients cared for by primary care physicians (PCPs) at the Beth Israel Deaconess Medical Center who had electronic access to their PCP visit notes. Among those submitting surveys, 576 free-text answers were identified and analysed (414 from female patients, 162 from male patients; 23–88 years). In addition, 13 patients (9 female, 4 male; 58–87 years) were interviewed. Results Patient experiences indicate improved understanding (of health information), better relationships (with doctors), better quality (adherence and compliance; keeping track) and improved self-care (patient-centredness, empowerment). Patients want more doctors to offer access to their notes, and some wish to contribute to their generation. Those patients with repeated experience reviewing notes express fewer concerns and more perceived benefits. Conclusions As the use of fully transparent medical records spreads, it is important to gain a deeper understanding of possible benefits or harms, and to characterise target populations that may require varying modes of delivery. Patient desires for expansion of this practice extend to specialty care and settings beyond the physician's office. Patients are also interested in becoming involved actively in the generation of their medical records. The OpenNotes movement may increase patient activation and engagement in important ways.
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              The role of Patient Health Engagement Model (PHE-model) in affecting patient activation and medication adherence: A structural equation model

              Background Increasing bodies of scientific research today examines the factors and interventions affecting patients’ ability to self-manage and adhere to treatment. Patient activation is considered the most reliable indicator of patients’ ability to manage health autonomously. Only a few studies have tried to assess the role of psychosocial factors in promoting patient activation. A more systematic modeling of the psychosocial factors explaining the variance of patient activation is needed. Objective To test the hypothesized effect of patient activation on medication adherence; to test the the hypothesized effects of positive emotions and of the quality of the patient/doctor relationship on patient activation; and to test the hypothesized mediating effect of Patient Health Engagement (PHE-model) in this pathway. Material and methods This cross-sectional study involved 352 Italian-speaking adult chronic patients. The survey included measures of i) patient activation (Patient Activation Measure 13 –short form); ii) Patient Health Engagement model (Patient Health Engagement Scale); iii) patient adherence (4 item-Morinsky Medication Adherence Scale); iv) the quality of the patients’ emotional feelings (Manikin Self Assessment Scale); v) the quality of the patient/doctor relationship (Health Care Climate Questionnaire). Structural equation modeling was used to test the hypotheses proposed. Results According to the theoretical model we hypothesized, research results confirmed that patients’ activation significantly affects their reported medication adherence. Moreover, psychosocial factors, such as the patients’ quality of the emotional feelings and the quality of the patient/doctor relationship were demonstrated to be factors affecting the level of patient activation. Finally, the mediation effect of the Patient Health Engagement model was confirmed by the analysis. Conclusions Consistently with the results of previous studies, these findings demonstrate that the Patient Health Engagement Model is a critical factor in enhancing the quality of care. The Patient Health Engagement Model might acts as a mechanism to increase patient activation and adherence.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                09 March 2018
                : 13
                : 875-877
                Faculty of Medicine, St George’s Hospital Medical School, London, UK
                Healthcare Area, Fondazione ISTUD, Milan, Italy
                Author notes
                Correspondence: Amir-Seena Saberi-Movahed, Faculty of Medicine, St George’s Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK, Tel +44 75 9218 7575, Email seena.saberi@
                Correspondence: Antonietta Cappuccio, Healthcare Area, Fondazione ISTUD, Piazza IV Novembre 7, Milan, Italy, Tel +39 34 7645 7072, Email acappuccio@
                © 2018 Saberi-Movahed et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.


                Respiratory medicine


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