Tables
- TABLE 1
Personal details and profile of the 74 physicians who wrote parallel charts
Sex Female 42 (31) Male 58 (43) Age years 52 (31–69) Professional years 23 (5–40) Region of origin Northern Italy 45 (33) Central Italy 27 (20) Southern Italy 28 (21) Work setting Working in a hospital 47 (35) Working in local public healthcare facilities 41 (30) Working in a private clinic 9 (7) Working as a private practitioner 3 (2) Specialisation Respiratory diseases 86 (64) Internal medicine 14 (10) Data are presented as % (n) or mean (range).
- TABLE 2
Characteristics that influenced the narrative style chosen by pulmonologists
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts Charts 150 153 59 Region of origin Northern Italy 39 (64) 49 (80) 12 (20) Central Italy 46 (45) 32 (32) 22 (22) Southern Italy 41 (41) 41 (41) 17 (17) Work setting Working in a hospital 38 (66) 48 (84) 14 (26) Working in local public healthcare facilities 43 (62) 37 (54) 20 (29) Working in a private clinic 57 (17) 30 (9) 13 (4) Working as a private practitioner 45 (5) 55 (6) 0 (0) Age years 30–39 47 (21) 44 (20) 9 (4) 40–49 44 (46) 46 (48) 10 (10) 50–59 39 (43) 45 (50) 15 (17) 60–69 39 (40) 34 (35) 27 (28) Data are presented as n or % (n).
- TABLE 3
Number of characters and time spent writing the parallel charts
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts Charts 150 153 59 Characters n ≤1000 1 (2) 24 (36) 10 (6) 1001–2000 31 (43) 50 (76) 39 (23) 2001–3000 31 (43) 20 (30) 22 (13) >3000 36 (54) 7 (11) 29 (17) Time spent writing min <30 28 (27) 54 (71) 33 (15) 30–60 33 (44) 23 (30) 30 (14) >60 39 (52) 23 (31) 37 (17) Data are presented as n or % (n).
- TABLE 4
Personal details of the patients described in the parallel charts and their influence on the narrative style
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts Easy Difficult Easy Difficult Easy Difficult Total at the beginning 65% 35% 72% 28% 26% 74% Emotions at first visit (n=93) (n=51) (n=101) (n=38) (n=14) (n=39) Positive 16% 6% 19% 11% 29% 5% “During the visit, the patient appeared to me serene, optimistic and open to an exchange of views” “The patient is very hopeful and full of trust” Fear and pain 57% 34% 62% 29% 50% 26% “He told me he was afraid that at 48 he was already a finished man” “He seemed tired, rigid, not in his usual mood. His way of dressing appeared unkempt, sloppy and a bit messy, not impeccable as usual” Anger and neglect 7% 28% 5% 24% 0% 59% “The patient, at the beginning of the visit, was serene, because he was convinced he was not ill, but that his problems were normal for smokers and that I would have told him that he was fine” “He was very aggressive and angry about his disease, and he criticised all the people he was talking about, but he was actually angry with himself” Submission and shame 20% 34% 16% 37% 21% 10% “There was a certain resignation about him, knowing that he had smoked for years” “She seemed tired, physically and morally, confused and resigned” Smoking at first visit (n=96) (n=50) (n=109) (n=41) (n=11) (n=43) Yes 56% 84% 59% 80% 55% 84% Nonsmoker/already quit 44% 16% 41% 20% 45% 16% - TABLE 5
Pulmonologists' personal decisions and emotions as described in the parallel charts, and their influence on the narrative style
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts Easy Difficult Evolved Easy Difficult Evolved Easy Difficult Evolved Total 65% (n=98) 2% (n=3) 33% (n=49) 72% (n=110) 11% (n=16) 17% (n=26) 24% (n=14) 46% (n=27) 31% (n=18) Reasons that led to therapy change Illness-oriented 52% 0% 71% 40% 0% 35% 50% 28% 60% “The change of therapy, combined with encouragement, was the change the patient needed to get out of the spiral of anxiety that enslaved him” “If we try to give you another bronchodilator instead of cortisone, it will be like having a car with two engines” Disease-oriented 48% 100% 29% 60% 100% 65% 50% 72% 40% “A proper diagnosis through anamnesis and spirometry. Therefore, initiated therapy recommended by the international COPD guidelines” “I explained to him that, after seeing the spirometry results, he could not fail to follow my advice and that I would facilitate his tasks with a simpler, but still effective therapy” Physicians’ emotions after communication of therapy change Satisfaction and trust 55% 33% 37% 51% 15% 24% 55% 19% 8% “I felt happy seeing that in a few minutes the husband, in front of the opportunity to modify a therapy that was not objectively optimal, returned to smile, with a much less concerned expression” Anger and discomfort 5% 67% 37% 3% 62% 14% 27% 5% 46% “I felt the patient distant and unwilling to follow the directions given, especially for what concerns the behavioural changes. It seemed that she did not care about her health” “Almost helpless … I thought it was a failure” Duty and responsibility 40% 0% 37% 46%% 23% 62% 18% 76% 46% “I felt I was responsible for his happiness” “I felt obliged to help him and make him change his mind” Smoking cessation strategies Reprimands 24% 100% 35% 67% 75% 54% 80% 90% 89% “I ask him if he still smokes and he answers yes. AT THIS POINT, I burst out and I rebuke him because he KEPT SMOKING. I added that it's not right that I and others have to sustain healthcare expenditure while he continues to be addicted to nicotine” Compromise 57% 0% 48% 27% 25% 38% 20% 10% 11% “I also took the opportunity to remind her of the damage of cigarette smoke and how she had been good recently, in reducing the daily number of cigarettes” Counselling 19% 0% 17% 7% 0% 8% 0% 0% 0% “During my next visit, I tried to make the patient feel at ease, in order to better understand the stressful situations that led her to her compulsive desire of smoking” COPD: chronic obstructive pulmonary disease.
- TABLE 6
Results of healthcare relationships in terms of therapy, activities resumed, pathway of care and adherence, their correlation to the narrative style, and the type of relationship established
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts Easy Difficult Evolved Easy Difficult Evolved Easy Difficult Evolved Physicians' impression on how patients lived the therapy Negatively 4% 100% 7% 7% 75% 9% 0% 61% 17% “A disaster, a bigger challenge for her, a defeat” Positively 64% 0% 54% 58% 25% 74% 60% 39% 61% “I think the patient experienced care in an authentic way, knowing that there are not many other possibilities that effective … so, all in all, he was grateful to the scientific world” “But when he realised its immediate effectiveness and ease, he strongly adhered to the therapy” As a liberation 32% 0% 39% 35% 0% 17% 40% 0% 22% “I was glad that an elderly widow had come back to plan a six-month summer vacation in advance. The therapy has restored her confidence” “In my opinion, the patient has experienced cure as a new opportunity to live his life” Resumption of the activities interrupted due to disease No 8% 33% 2% 7% 36% 4% 15% 56% 7% “I knew he had abandoned the therapy I had prescribed because the results were probably not the expected ones” Yes 47% 33% 44% 39% 29% 64% 38% 6% 46% “Thanks to the new therapy, he regained his desire to live, made of small but important things: meeting friends, talking to the newsagent, sometimes playing bowls, feeling alive again” “Working continuously, without frequent breaks, he can meet his deadlines and can continue to play soccer” Yes, with some limitations 45% 33% 53% 54% 36% 32% 46% 39% 47% “He is a demanding person. He cannot do things that maybe other people of his age without COPD could do. But let's not let it go … do not ever say it” Thinking back to the pathway of care, I think … It was difficult 1% 33% 16% 0% 14% 5% 14% 40% 8% “The path has been slower and fuller of obstacles than I had expected at the beginning” Something could be improved 15% 33% 11% 22% 36% 18% 57% 25% 31% “I think it's also necessary to have a psychological support for family members” I did my best 48% 0% 27% 52% 36% 27% 14% 15% 46% “I think the path of the patient is very satisfactory for the results obtained, which of course must be maintained” Listening to the patient is the 35% 33% 46% 26% 14% 50% 14% 20% 15% key for success “Understanding her biggest concern and sharing it with her motivated the patient to follow the cure prescribed, also ensuring a continued adherence” Adherence Yes 100% 67% 97% 98% 64% 100% 100% 44% 100% COPD: chronic obstructive pulmonary disease.
- TABLE 7
Lessons acquired by physicians when writing and how they relate to the narrative style
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts From this experience, I've learned … To be perseverant 13% (n=16) 12% (n=15) 16% (n=6) “I have learned that even slight improvements need to be pursued to improve the quality of life of each individual!” “You have to wait patiently for the result” New aspects of COPD 16% (n=20) 28% (n=35) 13% (n=5) management “Too many times we focus only on the superficial and mainly clinical aspects; in the case of a COPD patient, smoking is often a hint, a sign of other types of discomfort” “The pharmacological prescription alone, if not accompanied by proper education, is unlikely to succeed” The importance of true 72% (n=90) 60% (n=75) 71% (n=27) listening “From the relationship with this patient, I learned that we must first cure the wounded soul of the lion, and only then intervene on the pathology” “That very often the quality of life and the resumption of a previously lost activity is much more important to the patient than having improved functional parameters or laboratory data” “We physicians are focused on the perfect diagnosis, but in this relationship I learned that often the patient makes the diagnosis, we are the translators of expressions and clues. As investigators, we can find the solution among the smallest clues, those hidden in the heart of the people” COPD: chronic obstructive pulmonary disease.
- TABLE 8
Appreciation of the educational project in relationship to the narrative style
“Core” parallel charts “Contingent” parallel charts “Moral” parallel charts The project influenced my daily practice Yes, partially or entirely 85% (n=113) 83% (n=112) 60% (n=28) “This approach has greatly improved my relationship with patients, making me understand that empathy associated with drug therapy can be useful in treating not only the disease but also the person” “Yes! I am more confident about the good performance of my prescriptions” No 0% (n=0) 5% (n=7) 17% (n=8) “I'm not used to writing parallel charts. I don't know how to describe my feelings, I honestly don't really like it” I already applied this approach 15% (n=20) 12% (n=16) 23% (n=11) “I like to think of my patients not just as clinical cases, I think I do this every day. Sure, writing is another thing, but I'm still motivated” Writing the parallel chart … Was beneficial and liberating 38% (n=43) 12% (n=15) 38% (n=12) “It was liberating, almost therapeutic” “Satisfied and accomplished” “Interested in applying a methodology that I have not used to date” “The narration has put me at the patient level, a parallel level, but with meeting points. It does not exist in geometry but in reality, it does!” Made me reflect 33% (n=38) 31% (n=39) 13% (n=4) “By concentrating on the patient's experience, the doctor is obliged to expose himself as a person, sympathetic with the subject visited, because he is subject to the same psycho-social and affective dynamics” “It caused me not to run, but to think and rethink, he brought back the focus on the man, rather than on the patient” Made me feel complete 23% (n=26) 10% (n=13) 38% (n=12) “A useful moment of reflection. Often in the hospital you feel a machine that has to “crunch” visits. Thanks to writing the parallel charts I felt human once again” “I felt helpful and positive, happy with my work and the relationship I can build with several patients. Watching such situations makes us realise how important the emotional aspects of our profession are and I hope that other colleagues who are less interested in this aspect will see the improvements that this approach can make to people's lifes” Was demanding 6% (n=7) 5% (n=6) 13% (n=4) “I have struggled a bit to detach myself from the scientific methodology I'd been using for years, but it was a great challenge and I hope I can do a decent job”
Vol 4 Issue 2
Table of Contents
Narrative medicine educational project to improve the care of patients with chronic obstructive pulmonary disease
