Narrative medicine: the story as text
Table of contents
The patient in bed 4 says the same thing for the third time: the pain started "the day my daughter left". In the progress notes, the sentence becomes "pain for three weeks, insidious onset". The clinical information is there. What the patient meant, however, was left out, and perhaps it was exactly what explained why she kept coming back to the emergency department.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
Narrative medicine was born from the idea that these stories deserve to be read with the same care a good reader gives to a text. This guide explains what it is, how its main methods work, what the reviews found when it entered medical training and how a professor or a student can start practicing it.
Key points
- Narrative medicine is clinical practice with narrative competence: the ability to recognize, absorb, interpret and act on the stories of others.
- The central methods are close reading of texts and reflective writing.
- The model describes four narrative situations: doctor and patient, doctor and self, doctor and colleagues, doctor and society.
- A review of 36 articles found an effect on attitudes, knowledge and skills, but clear evidence of behavior change is lacking.
- Reflective writing usually works better combined with other teaching strategies than on its own.
What narrative medicine is
Narrative competence
The term was proposed by Rita Charon, who defined narrative competence as the ability to recognize, absorb, interpret and act on the stories and suffering of others (Charon, 2001). Medicine practiced with this competence was called narrative medicine and proposed as a model of humane and effective practice (Charon, 2001).
At the same time, in the United Kingdom, Trisha Greenhalgh and Brian Hurwitz published a series on narrative-based medicine, opened by a text with the question "why study narrative?" (Greenhalgh and Hurwitz, 1999). The two paths cross: both treat the patient's account as an object worthy of interpretation.
Four narrative situations
The 2001 article describes four central situations in medicine that the narrative approach illuminates (Charon, 2001):
- Doctor and patient: reaching the patient in the experience of illness.
- Doctor and self: recognizing one's own path in the profession.
- Doctor and colleagues: recognizing the bond and the duties toward other professionals.
- Doctor and society: opening a consequential conversation with the public about care.
The list shows that the method goes beyond the consultation. It also helps the doctor understand what the profession does to them.
What narrative medicine leaves to other guides
The clinical history is also diagnostic data, and much of the diagnosis comes from it, as discussed in the guide on signs, symptoms and history. Narrative medicine looks at another side of the same account: the words chosen, the order of the facts, what stays silent. The relationship between empathy and reasoning in the consultation is the subject of its own guide.
The methods: reading and writing
Close reading
Close reading, or close reading, is the exercise of reading a short text slowly, such as a short story, a poem or an excerpt from a report, and asking what it says and how it says it (Charon, 2001). In a group, the teacher draws attention to five elements that also appear in a consultation:
- Who narrates and from what point of view.
- Time: the order in which the facts appear and what is told first.
- Space: where the story happens and what that changes.
- Metaphors and the words that repeat.
- What is missing: what the narrator avoids saying.
Trained on a literary text, this gaze moves to the consultation. The patient who dates the pain by her daughter's departure is choosing a time marker, and the marker says something.
Reflective writing
Reflective writing asks the student to write about a clinical experience and about what it stirred in them (Wald and Reis, 2010). The authors describe reflective capacity as an essential feature of competent clinical practice and report the experience of giving individual feedback, by teachers from different fields, on the students' texts (Wald and Reis, 2010).
The same article notes that this kind of teaching raises difficult questions: how to define reflection, how to design the program, how to know whether the method works and how to assess the result (Wald and Reis, 2010).
The parallel chart
A common form of reflective writing is the parallel chart: alongside the technical record, the student writes in plain language what they experienced with that patient. An eight-week course evaluated in a 2026 study combined close reading, the parallel chart and reflective group discussion (Shen et al., 2026).
What the reviews show
Attitudes and skills, yes; behavior, still uncertain
A systematic review analyzed 36 articles on teaching narrative medicine and classified the results using the Kirkpatrick scale and the BEME scale (Milota et al., 2019). The authors found a clear and replicable teaching structure and a positive impact on participation, attitudes, knowledge and skills (Milota et al., 2019).
According to the same review, clear evidence of an effect on students' behavior or on their interaction with colleagues and patients is missing, and it is still uncertain whether the effect of the classes reaches patients (Milota et al., 2019). It is the same pattern that appears in many teaching evaluations: the measured effect stays close to the classroom.
Reflective writing in communication teaching
A review on reflective writing in communication teaching for medical students identified 1,325 studies, read 101 in full and included 12 articles (Franco et al., 2022). The central conclusion is that reflective writing rarely appears as an isolated practice: it comes combined with other teaching strategies (Franco et al., 2022).
Through writing, students identified structural, emotional and relational aspects of communication, but few studies found a positive correlation between reflective capacity and communication skill (Franco et al., 2022).
A recent study with a control group
In the 2026 study, third-year students at a college in Shanghai were randomly assigned to the narrative medicine course or to the standard curriculum (Shen et al., 2026). After adjustment for baseline scores, the course group had higher scores for self-reported empathy and for the cognitive dimension of empathy, with no difference on the compassionate care subscale (Shen et al., 2026).
The interviews in the same study described a shift in perspective, from a disease-centered view to a person-centered one (Shen et al., 2026). It was a pilot study at a single center, with a short-term measure, and the authors themselves present it that way.
How to bring narrative medicine into training
Start small
A close reading session fits in half an hour: a one-page text, five minutes of silent reading, a prompt for writing and a group conversation. The format is in tune with active learning, because the student produces instead of only listening.
Choose short and varied texts
Short stories, poems, letters and patient accounts all work. The criterion is that the text has layers and allows for different readings. Medical texts work too, such as a chart note read as if it were literature: who narrates, what was left out, which words were chosen. The guide on how to organize clinical reasoning in the chart shows the technical side of that same text.
Give feedback on what was written
Reflective writing pays off more with a response. The experience described in 2010 provided for individual feedback from teachers in different fields (Wald and Reis, 2010). The feedback addresses the text and the reflection, not the person. The guide on feedback in clinical cases brings principles that apply here.
Combine it with other strategies
The 2022 review showed that reflective writing almost always appears mixed with other strategies (Franco et al., 2022). A narrative medicine session can come before a consultation simulation or after a discussion of case-based learning.
Assess with care
Measuring satisfaction alone says little. A better design combines a validated instrument, analysis of the texts produced and follow-up during the clerkship, knowing that the effect on behavior is the hardest to show (Milota et al., 2019).
How the student can practice alone
Write after a memorable consultation
Ten minutes are enough. Describe what happened, what the patient said in their own words and what you felt. Reread it the next day and notice what changed in your reading. The habit connects with metacognition in medicine, because it forces you to look at your own thinking.
Note down the patient's words
In the clinical history, record at least one literal sentence from the patient, in quotation marks. The sentence keeps what technical translation erases and can be useful again at the next consultation.
Read literature with a clinical eye
One short story a week, read with the five questions of close reading, trains the same muscle. The gain appears when the question "what is missing from this account?" starts to come up on its own on the ward.
Protect privacy
Reflective texts about patients need care: remove names, dates and details that identify the person, and agree with the group that what is read in the circle stays in the circle.
The story in clues on NEXO
On NEXO, each case of the day is a short narrative told in up to six clues. The order in which the clues appear matters: a detail from the history can arrive before the physical examination, and a fact that seemed secondary can change the reading of the case. The cases are fictional with a real clinical presentation, and the Multimedia mode brings cases with imaging exams and auscultation.
Reading the clues with attention to order and to what is still missing is an exercise similar to close reading, applied to diagnostic reasoning. The guide what NEXO is explains the whole game, and how the modes are unlocked is on the NEXO economy page.
If you coordinate a medical school, a student league or a residency and want to use cases in group activities, see NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Doctors who review cases take part through NEXO Curator, and those who create health content on social media, including in story format, can take part through NEXO Creators.
Frequently asked questions
What is narrative medicine?
It is clinical practice with narrative competence, the ability to recognize, absorb, interpret and act on patients' stories (Charon, 2001).
Who created narrative medicine?
The term was proposed by Rita Charon, of Columbia University, in a 2001 article.
What is close reading?
It is reading a short text slowly and asking who narrates, in what time and space, with what metaphors and what is left out.
What is a parallel chart?
It is a written record in plain language, alongside the technical chart, about what the student experienced with a patient.
Does narrative medicine work?
A review found an effect on attitudes, knowledge and skills, but clear evidence of behavior change is lacking (Milota et al., 2019).
How to start at medical school?
With a short close reading session and a prompt for reflective writing, followed by conversation and feedback.
Narrative medicine checklist
- Choose a short text with more than one possible reading.
- Read slowly, in silence, before discussing.
- Ask who narrates and what is left out.
- Write for ten minutes about a clinical experience.
- Record one literal sentence from the patient.
- Give or ask for feedback on the text, not on the person.
- Protect the identity of those who appear in the story.
Want to read a case in clues? Play the case of the day on NEXO.
References
- Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001. https://pubmed.ncbi.nlm.nih.gov/11597295/
- Greenhalgh T, Hurwitz B. Narrative based medicine: why study narrative? BMJ. 1999. https://pubmed.ncbi.nlm.nih.gov/9872892/
- Wald HS, Reis SP. Beyond the margins: reflective writing and development of reflective capacity in medical education. J Gen Intern Med. 2010. https://pubmed.ncbi.nlm.nih.gov/20407840/
- Milota MM, van Thiel GJMW, van Delden JJM. Narrative medicine as a medical education tool: A systematic review. Med Teach. 2019. https://pubmed.ncbi.nlm.nih.gov/30983460/
- Franco RS, Franco CAGDS, Severo M, Ferreira MA, Karnieli-Miller O. Reflective writing in the teaching of communication skills for medical students-A systematic review. Patient Educ Couns. 2022. https://pubmed.ncbi.nlm.nih.gov/35063310/
- Shen X, Bu R, Geng M, Chen Y. A mixed-methods evaluation of a narrative medicine course and its impact on empathy development among medical students. BMC Med Educ. 2026. https://pubmed.ncbi.nlm.nih.gov/42231272/