Prospective Clinical Research Report

Journal of International Medical Research

50(2) 1–12
Narrative medicine: feasibility ! The Author(s) 2022
Article reuse guidelines:
of a digital narrative diary sagepub.com/journals-permissions
DOI: 10.1177/03000605211045507
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Maria Cecilia Cercato1 , Elvira Colella2,

Alessandra Fabi2, Isabella Bertazzi2,
Barbara Giuseppa Giardina3, Paolo Di Ridolfi3,
Mara Mondati3, Patrizia Petitti3,
Liciano Bigiarini3, Virginia Scarinci4,
Alessandro Franceschini5, Francesca Servoli4,
Irene Terrenato6, Francesco Cognetti2,
Giuseppe Sanguineti3 and Cristina Cenci5

Abstract
Objectives: We implemented narrative medicine in clinical practice using the Digital Narrative
Medicine (DNM) platform.
Methods: We conducted a preliminary, open, uncontrolled, real-life study in the oncology and
radiotherapy departments of Istituto di Ricovero e Cura a Carattere Scientifico National Cancer
Institute Regina Elena, Rome, Italy. We recruited adult Italian-speaking patients who then com-
pleted the DNM diary from the start of treatment. The primary endpoint was DNM feasibility;
secondary endpoints were health care professionals’ opinions about communication, therapeutic
alliance, and information collection and patients’ opinions about therapeutic alliance, awareness,
and coping ability. We used open- and closed-ended questions (scores 1 to 5) and a structured
interview.
Results: Thirty-one patients (67%) used the diary (84% women). Health care professionals’ mean
scores for feasibility and utility were
4.0. Patients’ utility scores were related to health care
professionals’ feedback regarding the narratives. The main advantages for health care

5
Digital Narrative Medicine (DNM srl), Rome, Italy
6
1
Epidemiology and Tumor Registry Unit, IRCCS Regina Biostatistics and Bioinformatics Unit – Scientific
Elena National Cancer Institute, Rome, Italy Direction, IRCCS Regina Elena National Cancer Institute,
2
Medical Oncology 1 UOC, IRCCS Regina Elena National Rome, Italy
Cancer Institute, Rome, Italy Corresponding author:
3
UOC Radioterapia, IRCCS Regina Elena National Cancer Maria Cecilia Cercato, Epidemiology and Tumor Registry
Institute, Rome, Italy Unit, IRCCS Regina Elena National Cancer Institute,
4
Digital Library «R. Maceratini», IRCCS Regina Elena Via Elio Chianesi 53, Roma 00144, Italy.
National Cancer Institute, Rome, Italy Email: [email protected]

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2 Journal of International Medical Research

professionals were the opportunity to obtain relevant patient data and to strengthen communi-
cation and patient relationships (mean scores 4.4–5.0). Both groups strongly encouraged intro-
duction of the diary in clinical practice.
Conclusion: Use of the DNM in oncology patients assisted clinicians with understanding their
patients experience.

Keywords
Narrative-based medicine, digital diary, digital narrative medicine, personalized medicine,
personalized care, chemotherapy, radiotherapy
Date received: 5 November 2020; accepted: 15 July 2021

Introduction that provides health care professionals

with information that can be used for diag-
Understanding the causes of a patient’s
nosis or the personalization of treatment.
doubts and fears may help clinicians to pro-
Although the Italian Istituto Superiore di
vide more detailed explanations, psycholog-
Sanità published recommendations in 2014
ical advice, or to be more attentive to
for the implementation of narrative medi-
scheduling to improve patients’ awareness,
cine in the management of rare and chronic
empowerment, and treatment adherence.
degenerative diseases, no standard method
However, for this, appropriate interaction is currently available in Italy for the man-
with each patient is needed. If adequately agement of oncology patients.
oriented, narrative medicine may help to A specific digital platform has been
improve personal relationships, therapeutic developed to obtain guided narratives
alliance, and promote adherence to treat- from patients during chemotherapy or
ment while fostering the professional radiotherapy for solid tumors.6 The tool
growth of clinicians. This approach may was designed to obtain information about
provide clinicians with a deeper knowledge barriers to treatment adherence and to
of the patient and help them to obtain facilitate the relationship between health
information that is difficult for patients to care professionals and patients. Herein, we
communicate during chemo- or radiothera- report a preliminary study aimed to evalu-
py sessions and follow-up visits. ate the feasibility, practicability, and self-
Approximately 30 years ago, narrative assessed utility of the digital narrative med-
medicine was first described as a new icine approach from the perspective of both
approach to improving the patient–clinician patients and health care professionals.
relationship.1 Kleinman introduced the use
of narratives as a tool to collect and inter-
pret information on the patient’s experience Methods
of illness, not only to enrich knowledge
about their physical and psychological con-
Patients
dition but also to formulate a correct diag- Two groups of patients from the Istituto di
nosis.2–5 Narratives may have therapeutic Ricovero e Cura a Carattere Scientifico
potential and may be applied in a way (IRCCS) National Cancer Institute Regina
Cercato et al. 3

Elena in Rome, Italy were included, 17 – 18/01/2018). Patients gave their written
namely, patients with breast or colorectal informed consent to participate in the
cancer receiving chemotherapy in the study, to use the digital narrative diary
Medical Oncology 1 Department, and (DNM), and to the confidential data han-
patients with a solid tumor receiving radio- dling procedures for research and assistance
therapy in the Radiotherapy Department. according to the Italian Law 193/2006 on
These departments could ensure that each Privacy and Safeguarding of Sensitive
patient was followed up by a single health Data and the General Data Protection
care professional during the study. Regulation of the European Union 2016/
All consecutive patients who fulfilled the 279 (Personal data code protection,
inclusion criteria (age
18 years, Italian Regulation (EU) 2016/679).8,9
speaking, able to use electronic devices, This project was performed according to
having an E-mail account) and who were the principles of the Declaration of
admitted for treatment to one of the two Helsinki. Patients’ priorities, experiences,
departments were invited to take part in and preferences were constantly taken into
this study. account during the collection of digital nar-
rative outcomes. Patients were not directly
Health care professionals and project involved in the design of the study but were
team informed of the outcome of the research in
personal communications with health care
Health care professionals included in the professionals.
study were those trained in the application
of narrative medicine who were able to Intervention
follow up participating patients from
admission to the end of their treatment, The Digital Narrative Medicine
according to common practice;7 these com- (DNMLAB) is a digital platform developed
prised physicians in the Oncology by an innovative non-profit start-up (DNM
Department and nurses in the srl, Rome, Italy). The platform is designed
Radiotherapy Department. The entire proj- to help implement narrative medicine in
ect team included other professionals clinical practice. This method can provide
involved in the study design and analysis support to patients in the production of
with expertise in the application of narra- narratives and assist health care professio-
tive medicine in research projects: an oncol- nals in interpretating patients’ narratives.
The platform uses a set of narrative
ogist and epidemiologist, an
prompts created for specific objectives
anthropologist, a philosopher (all trained
(Table 1). The prompts may be shared
in qualitative research methodology), and
with other centers and health providers,
two librarians.
contributing to the definition of common
tools for the application of digital narrative
Study design and ethical considerations medicine in different therapeutic fields. The
This was a preliminary, open, uncontrolled patient accesses the platform via a comput-
study in a real-life setting. The study was er or smartphone and writes their story,
approved by the Ethical Committee of guided by prompts that are presented
IRCCS Regina Elena, Rome, Italy twice a week according to an agreed
(AMENO study: Registro Sperimentazioni sequence, in two waves over a period of
IFO 877/16 – 14/12/2016, and AMENART 3 months. The patient can decide to
study: Registro Sperimentazioni IFO 1034/ ignore a prompt and to freely produce the
4 Journal of International Medical Research

Table 1. Digital Narrative Diary: prompts used in the AMENO and AMENART studies

Narrative prompts Translation

Tutto
e cominciato quando . . . It all started when . . .

Le cure: come le vivo e cosa ne penso How I live with and what I think about the treatments
Oggi mi sento . . . – Today I feel . . .
Le parole che mi aiutano . . . e le parole The words that help me . . . and the words I can’t stand . . .
che non sopporto . . .
La mia vita quotidiana . . . My daily life . . .
Potrei stare meglio se . . . I could feel better if . . .
Volevo raccontarle che . . . I want to tell you that . . .
In questo momento i miei pensieri Right now my thoughts are focused on . . .
si concentrano su . . .
Vorrei . . . I would like to . . .
In questo momento, le cure . . . Right now, the treatments . . .
Credo che potrebbe essere utile . . . I think it might be helpful to . . .
La mia vita adesso . . . My life right now . . .
Per me potrebbe essere utile . . . For me it could be helpful . . .
AMENO, Application of Narrative Medicine in the Chemotherapy Treatment of Oncological Patients; AMENART,
Application of Narrative Medicine in Radiotherapy.

narrative according to their observations. Endpoints

Moreover, the patient can write or record
The main endpoint of this study was feasi-
their story. The team project predefines a
bility of the DNMLAB platform. The mea-
limit for the length for the response to
sure of feasibility according to health care
help patients focus on specific aspects of
professionals was ease of use and time
their experience. With the patient’s consent, needed to use the platform. Feasibility was
the health care provider can share the story assessed by patients in terms of accessibili-
with other caregivers directly via the platform ty, ease of use, and satisfaction.
and notes that are not visible to the patient Secondary endpoints were the opinions
can be exchanged among team members. of health care professionals about improve-
The digital diary was provided to both ments in communication, therapeutic alli-
groups of patients concomitantly with the ance, and collection of information that
start of their treatment. Health care profes- would otherwise be unattainable as well as
sionals subsequently reviewed the narrative patients’ opinions regarding the ease in pro-
texts and discussed them with patients ducing a story, effectiveness in terms of
during scheduled visits. being better listened to and better under-
Each patient gave their specific consent stood, initiation of a therapeutic alliance,
for the use of their anonymized information and increasing awareness of and coping
in research studies, communication cam- ability with their disease.
paigns, and guideline production. Assessment was performed at the end of
DNMLAB cannot be used by patients to the study using questionnaires with open-
communicate emergency conditions. and closed-ended questions. Answers to
DNMLAB uses encryption and respects closed-ended questions were scored on a
the privacy and safety of patient data, 5-point Likert scale, with scores from
according to current health care system 1 ¼ complete disagreement to 5 ¼ complete
regulations. agreement.10
Cercato et al. 5

A structured interview was used to inves- We carried out thematic qualitative anal-
tigate the reasons behind not participating ysis of all texts, narratives, open-ended
in the project, opinions regarding imple- questions, and comments. Texts were ana-
mentation in clinical practice, and the inten- lyzed either manually or using Microsoft
tions to make use of the tool in the future Word and a word cloud generator, avail-
(Table 2). able in DNMLAB. Three health care pro-
fessionals (AF, EC, BCG) and two
Statistical analysis additional researchers on the team (the
oncologist/epidemiologist [MCC] and the
In line with qualitative research methods, anthropologist [CC]) independently ana-
the sample size was defined so as to assess lyzed the texts. Patients’ narratives were
the study objectives using descriptive anal- analyzed according to Kleinman classifica-
ysis. Numerical data of continuous varia- tion, distinguishing between disease-
bles are presented as mean and standard centered narratives and illness-centered
deviation (SD) or median and range. narratives that focused on personal experi-
Discrete variables are reported as frequency ence with the disease, and sickness-centered
and percentage. Patients were considered to narratives focusing on social perception of
participate in the study if, after being invit- the patient and disease.11 Open interpreta-
ed by E-mail, they responded to at least one tive coding was used to define the emerging
narrative prompt. topics. The results were presented to and

Table 2. Results from the 15 patient interviews addressing lack of participation in the AMENO and
AMENART studies

1. Please explain your reasons for not using the digital Number of
diary. (more than one option could be selected) responses

a. I had forgotten the E-mail invitation to participate 1

b. I do not feel comfortable with digital technology 3
c. I found it difficult to use 0
d. I had technical difficulties trying to use it 3
e. I did not feel like talking about myself 4
f. I do not believe it is really useful 2
g. I prefer talking about myself during medical visits 3
h. I did not really understand what it was for 1
i. I was worried that my privacy was not guaranteed 1
j. Other reasons (lacking time to dedicate to myself, physical and 4
concentration difficulties, lacking continuity of care with the same
doctor).
2. Which are your intentions regarding diary use in the
near future? (more than one option could be selected)
a. I will inform my doctor that I do not intend to use it 1
b. I would like to receive a new E-mail invitation to participate 6
c. I will start using it 2
d. I do not think I have time enough for this project 1
3. Do you consider the diary useful in personalizing care? 3.7 (median score)
(express your evaluation using a score from 0 to 5)
AMENO, Application of Narrative Medicine in the Chemotherapy Treatment of Oncological Patients; AMENART,
Application of Narrative Medicine in Radiotherapy.
6 Journal of International Medical Research

discussed among the entire research team. one from the Oncology Department and
We used the SQUIRE reporting guidelines five from the Radiotherapy Department
in this study.12 (Table 4).

Results Patients’ evaluation of DNMLAB

Forty-six patients were invited to take part Final evaluation of the feasibility and utility
in the study (26 receiving chemotherapy of the narrative medicine diary was avail-
and 20 receiving radiotherapy); 31 patients able for 14 patients receiving chemotherapy
(67%) agreed to participate, 15 (48%) from and for 16 patients receiving radiotherapy.
the Oncology Department and 16 (52%) One patient in the chemotherapy group
from the Radiotherapy Department. The could not complete the final questionnaire
median age was 58 years (range 31–79) in owing to occurrence of a stroke event.
patients receiving chemotherapy, and All items related to feasibility received a
48 years (range 31–67) in patients receiving mean score
4 by patients receiving chemo-
radiotherapy; the median age of the total therapy as well as by those receiving radio-
was 52.5 years (range 31–79). Overall, 20 therapy. Patients receiving chemotherapy
patients (65%) had breast cancer, nine mainly related the utility of the platform
had colorectal cancer (29%) and two (6%) to increased personalization of treatment.
had a different solid tumor. Only five par- The items addressing a possibility to express
ticipants were men (Table 3). The results one’s point of view and a perception of
from interviews investigating patients’ lack effectiveness in taking charge had mean
of participation are reported in Table 2. scores
4 whereas items related to disease
Patients’ customary use of electronic devi- awareness and coping with the disease had
ces and a predisposition to talk about one- scores <4. Assessment of platform utility
self were the main drivers of participation was related not only to treatment personal-
among patients. ization but also to improved disease aware-
Participating health care professionals ness among patients receiving radiotherapy
comprised two oncologists and six nurses, (Table 5).

Table 3. General patient characteristics

Characteristics Invited, n Participants, n (%)

Population size 46 31 (67)

Sex (male/female) 8/38 5/26 (16/84)
Age (years), median (range)
 Chemotherapy 55 (31–79) 58 (31–79)
 Radiotherapy 52 (31–73) 48 (31–67)
Cancer site
 Breast 28 20 (65)
 Colon/rectum 14 9 (29)
 Other 4 2 (6)
Treatment group (health care professionals)
 Chemotherapy (two oncologists, one nurse) 26 15 (48)
 Radiotherapy (five nurses) 20 16 (52)
Narrative path: prompts with a reply 168/202 (83)
Cercato et al. 7

Table 4. Evaluation of the digital narrative diary by health care professionals

Likert score, mean (SD)

Health care professionals’ assessment Oncologists (n ¼ 2) Nurses (n ¼ 6)

Feasibility
Diary user friendliness 4.8 (0.4) 4.6 (0.5)
Diary immediacy and comprehensibility 4.0 (1.2) 4.6 (0.5)
Time management 4.5 (0.6) 4.2 (0.4)
Optimized clinical examination (length) 4.5 (1.0) 4.2 (0.4)
Optimized clinical examination (quality) 4.5 (0.6) 4.6 (0.5)
Utility
Improved communication 4.4 (0.9) 5.0 (0)
Improved care relationship 4.4 (0.9) 5.0 (0)
Deeper knowledge of patient 5.0 (0) 4.4 (0.9)
Improved therapeutic alliance 4.2 (0.4) 4.8 (0.4)
Focus on care history 4.0 (0.7) 4.8 (0.4)

Table 5. Evaluation of the digital narrative diary by patients

Likert score, mean (SD)

Chemotherapy Radiotherapy
group group
Patients’ assessment (n ¼ 14)* (n¼16)

Feasibility
Diary user friendliness 4.5 (0.9) 4.8 (0.4)
Diary immediacy and comprehensibility 4.6 (0.5) 4.8 (0.4)
Adequacy of one’s own computer skills 4.4 (0.7) 4.1 (1.4)
Opportunity to express oneself 4.6 (0.7) 4.7 (0.6)
Opportunity to provide personal information 4.4 (0.7) 4.2 (1.0)
that is otherwise unavailable
Utility
Possibility to express one’s own point of view 4.5 (0.7) 4.4 (0.7)
Perception of effectiveness in taking charge 4.0 (1.1) 4.4 (0.8)
Improved awareness 3.8 (1.1) 4.2 (0.9)
Improved empowerment and self-confidence 3.6 (0.8) 3.9 (1.1)
Improved care relationship 3.9 (0.9) 4.1 (0.7)
Recommendation to introduce it in clinical practice 4.5 (0.8) 4.6 (0.6)
*One patient was unable to complete the questionnaire owing to a stroke during chemotherapy treatment.

items among nurses. The main advantages

Health care professionals’ evaluation of
for health care professionals were the
DNMLAB opportunity to obtain relevant patient
Among health care professionals, the mean data and to strengthen communication
feasibility score was >4 for all items except and patient relationships (mean scores
comprehensibility of the diary among 4.4–5.0) (Table 4). Interviews showed that,
oncologists (score of 4.0) and >4 for all in the opinion of health care professionals,
8 Journal of International Medical Research

organizational barriers to the long-term guiding narrative prompts, disease-

implementation of DNMLAB may exist. centered prompts were mainly focused on
the time and process of diagnosis (“It all
Text analysis started when . . .”) and on aspects related
to chemotherapy or radiotherapy, essential-
We analyzed all narratives, comments, and
ly toxicity. Whereas diagnosis-related
texts from the open-ended questions. In aspects were generally described using
accordance with the study aim, health care more technical language, adverse side
professionals individually applied their effects of therapy were often described
patients’ narratives to clinical practice by according to the individual’s experience,
integrating them with clinical data in the providing a deeper, more complex, and
path of care for each patient. Word clouds unique description of the patient’s physical
were generated and interpreted for each and psychological status that would not
patient (Figure 1). Patients’ narratives otherwise be obtainable using standardized
were also manually analyzed according classification. Examples of such descrip-
to Kleinman classification.11 As for the tions from our study participants include
the following: “I feel like I am wandering
in a reality that acts around me but does
not affect me closely. I am asleep and I
really feel the need to rest. Sleeping until
the morning when I have difficulty opening
my eyes. An intrusive, heavy, and at the
same time almost artificial sleep. With
cold sweats regardless of the temperature,
and a sense of inadequacy.” Moreover,
through patients’ narratives regarding
their daily life activities and expectations,
clinicians were provided with a suitable
tool for developing a tailored and personal-
ized approach to therapy. Clinicians also
had the opportunity to redefine their ideas
about patients’ real lives: “I found out that
during chemotherapy, patients have a much
more intense and active daily life than I
could imagine.”
Furthermore, using the narrative
approach, otherwise unobtainable relevant
aspects that influenced treatment adherence
emerged, as follows. “I had known the
patient for several years, but she had
never revealed to me that she had a daugh-
ter who was severely disabled since birth,
for fear of biasing the choice of treatment
toward less toxic but less effective drugs.”
Figure 1. Example word clouds generated “The patient described how her cancer was
from narratives of (a) 31-year-old woman, nothing in comparison with the pain of
(b) 58-year-old man, (c) 46-year-old woman. forced separation from her children that
Cercato et al. 9

had been imposed on her; her only motiva- the opportunity to deepen their knowledge
tion for cure was to be able to reunite with of illness-related aspects (i.e., toxic side
them one day.” effects in daily life in the patient’s own
Finally, the need to be considered words) and to enhance the multidisciplinary
“normal” when receiving often pitiful or approach. Responses from both oncologists
embarrassed looks from others who still and nurses indicated that the digital narra-
consider cancer to be taboo emerged tive medicine enabled them to obtain infor-
among the sickness-centered themes: mation that the patient would otherwise be
“Avoiding those who were likely to pity unable to communicate, which could
me, even if without malice, was one of the improve the therapeutic alliance and
very first things I did. I can recognize them patients’ adherence to treatment.
right away; they have “the poor girl” In this experience, narratives were
stamped on their faces.” Word clouds guided by prompts prepared by specialized
from selected patient diary narratives are professionals to obtain information that is
shown in Figure 1a to 1c. difficult to retrieve during typical chemo-
therapy or radiotherapy sessions. The digi-
tal platform provided patients with a
Discussion
private digital space where personal opin-
This preliminary study showed that use of ions, desires, fears, and requests could be
the DNMLAB digital platform in oncology expressed in a timely manner and without
outpatients receiving either chemotherapy interference, as well as the certainty that the
or radiotherapy was feasible and considered descriptions would be read and given atten-
useful by both patients and health care tion. Nevertheless, the narratives were
professionals. guided to assure that the issues described
Among patients in both therapy settings, would be relevant to the cure.
usefulness mainly referred to an improved In light of this, the present results further
opportunity to personalize treatment. support the notion that narrative medicine
Scores regarding improving awareness and may be introduced into clinical practice to
empowerment in the radiotherapy group complement evidence-based medicine
(>4) differed from those in the chemother- because health care professionals consider
apy group (<4). According to the narra- it a useful tool for improving patient
tives, this difference can be attributed to a outcomes.
path guaranteeing continuity of care with Apart from the oncological setting, sto-
the same health care professional during rytelling is central to the management of
the duration of radiotherapy. These data many clinical conditions like heart failure,
are noteworthy, particularly when consider- cardiovascular disease, and epilepsy, and
ing that continuity of care with the same some authors have reported data concern-
clinician is associated with improved ing the beneficial use of the digital platform
patient outcomes.13 Responses from oncol- DNMLAB.14–16 In the preliminary assess-
ogists indicated that digital narrative medi- ments, the strongest advantages of use of
cine could improve the relationship with the the digital diary reported by health care
patient, understanding of the condition as professionals were the disclosure of relevant
experienced by the patient, and could opti- patient information that was not otherwise
mize time management during scheduled obtainable, optimization of clinical exami-
visits. Additionally, oncologists appreciated nations, and improved patient–doctor rela-
that the present project was an opportunity tionships and doctor-to-doctor
for professional growth, mainly owing to communication.14 Despite this, although
10 Journal of International Medical Research

narrative medicine has attracted interest encourage further investigation to validate

over the past few decades, a standard this instrument and to propose an organi-
method in oncological clinical practice is zational pathway for health care institu-
still lacking.17 Several narrative research tions. At our institute, we are currently
studies on illness narratives and parallel conducting other studies exploring different
charts (personal notebooks in which clini- settings, which include a larger number of
cians can write down reflections and feel- patients and health care professionals oper-
ings) have provided insights for clinical ating in different roles and disciplines, with
practice and health care service the aim to validate use of the digital narra-
organizations.18,19 tive path in oncological clinical care. It will
Time spent producing narratives is treat-
be necessary to educate participants, and
ment time that does not necessarily create a
this new method will need to be adopted
burden on organizations and caregivers.20
in clinical practice. In fact, participants con-
On the contrary, facilitating treatment
sistently reported that although feasible and
adherence and teamwork can substantially
reduce time and costs.16,21 However, the useful in their personal practice, the digital
introduction of a systematic narrative path is not entirely suitable for the current
approach into clinical practice, training to organization of their institution.22
improve narrative skills among physicians, A limitation to this study was that there
and a change in clinicians’ perspectives was a small number of participants. This
toward care are required.7 In a further qual- limited the duration of the study, the
itative study aimed at exploring the impact number of patients that could be included,
of this approach on health care professio- and prevented testing of the platform
nals’ perception of their own role, our throughout the entire study period as well
results showed that the diary was appreci- as pathways of care and follow-up.
ated as a tool for application in narrative-
based medicine, and the reading/writing
format was considered to be of high quality Conclusion
and suitable for clinical practice. The nar-
rative approach involves personal experi- DNMLAB is a new tool for use in narrative
ence and emotional resonance with health medicine. We proposed a specific approach
care professionals, leading them to redefine using the prompts in DNMLAB to produce
their values in terms of health and disease. patient narratives, aimed at retrieving
This study pointed out that the narrative patient information that is otherwise unat-
medicine approach must be viewed in the tainable. The platform was considered fea-
light of relational systemic theory, taking sible and useful by oncology outpatients in
into account the following aspects: training different settings and by health care profes-
in narrative medicine itself, the acquisition sionals in charge of their treatment.
of professional skills by practitioners, and
the organizational development of the insti-
tution (i.e., organizational structures but Acknowledgements
also values and professional work Editorial assistance was provided by Laura
culture).22 Brogelli, PhD, Barbara Bartolini, PhD and
Although this was a preliminary study Aashni Shah (Polistudium SRL, Milan, Italy).
aiming simply to assess the feasibility of Technical assistance for the word clouds
this tool and a specific method, we believe images was provided by Leonardo Lancioni
that the results presented here will (DNM SRL, Rome, Italy).
Cercato et al. 11

Authors’ contributions digital diary. Recenti Prog Med 2018; 109:

MCC and CC performed the study and prepared 324–327.
the article. EC, AF, IB, BGG, PDR, MM, PP, 8. Personal data code protection. Legislat.
and LB enrolled the patients. AF, EC, BCG, decree No. 196 of 30 June 2003. published
in the Italian official Journal N. 174, July 29,
MCC, and CC independently analyzed the
2003, supplementary N. 123. Available:
texts. VS, FS, and AF edited the bibliographic
https://www. camera. it/parlam/leggi/delegh
research and contributed to the discussion. IT
e/Testi/03196dl.htm [Accessed 31 May
assisted in sample collection and statistical anal-
2021].
ysis. FC and GS revised the manuscript. All the 9. Regulation (EU) 2016/679 of the European
authors have read and approved the final version Parliament and of the Council of 27 April
of this manuscript. 2016 on the protection of natural persons
with regard to the processing of personal
Declaration of conflicting interest data and on the free movement of such
The authors declare that there is no conflict of data, and repealing directive 95/46/EC
interest. (General data protection regulation. pub-
lished in the official Journal of the
Funding European Union L 119, May 4, 2016.
Available: https://op.europa.eu/it/publica
This research received no specific grant from any
tion-detail/-/publication/3e485e15-11bd-
funding agency in the public, commercial, or
11e6-ba9a-01aa75ed71a1/language-en
not-for-profit sectors. Editorial assistance was [Accessed 31 May 2021].
supported with internal funds. 10. Cohen L, Manion L, Morrison K. Research
Methods in Education. 5th Edition. London:
Routledge Falmer, 2000.
ORCID iD
11. Kleinman A. The illness narratives:
Maria Cecilia Cercato https://orcid.org/0000- Suffering, healing, and the human condition.
0002-8346-6601 Acad Med 2017; 92: 1406. doi: 10.1097/
ACM.00000 00000 001864
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