Archive for the ‘Program Development’ Category

Nurse-Poet-Writer Cortney Davis Responds To Thomas Long’s Blog On Nurse Writers

Wednesday, January 6th, 2010

Commentary by Cortney Davis, MA, APRN, Nurse practitioner, Sacred Heart University Health Services, Fairfield, Connecticut

Thank you to Dr. Thomas Long for his excellent blog entry and for his continued championing of nurses' writing. I also wonder why nurse-writers don't have a wider audience. Specifically, as I see more and more narrative medicine courses offered to medical students, I wonder why many nursing programs still fail to utilize the creative writing of nurses-why not narrative nursing courses? After reading Dr. Long's blog, I asked my husband, a physician, why he thought nurse writers were not as well respected (and as widely read) as doctors who wrote. His answer was immediate: "Authority," he said. "People think that because doctors have more authority in the work place, they also have more authority on the page." There is certainly some truth in this, as Long points out. Doctors are often seen as the embodiment of strength and "curing" and nurses, whether male or female, are often seen as the embodiment of a softer, more feminine "caring"-and I think there are other factors at work here as well.

One reason nursing programs may have been slow to incorporate nurses' writing is the myth of "natural empathy." Some have assumed that those who go into nursing are already compassionate and empathic (sometimes they've even been seen as bleeding hearts, ruled by the emotions and not by the mind). Therefore it might seem that nursing students, those sensitive souls, wouldn't require the humanities to awaken them to their patients' suffering. The companion myth is that of the "distant physician." It's often assumed that medical students are more interested in the illness than in the patient and therefore would benefit from studying the humanities in order to become more empathic providers. Of course, neither myth is valid, although there is a kernel of truth in both. Indeed, when nurses first began publishing their creative writing, some of that writing was overly sentimental and, in some cases, poorly crafted. When doctors first began offering their creative writing, some of it was overly cerebral and occasionally cold. Now, after several decades, nurse- and doctor-writers have honed their skills and found their voices; the best of them are accomplished, professional and writing on equally high levels.

Another factor relates both to the question of who has the authority and to the myth of natural vs. learned empathy. "Nursing Education," that big generic machine, for many years also viewed, if secretly, physicians' work as having more authority, if not more worth, than nurses' work. This bias was spurred on by many things, including the belittling of the nursing profession by doctors, by hospital administration, by the media, and sometimes even by patients and nurses themselves. This led nursing educators to do their best to rid nursing programs of any hint of "softness"-that natural empathy taken to its limits-and to forge nursing education into a research-based, scientific endeavor. As Long notes, this brought the study of nursing from the hospital bedside to the classroom. Almost at the same time, in the 1970s, along came "medical humanities," the study of literature meant, among other things, to foster more empathic, nurse-like compassion in medical providers. As medical schools began offering courses in the arts, humanities and creative writing as a way to increase students' awareness of the "softer side" of caregiving, nursing programs hurried ever farther away from touch and ever closer to technology.

Nursing, it seems to me, missed the boat; only now is it, in some instances, trying to catch up. Still, the majority of nursing programs today have neither the time nor the inclination to offer humanities or writing courses to student nurses. If nursing students are asked to keep journals, the journals are too often seen as an exercise tangential to the real studies; when medical students are asked to keep journals, the journals are often lauded as intimate glimpses into the trials and triumphs of learning medicine-and some of those journal entries are published as beacons to guide other medical students. If the majority of nursing programs are not honoring the creative writing of nurses and using that writing to help guide their students, should we wonder why the names of the best nurse-writers producing poems, essays and novels today are not well known?

That said, some interesting things are happening which give me hope that, little by little, nurses' writing is moving into a more mainstream consciousness. Nurses' creative writing, while still for the most part under utilized within nursing education (and here let me recognize and thank Thomas Long and the many other educators who do value nurses' writing and fight to include it in their courses), is becoming more and more visible, as Long also points out, in the "secular" literary world. Rattle, an excellent and widely read literary journal, featured a "Tribute to Nurses" in the winter 2007 issue, publishing poems and essays by 24 nurses. Many of the poetry volumes, novels and essay collections by nurse-writers have been published by literary presses-among them the University of Iowa Press, Calyx Books, Beacon Press, Random House, and Kent State University Press-rather than by nursing presses. Many nurse-writers have won impressive literary awards-including National Endowment for the Arts Fellowships-which have no connection to nursing or medicine. It seems to me that nurses who write are finding new and exciting outlets and are being recognized not as nurse-writers but as writers.

Yet, within the halls of nursing and medical education, until we move beyond myth and presumption and accept that nurses and doctors are co-workers in the same mysterious and amazing world of caregiving; that we all long to find ways to deal with the complicated emotions our work engenders; that we all want to know what others like us are thinking and feeling; and that we all have essential stories and important contributions to make to students and to the humanities canon-well, until then, we nurses who write, although literary equals to physicians who write, will not enjoy equal recognition.

The Bellevue Literary Press

Tuesday, December 15th, 2009

Concerning the heavenly movements

Commentary by Erika Goldman, Editorial Director, Bellevue Literary Press

Our mission at Bellevue Literary Press is to publish books at the nexus of the arts and the sciencesawith a special focus on medicine. What counts for us is high-quality, authoritative writing, which might take the form of well-crafted history of medicine or science, or a novel where illness is a theme, though not necessarily a central one. Some of our authors are physicians, others, full-time writers.

The fun has been in exploring the variety of directions in which we can go while fulfilling our mission. While we focus on narrative nonfiction and literary fiction, we've also done photo essays, creative nonfiction, and a literary anthology. Our first books appeared in the spring of 2007, but we're lucky enough to have already received some major media coverage, including feature pieces in the New York Times and the Associated Press. Even as newspaper and magazine book review sections are shrinking or disappearing, our books are getting significant review attention.

We publish on average six non-fiction and two fiction titles a year. And we're the only trade book publisher (as opposed to academic or professional press) to be directly connected to a major medical centeraNew York University Langone Medical Center. We're proud to have published The Best of the Bellevue Literary Review, which we've been promoting to medical schools across the country. Danielle Ofri and her team have created an extensive companion study guide that makes it ideal for course adoption in medical humanities programs.

Our biggest nonfiction success to date has been The Lives They Left Behind: Suitcases from a State Hospital Attic, a history of American psychiatric institutionalization, which was written up in the New York Times, USA Today, Newsweek, Newsday and the Washington Post. After selling through several printings of the original hardcover, we reissued the book a year later as a paperback.

The work of fiction for which we've gotten the most attention to date is Tinkers by Paul Harding. Recently short-listed for the Center for Fiction's 2009 First Novel Prize, it explores the impact of illness on families and the bonds that link generations. Marilynne Robinson called it "truly remarkable," Publishers Weekly and Library Journal both gave it starred reviews, and it has an avid following among prominent independent booksellers who hand sell it to their customers.

At a time when mainstream publishers are cutting back their lists and staff, we're nicely positioned because we publish well-written, accessible books on subjects that people care about, including medicine and illness. Our material comes to us in a variety of waysavia literary agents or other industry contacts (including our own authors), our friends at the BLR, or "over the transom" (writers contacting us directly)aand our criteria for selection involve an assessment of the style and quality of the writing, how the finished book would serve our mission, and its marketability. We have a relatively small overhead so we don't have to sell tens of thousands of copies to make our business work. We want our books to be read and to carry their costs but as a nonprofit we're not subject to the same intense bottom line pressure that's made the blockbuster mentality dominant in the commercial publishing business.

So while this may be a particularly challenging economic environment for the book business, it's a fascinating moment to be a small press publisher. We're lucky enough to have attracted extraordinary authors, and our distributor, Consortium, has been wonderful, giving us the encouragement and support we need to flourish. If you think you may have a project for us, don't hesitate to be in touch.

How to Grow a Healthcare Humanities Program: 15 Steps For Success In Harsh Economic Times

Tuesday, November 17th, 2009

Portrait of Hippocrates sitting, reading.

Commentary by Allan Peterkin, MD., Associate Professor of Psychiatry and Family Medicine, University of Toronto; Head of The Program in Narrative and Healthcare Humanities; founding editor, ARS MEDICA: A Journal of Medicine, The Arts and Humanities

Most medical schools in North America have Bioethics divisions but not all have humanities programs. In the current climate of funding cutbacks and loss of investments for establishing new university Chairs, many academics assume that they will never have the resources to develop a new humanities program for their students in healthcare.A In this essay educators are encouraged to move forward all the same. By growing a grass-roots program and building a vibrant humanities community on their campus, they can have impact on the culture of learning at their institution and become a vital resource for their university. Administrators may then be persuaded to pay heed to the results and to offer administrative, institutional and financial support. Here are fifteen steps that were employed at the University of Toronto medical school and led to the granting of official status to the author's program and to pledges of funding from multiple sources.

1) Start with a hospital-based initiative and make sure colleagues and administrators know about your work. Hold monthly, inter-disciplinary lunchtime meetings with engaging speakers tackling "out of the box" subject matter. We've had sessions given by a family doctor studying to be a professional buffo clown, a toxicologist discussing poisons in opera, a nurse-dancer addressing the need for movement for children in hospital and how that might impact hospital design and a social worker offering `on the spot Atraining` for mindfulness in the hospital setting. Cast a broad net. Invite students and faculty from both health and arts disciplines. Advertise events in your university newspaper and hospital bulletin. Serve snacks (if you can!) Ask participants to fill out evaluations of the sessions . Keep these in orderAto demonstrate impact and for fine-tune your programming.

2) Choose a name for your program and be inclusive. We called our initiative "The Program in Narrative and Healthcare Humanities" in order to have appeal across disciplines. Some non-physician colleagues and other clinicians may object to (or feel excluded by) a "medical" humanities nomenclature.

3) Consider starting a newsletter, blog or print/online journal. We started "ARS Medica: A Journal of Medicine, The Arts and Humanities" 5 years ago with a small start-up fund from our very supportive Department Head and established a voluntary editorial board. The journal was/is a labor of love and has become the voice of our emerging discipline. Government arts grants have followed and the journal hit the radar of the university administration when we introduced a study guide with questions for reflection and study. The journal is now offered free of charge to all first year medical students in an innovative pilot research initiative.

4) Form partnerships with non-medical colleagues. Contact the heads of the English, History, Philosophy and Film Studies Departments and invite them and their colleagues/students to your monthly meetings. Find out who has a particular interest in health/disability/illness/narrative studies and ask them to present or to be a discussant.

5) Form partnerships with other healthcare humanities organizations nationally and internationally to obtain further guidance in establishing your local program. Join list-serves. (For example both the NYU Literature, Arts, and Medicine Database and the Literature and Medicine affinity group of the American Society of Bioethics and Humanities have been extremely helpful in assisting us to choose literary content for teaching students and for canvassing what's being done in the field.)

6) Form writing and research alliances with local, national and international colleagues. Publications and presentations are hard to ignore by funders and Deans.

7) Infuse your own department/faculty with humanities projects and seize opportunities to introduce arts-based content into existing curricula and lecture content. Ask to give a Grand Rounds on an art-based theme. Organize a student art exhibit in the lobby of your hospital or a yearly humanities essay contest. Introduce a poem or short text into morning rounds and link it to the subject matter or diagnosis at hand. Submit a workshop to a faculty development/ CME conference. (We offered three narrative-based medicine workshops to the Department of Family Medicine which were highly rated and subsequently increased the demand for training on reflection which incorporated writing and reading tasks). Make sure your offerings appear on your Departmental and Hospital websites.

8.) Form a list-serve and build a virtual humanities community for students and faculty. You'll discover that many of your colleagues (including those in non-clinical fields like research) are using arts-based teaching innovations but believe that they are working in complete isolation. They will be delighted to find like-minded educators and scholars at their own university and will also support future, more formal initiatives and funding requests. Build a website outlining the history of your program, listing affiliated faculty and summarizing presentations, initiatives and publications. Provide links to other healthcare humanities websites and organizations and ask to be listed on their websites as well. Post narratives and educational resources (like lists of films/texts useful in teaching). Become a "Go To" resource for colleagues in curriculum design and interprofessional learning.

9) As you build links with colleagues, prepare a list of possible electives which can be offered to students and residents. We have offered electives in guided reading on specific topics, creative writing and editing (working with Ars Medica editors) and have facilitated links with non-medical faculties. Make sure these electives meet the standards of your school and ensure that they are included on your website and in the syllabi of offerings for students and residents. Keep evaluations as evidence of your impact.

10) Hold evening events in the homes of your humanities faculty several times per year. A movie night for students and residents works well, as does the showing of episodes of specific TV series such as House or Nurse Jackie. Allow trainees to suggest content or to be a discussant.ASuch meetings build morale, foster community and help to advertise your other initiatives. Attendees may then volunteer to help you with specific tasks related to your program-building (publicity, research, writing letters of support etc.)

11) Organize an annual or bi-annual conference on a health humanities- based theme and hold it on campus. Last year we paired up with colleagues from the Department of English and offered a multi-disciplinary, international colloquium called Narrative Matters. One of our speakers was Dr Rita Charon, founder of the Narrative Medicine Program at Columbia University. Our Deputy Dean of the medical school was more than happy to introduce Dr Charon, but also took notice of the breadth of our initiative.

12) Offer to consult to your faculty on developing the potential links between the humanities and faculty wellbeing, professionalism, reflective capacity and interprofessionalism. Prepare/post resources of readings, films, writing exercises and websites which may be useful in teaching, personal learning or research. By offering our services, we were able to create 2 new courses on reflection and writing and to produce a humanities reader for first year medical students. We built the case that humanities-based initiatives needn't "steal" or compete with precious lecture time, but can be introduced organically at all levels of training from the pre-clinical years to Continuing Medical Education initiatives.

13) Hone your qualitative research skills and link with local, interested consultants. The impact of most humanities-based initiatives cannot be captured by standard bio-medical research protocols. Nonetheless your Dean will likely request proof for the relevance of your work, its impact on learning and for publications in peer-reviewed journals.

14) Act like an official program until you become one.AForm an official working group/program development committee. Keep minutes of your meetings. Prepare an annual report and then request to share it with/present it to your hospital Chief, Departmental Chair, Dean and other educational Deans at your faculty.

15) Choose your moment to request more official status (ie to be identified as a University program/resource rather than a local, hospital or specialty-based one) Be aware of trends in curriculum development within your Faculty (ie the introduction of a new portfolio for teaching, increasing demand for narrative-based interprofessionalAseminars.) as these may offer opportunities for enhancing the profile of your work. List affiliations/partnerships with other departments at your school to show that you have the support of key players on campus. Prepare a three year budget. Your start-up year should be at least 20% more than years two and three. Prepare a dream list for future development. (We hope to have a writer in residence and a fully endowed Chair at our university within 5 years). Explore all funding options including existing competitions for innovation in course design or inter-professional teaching. Your Dean may be more willing to match funds from your department, hospital or outside sources, rather than to fund your program in its entirety.

Readers of this blog are invited to share practical strategies of what has been successful (or less so) in their own settings. Let the dialogue begin!

Creating And Maintaining Participant Interest In The Medical Humanities

Wednesday, October 28th, 2009

Everest region: Living in harmony with nature. Photograph

Commentary by P. Ravi Shankar, M.D., Department of Medical Education, KIST Medical College, Imadol, Lalitpur, Nepal

In previous blog articles I looked at medical humanities teaching in Nepal, explored the link between trekking and the medical humanities in a Nepalese context, and discussed the benefits and disadvantages of English as the language of medical humanities teaching. In this article I will share my experiences of creating and maintaining interest in the medical humanities (MH) among student and faculty participants in two Nepalese medical schools.

The voluntary module at Pokhara

At the Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal a voluntary module was conducted for interested students and faculty members. (1, 2) Students from the third semester (basic sciences) and the fifth and sixth semester (clinical sciences) participated. Interested faculty members also joined the module.

Interest about the module was created through interactions at individual and group level with students and through posters and notices put up on the notice boards and prominent places on campus. (3) Students were invited to 'try out' the module for one or two sessions. If they found the module interesting they could continue- otherwise they could opt out.

Sessions for basic science students at Pokhara

The sessions for the third semester students were conducted during the afternoon lunch break. Each session was of 30 minutes duration. The number of students was small, not more than eight and they were highly motivated. Due to various problems sometimes students could not attend the sessions. I decided to be flexible over attendance. The module used small group, activity based learning strategies. Literature and art excerpts, case scenarios and role plays were used to explore the subject. The students were particularly interested in using role plays to explore various scenarios.

Creating a sense of belonging among the group of students was important. On occasions I distributed 'Thank You' notes to the students which had a photograph of a particular location in Nepal, very scenic country. Periodic assessments of the participants were carried out by the facilitator and constructive suggestions for improvement provided where required. We had a get together over tea and snacks at the end of the module. Group photographs were taken and the students were given a letter signed by the Dean of the institution and myself stating the various skills they had acquired during the module, as well as a certificate of module completion. The specific skills acquired were an appreciation of the patient perspective on sickness and health, awareness of the effect of sickness of a loved one on the caregiver, ability to break bad news gently and humanely, understanding of the patient-doctor relationship and recent developments on this topic, knowledge of the process of obtaining informed consent from the patient/patient's legal representative, and knowledge of the complex issues underlying abortion among others. Students were informed that they and their seniors on the clinical side were the first MH students in Nepal and their inputs and feedback would be useful for conducting future modules.

Sessions for clinical students at Pokhara

The sessions for the fifth and sixth semester students were held two days a week after 7.30 pm. Extra sessions were conducted when required. My colleague, Mr. P. Subish was kind enough to offer the meeting hall of the Drug Information Center (DIC) for holding the sessions. The place was comfortable and quiet and offered a relaxed and protected environment for the participants. The participants were interested in using role plays to explore issues in MH. They were also interested in using debates to explore controversial topics. The inputs and knowledge of the faculty participants was useful. Tea was served during the sessions. The discussions were free and frank and the teacher-student relationship was friendly. With the passage of time, the sessions became an intellectually stimulating get together of friends and colleagues. We had fun while learning!

'Thank you' notes and regular constructive feedback were provided to the participants. The participants also assessed the facilitator periodically. The sessions were conducted using a small group format. All the participants were staying on campus or nearby and the sessions could go on till late at night (around 10 pm). Pokhara is a small city and shuts down early except at the tourist hub of Lakeside. Though the module was not included in the formal curriculum and had no marks allotted to it in the examinations, the participants were beginning to understand the importance of the subject for their future practice.

Students who participated had an understanding of what sickness meant to the sick person and his/her family. They were able to consider sickness in the context of social, economic, cultural and family background of the sick person. In the hospital they witnessed the process of obtaining consent for various procedures and as they had already designed an informed consent form and discussed various aspects of the process of obtaining informed consent they were better able to understand and appreciate the importance of the procedure. During their Psychiatry posting they were more comfortable dealing with mentally ill persons and obtaining a psychiatric history. They had developed a historical background regarding improvements in the management of the mentally ill in Western countries and strongly felt the management of the mentally ill in health institutions and in Nepalese society as a whole should improve.

In Nepal for a long time abortion was illegal except in certain circumstances. Recently abortion has been legalized and women occasionally visit the Gynecology OPD at Manipal Teaching Hospital seeking abortion. Students who had taken the module were better able to understand various issues underlying abortion and the far reaching psychological effects it can have on the women and their families. Following the module students were more comfortable discussing issues of human sexuality. Nepal is a conservative society and these issues are not generally discussed; there is a great deal of secrecy and embarrassment associated with sexuality. Students who completed the module were able to discuss these aspects during history taking with patients and were able to put the patient at ease about these 'sensitive' topics.

Module for faculty members at KISTMC

KIST Medical College (KISTMC) is a new medical school in Lalitpur district of Kathmandu valley, Nepal. The management was interested in further developing humanistic qualities among doctors and faculty members of the institution. An Internal Medicine specialist, Dr. Piryani, was interested in MH and joined me as a co-facilitator. . The experience of the MCOMS module was useful in developing a module. The module was conducted during Sunday afternoons. (Sunday is a working day in Nepal where Saturday is the weekly day off.) The sessions were held in the 'Doctor's room'. We used PowerPoint slides to link together various activities and different aspects of the presentation.

I was apprehensive about dealing with faculty participants. The group was very diverse with basic science faculty, physicians, surgeons, dentists and medical and dental officers. Initially the module was conducted in a similar fashion to the pioneering one at MCOMS. However, the faculty members were not comfortable with role plays and felt it was childish. They were uncomfortable openly discussing issues of human sexuality. (4) They wanted the sessions to more closely reflect various issues and problems they encounter in practice. Regular participant feedback was obtained at the end of each session and informal feedback through interaction with participants.

Based on their feedback we decided to change the nature of the sessions. The number of role plays was reduced and group work and presentations were used to explore MH. During the session on 'Dealing with the HIV-positive patient' an example of group work given was 'Should HIV-testing be made mandatory before surgery in KIST Medical College? Should other patients in the ward be told that a particular patient is HIV-positive? Should commercial sex workers be registered and HIV testing be made mandatory for Commercial Sex Workers?'

KIST Medical College at the time had just started hospital operations and we wanted to obtain guidelines and standard operating procedures for the hospital also. Certain protocols linked to topics covered during the module were developed for further discussion. The group work and the activities were designed keeping in mind that participants were clinicians and faculty members. Another activity was as follows: 'An HIV-positive patient has been admitted in KIST Medical College. A batch of first year students has come to your unit for their weekly clinical posting. Chalk out a plan of action regarding how you will use the patient to teach students about dealing with the HIV-positive'. The presentations were about various procedures and mnemonics developed for 'Breaking bad news' and their applicability in Nepal, the effect of modern psychiatric medicines on the management of the mentally ill, and the effect of the prolonged conflict in Nepal on access to health facilities among others. Presentations were on medical humanities topics of importance in daily practice.

The literature excerpts were felt to be difficult by the participants and were discontinued. Each session concluded with a summing up by the facilitators regarding why the particular topic was important to practicing clinicians and medical educators.

Module for students at KISTMC

The author gave a presentation about MH to various faculty members (especially new members) and the college management. A case was made for teaching MH to medical students. The management was supportive and a MH module was started for the undergraduate MBBS students of the institution in February 2009. The module was planned using the experience gained at MCOMS and at KISTMC. Valuable inputs were offered by international experts like Dr. Johanna Shapiro and Dr. Huw Morgan. Dr. Morgan was a cofacilitator for certain sessions.

The module is held every Wednesday from 8 am to 9.30 am. A big room at the top floor of the hospital is used for the sessions. The room gives us the flexibility to arrange seating according to our requirements. Mikes and speakers and a central area for conducting role plays are present. Flip charts and the LCD projector are used. The students are divided into various groups. Considering previous feedback literature excerpts are not used. To explore MH, paintings-which do not have the cultural and linguistic barriers associated with literature-are used, as well as group work, case scenarios, and debates.

The module is activity-based and all 75 first year students attend. Considering the large student number and the need to develop new facilitators for this and future modules, six clinical and basic science faculty members were selected as cofacilitators. Various innovations have been carried out during the module to maintain participant interest. Music I feel is a powerful means for exploring MH so songs and music are part of the session these days. We have devised an activity where the student group sign a song or recite a poem about a scene depicted in a painting. The facilitators often join in! Most sessions have an 'Open Space' (Khula Manch in Nepali) were the participants recite poems and sing songs on various topics.

Thus I have used a variety of approaches to maintain interest in Medical Humanities among both student and faculty participants. It has been a challenge to maintain interest in a subject which is not a formal part of the curriculum and which is not assessed. However, I have relished taking up the challenge!

References:
1. Shankar PR. A voluntary Medical Humanities module at the Manipal College of Medical Sciences, Pokhara, Nepal. Family Medicine 2008; 40:468-70.

2. Shankar PR. A Voluntary Medical Humanities Module in a Medical College in Western Nepal: Participant feedback. Teaching and Learning in Medicine. 2009;21:248-53.

3. Shankar PR. Running a voluntary module - Personal experiences. Journal of Medical Sciences Research. 2007;2:55-58.

4. Shankar PR. Design the shoe according to the foot! The Clinical Teacher 2009; 6:67-8.

The Story As Chameleon: A Transformation

Monday, September 14th, 2009

A chameleon sitting on a branch of a tree. Colour half-tone. 1926.

Commentary by Patricia Stanley, M.B.A., M.A., Guest Faculty, Program in Narrative Medicine, Columbia University’s College of Physicians and Surgeons; Clinical Coordinator, Masters in Narrative Medicine

There is a short story, "The Shawl", by Louise Erdrich, which is about story and memory and the reworking of old stories into new ones to effect healing. (1) A story of a child being thrown to the wolves is transformed generations later into the child's heroic leap to save a family, the tribe, the pride of the reservation. This story has particular meaning for me since I too have transformed a tragic story from a past time of much suffering into a reason to heal and to bring healing to others through my work as a health advocate. As Arthur Frank writes in The Wounded Storyteller (pp. 23-24):

To think with a story is to experience it affecting one’s own life and to find in the effect a certain truth of one’s own life . . . Being responsible to these stories, thinking with them, depends on telling certain stories over and over, hearing different nuances of potential meaning as the story is told in different circumstances and at different ages of our lives.

The Beginning

After my husband's death from a ten year battle with cancer, I was beset by loss, the loss of my husband, the loss of my old life. I needed a new purpose. I also was haunted by images of patients, alone and isolated as they tried to navigate the medical maze of specialists, community hospitals and urban teaching medical centers, insurance regulations, clinical trials, endless interventions and medical decision making. Towards the end of that decade, a small seed for a new beginning was planted after a doctor remarked: "You know, you should consider becoming a patient advocate." And so in January, 2002, I enrolled in the Masters in Health Advocacy Program at Sarah Lawrence College under the expert guidance of Marsha Hurst and began my transformation from a Westchester widow to an agent for change. That summer, I took Sayantani DasGupta's popular course: "Illness Narratives: Understanding the Experience of Illness." There I found my niche in the new literary genre related to memoir and autobiography called illness narratives or pathography.

As part of the grieving process and finding meaning in my new life and in need of developing skills to help others as an advocate, I developed an insatiable thirst for these stories of suffering. They became a way for me to connect to the embodied suffering that I had recently experienced with my husband. In this class I witnessed the healing that develops from the process of writing in which patients discover their story of survival, move it from talk to the visible page, where they can recover, revise and thereby control the meaning of what has happened to them. I experienced how writing and sharing a story enables a person to feel the connection with stories that reach beyond one's own personal story, a connection to something larger than oneself. Witnessing these stories enabled me to understand the many variations on suffering and to respect the connections and the differences that each story evoked. Most importantly, I felt that I was not alone with my experience but that I was part of a community.

A Door Opens

I was hooked. Because Sayantani included a fair amount of narrative theory in the syllabus, I became acquainted with and actually quite dazzled by the writings of Rita Charon. I asked Sayantani for an introduction to the veritable source of "narrative medicine," not once but at least twice to see if I could become an intern. I also repeated Sayantani's course in the fall to take advantage of a more complete syllabus than was given in the intensive six week summer course and an additional oral history project. That winter and spring, I helped a Sarah Lawrence economics professor teach Economics 101 to inmates attending the college at the Bedford women's correctional facility. That experience fueled my interest in stories, how they are ever so singular while still so clearly part of the common human fabric.

Fortunately the next summer Rita Charon had been awarded an NEH grant to develop a curriculum to train health care providers with narrative competence. I met her and she took me on as an intern to assist in the coordination of that grant and to help in whatever way possible with the seemingly endless list of projects in which she was involved. I have never left.

The oral history project that Sayantani DasGupta assigned in that fall course began another interest and passion for interviewing and recording the stories of others, primarily those involved in some way with illness. I did a capstone project for my Masters which was to conduct oral histories of patients from the Dickstein Cancer Center. I interviewed, recorded, transcribed and wrote their interviews and gave each patient both the oral and written narratives for their own use. I was astounded by how eagerly they talked to me, sharing hours of memories, reflecting on the meaning of illness in their lives. This oral history thread has continued to be a significant part of my narrative work.

Field Work in Narrative Medicine

I have been immersed in narrative medicine since the summer of 2003. As part of Rita's NEH project, I became a member of the faculty that facilitates the annual workshops conducted by the Program in Narrative Medicine to train outside healthcare providers and others in the art of narrative competence. I have also been part of the planning process for the Masters in Narrative Medicine which begins this fall at Columbia. Based upon my fieldwork that I will describe in the next few paragraphs, my ongoing role for the Masters will be to supervise clinical internships for the students.

After I graduated from Sarah Lawrence with a Masters in Health Advocacy, Rita offered me an opportunity for my own workshop with patients. I had had a previous opportunity one summer to co-facilitate with Rita a narrative intervention with the doctors, nurses and social workers on the pediatric oncology floor at Morgan Stanley Children's Hospital (CHONY). I also had sat in on narrative rounds, a thriving biweekly group of clinicians, nurses and social workers from the oncology floor at NY-Presbyterian Hospital who wrote together about their clinical experiences and read to one another what they had written. From this experience came the idea to add the patient's voice. Rita offered me the chance to begin a narrative writing workshop that combined oncology outpatients with family caregivers and clinicians. One oncology doctor had funding from the patient foundation, Team Continuum, and an oncology social worker was eager to co-facilitate. We put up flyers and sent out the call for participants.

As a result, one Tuesday evening in September 2006, thirteen courageous people arrived on the sixth floor of Milstein Hospital in search of something called a narrative writing workshop. That first year the group was composed of all women: one oncologist, two nurses, two caregivers and seven patients. We read together Rita's book, Narrative Medicine and excerpts from illness narratives. We wrote at each monthly meeting and shared our writing, and we became a community. Let me quote from one of the members:

Do not be deceived, this is no ordinary group…There is no doubt they lost a lot, almost everything, but they found the strength to come together to talk, to write, to read, to trust again, and to continue living.

With the ongoing financial support of Team Continuum, we planned the second year, invited some guest speakers and ventured forth to see a movie together, The Diving Bell and the Butterfly.

Now at the end of our third year, our workshop has 19 members and a waiting list. We are a diverse group including patients who are in remission and patients who are in active treatment, patients who are living with chronic illness and those who are just now experiencing the pain, fear and loss of control owing to a new diagnosis or a recurrence. We have doctors, nurses and social workers; we have members who fit into several categories simultaneously: clinician, patient, bereaved persons. And we have men and women.

We have read together a wide range of work from Joan Didion to Marcel Proust; explored visual art from master paintings to comics; shared our favorite songs; and every session we write together is all in the service of using art to inspire creative exploration of the experience with chronic illness and loss.

We have expanded the program to include some daytime events that gather additional patients, caregivers and clinicians around a table making books, writing poetry, combining text and art through collage. We have put poems in the waiting rooms on the oncology floors for patients and families to enjoy and take home.

We have expanded our team of facilitators to include an artist, a poet and a writing coach who have in turn inspired members of the narrative writing workshop to put together a book, Inspiration, an anthology of poetry and prose, photography and collage. In June, we held a reading event at the hospital during which members read from the book to an audience of 100+ doctors, patients, family members, friends, and colleagues. Copies (1000) of the anthology have been dispersed far and wide to other hospitals, clinicians, families and patients. This workshop is fully funded for the coming year and the members are eagerly working on another book.

Fieldwork: Oral History, a Narrative Application

My interest in oral history has been a constant thread in the fabric of my narrative work. I am in the process of conducting a series of oral history interviews with the past president(a reign of 40 years) of Blythedale Children's Hospital in Valhalla, NY. He transformed Blythedale from a small convalescent home into the highly regarded independent children's rehabilitative hospital that it is today. The oral history thread also led me to initiate the weaving of a video story project into the curriculum at the Mt. Pleasant Blythedale School. The students at this Special Acts District School are all patients of Blythedale Hospital. This project is based on the StoryCorps model and in fact the school has become a community member with StoryCorps. Parents and children have recorded interviews in the StoryCorps booth at Grand Central Station and at the school. An oral history expert from Columbia University's oral history department has trained the teachers on the use of oral history in a secondary school curriculum. We have built a video story studio and have received a grant from Pace University to purchase professional video equipment, computer and editing software. The project has become a multi-pronged initiative incorporating the idea of story, listening, interviewing and writing throughout the curriculum giving the students the skills and opportunity to advocate for themselves, to give voice to their feelings and to utilize narrative competence for any number of creative and useful projects.

Full Circle

In "The Shawl," the narrator at the end of that saga of suffering says:

Now, gradually, that term of despair has lifted somewhat and yielded up its survivors. But we still have sorrows that are passed to us from early generations, sorrows to handle in addition to our own, and cruelties lodged where we cannot forget them. We have need to forget. We are always walking on oblivion's edge. (1)

My experience with narrative medicine and with the video story project at Blythedale has become my new story, one of survival from a tragic experience of personal loss. The sorrow is still there but something so strong and affirming as this work in narrative medicine has given me a healthy distance from oblivion's edge. For that I am most grateful.

NOTE: I found the metaphor for the title of this commentary in Sherry Reiter's new book: Writing Away the Demons: Stories of Creative Coping through Transformative Writing (St. Cloud: North Star Press, 2009) p.257.

Reference 1. Erdrich, Louise, "The Shawl". Literary Cavalcade, May 2002 54 (8): p.23.

 

Interesting Lectures Online

Wednesday, May 27th, 2009

The University of North Carolina School of Medicine’s Bullitt History of Medicine Club held numerous interesting talks in 2008-2009 that are available online at their site.

Felice Aull

Walking The Dog: Incorporating Poetry To Help Learners Connect With Relationship-Centered Care

Thursday, April 30th, 2009

Satirical scene with doctor diagnosing well to-do man with Diabetes
Commentary by Johanna Shapiro, Ph.D., Professor, Department of Family Medicine and Director, Program in Medical Humanities & Arts, University of California Irvine School of Medicine

Theories of relationship-centered care

The concept of relationship-centered care (RCC) (1) and the related theory of human interaction designated Complex Responsive Processes of Relating (2) remain exceptionally fruitful ways of thinking about doctors and patients. Relationship-centered care includes attention to the personhood of both doctor and patient, as well as their respective roles; awareness of the importance of emotions in both the patient and the doctor; and recognition of the reciprocity of influences from both doctor and patient (and from the wider healthcare system and society itself) on the relationship itself (1,3,4). RCC challenges the notion of compassionate detachment and instead explores connection and engagement with patients as the most appropriate and moral foundation for relationship.

The theory of Complex Responsive Processes of Relating (2) highlights the nonlinear, reciprocal, and self-organizing nature of human interaction. It specifies that patterns of meaning and relating are co-created continuously throughout the communicative encounter; and that such patterns may repeat themselves, or due to the introduction of "novelty," may develop spontaneously in new directions. As Suchman writes, "the development of new patterns depends upon the diversity and the responsiveness in the interaction." (p. S42). In other words, encounters between doctors and patients that allow, even invite, variety and divergence from unprofitable patterns are most likely to evolve into more meaningful and more authentic ways of being in relationship, which ultimately serves patient well-being. This view acknowledges that patients as well as physicians exercise continually shifting power in the encounter; and therefore physicians have limited control in terms of outcomes.

Implications of RCC/CRPR for "noncompliance"

Although RCC and CRPR have implications for all aspects of the patient-doctor encounter, they are especially relevant in situations of perceived patient "noncompliance." Advances in social science research have helped challenge simplistic conceptualizations of adherence and compliance, in which doctor-patient communication consists of the doctor prescribing medication and the patient taking it. More recently scholars have introduced the term "concordance" to indicate the complex processes that must occur between physicians and patients in order to result in patient cooperation with the prescribed treatment regimen (5). For example, concordance implies an open exchange of ideas, rather than top-down orders, and focuses on both physician and patient values and priorities, rather than on those of the patient alone.

Nevertheless, walking the corridors of a contemporary hospital of clinic, one rarely hears reference to "lack of concordance." Chart notes still read, "Patient noncompliant with medication," with all the frustration and patient blame this term has come to imply (6). Neither do we often hear clinicians contemplating the implications of their diabetic patients' - or their own - emotional responses to their disease for the meaningfulness of future patient encounters; nor the applications of complexity theory to patient compliance. On these significant dimensions of interaction around diabetes care, as in so many other aspects of medical education, the gap between the formal and the hidden curriculum remains pronounced (7). In my comments below I will focus specifically on current attitudes of physicians and students toward the management of diabetic patients; and how the use of a poem can help learners clarify principles of RCC and CRPR that are pertinent to adherence/compliance dilemmas.

The frustrating case of diabetes

In the diabetic patient population, noncompliance is a widespread (and ill-defined) problem, with estimated rates ranging from 30-80%. The inability to "control" the patient, and therefore "control" the patient's blood sugar, is a source of substantial exasperation, even despair, among physicians. Yet one study (6) found that, despite physicians' awareness of the complex constellation of psychological and social factors that constitute obstacles to treatment, they routinely failed to address these issues in clinical encounters, relying on directive, one-way communications about numerical monitoring and outcomes. In other words, these physicians persisted in a linear, cause-and-effect, power-down communication model that ignored the complexity, emotionality (in themselves or their patients), spontaneity, and power fluctuations that occur continuously between doctor and patient. In another study of physician attitudes toward poor compliance in patients with diabetes, it appeared that doctors relied primarily on shock, pressure, and the threat of hospitalization to influence patients toward improved compliance, as defined by the physician (8).

Medical students as well can cling to the straightforward, linear models of communication that are often mistaken for patient education in the management of diabetes. Their focus (understandably, from their perspective as learners), is on diagnosis of the physical ailment. Once this is achieved, the rest seems easy to them: the doctor tells the patient what to do; and the patient, who naturally wants to recover, does it (9). One study noted that, in actual encounters with patients with diabetes, the most frequently reported challenge to student worldviews was how to achieve patient compliance (10). It does not require a great leap to expect that these students will likely become patronizing, directive, yet also despondent and frustrated physicians.

Poetry to the rescue?

While it is obviously crucial to help students rethink their assumptions about and gain insight into the relational foundation of medicine and the complex nature of communication, especially around the issue of compliance, the methods for doing so remain unsettled. By definition, RCC and CRPR are intricate, multifaceted constructs at variance with more simplistic mechanistic models of doctor-patient interaction, and this suggests that the ways of developing conversations addressing them must be versatile as well. Under these conditions, literature and poetry may well have a role to play in helping students develop more critical, self-aware thinking about relationship in general, and in particular about the process through which patients and physicians achieve concordance regarding drug and lifestyle regimens. To illustrate this point, I would like to consider John Wright's wonderful poem "Walking the Dog," (11) and how it clarifies and concretizes aspects of both RCC and CRPR, as well as complexifies students' thinking about patient compliance.

Walking the dog

In "Walking the Dog," a doctor looks at an old problem - an overweight patient with diabetes - in a new way. The doctor is frustrated - obesity and high blood sugars are killing his patient. He turns the problem over and over in his mind. What can he do? At last he has an epiphany - he will give his patient a little dog that she can walk, thereby providing her with much-needed exercise, that will in turn lower her weight and her sugars, and prolong her life. And, like the conscientious physician he is, he prescribes the puppy in a precise dosage: the animal must be walked twice a day!

At this point in the poem, the author (himself a physician) has already caught our attention. Prescribing a pet! This unusual approach helps students think outside the box in terms of innovative therapies. It also is an excellent illustration of the CRPR principle that patterns of meaning and relating are continuously created, and that while they may exhibit stability, sometimes new patterns arise spontaneously (novelty). At this point the students think they "get the message": treatment can involve something more than medication. Be bold, be daring! They can "tell" their patients to take a walk! They admire the physician for being so creative. But the author provides an additional twist (yet more novelty). To their chagrin, the students discover that the treatment doesn't work, at least not in the way the doctor thought it would. As it turns out, while the patient is delighted with her little puppy and cuddles it affectionately, it is her "lean" husband who "faithfully" complies with the prescription of twice-a-day dog walking. Twelve years later, happy but presumably still obese and still diabetic, the patient dies.

The narrative arc of the poem is so unexpected that it inevitably provokes a chuckle. Nonetheless, it is troubling to students on several counts. First it turns the concept of compliance on its head by showing that, in the poem, the compliance achieved is perfect but meaningless because the wrong person is doing it. This nonsensical take suggests that compliance is only one aspect of the encounter between patient and doctor and should not always be regarded as the only measure of success. Both the narrator (and we, the readers) have to grapple with the fact that patients don't always do what doctors tell them to do. In CRPR terms, students learn that doctors do not have omnipotent control over their patients. In discussing why the patient may have been unable to or uninterested in walking her puppy, students realize that following "what the doctor says" is influenced by many factors; and that while the physician's power may be rooted in expertise, in this case the patient has her own power, and exercises it by choosing a relationship with the puppy that is very different than the one the doctor envisioned, but one that nevertheless brings her joy.

In one final twist, the poem's artistry offers an additional puzzle. Somehow, despite the physician's initial frustration, despite the failed prescription, despite the ultimate demise of the patient, this is a gentle, bemused, and humble poem that effectively conveys the value of the doctor's caring and concern for his patient. From an RCC perspective, the poem shows us a doctor, patient, (and spouse) who are not simply roles, but people with emotions, idiosyncracies, frustrations, and affections. The narrator, for example, is well aware of both his own emotions, and those of his patient, and he is not afraid to introduce novelty to attempt to create new patterns in the situation.

Perhaps one of the most important lines occurs early in the poem, when the doctor realizes that his patient's health is deteriorating and that, so far, he hasn't been able to save her. At this point the narrator says, "So/I thought." This line illustrates the self and situational awareness that CRPR and RCC both advocate. By reflecting on his own and his patient's limitations, and the exasperation he feels at these constraints, the physician is able to develop empathy. Unwilling to give up or emotionally abandon his patient, he also resists giving in to his own annoyance and helplessness. Instead he keeps trying. In CRPR terms, the physician approaches his patient's "noncompliance" with curiosity, compassion, and more than a modicum of humor, rather than fear and defensiveness. Rather than burden himself with self-blame and guilt (the consequences of unrealistic control aspirations), he simply remains open to the possibility of change. And apparently he remains open for twelve years. Did he achieve better A1C numbers in his patient? Did he extend the patient's life? The poem is silent on these questions. But most students feel that doctor and patient shared a precious partnership, and that the physician's position in relation to the patient was fundamentally a moral one.

Conclusion

Prose and poetry have an important contribution to make in helping medical students engage with the abstractions of conceptual theories such as RCC and CRPR even as they wrestle with the challenges of issues such as adherence/compliance. Of course, the relational and communicative questions raised by RCC and CRPR play out daily between doctors, medical students, and patients, and obviously such encounters provide fertile soil for examination. Physician educators (12) have crucially advocated, and rightly so, for real-time, moment-by-moment awareness of actual clinical process. But just as Dr. Wright found value in retrospective reflection about himself and his patient, so too can students benefit from teaching experiences in which the priority is stimulating critical awareness, as well as the multi-tasking reflection that is required at the bedside. Through humanities teaching such as I have described above, the ways of perceiving and being that RCC and CRPR encourage become increasingly accessible and meaningful to students, and help create and sustain "attitudes of readiness" that, in turn, will seamlessly interface with and support their "real" lives as burgeoning physicians.

References
1. Beach MC, Inui T, and the Relationship-Centered Care Research Network. Relationship-centered care: a constructive reframing. Journal of General Internal Medicine, 2006;21:S3-8.

2. Suchman AL. A new theoretical foundation for relationship-centered care: complex responsive processes of relating. Journal of General Internal Medicine, 2006;21:S40-45.

3. Frankel RM, Inui TS. Re-forming relationships in health care. Journal of General Internal Medicine, 2006;21:S1-2.

4. Duffy FD. Complexity and healing relationships. Journal of General Internal Medicine, 2006;21:S45-46.

5. Chatterjee JS. From compliance to concordance in diabetes. Journal of Medical Ethics, 2006;32:507-510.

6. Wens J, Vermeire E, Van Royen P, Sabbe B, Denekens J. GP's perspectives of type 2 diabetes patients' adherence to treatment: a qualitative analysis of barriers and solutions. BMC Family Practice, 2005;6:20

7. Hafferty F, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine, 1994;69:861-71.

8. Freeman J, Loewe M. Barriers to communication about diabetes mellitus. Patients' and physicians different views of the disease. Journal of Family Practice, 2000;49:507-12.

9. Anderson RM, Robins LS: How do we know? Reflections on qualitative research in diabetes. Diabetes Care, 1998;21:1387-1388.

10. Mitchell A, Paul TJ, LaGrenade J, McCaw-Binns A, Williams-Green P. Assumptions about disease treatment challenged in a family health clerkship: views of first clinical year medical students. Education Health, 2005;18:14-21.

11. Wright JC. Walking the dog. In Belli A, Coulehan J (eds). Blood & Bone: Poems by Physicians. (Iowa City: University of Iowa Press) 1998, p. 55.

12. Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role modeling humanistic behavior: learning bedside manner from the experts. Acadamic Medicine, 2006;81:661-7..

English As The Language Of Medical Humanities Learning In Nepal: Our Experiences

Wednesday, April 22nd, 2009


Commentary by P. Ravi Shankar, M.D. and Rano Mal Piryani, M.D., Department of Medical Education, KIST Medical College, Lalitpur, Nepal

A previous blog (Shankar R., Medical Humanities: Sowing the Seeds in the Himalayan Country of Nepal). and journal articles (1, 2) described medical humanities modules at two Nepalese medical schools. Here we discuss some aspects of language choice when teaching medical humanities to participants.

Language is a touchy issue among students. Many Nepalese medical schools admit students from Nepal, India, Sri Lanka and few students from other countries. Most Nepalese students have Nepali or Nepal Bhasa (Newari) as their mother tongue. The Indian students speak a variety of languages; however, Hindi is the national language of India. Neither group is favorably disposed towards the other's language. English is the medium of instruction and is accepted by all (students and teachers).

Multiplicity of languages

The multiplicity of languages spoken in South Asia creates its own set of problems. Often the language of the dominant ethnic or religious group or of the majority of people is selected as the national language. However, the minority groups are often decidedly lukewarm towards this 'national language' and feel they may be at a disadvantage compared to 'native speakers' with regard to the national language. English often steps in as a compromise language. Due to the British legacy English is a familiar tongue and is also not the 'mother tongue' of South Asia's various ethnic groups. Only a very small minority have English as their native language. So all groups have an equal status as regards English and the issue of language can be resolved amicably at least for a certain period.

Language of higher education

English is the language of higher education in Nepal. Classes are conducted in English in universities and colleges. The language of interaction in the classroom may be Nepali or other languages. Also often the slides and other audiovisual materials are written in English while the subject matter is explained and discussed in a mixture of English and Nepali. Certain posh English medium schools in South Asia insist that students use only English within the campus to ensure that they become more familiar with English, especially the spoken language.

Language of teaching the Medical Humanities

A voluntary Medical Humanities module was conducted at the Manipal College of Medical Sciences, Pokhara, Nepal (1, 2). The majority of student participants were from two countries, Nepal and India. Literature and art, case scenarios, group work, debates and role plays were used to explore various aspects of the humanities. The debates and role-plays were conducted in English and language did not seem to act as a barrier to communication. The only problem noted was with literature excerpts. The English was felt to be tough on occasions by the participants and they had difficulty identifying with the situation depicted in certain excerpts.

The authors had conducted a module for faculty members and medical/dental officers at KIST Medical College, Imadol, Lalitpur, Nepal which also used English as the language of learning. The difference from MCOMS was that most of the participants were Nepalese. The authors used 'different' literature excerpts keeping in mind feedback from the participants of the Pokhara module. The excerpts were simplified. However, again the participants had problems with certain of the literature excerpts. Language difficulty and inability to identify with the situation depicted were again cited. The role-plays were conducted in Nepali and the group work was presented using a mixture of Nepali and English. As is common, the writing was in English but the presentation often in Nepali!

Art as a substitute for literature

At present, the authors are conducting a module for medical students at KIST Medical College. Six of the faculty participants of the previous module have joined as facilitators for the student module. The module again uses English as the language of learning. Keeping in mind previous experiences, the authors are not using literature excerpts in the module. It has been our consistent observation that painting and art has the ability to overcome linguistic, cultural, social and other barriers. We are using paintings for various sessions and the feedback has been positive. The role-plays are usually conducted in Nepali and the group work presentations are carried out in English and Nepali.

Jekyll & Hyde

We feel that being exposed to English right from childhood, students in South Asia accept it as a working language. Most however, speak a different language at home and this causes a dichotomy. May be we develop a split personality, a kind of Jekyll and Hyde phenomenon. English describing common place events and household and social activities may be especially difficult as these events are often described using local languages in our setting. Fruits, vegetables, flowers, common implements and religious and other customs and ceremonies common in the west are often difficult for South Asians to understand and comprehend.

Disadvantages and Advantages of English

Using English has the disadvantage of excluding patients from deliberations and decisions about their condition in many cases and may preserve and perpetuate an elite, snobbish image of the medical profession. Does thinking in the western language westernize our thoughts and our outlook? Do we loose the ability to think and understand the native perspective? Do we become 'brown sahibs'? Could this be one of the reasons behind the massive brain drain and migration to the English speaking west? Are we becoming strangers in our own countries?

English also has many advantages. South Asians have easy access to the vast amount of medical and non-medical literature written in English. In the case of the Medical Humanities we were and are fortunate to be able to access and use material in English. Also we can more easily communicate our findings and observations to other workers in the field. Western teachers also find it easier to help and contribute to a course using English as the language of learning.

Language and literature

We wonder, sometimes whether language is the only factor behind this lack of identification with and difficulty in understanding literature. In South Asia, after completing ten years of schooling students diverge into three streams, arts (humanities), commerce, and science. The top ranking students usually go for science. For getting admission to medical school it is mandatory that the student takes the science stream and studies Physics, Chemistry and Biology during the last two years of schooling. A study conducted at MCOMS had shown that preclinical students read widely beyond their course and were interested in literature. (3) However, information on reading habits of doctors is lacking. Could it be possible that doctors have not developed the ability and the aptitude to understand and appreciate literature? A demanding professional career may have prevented them from developing interests beyond medicine. Could the teaching of arts in schools, or the lack of it, have been partly responsible for this lack of interest? Certain aspects of arts and crafts teaching in South Asian schools and the language of instruction at school have been covered in a recent blog article (Shankar R.A Arts and humanities: a neglected aspect of education in South Asia, British Medical Journal: Medical Humanities blog).

Our experience with using English for humanities modules has been largely positive. But as English is the medium of instruction in medical school we are conditioned to the language and the viewpoint and thinking framework it imposes. Most of us are comfortable with English and will have difficulty dealing with technical medical terms in native languages. I think we will continue to use English as the language for Medical Humanities modules as long as it remains the medium of instruction. We have accepted its advantages and disadvantages and at present are unable to look beyond English. Eventually English may become more localized and accepted as a South Asian language or the region will develop another link language and medium of instruction. Which one of these two scenarios will come to pass only time will tell but considering past and present experience we think the former may be more likely!

References:
1. Shankar PR. A Voluntary Medical Humanities Module in a Medical College in Western Nepal: Participant feedback. Teaching and Learning in Medicine (in press)
2. Shankar PR. A Voluntary Medical Humanities Module at the Manipal College of Medical Sciences, Pokhara, Nepal. Family Medicine 2008; 40:468-470.
3. Shankar PR; Dubey AK; Mishra P; Upadhyay DK. Reading Habits and Attitude Toward Medical Humanities of Basic Science Students in a Medical College in Western Nepal. Teaching and Learning in Medicine 2008; 20:308-13.

Announcement: Center for the Humanities and Health

Monday, April 20th, 2009

King’s College London has established a Center for the Humanities and Health, with the help of a Wellcome Trust award. They are offering a research fellowship. The deadline for submission is May 5.

Let The Living Teach Physicians About Healing

Sunday, April 12th, 2009

A physician watching over a sick child.
Commentary by Felice Aull, Ph.D., M.A.; Adjunct Associate Curator, New York University School of Medicine; Editor in Chief, Literature, Arts, and Medicine Database

In a recent op-ed piece in the New York Times ("Dead Body of Knowledge") Christine Montross made a plea to continue the long tradition of cadaver dissection in medical education.A Montross, a physician and author of the thoughtful book, Body of Work: Meditations on Mortality from the Human Anatomy Lab, argues that anatomy courses based on human dissection offer "a safe and . . . gradual initiation into the emotional strain that doctoring demands." She is concerned that recent trends to incorporate advanced imaging techniques into the anatomy lab may even replace dissection completely and believes that medical students will miss out on the emotional conditioning that human dissection provides. A few days later the New York Times published six letters to the editor responding to Montross’s essay — all of them written by medical professionals or medical students. Five of the six letter writers supported Montross’s position, but a Stanford University professor disagreed, stating that "teaching anatomy cannot be couched in an either or framework; instead, technology and cadavers should enhance each other." I agree with the Stanford professor and here argue that dissection of a preserved cadaver, while it has much to offer for medical education, is not a teaching tool to help physicians and other health professionals "cope" with the emotional demands of working with sick and dying human beings. It has, to the contrary, been noted that the inevitable objectification of the body that takes place as the cadaver is dissected during months of anatomy teaching, marks the beginning of the developing physician’s professional detachment — a detachment that needs to be unlearned and guarded against so that it does not interfere with appropriate care for patients.

Writes one student during her anatomy course, "I can see how easy it is for health professionals to focus on the body and not on the person" (p. 38, Anatomy of Anatomy in Images and Words, by Meryl Levin). And another writes, "I suppose I have become comfortable, or at least reconciled to the reality of the next 10 weeks. I don’t like that. I don’t like that I have stopped truly thinking about the experience, because there is still a lot to think about. These cadavers did once live, breathe, eat, and sleep before they so graciously donated their bodies to medicine" (p. 58, Anatomy of Anatomy). These thoughtful comments were written by anatomy students who volunteered to participate in a project that photojournalist Meryl Levin initiated several years ago, culminating in her book, Anatomy of Anatomy in Images and Words. The students wrote journal entries during their anatomy course, which forced them to reflect on their experience. Most medical students do not participate in such ongoing reflective exercises while they take gross anatomy, or even after they complete the course. Even the memorial services that are often held at the end of anatomy classes do not address the problem of professional detachment and certainly do not address questions of how to interact with dying patients and their families. Following such a memorial service, one student noted that "I found it hard to become very emotional about these prosections, these bodies, these individuals, these first patients of mine. Maybe I am on my way to acquiring some of the tools I will need to become a physician — a scary thought though, because that is not the kind of physician that I would like to become. . . . must we have a memorial service each time we encounter death in some form or another? It worries me a little that we (or I) needed the service to step back for this all-important reflection, something so many of us could not or would not have done on our own, individually. Hopefully dealing with death will be different — not easier, just different — the next time around" (p. 124, Anatomy of Anatomy).

There are, it is true, some medical schools that nowadays recognize the problem of professional detachment and its early beginnings in the experience of intensive cadaver dissection in the gross anatomy lab. Most notable among them is the University of Massachusetts Medical School, which, under the guidance of anatomy instructors and thanatologist, Sandra Bertman, work with students to help them recognize and articulate (verbally and in drawings) their own fear of sickness and death and other implications of working on the dead-see annotations of Facing Death: Images, Insights and Interventions, and One Breath Apart: Facing Dissection, Bertman’s books detailing this approach.

But what will dealing with death be like when it happens to a person the physician has been treating? The artificially preserved cadaver of the anatomy lab cannot be equated with the complex physiologic and emotional processes of becoming sick and of dying, and its dissection cannot be equated to working with suffering or dying patients and those who love them. The cadaver is a static entity, a representation of what once was, not a process that the student has witnessed as it was unfolding. Newer imaging techniques at least allow observation of some body processes, even if they do not provide the emotional substrate for that body and its interactions with others. Although students may project their fears onto the cadaver, the cadaver cannot help them to negotiate the needs of unpredictable and changeable human beings-human beings who, as physicians, they will come to know, however fleetingly. That negotiation can only be learned about and confronted by working with the living and continually reflecting on that work. Generations of medical students have, after all, learned anatomy from cadaver dissection, but physicians have been criticized for failing to engage with dying patients and their families. It is the incorporation of a medical humanities perspective into all phases of medical education, not cadaver dissection per se, that attempts to address such problems.

References
Bertman, Sandra L. One Breath Apart: Facing Dissection (Newton, Mass: Ward Street Studio) 2007

Bertman, Sandra L. Facing Death: Images, Insights, and Interventions (Washington, Philadelphia, London: Hemisphere) 1991

Levin, Meryl. Anatomy of Anatomy in Images and Words (Third Rail Press



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