Literature, Arts and Medicine Blog

As one might expect, much of medical training occurs in the inpatient setting. Teaching hospitals, brimming with an elaborate hierarchy of trainees and supervisors, offer a critical mass of patients and pathology. Typically these patients present with exceptionally complex histories and comorbidities enriching the substrate of the teaching environment. Counter-intuitively, most doctors do not work in inpatient settings. This is especially true for psychiatry wherein the great majority of practitioners work in the outpatient setting, practicing various forms of psychotherapy.

Unlike in other fields of medicine, residents in psychiatry experience virtually no outpatient psychiatry until their third year (PGY-3). Most psychiatry residents therefore spend a minimum of six years of training before they venture beyond the frontier of outpatient psychiatry, into a wilderness they will eventually call home. For many, this is the moment they have been waiting for since deciding to become a doctor: their first therapy session.

Angst is perhaps the most suitable name for the escalating feeling leading to that first 45-minute office visit. Beyond simple anxiety or worry, there are existential elements implicating one's life, career, and purpose in the world. Additionally, there is both hope and dread- hope that salvation will eventually come (the patient will get better), and dread that you will be unable to bring it. Unlike the inpatient setting, befit with teams of providers embedded in elaborate systems of care (however under-funded and uncoordinated), the outpatient office can be a shockingly lonely venue, a small island where you sit naked waiting to be eaten by a large animal.

From one perspective, there is not much difference between a typical 20-30 minute encounter or "therapy session" on an inpatient unit and a 45-minute office based session. Yet there is an irrational pressure put upon oneself to make the most of an outpatient visit and a simultaneous intense fear that 45 minutes will be way too long (never in the hospital does one have time to worry about running out of things to say). Undoubtedly connected to the well-intentioned (and yet grandiose) identity as healer, this pressure suggests you alone will be in charge of saving your patient's life. Adding to this self-conscious uncertainty is the loss of anonymity afforded to inpatient providers. No longer able to hide behind the tribal masks and dress of the hospital ward treatment team, one's nakedness is more viewable in the outpatient setting.

Most concerning is the realization that, unlike inpatients who often draw from a more familiar cast of acutely ill characters (the demented elderly woman who screams all night after a recent infection, the manic psychotic young man from another state off his meds, the chronically homeless schizophrenic with a recent decompensation…), outpatients can come from anywhere. Fresh off the inpatient unit, I remember once thinking in early July, "Who is this stranger?" I was sitting opposed to a fashionably-dressed middle-aged man on a single antidepressant discussing his upcoming trips for business and summer vacations. Several years since a recent major depressive episode and suicide attempt, it was as though we sat chatting, comfortable by a campfire, the specter of his disease far from our minds.

It wasn't until I returned to the hospital that I appreciated the outpatient setting for what it truly is. Amidst the reverse culture shock of a long call night in the emergency room, I found myself between three newly admitted and screaming patients; one in withdrawal begging for more benzos, another acutely manic and irritable, the third demanding discharge despite a near-lethal overdose just hours afore. I missed my verdant, tranquil island.

It was at this point that I could look back at the thick, threatening, overgrown paths I had traversed and appreciate the open air of my surroundings. It was a few weeks later until I realized who else had been through those woods, lived even deeper in the dark recesses of the forest.

Now sitting in my office I strategize with patients on how to maximize their island time. I wonder how to keep the campfire burning so that we may "talk" as long as possible. And most importantly I try to mentally prepare for the day when a patient must return to those deep dark woods and how I can best make that journey with them.

-Arthur Robinson Williams

Arthur Robinson Williams is a PGY-3 Resident in the Department of Psychiatry at New York University specializing in addiction psychiatry, ethics, and research. He earned his M.D. and a Master in Bioethics at the Perelman School of Medicine at the University of Pennsylvania and the Penn Center for Bioethics.

Laura Ferguson came to the NYU School of Medicine as artist in residence in 2008 and currently has an exhibit of her artwork in the MSB Gallery at NYU - Langone. In a previous blog post, Ms. Ferguson discussed how she uses medical imagery in her work. In speaking with her by phone in the days following the opening of the current exhibit, I asked her to discuss her work with medical students who study anatomical drawing with her during an eight session elective, 'Art & Anatomy,' in NYU's Master Scholars Medical Humanism Program.

-Lucy Bruell, Editor-in-Chief, Literature, Arts, and Medicine Database

I came to NYUSOM with the idea that an artist’s perspective could be of value to the medical school community. This exhibit is a chance for me to show what I’ve been doing as an artist in the four years that I’ve been here. I've learned so much in my interactions with faculty, staff, and students. This is a chance for me to give back and to share what I’ve been doing, which was part of my original goal. My work with students has been a big part of that.

When I first came in, the first year, the students would study gross anatomy the first semester of medical school, and those who wanted to took my class in the spring semester. In other words, they’d have dissection in the fall, and then drawing in the spring. But after that, the curriculum started changing, and now they have gross anatomy spaced out over 18 months. And they may take my class whenever they want to, because it’s given every spring and fall semester, so they may be at different stages in learning anatomy. Some of them may even take my class before starting gross anatomy, so I become the person who introduces them to the lab, which I wasn’t expecting. But I've always thought that drawing is a great way to learn.

I basically learned anatomy through drawing. You spend so much time communing with the object or the thing that you’re drawing that you come to know it in a way that’s much deeper than dissecting it or just looking at it in a book. It’s a very different relationship to being with the cadaver, or the bone. Drawing in the anatomy lab is much more open ended; it’s just about the process of learning and drawing. You don’t have to memorize anything, or have a test afterwards, so it’s very relaxed, freer. There’s also a mindfulness that you get into when you’re drawing, that I thought would also be a good experience for doctors-to-be, just to have a different connection to the bodies. Another aspect is the idea of individuality, which is an important part of gross anatomy. The fact that there are all these different cadavers, all these different people, and each one is different from the others. The students get to look at different ones and see all these anomalous things. But when they’re looking at the anomalous things, it’s largely to see pathologies, or things that are wrong. Obviously they need to learn that sort of stuff, but my approach, especially as someone with scoliosis, is more to just appreciate the individuality; that we’re all different inside, just as we’re all different on the outside.



The class is held in the anatomy lab. When you enter, there’s a study room in the middle, with just tables. You don’t see any cadavers when you first look in. And then on the two sides there are two rooms that have all the cadavers. We first meet in that middle room, and I start them off with drawing bones. Next, I give them a tour of the cadavers, especially for the ones that haven’t been in the lab before, and when they’re ready, I let them start drawing in there. Sometimes we actually take out a heart or a lung from the cadavers on a tray, and they draw it. It can be a little tricky, because we have to depend on what stage the students are at in dissecting: when they've just begun, there's not much to look at or draw, and when they're almost done, the cadavers may be hard to look at. But we manage to find something to draw at all these different stages.




In the beginning, I tried to get the students to talk about the emotional side of being in the anatomy lab. Some did, but others were resistant, and would just say "We’re fine. After the first day we got used to it." Which is probably true on one level, but on another level, there has to be a lot going on - it’s such a profound experience. But when you’re drawing, you’re expressing yourself, whether you like it or not. Something’s coming out of you - especially if you’re drawing from a cadaver or a part of one. You’re bound to be, on some level, dealing with feelings. To let it happen, in an open, non-judgmental environment, has an effect. And students do talk to me at different times about the deeper issues of being in the anatomy lab, how they deal with that in different ways…

The biggest problem for students is time, so the class is a treasured thing. They can’t always make it to every session. But the ones who do come, I think it means a lot to them. I’ve been very amazed and interested to find how many of the students actually have some sort of arts background, or humanities background, and for them it’s a link to a whole other side of themselves that they may feel they have to put aside in medical school. So it can be very meaningful - their drawings are something they can show to their friends and family- they can make that connection to the other side of their interests that they had before they started medical school.

Laura Ferguson's exhibit will be on display until August 13th. An exhibit of student work is scheduled for November.

Editor's Note: I met Rachel Hammer, a third year medical student and MFA candidate at the Mayo Clinic, last month at the American Society of Bioethics and Humanism conference in Minneapolis where she presented a poster about a student poetry group. When I mentioned that I worked at Bellevue, she told me about a recent meeting at the medical school where the novel, Tinkers, was discussed in a narrative medicine group. Tinkers, as many of you know, was published by the Bellevue Literary Press and received a Pulitzer Prize for fiction. I asked Rachel if she would write about the group and its discussion of Tinkers.

Commentary by Rachel Hammer, MS3 and MFA Candidate, Mayo Medical School

The Mayo Clinic College of Medicine's Narrative Medicine group started in response to an ornament in Evelyn Waugh's Brideshead Revisited. A skull sits in a bowl of roses in the dorm room of Waugh's protagonist, Charles Ryder, in a section entitled, "Et En Arcadia Ego." Arcadia, legend has it, is the field described by Pliny the Elder where a shepherd wet his finger with spit and traced his friend's shadow against a tomb-the first painting-suggesting whilst setting the precedent that art is inspired when humans face their mortality. Art, thus, is humankind's response to death.

After hours in the medical school anatomy lab in the first year, we had stared at skulls and the dead long enough to stir substantial need for creative expression. A group of us began to meet to read poetry and excerpts from novels. I had read Rita Charon's Narrative Medicine, and visited the Masters Program at Columbia, where I learned some basic exercises in "attention, representation, and affiliation" and so I offered to facilitate the sessions. We are graciously funded by the Walt Wilson Art in Medicine grant. Our group meets for lunch once a month and is open to all medical students. Students sign up to attend, and we cap the group at twenty members. I choose the excerpts, usually something I come across in my MFA coursework.

For the October meeting I chose to read from Tinkers by Paul Harding, a work that I thought would resonate with first year students going through the emotional and physically arduous anatomy block. The excerpt (pages 178-184), was the touchstone for a discussion on experiences of cognitive dissonance when bearing witness to humanity out of context, such as the discomfort one may experience in dissecting a cadaver.

Tinkers is broken into segments with alternating narrators, Howard, the father, and George, his son, each tell the stories of their lives, with modest overlap. Real time in the book works backward, counting down the last days of George's life; time within memories works forward. Father and son as co-protagonists are like two gears, intimately related and yet spinning with force and purpose all their own.

In the excerpt, George, near death, loses consciousness in the living room where he lay in his bed surrounded by family. As always in our Narrative Medicine group practice, we read the passage to ourselves, closely, deliberately. Then we read the passage again, together, aloud. We then discuss what we recognize, what surprises us, and what it means to us, today, as we chance to encounter it.

We were struck by the language of natural elements Harding used to describe the dying bodies: Salt, wood, minerals, legs like planks, feet like lead weights, salt-cured, metal strengthened, dried veins, strong as iron chains, exhausted engine, bushings. Someone remarked that in other settings, when humans are described reductively in terms of their elemental components, their inner workings likened to the machinery of a clock, we are repulsed. How dare we consider humans as mere material! But in the space of death, written with the reverence of a poet, George returning to mere material is a beautiful, honorable fate. Recognizing that George spent his life as a clockmaker-that there was nothing for which he had more passion than clocks-his, then, is a righteous transfiguration indeed; that in death, he would morph to resemble the very thing he most loved in life, the wood, the chains, the lead weights, the bushings of a clock.

One student linked the end of the passage (p.184) to themes of TS Eliot (The Four Quartets was a previous reading in this group). She recognized the confusion of time in the space of death and grief-"imagining was as it is still approaching"-as a collision of past and future. Sharing our fears of death for ourselves, worry of bodily pain, we saw in ourselves the family Harding describes hovering around George:

(…"that they mourn because of the inevitability of the was and apply their own wases to the it [dead body], which is so nearly was that it will not or simply cannot any longer accept their human grief) as its broken springs wound down or its lead weights lowered for the last, irreparable time."

We discussed the extent to which our efforts in palliation and comfort are more for the provider than the patient. How some things are irreparable, and how seldom we can admit this to ourselves.

Since this passage was intended for the reflection of the first year students, as they loom over their assigned dead bodies like belated Fates, I asked them to reflect on the language in this passage while contemplating what it means to be dead, and what it means to encounter the dead. As you pick away at the crust of another human, now lifeless, out of context, consider the story that lies beneath. Our bodies, universes unto themselves, are, in fact, neither simple nor always logical, but ever so elegant.

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

In previous articles in the Literature, Arts, and Medicine blog we discussed sowing the seeds of Medical Humanities in the Himalayan country of Nepal; teaching Medical Humanities (MH) in English which, though the language of instruction, is not the native language of the participants; and also the challenge of creating and maintaining participant interest in MH.

MH was started as a voluntary module at Manipal College of Medical Sciences (MCOMS), Pokhara (1) and then we (PRS and RMP) conducted modules for faculty members at KIST Medical College (KISTMC), Lalitpur. In 2009 and 2010 we conducted modules for first year students at KISTMC. In this blog article we describe what in our opinion worked in the four modules and what did not and reflect on possible reasons for the same. Our experiences may be of interest to other MH educators, especially in developing countries.

What Worked

Small groups:

Small groups worked well in all four modules we organized and are an excellent way to learn MH. Small groups work together at a given activity and share ideas. In MH, unlike other more formal medical subjects, there may be no particular well defined solution of a problem. Participants mainly reflect on a painting, a case scenario, or a problem and share their views. In social sciences as opposed to the biological and physical sciences there may not always be a 'particular' way to solve a problem. One problem we faced was that not all members of small groups were active. We could only gently nudge the reluctant individuals into more active participation. We tried giving participants greater responsibility for self-managing small groups. We asked the groups to select from among themselves a group leader, a time keeper, a recorder and a presenter and rotate these roles during different sessions.

Paintings:

Paintings were a great success. We incorporated them more and more in successive modules. We have described our experience of using paintings in MH in a recent article. (2) Our major source of paintings was the Literature, Arts, and Medicine Database maintained by New York University. The database arranges literature excerpts, paintings, and videos according to different subject categories. Online access to photos of paintings and their annotations were useful. Participants were able to relate to the paintings, which were mainly from a western context. In Nepal only students from a science background take up medicine and most were not previously exposed to art appreciation and critical analysis of paintings. Most participants enjoyed the paintings but also recommended more use of art from Nepal.

Case scenarios and role-plays:

These were extensively used throughout. The case scenario usually had an ethical or a social issue which had to be explored wit role-plays by participants. A variety of issues such as diseases with social stigma, abortion, euthanasia, mental illness, patient confidentiality-among others-were explored. Student participants enjoyed role-play and interpreting different scenarios. Students brought out many issues and sometimes interpreted the scenario in a novel manner. Role-plays in KISTMC also served to bridge to a certain extent the language barrier as they were conducted in Nepali, the national language. We also introduced an exercise of interpreting scenarios depicted in paintings using role-plays, which was extremely popular with students. Interestingly, participants of the faculty module had problems with certain role-plays dealing with sexual and reproductive issues.

Debates:

Debates were used to explore certain issues in MH, for example, euthanasia, whether students from non-science backgrounds should be allowed to take up medicine, the nature of the doctor-patient relationship. Participants enjoyed debates but due to time constraints, full fledged debates-which require more thought and deliberation-could not easily be organized. Debates were more effective in the recently concluded MH module (2010). Students showed greater interest in the module as evidenced by their greater participation in group activities and high attendance (above 80%) even before assessments. In light of our previous experience, we modified the format so that the group/s speaking for the proposition would first put forward their points and then the group/s speaking against would counter those points. In addition to arguments prepared during the ten minutes allotted to the activity, students also had to oppose arguments put forward by the opposing group/s on the spot. We concluded that debates can be a good way to explore controversial issues.

Flip charts and flip boards:

These have the advantages of flexibility and ease of use. Flip charts are an excellent way for noting down the results of small group work and for small groups to present their findings to the whole house. We have been using flip charts effectively during Pharmacology practical sessions. During MH sessions flip charts were used to note main points and by presenters to guide their presentations. Flip charts are an excellent way for noting down the results of small group work and for small groups to present their finding to the whole house. On reflecting after the sessions it was our opinion that participants used flip charts in the same manner during both MH and Pharmacology practical sessions. Flip charts could have been used in a more creative manner during MH sessions. Certain groups did so but we could have developed and given guidelines to the groups. Creativity also may require a certain amount of artistic talent and ability among group members.

Venue of the sessions:

All student sessions were conducted in the college auditorium. The auditorium offers an empty space about 30 m x 30 m which can be arranged and organized to meet specific requirements. Students could be arranged in small groups with a separate area for role-plays and a main projection area. The only problem was the auditorium was being used for a variety of activities and we had to rearrange it before each session. A free area that can be reconfigured and rearranged to meet specific requirements is ideal for small group sessions that require creativity and flexibility, unless you can get a dedicated area for sessions, which can be difficult in developing nations.

What Did Not Work

Literature excerpts:

Literature excerpts have been widely used in MH sessions in the west. In the module at MCOMS, Pokhara, and in the faculty module at KISTMC we used literature excerpts. The excerpts were in English and participants often felt they were difficult to understand and the language was difficult. In MCOMS the participants were multinational. In KISTMC the major problem was getting literature excerpts in Nepali relevant to MH and the particular topic being covered. For English excerpts the Literature, Arts, and Medicine Database made the task easier as excerpts were arranged according to subject matter. We did not use literature during the two student modules; however, considering the complexity of issues which can be provoked and addressed by good literature we are thinking about how to incorporate it in future modules.

Reflective writing assignments:

MH is basically a process of reflection about various events in medicine. Reflective writing can be a good method to get participants to reflect. We tried giving reflective writing assignments to participants, but only participants in the MCOMS module, which was voluntary, were regular in submitting their assignments. Assignments were not used in the faculty module. In the 2009 student module submission was irregular. In the 2010 module students submitted more regularly. In South Asia compared to the west students are younger and less mature when they enter medical school. There is a dichotomy between arts and science in the education system. Creative writing and keeping a personal diary are not very common. These could be reasons why students were not very comfortable with reflective writing. However the interest and participation of the 2010 batch gives us hope that this could be a modality to be considered in future.

Medical Humanities online:

We created a medical Humanities group on the web (a private Google group). Slides of various topics, other material and selected publications related to MH were uploaded. There is also a discussion forum where individuals can discuss and comment on various topics. Participation in the group is voluntary. We invited selected faculty and other experts and sent an invitation to all students who participated in the module. Problems of net access, lack of time, and a hectic academic schedule were cited as possible reasons for not joining and not being active in the group.

Creating interest among other faculties:

Over the four years of MH only few faculty members were interested in being module facilitators. During the 2009 student MH module six faculty members from various departments joined as co-facilitators. Many of them were not entirely comfortable with small group learning and with using art and role-plays in medical education. Many were clinicians and their tight clinical schedule could have been a hindering factor. During informal discussion with western MH educators a factor which emerged was only faculty with a personal interest in the arts or with a hobby related to the arts like photography, painting, sculpture and creative writing may be interested in MH. Lack of success in creating new facilitators may be a limiting factor for the module in future.

Creating linkages with persons outside the traditional world of medicine:

In the west MH programs use resources and facilities from many sources. Artists, writers, philosophers and others have made a significant contribution to MH. In the west most medical schools are in a University sharing a campus with other disciplines while in Nepal medical schools usually exist in isolation. We were successful to a certain extent in that we wrote about using art in the education of doctors for a Nepalese magazine and created a certain amount of interest among people outside traditional medicine. The challenge will now be to transform interest into action.

The situation in South Asia is in many ways different from the west. Also batches of students and individuals vary in their interests and aptitude. Tailoring a module to meet the aspirations of groups and individuals is a challenge. Flexibility and an open mind could be important in meeting the challenge!

References

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

2.Shankar, P. R. and Piryani R. M. Using paintings to explore the Medical Humanities in a Nepalese medical school. BMJ Medical Humanities 2009; 35:121-122.

Commentary by Amy Ellwood, MSW, LCSW; Professor of Family Medicine & Psychiatry, University of Nevada School of Medicine, Las Vegas, Nevada

Communicating Through Story

Storytelling has been around since the dawn of time. Before the invention of paper, the Gutenberg press, telephone, television, internet, Kindle, texting, tweeting, Skyping, and emailing, people communicated by actually talking to each other face to face. Before language evolved, animal species communicated through grunts, howls, screeches, and gestures. Body language and micro expressions say more than most verbal communication (Ekman, 2003).The story teller often had a place of status in tribal cultures because he/she was the keeper of the tribe's history. When there was no written word, people would gather around the fire and tell stories. Stories provided entertainment, education, history and cultural preservation (Biesele, 1986). Adults and children alike, fully present, would sit with each other listening to the stories. Sharing time and history helped to develop a sense of community and adaptation.

Today many of the younger generation communicate with electronic devices in incomplete sentences and symbols rather than talking to another person. The context and body language are obliterated. Watching someone fixated on an inanimate smart phone while texting reminds me of a baby mesmerized while watching a crib mobile. Smart phones have positive uses but the list of problem behaviors associated with smart phones is growing (Bianchi, Phillips, 2005). Some of the problems include "BlackBerry Thumb" (Avitzur, 2009), texting tendonitis (Menz, 2005), increased risk for automobile accidents, escape from aversive situations, loss of sleep, decreased work productivity, excessive mobile phone bills, and others.

Reading Stories with Resident Physicians

Within the medical culture, communication is often a staccato-like list of acronyms and laboratory data shared among medical professionals. Translating this information into a language that the patient or patient's family can understand to make informed decisions is difficult for some clinicians. Developing empathy for those experiencing a health crisis and teaching about empathy can be challenging. Some feel that you either have it or you don't, based on lessons learned in the family of origin and quality of attachments. Using medical humanities concepts and tools to teach about ethics, empathy and other issues is a newer approach in medical education that is becoming more prevalent.

Several years ago I attended a family medicine conference where one of the workshops was on medical humanities. We read poems, short stories and discussed ways literature could be used to teach in medical education programs. I had been using movie segments to teach about various behavioral science topics for years (Alexander, 2005). Following the humanities workshop, I decided to try something new that would be more interactive.

Family Medicine and OB/GYN Residents Read "Indian Camp"

After perusing many short stories from my own library, I selected "Indian Camp" by Ernest Hemingway. Resident teaching conferences are usually one hour. It was important to find a story that was not too long or too short, too simple or too complex. This is a short story of a white physician who is called to an Indian camp in the Great Lakes area to assist an Indian woman in prolonged labor. The white doctor takes his young son and the child's uncle along. Other characters in the story include the birthing Indian woman, her husband, an old Indian woman, and the Indian guides. The woman has been in labor for days and is not progressing. Her husband lies in the bunk above her because he had cut his foot with an ax three days before. The doctor tells his young son that, "her screams are not important". The doctor does a crude C-section while the young boy witnesses the birth of the infant. In the bunk above, the Indian husband slits his throat from ear to ear and the blood pools down to the bunk below. On the way home, the young boy asks his father if ladies always have a hard time having babies and wonders if many men kill themselves. The doctor tells him that no, not many men kill themselves and that birthing babies is not difficult. The white men then get back in the canoe and return to their white world.

"Indian Camp" can be read in 10-15 minutes, although resident physicians whose primary language is not English might need more time and might not get the subtle nuances of the story. The story is an initiation story from life to death. The images of light and dark mirror the events in the story and the author's own life. "Indian Camp" is filled with issues for discussion: gender, culture, power, Native American healing practices, suffering, suicide, impact of witnessing trauma on a young child, and much more. After the residents read the story, I had them break into groups of 2-3. A colleague helped make fold over name cards that were placed on the table in front of each group. Each card had the name of one of the characters in the story and with a clip art picture of the character.

The story is told from the perspective of the doctor's son, not from that of the birthing mother. The residents were asked to tell the story from the perspective of the other characters. As a family systems trained clinician, I have learned to listen to the other voices in the family narrative. Medical education tends to focus on one system using a high powered lens. Asking probing questions about the other characters’ perspectives helped residents to see from a wider lens.

Another faculty member and I started the discussion by asking, "Is Dr. Adams a villain or hero?" What did it mean when he didn't hear the woman's screams? Why did he bring his young son along? Why was the uncle there? Why did the Indian husband kill himself? What was it like for the Indian medicine woman to have a white male come in and take over? These are questions that resonated in my mind when reading the story for the first time.

The family medicine residents quickly focused on the issues of gender and power as well as what it must have been like for the Indian medicine woman to have a white male physician come in and take over the care of the laboring Indian woman. In many tribal cultures, men are not allowed in the birthing hut. Family medicine residents wondered why the doctor used crude instruments rather than bringing his own instruments. All of the family medicine residents expressed concern for the doctor's young son who witnessed the traumatic events. When discussing why the doctor did not hear the woman's screams, the OB-GYN residents voiced that the doctor was focused on doing the C-section to save the woman and the infant.

Reading "The Yellow Wallpaper"

I tried the process again with "The Yellow Wallpaper" by Charlotte Perkins Gilman after finding Tucker's article about reading this story with medical students (2004). "The Yellow Wallpaper" is rich with issues for discussion. Postpartum psychotic depression, repression of women's intellectual interests and role outside the home as well as the ethics of the physician husband treating his wife offer a plethora of possibilities for discussion. Gilman's story is longer than "Indian Camp" and took the family medicine residents 25-30 minutes to read. This left only 30 minutes to have the discussion from various perspectives. Residents reported that they were not used to reading stories with such flowery language and found it less enjoyable than "Indian Camp". Most of our residents are currently male but the one female resident found it pleasurable reading. None of the family medicine residents were familiar with "The Resting Cure" that was prevalent in the early 1900's.

Final Comments

There are always a couple of residents who ask, "Why are we doing this?" "How will this help me run a code?" I only read medical journals, why do I have to read this?" The majority of the family medicine residents did not question the validity of this teaching process. The OB-GYN residents were initially very reserved not knowing what to expect but then became activated as the story unfolded. As the process evolved, the facilitators were less directive and the group took off. As in most groups, the group does the work! At the end of the hour, residents were making positive comments about what an enjoyable learning experience this was and that they would like to do it again but with stories that were more like "Indian Camp" than like "The Yellow Wallpaper".

During the past six years I have utilized "Indian Camp" three times with family medicine residents and once with OB-GYN residents. I used "The Yellow Wallpaper" once with family medicine residents and plan to use it with psychiatry and OB- GYN residents in the future. It will be interesting to see how the process evolves with different specialties and to learn which issues become the focus of the discussion.

References

Alexander M, Lenahan P, Pavlov A (Eds). Cindemeducation: A Comprehensive Guide to Using Film in Medical Education, Oxford: Radcliffe Publishing, 2005

Avitzur O. Rx for BlackBerry thumb, Consumer Reports, January 2009, p. 12

Bianchi A, Phillips JG. Psychological predictors of problem mobile phone use. Cyberpsychol Behav. 2005 Feb; 8(1): 39-51

Bisele M, How hunter-gatherers' stories "make sense": semantics and adaptation, Cultural Anthropology, Vol 1. No. 2, The Dialectic of Oral and Literary Hermeneutics (May 1986), pp. 157-170

Ekman P. Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life, New York City: Henry Holt and Company, LLC, 2003

Menz RJ. "Texting" tendonitis. Med J. Aus. 2005, March 21, 182:6: 308

Tucker P, Crow S, Cuccio A, Schleifer R, Vannatta JB. Helping medical students understand postpartum psychosis through the prism of "The Yellow Wallpaper" by Charlotte Perkins Gilman, Academic Psychiatry 2004, 28: 247-250

Commentary by Katherine D. Ellington, Class of 2011, St. George’s University School of Medicine; Creator, Producer and Host, AMSA National Book Discussion Webinars

Over the last year, I've had the opportunity to create, develop and implement the American Medical Student Association (AMSA) National Book Discussion Webinars. A diverse group of physicians have discussed their books, writing pursuits, work experiences, and lives. The AMSA National Book Discussion Webinars offer a unique online experience between physician-authors and medical students to encourage reading beyond the medical school curriculum, both for professional development and for personal enrichment. The group of physician-authors selected represent a cross-section of backgrounds and their books were chosen based on relevant themes to engage the AMSA community.

New technology: What is a webinar?

Webinar technology is a new tool emerging in the world of medicine and elsewhere, making it possible to connect people beyond conference calls and e-mails. During webinar sessions online participants have the opportunity to watch, listen, use text chat, ask questions and have a discussion with the presenter and host. There's also a presentation area for slides and document sharing. Desktop sharing and audience polling are also possible. The real-time session includes time for questions or discussions either via chat or live by phone or VoIP (voice over Internet Protocol) for a complete online experience.

While some physicians presenters were concerned about being able to use the technology, doing a trial-run before the session made it possible to setup and then present during the actual webinar with ease. Physician comments indicate overwhelmingly positive experiences with the webinar technology.

Exploring texts beyond the medical school curriculum

The inaugural session was held in February 2009 with well-known psychiatrist-author Samuel Shem, M.D.(pen-name of Steve Bergman, M.D., Ph.D.) discussing his new book, The Spirit of the Place, along with his Annals of Internal Medicine article, "Fiction as Resistance." In contrast, the following month a young cardiologist and physician-writer Sandeep Jahaur talked about his book, Intern, and New England Journal of Medicine essay "The Demise of the Physical Exam." The webinar sessions have allowed for conversations beyond the books and articles selected; for example Dr. Katrina Firlik's discussion about women in medicine offered themes beyond her memoir Another Day in the Frontal Lobe. Neurosurgeon Nozipo Maraire participated in this session as a special guest to provide her insights on family life and medicine. Dr. Maraire's work of fiction Zenzele: A Letter to My Daughter, was written during the long nights of her residency training at Yale.

AMSA National Book Discussion Webinars have also touched on dilemmas within health care. Dr. Audrey Young's discussion of her latest book, The House of Hope and Fear: Life Inside in a Big City Hospital, helped us think about how the commitment of public hospitals to indigent communities is complicated by the need to control health care costs, and how the complexity of "cost-shifting" becomes the physician's burden and affects everyone. This conversation continued on through the summer to the fall when Dr. Young joined in a dialogue with pediatrician and health policy expert Dr. Fitzhugh Mullan. In this webinar on Narrative Matters, Dr. Mullan described health policy writing as political narrative that falls between editorial and short story memoir.

"I was telling stories that were pertinent to people's concerns about health care and that were, to some degree, a goad to those in charge. My writing was an invitation to change things."
Fitzhugh Mullan, M.D.

Like Samuel Shem, Dr. Mullan and Dr. Young talked about their writing as a tool for advocacy and activism in medicine, a long-held AMSA theme.

Bringing physician's stories closer to students

Book titles have been selected in some cases many months in advance, yet the webinar announcements and schedule give participants at least a few weeks to read the book and articles before registering and joining a webinar session. The selected articles provide a glimpse of the physician's writing in a different context. The hour-long program format also allows for a "reader's response" when participants can take a few minutes to comment about their perspectives on a book and/or article, further enriching the dialogue. These webinars close the distances that separate dispersed but enthusiastic students who read and wish to share in a group experience.

To date, the AMSA National Book Discussion Webinars has had more than 500 participants and 18 physician-writer presenters. Webinars are scheduled to accommodate physician and physician-in-training schedules in order to encourage participation of a national audience. Each webinar session is limited to 25 participant connections; preference is given to AMSA members and chapters viewing as groups. Feedback and audience survey results indicate positive experiences among participants. The power of physicians' storytelling resonates through these webinars that connect storytellers and medical and premedical students, interns and residents, physicians, health professionals, and those in the medical humanities field. The live webinar is authentic and allows for an informal, shared experience and unique learning opportunity.

For further information: bookdiscussiongroup@amsa.org

References

Firlik, Katrina. Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside. New York: Random House;2007

Jauhar, Sandeep. Intern: A Doctor's Initiation. New York: Farrar Strauss Giroux;2009.

Jauhar S. The demise of the physical exam. N Engl J Med. 2006;354(6):548-51.

Maraire, Nozipo, Zenzele: A Letter to My Daughter. New York: Delta;1997

Mullan, Fitzhugh and Ficklen E. ed. Narrative Matters: The Power of the Personal Essay in Health Policy. Baltimore: Johns Hopkins Press;2006.

Shem S. The Spirit of the Place. Kent: Kent State University Press;2008.

Shem S. Fiction as resistance. Ann Intern Med. 2002;137:934-7.

Young, Audrey. The House of Hope and Fear: Life in a Big City Hospital. Seattle: Sasquatch Books;2009.

I’d like to call attention to yesterday’s announcement of the 2010 PEN/Faulkner Award for fiction, Author Sherman Alexie is the winner for fiction (War Dances, annotated in the Literature, Arts, and Medicine Database) and if you haven’t read any of his work you are missing a treat. He is a prolific author of essays, fiction, poetry, and also wrote three screenplays. Figuring in much of his work are his experiences as a Coeur d’Alene/Spokane Indian who lived on the "rez" interfacing with "white" society and who continues to span these borders off the reservation. His style and point of view are unique — humorous, perceptive, original, pointed, poignant. Coincidentally, I had just finished annotating and posting the film, Smoke Signals, for which Alexie wrote the screenplay, when I learned that he was the recipient of this award. Every time I watch that film I find something new to savor so I was particularly pleased to learn of this award.

Felice Aull

Commentary by Hedy S. Wald, Ph.D., Clinical Assistant Professor of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI

May, 2006. We treated our Doctoring small group to a nice home-cooked meal to celebrate the conclusion of their first year of medical school-eight students, two lucky teachers. Students, after all, are hungry for knowledge but they're also hungry. We had grown to know these now 25% doctors through didactic but more so through their reflective narratives that we were privileged to receive and respond to…After dessert, I surprised each of them with a personalized binder of all their narratives plus the written feedback they had received over the course of the year from their co-teachers-Hedy (me), a clinical psychologist and Steve, a family physician. The teachers lugged home extra large binders with all the students' writings and feedback, precious cargo indeed. I hoped the students would hold onto the experience, maybe even look back one day upon those texts, tangible evidence of their metamorphosis. I got choked up that evening. With good reason.

It is a mysterious process, this reading and responding with written individualized feedback to students’ reflective narratives as we accompany them on their journey of personal and professional identity development. Rita Charon captured the awe: "What a remarkable obligation toward another human being is enclosed in the act of reading or listening" (1, p.53) This became my mantra as I diligently typed at my computer, striving to craft meaningful, quality feedback to the students’ narratives that had sailed across cyberspace to land on my screen. I tried hard to establish a "comfort zone", a trusting "mentor" relationship where an embryo doc could safely share vulnerabilities and uncertainties, personal angst and yes, triumphs, dramatic moments and perhaps even more meaningfully, everyday moments of caring that should be recognized by a self-aware, mindful practitioner (student and teacher alike). And, I learned, it wasn't a bad idea to keep "oven mitts" (2) nearby for the "hot" stuff, the personal and/or professional content that can be challenging for both writer and reader, albeit less frequently encountered. Life is not sanitized, homogenized, or neatly packaged. Neither are narratives.

Interactive Reflective Writing

Some background. Several years ago, Warren Alpert Medical School of Brown University (Alpert Med) included an interactive reflective writing innovation within their Doctoring course (3) for first and second year students; the current curriculum includes this as well. I was there from the get-go. Students send confidential "field notes" by email throughout the year- in response to structured narrative prompts on patient encounters and other topics-and receive written feedback from an interdisciplinary team. Early on, I sensed something special unfolding…Narrative medicine enthusiasts will not be surprised to hear about the perceived benefits of hearing a student’s voice within narrative (valued as distinct from the usual group dynamic), witnessing the representation of their experience in the written word to give it meaning, and deepening learners' reflective capacity through this process. "Clinicians donate themselves as meaning-making vessels to the patient who tells of his or her situation", Charon observed (1, p.132)…And the embodiment of this? The meaning-making vessel of narrative. Written feedback, I would suggest, is potentially a "meaning-making vessel" in its own right. Indeed, the "interactive" nature of this paradigm has pedagogic value, students have noted, as they appreciate writing with an "audience" in mind. (4) Narratively humbling indeed for those in that audience. (5)

Narrative content in a longitudinal context, Steve and I noticed, documented our students’ learning journey. But what of the teachers, the "seasoned travelers"? (6) It’s not about us, it’s about them (our learners). I know this. But maybe, just maybe, it’s about us too. Narrative connects on so many levels. We know this. It reminds us, inspires us, nourishes us. Students’ revelations within confidential interactive reflective writing can have a powerful impact, touching one’s heart and soul. Through authentic engagement, I found that their writings about clinical encounters (including personal and professional issues) served as narrative triggers for my associations. I experienced a flow, sometimes tidal wave of cognitive and affective responses, personal and clinical recollections, a potential treasure trove to share. Yet I would not share it all; educational responsibility prevails, judgments need to be made, and students don't want to read novels on their narratives anyway. Ultimately, something about this experience resonated with a key concept I had learned in narrative medicine: the "parallel chart" teaching tool, (1) inviting further contemplation.

Rita Charon appreciated the value of considering the nuance and texture of patients' experiences of illness as well as what students themselves were undergoing in providing patient care, even though "you cannot write that in the hospital chart, we will not let you". (1, p.156) "And yet", she instructed clerkship students (and later, residents as well), "it has to be written somewhere. You write it in the parallel chart" (1, p.156) In similar fashion, I suggest, the teacher's experience of the student's narrative, of the student's "narrative writing in the service of the care of a particular patient" (1, p.157) can be considered a "parallel 'parallel chart'". In essence, my narrative writing evoked by the student's text is in "the service of the care of a particular student", regardless of whether all of it or none of it appears in my formal written feedback.

The Teacher's Experience

What of this living organism, this "parallel 'parallel chart'"? Might it offer opportunities for a parallel process of transformative growth of a teacher? Let the student's narrative "brew". (7) Allow the narrative to speak to us, guide us, enhance our awareness, then trust our instincts, use our curiosity, and sift through our "parallel 'parallel chart'" to craft feedback of substance and worth…all in the service of the student, yet with mutual benefit. Let the teacher's narrative "brew" too. Professor Lee Jacobus' observation that "time moves on once the book is gone from the writer's hand and the writer is no longer the person who wrote the book" is germane (blog review of Margaret Atwood's Negotiating With the Dead: A Writer on Writing). (8) The student is no longer the person who wrote the reflective narrative; neither, I would assert, is the teacher who responded to it. It's called Education. And it gives "faculty development" a whole new meaning. The intersubjective process of transformative growth (1), I now realize, is not the student’s sole proprietorship. (9)

So we sift, filter, craft, and mold our "parallel 'parallel chart'" for most effective educational impact. My research colleagues at Alpert Med (Drs. Reis, Monroe, and Borkan) and I recently offered the BEGAN tool, the Brown Educational Guide to the Analysis of Narrative to help guide faculty with this process, describing integration of personal and clinical experiences, reflection-inviting questions, elements of close reading, as well as student text quotes within written feedback to students' narratives. (10) Be a "generous listener" (11) but more than that, use that "parallel 'parallel chart'" to support and challenge the learner toward deeper reflection, understanding, and meaning making. Oh, and be sure to pause before hitting the SEND button, we advise, to avoid foot in mouth disease and other such maladies.

Concluding Reflections

The literature is replete with explorations of what doctors find meaningful about their work, what it is that sustains them-making a difference in someone's (the patient's) life is often mentioned. (12) Within medical education, connecting to students through their narratives about connecting with patients can help make a difference in students' lives and our own. "Learn from every patient", the teacher teaches the student. "Learn from every student", the narrative teaches the teacher. And we do. Impressed with the power of narrative, a primary care doc, for example, recently remarked to me that reading and responding to students' narratives was helping remind him why he went into this business. As for me, I've grown as a teacher, colleague, and writer. Teacher me now routinely uses my "parallel 'parallel chart'" (with deepened insights) and BEGAN tool to craft what I hope is useful, meaningful individualized feedback to reflective narratives in the Alpert Med family medicine clerkship. My colleague self "ping-pongs" ideas (based on my response flow) with co-facilitators within small group teaching and with research colleagues, sparking creative output. I'm also fortunate to be able to reflect on their written feedback to students derived from their own "parallel 'parallel charts'". As a writer, narrative flow has led to gratifying creative and academic writing accomplishments; JAMA, Newsweek, Academic Medicine, and more. Correlation does not imply causation, but it sure feels that way. It's been a remarkable journey.

I ran into one of my original first-year Doctoring course students recently at an Alpert Med seminar. He looked good, more polished and self-assured, excited about Match Day in March, he told me. We took a moment to reminisce about the "good ol' days" of Doctoring and my, how time had flown. "I still have the binder", he grinned as he walked away and made my day. "So do I", I whispered, "So do I".

References

1. Charon, R. Narrative medicine - honoring the stories of illness. New York: Oxford University Press, 2006.

2. Ellis, K. Plenary on Close Reading. Advanced Narrative Medicine Workshop - Program in Narrative Medicine. College of Physicians & Surgeons of Columbia University, June 23, 2008.

3. Monroe A, Ferri F, Borkan J, Dube C, Taylor J, Frazzano A, Macko M. Doctoring. Providence, RI: Warren Alpert Medical School of Brown University, 2005-10.

4. Wald HS, Davis SW, Reis SP, Monroe AD, Borkan, JM. Reflecting on Reflections: Medical Education Curriculum Enhancement with Structured Field Notes and Guided Feedback. Acad Med, 2009; 84(7): 830-7.

5. DasGupta, S. Narrative Humility. Lancet, 2008; 371: 980-1.

6. Kerka, S. Journal writing and adult learning. ERIC Dig., 1996; 174:1-4.

7. Wald HS, Reis SP. A Piece of My Mind. Brew. JAMA, 2008; 299:2255-6.

8. Jacobus, L. http://literatureartandideas.blogspot.com/ [Accessed February 16, 2010].

9. Wald, HS. I've Got Mail. Fam Med, 2008; 40(6): 393-4.

10. Reis SP, Wald HS, Monroe AD, Borkan JM. Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative): A framework for enhancing educational impact of faculty feedback to students' reflective writing. Patient Educ Counseling, 2010; doi:10.1016/j.pec.2009.11.014.

11. Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional Formation: Extending Medicine's Lineage of Service Into the Next Century. Acad Med, 2010; 85(2): 310-7.

12. Horowitz CR, Suchman AL, Branch WT, Frankel RM. What Do Doctors Find Meaningful about Their Work? Ann Intern Med, 2003; 138(9): 772-5.

Commentary by Jack Coulehan, M.D. M.P.H., Professor Emeritus of Preventive Medicine and Fellow, Center for Medical Humanities and Bioethics, Stony Brook University, New York

Many authors who write about empathy in medicine are careful to draw a bright line between sympathy and empathy. For example, Hojat in his excellent survey of research on Empathy in Patient Care, considers the two concepts as almost dichotomous, albeit with a small area of overlap. (1) In this categorization, empathy is a cognitive attribute that allows us to understand the selfhood of another person, or, as Hojat puts it, "the kind and quality of the patient's experiences." (1, p. 12) Alternatively, sympathy is an affective or emotional attribute that plays a somewhat ambiguous, if not detrimental, role in medical practice. The bottom line message is that experiencing too much sympathy for patients distorts the clinician's medical judgment, thus harming the patient; and at the same time causes the clinician to "absorb" too much suffering, thus leading to professional burn-out. Interestingly, these authors seem unconcerned about the question of too little sympathy. Presumably, they agree that clinicians ought to care for their patients, i.e. feel-for or have compassion. Therefore, they must believe that a modest amount of sympathy is essential for patient care, but they never discuss how to develop or maintain sympathy. Their main concern is that it not be confused with empathy.

Empathy

Empathy is a hard nut to crack because it challenges the conventional medical opinion that thinking is thinking and feeling is feeling and never the twain shall meet. Empathy is a process by which we try to understand other people's experience: how they feel, where they are coming from. To the extent that we accomplish this, we are considered empathic and should score highly on a reliable test of this quality. Thus, empathy is a cognitive process, but the content (the known) includes emotions. To "know" emotions we have to feel them. Jodi Halpern uses the term resonance emotions to describe these feelings generated in the clinician as she practices empathy. (2) She writes, "The special professional skill of clinical empathy is distinguished by the use of this subjective, experiential input for specific, cognitive aims. Empathy has as its goal imagining how it feels to be in another person’s situation." (3)

I speak of "practicing," rather than "having," empathy because I want to focus on the professional skill component, rather than the natural endowment (i.e. more or less hardwired) component. In Howard Spiro's famous essay "What is empathy and can it be taught?" he answers the second question with a qualified "yes." He writes that "a better question might be, 'Can we recover the empathy we once had?'" (4) Arguing that the process of medical education tends to diminish our openness to others' feelings and experience, Spiro believes that enhancing clinical empathy is more of a restoration project, rather than a pedagogical one. Perhaps he overstates the case, but it is clear that medical education tends to narrowly focus students' attention on patients-as-objects, thus down-regulating their receptors for experiencing patients-as-subjects. It can be argued that concepts like detachment, detached concern, and clinical distance describe an unfortunate situation that needs to be remedied, rather than a professional ideal.

Sympathy

What does this have to do with sympathy? I take sympathy to mean an emotional state in which we desire to "feel another person's emotions better" (Hojat's language, 1, p. 11). In clinical medicine this translates to "connect with" another person's suffering. In other words, to have sympathy for a patient is to have genuine care or compassion for that patient. Perhaps it is useful to warn students against submerging themselves in excessive sympathy, but I doubt it. After many years of observing medical students, residents, and senior physicians in practice, I don't believe that over-identification with patients is much of a problem. Some doctors seem not to connect with their patients as persons. In other words, patients don't engage much of a sympathetic response. I suspect these non-sympathetic doctors would also score poorly if they were subjected to an accurate test of clinical empathy. another group of doctors seem genuinely to care for their patients. They have a great deal of sympathy for patients. However, these clinicians appear to have the emotional resilience that allows them to experience sympathetic feelings, but also maintain a clinical perspective. I suspect these sympathizers would also score highly if they were subjected to an accurate test of clinical empathy.

Empathy and Sympathy

This brings me back to the original distinction between empathy and sympathy. I agree that a distinction exists, but I submit that the relationship is more complicated than most writers portray it. In many ways sympathy and empathy parallel one another: sympathetic clinicians tend to work harder at being empathic; unsympathetic doctors tend not to devote much effort to empathy. At the same time, empathy is clearly a cognitive process by which we may approximate an understanding of another's situation and feelings, while sympathy is an emotional state of affirming the other person while experiencing something of his or her suffering.

Concluding Thoughts

Let me conclude with the following observations:
1. Empathy precedes sympathy. I can't sympathize with a person unless I have some understanding of how he or she feels.
2. Sympathy feeds empathy. My feeling-for a person's suffering makes me more likely to engage that person empathically.
3. Clinicians are more likely to be compromised by having insufficient sympathy than by having excessive sympathy.
4. My use of the term "sympathy" may be somewhat at variance with the way Hojat and others define it. However, I believe that, insofar as the versions are different, my version corresponds better with common usage, while their version, in which sympathy is considered egoistic as opposed to altruistic (1), is somewhat confusing and perhaps a straw man.

References
1. Hojat M. Empathy in Patient Care. New York, Springer, 2009, pp. 10-15
2. Halpern J. Empathy: Using resonance emotions in the service of curiosity. In: Spiro H et al (Eds.) Empathy and the Practice of Medicine, New Haven, Yale University Press, 1992, pp. 160-73.
3. Halpern J. What is clinical empathy? J Gen Intern Med. 2003; 18: 670-674
4. Spiro H. What is empathy and can it be taught? In: Spiro H et al (Eds.) Empathy and the Practice of Medicine, New Haven, Yale University Press, 1992

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.