Medical Humanities - Initiating the Journey at Xavier University School of Medicine

August 26, 2014 at 11:30 am

Dr P. Ravi Shankar has been facilitating medical humanities sessions for over eight years, first in Nepal and currently in Aruba in the Dutch Caribbean. He has a keen interest in and has written extensively on the subject. He has previously written several pieces for the Literature, Arts, and Medicine blog.

I have always enjoyed facilitating medical humanities sessions right from the time I facilitated my first voluntary module for interested students at the Manipal College of Medical Sciences, Pokhara, Nepal in 2007. The energy level during the inaugural module was incredible. The participants, both students and faculty, and I really enjoyed the evening sessions and the feeling of freedom and discovery as we did various activities and discussed different issues. We had a lot of fun.

When I joined Xavier University School of Medicine (XUSOM), on the beautiful island of Aruba in January 2013, the Dean, Dr Dubey was keen that I facilitate a medical humanities module for the undergraduate medical (MD) students. The school had just shifted to an integrated, organ system-based curriculum from the traditional discipline based model common in offshore Caribbean medical schools. Didactic lectures were the main teaching-learning methodology but the school was working towards introducing small group activities and problem based learning sessions. I decided to facilitate a short medical humanities (MH) module for the incoming first semester students.

At that time the school had only lecture rooms and a traditional desk and chair seating arrangement. Luckily the desks could be rearranged, and I conducted my first session in the lecture hall with the students arranged in four small groups. Some of the students had completed a premedical course of study in the institution and were only familiar with lecture based-teaching. Small group activity was something new for them. Medical humanities do not occupy an important position in the United States Medical Licensing Exam (USMLE) Step 1, and students in Caribbean medical schools focus on step 1 preparations. Subjects which are not tested or tested less in step 1 are not considered important. MH is thus not commonly offered in offshore schools.

The first group of students: I concentrated on six topics for the inaugural and subsequent medical humanities modules. These were empathy, the patient, the family, the doctor, the patient-doctor relationship, and the medical student. The modules were activity based and I used case scenarios, role-plays, debates and paintings to explore different subjects. The learning objectives of each session were listed in the study outline posted on the class server and also highlighted at the beginning of the sessions. For example, for the session 'The doctor' had these objectives:

At the end of this session students will be able to:
•Obtain a perspective on what it means to be a doctor
•Explore balancing a meaningful personal life with a busy and rewarding professional career
•Understand 'certain' influences and pressures on a doctor today
•Interpret the changing role of doctors through paintings and stories

Certain students enjoyed the freedom and flexibility offered by the module while others tended to 'misuse' the freedom. I had a few disciplinary issues which I had to deal with carefully as I did not want students to feel intimidated. I did not confront the students with disciplinary problems during the class but had a quiet word with some of them after the session. The formative assessment rubric addressed issues like attendance, punctuality, discipline and commitment and students who worked harder and showed greater commitment performed better in the assessment. Also for each session each small group had a group leader who was responsible for keeping the group active and focused on various tasks. The role was rotated during different sessions. I wanted them active, focused and interested in the activities and the subject. Among the various activities employed, students eventually did well in interpreting paintings and in the debates. The role-plays however needed more work. They often did not explore the issues in sufficient depth and students felt inhibited to act out certain scenarios in front of their classmates. This was in contrast to the students in Nepal who had enjoyed the role-plays with their skits and acting became richer and more complex as the module progressed.

Two of the role-plays I introduced were:
1. Ms. Mohini is a 28 year old lady from South Asia who was trafficked and was compelled to become a commercial sex worker. After ten years of service she was sent back to her country and village as she became HIV positive. The disease is at an advanced stage and she has no money for treatment. Her family has reluctantly allowed her to stay with them but is not happy that a retired prostitute is living with them. Explore what it means to be sick using a role-play. (Used during the session 'What it means to be sick')
2. Dr. Richard is an Internal medicine specialist in Toronto. He has been treating a twenty-two year old college student named Rachel for the last five years. The lady suffers from severe attacks of migraine and is on drug prophylaxis. Richard has realized that he is in love with Rachel. He wants to live happily ever after with her. However, he is not sure about whether it would be correct for a doctor to marry his young female patient. Analyze the issues involved using a role-play. (Used during the session 'The patient-doctor relationship')

Among the different cohorts of first semester students I found the fall 2013 and the spring 2014 cohorts to be the most interested and active (XUSOM, like most offshore Caribbean medical schools, admits students three times a year in January, May and September). These students created interesting role-plays to explore various issues based on the scenarios provided. The debates and the interpretation of paintings were also rich and varied. I enjoyed facilitating these groups. These two cohorts had a few students who were active, dynamic and committed and with good leadership skills. They were able to motivate and stimulate their colleagues to give their best. They also had good acting skills, which was useful during the role-plays. With greater exposure to small group learning these cohorts were more comfortable with group work and the academically stronger students were more willing to support students who were less strong academically. Class sizes at XUSOM are small and till date around 90 students have completed the program.

Co-facilitators:

At XUSOM many students, though American or Canadian citizens, are of South Asian or Middle Eastern descent. There were no major cultural and other problems involved for me in facilitating this group of students. Many students were interested in this new perspective and in understanding the art of medicine. XUSOM also offers courses in English and scientific communication to premedical students and the faculty members teaching this subject eventually joined me as co facilitators during the module. They were from a liberal arts background and were able to offer a 'different' (often a layperson) perspective during the various activities and the discussion. A challenge I faced similar to Nepal was that not many 'medical school faculty' were interested in MH and in co-facilitating the module, though two or three did attend certain sessions.

Small group learning room and other developments:

Over the preceding twenty-month period MH has become an accepted part of the school curriculum. The school created a separate room dedicated to small group learning with comfortable seating, white boards, flip charts and projection facilities. The room is now being used for various small group activities including problem based-learning. Slowly there is a greater number of small group learning and self-directed learning activities at the school. MH is now an established discipline at the school and the module is a part of the patient, doctor and society module for first semester students. Students' ability to show empathy, make their patient feel comfortable and obtain a proper history is assessed at the end of the first semester using standardized patients. Students also visit a local general practitioner every fortnight to learn history taking skills and interact with patients. I am sure MH will progress and grow in the sunny, hospitable climate of the one happy island of Aruba in the Southern Caribbean.

You can learn more about the MH modules in a forthcoming article in the Asian Journal of Medical Sciences titled 'Four semesters of medical humanities at the Xavier University School of Medicine, Aruba.' (in press)
Photos courtesy of Dr. P. Ravi Shankar

What Is Medical Humanities and Why?

January 25, 2008 at 11:25 am

Left and right brain function
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

"Medical humanities" is one of those I-know-one-when-I-see-one terms. Taken literally, the two words have about the same level of specificity as would "medical sciences," which includes everything from biochemistry to pathology. No wonder our scientific colleagues press us to give a more precise definition or, even better, an accurate description of just what we are trying to accomplish in medical humanities curricula. Unfortunately, believers tend to assume that our colleagues might easily understand the importance of medical humanities, if only they opened their eyes and adopted a different paradigm. In my experience only underdogs and fuzzy thinkers ever talk about paradigms.

To me it's surprisingly difficult to say with any degree of clarity what medical humanities is. It certainly isn't the medically relevant content of allaor most, or for that matter, anyaof the traditional humanities disciplines. We don't engage literature, history, philosophy, anthropology, religion, and so forth in any substantive way. While we do, or should, teach bioethics content in some depth, medical humanities folks often recluse themselves from bioethics as such. Yes, we dabble in literature, and more generally, narrative. History plays a role and sometimes theater and film. But what else? Does humanities include communication skills? Or spirituality? And what about more traditional stuff like medical sociology?

Medical humanities relates to, but is not identical with, the art of medicine, for which nowadays we often use the word "doctoring." Doctoring requires communication skills, empathy, self-awareness, judgment, professionalism, and mastering the social and cultural context of personhood, illness, and health care. Learning doctoring includes a process of character formation that requires years of role modeling and guided practice. We base our claim for the importance of medical humanities on the assumption that our teaching contributes significantly to the development of doctoring skills. However, a moment's thought should tell us that physicians of the past must have learned these skills without studying such a discipline, and many continue to do so today. Thus, whatever medical humanities is, it's not a sine qua non for professional formation.

The claim that medical humanities curricula help our students become better doctors has another interesting aspect. Our use of the term "better" suggests a practical moral dimension, i.e. young physicians will care for their patients more effectively, if they study medical humanities. However, although humanities disciplines once counted moral education among their goals, they no longer do so. Today you don't study history or literature to become a better person. So, from an academic perspective we appear to be way off-base when we co-opt these disciplines for a practical moral goal not shared by their "mother" departments. This makes defining what we're doing even more confusing.

Despite all this, medical humanities feels right. As with any new field, it's full of enthusiastic advocates who aren't afraid of rocking the boat. At present medical education is a patched-up old hull that could sink at any time. Boat rockers are important to help convince the rest of us that we better get to the shipyard quickly and find ourselves a new model. I suspect that humanities educators who succeed at this do so because they are sensitive and thoughtful people who care passionately about medical education and not because they know a lot about philosophy or literature. Medical humanities also points the way toward remedial education in habits of the heart. Nowadays, our culture disvalues liberal education, is skeptical of virtue, and, in particular, glorifies self-aggrandizement over altruism. Thus, today's medical students usually lack a liberal education and often a belief in virtue. These factors make them more vulnerable to a culture of medicine that reinforces egoism, cynicism, and a sense of entitlement. Medical humanities (whatever it is) may assist students in resisting these negative forces by opening their hearts to empathy, respect, genuineness, self-awareness, and reflective practice. As John Gregory wrote, "A gentle and humane temper, so far from being inconsistent with vigor of mind, is its usual attendant; rough and blustering manners generally accompany a weak understanding and a mean soul…" 1

1.Gregory J. Lectures on the Duties and Qualifications of a Physician. London, W. Strahan and T. Cadell, 1772. Reprinted in McCullough LB (Ed.) John Gregory's Writings on Medical Ethics and Philosophy of Medicine, Dordrecht, Kluwer Academic Publishers, 1998, p. 182.

Further Reflections on Medical Humanities

December 22, 2007 at 3:32 pm

Left and right brain function
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

 

The intriguing musings of Brian Dolan on this blog (Medical Humanities: Education or Entertainment?) and the incisive comment by Schuyler Henderson inevitably provoke further reflection on the medical humanities and what they are doing in medical education. I would like to add, somewhat discursively but I hope ultimately relevantly, to the discussion as follows.

In his inaugural speech as first president of the Czech Republic after the so-called Velvet Revolution brought about the downfall of communism, Vaclav Havel, also an internationally renowned poet, reflected on how new societies must be built. (1) He observed that everyone was looking toward the new government to tell them what to do, to lead them into a new way of living and a new way of being. But Havel claimed that the established political and institutional structures were unavoidably compromised, having been constructed during, and based on the assumptions and priorities of, the communist dictatorship. The people could not rely on existing bureaucracies and institutions - what already was - for guidance. Instead, they had no choice but to turn to each other. Stumbling and staggering, they would have to risk building a new world together.

Now I am not suggesting that the current medical education establishment is a communist regime; nor that medical humanities represent the voice of a people seeking liberation and freedom. Metaphor has its limits; and six years later, Havel acknowledged that although societies need to listen to poets as much as bankers or stockbrokers, the world cannot easily be transformed into a poem. (2) However, I do believe there are instructive implications to be gleaned from Havel's call to a populist-based rethinking of common assumptions in terms of ongoing debates about medical education and medical humanities.

Specifically, one of the things we learn from Havel's speech is that it is very difficult for any institutionalized power structure to change itself. The institution of medicine is deeply rooted in certain mechanistic, linear, positivist, objectivist, and reductive assumptions that are expressed every day in the ways physicians behave and the system as an entirety works; and which make it difficult to see the humanities as anything other than, at best, a nice but not essential, part of medical education; and at worst, pretty much a waste of time. Even if institutionalized medical education "makes room" for the humanities, it will do so on its own terms. This is not necessarily bad, but it is also not necessarily sufficient. As a particular instance of this difficulty in expanding its parameters, I will offer the example of "rigor" vs. "entertainment."

A pervasive criticism of the humanities among basic scientists and many clinicians as well is that they are a "soft" endeavor, a pursuit falling entirely outside the realm of science. The implication is that, therefore, they have little or no place within a scientifically-based profession such as medicine. The demand from the existing power structure of medical education is that the humanities justify themselves as a "rigorous" discipline; and many within the humanities are only too happy to attempt to comply.

Now, anyone who has sat through a course on postmodern literary theory should have no doubts that the approach taken by the academy to the humanities can be as intellectually rigorous as any course in biochemistry or pathophysiology. However, perhaps this is not the point, or at least not the most important point. No one would deny that one of the potential contributions of the humanities is to develop in its students the fostering of critical reasoning and judgment based on close observation of textual evidence and lucid argumentation in support of such. But is that the main reason the humanities are part of medical education?

We can discover one possible answer in Margaret Edson's play, Wit. (3) Here we see the fiercely intelligent scholar Vivian Bearing coming up against the limits of intellect in her struggle against ovarian cancer. It is not that her brilliance is irrelevant, but that it can carry her only so far in her journey toward death. What she needs at some point is compassion, empathy, nurturance, and caring (stereotypically embodied in the nurse Susie). The play in its entirety conveys the realization that intellect unaccompanied by love is lacking in the face of suffering and death.

How does this lesson pertain to the question facing teachers of medical humanities regarding the relevance of their discipline to medicine? One possibility is that we should not feel constrained to argue the issue solely on the grounds chosen by the medical education establishment. As outsiders in the culture of medicine, humanities scholars understandably feel the need to gain credibility and legitimacy. Also understandably, they believe that they can best do so by accommodating to this system's rules: e.g., set behavioral objectives, define skill sets, identify competencies, quantitatively measure impact. There is nothing terribly wrong with taking this approach. But I question whether following rules promulgated by the basic sciences adequately conveys the richness, complexity, and yes ineffability that the humanities have to offer medical students.

No one disputes that rigor, cognitive discipline, and the development of intellectual faculties should be stimulated at all levels of the academy, equally in biochemistry and in a class on pathography. But is intellectual rigor the only thing that matters in this debate? No one wants to water down their discipline, least of all "outsiders" accused of softness and marginality. Because humanities scholars in these settings are not training other humanities scholars, but physicians, the goals and emphases of their teaching must be different. To my mind, the issue is not dumbing-down or watering-down, but essentializing, focusing on the heart of the humanities that is of real value to the physician. This may be defined in part by "rigor," but as Wit suggests, it may be defined according to other criteria as well, if we choose to do so.

I do not think that, at this moment, we have agreement on what should comprise this essential humanities core. But it is clear to me at least that the great, unique power of the humanities lies in their capacity to engage the emotions as well as the intellect, to move the heart while provoking the mind. In this regard, the humanities are supremely relevant to the education of physicians, because this balance of intellectual steadiness and emotional tenderness (in the words of Jack Coulehan) is exactly what is required of them in every single clinical encounter. (4) Emotionally connecting with (as opposed to simply intellectually comprehending) issues of multiple perspectives, ambiguity, complexity, failure, suffering, commitment, and devotion (to mention only a few) cannot be avoided in medicine, and can only be learned through engagement with the humanities in some form or other.

And this brings us to Brian Dolan's speculations about "entertainment." Suppose medical students' exposure to the humanities is not always "rigorous"? Suppose it involves attending the above-referenced play Wit; or strolling through a museum; or writing a poem? Suppose the humanities do, at times, "entertain" their students? Who is to say that it is not through "entertainment" that equally important educational experiences can occur? We in medical education should be exquisitely aware of the power of the hidden curriculum, a curriculum that technically does not exist at all, yet shapes student attitudes and values more strongly than any formal course. (5) The method of delivery should be just that - a means to an end. It is because we are often not clear on what we really hope to achieve with our medical students in bringing them into with the humanities that we focus so obsessively on whether our teaching sufficiently conforms to the "rigorous" standards of other aspects of the curriculum.

Humanities are a way to teach people to think about, understand, be moved by and engage with the human condition. If we can accomplish this end, in ways that are rigorous, or entertaining, or both, we will be on the path to creating a new "society" of physicians, who look at patients and doctoring very differently than the present generation. In doing so, we cannot rely on the educational institutions in which we find ourselves, because they were created out of modernist, Flexnerian assumptions about the nature of health, illness, and medicine. We must rely on each other, on communities of individuals, comprised of humanities scholars, clinicians, and even basic scientists who share certain visions and aspirations for healthcare, and who are willing to risk teaching in ways that honor the full potentiality of the humanities in medical education.

References

1. Havel, V. New Year’s address to the nation. 1990.http://old.hrad.cz/president/Havel/speeches/1990/0101_uk.html

2. Havel, V. A farewell to politics. The New York Review of Books. 49:16, October 24, 2002. http://www.nybooks.com/articles/15750

3. Edson, M.. W;t. New York: Faber and Faber, 1999

Coulehan, J.L. Tenderness and steadiness: emotions in medical practice. Literature and Medicine. 14:222-36, 1995

Lempp, H. and Seale, C. the hidden curriculum in undergraduate medical education: qualitative study of medical students’ perception of teaching. British Medical Journal. 329:770-3, 2004

Medical Humanities: Education or Entertainment?

November 8, 2007 at 4:46 pm

Medical Humanities: Education or Entertainment?

Commentary by Brian Dolan, Ph.D., Professor of Social Medicine and Medical Humanities at University of California at San Francisco

A few weeks ago, I hosted a workshop for faculty from a number of campuses who work within medical centers and are involved with medical humanities courses or programs. My opinion at that time was that scholarship and courses in the medical humanities needed to be academically rigorous to gain credibility amongst medical educators who are obsessed with defining skill sets, setting objectives, and measuring the "impact" of course content. I was (and am) not prejudging anyone's commitment to academic standards. But if anyone had experience anywhere close to my own, it probably involved meeting with skepticism from within medical centers about the uses, or "value added," of providing instruction in medical humanities in an already overcrowded curriculum. Fundamentally the challenge of maintaining a role for medical humanities seems to lie in balancing the students' desires for freedom of intellectual inquiry with an institutional pressure to herd.

I asked others what kinds of projects are supported under the name of medical humanities in their institutions. Does a jazz session count? Painting? Poetry writing is very popular amongst students, residents and faculty, but why, I wondered, can't that just be called a hobby? On the other hand, we have an "art for recovery" program, and it raises provocative questions and potential data about the importance of humanities-based therapeutic intervention for patient care. Thinking I was playing devil's advocate, I asked why all this had to be brought further into the classroom and formalized, naming specific skills and objectives to be met through such instruction? Might that raise further problems rather than provide increased opportunities for the students? What follows is a paraphrasing of my thoughts and discussions about this.

Would medical students want to pursue course work laden with the requirements that match the rigor and standards set for students geared for a different degree path? Why not, I thought. When I was in college I took electives to see what other fields were all about and I didn't expect to be given a watered-down version. It would be offensive to humanities scholars to ask them to present their subject in a different way to medical students. Esteemed colleagues of mine who hold MDs and teach courses in writing believe in the rigor of course workathey themselves have enrolled in humanities courses and on occasion received other degrees. On the other hand, I repeatedly hear that medical students don't read, so don't assign too much. And is going into Foucault's notion of the "clinical gaze" really necessary? Is there utility in making medical students genuflect to the humanist-theorists in the way that professional humanists need to do for career advancement?

But who said anything about professional humanists (i.e., people with PhDs in history, literature, philosophy, etc.)? I have also been told that medical students will not really pay attention unless the instructor has a MD. They need role models, leaders who will show them that it is OK for MDs to pursue such interests. Also, unless you have been in the clinic, it's hard to share the emotional reasons why humanities are useful. It sounds like it's therapy, I say, a different kind of utility than opening up new research methodologies for reflecting on the complexities of modern medicine. It then struck me that the distinction between "education" or "entertainment" is not absolute but relative to what one wants out of it. The humanities can represent deeply philosophical, pragmatic, emotionally driven and/or entertaining approaches to understanding the human condition and the social relations of physicians, scientists, patients and the rest of the world.

The dilemma of medical humanities is not that it is reduced to a formulaic set of educational goals or dismissed as a form of entertainment, but that it is a "field" with no boundaries, yet apparently centered on each individual. To think and act like a humanist-physician or humanist-scholar requires an understanding of one's relationship to the rest of the world. Whether one is analytical in approach or expressive, a chronicler of the times or a jazz musician, the humanities supports your form of engagement. It seems counterproductive to reduce this to skill sets and the mechanics of cognition. "The medical humanities" is a form of consciousness about all that is educational and entertaining about being human. It embraces what should be the overwhelming commitment of every medical school: to honor art and humanism in medicine, however that is expressed, and by whomever it is expressed. The lesson of medical humanities ultimately relates to respect for others' views, but formalizing that runs the risk of excluding people from that lesson-plan. My feeling now is that medical humanities should not be curricular-bound; it is too big for that. Rather, it should be articulated and supported as part of campus culture, contributed to by everyone who thinks of themselves as a humanist. This does not exclude instruction or "education," but neither does it dismiss "entertainment." In fact, make the elective or non-credit classes entertaining. After all, that might be more important than subjecting students to another test.

Establishing a Medical Humanities Program at George Washington University School of Medicine

September 23, 2007 at 3:17 pm

Portrait of Hippocrates sitting, reading.

Commentary by Linda Raphael, Ph.D., Director of Medical Humanities and Associate Clinical Professor of Psychiatry and Behavioral Sciences

My introduction to medicine and humanities occurred at a Narrative Medicine Seminar in New York in 2003. I was attracted to the seminar because my teaching and writing have focused on narrative theory and representations of the Holocaust in literature and film. Thus, how one tells stories, especially stories about pain and suffering, have long been an interest of mine. I was excited to find physicians, nurses, social workers, psychologists, historians, philosophers, and literature professors gathered to discuss the world of medicine and illness from a variety of perspectives. When I heard Shlomith Rimmon-Kenan's talk, "Whose Story Is it Anyway?" I was convinced by the close reading of a patient's story which had been determined and then narrated by family members and medical institutions that the relationship between the world of medicine and narrative theory was well worth pursuing. At the end of the seminar, I mentioned my interest in developing a course for GWU School of Medicine to Rita Charon, Director of the Program in Narrative Medicine at Columbia’s College of Physicians and Surgeons, whose encouragement was immediate. Both she and one of her colleagues know the Medical Director at GW Hospital and put me in touch with him because they knew he would be interested in humanities and medicine. I then started on an unanticipated and exciting path that led to developing a program rather than one course.

After meeting with the Medical Director I sought out medical faculty who were interested in medicine and humanities. I heard from a professor in the Physician Assistant program with whom I was acquainted about a few physicians on the faculty who would be interested in humanities. One of them discussed the idea with the Dean of the School of Medicine, which led to a meeting with me. Soon after that, I was asked to write a proposal for a program in medicine and humanities. I turned to Ann Hawkins of Penn State Hershey Medical Center, whom I had met briefly at the seminar at Columbia, and then to Kathryn Montgomery, of Feinberg School of Medicine at Northwestern University. Their generous sharing of materials and ideas enabled me to write the proposal that convinced the Dean that I would be able to initiate a small program in medicine and humanities.

My initial appointment was part-time (2005-06). I have worked under both the Dean and the Associate Dean for Academic Affairs. They have been extremely supportive (both have taught in the courses) and have carefully thought through how we can best introduce humanities into the medical school curriculum. They combine a visionary perspective and a cautious understanding of what will work and at what pace we should move. We introduced three electives in medicine and literature - greatly aided by the NYU Literature, Arts, and Medicine data base - for First Year students in their second term. Thirty-five students (approximately one fifth of the class) enrolled, which the deans and I regarded as a very positive sign. The courses were taught by me, the deans, and other physicians (a different doctor at each class session). It has been no problem finding doctors who are excellent and willing teachers. In the summer of 2006 I introduced a humanities session (reading distributed in advance followed by discussion and sometimes short writing exercises) to the clerkships; initially pediatrics, then primary care, and soon all. We have had book groups to which the entire medical school is invited, and I have also gathered faculty who express interest in small groups to discuss a book.

In the 2006-07, the university (Academic Affairs) gave me a grant for five Medical Humanities interdisciplinary seminars (art history, poetry, fiction, etc) and 30-35 townspeople, students, faculty and staff attended each session. The evaluations were positive, and Academic Affairs funded the seminars for a second year (2007-08). In this same year I added sessions with residents; these have included primary care medicine and psychiatry, and soon Ob/Gyn. We have had several book group sessions, some advertised to the entire medical community and others to individuals who have expressed interest in a reading group. The Dean was the first to suggest that we have an all medical school group, and he has continued to be a great enthusiast (and fine reader!). Finally, we now have, in addition to the two courses for First Year students, two courses for Second Year students.

My position is now full-time. Student evaluations for the electives have been extremely positive, and those who take the first-year electives tend to sign up for the second-year offerings. Some students have reported that they would like very much to take a humanities course, but they pass up the chance to take an elective because they worry that they won't have enough time to study their required medical school course material.

The most important factors in the development of this program have been the enthusiasm and generous support from others in the field, a dean who was an English major and who continues to love to read and discuss literature, a medical school that prides itself on training students in the art of medicine, and the national visibility of other programs.

The Craft of Writing: A Workshop for Doctors-in-training

September 9, 2007 at 5:55 pm

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004Commentary by Anna Reisman, M.D., Co-Director, Department of Internal Medicine Writers' Workshop, Yale University School of Medicine

In this blog, I'll tell you about a writing workshop for residents at Yale that centers on the craft of writing, and I'll argue that this focus has great value for doctors-in-training.

We created the Yale Internal Medicine Residency Writers' Workshop in 2003 to enhance residents' power of observation, provide a creative outlet, increase empathy, encourage reflection, and, through all of these, to combat burnout. The annual workshop runs for two full days each November and was led by Abraham Verghese in year 1 and Richard Selzer in years 2-4 (Selzer and I will co-run this year's workshop). The participants, mostly internal medicine residents with a smattering from psychiatry, pediatrics, and surgery, submit a piece of fiction or nonfiction prose. We spend a good portion of the time critiquing these manuscripts in detail. Unlike the writing that goes on in other residency programs and medical schools, where the idea is to set down one's thoughts and experiences in ordinary prose (i.e. journal entries, critical incident reports, parallel charts), our focus is on the writing itself: how to relate our experiences, and those of our patients (whether imagined or real), in clear, resonant, interesting, and lively prose. The Department sponsors a Grand Rounds on writing and medicine two months later, as well as a reading for faculty and residents and an annual publication called Capsules that is distributed widely. This year, we created sound files of some of the readings: (http://residency.med.yale.edu/writer.html )

In a study of the workshop, we found some of what we had expected: residents in focus groups reported a heightened awareness of patients' humanity and enhanced self-awareness. What we hadn't expected, and what we believe was one of the key ingredients to the workshop's success, was that the process of sharing writing created a unique camaraderie. The group bonded because everybody was similarly vulnerable.

Does a focus on the craft of writing make better doctors? Or does spontaneous, unpolished writing accomplish the same thing? I believe that there is a role for both in medical training. Informal writing - journal writing, for example - can be a very effective way to process our many often overwhelming experiences. Similarly, sessions devoted to writing critical incident reports can be a way to bring disturbing interactions (that might otherwise never see the light of day) to a discussion format with peers.

Taking the next step - finessing one of these unpolished pieces into a publishable piece of writing - is something else altogether. In the process of reworking the language, the rhythm, the images, the presentation of ideas, the writer must explore the experience more thoroughly in order to make the story logical and clear. For example, my own journal is a rich repository of experience but when I extract a section and prune and shape it into an essay or story, that is when I really start to understand its deeper meaning.

An emphasis on craft will, of course, appeal to a subset of residents who are interested in improving their creative writing skills. But shouldn't all physicians be able to write clearly? I believe that an opportunity to gain tools for expressing one's thoughts and beliefs in a variety of settings — whether writing a story, an opinion piece for a newspaper, or a research study — should not be missed. You can't go wrong with good writing skills.

 

 

The Patients as Teachers, Medical Students as Filmmakers VIdeo Project: The Video Slam

August 13, 2007 at 1:26 pm

Boy looking at camera is the teacher!Commentary by Dan Shapiro, Ph.D., Director, Medical Humanities Program, University of Arizona College of Medicine

Last year I asked 8 medical students to make films about patients. In pairs, they spent 8 months visiting and filming a patient and filming their real lives. They had to make at least three visits (most made 5-6), interview someone else in the patient’s life, go to a medical visit, and capture how the patient adhered, or failed to adhere, to the medical regimen. In fact, they went to home visits, birthday parties, festivals, sat in waiting rooms and met with a variety of health professionals. Then we edited their videos down to 7 minutes and showed them publicly and then in the curriculum.

Here’s the idea behind the project. Our medical school curricula have evolved, but were largely constructed between 1910 and 1950 when most patients presented with acute illnesses. Lengths of stay averaged more than three weeks in some hospitals and the medical trainee could watch, first hand, the entire illness experience from start to finish. Now, we spend 75% of our health care dollars on chronic illnesses and yet our trainees only see a smidgeon of the patient’s life.

In 1987 I was diagnosed with Hodgkin’s Disease and spent the next five years in and out of treatment. I had a few relapses, a bone marrow transplant, and more chemotherapy and radiation than one person should be allowed to enjoy. Along the way, I met a lot of physicians. While they were pleasant and competent, few had any idea of what it was like to live with the disease and its harsh treatments. And if they’d had a better idea of what it was really like to live with illness — they could have done a better job of preparing me for the predictable psychological and physical challenges I endured.

So, a few years ago I was editing a home vacation movie (new macintosh software gave all of us access to great editing software) when I noticed that there were things on the tape I hadn’t seen when I’d been taping the experience. I also observed that the act of editing is time consuming and requires careful thought — creating an organized narrative means understanding the important and less important parts of a person’s story. That’s where the idea came from.

We made four brief films including a woman with metastatic breast cancer, a young man with AIDS, a family coping with juvenile onset diabetes, and a woman living with a head injury, status post motor vehicle accident 25 years ago (in which her daughter was killed). While 8 data points are hardly convincing, to a person the medical students described this is as highly impacting experience and as of this writing I have 19 students signed up for this year’s project. They’ll likely work in groups of two or three.

Consider some of the issues portrayed on the films: Some are practical, such as, How do you get a six year old child to take a needle regularly? Which approaches to adhering to complex mediclal regimen work the best? And some are psychological, such as, How do you cope with the question of why me? How do you keep going when you’re convinced you’re about to die?

Here’s the bottom line:
Until our medical training systems realign to focus more energy on prevention and care of the patient with chronic illness, it behooves us to invite articulate patients to teach our students — our physician teachers have part of the story AND our patient experts have part of the story.

I’ll step off this little soap box now. Thanks for reading my diatribe.

Video excerpt at public TV station, KUAT website

Please send comments and questions to this blog, and feel free to e-mail Dan Shapiro at shapiro@u.arizona.edu