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Becoming a doctor: fostering humane caregivers through creative writing
Patient Education and Counseling 45 (2001) 13±22
Becoming a doctor: fostering humane caregivers through creative writing$ David Hatem*, Emily Ferrara University of Massachusetts Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
Abstract We qualitatively examined themes covered in a creative writing elective designed to enhance pre-clinical medical students' writing, observation, and re¯ection skills relative to experiences in their medical education. Qualitative analysis of writings' themes was carried out via iterative consensus building process and validated through member checks and literature review. Fourteen students completed the elective, seven for each year it was given. Students submitted 86 written pieces. Qualitative analysis demonstrated the presence of nine themes: students' role confusion, developing a professional identity, medicine as a calling, physician privilege and power, humanizing the teacher, the limits of medicine, death and dying, anticipating future challenges, and identi®cation with the patient. Students evaluated this creative writing course favorably, indicating value in writing and re¯ection. Themes covered are of concern to second-year medical students as well as other trainees and practicing physicians. Writing may aid in the professional development of physicians. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Narrative; Physician±patient relationship; Creative writing; Re¯ective practice; Empathy
1. Introduction Re¯ection is a critical part of professional training [1]. It is intimately connected with self-awareness, and together they help physicians and physicians in training to examine beliefs and values, deal with strong emotions, and resolve interpersonal con¯ict [2±4]. Schon distinguishes between re¯ection in action, ®ne tuning an act in the middle of performing it as a function of thinking about what you are doing, and re¯ection on action, thinking about an act or event at a time separate from that event [1]. Often, the most vexing problems require re¯ection on action. While training which incorporates re¯ection and self-awareness takes place in some medical schools and residency programs [5±10], this is not a uniform part of curricula. One outcome of re¯ection can be enhanced self-awareness, which is felt by many to be critical to a physician's work [3]. One method to encourage re¯ection is through the writing and sharing of narratives or critical incidents [11±13]. Narrative probes the depths of medical experience [14], $
Received from the Division of General Medicine, Primary Care and Geriatrics (DH) and the Office of Medical Education (EF), University of Massachusetts Medical School, Worcester, MA. Presented in part at the Communication in Medicine Conference, Chicago, IL, July 1999. * Corresponding author. Tel.: 1-508-856-5972; fax: 1-508-856-8085. E-mail address: [email protected] (D. Hatem).
allows for greater understanding of our patients [15], our work, and ourselves [16]. In addition, writing narratives has demonstrated positive health and behavioral effects in such varied groups as prisoners, distressed crime victims, ®rst time mothers, men who have been laid off from their jobs, arthritis and chronic pain sufferers, and medical students [17]. If patient care is enhanced by eliciting and understanding the patient's perspective [16,18], we postulated that setting aside time to re¯ect on students' early patient encounters from multiple perspectives (the patient's, the student's, and the doctor's) would make students' future patient care more humane. In a parallel fashion, by having faculty set aside time to listen to the students' perspectives, we hoped to make their educational experience more humane, thus creating a program that strives to live up to the ideals it advocates. This contrasts with the concept of the ``hidden curriculum'' in which researchers have identi®ed a discordance between principles that are taught and principles that are practiced [19]. In order to enhance students' opportunities for re¯ection, we established an elective for second-year medical students entitled ``Creative Writing for Medical Students.'' It gave students the chance to write about and discuss signi®cant experiences related to their medical education as they were going through these experiences. We report the elective's outcomes based on the ®rst 2 years of students' writing. Our
0738-3991/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 1 ) 0 0 1 3 5 - 5
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aim in analyzing the students' writing was to understand the challenges and unique issues faced by second-year medical students in the process of their professional development as prospective physicians. 2. Methods 2.1. The course We began an elective course for second-year students, ``Creative Writing for Medical Students,'' in the fall of 1997. The course aimed to help students write clearly about their experiences, describe their observations, and distinguish between observations and conclusions. Students carried this out by writing in response to speci®c assignments, then sharing their writing samples with others, with the opportunity to receive constructive feedback. While their experiences were the starting point of their assignments, they were free to write ®ctionalized accounts or poems. In taking part in this elective, students considered how writing and re¯ecting on their experiences in¯uenced their personal and professional development. The elective took place in the fall semester, and met biweekly for seven 1.5 h sessions. For each session students wrote narratives or poetry on suggested topics in advance of the session, and then read and re¯ected on these during the session. Topics included a signi®cant experience in medical school, a memorable patient, writing from the patient perspective, the decision to become a doctor, and student± teacher, student±patient, and physician±patient interactions. The elective was given again in the fall semester of 1998. In both academic years, students chose to continue meeting with course faculty during the spring semester as well. During the spring semester, they wrote on topics of their own choosing although most narratives continued to focus on issues raised by their medical education. Both semesters' writing was included in the analysis. 3. Data analysis While students evaluated the experience relative to whether the course met its objectives, we concentrate and report here only the qualitative (thematic) analysis of students' writing. This analysis was done through an iterative consensus-building process in which writing was coded independently by each of two faculty evaluators (DH and EF). Themes were identi®ed in students' writing and then discussed. Writing was analyzed until no new themes emerged. Disagreements about coding and themes were resolved in face-to-face meetings. Themes selected were validated by use of the standard qualitative method of triangulation. Triangulation in this study included member checks, showing the themes identi®ed by the faculty evaluators to the elective participants for their input, seeking
their agreement or addition of themes. There were no additional themes identi®ed by students in the elective. Another validation step was to compare themes that emerged to literature on the personal and professional development of medical students as a method of seeking the ``relatedness'' of the work [20]. Given the limited data on the day-to-day challenges of second-year medical students, our analysis was exploratory in nature and did not utilize a preset or established framework for interpretation of ®ndings. Students gave their permission for literary work to be quoted. 4. Results Seven students completed the requirements for the course each year that it was offered (total 14). Eighty six ®nished pieces of writing were submitted. Qualitative analysis of the writing showed work to be divided into nine themes (see Table 1). Most of the writing cut across all themes with the exception of the six pieces on the theme ``Humanizing the Teacher''; these writings were exclusively assignmentdriven. What follows is a discussion of each of these themes and representative issues raised within them. 4.1. Medicine as a calling Students' writings spanned a continuum from the lofty goals and larger context of the students' experiences of being called to the profession of medicine, to their most concrete examples of medicine's art. While deciding to attend medical school was an early goal for some, the decision for others was a conscious one involving the determination to choose something different from other family members. For several others, it involved abandoning one career, going back to school, and moving away from other pursuits, such as business, engineering, or writing. Those who shifted careers seemed to feel an inherent ``rightness'' in their decision, which helped them in dif®cult times as they got caught up in mundane details of studying overwhelming amounts of material, but they gave voice to their doubts which they experienced at times like this. Adherence to an ideal image of the goals and values of medicine permeated these writings for some, while others were able to point to more speci®c events that led them to Table 1 Creative writing themes (n: number of writings on theme) Medicine as a calling Role confusion and conflict Identification with the patient Developing a professional identity Physician privilege and power Humanizing the teacher Death and dying The limits of medicine Anticipating future challenges
[11] [11] [10] [10] [5] [6] [8] [14] [11]
D. Hatem, E. Ferrara / Patient Education and Counseling 45 (2001) 13±22
pursue a career in medicine. One student wrote of spending a day in an AIDS clinic, watching the doctor practice technically competent care while also dealing with the human and public health needs of his patients as he advocated for their use of a needle exchange program. Similarly, students witnessed the ideals of medicine in practice, further underscoring their perception of medicine as a calling. This most commonly took the form of coming to an understanding of the patient's story, moving beyond an accounting of their symptoms to a narrative of their worries, their concerns, and ultimately their life. One such account details a nervous student, overjoyed at having a new beeper, whose purpose is to notify the student that it is time to perform an autopsy, part of the required curriculum in the second year. She will then assist in cutting the body, removing organs, generating microscopic slides, trying to solve the mystery of what led to the patient's death. This is contrasted with her imaginative rendering of the last days of the woman's life, the tearful goodbye from her husband, and their last moments together, lending a whole new meaning to her hearing the beeper tone sound, and serving to temper her joy in a poem entitled ``The Grim Beeper.'' One additional piece begins as one of the students introduces us to her patient graphically, announcing: The massive gentleman on the bed is unwell. What follows is an account of an obese gentleman whose layers of skin have come to serve as protection against the discrimination he has been subject to throughout his life. Through her sensitive persistence, the student uncovers not only his medical dif®culties, but also his home challenges, including the fact that his wife has just undergone bypass surgery. His thankful look con®rms her role and the value of her uncovering this detail. In an ironic twist at the end, the attending physician comes into the room, and we note that the bene®t of the patient's story is lost on him, as he neither elicits nor apparently notes the last bit of communication between the patient and the student. The doctor walks in and the mood of the room shifts to the professional. The man becomes the patient who needs to be examined and the student there to pick up all the physical signs of illness from the specimen on the bed. From head to toe, systematically, the doctor reviews each major system in order and the interview is over. The student follows the doctor out of the room, but not before she turns back to bid farewell to the man on the bed. He still looks as weary, but his lips are slightly lifted at the corners. 4.2. Role confusion and role conflict Students frequently explored their feelings of uncertainty about their role in the medical encounter, and the confusing, sometimes overwhelming nature of medical school
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experiences. These writings often depicted medical students in the midst of early patient experiences, expressing mixed feelings, from the exhilaration of practicing new skills well, to the sense of awe and amazement when they witnessed their faculty preceptors interview, asking questions that they had not anticipated or even thought of. The effect of this was to make it clear that seeing patients went beyond technical skill and became a profoundly human encounter. Several discussed their role as medical students as an inbetween place. They were not yet physicians, and they repeatedly wondered whether they had made the right decision to go to medical school, whether they would ever feel that they had enough skill, and if they would ever get over the feeling of being totally overwhelmed. Being lost in a forest was one metaphor used to describe the medical school experience. There were additional pieces written about events that students knew were important, but had not been fully processed. One example is the student who had worked in a nursing home and had visited an elderly, dying woman whom most of the staff avoided. Each time the student went to work, she rushed through her other chores and left time to visit with this lonely, confused woman. Unable to explain the impulse to visit this dying patient, she simply kept her company regularly until her death. What role had she played? Did the patient bene®t in any way? These were typical questions raised by students who wrote about similar experiences with patients. The confusing world of medicine, new language, new skills, and emerging new identities, led one student to observe: Somehow, a stethoscope Swung carelessly around our necks Endows us with the authority To pick, prod, and poke The unsuspecting elderly Affectionately known as GI West 120, neuro 312. . . Later, she re¯ects on her new, emerging identity, with a note of collective caution. Beacons of wisdom, Able to buy beer But not rent a car Who do we think we are? 4.3. Identification with the patient These writings focused on incidents and experiences in which the students identi®ed with a patient, or failed to identify with a patient despite struggling to understand the patient's perspective. One student expressed surprise at ®nding a similarity with the patient, a prisoner in shackles brought into an ER for
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treatment. They were the same age, although in reality these two individuals were worlds apart. Another student, who served as a ``patient sitter'' for a suicidal patient who had suffered severe, self-in¯icted burns, strained to understand what drove the patient to such an extreme and self-immolating act: Did she stand in the shower? and turn the water up until it was scalding? or did she turn the water on, testing, testing, the way I do each day, maybe absently scratching my calf with my foot, before recognizing yes, this is the temperature I want, now. Did she know, as she pulled off her shirt, unbuttoned a skirt, unhooked her bra? I see my clothes fall in a heap on the bathroom ¯oor. Did she look her body up and down in the mirror? Was it fogged with steam from the scalding stream? The triggering of identi®cation with a patient, through a past experience with illness or injury, or through an unexpected association, was another strand of this theme. One student wrote about her experience of identifying with a faculty member through the shared experience of a chance encounter outside the classroom, in the of®ce of a massage therapist. The faculty member had been diagnosed with metastatic breast cancer, and had spoken about it to the class. The student worried about being able to measure up to the faculty member's courage and stamina: I feel a sudden twinge in my tender breast and wonder if this is how it started for her. Does being a doctor make it better for her or would it be easier to be protected from knowing too much like everyone else. I am suddenly afraid of knowing too much of the responsibility of being too close to death my muscles tense as though already weighted down with the burden. One student recounted the story of walking along as an adolescent, tripping over ``a piece of grass'' and breaking his arm in the process. The story seemed to rise up as a result of an encounter with a medical ICU patient who had Lupus, and was not doing well. He noted that all the doctors could tell her ``is that she was just walking along, and for some reason that no one could have predicted, she stumbled and her life changed forever.''
4.4. Developing a professional identity A subset of the students' writing dealt with the development of their professional identity. This had multiple aspects. Some witnessed encounters in which they observed or interacted with patients whom they recognized that they either did not like, or would not come in contact with in their more ordinary day-to-day existence. Realizing that they had to keep their judgments to themselves when dealing with injection drug users or arrogant patients, they concentrated on the clinical outcome they were trying to effect. A critical step in the writing seemed to be recognition of their personal reaction, followed by an active decision to keep this reaction out of the encounter with the patient. Such clear separation between personal judgment and reactions to patients was not always evident, as in one person's inability to feel empathy for a patient who delivered a baby with a neural tube defect and had not taken her pre-natal folate to prevent this. In the encounter, she reported being angry, and on further re¯ection she realized: When my day was ®nally over, and I lay in bed in the darkness, it suddenly occurred to me why the baby's mother had made me so angry. She had so easily achieved in her 20 years what I haven't been able to in my 38 childless years. For the ®rst time that day, I cried. Others re¯ected on their personal discomfort with speci®c situations. The very personal questions in the sexual history were troublesome for one participant, but then led her to wonder how much of this re¯ected the in¯uence of her upbringing, namely being told by her parents that she should not ask prying questions of others. Becoming aware of their reactions and sorting out where they came from seemed critical in searching for meaning in these troubling encounters. Others wrote about times when they were able to make clear distinctions in the encounter. Most commonly, this revolved around their being able to see the individual patient's illness and symptoms in the context of the patient's life, as distinct from the more narrow pathological focus on disease. One poem contrasted a patient's seeking treatment for disease in the doctor's of®ce, and treatment for her illness, in a church. She pulls open the heavy door and shuf¯es across the granite foyer, worn shiny and smooth by years of penitent feet. . . Burnished wooden pews glow. . . and she eases herself to her knees. She pulls open the heavy door and shuf¯es across the linoleum foyer, scrubbed shiny and smooth each night by scouring hands. . . .she makes her way into the brilliantly lit waiting room.
D. Hatem, E. Ferrara / Patient Education and Counseling 45 (2001) 13±22
As the encounter concludes, there seems to be an inexorable blending of the physician and priestly function: The dappled light is getting lower, The exam room door swings open and the white-clad doctor briskly steps in. A hint of incense twirls in the gathering dusk. The creased edges of the written prescription feel sharp in her ®ngertips And she is comforted. For disease to the doctor, for healing to the priest? The boundaries are not so clear as the poem concludes. 4.5. Physician privilege and power In their writings students often explored their feelings, commonly feelings of discomfort and disturbance, about physicians' power and privilege within society at large, and within the doctor±patient encounter. These writings often illustrated a developing awareness of the impact of the power differential within the doctor±patient relationship. Although physicians' power in society seemed to run through most pieces as an undercurrent, one student grappled directly with the prospect of his own increasing power/privilege and responsibility, as he followed the path to physicianhood: Doctors are the adults of the adult world. . .if I had already become an adult in the ordinary sense, I had yet to become that special species of super-adult I was aiming for. The theme of technical versus personal care is also explored in this section on power and privilege. In particular, the writing pointed to the sometimes enigmatic and `magical' healing power of the doctor±patient encounter. One student described her dismay at learning of her preceptor's effect on his patient, by virtue of his charismatic nature rather than his surgical skills. Most often, the focus of these pieces was the depiction of the intimacy in the doctor±patient relationship, and the physician's physical access to the most private parts of patients' bodies. One poem likens a patient awaiting the doctor's arrival to a woman awaiting the arrival of her lover. The feelings of alienation that can arise between the doctor and patient were palpable in other writings. The ways that the power differential may negatively impact the encounter were explored in a piece in which a past violation in a patient's life is triggered by the physical exam: The patient was left to undress alone. When the doctor returned, she was picked at and prodded and stared into deeply. She opened her mouth, turned her head, and swallowed on command. Her breasts were examined for any imperfections. . . `Come closer to me and spread your legs apart.' The doctor's command made her shudder, yet she had
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learned how to obey. She closed her eyes and put her arms over her head. `Don't tell me to try to relax. Just go hide behind that sheet of yours and do what you need to do.' The speculum ripped open years of old wounds, yet she didn't make a sound. She didn't cry then, why should now be any different? 4.6. Humanizing the teacher Featured prominently in the work of those who took part in the elective were stories about teachers. While this was a topic that students were assigned to write about, many of their stories also overlapped, and were included with other themes. Only those that talked solely about teachers were included in this category. Most prominent were stories that focused on the humanity of teachers, with students expressing gratitude and surprise at their teachers' humility and simple kindness. These included the pathologist who brought a classical guitarist to the ®nal class of the semester to ``serenade his class,'' and the physiologist who offered a towel and a change of clothes to a student who had been caught out in the freezing rain. Teachers' acts outside the classroom were not the only events noted, with one person noting the particular skill and care with which she was taught how to perform her ®rst pelvic exam by a standardized patient instructor in a piece entitled ``My Guide.'' I have never seen this place the darkness blinds I rely on my guide and my hands to see, to learn the geography of this mysterious place I wish I were somewhere else studying micro or not anywhere else but here. Running away again, Uncomfortable. . . She brings me back with her hearty laugh she speaks of her children then, ``a little more to the right, you've got it,'' an ovary An ovary!! Or not thank you anyway for sharing this amazing place that nurtured four children and one student. Also memorable were negative experiences, including the student who watched her attending physician preceptor rush
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through an examination, skipping things she would ordinarily do, and later admitting that her dislike for the patient in¯uenced her actions. Another student presented a story of a physician whose questioning of his patient led to her disclosure of suicidal intent. After the disclosure, the physician simply moved on to the next question, never stopping to address the issue the patient had raised, leaving the student similarly shocked into silence. 4.7. Death and dying Medical education in the ®rst 2 years often brings students into their ®rst encounters with mortality, their own and that of their patients, through their experiences of dissecting a cadaver, of assisting on an autopsy, and of the opportunities they have to interact with dying patients. This topic was also explored from yet another perspective: that of experiencing the death of a classmate by suicide. Most often, these writings explored the topic from the patient's perspective. In addition to an awareness of patients' fears in the face of terminal diagnoses, the return of cancer, a positive breast biopsy, was an awareness of patients' desire to live. Juxtaposed against this were writings that explored the perspectives of patients who are terminally ill and essentially ``waiting to die.'' I am tired of telling them I am not afraid. I am tired of dreaming. I am tired of waiting For God to come and take me home. I am tired of giving up my body To the hands of strangers. They touch me in places I did not tell them they could. I need to ®nd the quiet, quiet place I need to ®nd peace The overarching task of this topic area, it seemed, was in each student's struggle to make sense of life, to honor and venerate it, and to begin to understand and confront their own mortality, and the mortality of their loved ones. 4.8. The limits of medicine This category of writings bridges the span from students' experiences of confronting the limits of medicine and their own personal limits, to rising to the challenge of ®nding balance in their lives. Students sought balance through efforts to live, study, and practice medicine mindfully, most commonly in the form of taking measures to allow for self-care. One student recounted a day of working in an HIV linic, where time was limited and patients' needs seemed unlimited: We barely scratch the surface of his emotional state, but the waiting crowd in the lobby grows and his compli-
cated medical problems have taken up the allotted time. . . A few needle sticks for a new CD4 and viral load are done and he slips out of the clinic, back to the cool November day. Another student, in telling the story of a stroke patient who was dealing with the dire impact on his ability to perform the simple tasks of daily living, re¯ected on this with resignation: I imagined myself in his situation and how helpless I would feel. However, there was nothing much I could do or ®x. Sometimes I wonder if being an automobile mechanic would be easier since automobile problems are much easier to identify, and almost everything is reparable. However, there are limits to what can be done for the human body. On the other end of the continuum of this category's themes, the appreciation of the joy and beauty of living mindfully in the midst of their busy lives was captured in the students' writings. In one poem, a physician was taking a coffee break, the mug ``brought to his mouth in joyous rejuvenation.'' Other mindful activities written about included a student's participation in a 15-mile run with his parents' running club, and another student's re¯ections on a summer spent in Cuba in a language immersion experience. A juxtaposition of the simple joys of daily life and the demands of medical education were central to a poem by one student who appeared, for one blissful moment, to have struck a ®ne balance: The hospital speaks and tonight I ®nally hear it walking slowly down the sidewalk my backpack light without its usual load only my stethoscope inside but it's heavy enough tonight the patients have drained me and I'm empty and light. . . I pause for a moment Standing by myself In the darkened parking lot An occasional snow¯ake settling lightly on my hair I turn back the way I've come and take a deep breath I listen to the hospital I don't really understand what it's trying to say but at least I'm listening. 4.9. Anticipating future challenges The writings in this category chronicled the students' anticipation of the challenges of the future, whether in medical school, in residency education, or in practice.
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The essays and poems tackle such issues as: feeling swallowed up, transformed, or destroyed by the process of medical education (experienced as a kind of death), and anticipating the future application of knowledge accumulated in the classroom or lab. In a poem, one student used the metaphor of making a necklace to symbolize the medical education process, beads offered by faculty and patients alike: But then another doctor holds out a bead to me, like a jewel he guides my hand as I slip it on the string, reminding me of how beautiful my necklace is becoming. . . I lay my hand on the warm skin of a patient's chest, feeling his heart Beating into my palm, not even realizing until later That without even moving he offered me another bead. This student speaks of the ``un®nished necklace'' for which she is desperately trying to ``keep any of the other beads from falling off. The necklace has no power to comfort me tonight, wondering whether I will ever be able to wear it around my neck.'' Another student explored his sense of being outside the hallowed halls of medicine, not yet a full-¯edged member of the profession. For now, ``The enemy was doctors in general, but mostly one doctor in particular.'' He speaks of his father, a doctor, and of his own attachment to the ``undoctorly'' habit of smoking cigarettes, something frowned upon by most practicing physicians. Will the future lead to his quitting smoking? If so, is he succumbing to the transformation of becoming a doctor? Or will the rebellion continue? The writing done by the students as they neared the beginning of the clinical clerkships year, served as a vehicle for ``trying on'' the intensity of emotions and experiences of an overworked intern. The character in the following story is experiencing the demands and subsequent exhaustion of ``the last day of the three-day stint on call.'' ``How many admissions could one possibly do?'' the intern lamented. ``Perhaps, my coworkers had come to accept the glazed look of an intern,'' the character stated, as she noted her dread of tasks that she once, as a student, had anticipated ``with such relish.'' The character also expressed the realization that despite having delved into her patients' personal lives to an extreme level of intimacy, she doubted that she would recognize them if she ran into them in the grocery store. ``What had I become?'' she asked herself. 5. Discussion We have described the structure and themes written about by students in our creative writing elective over the ®rst 2 years of its existence. Students rated the experience highly, making particular note of the value of the time to re¯ect on
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their experiences, to understand themselves better, and to hear the points of view of their fellow students. This is similar to programs in other medical schools that have been written about [21±24]. Particular challenges frequently voiced during the course included ®nding time to write in the midst of a busy schedule as well as taking the time to focus their attention on one experience or idea and to make clear observations about it. In short, these challenges seem to parallel the challenges that students, residents, and practicing physicians face throughout their career [25]. Several other areas related to the elective warrant further discussion. While this is one elective at one medical school, it is important to consider whether the issues covered by this program apply to students at other medical schools, other trainees, or even practicing physicians. Such external validity seems evident when placing the issues covered and themes generated in the context of other medical literature. Literature related to the sociology of medicine and socialization into the profession has considered many of the themes outlined here [26,27]. We consider our data primary supportive evidence that such issues generalize beyond our student population. Understanding the limits of medicine, from both a technical and personal standpoint, is an ongoing challenge, and acknowledging personal limits can be source of physician stress. The high incidence of depression, suicide, social isolation, alcoholism, and drug abuse and the declining satisfaction with work among physicians are all testaments to the notion that there is dif®culty coping with some of these stressors [28±35]. Attention to self-awareness and incorporating re¯ection into training and practice have been advocated as one way for physicians to deal with this stress and the limitations of medical inquiry [36]. Programs in which re¯ection aims to increase self awareness have been associated with better healing relationships with patients and enhanced coping with stress [36±38]. Writing programs such as ours which increase time for re¯ection and understanding student experiences may help with the stress of medical education, enhance the therapeutic nature of the clinical encounter, and contribute meaning to the work of doctoring [12,39±41]. The concept of medicine as a calling was frequently re¯ected in patient stories. Such stories are increasingly ®nding their way into medical journals like the ``On Being a Doctor'' column in the Annals of Internal Medicine, ``A Piece of My Mind'' in JAMA, ``Medicine, Science, and Society'' in the American Journal of Medicine, and ``Re¯ections'' in the Journal of General Internal Medicine among others. Similar sentiments and stories were found in our elective with students writing about their challenges and early successes in patient encounters, which reminded them of their motivation for entering the profession. A speci®c subset of student stories dealt with the surprise students felt when they realized the narrow line that divided them from the patient in front of them. Identi®cation of the student with
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the patient was the most common reason for their seeing this line as narrow. This identi®cation is clearly the precursor for empathy, a learnable skill that is essential for physicians [42]. One critical aspect of students' development of the skill of empathy is the ability to obtain the patient's perspective, which has been demonstrated to be associated with greater patient satisfaction and improved clinical outcomes in selected diseases [43±45]. Death and dying, a challenge to our students, is a challenge to many physicians. Current national efforts to improve palliative care skills testify to this challenge, and illustrate that there is room for us all to re®ne our skills in this area [46]. It is interesting to note that students' writings about death and dying came up most frequently in response to the ``patient perspective'' assignment. This may suggest that students' limited experiences with death and dying require them to view such an experience from the perspective of another person. Several areas seemed unique to students or trainees, re¯ecting the dilemmas of seeing patients while still feeling like a neophyte. They were in situations where they had multiple titles Ð student, student±doctor, fellow human being Ð but were not sure which role to take on. Students wrote about seeing their teachers manage multiple roles. In these stories, faculty modeled, both successfully and unsuccessfully, the skills that students were trying to acquire. Such role modeling can serve as a critical component of signi®cant learning experiences [47]. Developing a professional identity as a physician is an important task. This may be especially challenging during medical school when the tasks of personal identity are being consolidated, chie¯y centered on establishing personal autonomy and competence [48]. Students' questions about their current and future competence, whether they could live up to their own or the profession's expectations were frequently raised in their writing. Their personal and professional identities can be further consolidated through raising and discussing future challenges. Parallels can be made to the concepts of anticipatory guidance and professional practice to justify such exercises [1,49]. Several limitations need to be discussed. This is an elective experience for a limited number of students. Whether the depth we achieved in our work would have been achieved with students less intrinsically motivated to write is unclear. Themes generated by students may re¯ect in part the topics assigned as opposed to a de novo listing of their concerns in their medical education. After looking closely at this elective, its strengths, and limitations, placing the students' stories in a broader context of literature on narrative seems warranted. Narrative puts us in touch with a fundamental way that people live. People ``dream in narrative, daydream in narrative, remember, anticipate, hope, despair, believe, doubt, plan, revise, criticize, construct, gossip, learn, hate, and love by narrative'' [50]. While patients suffer from disease, it is their lived
experience of illness that is unique, personally challenging, and requires them to cope, all in the effort to give their own life meaning. Stories which aid the integration of patient's disease experience with their person are stories that physicians can help patients write. In considering narratives and trying to interpret their meaning, whether it is for our patients or students, Clouser suggests that narrative analysis fosters several ``qualities of mind.'' These include critical abilities, ¯exibility of perspective, nondogmatism, discernment of values, and empathy and selfknowledge. These qualities seem especially useful when used in helping patients interpret meaning in their illness stories [51]. To date, there are limited long-term outcome data on the effect of writing narratives directly applicable to medical students. The extensive work of Pennebaker and his colleagues demonstrates multiple physical and psychological bene®ts among varied populations dealing with signi®cant transitions or stress [17,52±55]. Writing about prior trauma was shown to boost immune response to Hepatitis B vaccination among a sub-group of New Zealand medical students [56]. A recent report demonstrated clinical improvement in lung function (increased FEV1) in patients with asthma, and a reduction in disease activity (measured by disease severity score) in patients with rheumatoid arthritis who wrote about stressful experiences when compared to matched controls who wrote about neutral topics [57]. There is currently no clear parallel outcome for student narratives in volunteer populations not known to be undergoing undue stress. This is an area for further study. 6. Practice implications While long-term outcomes of this elective have not been demonstrated, there are several implication of the results. Having students struggle with, articulate, and clarify their professional dilemmas is a ®rst step in working through them. Holding such a course, one which attempts to model the skills in the teacher±learner dyad Ð listening actively, giving respectful feedback, observing, and speaking with clarity Ð that we are trying to create in the physician± patient relationship can serve as a model for fostering the development of values in professional education. The nature of the topics discussed are clearly issues important to physicians and physicians-in-training, as evidenced by the themes placed in the context of other medical literature. Such writing could be used as a way for faculty to understand the unique challenges faced by the students they teach, and to tailor learning objectives to ®t their unique needs. In considering the place of creative writing as a means for re¯ection in medical education, the physician-poet William Carlos Williams seems to imply that the two activities, writing and caring for patients, are not as far apart as some would think.
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The physician enjoys a wonderful opportunity actually to witness the words being born. Their actual colors and shapes are laid before him carrying their tiny burdens which he is privileged to take into his care with their unspoiled newness. He may see the dif®culty with which they have been born and what they are destined to do. No one else is present but the speaker and ourselves, we have been the words' very parents. Nothing is more moving. As he then continues in this passage, he links the process of doctoring and the process of writing, simply suggesting that, if we look carefully, they can be one and the same experience. For under that language to which we have been listening all of our lives a new, a more profound language, underlying all the dialectics offers itself. It is what they call poetry [58].
Acknowledgements We would like to thank Donna Qualters, Ph.D., for her encouragement in establishing this elective. We would also like to thank Matt Lally, Jeff Goodman, Karen Conway, Sean O'Reilly, Christine Young, Theresa Chen, Clara Stringer, Paulette Kimball, Liz Rourke, Eric Nelson, Heather Schwemm, Greg Piazza, Peter Smith, and Madeleine Carey for their enthusiastic participation, and Heather Ristuccia, Pius Ogagan, and Miguel Rodriquez for their contributions. References [1] Schon DA. Educating the reflective practitioner. San Francisco, CA: Josey-Bass, 1991. [2] Epstein R. Mindful practice. JAMA 1999;282:833±8. [3] Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. JAMA 1997;278:502±9. [4] Balint M. The doctor, his patient and the illness. London: Pitman, 1964. [5] Brock CD, Stock RD. A survey of Balint group activities in US family practice residency programs. Fam Med 1990;22:33±7. [6] Hewson MGA. Reflection in clinical teaching: an analysis of reflection-on-action and its implications for staffing residents. Med Teach 1991;13:227. [7] Novack DH, Kaplan C, Epstein RM, et al. Personal awareness and professional growth: a proposed curriculum. Med Encounter 1997;13:2±7. [8] Novack DH, Volk G, Drossman DA, Lipkin Jr. M. Medical interviewing and interpersonal sills teaching in US medical schools: progress, problems, and promise. JAMA 1993;269: 2101±5. [9] Novack DH, Dube C, Goldstein MG. Teaching medical interviewing. Arch Intern Med 1992;152:1814±20. [10] Makoul G, Curry RH, Novack DH. The future of medical school courses in professional skills and perspectives. Acad Med 1998;73:48±51. [11] Branch W, Pels RJ, Lawrence RS, Arky R. Becoming a doctor: critical-incident reports from third-year medical students. N Eng J Med 1993;329:1130±2.
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[12] Branch WT, Suchman AS. Meaningful experiences in medicine. Am J Med 1990;88:56±9. [13] Lichstein PR, Young G. My most meaningful patient: reflective learning on a general medicine service. J Gen Int Med 1996;11:406± 9. [14] Quill T, Frankel R. Why use stories in teaching. Med Encounter 1994;11:8±9. [15] Charon R. To render the lives of patients. Literature Med 1986;5:58± 74. [16] Anderson C. Carry me forward . . . into the future in your heart: the place of narrative in health professions education. Med Encounter 1994;11:9±11. [17] Pennebaker JW. Telling stories: the health benefits of narrative. Literature Med 2000;19:3±18. [18] Kravitz RL, Cope DW, Bhreny V, Leake B. Internal medicine patients' expectation for care during office visits. J Gen Int Med 1994;9:75±81. [19] Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med 1998;73(4):403±7. [20] Frankel R, Inui T. Evaluating the quality of qualitative research: a proposal pro tem. J Gen Int Med 1991;6:485±6. [21] Moore-West M, Testa RM, O'Donnell JF. A life in medicine: stories from a Dartmouth Medical School elective. Acad Med 1998;73:153± 9. [22] Poirier S, Ahrens WR, Brauner DJ. Songs of innocence and experience: students' poems about their medical education. Acad Med 1998;73:473±8. [23] Anderson CM. Forty acres of cotton waiting to be picked: medical students, storytelling, and the rhetoric of healing. Literature Med 1998;17:280±97. [24] Reifler DR. I actually don't mind the bone saw: narratives of gross anatomy. Literature Med 1996;15:183±99. [25] Carroll JG, Lipkin M, Nachtigall, Weston W. A developmental awareness for teaching doctor/patient communication skill. In: Lipkin M, Putnam SM, Lazare A, editors. The medical interview. New York, NY: Springer, 1995. [26] Fox RC. The sociology of medicine: a participant observer's view. New York, NY: Prentice-Hall, 1988. [27] Fox RC. Essays in medical sociology: journeys into the field. New Brunswick, NJ: Transaction Books, 1988. [28] McCue J. The effects of stress on physicians and their medical practice. N Eng J Med 1982;306:458±63. [29] Vaillant G, Sobowale N, McArthur C. Some psychologic vulnerabilities of physicians. N Eng J Med 1972;287:372±5. [30] Smith J, William D, Witzke D. Emotional impairment in internal medicine house staff. JAMA 1986;255:1155±8. [31] McAuliffe WE, Rohman M, Santaangelo S, et al. Psychoactive drug use among practicing physicians and medical students. N Eng J Med 1986;316:805±10. [32] Martin M. Psychiatric problems of physicians and their families. Mayo Clinic Proc 1981;56:35±44. [33] Brewster JM. Prevalence of alcohol and other drug problems among physicians. JAMA 1986;255:1913±20. [34] Rucinski J, Cybulska E. Mentally ill doctors. Br J Hosp Psychiatry 1985;33:90±4. [35] Steppacher RC, Mausner JS. Suicide in male and female physicians. JAMA 1974;228:323±8. [36] Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med 1990;150:1857±61. [37] Marshall AA, Smith RC. Physicians' emotional reactions to patients: recognizing and managing countertransference. Am J Gastroenterol 1995;90:4±8. [38] Gorlin R, Zucker HD. Physicians' reaction to patients: a key to teaching humanistic medicine. N Eng J Med 1983;308:1059±63. [39] Matthews DA, Suchman AL, Branch WT. Making connexions: enhancing the therapeutic potential of patient-clinician relationships. Ann Int Med 1993;118:973±7.
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[40] Suchman AL, Matthews DA. What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care. Ann Int Med 1988;108:125±30. [41] Suchman AL, Branch WT, Matthews DA. The role of the medical interview in the physician's search for meaning. In: Lipkin M, Putnam SM, Lazare A, editors. The medical interview. New York, NY: Springer, 1995. [42] Spiro H. What is empathy and can it be taught. Ann Intern Med 1994;116:843±6. [43] Smith RC, Hoppe RB. The patient's story: integrating the patientand physician-centered approaches to interviewing. Ann Int Med 1991;115:470±7. [44] Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Int Med 1985;102:520±8. [45] Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision-making styles. Ann Int Med 1996;124:497±504. [46] Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Int Med 1997;127:225±30. [47] Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending-physician role models. N Eng J Med 1998;339:1986±93. [48] Gaesnbauer TJ, Mizner GL. Developmental stresses in medical education. Psychiatry 1980;43:60±70. [49] Iazzetti L. Anticipatory guidance: having a dog in the family. J Ped Health Care 1998;12:73±9.
[50] Widdershouen G. The story of life: hermeneutic perspective on the relationship between narrative and life history. In: Josselson R, Lieblich A, editors. The narrative study of lives. London: Sage, 1993. [51] Clouser KD. Humanities in medical education: some contributions. J Med Philos 1990;15:289±301. [52] Pennebaker JW. Opening up: the healing power of expressing emotions. New York: Guilford Press, 1997. [53] Spera SP, Buhrfeind ED, Pennebaker JW. Expressive writing and coping with job loss. Acad Manage J 1994;37:722±33. [54] Richards JM, Beal WE, Seagal JD, Pennebaker JW. Effects of disclosure of traumatic events on illness behavior among psychiatric prison inmates. J Abnormal Psychol 2000;109:156± 60. [55] Rime B. Mental rumination, social sharing, and the recovery from emotional exposure, in emotion, disclosure, and health. In: Pennebaker JW, editor. Washington, DC: American Psychological Association, 1995. [56] Keith J, Petrie KJ. Disclosure of trauma and immune response to hepatitis B vaccination program. J Consulting Clin Psych 1995;63:187±92. [57] Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis. JAMA 1999;281:1304±9. [58] Williams WC. The autobiography of William Carlos Williams. New York: New Directions, 1967.
Becoming a doctor: fostering humane caregivers through creative writing$ David Hatem*, Emily Ferrara University of Massachusetts Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
Abstract We qualitatively examined themes covered in a creative writing elective designed to enhance pre-clinical medical students' writing, observation, and re¯ection skills relative to experiences in their medical education. Qualitative analysis of writings' themes was carried out via iterative consensus building process and validated through member checks and literature review. Fourteen students completed the elective, seven for each year it was given. Students submitted 86 written pieces. Qualitative analysis demonstrated the presence of nine themes: students' role confusion, developing a professional identity, medicine as a calling, physician privilege and power, humanizing the teacher, the limits of medicine, death and dying, anticipating future challenges, and identi®cation with the patient. Students evaluated this creative writing course favorably, indicating value in writing and re¯ection. Themes covered are of concern to second-year medical students as well as other trainees and practicing physicians. Writing may aid in the professional development of physicians. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Narrative; Physician±patient relationship; Creative writing; Re¯ective practice; Empathy
1. Introduction Re¯ection is a critical part of professional training [1]. It is intimately connected with self-awareness, and together they help physicians and physicians in training to examine beliefs and values, deal with strong emotions, and resolve interpersonal con¯ict [2±4]. Schon distinguishes between re¯ection in action, ®ne tuning an act in the middle of performing it as a function of thinking about what you are doing, and re¯ection on action, thinking about an act or event at a time separate from that event [1]. Often, the most vexing problems require re¯ection on action. While training which incorporates re¯ection and self-awareness takes place in some medical schools and residency programs [5±10], this is not a uniform part of curricula. One outcome of re¯ection can be enhanced self-awareness, which is felt by many to be critical to a physician's work [3]. One method to encourage re¯ection is through the writing and sharing of narratives or critical incidents [11±13]. Narrative probes the depths of medical experience [14], $
Received from the Division of General Medicine, Primary Care and Geriatrics (DH) and the Office of Medical Education (EF), University of Massachusetts Medical School, Worcester, MA. Presented in part at the Communication in Medicine Conference, Chicago, IL, July 1999. * Corresponding author. Tel.: 1-508-856-5972; fax: 1-508-856-8085. E-mail address: [email protected] (D. Hatem).
allows for greater understanding of our patients [15], our work, and ourselves [16]. In addition, writing narratives has demonstrated positive health and behavioral effects in such varied groups as prisoners, distressed crime victims, ®rst time mothers, men who have been laid off from their jobs, arthritis and chronic pain sufferers, and medical students [17]. If patient care is enhanced by eliciting and understanding the patient's perspective [16,18], we postulated that setting aside time to re¯ect on students' early patient encounters from multiple perspectives (the patient's, the student's, and the doctor's) would make students' future patient care more humane. In a parallel fashion, by having faculty set aside time to listen to the students' perspectives, we hoped to make their educational experience more humane, thus creating a program that strives to live up to the ideals it advocates. This contrasts with the concept of the ``hidden curriculum'' in which researchers have identi®ed a discordance between principles that are taught and principles that are practiced [19]. In order to enhance students' opportunities for re¯ection, we established an elective for second-year medical students entitled ``Creative Writing for Medical Students.'' It gave students the chance to write about and discuss signi®cant experiences related to their medical education as they were going through these experiences. We report the elective's outcomes based on the ®rst 2 years of students' writing. Our
0738-3991/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 1 ) 0 0 1 3 5 - 5
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aim in analyzing the students' writing was to understand the challenges and unique issues faced by second-year medical students in the process of their professional development as prospective physicians. 2. Methods 2.1. The course We began an elective course for second-year students, ``Creative Writing for Medical Students,'' in the fall of 1997. The course aimed to help students write clearly about their experiences, describe their observations, and distinguish between observations and conclusions. Students carried this out by writing in response to speci®c assignments, then sharing their writing samples with others, with the opportunity to receive constructive feedback. While their experiences were the starting point of their assignments, they were free to write ®ctionalized accounts or poems. In taking part in this elective, students considered how writing and re¯ecting on their experiences in¯uenced their personal and professional development. The elective took place in the fall semester, and met biweekly for seven 1.5 h sessions. For each session students wrote narratives or poetry on suggested topics in advance of the session, and then read and re¯ected on these during the session. Topics included a signi®cant experience in medical school, a memorable patient, writing from the patient perspective, the decision to become a doctor, and student± teacher, student±patient, and physician±patient interactions. The elective was given again in the fall semester of 1998. In both academic years, students chose to continue meeting with course faculty during the spring semester as well. During the spring semester, they wrote on topics of their own choosing although most narratives continued to focus on issues raised by their medical education. Both semesters' writing was included in the analysis. 3. Data analysis While students evaluated the experience relative to whether the course met its objectives, we concentrate and report here only the qualitative (thematic) analysis of students' writing. This analysis was done through an iterative consensus-building process in which writing was coded independently by each of two faculty evaluators (DH and EF). Themes were identi®ed in students' writing and then discussed. Writing was analyzed until no new themes emerged. Disagreements about coding and themes were resolved in face-to-face meetings. Themes selected were validated by use of the standard qualitative method of triangulation. Triangulation in this study included member checks, showing the themes identi®ed by the faculty evaluators to the elective participants for their input, seeking
their agreement or addition of themes. There were no additional themes identi®ed by students in the elective. Another validation step was to compare themes that emerged to literature on the personal and professional development of medical students as a method of seeking the ``relatedness'' of the work [20]. Given the limited data on the day-to-day challenges of second-year medical students, our analysis was exploratory in nature and did not utilize a preset or established framework for interpretation of ®ndings. Students gave their permission for literary work to be quoted. 4. Results Seven students completed the requirements for the course each year that it was offered (total 14). Eighty six ®nished pieces of writing were submitted. Qualitative analysis of the writing showed work to be divided into nine themes (see Table 1). Most of the writing cut across all themes with the exception of the six pieces on the theme ``Humanizing the Teacher''; these writings were exclusively assignmentdriven. What follows is a discussion of each of these themes and representative issues raised within them. 4.1. Medicine as a calling Students' writings spanned a continuum from the lofty goals and larger context of the students' experiences of being called to the profession of medicine, to their most concrete examples of medicine's art. While deciding to attend medical school was an early goal for some, the decision for others was a conscious one involving the determination to choose something different from other family members. For several others, it involved abandoning one career, going back to school, and moving away from other pursuits, such as business, engineering, or writing. Those who shifted careers seemed to feel an inherent ``rightness'' in their decision, which helped them in dif®cult times as they got caught up in mundane details of studying overwhelming amounts of material, but they gave voice to their doubts which they experienced at times like this. Adherence to an ideal image of the goals and values of medicine permeated these writings for some, while others were able to point to more speci®c events that led them to Table 1 Creative writing themes (n: number of writings on theme) Medicine as a calling Role confusion and conflict Identification with the patient Developing a professional identity Physician privilege and power Humanizing the teacher Death and dying The limits of medicine Anticipating future challenges
[11] [11] [10] [10] [5] [6] [8] [14] [11]
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pursue a career in medicine. One student wrote of spending a day in an AIDS clinic, watching the doctor practice technically competent care while also dealing with the human and public health needs of his patients as he advocated for their use of a needle exchange program. Similarly, students witnessed the ideals of medicine in practice, further underscoring their perception of medicine as a calling. This most commonly took the form of coming to an understanding of the patient's story, moving beyond an accounting of their symptoms to a narrative of their worries, their concerns, and ultimately their life. One such account details a nervous student, overjoyed at having a new beeper, whose purpose is to notify the student that it is time to perform an autopsy, part of the required curriculum in the second year. She will then assist in cutting the body, removing organs, generating microscopic slides, trying to solve the mystery of what led to the patient's death. This is contrasted with her imaginative rendering of the last days of the woman's life, the tearful goodbye from her husband, and their last moments together, lending a whole new meaning to her hearing the beeper tone sound, and serving to temper her joy in a poem entitled ``The Grim Beeper.'' One additional piece begins as one of the students introduces us to her patient graphically, announcing: The massive gentleman on the bed is unwell. What follows is an account of an obese gentleman whose layers of skin have come to serve as protection against the discrimination he has been subject to throughout his life. Through her sensitive persistence, the student uncovers not only his medical dif®culties, but also his home challenges, including the fact that his wife has just undergone bypass surgery. His thankful look con®rms her role and the value of her uncovering this detail. In an ironic twist at the end, the attending physician comes into the room, and we note that the bene®t of the patient's story is lost on him, as he neither elicits nor apparently notes the last bit of communication between the patient and the student. The doctor walks in and the mood of the room shifts to the professional. The man becomes the patient who needs to be examined and the student there to pick up all the physical signs of illness from the specimen on the bed. From head to toe, systematically, the doctor reviews each major system in order and the interview is over. The student follows the doctor out of the room, but not before she turns back to bid farewell to the man on the bed. He still looks as weary, but his lips are slightly lifted at the corners. 4.2. Role confusion and role conflict Students frequently explored their feelings of uncertainty about their role in the medical encounter, and the confusing, sometimes overwhelming nature of medical school
15
experiences. These writings often depicted medical students in the midst of early patient experiences, expressing mixed feelings, from the exhilaration of practicing new skills well, to the sense of awe and amazement when they witnessed their faculty preceptors interview, asking questions that they had not anticipated or even thought of. The effect of this was to make it clear that seeing patients went beyond technical skill and became a profoundly human encounter. Several discussed their role as medical students as an inbetween place. They were not yet physicians, and they repeatedly wondered whether they had made the right decision to go to medical school, whether they would ever feel that they had enough skill, and if they would ever get over the feeling of being totally overwhelmed. Being lost in a forest was one metaphor used to describe the medical school experience. There were additional pieces written about events that students knew were important, but had not been fully processed. One example is the student who had worked in a nursing home and had visited an elderly, dying woman whom most of the staff avoided. Each time the student went to work, she rushed through her other chores and left time to visit with this lonely, confused woman. Unable to explain the impulse to visit this dying patient, she simply kept her company regularly until her death. What role had she played? Did the patient bene®t in any way? These were typical questions raised by students who wrote about similar experiences with patients. The confusing world of medicine, new language, new skills, and emerging new identities, led one student to observe: Somehow, a stethoscope Swung carelessly around our necks Endows us with the authority To pick, prod, and poke The unsuspecting elderly Affectionately known as GI West 120, neuro 312. . . Later, she re¯ects on her new, emerging identity, with a note of collective caution. Beacons of wisdom, Able to buy beer But not rent a car Who do we think we are? 4.3. Identification with the patient These writings focused on incidents and experiences in which the students identi®ed with a patient, or failed to identify with a patient despite struggling to understand the patient's perspective. One student expressed surprise at ®nding a similarity with the patient, a prisoner in shackles brought into an ER for
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treatment. They were the same age, although in reality these two individuals were worlds apart. Another student, who served as a ``patient sitter'' for a suicidal patient who had suffered severe, self-in¯icted burns, strained to understand what drove the patient to such an extreme and self-immolating act: Did she stand in the shower? and turn the water up until it was scalding? or did she turn the water on, testing, testing, the way I do each day, maybe absently scratching my calf with my foot, before recognizing yes, this is the temperature I want, now. Did she know, as she pulled off her shirt, unbuttoned a skirt, unhooked her bra? I see my clothes fall in a heap on the bathroom ¯oor. Did she look her body up and down in the mirror? Was it fogged with steam from the scalding stream? The triggering of identi®cation with a patient, through a past experience with illness or injury, or through an unexpected association, was another strand of this theme. One student wrote about her experience of identifying with a faculty member through the shared experience of a chance encounter outside the classroom, in the of®ce of a massage therapist. The faculty member had been diagnosed with metastatic breast cancer, and had spoken about it to the class. The student worried about being able to measure up to the faculty member's courage and stamina: I feel a sudden twinge in my tender breast and wonder if this is how it started for her. Does being a doctor make it better for her or would it be easier to be protected from knowing too much like everyone else. I am suddenly afraid of knowing too much of the responsibility of being too close to death my muscles tense as though already weighted down with the burden. One student recounted the story of walking along as an adolescent, tripping over ``a piece of grass'' and breaking his arm in the process. The story seemed to rise up as a result of an encounter with a medical ICU patient who had Lupus, and was not doing well. He noted that all the doctors could tell her ``is that she was just walking along, and for some reason that no one could have predicted, she stumbled and her life changed forever.''
4.4. Developing a professional identity A subset of the students' writing dealt with the development of their professional identity. This had multiple aspects. Some witnessed encounters in which they observed or interacted with patients whom they recognized that they either did not like, or would not come in contact with in their more ordinary day-to-day existence. Realizing that they had to keep their judgments to themselves when dealing with injection drug users or arrogant patients, they concentrated on the clinical outcome they were trying to effect. A critical step in the writing seemed to be recognition of their personal reaction, followed by an active decision to keep this reaction out of the encounter with the patient. Such clear separation between personal judgment and reactions to patients was not always evident, as in one person's inability to feel empathy for a patient who delivered a baby with a neural tube defect and had not taken her pre-natal folate to prevent this. In the encounter, she reported being angry, and on further re¯ection she realized: When my day was ®nally over, and I lay in bed in the darkness, it suddenly occurred to me why the baby's mother had made me so angry. She had so easily achieved in her 20 years what I haven't been able to in my 38 childless years. For the ®rst time that day, I cried. Others re¯ected on their personal discomfort with speci®c situations. The very personal questions in the sexual history were troublesome for one participant, but then led her to wonder how much of this re¯ected the in¯uence of her upbringing, namely being told by her parents that she should not ask prying questions of others. Becoming aware of their reactions and sorting out where they came from seemed critical in searching for meaning in these troubling encounters. Others wrote about times when they were able to make clear distinctions in the encounter. Most commonly, this revolved around their being able to see the individual patient's illness and symptoms in the context of the patient's life, as distinct from the more narrow pathological focus on disease. One poem contrasted a patient's seeking treatment for disease in the doctor's of®ce, and treatment for her illness, in a church. She pulls open the heavy door and shuf¯es across the granite foyer, worn shiny and smooth by years of penitent feet. . . Burnished wooden pews glow. . . and she eases herself to her knees. She pulls open the heavy door and shuf¯es across the linoleum foyer, scrubbed shiny and smooth each night by scouring hands. . . .she makes her way into the brilliantly lit waiting room.
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As the encounter concludes, there seems to be an inexorable blending of the physician and priestly function: The dappled light is getting lower, The exam room door swings open and the white-clad doctor briskly steps in. A hint of incense twirls in the gathering dusk. The creased edges of the written prescription feel sharp in her ®ngertips And she is comforted. For disease to the doctor, for healing to the priest? The boundaries are not so clear as the poem concludes. 4.5. Physician privilege and power In their writings students often explored their feelings, commonly feelings of discomfort and disturbance, about physicians' power and privilege within society at large, and within the doctor±patient encounter. These writings often illustrated a developing awareness of the impact of the power differential within the doctor±patient relationship. Although physicians' power in society seemed to run through most pieces as an undercurrent, one student grappled directly with the prospect of his own increasing power/privilege and responsibility, as he followed the path to physicianhood: Doctors are the adults of the adult world. . .if I had already become an adult in the ordinary sense, I had yet to become that special species of super-adult I was aiming for. The theme of technical versus personal care is also explored in this section on power and privilege. In particular, the writing pointed to the sometimes enigmatic and `magical' healing power of the doctor±patient encounter. One student described her dismay at learning of her preceptor's effect on his patient, by virtue of his charismatic nature rather than his surgical skills. Most often, the focus of these pieces was the depiction of the intimacy in the doctor±patient relationship, and the physician's physical access to the most private parts of patients' bodies. One poem likens a patient awaiting the doctor's arrival to a woman awaiting the arrival of her lover. The feelings of alienation that can arise between the doctor and patient were palpable in other writings. The ways that the power differential may negatively impact the encounter were explored in a piece in which a past violation in a patient's life is triggered by the physical exam: The patient was left to undress alone. When the doctor returned, she was picked at and prodded and stared into deeply. She opened her mouth, turned her head, and swallowed on command. Her breasts were examined for any imperfections. . . `Come closer to me and spread your legs apart.' The doctor's command made her shudder, yet she had
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learned how to obey. She closed her eyes and put her arms over her head. `Don't tell me to try to relax. Just go hide behind that sheet of yours and do what you need to do.' The speculum ripped open years of old wounds, yet she didn't make a sound. She didn't cry then, why should now be any different? 4.6. Humanizing the teacher Featured prominently in the work of those who took part in the elective were stories about teachers. While this was a topic that students were assigned to write about, many of their stories also overlapped, and were included with other themes. Only those that talked solely about teachers were included in this category. Most prominent were stories that focused on the humanity of teachers, with students expressing gratitude and surprise at their teachers' humility and simple kindness. These included the pathologist who brought a classical guitarist to the ®nal class of the semester to ``serenade his class,'' and the physiologist who offered a towel and a change of clothes to a student who had been caught out in the freezing rain. Teachers' acts outside the classroom were not the only events noted, with one person noting the particular skill and care with which she was taught how to perform her ®rst pelvic exam by a standardized patient instructor in a piece entitled ``My Guide.'' I have never seen this place the darkness blinds I rely on my guide and my hands to see, to learn the geography of this mysterious place I wish I were somewhere else studying micro or not anywhere else but here. Running away again, Uncomfortable. . . She brings me back with her hearty laugh she speaks of her children then, ``a little more to the right, you've got it,'' an ovary An ovary!! Or not thank you anyway for sharing this amazing place that nurtured four children and one student. Also memorable were negative experiences, including the student who watched her attending physician preceptor rush
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through an examination, skipping things she would ordinarily do, and later admitting that her dislike for the patient in¯uenced her actions. Another student presented a story of a physician whose questioning of his patient led to her disclosure of suicidal intent. After the disclosure, the physician simply moved on to the next question, never stopping to address the issue the patient had raised, leaving the student similarly shocked into silence. 4.7. Death and dying Medical education in the ®rst 2 years often brings students into their ®rst encounters with mortality, their own and that of their patients, through their experiences of dissecting a cadaver, of assisting on an autopsy, and of the opportunities they have to interact with dying patients. This topic was also explored from yet another perspective: that of experiencing the death of a classmate by suicide. Most often, these writings explored the topic from the patient's perspective. In addition to an awareness of patients' fears in the face of terminal diagnoses, the return of cancer, a positive breast biopsy, was an awareness of patients' desire to live. Juxtaposed against this were writings that explored the perspectives of patients who are terminally ill and essentially ``waiting to die.'' I am tired of telling them I am not afraid. I am tired of dreaming. I am tired of waiting For God to come and take me home. I am tired of giving up my body To the hands of strangers. They touch me in places I did not tell them they could. I need to ®nd the quiet, quiet place I need to ®nd peace The overarching task of this topic area, it seemed, was in each student's struggle to make sense of life, to honor and venerate it, and to begin to understand and confront their own mortality, and the mortality of their loved ones. 4.8. The limits of medicine This category of writings bridges the span from students' experiences of confronting the limits of medicine and their own personal limits, to rising to the challenge of ®nding balance in their lives. Students sought balance through efforts to live, study, and practice medicine mindfully, most commonly in the form of taking measures to allow for self-care. One student recounted a day of working in an HIV linic, where time was limited and patients' needs seemed unlimited: We barely scratch the surface of his emotional state, but the waiting crowd in the lobby grows and his compli-
cated medical problems have taken up the allotted time. . . A few needle sticks for a new CD4 and viral load are done and he slips out of the clinic, back to the cool November day. Another student, in telling the story of a stroke patient who was dealing with the dire impact on his ability to perform the simple tasks of daily living, re¯ected on this with resignation: I imagined myself in his situation and how helpless I would feel. However, there was nothing much I could do or ®x. Sometimes I wonder if being an automobile mechanic would be easier since automobile problems are much easier to identify, and almost everything is reparable. However, there are limits to what can be done for the human body. On the other end of the continuum of this category's themes, the appreciation of the joy and beauty of living mindfully in the midst of their busy lives was captured in the students' writings. In one poem, a physician was taking a coffee break, the mug ``brought to his mouth in joyous rejuvenation.'' Other mindful activities written about included a student's participation in a 15-mile run with his parents' running club, and another student's re¯ections on a summer spent in Cuba in a language immersion experience. A juxtaposition of the simple joys of daily life and the demands of medical education were central to a poem by one student who appeared, for one blissful moment, to have struck a ®ne balance: The hospital speaks and tonight I ®nally hear it walking slowly down the sidewalk my backpack light without its usual load only my stethoscope inside but it's heavy enough tonight the patients have drained me and I'm empty and light. . . I pause for a moment Standing by myself In the darkened parking lot An occasional snow¯ake settling lightly on my hair I turn back the way I've come and take a deep breath I listen to the hospital I don't really understand what it's trying to say but at least I'm listening. 4.9. Anticipating future challenges The writings in this category chronicled the students' anticipation of the challenges of the future, whether in medical school, in residency education, or in practice.
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The essays and poems tackle such issues as: feeling swallowed up, transformed, or destroyed by the process of medical education (experienced as a kind of death), and anticipating the future application of knowledge accumulated in the classroom or lab. In a poem, one student used the metaphor of making a necklace to symbolize the medical education process, beads offered by faculty and patients alike: But then another doctor holds out a bead to me, like a jewel he guides my hand as I slip it on the string, reminding me of how beautiful my necklace is becoming. . . I lay my hand on the warm skin of a patient's chest, feeling his heart Beating into my palm, not even realizing until later That without even moving he offered me another bead. This student speaks of the ``un®nished necklace'' for which she is desperately trying to ``keep any of the other beads from falling off. The necklace has no power to comfort me tonight, wondering whether I will ever be able to wear it around my neck.'' Another student explored his sense of being outside the hallowed halls of medicine, not yet a full-¯edged member of the profession. For now, ``The enemy was doctors in general, but mostly one doctor in particular.'' He speaks of his father, a doctor, and of his own attachment to the ``undoctorly'' habit of smoking cigarettes, something frowned upon by most practicing physicians. Will the future lead to his quitting smoking? If so, is he succumbing to the transformation of becoming a doctor? Or will the rebellion continue? The writing done by the students as they neared the beginning of the clinical clerkships year, served as a vehicle for ``trying on'' the intensity of emotions and experiences of an overworked intern. The character in the following story is experiencing the demands and subsequent exhaustion of ``the last day of the three-day stint on call.'' ``How many admissions could one possibly do?'' the intern lamented. ``Perhaps, my coworkers had come to accept the glazed look of an intern,'' the character stated, as she noted her dread of tasks that she once, as a student, had anticipated ``with such relish.'' The character also expressed the realization that despite having delved into her patients' personal lives to an extreme level of intimacy, she doubted that she would recognize them if she ran into them in the grocery store. ``What had I become?'' she asked herself. 5. Discussion We have described the structure and themes written about by students in our creative writing elective over the ®rst 2 years of its existence. Students rated the experience highly, making particular note of the value of the time to re¯ect on
19
their experiences, to understand themselves better, and to hear the points of view of their fellow students. This is similar to programs in other medical schools that have been written about [21±24]. Particular challenges frequently voiced during the course included ®nding time to write in the midst of a busy schedule as well as taking the time to focus their attention on one experience or idea and to make clear observations about it. In short, these challenges seem to parallel the challenges that students, residents, and practicing physicians face throughout their career [25]. Several other areas related to the elective warrant further discussion. While this is one elective at one medical school, it is important to consider whether the issues covered by this program apply to students at other medical schools, other trainees, or even practicing physicians. Such external validity seems evident when placing the issues covered and themes generated in the context of other medical literature. Literature related to the sociology of medicine and socialization into the profession has considered many of the themes outlined here [26,27]. We consider our data primary supportive evidence that such issues generalize beyond our student population. Understanding the limits of medicine, from both a technical and personal standpoint, is an ongoing challenge, and acknowledging personal limits can be source of physician stress. The high incidence of depression, suicide, social isolation, alcoholism, and drug abuse and the declining satisfaction with work among physicians are all testaments to the notion that there is dif®culty coping with some of these stressors [28±35]. Attention to self-awareness and incorporating re¯ection into training and practice have been advocated as one way for physicians to deal with this stress and the limitations of medical inquiry [36]. Programs in which re¯ection aims to increase self awareness have been associated with better healing relationships with patients and enhanced coping with stress [36±38]. Writing programs such as ours which increase time for re¯ection and understanding student experiences may help with the stress of medical education, enhance the therapeutic nature of the clinical encounter, and contribute meaning to the work of doctoring [12,39±41]. The concept of medicine as a calling was frequently re¯ected in patient stories. Such stories are increasingly ®nding their way into medical journals like the ``On Being a Doctor'' column in the Annals of Internal Medicine, ``A Piece of My Mind'' in JAMA, ``Medicine, Science, and Society'' in the American Journal of Medicine, and ``Re¯ections'' in the Journal of General Internal Medicine among others. Similar sentiments and stories were found in our elective with students writing about their challenges and early successes in patient encounters, which reminded them of their motivation for entering the profession. A speci®c subset of student stories dealt with the surprise students felt when they realized the narrow line that divided them from the patient in front of them. Identi®cation of the student with
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the patient was the most common reason for their seeing this line as narrow. This identi®cation is clearly the precursor for empathy, a learnable skill that is essential for physicians [42]. One critical aspect of students' development of the skill of empathy is the ability to obtain the patient's perspective, which has been demonstrated to be associated with greater patient satisfaction and improved clinical outcomes in selected diseases [43±45]. Death and dying, a challenge to our students, is a challenge to many physicians. Current national efforts to improve palliative care skills testify to this challenge, and illustrate that there is room for us all to re®ne our skills in this area [46]. It is interesting to note that students' writings about death and dying came up most frequently in response to the ``patient perspective'' assignment. This may suggest that students' limited experiences with death and dying require them to view such an experience from the perspective of another person. Several areas seemed unique to students or trainees, re¯ecting the dilemmas of seeing patients while still feeling like a neophyte. They were in situations where they had multiple titles Ð student, student±doctor, fellow human being Ð but were not sure which role to take on. Students wrote about seeing their teachers manage multiple roles. In these stories, faculty modeled, both successfully and unsuccessfully, the skills that students were trying to acquire. Such role modeling can serve as a critical component of signi®cant learning experiences [47]. Developing a professional identity as a physician is an important task. This may be especially challenging during medical school when the tasks of personal identity are being consolidated, chie¯y centered on establishing personal autonomy and competence [48]. Students' questions about their current and future competence, whether they could live up to their own or the profession's expectations were frequently raised in their writing. Their personal and professional identities can be further consolidated through raising and discussing future challenges. Parallels can be made to the concepts of anticipatory guidance and professional practice to justify such exercises [1,49]. Several limitations need to be discussed. This is an elective experience for a limited number of students. Whether the depth we achieved in our work would have been achieved with students less intrinsically motivated to write is unclear. Themes generated by students may re¯ect in part the topics assigned as opposed to a de novo listing of their concerns in their medical education. After looking closely at this elective, its strengths, and limitations, placing the students' stories in a broader context of literature on narrative seems warranted. Narrative puts us in touch with a fundamental way that people live. People ``dream in narrative, daydream in narrative, remember, anticipate, hope, despair, believe, doubt, plan, revise, criticize, construct, gossip, learn, hate, and love by narrative'' [50]. While patients suffer from disease, it is their lived
experience of illness that is unique, personally challenging, and requires them to cope, all in the effort to give their own life meaning. Stories which aid the integration of patient's disease experience with their person are stories that physicians can help patients write. In considering narratives and trying to interpret their meaning, whether it is for our patients or students, Clouser suggests that narrative analysis fosters several ``qualities of mind.'' These include critical abilities, ¯exibility of perspective, nondogmatism, discernment of values, and empathy and selfknowledge. These qualities seem especially useful when used in helping patients interpret meaning in their illness stories [51]. To date, there are limited long-term outcome data on the effect of writing narratives directly applicable to medical students. The extensive work of Pennebaker and his colleagues demonstrates multiple physical and psychological bene®ts among varied populations dealing with signi®cant transitions or stress [17,52±55]. Writing about prior trauma was shown to boost immune response to Hepatitis B vaccination among a sub-group of New Zealand medical students [56]. A recent report demonstrated clinical improvement in lung function (increased FEV1) in patients with asthma, and a reduction in disease activity (measured by disease severity score) in patients with rheumatoid arthritis who wrote about stressful experiences when compared to matched controls who wrote about neutral topics [57]. There is currently no clear parallel outcome for student narratives in volunteer populations not known to be undergoing undue stress. This is an area for further study. 6. Practice implications While long-term outcomes of this elective have not been demonstrated, there are several implication of the results. Having students struggle with, articulate, and clarify their professional dilemmas is a ®rst step in working through them. Holding such a course, one which attempts to model the skills in the teacher±learner dyad Ð listening actively, giving respectful feedback, observing, and speaking with clarity Ð that we are trying to create in the physician± patient relationship can serve as a model for fostering the development of values in professional education. The nature of the topics discussed are clearly issues important to physicians and physicians-in-training, as evidenced by the themes placed in the context of other medical literature. Such writing could be used as a way for faculty to understand the unique challenges faced by the students they teach, and to tailor learning objectives to ®t their unique needs. In considering the place of creative writing as a means for re¯ection in medical education, the physician-poet William Carlos Williams seems to imply that the two activities, writing and caring for patients, are not as far apart as some would think.
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The physician enjoys a wonderful opportunity actually to witness the words being born. Their actual colors and shapes are laid before him carrying their tiny burdens which he is privileged to take into his care with their unspoiled newness. He may see the dif®culty with which they have been born and what they are destined to do. No one else is present but the speaker and ourselves, we have been the words' very parents. Nothing is more moving. As he then continues in this passage, he links the process of doctoring and the process of writing, simply suggesting that, if we look carefully, they can be one and the same experience. For under that language to which we have been listening all of our lives a new, a more profound language, underlying all the dialectics offers itself. It is what they call poetry [58].
Acknowledgements We would like to thank Donna Qualters, Ph.D., for her encouragement in establishing this elective. We would also like to thank Matt Lally, Jeff Goodman, Karen Conway, Sean O'Reilly, Christine Young, Theresa Chen, Clara Stringer, Paulette Kimball, Liz Rourke, Eric Nelson, Heather Schwemm, Greg Piazza, Peter Smith, and Madeleine Carey for their enthusiastic participation, and Heather Ristuccia, Pius Ogagan, and Miguel Rodriquez for their contributions. References [1] Schon DA. Educating the reflective practitioner. San Francisco, CA: Josey-Bass, 1991. [2] Epstein R. Mindful practice. JAMA 1999;282:833±8. [3] Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. JAMA 1997;278:502±9. [4] Balint M. The doctor, his patient and the illness. London: Pitman, 1964. [5] Brock CD, Stock RD. A survey of Balint group activities in US family practice residency programs. Fam Med 1990;22:33±7. [6] Hewson MGA. Reflection in clinical teaching: an analysis of reflection-on-action and its implications for staffing residents. Med Teach 1991;13:227. [7] Novack DH, Kaplan C, Epstein RM, et al. Personal awareness and professional growth: a proposed curriculum. Med Encounter 1997;13:2±7. [8] Novack DH, Volk G, Drossman DA, Lipkin Jr. M. Medical interviewing and interpersonal sills teaching in US medical schools: progress, problems, and promise. JAMA 1993;269: 2101±5. [9] Novack DH, Dube C, Goldstein MG. Teaching medical interviewing. Arch Intern Med 1992;152:1814±20. [10] Makoul G, Curry RH, Novack DH. The future of medical school courses in professional skills and perspectives. Acad Med 1998;73:48±51. [11] Branch W, Pels RJ, Lawrence RS, Arky R. Becoming a doctor: critical-incident reports from third-year medical students. N Eng J Med 1993;329:1130±2.
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