A course in creative writing was designed as a possible tool in medical education. Twelve volunteers (six doctors and six non-medical staff) participated in seven workshops held weekly. Four aims were identified: to help put thoughts onto paper; to facilitate interpretation of narrative; to encourage expression of emotions related to illness and death, and to encourage creativity. The course was evaluated using participant observational analysis and two questionnaires. This paper discusses the outcomes in relation to these aims, but identifies additional issues raised by the development.
Only six of the 12 participants produced a final piece of written work, with lack of self discipline being cited as the chief reason. There was a strong tendency for self reflection in the group, which needed appropriate support. How creativity can be encouraged remains unclear. The value of multidisciplinary learning in this context was identified.
The value of creative writing for medical education remains difficult to measure, but the participants agreed unanimously that the course would be an enjoyable way of encouraging medical students in its stated aims.
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Throughout the UK and abroad1–6 modules in humanities are being increasingly offered as part of undergraduate medical education. The graduate course in medicine at the University of Cambridge, which started in September 2001, provided the opportunity to consider how a strand in literature could be developed within the course. Creative writing workshops could be used to enable students to develop their creative and reflective thinking, whilst also developing their writing skills. A course was designed and piloted with a group of volunteer staff from a local district general hospital. This article will describe the development, delivery, and evaluation of the course, and will discuss the lessons learnt.
None of the authors involved in the project had any previous experience in delivering creative writing classes. The objectives of the pilot study were therefore primarily to gain experience of delivering this type of course prior to offering the course to medical students. The aim was also to assess the effectiveness of the course in meeting specified aims, and to identify any practical issues in its delivery.
PREPARATION: DEFINING AIMS
A literature search identified four specific interrelated aims for the course. These were to:
Get thoughts onto paper
Facilitate interpretation of narrative
Help express issues related to illness and death
Reflective writing has been described as a method of developing skills in interpretation of patient narrative.7 This in turn may help doctors to acknowledge the plight of others and also to recognise their own personal journey in medicine. The importance of the patient’s narrative is central to the practice of medicine,8,9 with the exchange between the doctor and the patient taking narrative form.
Writing has been described as different from talking or thinking in having a deeper reflective and educative function.10 It enables the writer to discover and clarify thoughts and ideas which remain unchanged on the page, and allows exploration of previously unacknowledged issues. Creative writing can also relieve stress and foster understanding.10,11 It was felt that this approach might be particularly refreshing for medical students, as it would give them the opportunity to be creative, rather than suffer the “scarcely tolerable burden of information that is imposed (which) taxes the memory but not the intellect”12 by courses based on biomedical knowledge.
Whilst these published aims appealed to the authors, the decision to run a pilot study reflected a desire for practical experience as well as objective evidence of educational benefits. The pilot study consisted of seven 90 minute workshops (see box one), each with different objectives. It was agreed that by the end of the last workshop participants should have produced a piece of written work that was in some way related to their job in the hospital. This might test the fourth aim, that of encouraging creativity. The course was accompanied by a collection of resource material to act as stimuli: extracts from prose and poetry chosen for their relevance to the workshops.
A set of ground rules was included, which were agreed at the beginning of the course (see box two).
12 members of hospital staff were recruited, seven following personal invitation, and five as the result of an advertisement in the hospital library. Of these six were doctors and six non-medical, consisting of the librarian, a clinic receptionist, a medical records clerk, a personnel officer and two senior managers. There were nine women and three men. The objectives for the pilot study were explained during recruitment.
The workshops ran one evening a week for seven weeks within the hospital.
Questionnaires were given to participants at the beginning and the end of the course. The first questionnaire was designed as a “starting point” to get people to put pen to paper, but also to try to identify what participants hoped to gain from the course. The final questionnaire was focused on assessing whether the stated aims of the course had been met, and how the course could be improved. The authors were participants in the course and spent time after each workshop discussing and recording observations about the session. These were transcribed and later discussed again. Further informal discussion took place. Because of an agreement to maintain confidentiality about matters raised within the workshops, these discussions addressed process rather than content. RO facilitated the workshop “Leaving reality behind”, and SG facilitated the rest. JH was present as participant observer in five of the seven workshops.
Box one: the workshops
Motivations and blocks to writing: Within groups participants considered what motivated or blocked writing. They then carried out an exercise in retrieving memory onto paper. Writing a story: narrative and voice: Participants were asked to consider how character is defined. Based on a newspaper article, the group developed character profiles for two people, and redrafted them either more or less sympathetically. Participants then had to write a short story in their own time based on the characters. Forming words: anger and calm: Participants had to write down all the things that made them angry and then give vent to their anger on the page. Key words or phrases were then identified and shared. A similar exercise was then carried out using the word “calm”. Forming words: sorrow, pain, and joy: Participants were asked to bring their own examples of literature expressing these emotions. These were discussed in groups and then participants wrote about a painful experience, and shared their writing with a partner. A similar exercise was carried out with joy. Leaving reality behind: Participants were asked to record their dreams for a week. These were used as a basis for producing imaginative writing and a discussion on the nature of reality Plain English: Participants were asked to bring along examples of writing found within the hospital and to work on this to simplify it. Principles of post-structuralism were introduced On being a doctor: The final two weeks were given for participants to write a piece to do with their work in the hospital. These were presented and discussed. Participants were asked to reflect during this exercise on the original aims of the course.
Box two: ground rules
Bring writing paper, writing pen, and coloured pen for corrections
Observe silence when writing in a workshop—creative thought is impaired by superficial conversation
Try to write as much as possible in the given time—the movement of pen on paper sometimes produces material you had no idea about. You are not just working with the conscious mind
Don’t be too self conscious about the work produced—it’s raw, waiting to be worked on, you’re not trying to prove anything
Be supportive of each other and criticise constructively (Pendleton’s rules, www.trainer.org.uk/members/tools/pendleton_rules.htm)
Do not show off—it intimidates other people
Be prepared to share your work with others in the group, but maintain confidentiality outside the group.
Participants had the opportunity to see the final paper and to comment on and modify it.
Those who attended consistently maintained a high level of enthusiasm for the course, which was highly rated in the final questionnaire. The initial questionnaire showed that participants had different levels of experience of creative writing and a variety of expectations for the course. The latter were broadly in line with the stated aims of the course.
Some people were more vocal than others during the sessions, but this changed as the workshops proceeded. The quietest member became noticeably more confident and later made the comment that she had initially felt inhibited by “all those grand people”, but that this had changed as the course progressed. There were times when one member produced visible discomfort in another—for example, when discussing how to define someone’s character with reference to weight. There also appeared to be a competitive element between two of the men, which caused ongoing tension. Attendance was variable, the main reason given being conflicting commitments.
The delivery of the workshops went more or less according to the initial written plan. The main constraining factor was time. One and a half hours went by very quickly in all the workshops, and comments were made that this should be extended to two hours. There did not seem to be enough time to discuss, and to give feedback about, everyone’s work, although this could have been improved by breaking up into groups. Within smaller groups there was a tendency for freer discussion to take place.
The ground rules were stated at the first workshop, and again at the third as there were new participants. Some were easier to follow than others. The most difficult problem to deal with was a tendency amongst some members to show off their knowledge, which did have an inhibitory effect on others. Reminding the members of this rule helped and comments were made on several occasions about the high level of support the group developed for one another.
HOW WERE THE AIMS OF THE COURSE MET?
Getting thoughts onto paper
The first workshop addressing blocks and motivations aimed at this, but it became a recurrent theme throughout the course. It was agreed that the only way to do this was just to do it and that this was “a good discipline to cultivate” (for doctors). Having the structure of the workshops helped, but there remained difficulties for some participants in developing the self discipline required to write outside this protected time. Problems identified included pressures from work and family, but also an admission of intellectual laziness. It was requested that a further ground rule be added, which was to do the homework promptly. This particularly applied to those who felt blocked about writing in the first place. A firm structure to the course seemed to be valued by participants in which to develop their own creativity, but self discipline seemed to be a crucial factor. Such a course must remain optional because of the level of motivation required to do it. Of the 12 people who began the course only six managed to produce a final piece. How the structure of such a course influences creativity invites further research. It was queried whether the word “creative” was superfluous, as all writing could be considered a creative act.
Facilitating interpretation of narrative
The second workshop describing characters from a newspaper article was aiming at this, but perhaps should be renamed “describing character”. Various issues were identified, including how much instant assessments of character are made based on stereotypes (of gender, age, appearance, etc), and how much this relates to the writer (or doctor/observer) rather than to the character as such.
Helping to express issues related to illness and death
The third and fourth workshops were primarily aimed at this, and were the most animated, with clear enjoyment from the participants, who became less inhibited about discussing their work. There appeared to be a therapeutic element to being given the opportunity to discuss emotional issues within a “safe haven”, and participants needed to be reminded that the aim was to develop creative writing skills rather than to express emotion. There was a tendency to self reflection, not just about medical practice but about other personal issues. Whilst this has been described as a possible benefit for doctors13 there are dangers also in entering into areas of emotional pain. Tears were shed on several occasions (mainly from laughter rather than sorrow). If the workshops are to be offered to students then the consequences should be considered, with appropriate support if necessary.
Workshops five and six were primarily designed for this, and these were the ones that received the most mixed response. “Leaving reality behind” required participants to change from writing about what they saw as rational to what they considered to be irrational, using their own dreams, with extracts from Sigmund Freud, James Joyce, and Vaslav Nijinsky as stimuli. Some participants found this difficult, perhaps unwilling to make the leap required from one fixed, “logical” view of how to write things to another, where there was no clear direction or ending. Others, however, found it exciting. One participant commented the “dreams are like life, with no clear beginning and no ending”. Workshop six similarly had a mixed reaction, and might have been improved if the objective had been more clearly stated, which was to consider the power of words, particularly in relation to medical practice. One participant commented that this was “very difficult and over my head” (English was not her first language), although others were positive about the value of clear expression. SG, who facilitated the session, felt it was too prescriptive, and that the issues raised could be dealt with by incorporating them into the other workshops.
Whether true creativity can really be taught remains unclear, but it could be encouraged by giving permission to “give up” or challenge preconceived notions.
Only six participants were able to produce a final piece, which may suggest the course was only partly successful in this aim.
OTHER LESSONS LEARNT FROM THE COURSE
Reflections on medical education
Of the six final pieces it was perhaps coincidental that four were to do with the participants’ own experience of medical education. Each one expressed the view that this had not prepared them for the realities of being a doctor, particularly the emotional or ethical aspects. This was something that will need to be considered in designing other aspects of the graduate course curriculum.
The value of a multidisciplinary group
The creative writing process provided a level playing field for doctors and non-medical staff, with no one individual being an authority. The presence of non-medical participants had definite advantages: barriers were broken down as the course proceeded, and participants seemed to see themselves and others less in the “official” role of doctor, manager, clerk, etc and more as individuals. This would seem to be desirable for good relations generally. The medical participants had much to learn about creative writing from their non-medical colleagues. In a module for students it would seem desirable to open the workshop to interested non-medical staff. Other initiatives have invited resident writers, which could be considered.
It was generally agreed that the course had been hugely enjoyable. Whether this should be an aim in itself is debatable, but in a medical course with a lot of prescriptive work this must be seen as a welcome relief. Enjoyment of writing could increase self confidence in the process of representing both themselves and others, which is part of being a doctor. It could also lead to reflection on the writing of others and enjoyment of reading.
The authors had not anticipated the amount of self reflection developed in the group beforehand. Whilst this was agreed to be a positive thing in terms of sorting out of values there were possible dangers in exploring emotional issues, which needs to be recognised. The focus must be on creative writing not the development of a psychotherapeutic group.
It was unanimously agreed that the course would be of value to medical students, yet it remains unclear how transferable the lessons learnt from this pilot study might be. The participants were self selected and therefore more motivated than others to gain from it. The final questionnaire gave little clue as to how useful the activity really was, both in the short and long term.
The course was enjoyable for all the participants, but also raised challenges, some of which had not been foreseen. The dynamic of the group was important, and ground rules appeared to play a key role. Raising emotional issues could lead to difficulties. The pilot study offered us valuable insight and experience, and challenges have been highlighted for those wishing to provide similar courses.
As a result of this experience we would wish to include multidisciplinary involvement for medical students, as this had an unexpectedly positive effect.
The authors would like to thank the following for their help and support in developing the creative writing workshops: Judith Eagle, Richard Horton, Joanne Lucas, Miranda Pearson, Tom Sherwood, Paul Siklos.
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