Becoming a doctor: fostering humane caregivers through creative writing☆
Introduction
Reflection 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 conflict [2], [3], [4]. Schon distinguishes between reflection in action, fine tuning an act in the middle of performing it as a function of thinking about what you are doing, and reflection on action, thinking about an act or event at a time separate from that event [1]. Often, the most vexing problems require reflection on action. While training which incorporates reflection and self-awareness takes place in some medical schools and residency programs [5], [6], [7], [8], [9], [10], this is not a uniform part of curricula. One outcome of reflection can be enhanced self-awareness, which is felt by many to be critical to a physician’s work [3].
One method to encourage reflection is through the writing and sharing of narratives or critical incidents [11], [12], [13]. Narrative probes the depths of medical experience [14], 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, first 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 reflect 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 identified a discordance between principles that are taught and principles that are practiced [19].
In order to enhance students’ opportunities for reflection, 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 significant experiences related to their medical education as they were going through these experiences. We report the elective’s outcomes based on the first 2 years of students’ writing. Our 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.
Section snippets
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 specific assignments, then sharing their writing samples with others, with the opportunity to receive constructive feedback. While their experiences were the starting point of
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 identified in students’ writing and then discussed. Writing was analyzed until no new themes emerged. Disagreements about coding and themes
Results
Seven students completed the requirements for the course each year that it was offered (total=14). Eighty six finished 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 assignment-driven. What follows is a discussion of each of these themes and representative issues
Discussion
We have described the structure and themes written about by students in our creative writing elective over the first 2 years of its existence. Students rated the experience highly, making particular note of the value of the time to reflect on 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], [22], [23], [24].
Particular challenges frequently voiced
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 first step in working through them. Holding such a course, one which attempts to model the skills in the teacher–learner dyad — listening actively, giving respectful feedback, observing, and speaking with clarity — that we are trying to create in the physician–patient relationship can serve as
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 (58)
- et al.
Meaningful experiences in medicine
Am. J. Med.
(1990) Anticipatory guidance: having a dog in the family
J. Ped. Health. Care
(1998)- Schon DA. Educating the reflective practitioner. San Francisco, CA: Josey-Bass,...
Mindful practice
JAMA
(1999)- et al.
Calibrating the physician
JAMA
(1997) - Balint M. The doctor, his patient and the illness. London: Pitman,...
- et al.
A survey of Balint group activities in US family practice residency programs
Fam. Med.
(1990) Reflection in clinical teaching: an analysis of reflection-on-action and its implications for staffing residents
Med. Teach.
(1991)- Novack DH, Kaplan C, Epstein RM, et al. Personal awareness and professional growth: a proposed curriculum. Med...
- et al.
Medical interviewing and interpersonal sills teaching in US medical schools: progress, problems, and promise
JAMA
(1993)
Teaching medical interviewing
Arch. Intern. Med.
The future of medical school courses in professional skills and perspectives
Acad. Med.
Becoming a doctor: critical-incident reports from third-year medical students
N. Eng. J. Med.
My most meaningful patient: reflective learning on a general medicine service
J. Gen. Int. Med.
Why use stories in teaching
Med. Encounter
To render the lives of patients
Literature Med.
Carry me forward … into the future in your heart: the place of narrative in health professions education
Med. Encounter
Telling stories: the health benefits of narrative
Literature Med.
Internal medicine patients’ expectation for care during office visits
J. Gen. Int. Med.
Beyond curriculum reform: confronting medicine’s hidden curriculum
Acad. Med.
Evaluating the quality of qualitative research: a proposal pro tem
J. Gen. Int. Med.
A life in medicine: stories from a Dartmouth Medical School elective
Acad. Med.
Songs of innocence and experience: students’ poems about their medical education
Acad. Med.
Forty acres of cotton waiting to be picked: medical students, storytelling, and the rhetoric of healing
Literature Med.
I actually don’t mind the bone saw: narratives of gross anatomy
Literature Med.
The effects of stress on physicians and their medical practice
N. Eng. J. Med.
Cited by (78)
Breaking the spell: Narrative Medicine applications for Psychogenic Nonepileptic Seizures (PNES)
2021, SeizureCitation Excerpt :They find “comparable effects” for writing and talking” [11]. Hatem and Ferrara state that use of writing narratives “has demonstrated positive health and behavioral effects in such varied groups as prisoners, distressed crime victims, first time mothers, men who have been laid off from their jobs, arthritis and chronic pain sufferers, and medical students” [12]. Pennebaker and Seagal warn “painful events that are not structured into a narrative format may contribute to the continued experience of negative thoughts and feelings,” but “constructing stories facilitates a sense of resolution, which results in less rumination and eventually allows disturbing experiences to subside gradually from conscious thought” [13].
Narrative medicine applications for neuro-oncology patient identity and quality of life
2021, Journal of Clinical NeuroscienceCitation Excerpt :They indicate the importance of the narrative method as applied for professional formation of medical students so that “having students struggle with, articulate, and clarify their professional dilemmas is a first step in working through them.” The narrative provider-patient dyad is thereby presented by “the skills in the teacher-learner dyad—listening actively, giving respectful feedback, observing, and speaking with clarity” and serves as “a model for fostering the development of values in professional education” [20]. Narrative Medicine and narrative interventions may be consistently applied across a wide range of clinical and educational applications.
Navigating uncertainty: Narrative medicine in pregnancy options counseling education
2019, Patient Education and CounselingCitation Excerpt :NM can provide learners with the capacity to “recognize, absorb, interpret and act on the stories and plight of others” [15]. Narratives in medical education, including those of patients and physicians, as well as those found in literature and film, have been used in “difficult to teach” educational competencies such as empathy, patient centered care and communication [16–20]. Columbia University Medical Center (CUMC) has used NM in medical teaching since the early 1990s.
Thinking about Difficulties: Using Poetry to Enhance Interpretative and Collaborative Skills in Healthcare Ethics Education
2020, Cambridge Quarterly of Healthcare EthicsNursing privilege: A concept analysis
2024, Nursing OpenHow Medical Students make Meaning of Uncertainty Through a Novel Pediatric Psycho-oncology Rotation
2024, Health Professions Education
- ☆
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.