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Open Access Publications from the University of California

Volume 2 Issue 1 2006

Foreword

A Sampling of the Medical Humanities

This article provides an introduction and overview to this special issue of JLTA. It provides summaries of the articles and highlights some of the key points readers might take away from perusing this work.

Narrative and Storytelling

Creating Conversations: Finding Ways to Promote Humanities in Large Medical School Courses

Since the publication of Samuel Shem’s House of God, medical students and residents have been famous for their cynical conversations about patients and life on the wards. This image is largely a caricature, yet peer pressure, medical machismo, stressful working conditions, and house staff subculture do foster negative attitudes and images. A challenge for medical faculty is to facilitate conversations that help students work through their fears and insecurities in ways that promote positive values, build character, and remind students of the ideals that drew them to the healing professions. Providing such an environment and structuring such conversations can be difficult, especially in the large classes and busy schedules that typify most of pre-clinical education. The following article describes an effort to facilitate such conversations.

Medicine and the Silent Oracle: An Exercise in Uncertainty

This article describes a simple in-class exercise in reading and writing that, by asking participants to write their own endings for a short narrative taken from the Journal of the American Medical Association, prompts them to reflect on the problem of uncertainty in medicine and to apply the literary-critical techniques of close reading both to the content and the form of a story that describes and enacts the challenges of making decisions in the face of uncertain knowledge.

Who is My Patient? Use of a Brief Writing Exercise to Enhance Residents' Understanding of Physician-Patient Issues

Writing workshops and narrative experiences for medical trainees can be a useful way to approach certain issues in their education. This article describes a brief writing exercise that can be used for physicians in training to help them recognize issues of countertransference in the doctor-patient relationship. While these issues are generally covered as part of residents’ behavioral science curriculum, this exercise allows trainees to use a creative method in order to uncover them. To date, this exercise has been used in two residency programs with residents informally expressing improved understanding of their own experience with patients.

Donning the White Coat: The Narrative Threads of Professional Development

Much has been written recently about medical professionalism, about how we define it, and about how to educate our students in this domain. While there seems to be consensus as to what constitutes professionalism, there remains a good deal of uncertainty as to how best to teach students to meet their obligations to their patients, to society, and to their profession. This essay will examine some of the recent discourse on professionalism education, and will then describe the Family Medicine clerkship narrative medicine curriculum at Keck School of Medicine. By creating time and space in the formal curriculum for reflection with teachers and mentors, we believe that we provide students with an opportunity for the active, self-changing work that is essential for successful personal and professional formation.

FLAP: Personal Writing as a Tool for Physician Well-being

There are many physical and emotional demands that are required in the professional training and socialization of a physician. Writing for self-expression and awareness has been shown to improve personal growth and decrease stress levels. Using writing as a tool in residency training as a forum for exchange and self-expression can foster a healthier learning environment. FLAP, Family Practice Literature and Arts Periodical, is a community--family practice residency-based--publication that allows residents and faculty to share their literary talents. It focuses on physician well-being and how writing can be used as a tool to manage stress. It is an English-Spanish bilingual publication that supports many forms of artistic expression and the diverse cultural and languages backgrounds represented by the residency community. It has received much positive feedback from residents and staff for its affirmation of physicians' professional development and attention to self care.

Once Upon a Time. . . At The Tenth SOBRAMFA International and Academic Meeting - S. Paulo - Brazil

In Brazil, medical practice and the predominant medical education model are based on specialization. Methodologies such as patient-centered medicine and narrative medicine are either unknown or not applied in a systematic way. In order to draw students’ and doctors’ attention to these approaches during the TENTH SOBRAMFA INTERNATIONAL AND ACADEMIC MEETING, an informal event called “Narrative Session” was presented. The meeting’s attendees were asked to send patients’ stories in advance. The stories submitted were selected and classified according to medical sociologist Arthur Frank’s description of three structures or skeletons of narrative – restitution stories, chaos stories, and quest stories. A special ambiance – a setting evoking The Tales of 1001 Nights– was created for the presentation. The narratives performed showed the narratives’ healing and didactic potential for patients, doctors, and students.

A Humanities-Based Capstone Course in Medical Education: An Affirming and Difficult Look Back

In a new required capstone course for medical students, students at the Northeastern Ohio Universities College of Medicine were asked to reflect on their relationships with patients, their colleagues, themselves and their families, and the communities they serve, using the humanities, particularly narrative domains, as the primary vehicles for such reflection. Here we describe the course requirements and organization, then elaborate on how it was received by patients through not only course evaluations but also our own instinctive sense as teachers of how things went. We offer observations on what went right, what went wrong, and how we might do things differently.

Poetry

Clinical Poems and Clinical Conversations: Some Thoughts on Working with Family Medicine Residents

Abstract: This paper describes an experiment in which Family Medicine residents composed, read, and discussed their poems as a way of bringing to life their often complex relationships with patients. It argues that this approach mobilizes the physicians’ own creativity in the service of reflective practice and improved doctor-patient relationships. This method further increases mental “space” within the physician and between doctor and patient. It can supplement the more usual approach to teaching medical humanities, wherein great literary works and the writing of famous physicians are explored for the insights they offer to healthcare practitioners.

On the Use of Poetry in Medical Education

Poetry can be a powerful tool in teaching students and residents interpersonal and scientific aspects of clinical medicine. Advantages of using poetry include emotional intensity, succinct, portable formulations and communication of encompassing, ‘existential’ truths. Limitations include learners’ lack of familiarity with the medium of poetry, and the need to negotiate multiple, complex meanings. In addition, the indirection and multiple meanings of poetry require a different interpretive approach and mindset than one put forth by a scientific model of inquiry. Applicable poetry can be found in standard collections, but which poems are used often depends on the individual instructors’ preferences and personal reading experience. They can be incorporated into different teaching settings, such as lectures or seminars, depending on the application. Poems can be used to explore questions relating to the nature of the medical profession. They can also be used to explore broader clinical topics, or to highlight a focused clinical point. Several examples are provided in this paper. Overall, poetry can enhance clinical learning by honing emotion, psychological insights, and observational skills.

Writing to Heal Thyself: Physician as Person & Person as Physician

An experienced physician-teacher shares her own experiences with loss in medicine and loss in her personal life. Through personal writings during her divorce, she exemplifies the healing effect writing can have during difficult transformations that occur in life. She shares her bias that physicians need to accept and own their emotions and can use reflective writing as a tool toward developing greater professional skills. In the end, reflective writing skills offer physicians a means to become more emotionally aware and more available to patients’ needs.

Performing Arts

Moral Imagination Takes the Stage: Readers’ Theater in a Medical Context

In this article, we describe an elective course using readers’ theater with students in the health care professions and the arts. Readers' theater is a technique used for the performance of literature in which texts are staged with minimal production values and scripts are not fully memorized. These techniques are drawn upon more commonly in theater and performance studies classrooms, but we found them to be effective as tools for connecting future health care providers with their local communities. With a central theme of age and aging, we chose non-dramatic works of literature and adapted them for dramatic readings at retirement communities in Berkeley and Oakland, California.

What's Eating Gilbert Grape?: A Case Study of Chronic Illness

Cinemeducation refers to the use of movies or movie clips to educate learners about the psychosocial aspects of health care. This paper describes the use of a clip from the movie, What's Eating Gilbert Grape? to teach medical students about chronic illness. The clip is used to set up a case study based on the lead character, Gilbert Grape. For the sake of the seminar, Gilbert is given a diagnosis of low back pain. After watching the clip, learners are asked to construct a genogram and family circle of the home context and then hypothesize about the possible causes of Gilbert's back pain. The educators then use the “case” as a basis for an exemplary patient-based chronic illness presentation. This presentation is designed to serve as a model for the students, who are asked to interview a patient and family and make their own patient-based chronic illness presentation at the end of their clerkship month. Anecdotal evidence suggests that cinemeducation is an effective and entertaining way of presenting didactic material, including teaching assessment and case management skills, to health care professionals. Suggestions are made for possible future research in this innovative teaching technique.

Music, Medicine, and the Art of Listening

The use of the arts in medical education has become increasingly widespread. Narrative and visual media, in particular, have received great attention as tools for teaching skills of empathy, observation and reflection. Music, however, has been relatively less applied in this context, and may be perceived as lacking immediate relevance to medicine. In this article, we first review various areas of interface between music and medicine. We then describe a curricular innovation undertaken at our institution using musical performance to demonstrate the value of music as a metaphor for communication in the practice of medicine.

Multimedia Approaches

The Appreciative Pedagogy of Palliative Care: Arts-Based or Evidence-Based?

The authors integrate poetry and narrative into their self-study application of the research methodology known as Appreciative Inquiry (AI) focused on: (a) their personal and professional practice and development; (b) their teaching practice in universities and informal/popular education settings; and, (c) their educational research in the area of hospice and palliative care giving. AI is both an arts-based participatory philosophy of practice and a qualitative research methodology.

Incorporating the Arts and Humanities in Palliative Medicine Education

The arts and humanities allow the teaching of palliative medicine to come alive by exploring what is often regarded as the most frightening outcome of the illness experience – death and dying. Palliative medicine focuses on the relief of suffering, but how can suffering be understood if the story of the patient is not told through prose, poetry, music, and images? This article describes how teaching can incorporate the power of story through the arts to enrich the palliative medicine curriculum. Also presented is a developmental schema, devised by Bernice Harper, whereby learners can assess and understand their journey as health professionals as they increase their capacity to cope emotionally with the dying process of their patients. Narrative medicine also serves to ground related teaching about pain, near death awareness, and grief and loss in the experience of the patient and family as well as that of the health professional. Art is created in relationship- centered care in which the clinician and patient interact through the telling and listening to stories. Relationship is established through this acknowledgment of the shared humanity of patient and clinician..

Healing and the Arts: A Powerful Metaphor for Teaching about Healing and for Teaching Medical Humanities

For several years an interdisciplinary course called “Healing and the Arts” has been offered to undergraduates and medical students in a BA/MD program at the University of Missouri-Kansas City. Its stated purpose is to give students a theoretical and practical understanding of how the arts can be a healing force in people's lives. Healing is addressed in a broad sense that takes into account the larger factors of health and illness, such as the roles and responsibilities of patients, the cultural perspectives of sickness and health, and the influence of religious or moral beliefs and practices. The three units of the course are: 1) Art and Healing of Self and Others; 2) Art, Healing and Society; and 3) Art, Healing and Spirituality. Each unit includes appropriate literature assignments and art experiences. Oliver Sacks' book, The Man Who Mistook His Wife for a Hat, provides numerous examples of healing through music, art, spirituality and the helpful understanding of care givers. Music such as requiems, the blues and the compositions of Andrew Lloyd Weber provide examples of healing in a different sense. Plays, read or attended, offer additional dynamic experiences. Artists such as Frida Kahlo provide examples of the relation of illness and healing to the creation of visual art. The many art related responses to the 9/11 tragedy show how society sought its own healing. Students’ responses to the selections are evaluated through written papers and examinations as well as class discussions. The faculty members believe that, by introducing students to the positive aspects of the arts and how they have universally contributed to the healing of individuals, societies and cultures, they are teaching them the important balance between medical knowledge and the arts in their own lives.

Critical Thinking Synergism: Combining Therapeutic And Vocational Approaches To Teaching Medical Humanities

This article explores a qualitative evaluation of student and tutor perceptions of the educational aims, methods and impact of undertaking a new medical humanities student selected module (SSM) within one medical school in the United Kingdom. The findings of the study build on previous work within this subject area and provide insight of learning outcomes, suggesting implications for future curriculum development.

Research Approaches

Supporting the Health of College Solo Singers: The Relationship of Positive Emotions and Stress to Changes in Salivary IgA and Cortisol during Singing

Singers appear to experience health benefits from singing, but their art makes physical demands that may leave them prone to health problems. The study sought to measure singers’ immunocompetence under practice and performance conditions. Salivary IgA and cortisol measurements were assayed from multiple pre-post saliva samples obtained from 10 solo singers as they rehearsed and performed repertory in a college conservatory during a 10-week period. Confirming previous research on choirs, there was a significant increase in S-IgA after singing, and the effect was mediated by positive emotions of well being and feeling “high.” The extent to which singers reported that they were usually stressed while singing was significantly correlated with decreases in S-IgA. Satisfaction with performance correlated significantly with a decrease of cortisol after singing. In a regression analysis, the best predictive model for upward change in S-IgA included two significant variables from the questionnaire: feelings of well being and relative lack of concern with artistic identity (p < .018). These findings suggest that preserving solo singers’ positive emotions during singing may not only maintain their enjoyment of singing, but may also improve their immunocompetence in response to health risks.

The Use of Creative Projects in a Gross Anatomy Class

Introduction. Medical students often describe the gross anatomy course as both stressful and a rite of passage. Research differs as to whether the stress it engenders is significant or transitory. This qualitative study of first year anatomy student reports on the use of optional creative projects to promote reflection and reduce stress.

Methods. Over a three year period, 115 students, or 38.72% of all eligible students, opted to complete 1-2 arts or written creative projects during the anatomy course. Of these, 34 students gave us permission to analyze their projects, while 12 project completers and 12 project non-completers were interviewed to determine their views about the projects. Researchers developed coding schema and interview schedules that were used to assess and interpret the data.

Findings. On average, over a three year period, a little less than 40% of students selected the creative project option, with approximately equal numbers of male and female students represented. Comparing types of projects, art works were more celebratory and less reflective than written works. Comparing phases of projects, initial projects appeared more conflicted, while later projects showed more desensitization, appreciation, and satisfaction. Students expressed anxiety and ambivalence about anatomy and employed various defense mechanisms to resolve their feelings. Students completing projects reported that they both reduced stress and caused them to develop a richer appreciation for both anatomy and medicine as a whole, while non-completers acknowledged that viewing the projects helped them to better understand their own experience of anatomy.

Conclusions. For some students, creative projects may offer a more reflective and introspective way of wrestling with the ambivalent emotions anatomy raises than simple desensitization strategies of exposure.