Publication/Presentation Date
7-31-2015
Abstract
Writing in Medicine
Emma Schanzenbach1
Judith Colombo, MS, Stephanie May, MA1,2
1Organizational Effectiveness, Lehigh Valley Health Network
2Research Scholar Program Mentor
Abstract
The place of the humanities in the medical field has been debated since the turn of the twenty-first century. Many medical schools now offer reflective writing and other programs to try and use techniques from the humanities to improve the emotional intelligence and professionalism of doctors. Writing is a particularly important competency because it helps doctors communicate with their patient. This review examines what writing classes have already done for training doctors and the different approaches towards writing. Writing is a tool that can increase emotional intelligence of doctors by helping them to understand the narrative of the patient and can provide personal feedback to the professional concerning their job performance. There are many different approaches to this exercise in empathy and the existing approaches will be compared to writing’s place in the daily life of various physicians around the Lehigh Valley Health Network.
Keywords
Reflective writing, emotional intelligence, professionalism, patient communication
Introduction
To many in academia, the humanities and the sciences have become two separate worlds that rarely interact. It is a common perception that those that appreciate the humanities are more creative and imaginative, while those entrenched in the sciences tend to be more logical when approaching problem solving. University programs try to correct for the imbalance of the creative versus logical individuals, introducing general education requirements to round out the education of students and to allow them to gain insight to how the “other half lives.” In reality, many students tend to stick to what is familiar and do not venture too far from either the sciences or the humanities.
Though this common perception exists in the university system, medicine can offer a rare combination of the creative and the logical, the scientific and the humanities-based intelligence, through the provider-scientist’s interaction with their patient. In 1997, Brendan Sweeny gave a James Mackenzie Lecture titled: “The place of humanities in the education of a doctor” (1998). Sweeny emphasized that although knowledge in the humanities is rarely considered when assessing the potential success of a doctor, there are places where the humanities can answer questions that science cannot. Humanities, as the name suggests, explores the human condition as validly as science, albeit differently. For example, a greater understanding of the human condition can help both the patient and doctor deal with the concept of death when medicine is unable to intervene. It is part of the doctor’s role to provide support for the suffering in people’s lives and if they are unable to do so, the level of care, especially in palliative situations, can sometimes suffer (Sweeny, 1998). Sweeny emphasizes that illnesses have meaning, and grasping the meaning of that illness can give insight to life in the same way that the existential musings of ancient and modern philosophers attempt to breathe life and purpose into humanity’s existence (1998). As a human caring for other humans, it is the duty of physicians and other health care providers to navigate the uncertainties and sometimes-unfair conditions of their illness. Experiences in the humanities can bridge the gap from science to the patient and then bring a sense of closure back to the doctor in a way that simple understanding of science cannot.
An area that has been explored by various medical schools is the introduction of writing classes that force physicians – in – training to develop their skills in dealing with patient problems and other trauma in the work place (Fiegelson, 2005). Therefore, in this paper, I will examine what medical schools have previously done to improve physicians' emotional intelligence through writing and the applicability of such writing practices. Through this analysis, I hope to better articulate the place of writing and its applications to medicine as a specific part of the humanities. Also important to this analysis is the benefits to emotional intelligence that writing provides. This is an important topic to consider in the wake of technological change in healthcare and its effect on the patient-provider relationship.
Writing in Graduate Level Medical Education
After the first few years of medical school, medical students’ empathy scores on the Jefferson Scale of Physician Empathy-Student Version reach all-time lows (Chen, 2012). This proves a problem for the students as future medical professionals and for the hospitals that employ them (Chen, 2012). Hospitals and medical school programs have tried to tackle this by introducing creative writing programs that force training physicians to confront their action with patients
One way that medical schools, such as the University of Colombia, have tried to tackle the issue of increasing empathy in their students is through reflective writing exercises (Facioli, 2012). Mastery of this skill is often referred to proficiency in narrative medicine. Narrative medicine refers to the ability to understand what a patient communicates to a doctor and to be able to fill in the gaps in the narrative by really listening to what the patient says (Charon, 2001). This can help in a diagnosis when a list of symptoms in not enough to truly understand what the patient is going through. By experiencing suffering with the patient, the physician is able to help the patient find meaning in their suffering and help them heal, mentally and not just physically (Charon, 2001). In this way, a scientific approach to medicine falls short from providing an accurate mode of communication between the patient and doctor.
Humanities courses in medical schools typically ask students to reflect on different aspects of their clinical experience in the last two years of medical school. This is a critical point in time where students’ empathy scores tend to decrease compared to when they enter medical school (Chen, 2012). This is also a common practice in other areas of health care, such as Pharmacy School. Over three years in a Pharm.D program, students were required to take part in reflexive writing. This provided various benefits to the students because they were able to think about their own way of thinking, a type of metacognition that was instrumental in improving their ability to care (Nuffer, 2013). Professionalism can also be tested by analyzing the way that students think and feel about particular clinical experiences (Braun, 2013). By reviewing their own performance, students were able to better encounter similar situations with less awkward responses, acting as a source of warmth and calm for patients in uncomfortable situations.
This traditional method, to some medical schools, seems to be getting a bit stale and medical student writers often miss the point of the exercise. There have been various remodeled versions of the narrative writing class which emphasize more on elements of fiction writing or the students’ personal experiences with illnesses (Dasgupta, 2004; Reisman, 2006). This pulls to light different elements of empathy that are less apparent with reflective writing alone. For example, when examining their own experiences with illnesses, it became apparent that physicians are unaware of their own physicality (Dasgupta, 2004). They do not fully understand how they themselves process illnesses and therefore, it makes it difficult to process the illnesses of others with empathy. Taking a fiction writing approach, however, adds a different spin on interpreting the patient’s story. By using the Iowa Writer’s Workshop technique, a group of volunteers learned the different elements of plot and techniques to craft a story (Reisman, 2006). With a better understanding of plot, doctors can fill in the gaps in patient’s stories. This use for narrative medicine has been extended to the clinical setting, helping a patient on mechanical ventilation to communicate with no voice and improve the level of care received (Facioli, 2012). Therefore, the further application of narrative medicine and other writing competencies should be taken into consideration.
Applications for the Medical Field
Each of these writing exercises test a few key competencies that are instrumental in the medical careers, especially that of a physician. Most important to the provider is emotional intelligence and the fostering of the doctor-patient relationship. Instead of merely speculating how such classes would impact the role of a physician, I took it upon myself to discover the role of writing in various physicians’ lives around the Lehigh Valley Health Network. Participants were asked what kind of experience they had with writing previous to becoming a provider and also what role writing plays in their average workday. Table 1 contains a list of mentioned uses from an initial survey of doctors around the network.
From these interviews, I identified a few key competencies that overlap with the reflective writing courses, as demonstrated in Figure 1. As emphasized by Figure 1, the two main approaches to writing during the medical school career are slightly different. Reflective writing emphasizes self-improvement and focuses more on the provider than the patient. The fiction writing class focuses more on the perception of the patient. This pulls in the idea of understanding a narrative, which is key to correct diagnosis of a patient and communication with them. By emphasizing an important part of emotional intelligence that normal reflective writing classes are missing, the fiction writing class forces upcoming providers to get in the mind of the patient. Interpreting the patient’s condition and story is an important component of the emotional intelligence of a doctor. Therefore, the traditional reflective writing courses may not be fully grasping the situation in which the doctor must understand the patient’s needs to increase the level of care provided. Combining the two approaches to writing may actually provide the best experience for the budding physician as they can focus both on the patient and improving themselves as a provider.
Further Directions
Writing and competency in the humanities allows physicians to understand not only the way the human body works but the human condition. Empathizing with patients no matter who they are will allow doctors and other providers to provide the same level of care no matter to all people that walk through the hospital.
The use of writing classes during medical school forces physicians to develop important listening, reflective, and communication skills that bolster their emotional intelligence at the same time. With the advent of technological change in medicine, such as the switch to the federally mandated electronic medical records, doctors have even less time to speak with their patients. This makes emotional intelligence even more key to patient interaction because it allows providers to understand the full extent of the patient’s problem in mere minutes. By combining both story telling and narrative medicine the doctor becomes well versed in interpreting the condition and experience of the patient. For this reason, such writing classes should be a mandatory part of the medical education to keep up with the changing perception of the health care system.
Acknowledgements
I would like to thank all those who supported me through this process. Thank you to Judith Colombo and Stephanie May for serving as my mentors and supporting this project. I am grateful to the staff of Organizational Effectiveness for giving me an amazing learning experience. Thank you to Hubert Huang for organizing this program and providing opportunities for professional development. Special thanks to the doctors that took time to sit for the interviews and offering me invaluable advice in this preliminary study: Dr. Peter J Barbour, MD, Dr. Kristin Friel, MD, Dr. Donald Levick, MD, Dr. Gregory Brusko, DO, and Dr. Debra Carter, MD.
References
Braun, U. K., Gill, A. C., Teal, C. R., & Morrison, L. J. (2013). The Utility of Reflective Writing after a Palliative Care Experience: Can We Assess Medical Students’ Professionalism? Journal of Palliative Medicine, 16(11), 1342–1349. doi:10.1089/jpm.2012.0462
Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust.JAMA,. 2001, 286(15), 1897-1902. doi:10.1001/jama.286.15.1897.
Chen, D.R. Kirshenbaum, D.S., Yan, J., Kirshenbaum, E., Aseltine, R.H. (2012). Characterizing Changes in Student Empathy throughout Medical School. Medical Teacher, 34(4), 305-311. Doi:10.3109/042159X.2012.644600
Dasgupta, S., Charon, R. Personal Illness Narratives: Using Reflective Writing to Teach Empathy. Journal of the Association of American Medical Colleges. 2004, 79(4), 351-356.
Facioli, A. M., Amorim, F. F., & de Almeida, K. J. Q. (2012). A Model for Humanization in Critical Care. The Permanente Journal, 16(4), 75–77.
Feigelson, S, Muller, D. (2005). Writing About Medicine: An Exercise in Reflection at Mount Sinai (with five samples of student writing). The Mount Sinai Journal of Medicine, 72(5). 322-332.
Nuffer, W., Vaughn, J., Kerr, K., Zielenski, C., Toppel, B., Johnson, L., Turner, C. J. (2013). A Three-Year Reflective Writing Program as Part of Introductory Pharmacy Practice Experiences. American Journal of Pharmaceutical Education, 77(5), 100. doi:10.5688/ajpe775100
Reisman, A. B., Hansen, H., & Rastegar, A. (2006). The Craft of Writing: A Physician-Writer’s Workshop for Resident Physicians. Journal of General Internal Medicine, 21(10), 1109–1111. doi:10.1111/j.1525-1497.2006.00550.x
Sweeney, B. (1998). James Mackenzie Lecture 1997. The place of the humanities in the education of a doctor. The British Journal of General Practice, 48(427), 998–1102.
Appendix
Table 1. Physician Uses for Writing
Use for Writing
Percent Interviewees Mentioned
Communication
100%
Clinical Reports
20%
Professional Communication
80%
Patient Communication
40%
Leadership Skills
40%
Academia (Scientific Writing)
80%
Table 1. Physician Uses for Writing. Listed are percentages from a preliminary data collection during interviews with five practicing physicians. The most commonly mentioned use for writing was communication in general. Only one physician, from the neuroscience specialty, mentioned using writing skills to create clinical reports that tell the story of the patient.
Figure 1. Writing Competencies Necessary for Physicians
Figure 1. Writing Competencies Necessary for Physicians. This chart compares, visually, specific competencies mentioned by physician interviewees and how the different types of classes provide or do not provide similar competencies.
Published In/Presented At
Schanzenbach, E., (2015, July 31) Writing in Medicine. Poster presented at LVHN Research Scholar Program Poster Session, Lehigh Valley Health Network, Allentown, PA.
Department(s)
Research Scholars (Acknowledgements and Co-authored Publications), Research Scholars - Posters
Document Type
Poster
Comments
Mentor: Judith Columbo, MS
Mentor: Stephanie May, MA