Insights into Professional Identity Formation in Medicine: Memoirs and Poetry

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Notes

1. Rita Charon's Narrative Medicine: Honoring the Stories of Illness (New York: Oxford, 2006) describes the goals of narrative medicine (through methods including reading literature and reflective writing) as “extending empathy and effective care toward the patients we serve and building community with colleagues with whom we do our work,” with “narrating as an avenue toward consciousness, engagement, responsibility, and ethicality” (131). She voices appreciation for “deep and painful emotions” experienced by both doctors and patients (34) and outlines how “narrative methods can help bridge divides (between doctor and patient) erected by different notions of mortality, causality, context, and emotions” (35).

2. The literature on the benefits of fostering reflective practices in medical education is vast. See, for example, Ronald M. Epstein, “Mindful Practice,” Journal of the American Medical Association 232 (1999), in which critical self-reflection is described as “enabling physicians to listen attentively to patients’ distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight” (833); and Silvia Mamede and Henk G. Schmidt, “Correlates of Reflective Practice in Medicine,” Advances in Health Sciences Education 10 (2005), citing Cameron B. Guest, Glenn Regehr, and Richard G. Tiberius (“The Lifelong Challenge of Expertise,” Medical Education 38 [2001]: 78–81), who note that “reflection on practice and learning from experience are considered key requirements to acquire and maintain expertise in medicine” (328). In “Reflection, Perception, and the Acquisition of Wisdom,” Medical Education 42 (2008), Ronald M. Epstein describes the goal of reflection as “not only developing one's knowledge and skills but also habits of mind that promote informed flexibility, ongoing learning, and humility” (1048). Helpful reviews of the role of reflection include John Sandars, “The Use of Reflection in Medical Education: AMEE Guide No. 44,” Medical Teacher 31 (2009): 685–95; and Karen Mann, Jill Gordon, and Anna MacLeod, “Reflection and Reflective Practice in Health Professions Education: A Systematic Review,” Advances in Health Science Education Theory and Practice 14 (2009): 595–621.

3. See William Branch, “The Road to Professionalism: Reflective Practice and Reflective Learning,” Patient Education and Counseling (4 June E-publication, 2010) for a description of the transformative effects and enhancement of humanistic values of a pedagogy that utilizes critical reflection and the mastery of skills.

4. Poirier, Doctors in the Making, 70, citing chief resident Claire McCarthy's memoir.

5. Recent work buttresses this argument. With a focus on clinical skills for improved pain care, Beth B. Murinson, Aakash K. Agarwal, and Jennifer A. Haythornthwaite recognize how “the medical community is now acknowledging the necessity of emotional competence in the clinical sphere,” and more specifically how “in the pain-focused clinical encounter, emotional development allows clinicians to consistently exhibit compassion and empathy with shaping emotional responses to foster constructive communication,” in “Cognitive Expertise, Emotional Development and Reflective Capacity: Clinical Skills for Improved Patient Care,” Journal of Pain 9 (2008): 981. Similarly, “Emotional development is an important component of nascent professional competence and likely to be shaped by formative experiences,” according to Beth B. Murinson et al., in “Formative Experiences of Emerging Physicians: Gauging the Impact of Events that Occur during Medical School,” Academic Medicine 85 (2010): 1331. In line with the premise of Poirier's work, they posit that “increased awareness of the diversity and range of formative experiences will help prepare educators to more effectively guide positive emotional development, enhancing personal and professional growth during medical school” (1331).

6. In “The Role of Relationships in the Professional Formation of Physicians: Case Report and Illustration of an Elicitation Technique,” Patient Education and Counseling 72 (2008), Paul Haidet et al. highlight the role of relationships in the process of professional socialization, concluding that “students proceed through medical school embedded in complex webs of relationships in the learning environment that exert a powerful influence (both positive and negative) on their formation as physicians” (382). In regard to facing ambiguity and complexity, Rita Charon comments that the “ways of knowing in the humanities make room for ambiguity and interiority, opening a moral space within which to consider questions about one's own and others’ mystery and value,” in “Commentary on ‘Creative Expressive Encounters in Health Ethics Education: Teaching Ethics as Relational Engagement’,” Teaching and Learning in Medicine 21 [2009]: 163, and asserts that “medicine is fortified by narrative competence and humanities-derived skills,” in “Commentary: Calculating the Contributions of Humanities to Medical Practice—Motives, Methods, and Metrics,” Academic Medicine 85 [2010]: 935. The importance of the capacity of self-assessment (including reflection on sensations, images, feelings, and thoughts) for “cultivating sufficient mental stability to be open, curious, flexible, and present when faced with anxiety, uncertainty, and chaos” in a clinical situation is emphasized by Ronald M. Epstein, Daniel J. Siegel, and Jordan Silberman in “Self-Monitoring in Clinical Practice: A Challenge for Medical Educators,” Journal of Continuing Medical Education in the Health Professions 28 (2008): 8.

7. See, for example, Eta S. Berner and Mark L. Graber, “Overconfidence as a Cause of Diagnostic Error in Medicine,” American Journal of Medicine 121 (2008): S2–23. Mark L. Graber emphasizes the importance of reflective practice in promoting medical expertise in “Educational Interventions to Reduce Diagnostic Error—Can You Teach This Stuff?” Advances in Health Science Education Theory and Practice 14 (2009): 63–69.

8. Johanna Shapiro addresses the issue of fostering trainee empathy for patients in “Walking a Mile in Their Patients’ Shoes: Empathy and Othering in Medical Students’ Education,” Philosophy, Ethics, and Humanities in Medicine 3 (2008): 10, highlighting the need for “appropriate discourse on how to emotionally manage distressing aspects of the human condition” to help reduce trainees’ “resorting to coping mechanisms that result in distance and detachment.” According to Shapiro, helping to reduce “the sense of anxiety and threat … will enable trainees to learn to emotionally contain the suffering of their patients and themselves, thus providing a psychological sound foundation for the development of true empathy.” The use of poetry and its various elements including “vivid detail, metaphor, point of view, and emotional expression” (278) is highlighted by Johanna Shapiro and Howard Stein as a “method by which medical students can make emotional sense out of their relational experiences in medical school,” noting that “poems that focused on patients tended to express empathy and solidarity”; student writing also “showed empathy for the family perspective” (285), in “Poetic License: Writing Poetry as a Way for Medical Students to Examine Their Professional Relational Systems,” Families, Systems, and Health 23 (2005). In “Association of an Educational Program in Mindful Communication with Burnout, Empathy and Attitudes among Primary Care Physicians,” Journal of the American Medical Association 302 (2009), Michael S. Krasner et al. reported positive changes in empathy after a continuing medical education program for primary care physicians in which narrative medicine and appreciate inquiry exercises were used to “explore ways in which they successfully worked through difficult clinical situations and to identify personal qualities that promoted their successes” (1286).

9. M. L. Jennings cites burnout as an ethical issue in “Medical Student Burnout: Interdisciplinary Exploration and Analysis,” Journal of Medical Humanities 30 (2009), asserting that “burnout (and especially depersonalization) is likely to impair a student's ability to reflect and learn from past mistakes, care about her patients, and develop a mature, integrated professional identity” (262). Jennings argues that “medical student wholeness and engagement are essential for the training of caring, humanistic, and ethical physicians” (262), and cites C. Irvine's “The Ethics of Self-Care” (in Faculty Health and Academic Medicine: Physicians, Scientists, and the Pressures of Success, ed. Thomas Cole, Thelma J. Goodrich, and Ellen R. Gritz [New York: Humana, 2009], 127–31), that “self-care precedes patient care as the true ethical imperative of modern bioethics.” In this vein, Thomas R. Cole and Nathan Carlin assert: “The obligation to care for the patient entails the obligation to care for the self, for when the health of the physician is compromised, is not the quality of patients’ care also compromised?” in “The Art of Medicine: The Suffering of Physicians,” Lancet 374 (2009): 1414–15. Geoffrey Rees postulates that writing medical ethics may enable self-care in “fostering the ability to reflect on the mortal reality that is a condition of medical experience,” in “Mortal Exposure: On the Goodness of Writing Medical Ethics,” Perspectives in Biology and Medicine 51 (2008): 170. Furthermore, Johanna Shapiro, Deborah Kasman, and Audrey Shafer, “Words and Wards: A Model of Reflective Writing and Its Uses in Medical Education,” Journal of Medical Humanities 27 (2006): 231–44, provide a conceptual model of using reflective writing in medical education with components of provider well-being including emotional equilibrium, self-healing, and reducing isolation/restoring sense of community.

10. Frank's categorization of patients’ illness narratives are found in Arthur W. Frank, The Wounded Storyteller: Body, Illness, and Ethics (Chicago, IL: University of Chicago Press, 1995). Felicia G. Cohn et al. recently applied Frank's illness narrative typologies to reflective practice assignments in medical ethics and professionalism education, i.e. third-year medical students’ reflective narratives on conflicts of value encountered in their obstetrics-gynecology clerkship (“Interpreting Values Conflicts Experienced by Obstetrics-Gynecology Clerkship Students Using Reflective Writing,” Academic Medicine 84 [2009]: 587–96).

11. In “Mindful Practice,” Journal of the American Medical Association 232 (1999), Ronald M. Epstein describes how “to be empathic, I must witness and understand the patient's suffering and my reactions to the patient's suffering to distinguish the patient's experience from my own” (836). In his review of cognitive and affective processes in empathy development, Arno K. Kumagai, in “A Conceptual Framework for the Use of Illness Narratives in Medical Education,” Academic Medicine 83 (2008), translates the affective as involving “vicarious identification with another individual's experiences” (654), resonating with a potential function of poetry within the context of Shapiro's text. Poetic expression of such cognitive and affective processes, I might suggest, may also help the learner to “identify” with their own experiences, so to speak, fostering empathy toward self. As such, poetic expression can help “heal the healer,” with poetry fostering, according to Jack Coulehan and Patrick Clary in “Healing the Healer: Poetry in Palliative Care,” Journal of Palliative Medicine 8 (2005), “three aspects of healing [the healer]—the power of the word to heal (and also harm), the skill of ‘negative capability’ that enhances physician effectiveness, and empathic connection, or ‘compassionate presence’, a relationship that heals without words” (382).

12. Rita Charon's formulation of narrative competence in “Narrative and Medicine,” New England Journal of Medicine 350 (2004), includes “an awareness of the ethical complexity of the relationship between teller and listener,” encompassing a combination of textual, creative, and affective skills to “help them [physicians] achieve such elusive goals as humanism and professionalism” (863). She cites Tricia Greenhalgh and Brian Hurwitz, Narrative Based Medicine: Dialogue and Discourse in Clinical Practice (London: BMJ Books, 1998), and highlights the importance of providing physicians with “graduated skills in adopting patients’ points of view, imagining what they endure, deducing what they need, and reflecting on what physicians themselves undergo in caring for patients” (863).

13. In “Narrative Medicine” (Israel Medical Association Journal 11 [2009]), Einat Avrahami and Shmuel Reis describe how the “process of exercising narrative rationality within patient-centered medicine calls for an affiliation with patient and doctor illness stories” (217), citing Johanna Shapiro's “The Use of Narrative in the Doctor-Patient Encounter,” Families, Systems, and Medicine 11 (1993), and Charon, Narrative Medicine: Honoring the Stories of Illness in describing this as “the co-creation of stories” (217).

14. See Jennings's “Medical Student Burnout” for a review of theoretical models of medical student burnout which include a component of medical students “being susceptible to excessive detachment because they are still learning to modulate their emotions” (260). In “The Art of Medicine”: The Suffering of Physicians,” Lancet 374 [2009], Thomas R. Cole and Nathan Carlin write that “Humanizing Medicine depends in no small part on recovering the humanity of physicians” (1414); they go on to reflect on one means for addressing this issue: “Helping to recover meaning and to avoid burnout among vulnerable physicians involves respect for physicians’ stories, which in turn requires that physicians tell their stories” (1415), paralleling efforts of physician memoirs collected by Suzanne Poirier in Doctors in the Making.

15. Theoretical formulations encompassing these components of reflective competence include Donald A. Schon, The Reflective Practitioner: How Professionals Think in Action (New York: Basic Books, 1983); David Boud, Rosemary Keogh, and David Walker, eds., Reflection: Turning Experience Into Learning (London: Koga Page, 1985); Jennifer A. Moon, Reflections in Learning and Personal Development (London: Kogan Page, 1999); and Jack Mezirow, Transformative Dimensions of Adult Learning (San Francisco, CA: Jossey-Bass, 1991). These reflection dimensions are included in the “REFLECT” rubric for formative assessment of students’ reflective narratives, described in Hedy S. Wald, Shmuel P. Reis, and Jeffrey M. Borkan, “Reflection Rubric Development: Evaluating Medical Students’ Reflective Writing,” Medical Education 43 (2009): 1110-1.

16. Reflective writing has been described as an effective mechanism for promotion of self-reflection and self-directed learning within medical education. See Rita Charon, Narrative Medicine; Johanna Shapiro, Deborah Kasman and Audrey Shafer, “Words and Wards: A Model of Reflective Writing and Its Uses in Medical Education,” Journal of Medical Humanities 27 (2006): 231–44; and Hedy S. Wald et al., “Reflecting on Reflections: Medical Education Curriculum Enhancement with Structured Field Notes and Guided Feedback,” Academic Medicine 84 (2009): 830–37. Wald et al. highlight a student's description of written feedback provided through the “interactive” reflective writing pedagogy as “helping her not feel as if she were ‘writing in a vacuum’; in general, having an ‘audience’ in mind (e.g., ‘What would my teachers think of this?’) helping to add meaning to the field notes” (832), raising the question of whether this is germane to memoirs and poetry.

17. See Mary C. Beach and Thomas Inui, “Relationship-Centered Care. A Constructive Reframing,” Journal of General Internal Medicine 21 (2006): S3–8, and Sharon Dobie, “Viewpoint: Reflections on a Well-Traveled Path: Self-Awareness, Mindful Practice, and Relationship-Centered Care as Foundations for Medical Education,” Academic Medicine 82 (2007): 422–27, for an in-depth consideration of the four principles of relationship-centered care as defined by Beach and Inui: “(1) relationships in health care ought to include dimensions of personhood as well as roles, (2) affect and emotion are important components of relationships in health care, (3) all health care relationships occur in the context of reciprocal influence, and (4) relationship-centered care has a moral foundation” (S4). Sayantani DasGupta, “Reading Bodies, Writing Bodies: Self-Reflection and Cultural Criticism in a Narrative Medicine Curriculum,” Literature and Medicine 22 (2003), highlights contexts of both physician and patient within the medical encounter, describing literature as helping to “augment” the “recognition that not only patients but physicians themselves bring varied illness, class, gendered, ethnic, and sexual histories to their medical encounters and challenges the essentialist, homogenizing forces of medical training” (241). Elliot G. Mishler, “Patient Stories, Narratives of Resistance and the Ethics of Humane Care: A la recherché du temps perdu,” Health 9 (2005), captures a contextualized view of the clinical encounter as he describes the “patient's and health care provider's respective lifeworlds” (437), though focusing exclusively on patients’ stories in this work.

18. “The practice of medicine is fundamentally a moral endeavor,” write Catherine Wiggleton et al. in “Medical Students’ Experiences of Moral Distress: Development of a Web-Based Survey,” Academic Medicine 85 (2010): 111. In “Patient Stories, Narratives of Resistance and the Ethics of Humane Care,” Mishler writes of “interest in patients’ stories serving as both an ethical imperative and a conceptual resource for research, training and practice” (435), and we may conceptualize Poirier's and Shapiro's works as extending this notion to physicians’ stories. Along these lines, in “Developing ‘Ethical Mindfulness’ in Continuing Professional Development in Healthcare: Use of a Personal Narrative Approach,” Cambridge Quarterly of Healthcare Ethics 18 (2009), Marilys Guillemin, Rosalind McDougall, and Lynn Gillam “outline a personal narrative approach that facilitates ethical mindfulness” for healthcare professionals (197), “incorporating furthering previous learning of ethics knowledge, developing skills of narration, analysis, and reflection, and importantly, ethical engagement, while at the same time developing a dispositional way of being that will transcend the immediate situation into future clinical practice (206). Students’ narratives, Orit Karnieli-Miller et al. contend in “Medical Students’ Professionalism Narratives: A Window on the Informal and Hidden Curriculum,” Academic Medicine 85 (2010), “can serve as an instrument for the learning process toward changing the environment [informal and hidden curriculum] by encouraging mindfulness to these kinds of situations [negative behaviors in organizations], reflecting on them, and understanding what went wrong, their emotional content, and their negative influences on the self and others” (131). In “The Story of Ethics: Narrative as a Means for Ethical Understanding and Action,” Journal of the American Medical Association 273 (1995), John O’Toole relates the “two most profound aspects of ethical thinking—understanding relationships and embracing different perspectives” (1387) to the “responsibility [that] lies in the hands of the individual student to create his or her own stories and to explore those and other novel narratives in order to truly live as an ethical and empathic physician and human being” (1390).