Creative writing as reflective practice in health professions education

Emily Ferrara and David Hatem

INTRODUCTION

In the words of W Somerset Maugham, a physician-writer who tended the sick in London slums in the early twentieth century, 'the doctor . . . sees human nature bare'.¹

Whether physician, nurse or therapist, the role of caregiver affords a sacred proximity to the undeniable mysteries of human existence: the trials of illness, the resilience of the human spirit and ultimate mortality of the body. The use of creative writing in health professions education has the potential to illuminate both the plight and might of caring for the sick. When harnessed as a tool to support reflective practice, creative writing's power goes beyond inspired story-telling to support the development of self-aware, empathic, humanistic practitioners who are poised to deliver quality patient care.²

RATIONALE/LITERATURE REVIEW

Reflection in medical education is defined by Sandars as 'a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters'.³ Creative writing as reflective practice is grounded in the literature and medicine movement which took hold as an established scholarly field more than 30 years ago. It is widely accepted that 'Literature and Medicine share a fundamental concern - the human condition',⁴ and that both literature and medicine as fields of study have the capacity to promote 'depth of insight, acuity of perception, and skills in communication'.⁵ Reflective practice and transformational learning pedagogy took wing in the 1990s, and most recently, the fields of narrative-based medicine⁶ and narrative medicine⁷ have emerged as conceptual frameworks for guiding the provision of effective and deeply humane care. Rita Charon promotes the 'centrality and privilege of storytelling' in clinical practice, asserting that narrative engages a continuum of 'attention, representation and affiliation'.⁸ According to Charon, reflective writing serves as a seminal act of the representation aspect of this narrative continuum, an essential component of the process:

Better than just talking about these things in a support group or venting session, the actual writing endows the reflections with form so that others can join the writer in beholding it . . . If they can capture it with greater force and accuracy, it means that they are perceiving it better as it occurs.⁹

The uses of narrative in health professions training - whether through applying narrative-based skills in the patient encounter;^10,11 journaling in response to critical incidents;¹² or writing parallel charts, that is, writing in ordinary language about the trainee's experience of the patient encounter¹³ - are not uncommon. However, curricula employing narrative methods are often voluntary or elective in nature. In cases where narrative skills are a formal part of the required curriculum, these narrative components may be experienced by learners as a kind of 'window-dressing' rather than as an integral framework for the teaching of clinical skills. Making maximal use of narrative methods, including employing the humanities as an integral aspect of medical education, is argued to be a critical component in current efforts to enhance professionalism and humanistic development in medical trainees.¹⁴

The inclusion of narrative methods incorporating 'creative writing' as a form of reflective practice is even more scarcely documented in the medical literature, although there are a smattering of articles focused exclusively on the subject of poetry and other forms of creative writing used in medical education contexts, both at the medical student and resident learner levels.^15-21 Enhancing empathy and selfawareness, and increasing learners' appreciation of the perspectives of others (e.g. patients, peers) are common outcomes of these interventions. The writing of poetry by medical students 'appears to be one way students can make emotional sense of the different relational systems they encounter over the course of training', including their interactions with patients and their family members, and their relationships with various members of the healthcare team.²²

The recognition of the honored tradition of physician-authors of the twentieth century, such as W Somerset Maugham, William Carlos Williams and Anton Chekhov is ubiquitous, as is the burgeoning number of contemporary literary works of poetry, essays, short stories and memoir written by physicians, nurses and other healthcare professionals. These can be found in many venues: from the popular press (New York Times) to leading professional journals (Journal of the American Medical Association, BMJ), to academic and mainstream publishing houses. There are a wide array of columns in health professions journals devoted to the reflective and creative output of physicians, nurses and therapists, as well as literary journals devoted to the illness experience. Two such premier literary journals created just within the past decade are: Bellevue Literary Review, based out of the Department of Medicine at NYU Langone Medical Center, New York City; and ARS MEDICA: A Journal of Medicine, The Arts and Humanities, based out of the Department of Psychiatry at Mount Sinai Hospital, Toronto, Canada. Both journals provide companion teaching tools to encourage utilisation of the readings in the context of health professions education. This broad overview of the state of medical-themed literature affirms the fact that being a doctor, nurse, or therapist (or being 'in training' to become one) can be transformational in nature. These stories of transformation appear to be of mythic importance to the culture as a whole, and to the ongoing development of the healthcare professions.

Thus, there is a need for formalised opportunities for active reflection and introspection in health professions education at all levels, in order to engage in a meaningful way with the sacred and meaning-making dimensions of caregivers' work.²³²⁴ At the University of California, San Francisco, Rachel Naomi Remen's successful efforts to establish The Healer's Art, an elective course for medical students launched in 1993, broke new ground in this arena. In the academic year of 2006-07, the course was offered at more than 53 medical schools worldwide.²⁵ Offering a creative writing course which draws on narrative, reflective practice, and literature and medicine traditions, is another effective way to stimulate active reflection and introspection by students, particularly those who are drawn to creative expression through the written word.

The experience of 'seeing human nature bare' - whether in the medical student's first cut into the cadaver, or a nursing student's first encounter with an actively dying patient - can be a challenge to process while performing the necessary duties of their respective roles. The raw material confronting students during the training experience has the potential to be life-altering and uniquely impacts the formation of each student's personal and professional identity. These intense experiences, often referred to as critical incidents, require a 'container' to support students in their effort to traverse the soul-making work of becoming a doctor, nurse or therapist - or in educational vernacular: to achieve the competencies associated with professionalism. This requires integration of the newly acquired scientific knowledge base and clinical skills with the individual's personal identity, in order to develop a cohesive professional identity.

One of the most critical aspects of this important integrative work is the development of self-awareness in medical, nursing and therapist trainees. According to Kearney and colleagues: 'Self-awareness involves both a combination of selfknowledge and development of dual-awareness, a stance that permits the clinician to simultaneously attend to and monitor the needs of the patient, the work environment, and his or her own subjective experience'.²⁶ Kearney reports that empirical data supports the effectiveness of reflective writing as one of two methods found to enhance self-awareness (the other being mindfulness meditation).

The critical incident report (CIR) is a form of reflective writing that encourages students to identify an incident encountered in the course of medical training that has raised feelings of conflict or emotion that the student may experience as needing resolution. Although the writing in and of itself may be helpful to support reflective practice in students, CIRs have been found to provide greater value when used as a focus for group reflection.²⁷

Encouraging students to write reflectively about conflicts and emotions requires the provision of a safe place within which to allow the raw material to emerge. The first step is providing safety within the writing process itself; parameters laid out in expressive writing research methodology as outlined by James Pennebaker can provide faculty with a basis for framing reflective writing exercises in such a way to allow students to delve into particular aspects of their experience only when they feel ready to do so.²⁸

Creative writing courses - particularly those which engage creative writing as a form of reflective practice - provide the 'container' to allow for exploration and expression of the otherwise untapped, yet insistently emerging unconscious/sub- conscious thoughts and ideas. This makes them available to allow a greater degree of integration of biological, personal and interpersonal learning to occur during the training years. Exploration of issues usually not discussed and/or formally processed within the traditional medical school curriculum may be addressed in this way, as an antidote to the 'hidden curriculum'. This has been described by Hafferty as 'the commonly held understandings, customs, rituals, and taken for granted aspects of what goes on in the life space we call medical education'.²⁹ The hidden curriculum is a major influence on the learning environment, fully surrounding students in their day-to-day work, and involving interactions which may at times fall short of the ideal presented in the formal curriculum. Thus, the hidden curriculum can have a devastatingly negative effect on students' ability to maintain their sense of purpose and meaning in the face of the realities and limitations of clinical practice. It is hypothesised that the hidden curriculum contributes significantly to growing student cynicism as their training progresses,³⁰ indirectly teaching students to abandon idealism and their own personal identity and values to the detriment of their effectiveness, satisfaction and longevity in the profession.³¹

Shapiro, Kasman, and Shafer describe a model of reflective writing outlined as a linked continuum of writing, reading and listening. This process appears to be highly effective and practical in achieving pedagogical goals to enhance professional development, patient care, and practitioner well-being.³²