A Narrative Companion for the Medical Curriculum

Debra Hamer, Jesse Kancir, Jonathan Fuller, Ayelet Kuper, Pier Bryden, and Allan Peterkin

As we can all attest, the road to becoming a doctor is paved with privilege, challenges, and adversity. Students and physicians repeatedly confront their academic, physical, and emotional limits. Through the process, we often feel overwhelmed, desensitized, and lost. Perhaps what we are most at risk of losing as we acquire our professional identities are our distinct, individual identities. Yet we have the opportunity to weave both together through caring, reflective practices.

Within the medical education literature, narrative medicine and the medical humanities have been proposed as educational strategies to encourage learners to examine their relationships and to reflect on their attitudes when caring for patients. A narrative has the power to reach its audience through the transmission of language, ideas, imagery, experiences, and emotions, providing that audience with an understanding of other lived worlds – what we call ‘empathy’. The use of narratives in medical education may encourage learners to think critically not only about their experiences but also about their own shifting identities. A critical disposition and reflective capacity serve as support for trainees and doctors as they grapple with uncertainty, assumptions, and conflicts – both personal and professional.

At the University of Toronto, a group of students and medical educators – ourselves included – came together to evaluate how the undergraduate medical curriculum could better develop capacities for empathy, caring, and critical reflection. The medical humanities and narratives seemed to offer a way, but how could this approach compete for curriculum time with established pillars of the curriculum? Was it possible to create a humanities accompaniment to 2 the biomedical curriculum that would be genuinely integrated and adopted by learners? And how would the students take it up? It was out of this mélange of questions and challenges that the Companion Curriculum was born.

The Companion is a curriculum that links the science-focused undergraduate medical curriculum with relevant narratives selected from literature, visual art, and audiovisual texts. It provides an introduction to narratives created by writers, physicians, and patients with a talent for evoking reader responses. The selections aim to enrich the perspective that is brought to didactic biomedical lectures or to act as a commentary on the medical profession’s approach. The collection also aims to expose students to a variety of uses of language so as to enhance clinical description of illness and remind students of the power of communication and connection. In this way, the Companion allows students to develop curiosity and reflective capacity, while also fostering a community for reflection amongst their peers. Like any good companion, the humanities pieces support the core medical curriculum, giving it new perspectives.

The Companion was first conceptualized and supervised by Dr. Allan Peterkin at the University of Toronto. The project then grew to involve Drs. Michael Roberts, Ayelet Kuper, Pier Bryden, and Elizabeth Berger (faculty members); Drs. Debra Hamer and Caitlin McKeever (residents); Jonathan Fuller and Jesse Kancir (medical students); and Joan McKnight (our administrative coordinator). The project has also involved countless medical students from all four years of study who have shaped the selection of narrative pieces as well as how the pieces are used and distributed to learners. Unlike reading lists generated by faculty in other medical schools, our Companion is a student-generated project, which is crucial to its uptake and integration as well as its sustainability.

The Companion is divided into pre-clerkship and clerkship curricula to match the two distinct stages of medical education at the University of Toronto. The Pre-clerkship Companion complements the first two years of medical studies that explore health and disease through the basic medical sciences, such as anatomy, physiology and pathology, as well as the medical management of disease. The Companion mirrors the weekly lecture architecture, providing narrative content that parallels the learner’s biomedical studies. For each biomedical lecture there are a few select pieces of literature, reflective essays, poetry, or other media that echo elements of the medicine being taught (for a complete list of Companion texts, see http://www.health-humanities.com). Learners can thus come to imagine encounters with patients and their families despite minimal clinical exposure in the first two years. Some faculty members involved with this project initially selected pieces for this curriculum; later, a group of twelve students assumed the effort of collecting suggestions, finalizing selections, and obtaining permissions for distribution. We released the first-year Pre-clerkship materials in September 2011 and began distributing the second-year materials in September 2012.

In pre-clerkship, the Companion pieces have been printed and distributed as a preface to the weekly lecture note packages that are provided to students. The students are encouraged to use the humanities selections in whatever way they wish. Some read them during the breaks between lectures, while others find them to be a welcome place to encounter something beautifully written and to rest their minds as they prepare for exams. However they are used, the humanities pieces remain with the students as a reminder of a wider, humanistic perspective that otherwise may become lost among facts and mnemonics.

The Clerkship Companion is structured differently from the Pre-Clerkship Companion to reflect the transition at this stage in training to more independent clinical experiences. The 4 Clerkship Companion captures this change by presenting more clinically-directed narratives, accompanied by probing questions that can be used for self-reflection (see examples at http://www.health-humanities.com).

At the University of Toronto, clerkship is currently 77 weeks, and is divided into Year 3 (51 weeks) and Year 4 (26 weeks). During that time, clinical clerks rotate through different specialty areas (i.e. internal medicine, pediatrics, surgery, psychiatry, etc.) for up to eight weeks at a time. The Clerkship Companion offers two to three narrative pieces for each clinical rotation. The Clerkship Companion subcommittee included ten medical students who worked collaboratively with Dr. Hamer (resident) to select appropriate pieces. Each group member was assigned a specialty area and was responsible for finding pieces for that area of interest. Once pieces were found they were brought to the group for vetting and discussion, with a focus on finding pieces that would be interesting for learners as well as clinically relevant. The group then developed the series of reflective questions to be included with each piece.

The Clerkship Companion has thus far been distributed to learners by either email or in print form at the beginning of each rotation. We have encouraged Clerkship directors to use these materials as they see fit, allowing students access in a manner that reflects the demands of the rotation. While at this time most rotation coordinators simply send students the materials at the beginning of the rotation, we have also suggested sending a reading every one to two weeks, thereby creating a reminder for students that these materials are available and encouraged. More recently there has been a growing focus on faculty and resident development in order to generate more interest and competence in using these narrative pieces as part of clerkship teaching. For example, within the psychiatry clerkship rotation there is growing interest in starting a resident- 5 led teaching module based on the Companion materials in order to engage more students with the materials and to allow for deeper guided reflection.

The Companion is an organically grown humanities curriculum that takes as its primary source the perspectives of successive cohorts of medical students. At this time, new students are adding and changing the selected texts to reflect their interests and annual curricular changes as well as looking at new ways to distribute the materials. In Pre-Clerkship, we have begun to integrate the Companion using online social media platforms in a new website called ArtBeat, with blogging capabilities. This allows students to extend the discussion beyond the classroom and generates more spontaneous and authentic reflection.

Since its inception, the Companion has been propelled by the interest and passion of students, educators, and administrators at the University of Toronto. Support from all three levels is essential for the sustainability of the Companion Curriculum and for the success of any similar initiatives that we hope it will encourage. Interest in our project has been gaining momentum, including growing collaborations and student involvement. We are currently evaluating the Companion through student focus groups, which we expect will reveal its impact as well as challenges, surprises, and important lessons regarding our strategy of narrative-as-companion-to-the-curriculum.

Dr. Debra Hamer is a fourth-year psychiatry resident, Mr. Jesse Kancir is a fourth-year medical student, and Mr. Jonathan Fuller is an MD/PhD student. Dr. Ayelet Kuper is a Wilson Centre Scientist and internist at Sunnybrook Health Sciences Centre, Dr. Pier Bryden is a child psychiatrist at the Hospital for Sick Children, and Dr. Allan Peterkin is a psychiatrist at Mount Sinai Hospital. All authors are based at the University of Toronto, Canada.