I had seen Dr. Bryden in her role as pre-clerkship director at various talks this year and last, and what always struck me was the poise and thoughtfulness with which she spoke. When I found out that she had a background in history and philosophy, I was intrigued and immediately knew that I had to sit down with her and learn more about both her background and her thoughts on the role of the humanities in medicine, particularly in this time of curriculum renewal. I had the chance to meet Dr. Bryden in her office one afternoon, and found myself unable to rein in my curiosity. What follows is part of my conversation with Dr. Bryden.
On education and the role of the humanities
Cristina Balaita: To start, you did a Bachelor in History and an M.Phil in Politics before medical school. What influence do you think having done work in the humanities had on your eventual career path?
Pier Bryden: There is a literature that suggests that psychiatrists in particular are more likely to have come from a humanities background, which makes sense to me in a way, in that the project of psychiatry, in its most grandiose form is to try to understand human nature and the ways in which our natures can betray us—nature in its broadest sense: biological, psychological, and environmentally determined. I think that the breadth that I brought to my medical training was hugely helpful and probably helped nudge me toward psychiatry. Having said that, I hear more and more trainees in all areas of medicine who are bringing this enormous breadth to what they do, so I’m not sure it’s any longer the case that it would nudge one towards psychiatry. I think about public health, and I think about social determinants of health in other specialties and our growing understanding of how relationships with patients and our understanding of their backgrounds and their narratives can improve, for example, their diabetes management. I now realize that that breadth could have equipped me for any specialty; I had colleagues at the time who also came from humanities/social sciences backgrounds who ended up in surgery, family medicine, and internal medicine.
CB: You also did fellowships and child and adolescent psychiatry, and women’s health; what drew you to these in particular?
PB: I had been quite troubled as a teenager and had had contact with health professionals which I found very beneficial. I also had a family member who was quite unwell. I think that these experiences in my past really caught up with me in a positive way. I did pediatrics and child psychiatry as electives and I just thought, “wow, this is amazing!” I had an early experience that I still remember, where I was on an elective at the Janeway in Newfoundland. It was a combination of pediatrics and child psychiatry, and I still hadn’t decided yet, I was still thinking about internal medicine and neurology. There was a little girl who kept coming back with abdominal pain, and she kept coming back and coming back and there were a few times when she was going to be operated on for appendicitis and just at the end someone would say “I don’t know, it just seems really non-specific.” I got assigned to her and I would go and chat with her every day and because I was on elective and staying in residence, I didn’t really have anywhere to go home to, so I would sit with her. She got a lot of my time, maybe half an hour or forty minutes a day. Initially we would chat about not that much in particular but we got to know each other quite well and eventually this whole story came out that sadly she was being bullied and that she was being quite significantly physically abused by a teacher. I think what I realized was that in her particular case, she had had this initially very medical seeming presentation, but the answer was in the story. She was truly experiencing abdominal pain, I have no doubt about that, but as the story became clearer, she could distinguish between the abdominal pain that felt real to her and the abdominal pain she had fabricated not to go to school, and the relationship between the two of them. The results was that this young girl avoided surgeries, she avoided more investigations, and we could actually deal with what was concerning her. And that case — everyone says there is usuallya case that helps determine one’s career choice — although of course she wasn’t a case, she was a person, and that person, who must now be into adulthood, switched me. I thought “no, I’m not going to do peds, I’m not going to do internal medicine, I really want that time with patients to understand their stories,” and I just found the kid so funny, and fascinating, and brave. I was always drawn to [kids’] stories; they are still so much at the beginning. Maybe this was idealistic at the time but — and I still feel this way — I felt there was a chance to intervene and there was a chance to say, “let’s see if we can make this story go onto a better trajectory.” I kept that feeling; I had to train in adult psychiatry before I went back to child [psychiatry], but I never really wavered. I always had this feeling of child psychiatry as hopeful, and a chance to co-write a better story with a child and a family.
CB: That’s powerful. I think that for a lot of us looking forward, especially to clerkship, we need to be mindful of those experiences and take that time with the patients that we see.
PB: I think that as a clerk you often think that you have such a minimal role, but no one else on our team had that time to spend with that kid, and I did. As a clerk you are frequently the primary recipient on the medical team of the patient’s story; “so this is why this patient thinks this, this is why this patient doesn’t understand that, this is why this patient is nervous about what we are saying.” I think that it’s a very important role for you in addition to all of the other things you have to learn.
CB: I agree, and yet it can be so easy for us to get wrapped up in all of the medical things, and to think only about those, but then sitting down and talking with our patients is such a different thing…
PB: On a practical note, sitting down and talking to the patient is the best way to ensure you’ve learned your medicine because if you can’t explain to someone in plain language what’s going on with their body or their mind, or what the treatments are meant to do, you haven’t learned it properly. I think there are two aspects to it: that you’re firstly able to translate the patient’s story to the team, but also that you’re able to translate the medical story to the patient. The latter ensures that you really know what you’re talking about. Those moments where you are exchanging stories with patients are probably some of the key educational opportunities that you have.
CB: Speaking of education, what do you think that you, in your role as pre-clerkship director, but also coming from a humanities background, brought to the new curriculum?
PB: What I think I brought was a historical and philosophical perspective. I have an interest in the history of medical education, the trends of medical education, and what the future of medical education is going to look like. The philosophical approach I brought was a line of inquiry around the increasing complexity of medical environments and medical knowledge. As we discover more and more, we begin to understand more chillingly how little we know. The question then becomes how to design a curriculum that instills the right level of anxiety about what we don’t know, and also provides tools in the critical analysis of knowledge. There also has to be education around learning and cognitive strategies, such that students can learn what they need to know, but also how to unlearn it if it becomes obsolete. I also have colleagues who bring an encyclopedic knowledge of medicine, other colleagues who have generalist backgrounds, and people who have super specialized knowledge of a research base or of medical technology. I was one of many people who built the new curriculum; having just me would not have made for a good curriculum, but having me added to these other perspectives was a good thing.
Perhaps the other thing I contributed is a persistent belief that it’s very important for medical students to have a sense of narrative, a story of how everything makes sense in the context of taking care of a patient, or making a research discovery, or making a policy decision. As we conceptualized the new curriculum, we talked about introducing students to multiple bodies: the body of the patient, the body of the institution, the body of knowledge, the body of the culture, and the body of society, so that we can weave together a story that makes sense and allows us to hang all of these detailed areas onto at least a skeletal approach of what you are learning and how you are going to practice.
CB: It sounds like the new curriculum will be very integrative, that it brings together a lot of different elements. One of the projects we’re working on for ArtBeat is integrating some pieces of literature into CBL modules —
PB: — you are going to do that for us, I know, we’re really excited about that!
CB: Do you see that going further? Where else do you see opportunities for that kind of integration of the humanities?
PB: There are aspects of the humanities that need to be core to your medical training and there are aspects that are more about the how of medical training. The core areas, that I don’t think any medical student should graduate without having some training in, are the history and philosophy of science and medicine because you can only understand the limitations to our knowledge base and where we are going if you understand the history of the scientific method, how medicine evolved as a profession, and what its relationship with scientific inquiry has been. This also includes some parameters around research ethics, bioethics, and moral philosophy. Then I think there is the how which is fascinating, and that’s about the kind of thinking that has historically been integrated into the humanities that can be helpful to medical training. There’s persuasive evidence to suggest that if we borrow techniques of observation from art history and art observation and translate them to the physical exam and diagnostic imaging, that it helps students do better in those areas. Likewise, listening to narratives helps with understanding the patient history, learning about themes, and putting things together. There is also a growing literature on reading fiction as a pathway to empathy and the empathic imagination when we are trying to understand patient experiences. I think of these as methods that the humanities offer us to improve our practice. In terms of philosophy, the whole tradition of critical inquiry, the scientific method, aspects of critical appraisal and aspects of evidence based medicine that have grown out of philosophical thinking cross over into content areas. Primarily, philosophy gives us an ability to critically analyze the information that we are given. So I think the humanities are integral.
CB: Indeed they are. I think it’s important to always keep in mind that medicine is a fundamentally human endeavor. Sometimes in these first two years this notion can get a little lost with all of the theory, and it’s only on ASCM days that we remember that human element which is so important.
PB: And being with a person who is in pain, who’s afraid, who’s angry, who’s distressed, really does require some capacity on our part to be still and to be available and I think that sometimes the humanities—a film, a book, a painting, a piece of music, allow us to simulate that in a way that is helpful when we then come back to the patient. It gives us a chance to think about and manage the emotional reactions triggered by the artistic experience, and in doing so be more available to the real person when a similar situation occurs.
CB: Thank you for sharing these insights!
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