On the rare occasions that I’m able to meet with my non-medical friends, they ask me when I will finish my training. They might then commiserate over how long I’ve been in school, how they hardly ever see me on account of my 26 hour in-hospital shifts and 80-plus hour work weeks. Occasionally they ask me if I would do it all over again. My answer has been invariably no, often in jest, but sometimes in earnest, depending on the tribulations of my latest call-shift. Certainly I didn’t fully appreciate what I had signed on for when I started medical school. Only now, 8 years later, as I approach the end of my residency in Internal Medicine, do I have a grasp of what it means to be a physician.
Sir William Osler, widely regarded as the father of modern medicine, stated, “The practice of medicine is an art, not a trade, a calling not a business, a calling in which your heart will be exercised equally with your head.” But what exactly is the art of medicine? In a lecture to the Ontario Medical Association, renowned Canadian author Margaret Atwood described art as a nascent capability hardwired in all of us from our infancy.1 Indeed, infants are somehow able to comprehend a narrative before they can even speak. Our entire history as a species has been passed down through our writing, music, paintings, sculpture, dance, theatre, architecture- everything that we consider to be “art” tells a story revealing who we were at that specific moment in time. This also holds true in medicine. By taking a history, we are actually receiving and sharing the patient’s story. “Listen to your patient, he is telling you the diagnosis,” said Osler.
In medical school, we are ostensibly taught to treat the person, not the disease, inspired by the so-called “biopsychosocial” model. However, come exam time, the patient devolves back into a pattern of symptoms, signs, and abnormal test results matching a particular disease that we must identify out of a list of 4-5 choices, like a suspect in a police lineup. Little wonder then that the biomedical is still what prevails in medical training and propagates into clinical practice. We often refer to patients by their diagnosis, eg. “the non-compliant guy with the necrotic diabetic foot”. I suspect this same attitude may also be true in other healthcare professions. I can’t count the number of times a nurse has said to me something along the lines of: “the patient in 18 bed 2 wants something for pain” while not even knowing the patient’s name. So much for the “social” in biopsychosocial.
This process of dehumanization extends to medical trainees as well. My value as a resident has frequently been decided on the amount of service I can provide. Supply and demand. My identity and personal life have been subjugated by the almighty call schedule. I was not allowed to request time off a year in advance for personally significant events because it might have somehow “conflicted with the schedule”. When I had shingles, I was told that it was ok to work because my rash covered only one dermatome and I wasn’t contagious as long as no one touched my blisters. This helped me realize my importance early on: I was sawdust used to plug holes in the call schedule. By the end of first year residency, I already felt burned out.
My experience has been far from unique. Rates of burnout have been reported to be anywhere from 28-45% among medical students and 27-75% among residents.2 Depression or depressive symptoms are found in 20.9 – 43.2% of residents, depending on the instrument used to capture these diagnoses.3 Suicide is actually considered an occupational hazard in medicine4 and yet, how many of us are willing to admit that we have a problem? How can we provide empathic care to our patients when we ourselves are intermittently falling apart?
The medical humanities have been raised as one bulwark against the rising tide of depersonalization and burnout for trainees.5 The UK Association for Medical Humanities defines the discipline as “a sustained interdisciplinary enquiry into aspects of medical practice, education and research expressly concerned with the human side of medicine.”6 Studies have demonstrated that clinical empathy can be enhanced by studying the medical humanities7,8 which in turn can improve patient outcomes.9 As a result, they have become increasingly incorporated into medical education in the US, UK, Australia, and Canada.
When I was a clerk at the University of Toronto, faculty introduced a mandatory reflective writing curriculum called the Portfolio Course for which we would meet every few weeks with a small group of students and a couple of faculty preceptors to write a reflective piece about an assigned CANMEDS professional role. More recently, students and faculty at the University of Toronto have also instituted an optional Companion Curriculum whereby literary pieces are matched every week to themes and topics within the traditional medical curriculum. However, from speaking to various people and my own experience, the response to this initiative has been less than enthusiastic. This generic lack of enthusiasm for the humanities is perhaps not surprising. For students, the priority is to master the enormous volume of “hard” medical science and to pass their exams. The faculty are responsible for teaching this ever-growing body of knowledge and it can be difficult to see the value of sharing a poem or story, especially given their time limitations. Indeed, when the Portfolio course was first introduced, I thought it was a complete waste of time, although my pieces did make for useful fodder on the CaRMS (residency match) interview circuit. However, since carrying the burden of clinical duties throughout my residency, I now wish I had more protected time to reflect. Perhaps then I could have recognized the signs of burnout sooner and taken steps to fortify myself.
Research has shown that we begin medical school with lower rates of burnout, depression, and a higher quality of life than age-matched college graduates not enrolled in medical school.10 This is easy to understand, as many of us have been working towards that goal for years and to finally be accepted into med school confers a moment of elation. The future seems clear. We’re seemingly set on a path towards a meaningful and fulfilling career. However, we somehow emerge on the other side, transformed into physicians with staggering rates of burnout and mental illness. We’ve acquired the necessary medical knowledge and clinical skills to practice medicine and yet for many of us, we’ve exchanged optimism for cynicism, enthusiasm for resignation and empathy for frustration. This transformation is strikingly illustrated at the beginning of the classic satirical novel “The House of God” by Samuel Shem, as the narrator reflects on his first year of residency:
“… and I had been hurt, bad. For before the House of God, I had loved old people. Now they were no longer old people, they were gomers (“get out of my emergency room-ers” ), and I did
not, I could not love them, anymore. I struggle to rest, and cannot, and I struggle to love, and I cannot for I’m all bleached out, like a man’s shirt washed too many times.”11
Perhaps the humanities can still mitigate this transformation by offering, in the words of Dr. Rafael Campo, “a source of renewal, reconnection, and meaning.”
With a complete overhaul of the undergraduate medical curriculum at the University of Toronto being planned for the next academic year, I chose to pursue a medical humanities elective as I approached the end of my training and was invited to select literary pieces for an updated Companion Curriculum. As I sifted through volumes of poetry, artwork, memoir and other media created by patients, their family members, physicians and other healthcare workers, I was struck by how much these stories fully resonated with me. It was an important reminder that my experiences are not unique and that I am not somehow defective in my doubts and struggles. This process has helped me recognize the forces that have shaped the physician that I now am and to identify the many milestones in my development.
At the very beginning of medical school, we learned how to interview and examine a patient, establishing the foundations of the physician-patient relationship. As we learned more about physiology and how it goes awry in disease, we began to develop an appreciation and admiration for the strength and resolve of our patients as they cope with illness. I then reflected on my insecurities as we progressed to greater clinical responsibility, began to acquire clinical competency, and learned to care for the “whole person” rather than the disease, all as part of a complex healthcare team. Inevitably, despite all our efforts, we were faced with our first patient death and had to learn how to break bad news and to cope (vicariously) with death and dying. Finally and perhaps the most neglected learning point of all, we had to learn how to care for ourselves.
I have organized these new Companion Curriculum pieces according to these personal milestones and selected them on the basis of brevity, as I know how time-starved we all are. Each piece had to be evocative and relevant to real-life clinical practice. Due to my first criterion, the vast majority of the pieces are poems that can be read alone or in a group, in less than a minute. My aim was not for a rarefied application of literary criticism. I expect, or rather, hope that students and educators will see how these stories may mirror their own or those of their patients, and that readers may gain an appreciation for how profoundly illness and the physician-patient relationship shape all of our life narratives. This appreciation creates an opportunity for self-reflection and encourages, in the words of poet and physician Dr. Jack Coulehan, development of the attributes of “mindfulness, self-awareness and the moral imagination.”
When I applied to medical school, I cited a desire to apply my love and aptitude for the life sciences to help people in a meaningful way by diagnosing and treating illness. However, I’ve since realized how mutable and evanescent is the “science of medicine”. The knowledge that we memorize for today’s exam may become obsolete and forgotten tomorrow. In contrast, the stories, of our patients, our colleagues and our families, will endure. They are what I will carry with me as I embark on my own journey to personal wholeness and to commencing a clinical practice informed by humanism.
- Atwood M. The importance of literacy and the arts in community health. OMR. 2015; 82(7): 14-19.
- IsHak WW, Lederer S, Mandili C, et al. Burnout During Residency Training: A Literature Review. JGME. 2009; 1(2): 236-242.
- Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015; 314(22): 2373-2383.
- Rubin R. Recent Suicides Highlight Need to Address Depression in Medical Students and Residents. JAMA. 2014; 312(17): 1725-1727.
- Gordon J. Medical Humanities: to cure sometimes, to relive often, to comfort always. MJA. 2005; 182: 5-8.
- Evans M, Arnott R, Bolton G, et al. The medical humanities as a field of enquiry. Statement from the Association for Medical Humanities. J Med Ethics. 2001; 27: 104-105.
- Djikic M, Oatley K. The art in fiction: From indirect communication to changes of the self. Psychol AesthetCreat Arts. 2014; 8(4): 498-505.
- Pederson R. Empirical research on empathy in medicine – A critical review. Patient Educ Couns. 2009; 74: 339-46.
- Hojat M, Louis DZ, Markham FW, et al. Physicians’ Empathy and Clinical Outcomes for Diabetic Patients. Acad Med. 2011; 86: 359-364.
- Brazeau C, Shanafelt T, Durning SJ, et al. Distress Among Matriculating Medical Students Relative to the General Population. Acad Med. 2014; 89: 1520-1525.
- Shem S. The House of God. Berkley Books, New York. 2010.