Reflection by Owen Lewis
Since 2017, I have taught an elective course to second semester medical students on poetry reading and craft. It is a six-week elective, three hours per week, one of about a dozen arts electives offered to the students including photography, comic strip writing/drawing, studio drawing, playwriting, and others. The choice of one elective is required and is part of the Narrative Medicine program in the Columbia University Vagelos College of Physicians and Surgeons. The effectiveness of the art intensive electives depends on the overall Narrative medicine curriculum. The arts seminars are taught by practicing artists. I am a poet, and throughout my life have been drawn to the magic of words and their power to connect us one to another through a sharing of deeper experience (Lewis, 2023).
The chief aim of the Narrative Medicine program at Columbia/Vagelos is to develop reflection as a core professional skill. Reflection/reflective practice requires both the ability to observe acutely and understand one’s own barriers to, or distortions of, perception (Charon et al, 1995, 2016; Devlin et al, 2015; Cunningham et al, 2018). More broadly, the curriculum addresses the disconnection of patient and doctor in many contemporary practice settings. The power and meaning of poetry in a medical curriculum were explored in a podcast with British Medical Journal/Medical Humanities editor Brandy Schillace (Lewis et al, 2019).
This brief communication will highlight several obvious and non-obvious benefits to medical students, their training, and their future professional life of this arts curriculum, and specifically poetry. Qualitative data of these observed benefits are drawn from written student reflections on the course itself. The overall aims of the arts curriculum are to promote observational capacities including a subjective awareness, the use of intuitive faculties, and developing a multi-perspectivist approach to understanding. The collaboration engendered in this course creates a different way of relating among the students based on trust, understanding, and teamwork, not only between themselves and the teacher/artist, but, more importantly, between themselves.
The practice of medicine begins with observation of signs of illness and health. The context of observation and the subjective biases that shape observation no less important to accurate observation. For students first faced with observing a patient, neither context of the patient’s illness nor subjectivity can be fully appreciated at first. Students are preoccupied with finding the right professional stance, asking the right questions, and getting the right answer. Students at first often do not have the capacity to understand the fuller context of an illness in a patient’s life let alone their own emotional response to that clinical situation. Yet we want them to have an emotional reaction to clinical work and to know their emotions. Without this awareness of self, true connection is not possible. When a poem is read or a work of art observed, students are freer to respond to that work because they have no clinical responsibility to it and allows students to observe themselves.
As an example of training in observation from the poetry course, I will sometimes transcribe a poem we will study into a prose paragraph. The students read for content, react to the content, and note the moments of disjointed flow. When the poem is then presented as written with its organization of lines, both the clear and disjointed meanings take on other significance. How are the lines organized? Short or long? Is there punctuation? As line breaks throw emphasis onto different words in the sentences, how is the meaning altered? What does the stanzaic structure contribute? What does the white space contribute? What previously had been seen a disjointed meaning in a prose organization now can be seen as the author asking the reader to loosen his logic mind and follow the imaginative. Most importantly, the poem is asking the reader not only to understand but also to be aware of his feelings. When students share their various reactions, feelings and meanings, all justified by the poem, a more complex understanding of the poem emerges, and the shaping of observation by personal context becomes clear. All these poetry specific elements have their counterparts in other arts. The specific didactic approaches of this Poetry Reading and Craft course have been previously described (Lewis O, Jetté A, 2023).
Supporting the Intuitive
Some students come to the course with a prior interest in poetry. Some have had some exposure and want to learn more. Others seems to choose it randomly. From whatever point of entry, students frequently report that the seminar reminds them of a forgotten part of themselves, and for those who had had a more developed involvement with writing, re-encountering this art seemed to some students like encountering an old friend. The course occurs towards the end of the second semester and is felt as a welcome relief to the intense memorization that has been required to date and taps the use of other parts of the mind. Student relief and joy in this curriculum is felt to be reinvigorating. It can also feel frightening to some and disempowering. Some students have reported feeling on shaky ground in the first few sessions. These subjective reactions derive, I believe, because the poetry reading and writing taps another part of mind and being, namely the intuitive. The path to medical school does not rely on intuition. It involves factual and conceptual learning of the sciences and excelling in these studies. It favors memorization and logical processes. The Narrative Medicine (NM) curriculum in general, and the arts curriculum quite specifically, signal to the students that more than the logical mind is required to become a good doctor. That these skills are considered core skills underscores this work as an equally serious and rewarding part of the curriculum. The students’ own discoveries, or rediscoveries, of their artistic selves lead them to progressively trust the intuitive and its place in medicine. As we teach and value evidence-based medicine, and the standardization of treatment algorithms that it engenders, the intuitive, nonlogical part of mind does not seem to have a valued place. And yet, how many complex diagnoses and discoveries occur through a hunch, a flash of intuition?
Generosity, Teamwork, and New Ways of Relating
The Narrative Medicine curriculum in general, and particularly the workshopping of student writing in this course, provides the opportunities and exchanges for students to know and to be known by one other. At the heart of art is loss, vulnerability, and fragility. Over the course of the six-week curriculum, students come to share more of these aspects of themselves and to trust, through mutual exchanges, that they are not only accepted, but feel support for the very sets of feelings they had felt obliged to keep private. In response to sharing their work, students note a generosity of positive response, even as critical feedback was given. The sense of trust and teamwork sets a tone for future intra-colleague interactions and peer support. No matter how curricular approaches may try to minimize the competitive aspects of medical school education, the competition does exist. Experiences that offer a real counterpoint to competition are invaluable. The stresses of medical school, as great as they are, only amplify in practice. A core group of colleagues with whom one can puzzle over diagnosis and treatment choices, share doubts and mistakes, and find support for the rigors of patient care allows physicians to emotionally succeed in their professional lives. It is not unrealistic to expect that the precursors of trusting colleagues in this way can be established early in medical training.
Wonder, surprise, and creativity
Most medical students would note that education and training in general does not make much place for wonder, surprise, and creativity. There is much to learn, master, and assimilate. And yet, we want our students, whether they develop as clinicians or researchers, to maintain a sense of wonder and surprise at the entities they study or treat and bring creativity into the lab or the clinic. Best medical care must follow evidence-based algorithms, and yet these algorithms are only the scaffolding of patient care. As noted in the comments on fostering the intuitive mind, wonder and surprise and necessary precursors for challenging the intuitive and creative mind. While careful finetuning of such algorithms is important, real discovery emerges out of wonder and surprise. Good clinical care often proceeds from following established algorithms and then departing from them.
As is often said, medicine is both an art and a science. We know how to train students in the science of medicine. The art of medicine is practiced when the physician possesses the capacity to see every patient in the context of their lived story, and to see every illness in every patient with fresh eyes. This communication addresses an approach utilizing art to begin to train pre-clinical students in the art of medicine.
One student (Vancura, 2018) in a final reflection of the course wrote, “I saw that great poetry does not require extraordinary events to motivate it. Rather, poetry happens around us all the time and the best poems often tap into this, giving meaning to the ordinary or making us reconsider it in a new way. Similarly, I think that the best science seeks to illuminate the ordinary and allows us the see the same world in a constantly changing way.” When I later wrote requesting permission to quote him, he added, “I haven’t been able to keep up with any formal writing, but I have found myself stopping to appreciate moments from everyday life that would make for poetry, and even that has been enjoyable.”
Do we want our doctors seeing poetry in the everyday? What would that mean? If it means seeing freshly without preconceived ideas, seeing with heart as well as mind, and seeing with a readiness for connection, then the answer, I believe, is yes. Yes, we want our doctors to be able to see poetry everywhere.
Owen Lewis, M.D., Clinical Professor of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, Lecturer of Narrative Medicine in the Department of Medical Humanities and Ethics, and award-winning poet, most recently the Guernsey International Poetry Award.
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Cunningham H, Taylor D, Desai U, Quiah S, Kaplan B, Fei L, Catallozzi M, Richards B, Balmer D, Charon C. Looking Back to Move Forward: First-Year Medical Students’ Meta-Re ections on Their Narrative Portfolio Writings. Acad Med. 2018, June. 2018; 93(6):888–894.
Devlin MJ, Richards BF, Cunningham H, Desai U, Lewis O, Mutnick A, Nidiry MAJ, Saha P, Charon R. Where Does the Circle End? Representation as a Critical Aspect of Reflection in Teaching Social and Behavioral Sciences in Medicine. Acad Psychiatry. 2015 December; 39(6): 669-677
Lewis O. Why I Write (Poetry). J of American Psychoanalytic Association. 2023, 71(3): 565-568
Lewis O, Jetté A. On Teaching Poetry to Medical Students: A Conversation. Journal of Creative Writing Studies. 2023 (in press)
Lewis O, Spencer S, Schillace B. The Power of Poetry. British Medical Journal/Medical Humanities, BMJ Talk Medicine podcast. 12 September 2019. https://soundcloud.com/bmjpodcasts/the-power-of-poetry
Vancura B, personal communication, 2018.