Our content analysis first examined the main subject matter that students selected for their projects, i.e., what the project was primarily “about.” Not surprisingly, the largest number of students focused on patients as the subjects of their creative projects, particularly dying patients. A number of students tended to concentrate on themselves and their own experiences as medical students as the subject. Finally, several students in each year chose to reflect on personal contacts with illness and death.
The content analysis also considered the relational, professional, and ethical themes that concerned these third-year students. Themes might or might not coincide with the main subject of the project, but were issues that the students addressed at some level in undertaking the project. Although the projects varied greatly, some frequently-examined themes could be identified. For example, either directly or indirectly, many students considered the nature of the doctor–patient relationship and, in particular, what qualities contribute to a meaningful, appropriate, and supportive relationship. Some specifically probed aspects of doctor–patient communication, including telling the truth to dying patients. In these projects, the students voiced their own anxieties about speaking professionally yet compassionately, and frequently commented on communication failures in their putative professional role models, i.e., residents and attending physicians.
Related to the theme of relationship were projects in which students reflected on the role of emotions in patient care, particularly empathy, caring, and compassion, and on what might be acceptable limits to these emotions. Students worried about whether they cared too much about their patients, or not enough. They generally identified with patients and felt their suffering acutely, but wondered whether this emotional sensitivity might overwhelm them and render them either unprofessional or ineffectual. Students questioned how to retain their human responses to suffering, how to deal with their own helplessness and frustration, and how to express empathy for patients. Several students each year noted, as either an explicit subject or a touched-upon theme, both the parallels and the conflicts between the student's and the patient's roles. They expressed confusion and distress when they realized that the patient's agenda (i.e., to receive care and cure) might sometimes be at variance with the student's agenda (i.e., to finish on time, to look good in the eyes of the resident).
In a related vein, students also used their projects to better understand the patient's experience of illness and/or to remind themselves that they were treating a person, not merely a disease. A similar theme was the importance of carefully listening to and learning from patients. These projects seemed to reflect the attitude that only by paying careful attention to the totality of the patient could students truly comprehend the nature of disease and illness. Interestingly, relatively few students mentioned residents or attending physicians as teachers whom the students could emulate. A handful of students each year did present images of either contemporary or historical physicians as personal role models, but the majority of their projects highlighted “anti-role models,” in the sense that the students planned to learn from them as negative examples.
Many of the students concentrated on the socialization process directly, exploring the expectations and role requirements of the medical student within the hierarchy of medicine, the stresses and, at times, brutality of medical school, and the balance between personal and professional worlds. Some students focused on the challenges of newly introduced clinical responsibilities, their limitations and sense of inadequacy, feelings of being overwhelmed by too much information and knowledge to master, and the humiliating experience of being questioned by superiors about their knowledge base in a condescending or hostile manner. Other students expressed concerns about an encroaching desensitization, lack of humanity, and failures of empathy in themselves. They were deeply troubled that their experiences in medical school were making them less caring, kind, and compassionate human beings, and fretted about how the diminution of such qualities would affect them as physicians.
A substantial number of the students wrestled with issues of dying, end of life, and the limits of intervention. In their projects, they explored their own fears of death, their helplessness in the face of the dying process, and at times, their discomfort with the medical heroics engaged in to extend life, however briefly. They often searched for meaning in how patients died, whether through personal spiritual beliefs, through a desire to preserve the patient's dignity and humanity, or in the loving memories of family and friends.
In summary, through their creative projects, these students struggled with what, in our opinion, are perennial core issues in the socialization of physicians: the transformation from “ordinary person” to doctor, the nature of a meaningful relationship between the student–physician and the patient, the balance of personal life and career, ethical dilemmas, and difficult topics such as death and dying.
On a process level, we identified six categories by asking, when the students used creative projects to explore the socialization process, (1) What format did they use? (2) Whose point of view did they adopt? (3) What tone did they use? (4) To what extent did they empathize with patients? 5) To what extent did they demonstrate sympathetic understanding for themselves? and (6) Did they resolve the issues that concerned them?
What format did students use?
Format refers to the artistic form students chose to express themselves in their projects. The largest numbers of students selected either poetry or personal essays, followed by some form of artwork. Notably, a significant number of students (over a fourth in 2001–02) chose unique forms of self-expression outside these three major categories, such as song, dance, taste tests, imaginary chart notes, letters, videos, and skits.
What point of view did students adopt?
Point of view indicates which perspective (i.e., one's own, the patient's, another's) the student selected, and indirectly sheds light on where the student was developmentally in the socialization process. It is reasonable to speculate that learners will use a creative project to explore their own points of view when they are still unclear what those points of view are. Learners who are more certain of their own values and beliefs might be tempted to examine the patient's point of view more often. In these projects, the students most frequently adopted the first-person point of view, possibly reflecting that third-year medical students are essentially self-focused and absorbed with their own performances and experiences. A significant number chose the third-person point of view, either to describe patients or to write critical-incident essays, in this manner attempting to retain a somewhat more detached perspective. A handful of students adopted an omniscient perspective, while a sizeable minority of students moved back and forth between the first person and the second or third person, in this way simultaneously representing both the student's and the patient's points of view. This dual style seemed to reflect these students' developing awareness that physicians must consider not only their own perspectives, but those of their patients as well. A small number of students adopted the patient's perspective exclusively, writing in the patient's voice in the first person.
What tone did students use?
The tone students adopt to produce creative work provides insights into how they choose to portray themselves. Perhaps in keeping with a favored medical school coping strategy, about a fifth of the students used either an overtly humorous tone or one shaded more darkly and ironically, masking negative emotions with a sardonic twist. A similar number used what we labeled a reflective tone, thoughtfully ruminating on an event and seeking understanding and meaning. A smaller number of projects had a tragic/sorrowful tone. The remainder was fairly evenly divided among tones that could be characterized as empathic/compassionate, positive/hopeful, objective/detached, guilty/helpless, and frustrated/angry. Overall, these projects suggested that the students drew on a broad range of tones to effectively explore issues of socialization, and did not restrict themselves to mimicking the scientific mode of expression.
To what extent did students empathize with patients?
In our analyses, we defined empathy as an understanding of and emotional connection with other, in this case usually the patient or, less frequently, a family member. Empathy is generally considered a key component of medical professionalism. The large majority of medical students in our study were empathic toward the patients whom they described in their projects. Indeed, they often used their projects to explore intense, sometimes painful, emotions about the experiences of their patients, emotions that otherwise might have had little outlet in the usual course of training.
To what extent did students demonstrate sympathetic understanding for themselves?
The students tended to express somewhat less understanding and sympathy for their own situations. Even taking into consideration the larger number of projects where sympathetic understanding for self was not relevant, these students were more likely to express empathy for patients than they were to show sympathy toward themselves.
Did students resolve the issues that concerned them?
Since the students had struggled with difficult aspects of clinical medicine, we wondered to what extent they had resolved their issues upon completing their projects. In other words, did the student appear to have learned a lesson, reached a conclusion, or resolved a dilemma? Some research suggests that, at least for expressive writing, progression from lack of resolution to resolution is associated with improved mental and physical health,13 and, therefore, may be an important criterion to examine.
On this point, the students were almost equally divided. About half the students used their creative projects to move from lack of resolution to resolution; for example, coming to a clear determination about the limits of medical intervention, or the right of the patient to be treated with dignity. But a similar number of students ended their projects still questioning and uncertain. When we compared the two most common methods of self-expression, poetry and personal essays, we discovered an inverse relationship: students who chose to write poetry were more likely to remain unresolved about their issues, while students who wrote personal essays were more likely to reach resolution. This might have been a function of the method itself—writing an essay might be more effective in helping students resolve their dilemmas. On the other hand, it could be that students who had already reached resolution were more likely to choose a sequential, narrative form to express their thoughts.
Interestingly, across all three years of our study, there was relatively little variation in the percentages of students in the eight individual coding categories or their subcategories. The students in 2001–02 used more artwork and showed more variety in their creative projects than did those in the previous two years. They also tended to favor a humorous approach more than did the students in the other years. The students in 2000–01 relied more on first-person and less on third-person narratives than did the students in 1999–2000 or 2001–02, and were more likely to express an overall negative emotion in their work. They were also somewhat less likely to reach resolution than were the students in the other two years. These differences may have resulted from variations in the students or in the curriculum (i.e., an emphasis on point of view writing in 2000–01, and the introduction of a student art exhibit program in 2001–02), from the interaction between characteristics of the students and of the curriculum, or from other sources not identified.
Overall, it appeared that, in the students' third year of medical training, becoming a physician was still very much a work in progress. They struggled to understand perennial issues that have always concerned physicians, but were as likely to remain conflicted as they were to reach resolution. They tended to view their experiences in medicine from their personal perspectives, but demonstrated great empathy and fellow feeling for their patients as well. They seemed to have more antagonistic or problematic relationships with residents and attending physicians. Stylistically speaking, they experimented with a range of formats and tones in an effort to adequately capture their experiences with patients.
Typically, these students were reluctant to do the creative projects, and even more reluctant to share them in a group of their peers. Some students commented initially that such an activity was “busywork,” or something they could do “on their own time.” What struck the faculty participant–observers most forcibly was the contrast between the students' initial resistance to the task and the subsequent quality of the projects, as well as the intense emotional responses often evoked during the group sharing. The range of creative expression itself was noteworthy, especially because medical students are sometimes stereotyped as having an excessively narrow scientific focus with little appreciation for or understanding of the humanities. In our experience, given encouragement to do so, students freely experimented with various creative forms, including the literary, visual, and performing arts, and demonstrated impressive breadth of self-expression.
Despite their initial qualms, almost all students appeared to take the assignment seriously, and put effort and thought into their projects. The students were respectful of and clearly moved by each other's work. In general, the students used this opportunity to reflect on the process of becoming a physician in a way very different from that commonly adopted in medical school training. In the wrap-up discussions, students commented that creating the projects had often produced helpful insights about their clinical experiences; sharing the projects helped them realize that they were not alone in feeling anxiety, confusion, and even despair. As one student commented, “We talk about these things on the wards, but we don't talk about them like we're doing now. We're showing sides of ourselves that we've kept hidden til now.” Of note, a quantitative, eight-item questionnaire for assessing the students' perceptions of the humanities' usefulness in professional development was administered before and after completion of the creative project to a subset of students (n = 46) in 1999–2000. Data from this questionnaire indicated a significant and positive effect (pre-project completion mean = 3.8 (.61); post-project completion mean = 4.3 (.52); t = −3.95; p < .000).
Faculty facilitators were impressed time and again by the painfully honest, brave, and self-revelatory dimensions of the creative projects, the emotions revealed and the tears shed. We suspect that it was the active, imaginative, and creative nature of this experience that exerted such a profound influence on students. To verify this interpretation, as well as to determine the long-range influence if any of such a curricular intervention, we need more refined research.
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