Editor’s Note: This commentary commemorates the 10th anniversary of Academic Medicine’s Teaching and Learning Moments feature.
We have been graced with 10 years of Teaching and Learning Moments (TLM), a means by which Academic Medicine readers can gather in a clearing of sorts to reflect on our work in the care of the sick. Each TLM column is a double reflection, not only giving voice to a writer describing a moment where meanings crystallize out of a day lived around illness but also giving occasion for a wider reflection among all us readers. In his meditation on the life of a rural general practitioner, art critic and novelist John Berger1 writes of similar situations among colleagues: “It is as though the speakers bend over the subject to examine it in precise detail, until, bending over it, their heads touch.” Our heads touch as we consider these moments that open up in the day to reveal something to us about the lives we lead.
My essay, then, not to get too mathematically prissy about it, is a triple reflection as I gaze over a decade of our private reflections that become, through the agency of the journal, shared ones. That the columns are written by students, house officers, social workers, and attending physicians, among others, makes all the more catholic our capacity to teach and to learn from one another.
Writing So as to Perceive
The TLM feature enacts the kind of mindful practice many clinicians currently endorse.2 The short essays depict rich, multidimensional, complex situations through which the writer lived, told usually by a first-person narrator directly engaged in the care of the protagonist of the text, typically a patient or student. By virtue not only of the experience itself but the effort to write carefully, critically, creatively, and expectantly about the self in transit through the experience, the writer grows in insight or knowledge or recognition of self and other.3
And so the TLM feature models not only a premium on reflective practice but endorses an increasingly evident realization that writing is a critical and generative ingredient in the reflective care of the sick.4 The fact that TLM authors’ memories are written and not just remembered or told orally is pivotal, I think, in letting both the teller and the receivers derive full benefit from the event being represented. Philosopher Martha Nussbaum5 realized that there were things she could not “think” about within the writing style of the philosopher and, thus, had to seek asylum in literary writing:
The telling, if the story is a good one, is not accidentally connected with the content of the told. . . . No stylistic choice can be presumed to be neutral—not even the choice to write in a flat or neutral style.
We medical educators engaged in reflective writing have come to know a bit about why writing enables this recognition. At its most basic level, writing of an experience enables the writer to perceive the experience to begin with—in effect, to undergo that experience. Poet Adrienne Rich6 says about writing poetry that which is probably true of any creative writing: “Poems are like dreams: in them you put what you don’t know you know.” Many novelists and memoirists describe the same phenomenon—that writing about an experience becomes the avenue toward knowing about it. When psychoanalyst Hans Loewald7 described writing as a sensorimotor act that transforms the immaterial into the material so that the writer can communicate it to self and then to other, he upheld these discoveries of creative artists to apply to all of us who write.
The following reflection of mine arose in a setting where we use reading and writing pedagogically to accelerate and deepen the clinical lessons being learned in an intensive seminar at Columbia University Medical Center. As they read and write their way through the demanding semester, my students are becoming the kinds of readers and writers that Henry James8 describes in his essay “Criticism”:
To lend himself, to project himself and steep himself, to feel and feel till he understands and to understand so well that he can say, to have perception at the pitch of passion and expression as embracing as the air, to be infinitely curious and incorrigibly patient….
This is the kind of seeing that reflection encourages, the kind of knowing that writing supports, the kind of recognition that patients crave.
“To Feel and Feel Till He Understands”
Nineteen people—16 students, 2 faculty members, and an amanuensis—sit around a conference table for a seminar session. A senior member of the nursing school faculty describes why she selected the readings assigned for this session, a personal essay by a poet about the end of life and a short fiction about a young man dying of leukemia. Although these texts are both about dying, she chose them to help the group think about how patients acculturate to illness. Right away, the students jump into the conversation, noticing how marginalized the elderly man is by his frailty, how horribly isolated he becomes. One student says he couldn’t tolerate the young protagonist of the short story for his relentless violence, even though the character was close to death. Another wonders whether our cultural or personal tendencies get amplified when death nears. A physician faculty member asks whether we are all aware of the fact that our time is limited. One student says she never thinks of death. There is a pause in the rapid-fire conversation when a student, who has spoken in the past weeks of having had a serious illness, says, “I think about death all the time.”
This conversation occurred in a Macy Foundation–funded interprofessional education seminar called “Cultures of Health, Illness, and Health Care” that includes students and faculty from the four health sciences schools at Columbia—dental, medical, nursing, and public health. Every week of the spring semester, we meet for 90 minutes to discuss assigned readings, to go over our own writing on the readings, and to work in small groups on particular questions. In this session, we discussed poet Donald Hall’s essay “Out the Window”9 and Junot Diaz’s short story “The Pura Principle,”10 both published recently in the New Yorker. Students wrote ahead of class about ways in which these two men—an elderly New Englander dying of old age and a 20-something Dominican man from New Jersey dying of leukemia—faced death from within their own cultures.
What a remarkable experience it is for me to listen to these students opening up the substance of health care for one another. This short description of one stretch of conversation cannot convey how rich and risky are the discussions, how exposing the students and faculty have become toward questions deep to the self. The fact that these students from different health care professions together are bending their heads over these subjects makes all the more meaningful the teaching and learning moments we undergo, for not only do they learn of the plights of the sick but also come to recognize that they need one another to learn the most from their experiences. The weekly postings, written in response to the readings, bring forth increasingly consequential revelations about our backgrounds and lived experience that influence how we experience and care for patients. Early on, the students gently insisted that the faculty post their responses to our writing prompts ahead of class just like the students do, and so we are equal in our level of risk as we sit around the table.
The small-group work, done in tetrads of one student from each school, was recently devoted to a poem, “The Sick Wife,” written by Donald Hall’s wife Jane Kenyon,11 who died of leukemia not long after she wrote that poem. After a complex discussion of the poem, the students were asked to write the poem’s next stanza. After doing so, they read to one another what they wrote in their tetrads, and then some of them offered to read to the whole seminar. Some wrote from the perspective of the sick woman herself, about watching life shorten and escape her, whereas others wrote from the point of view of the “offstage” husband picking up groceries, the healthier one of the two preparing for a life alone.
Trusting one another, we say things about our patients and about ourselves that matter. We utter messy or half-formed thoughts knowing that, with the help of the group, the thoughts will become clear. Professional hierarchy has been trumped by singular contact. Oh, do I feel hopeful for our future as I witness this mutual opening of the self for the sake of our patients. Isn’t this what we are after in caring for one another and caring for the sick?
Making Singular Contact
The reflections never end. All of us who share in the care of the sick see more clearly every day ways to intensify the help we can give to our patients and to one another. Here, in the short representation I offer about an interprofessional seminar at Columbia, I combine the benefits of reflective reading and writing with the dividends of doing such teaching and learning on a health care team. We have widened the interpretive community by such teaching, displaying our conviction that better patient care will result when persons of diverse professional training contribute their insights and skills to that care. Reading together and writing together was the initiating force in bringing first the faculty members from all four of our schools together in a shared pedagogy and then in cohering students across the campus in a daring and, we are now demonstrating, successful effort to reach one another in our shared work in health care.
Over the first decade of the TLM feature of Academic Medicine, we readers have grown interiorly and intersubjectively, both in reaching toward the full power of examining our own lives in health care and in gathering in our clearings with all who take part in this peerless work. Let us, please, continue to reflect, to represent, to teach and learn through our growing sense of story and through our own accelerating grasp of the power of what these stories, told and heard, can reveal.
Acknowledgments: The author thanks the students and faculty in the Columbia–Macy Interprofessional Scholars Program, Columbia University Medical Center.
Funding/Support: Dr. Charon is supported by the Josiah Macy Jr. Foundation, Grant #B10-09.
Other disclosures: None.
Ethical approval: Not applicable.
1. Berger J, Mohr J A Fortunate Man. 1967 New York, NY Pantheon Books
2. Wear D, Zarconi J, Garden R, Jones T. Reflection in/and writing: Pedagogy and practice in medical education. Acad Med. 2012;87:603–609
3. Miller RE Writing at the End of the World. 2005 Pittsburgh, Pa University of Pittsburgh Press
4. Jurecic A Illness as Narrative. 2012 Pittsburgh, Pa University of Pittsburgh Press
5. Nussbaum M Love’s Knowledge: Essays on Philosophy and Literature. 1990 New York, NY Oxford University Press
6. Rich A On Lies, Secrets, and Silence. 1979 New York, NY W.W. Norton
7. Loewald H Sublimation: Inquiries Into Theoretical Psychoanalysis. 1988 New Haven, Conn Yale University Press
8. James HShapira M Selected Literary Criticism. 1981 Cambridge, UK Cambridge University Press
9. Hall D Out the window: The view in winter. January 23, 2012 New Yorker:40–43
10. Diaz J The pura principle. March 22, 2010 New Yorker:60–67
11. Kenyon J Otherwise: New and Selected Poems. 1996 Minneapolis, Minn Graywolf Press