Now in my final two years as a medical student, doing my clinical training at a large teaching hospital in Boston, I have left the books and classrooms behind and am seeing patients, working with my hands, thinking on my feet. The USMLE Step 1 exam was a gateway to this moment: Having proven ourselves on paper, my classmates and I have finally been allowed to don our business casual, our Danskos, our short white coats, and participate in the care of patients. Medicine has finally become a physical reality for us. I am referring both to seeing myself as a being actually capable of effecting change in the hospital and to understanding the reality of disease, manifested in the wrinkles, crepitus, hacking cough, and pain of my patients. The wards of the Brigham towers are a reification of Natasha Trethewey’s poem “Myth” from her collection Native Guard1:
… So I try taking,
not to let go. You’ll be dead again tomorrow.
The Erebus I keep you in—still, trying—
I make between my slumber and my waking.
It’s as if you slipped through some rift, a hollow.
I was asleep while you were dying.
Within their walls, patients almost-die, die, and sometimes live; we physicians and students have the privilege of intervening, in any way we can, when they are most vulnerable, most human.
Within the span of just a single academic year, I have learned more about people—their biggest failings and their most powerful triumphs—and more about what true love looks like, about just-perfect and dysfunctional relationships, about forgiveness and redemption, than I grasped in the 23 years that preceded it.
But my epiphanies are not unique; I share them with classmates, fellow medical students. We medical students represent a special demographic: We are insiders enough to understand the language of medicine, yet also possessors of all the innocence and idealism that characterize outsiders to the profession. Unfortunately, I’ve seen that these qualities are gradually lost as we advance in the profession, such that interns are more pragmatic, residents a mixture of pragmatism and cynicism, and attendings the least sentimental of all. This is not always synonymous with meanspiritedness; quite frequently, good intentions tempered with years of experience yield excellent clinicians. But I think my classmates would universally agree that, paradoxically, the further some people go in training, the more hard-hearted they become,2 and the less they are able to understand the patient’s perspective in a clinical encounter.
A brilliant classmate of mine, Shekinah Elmore,3 wrote, in a JAMA essay titled “The good doctor,” about her experience receiving a diagnosis of bilateral breast cancer at age 27, during the summer before her first year of medical school. Having survived rhabdomyosarcoma twice before in her youth, she was familiar with the terrain of cancer, yet the new diagnosis still left her dazed. Shekinah, confronted with the possibility of never realizing her dream of becoming a physician, went to an empty examination room and sat alone, silently crying. She noted that the oncologist gingerly approached her assistant and quietly asked, “Why is she crying?” In her commentary, Shekinah writes that the “mechanisms of heartbreak and loss are not on the docket of our formal education.” She wonders at the oncologist’s loss of imagination that impaired her from connecting with her grieving patient, and she discusses the hidden curriculum that is inevitably responsible for eroding the empathy of physicians in training.
I am part of a group of physicians and students from various hospitals around Boston who have come together because of our shared interests in not simply the humanities—including, among others, art, literature, and music—but especially in how these disciplines inform the art of medicine. Because we have all been positively impacted by our own extracurricular involvements in the arts, we see value in incorporating elements of them into the standard medical curriculum. To this end, we are canvassing the medical community for perspectives and input, and we are organizing town halls and events that showcase how the humanities and medicine edify one another. Our primary thesis is buttressed by data from countless studies that show that medical students and residents benefit in large ways from such interdisciplinary offerings. Research shows, sometimes through scoring systems and more often through qualitative assessments, that students grow in emotional maturity and professionalism, that they report being better able to understand the complexity of clinical scenarios, and that they feel like they are better observers and listeners as a result of what they have experienced in their humanities courses.4–6
Some will complain that the aforementioned studies lack scientific rigor and that the medical curriculum is too saturated anyway. My defense is that these claims are true, yet incomplete. Conclusions from social science data, such as those asserted in these studies, are hard to claim, hard to back up, and every advocate of the humanities knows this. Moreover, given the emergence of ethics and global health and other such courses that the medical curriculum has grown to encompass, it is true that the hard sciences often take a hit. I do not disagree with those who argue that art and literature alone do not an empathic clinician make; nor, conversely, do I believe that not experiencing humanities courses results necessarily in inhumanity. Our colleagues who sought MD-PhDs in immunology and went straight through to residency and practice are not necessarily hard and cold doctors. But what I and countless eminent physicians and medical educators are trying to posit is that the humanities can serve as a tool, an instrument with which instructors can reconnect students to fundamental human truths.
As an English major in college, I learned quickly that no matter how thoroughly I thought I had read a work of fiction, I never truly understood the mechanisms that made the story work until I had dissected it through a term paper. This lesson has proven true in medical school as well. As a first- and second-year Harvard Medical School student, I took electives such as “Training the Eye” (a class using the visual arts), “Religion and Death,” and “Spirituality and Healing in Medicine.” I have been a part of such rich discussions and such an interweaving of perspectives that I have walked away feeling enriched and enlightened. By looking at a Jackson Pollock painting with my classmates in a museum—and examining it through discussion facilitated by art educators (in an example of truly interdisciplinary teaching)—I have learned to see quietly. I have realized with a start how many observations and nuances in a painting (and to carry that metaphor forward, a clinical case or patient history someday) I could miss that my classmates note, and vice versa. Moreover, in the Training the Eye course, our professor, Dr. Joel Katz, has used images as a launching point for discussions that are critically needed but tenuous in content. For instance, while gathered around an ancient Greek sarcophagus at the Museum of Fine Arts in Boston, Dr. Katz led a group of internal medicine residents in discussions about their experiences with death, and how they handle it when their patients die. Dr. Katz says that these discussions are enormously difficult to have when they are personal, but that the detachment and academic objectivity induced by the purported narrative about the art piece allow a certain freedom in which his trainees can feel secure.7
Art, music, and literature are not the only tools in the humanities tool kit, but they are very effective ones. I believe that the arts, more than any other human creation, truly reflect human life and the human condition, as they are vested with the real circumstances and emotional narratives of the artists who endow them with meaning. There are more writers and artists among physicians than in possibly any other professional field, because many practitioners realize that by synthesizing their experiences in the written word or canvas, they are richer for it.8
But, most important, patients write.9 Patients write, draw, and play all the time—The wealth of new books about cancer, HIV, death, losing a loved one, coping, and the transforming effects of illness and grief that flood bookshelves every month are a testament to that. We physicians, as the health care providers for these patients, have an obligation to access this creative output. Having our finger on the pulse of what our patients are going through not only will, undoubtedly, make us more caring and more aware practitioners but also, importantly, will help us never to lose sight of their perspective—a grand idea in theory but, as even just my third year of medical school taught me and my classmates, much more difficult to enact in practice.
To close, I’d like to end with one of the greatest writers from the patients’ perspective that I’ve ever known—Joan Didion. In December 2003, the only child of Didion and her husband John Gregory Dunne fell into septic shock and lapsed into a coma at the Beth Israel North in New York City.10 On the evening of December 30, Didion and Dunne returned from the hospital to their apartment, where, in the midst of conversation, Dunne slumped in his chair, dead from a heart attack. “You can sit down to supper, and find that life has changed in an instant, the ordinary instant,” Didion11 wrote so movingly a year later in her memoir of the time, The Year of Magical Thinking.
All physicians need to make themselves familiar with Didion’s language, which powerfully expresses the patient view and so many difficult, nearly impossible-to-express emotions. I can divide my interactions with my patients into those that took place before and then after the weekend I spent devouring this book. It movingly reminded me to think of my patients and their experiences with illness as unlimited by the walls of the hospital—Patients take home with them their diagnoses, their transformations, their treatment regimens, their losses. Here is an excerpt:
In the version of grief we imagine, the model will be “healing.” A certain forward movement will prevail. The worst days will be the earliest days. We imagine that the moment to most severely test us will be the funeral, after which this hypothetical healing will take place. When we anticipate the funeral we wonder about failing to “get through it,”[…] We anticipate needing to steel ourselves for the moment: will I be able to greet people, will I be able to leave the scene, will I be able even to get dressed that day? We have no way of knowing that this will not be the issue. We have no way of knowing that the funeral itself will be anodyne, a kind of narcotic regression in which we are wrapped in the care of others and the gravity and meaning of the occasion. Nor can we know ahead of the fact (and here lies the heart of the difference between grief as we imagine it and grief as it is) the unending absence that follows, the void, the very opposite of meaning, the relentless succession of moments during which we will confront the experience of meaninglessness itself.
Acknowledgments: The author would like to thank Dr. Joel Katz and Dr. Susan Pories for their leadership in the arts and medical education, and for being invaluable mentors.
Other disclosures: None.
Ethical approval: Not applicable.