I confess that the most important year of my medical education was the year I spent away from formal training to begin a commitment to writing creatively. Now, 20 years into a career as an emergency physician as well as a writer and medical humanities educator, I rely on my story-making skills more often than any other clinical skill in my practice.
Sadly, patients’ lives have too much in common with the fictional characters I struggle to write. People with stormy back stories. People riddled with bad luck or whose expertise at self-destruction exceed my expertise to help them. And their troubles have layers: medical woes tangled up with mental illness; substance abuse and a hornet’s nest of social issues; as well as bruised hope and a mistrust of a health care system that treats them like poker chips.
Which is to say, my patients barely resemble the neatly constructed cases common in medical education, controlled problems where carefully chosen bits of information and details, if pieced together properly, will reveal “the” answer, usually a biomedical answer.
A more honest and valuable exercise for medical students would require that they take a list of disconnected details and craft possible questions. Navigating the choppy waters of ambiguity and uncertainty can be frustrating because medical knowledge is not much help when you have not figured out the questions. But that does not stop the reductionist muscles shaped in medical school from cramping details into a diagnosis.
In How Doctors Think, Jerome Groopman1 questions how doctors think when symptoms are vague, confusing, or the results inexact, or when faced with problems with little or no precedent.
I took story-crafting and writing skills to the bedside, the details of which have been written elsewhere.2 By reconceptualizing medical practice as a fundamentally creative act, the instability, uncertainty, and constraints that pervade clinical work became, to a degree, more familiar, comfortable, and constructive. In this article, I suggest we take this argument further and expand the traditional role of doctor as a science-using, evidence-based practitioner to include that of doctor as a “maker” (creator) and artist. Such a reimagining requires a shift in how we view medical knowledge and patients’ stories, as well as a new appreciation for “not-knowing” as a generative, creative space in medicine.
Creativity as Clinical Skill
Historically, doctors have always been “makers,” even if clinical practice has not been framed in this way. For example, we make prognoses, develop treatment plans, and build trust. And we use materials—knowledge, story, flesh, touch, blood, urine, advanced imaging, emotions, judgment. These fragments are pieced together to construct decisions at the bedside, a process that is defined in part by the materials selected, their weight of importance, and the situational and personal forces at work. To an artist, applying pressure and imagination to materials can make them meaningful.3
That said, I am treading cautiously. Creativity has been called a “weasel word” as it pertains to medical education4—a term that’s slippery to define and inflected with different personal meanings and assumptions. For this discussion, I will defer competing theories and definitions of creativity and concentrate on practical functions of creative thinking. Creativity encourages the search for new connections and relationships between disparate ideas, demands curiosity and the ability to ask different types of questions, emphasizes process on the road to product, and frames constraints as opportunities. Most important, it demands stepping outside our familiar comfort zones.5
I do not want to equate creativity and arts-based activities with humanistic goals; instead, I propose creative skills as valuable clinical skills. Uncertainty and ambiguity make up the ambient reality of medicine.6 Physicians tend to minimize or ignore this anxiety-ridden dimension of clinical practice. If creative thinking offers comfort, it comes from comfort with process, an intimacy with our mental map as we work through problems. The furniture maker Peter Korn7 writes that our worldview informs what we notice and how it is interpreted, and that a measure of a maker’s success is the transparency of his creation. The product represents an extension of our minds and our intentions outside ourselves. It’s not lost on me that makers often refer to their work with inanimate objects with more sensitivity and empathy than physicians describe decisions and interactions with patients. If the notion of “doctor as maker” serves to fortify the traditional image of medicine as an art, it does so on humanistic and instrumental grounds.
Knowledge as Material
The maker movement has been defined as an “umbrella term for independent inventors, designers, and tinkerers….”8 It empowers individuals to move from “passive users to active creators.”9 Makers become more sensitive to the way objects, processes, and systems are designed by ideating, prototyping, and iterating—the foundational principles of design thinking.
The specific details of design thinking are less important for this discussion than the sensitivity it brings to certain elements in decision making. This is important when considering that the misdiagnosis rate of approximately 15% is thought to result from cognitive traps and not lapses of knowledge,10 and 80% of the misdiagnoses causing serious harm stem from a “cascade” of cognitive errors, narrow frames, and ignoring conflicting information.11
Medical knowledge is never-ending and constantly shifting. Reports state that standard medical guidelines may change by 20% each year.12 There has always been and will always be too much to know; “medical knowledge is theoretically and practically limitless.”13 Medical education lavishes less attention on how knowledge operates as a material, a fragment used in the construction of decisions in the service of patient care. Information is not passively received from the world; we actively seek out data in the context of our goals. We privilege and choose certain information to work with and choose not to work with other information. We make decisions even before we are aware that we are making decisions.
Even decisions grounded on the best evidence can be charmed by the mind’s attraction to story over statistics. The confidence people have in their beliefs is not always a judgment on the quality of the evidence but a judgment of the coherence of the story their minds have managed to construct.14
When faced with uncertainty, the impulse for physicians is often to reach for more data; meanwhile, authors have advanced other approaches, including being more honest with our patients about the boundaries of knowledge,15 and calls to normalize uncertainty when it comes to diagnosis, prognosis, and even communication.16 To skillfully reset patient expectations, physicians must cultivate greater personal comfort with uncertainty. Paradoxically, this requires comfort in not-knowing.
Benefits of “Not-Knowing”
The more systemic uncertainty problem has origins, I believe, in the overwhelming emphasis on certainty and finding “the answer” that is prevalent in medical education. In medical school, I was valued and judged, and my career determined, in part by my ability to successfully learn facts and answer correctly questions designed to test those facts. To “not know” is to be wrong. A habit of “not-knowing” leads to misgivings about aptitude or work ethic. To a doctor-in-training, “not-knowing” can feel like drowning in a river of shame.
But for artists, there is value in not-knowing as a generative space.
In his essay “Not-Knowing,” the postmodernist writer Donald Barthelme asserts that writing is a “process of dealing with not-knowing, a forcing of what and how.”17 Not-knowing is crucial to art. It is a problem of a necessary kind. Staring down a white page can be terrifying because the writer recognizes that nothing is staring back. When signposts come into view, they belong to a developing map of understanding that is defined by the types of problems the artist chooses to embrace.
Barthelme does not problematize problems. In fact, he states that the “more serious the artist, the more problems he takes into account.”17 By favoring easy problems or more comfortable language, we evade our responsibility to question, probe, and challenge the messiness that others might otherwise encounter and accept without deeper examination. The work of an artist is interpreted, in part, by the questions he or she is asking.
The essay explores one writer’s attempts to wrestle with the function of art, and how to go about “rendering all this messiness.”17
Writing is a process, Barthelme argues; he then embarks on an exploration of the purpose and aims of that process. In medicine, the language of process commonly surfaces when discussing organizational systems issues. How can we get emergency department patients seen and evaluated more efficiently? Can we reduce catheter-related infections in hospitalized inpatients? Less frequently do we focus our attention on the process of everyday decisions, the many fragments of information that we collect and organize to make a diagnosis and treatment plan.
The emphasis on outcomes in medicine and the reductionist obsession that insists on a correct answer are appropriate, even necessary, when lives are at stake.
But raise the beams too brightly on outcomes and we risk blinding ourselves to the contextual messiness on which decisions are built. For example, framing problems in relation to the degree to which they resemble known solutions can influence the types of problems we take under consideration. Engaging with materials through the lens of possible solutions can impact how we listen to patient stories and what we regard as valid information. By starting with possible endings, we risk favoring “materials” that support our conclusions, ignoring those details or choices that might have captured our attention if we were thinking and listening more openly.
Doctors as Story Experts
I am an emergency physician, which means I am first and foremost a professional story listener. That requires a sensitivity to story structure, a working understanding of the anatomy that drives all good stories—character, desire, and conflict—and an appreciation for the tender and fragile nature of the stories patients share with us.2,18
When we ask doctors-in-training, “What’s the patient’s story?” we risk giving the false impression that stories exist as precious and complete objects awaiting unearthing. Most of my patients have not been to medical school, and I cannot expect them to feed me the exact information I am looking for. Their stories are narratives under construction, and listening as a writer keeps me tuned with a different ear.
The writer Eudora Welty19 described writing stories as moving into open spaces, and a very different narrative experience than reading and analyzing a story, a process of narrowing backward, akin to the writing process in reverse. When constructing stories, the writer is present at the beginning, holds each piece in her hands, works with characters, motivation, scenes, plot points, voice, etc. She is aware of the obstacles at play, the choices made in response to those obstacles, and the pressure as the stakes build.
By writing stories, I understand how hard it can be to tell stories just so, and I understand the fear and vulnerability that come with sharing profound experiences with strangers. Writing forces you into hand-to-hand combat with the sentence. You relate differently to language, not only to what has been said and how it was phrased, but you trip on the gaps, the critical silences, or evasions that might contain the very thing you need to hear but which is unsayable. Anna Deavere Smith20 wrote, “We can learn a lot about a person in the very moment that language fails them.”
A common frustration in emergency medicine is working with patient stories that are obliquely or incompletely told. What feels like a nonlinear and plotless sequence of details—especially when I am tired or rushed—can produce confusion and harbor the potential for cognitive treachery because our brain craves story. That power is responsible for story’s seductive beauty and its dangers.14
Our brain longs for narrative coherence. Hardwired to take cognitive shortcuts, it will weave random, incomplete data into a story. This surreptitious operation neglects ambiguity and minimizes doubt.21 It cares little for information it does not have, making us susceptible to creating a recognizable story, or shaping a more convenient story that is different from the one the patient is trying to tell.
We must be sensitive to the subtle ways stories operate because physicians make decisions based on these stories. Often, suboptimal outcomes are not the product of bad physicians, but rather very smart, sometimes brilliant, minds well versed in the medical literature who simply got the story wrong. Physicians are unduly confident when it comes to diagnosis, a dissonance that persists regardless of the degree of difficulty of the case.22
Disorganized stories are more than an academic concern in clinical practice because they can lead to disorganized responses. The best medicine will not work on the wrong story. So we must remain open to problems, to those elements that do not make sense, and it begins on the platform of story. At its fundamental core, the doctor–patient relationship involves the sharing of stories.23 Story is not a vehicle used in the service of reaching a diagnosis. Story should be the destination. Sometimes the best way to care for patients is to care for the stories they are sharing.
Doctors as Makers
The maker movement evolved with the democratization of knowledge that resulted from the maturation of social networks through the Internet and social media platforms. Expertise in a particular arena was less important because you could tap into the collective knowledge of the community. If you did not know how to solve a particular problem you knew how and where to find the answers. Having resources readily available empowered not-knowing and encouraged makers to ask questions and pursue solutions that fell outside of their comfort zones.24
Not-knowing is neither a lazy shrug nor permission to lower the intellectual bar, but a clarion call for a different type of rigor in medicine. It demands that novice physicians first master a necessary bank of knowledge and demonstrate requisite procedural skills. Only by cultivating a bedrock of knowledge can we begin to recognize what we do not know. Not-knowing is an openness of mind for considering complex or ambiguous cases. The bottomless wells of information readily accessible through our portable devices present opportunities for medical educators, from purveyors of facts to guides who help students interpret and make meaning of those facts when applied to the care of patients.
I am reminded how design thinking is similar to the scientific method: developing ideas, forming a hypothesis, testing and iterating based on the results, reaching a conclusion, and then communicating the process. Whether it is making physical objects, writing code, or creating stories, a reflexivity is built into the endeavor. The mode of inquiry is built into what you do. The problems you chose to dive into speak to the type of artist you are.
Physicians have a tendency to dismiss symptoms that do not point to biomedical causes.25 When this happens, physicians are not building understanding or listening, but selectively retrofitting elements to support preconceived conclusions. They are listening with an ear toward a specific narrative line and disregarding critical details that should capture their attention. The opportunity to come into close proximity with our thinking process and to train our minds to work more openly is a powerful function of the arts and creativity in medical education. Academic medical centers have been challenged to promote innovative practices, including divergent, out-of-the-box thinking.26 This requires a reconceptualization of the traditional health care team as well as transformation of the traditional educational model to include medical disciplines, humanities scholars, artists, and designers.
At Alpert Medical School we have been working to develop programs that provide students the opportunity to work with arts-based experiences.27 This has included collaborations with the Rhode Island School of Design (RISD)28 and the RISD Museum educators,29 the Brown University/Trinity Rep MFA program, Artists and Scientists as Partners, and various university and community partners. Though the objectives vary, they all share a component of creating spaces where students can play with uncertainty and not-knowing, develop comfort with novel experiences, think openly and make connections between disparate ideas, and discover their own vulnerabilities. In spaces ranging from lecture halls to horse stables, design studios to museums, we aim to bring students into new relationships with their thinking process, including recognizing the value of artistic habits and mind-sets.
Medical schools have collaborated with museums to foster “visual literacy,” that is, building observational skills, diagnostic acumen, and pattern recognition, along with nurturing reflection and empathy.30,31 A growing number of medical schools are using art museums and nonrepresentational art to cultivate creative and critical thinking skills.32–34
At the University of Michigan Medical School, Arno Kumagai35 developed the groundbreaking Family Centered Experience, a powerful longitudinal experience based on stories patient–volunteers tell of living with chronic, and sometimes terminal, illness. Students create visual or musical “expressions of the affective, experiential, cognitive, and existential lessons” they learned through these relationships with patient–volunteers.35 Students at the Cleveland Clinic Lerner College of Medicine participate in creative projects as a form of civic engagement and identity development.36,37 The College Colloquium program at Vanderbilt University School of Medicine has innovated traditional medical humanities into a program that centers on metacognition, critical thinking, cognitive flexibility, and learning agility.38
I believe medical education should be
committed to fostering creative and critical thinkers who innovate with ease, who are not rattled by uncertainty, who move agilely from one form of output to another, and who can communicate in multiple ways with acuity and clarity.3
Who would argue with such aims? Except this statement is one of the curricular objectives from RISD, an internationally famous art school. Many programs highlight the immensity and range of creative talents of medical students today. Creative skills are not habits for humanizing future physicians but another set of tools—low-technology tools—for health care providers to use to care for patients with unimaginably complex problems. By taking students out of their comfort zones and encouraging them to think critically and creatively about medical practice, maybe we will provide a generative space for them to understand their place in it. By allowing them to discover ways to work through not-knowing, maybe the next generation of physicians will be more sensitive to the materials they are holding between their anxious fingers. Maybe they will ask different types of questions, engage in conversations, seek compassionate solutions—not because they are striving to be more empathic, but rather, because they are trying to be more creative.
Acknowledgments: The author wishes to thank Dr. Brian Zink and Dr. Dina Himmelfarb for reviewing earlier versions of this manuscript. He would also like to thank Professor Ian Gonsher and colleagues in the Creative Scholars Project at Brown University, Dr. Allan Tunkel, Dr. Kevin Liou, Hollis Mickey, MA, Dr. Fred Schiffman, and so many students and faculty at Alpert Medical School, Brown University, and Rhode Island School of Design.
1. Groopman JE. How Doctors Think. 2007.Boston, Mass: Houghton Mifflin.
2. Baruch JM. Creative writing as a medical instrument. J Med Humanit. 2013;34:459469.
3. Hermano MAL, Somerson R. The Art of Critical Making: Rhode Island School of Design on Creative Practice. 2013.Hoboken, NJ: John Wiley Sons.
4. Bleakley A. Medical Humanities and Medical Education: How the Medical Humanities Can Shape Better Doctors. Abingdon, Oxon, UK: Routledge; 2015.
5. Marshall J. Connecting art, learning, and creativity: A case for curriculum integration. Stud Art Educ. 2005;46(3):227241.
6. Luther VP, Crandall SJ. Commentary: Ambiguity and uncertainty: Neglected elements of medical education curricula? Acad Med. 2011;86:799800.
7. Korn P. Why We Make Things and Why It Matters: The Education of a Craftsman. 2013.Boston, Mass: David R. Godine, Publisher.
8. Voight J. Which big brands are courting the maker movement, and why. Adweek. March 17, 2014. http://www.adweek.com/news/advertising-branding/which-big-brands-are-courting-maker-movement-and-why-156315
. Accessed June 6, 2015.
9. Bajarin T. Why the maker movement is important to America’s future. Time. May 19, 2014. http://time.com/104210/maker-faire-maker-movement/
. Accessed June 6, 2015.
10. Elstein AS, Schwartz A. Higgs J, Jones M, Loftus S, Christensen N. Clinical reasoning in medicine. In: Clinical Reasoning in the Health Professions. 1995.Woburn, Mass: Butterworth-Heinemann.
11. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med. 2006;145:488496.
12. Alper BS. How much does practice-guiding medical knowledge change in one year? Presented at: Medicine 2.0: World Congress on Social Media, Mobile Apps, Internet/Web 2.0; 2012; September 16, 2012, Boston, MA.
13. Christakis NA. The similarity and frequency of proposals to reform US medical education. Constant concerns. JAMA. 1995;274:706711.
14. Gottschall J. The Storytelling Animal: How Stories Make Us Human. 2012.Boston, MA: Houghton Mifflin Harcourt.
15. Smith AK, White DB, Arnold RM. Uncertainty—the other side of prognosis. N Engl J Med. 2013;368:24482450.
16. Salmon P, Young B. Creativity in clinical communication: From communication skills to skilled communication. Med Educ. 2011;45:217226.
17. Barthelme D, Herzinger KA. Not-knowing: The Essays and Interviews of Donald Barthelme. 1997.New York, NY: Random House.
18. DasGupta S. Narrative humility. Lancet. 2008;371:980981.
19. Welty E. The Eye of the Story: Selected Essays and Reviews. 1978.New York, NY: Random House.
20. Smith AD. Talk to Me: Listening Between the Lines. 2000.New York, NY: Random House.
21. Kahneman D. Thinking, Fast and Slow. 2011.New York, NY: Farrar, Straus and Giroux.
22. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 suppl):S2S23.
23. Charon R, Hermann N, Devlin MJ. Close reading and creative writing in clinical education: Teaching attention, representation, and affiliation. Acad Med. 2016;91:345350.
24. Gonsher I. Associate director, Creative Mind Initiative, November 6, 2015.Personal communication with J.M. Baruch, Brown University.
25. Seaburn DB, Morse D, McDaniel SH, Beckman H, Silberman J, Epstein R. Physician responses to ambiguous patient symptoms. J Gen Intern Med. 2005;20:525530.
26. Ness RB. Commentary: Teaching creativity and innovative thinking in medicine and the health sciences. Acad Med. 2011;86:12011203.
27. Liou KT, Jamorabo DS, Dollase RH, Dumenco L, Schiffman FJ, Baruch JM. Playing in the “gutter”: Cultivating creativity in medical education and practice. Acad Med. 2016;91:322327.
28. Auerbach K, Baruch JM. Beyond comfort zones: An experiment in medical and art education. J Learn Arts. 2012;8(1). http://escholarship.org/uc/item/5zs3s3wg
. Accessed June 6, 2015.
29. Liou K, Mickey H. Thinking about thinking: Pre-medical students in the museum. RISD Museum Web site. 2014. http://risdmuseum.org/manual/58_thinking_about_thinking_pre_medical_students_in_the_museum
. Accessed June 6, 2016.
30. Bardes CL, Gillers D, Herman AE. Learning to look: Developing clinical observational skills at an art museum. Med Educ. 2001;35:11571161.
31. Miller A, Grohe M, Khoshbin S, Katz JT. From the galleries to the clinic: Applying art museum lessons to patient care. J Med Humanit. 2013;34:433438.
32. Karkabi K, Wald HS, Cohen Castel O. The use of abstract paintings and narratives to foster reflective capacity in medical educators: A multinational faculty development workshop. Med Humanit. 2014;40:4448.
33. Schaff PB, Isken S, Tager RM. From contemporary art to core clinical skills: Observation, interpretation, and meaning-making in a complex environment. Acad Med. 2011;86:12721276.
34. Jacques A, Trinkley R, Stone L, Tang R, Hudson WA, Khandelwal S. Art of analysis: A cooperative program between a museum and medicine. J Learn Arts. 2012;8(1). http://escholarship.org/uc/item/36n2t2w9
. Accessed June 6, 2015.
35. Kumagai AK. Perspective: Acts of interpretation: A philosophical approach to using creative arts in medical education. Acad Med. 2012;87:11381144.
36. Kohn M, Kodish E. Reuniting through the medical humanities: Two educators, two programs. AMA J Ethics. 2015;17:491495.
37. Kohn M, Bernardo J, Huck D, Coble E. Multiple exposures—reflective writing in the first year of medical school. Virtual Mentor. 2011;13:471474.
38. Eichbaum QG. Thinking about thinking and emotion: The metacognitive approach to the medical humanities that integrates the humanities with the basic and clinical sciences. Perm J. 2014;18:6475.