AAMC Reporter: November 2008

Humanities 101: Poetry and Paintings Enter the Residency Curriculum

Internal medicine resident Xu Wang, M.D., Ph.D., was debating how to treat a critically ill woman with metastatic ovarian cancer. Should he perform an intubation—an invasive, painful procedure—to prolong her life, even if it would not cure her disease? Or were palliative measures more appropriate? The patient's family, Wang decided, should have the final say, and so he presented them with both options.

"The family's response was not surprising—they opted against intubation," Wang said. "And I avoided an invasive procedure and patient suffering."

Wang said he probably would not have thought so much about the patient's quality of life if not for Saint Barnabas Medical Center's humanities-focused internal medicine residency program in Livingston, N.J.

"When I would see a patient, I would first focus on their disease as something I needed to treat," he said. "Now, I see a person who may suffer from undergoing a painful procedure."

During training at inpatient facilities, residents read literary passages or journal articles and examine artwork that depicts patient care issues such as empathy, pain and suffering, and end-of-life care. Residents consumed by a heavy training schedule and who have increasingly smaller windows for direct patient contact can burn out and lose touch with the people they treat. By introducing humanities-based instruction last year, Saint Barnabas faculty hoped to reverse this trend and instill a strong sense of humanity and compassion into their young doctors, said Program Director Richard Panush, M.D.

"Humanities touch your soul. It makes you more sensitive to the human predicament," Panush said. "A proper and selected introduction to humanities can improve your capacity for caring, which makes you a better person and a better doctor."

Panush said the Saint Barnabas humanities program is unique in that it exposes residents to the arts almost literally at the patient's bedside. In between checking on patients during daily hospital rounds, residents examine a piece of art or literature and discuss their thoughts with a faculty member. Panush said that he particularly liked the residents' discussions on illness in art. For example, Panush said that the famous French impressionist Pierre-Auguste Renoir suffered from rheumatoid arthritis, but adapted his technique accordingly, eventually strapping his brush to his paralyzed fingers to paint. Through this conversation, residents could see the artist's triumph over disease. The Saint Barnabas curriculum also includes art that depicts pain or suffering, such as Edvard Munch's famous painting "The Scream."

Perhaps more of a reader than an art critic, second year Saint Barnabas resident Ramesh Guthikonda, M.D., was most touched by "Last Words," a Journal of Humane Medicine and the Medical Humanities article that describes an older, terminally sick physician imparting lessons about medicine and life to a younger doctor. The article's themes of finding a work-life balance, acknowledging other members of the health care team, and appreciating a chance to improve a patient's life through doctoring resonated with Guthikonda.

"Reading this gives you the wisdom of a 60-year-old when you are only 30 and have many more years of practice ahead of you," he said.

To understand the patient's perspective on the health care system, residents read news articles and other patient narratives. For a deeper understanding of how their education might affect them, residents read the book Body Language: Poems of the Medical Training Experience.

Aware of residents' intense schedules, Panush said that humanities lessons are intentionally short. Faculty members pick the content, although occasionally residents bring in their own materials to discuss. As a supplement, every week residents participate in hour-long conversations in which they analyze similar artistic pieces.

"We can't send them home to read Shakespeare and 'Of Human Bondage.' They just don't have the time," Panush said. "But they can read something together for a few minutes."

Sometimes these short humanities lessons can inspire trainees to identify and address any weaknesses in their provision of care, as was the case with Guthikonda. After realizing that he was not communicating very well with his native Spanish-speaking patients, Guthikonda registered for an introductory Spanish class while he was on vacation. From the language class, he learned the basics of Spanish vocabulary, grammar, and pronunciation. Now he rarely mispronounces his Latino patients' names, always silencing the "h" and rolling the "r."

"Although it looks small, something like saying someone's name correctly can really help build a better chemistry with patients," Guthikonda said. "Patients seemed really happy. They kept asking me, 'How did you pronounce my name right?'"

At Columbia University College of Physicians and Surgeons, obstetrics/gynecology residents are recording their experiences for reflection. This new curricular component is based on Columbia's larger Narrative Medicine Program, in which doctors, nurses, and therapists write down patient care experiences with the goal of better recognizing and interpreting individual situations, said Rita Charon, M.D., Ph.D., the program's director.

To more formally measure how humanities exposure was affecting residents' bedside manner, Saint Barnabas faculty members looked at trainee performance and patient care outcomes during the first year and found improvements in both areas. Moving forward, Panush said that faculty will conduct more data analysis on the program's efficacy, incorporate a similar component in the outpatient setting, and focus more on end-of-life care issues. Panush also hopes to create a formalized curriculum that he can show to educators at other residency programs.

"Our long-term goal is to share the lecture series and materials," he said. "If we are doing something that is improving patient care and resident performance, we want to disseminate it as widely as possible."

—By Elissa Fuchs