Program

Writing skills are an important aspect of effective communication for physicians as caregivers, researchers, and educators. The Cleveland Clinic Lerner College of Medicine Program has utilized a portfolio system for assessment since its inception. Students are asked to reflect both in a formative and summative fashion on their performance across nine competencies (including communication skills), recognize learning needs, and implement improvement plans. This approach encourages and assesses reflective practice skills and requires active student participation in the assessment process. This presentation will focus on challenges that have been encountered with regard to guiding students in the writing of formative and summative portfolios. We will also address the challenge of assessing poorly written portfolios. Basic skills in effective written communication certainly impact one's ability to write effectively in a reflective manner. In this presentation, we will present an overview of the portfolio program, discuss levels of desired reflective writing, and outline problems that we have encountered in this process including poor grammar and syntax, disorganization, lack of a reflective insight and quality to the writing, and an inability to cite appropriate evidence. Samples of student writing will be provided and examined in order to provide a forum for discussion on possible approaches to facilitating a student's ability to improve reflective writing skills.

Working with a core group of seven distinguished physicians who are affiliated with The Nebraska Medical Center--and partnering each one with a local writer in the workshop setting and in one-on-one collaboration--the aim of the Seven Doctors project has been to begin to document how attention to the study, craft, and mastery of writing helps these physicians live better lives and become happier at work and more engaged with patients and others.

Incorporating reflection into medical education is appealing for many reasons. The process of reflection is a key aspect of learning and therefore may enhance practice-based learning. Reflection may improve professional development as many formal reflection exercises address breeches of professionalism and discord between the hidden curriculum and formal curriculum. Reflection also is equated with more humanistic medical practice.

Critical incident reports are one of the better known strategies to incorporate reflection into medical education, though increasingly other strategies are being reported. However, these strategies have not met with equal success and some learners resent being "forced" to reflect while educators struggle with the role of assessment in reflective exercises. This raises interesting issues for discussion.

All panelists have sustained very successful reflective writing experiences in the clinical years and are co-collaborators in a qualitative study of these writings. This proposal is derived from a highly successful workshop at the 2006 AAIM and 2007 Generalists in Medical Education meetings that generated much more discussion than anticipated and thus seemed well-suited to this format and the focus of this meeting.

Most doctors already possess plenty of the attributes required of good writers: a steady flow of material (countless patient scenarios), good listening skills (empathy and diagnostic acumen), lots of practice (H & Ps and office notes), and a love of reading.

We will examine three celebrated short stories by doctor-writers: "The Use of Force" by William Carlos Williams, "Brute" by Richard Selzer, and "The Steel Windpipe" by Mikhail Bulgakov. All three tales involve angry, frustrated doctors and difficult, noncompliant patients. How are these stories similar? How are they unique? Why are they so effective? What lessons do they provide that may be applicable to our own writing?

We will discuss elements of "the doctor story" that are distinctive of this genre including the doctor as narrator, illness as metaphor (or not), and the many built-in conflicts (physician versus disease, physician versus uncertainty, physician versus constraints of time and economics, and sometimes physician versus patient and family). Style and voice will be explored.

Recommended resources that can facilitate the crafting of your stories and enhance your appreciation of stories by physician-writers will be presented. We will conclude with some brief writing exercises.

Commencing in October, 2003 all fourth year medical students rotating on the neurology clerkship at Montefiore Medical Center were required to submit a creative piece in lieu of one patient write-up. Instructions were purposefully kept vague to maximize the students' options for free expression. The assignment was to demonstrate understanding of the concept that "Neurology is not the study of neurological illnesses; rather, it is the study of human beings who have neurological illnesses which impact upon their lives and their families." The students were asked to present their creative pieces to the preceptor and fellow students on the final day of the rotation. No grade was given for the presentation. In the first three years of this pilot project 121 students submitted creative pieces. The vast majority chose a short story format but submissions also included poems, crossword puzzles, a short film, drawings and crafts. Most of the stories submitted were emotionally powerful and reflected that the presenter was deeply affected by the events described. The most common themes chosen were: degenerative neurological conditions, particularly dementia, in a family member of the student; devastating illnesses in patients seen on the ward and the impact on their families; fictional first person accounts of patients with incapacitating neurological conditions such as locked-in syndrome. Excerpts from some of these stories will be read. The assignment acknowledged the students' intrinsic humanism instead of treating "humanism" as a subject that had to be didactically taught to them. Most found the assignment a worthwhile, meaningful experience.

Part presentation, part group discussion, this session will explore the themes and purposes of student writing produced during a semester-long reading and writing workshop offered through the University of Iowa College of Medicine. Although supported by the College, the workshop was not led by medical professionals, and writing assignments were focused on craft rather than, explicitly, issues of medical practice or professional development. From the breadth of styles and subjects emerged recurrent themes of identities in flux, and tensions arising from protagonists shifting their identities from "object" of the medical profession to "subject" of the medical profession. The humor, sadness, anger, insight, and rough, unfinished quality of these pieces, in contrast to the polish and tidiness of many published essays on medicine, implies a [necessary?] divide between public and private in the trajectory of developing physicians.

I will read an excerpt from my creative non-fiction project about illness; describe the resources and programs at Stanford University School of Medicine that enabled me to work on it; and consider the value of engaging in creative writing and reflection while in medical school.

Three years before I began medical school, my husband was diagnosed with stage four stomach cancer. This summer, I began to write an account of what happened, to reflect on the meaning of those events, and to put them in a broader context. The specific aims of my writing are to bear witness, to remember, and to reconstitute a story of love that incorporates loss. I also seek to understand in my writing how my experience with illness frames my experience as a medical student—and how education and training reshape my memory. The process of writing has provided a way to reflect on the multiple and sometimes competing perspectives of patient, caregiver, student, and physician, as each grapples with the meaning of illness and how best to treat it.

The Scholarly Concentrations Program at Stanford provided a framework in which to envision this writing project and the resources and support necessary to accomplish it. This program may serve as a model whereby medical schools can facilitate creative writing among their students.

Beyond being a personally enriching pursuit, creative writing is a valuable forum in which to pose difficult questions about medicine, imagine solutions and ultimately cultivate better doctors, and better medicine.

For the past year, the University of Iowa Writing Center has sponsored a weekly, informal fiction-writing workshop group whose focus is reading, writing, and discussing fiction. Anyone is welcome to participate, and this semester, the group includes a physician, a quantum mechanics scientist, non-native English speakers, and several undergraduate students. The physician, a radiologist and internist, will discuss the challenges and benefits to physicians writing fiction in a diverse group that draws participants from across the university curriculum. A graduate of the Iowa Writers' Workshop and assistant director of the University Writing Center will discuss his decisions in structuring the workshop to take advantage of the group's diversity of background and experience. A brief formal presentation will be followed by an informal panel discussion.

Although many students expressed an interest in writing, the Medical College of Wisconsin lacked a coordinated program of opportunities to cultivate reflective writing for medical students. During the past three years, the authors, who are part of the new program in medical humanities at the Medical College of Wisconsin, instituted three major initiatives to provide these opportunities and foster an appreciation of the medical humanities. The first initiative is an M-4 elective that includes journaling and weekly meetings with a writing coach that culminates in a final product for publication or presentation. Student interest has skyrocketed from an average of 5 students enrolled through spring 2007 to 24 students who requested the elective for spring 2008. The second initiative is an M-1 Humanities Track piloted this year that includes structured opportunities for reflective writing with feedback provided throughout the academic year. More than 30 students requested the sixteen available slots in the first year. The third initiative is publication of an annual literary journal, Auscult. Highlighting writing from students as well as faculty, Auscult reinforces the goal of a lifelong involvement in reflective writing. Through integration of these initiatives, students have new opportunities for reflective writing as part of the overall medical school experience. Qualitative evaluations of these activities show that students value the opportunity to reflect upon their profession and to write for publication and personal growth. Sample student writings as well as an overview of each initiative will be presented.

This is a session for writers of creative nonfiction, whatever stage the project, combining practical advice with the opportunity for questions, answers, and sharing of experience. (Creative nonfiction is the wide field of writings that are nonfictional and also creative in that the persona or sensibility of the writer is an important part of the project.) The presenter will briefly diagnose the most common roadblocks for creative nonfiction writers and prescribe methods for getting around them. Then the session will open up for interchange. The session should be both helpful and inspiring for writers over a wide range of backgrounds and writing experience. The presenter is a practiced conductor of workshops for writers of all ages and professions, with a long-term interest in the many relations of literature and medicine.