Medical Humanities & Arts Course Descriptions

Undergraduate Medical Education

Year One

 

Human Kindness 1 Curriculum 2014-current; required component of Clinical Foundations 1
Johanna Shapiro, Ph.D, Julie Youm PhD, Aaron Kheriaty MD, Ralph Clayman MD

The purpose of the kindness curriculum is to give students a space to think about the role of kindness in clinical interaction; and to show them different facets of kindness through examining the construct through a variety of disciplinary perspectives.

The kindness curriculum consists of 6 required hours in the 1st year and 6 required hours in the 2nd year.

Course Objectives: Students will be able to demonstrate the following:

  1. Active knowledge of the history of kindness in medicine
  2. Active knowledge of the construct of kindness as situated within various ethical traditions
  3. Active knowledge of the neurobiology of empathy and kindness
  4. Specific performative and narrative techniques that communicate kindness to others
  1. Lecture 1: Overview of Human Kindness (history of kindness; ethics of kindness); patient presentation
  2. Lecture 2: “Being Present”: theater improvisational skills as relevant to clinical medicine (nonverbal behavior and observation; making connection with others)
  3. Lecture 3: Neurobiology of Kindness; Mindfulness and Loving-Kindness Meditation; Neurobiology component eliminated 2018.
  4. Lecture 4: Kindness and Compassion and their Opposites in Illness Narratives (eliminated 2015, substituted Standardized Patient stations – Difficult Encounter, Breaking Bad News, Cross-Cultural Encounter – to explore expressing empathy in difficult situations); SP encounter moved to Yr 2 2018, final MS1 session became physician-patient interviews in real-time modeling empathy and kindness.

Objectives

Objectives 2017

Curriculum:

 

Mindful Medicine

 

Anatomy of Anatomy:
Implications of the Anatomy Course for Future Professionalism (2009 – 2011)
Johanna Shapiro, Ph.D., Marianne Ross, Ph.D., Robert Leonard, Ph.D.

Course Description: This course explores implications and ramifications of dissection for future professionalism, including the student-physician/patient relationship and emotional detachment/connection.

Course Objectives: At the end of the course, students will be able to…

  • Identify and articulate expectations and attitudes about dissection
  • Identify, understand and respect attitudes and behaviors of others
  • Analyze his/her relationship with the cadaver
  • Use point-of-view writing to imagine the life of another, specifically the cadaver
  • Formulate an appropriate personal balance between emotional detachment from and emotional connection with the cadaver
  • Practice basic self-care skills in stressful situations
  • Demonstrate respect and consideration for the cadaver
  • Demonstrate respect and consideration for colleagues

Read the Anatomy Of Anatomy Elective Handout

 

Optional Anatomy Creative Projects
Human Gross Anatomy and Embryology(2003 –2010; 2015-current)
Johanna Shapiro, Ph.D., Robert Leonard, Ph.D., Marianne Ross, Ph.D., Trung Thai, M.D.; Jamie Wikenheiser, MD, PhD

Course Description: An optional two-part creative project has been incorporated into the Human Gross Anatomy and Embryology Course. It provides an opportunity for students to express their experiences in anatomy creatively through media such as poetry, prose and art.

Objectives:
Participation in this project is designed to accomplish the following:

    • Provide an opportunity for students to reflect on their initial expectations, thoughts, and concerns about gross anatomy through the use of creative media such as poetry, prose and art; and, upon completion of the course, to engage in retrospective reflection and personal assessment.
    • Improve faculty understanding of the anatomy experience from the perspective of students so that course adjustments can be made that enhance student learning as well as professional and personal growth.

Comments

 

Patient Stories/Doctor Stories 1999-current
Patient Stories, Doctor Stories: The Doctor-patient Relationship and the Experience of Illness in Literature (2000 – current)
Johanna Shapiro, Ph.D.; Tan Nguyen MD; Monisha Vasa MD

Course Description: This course uses short selections from literature, including poetry, short stories, and role-plays written mostly by doctors, patients, or medical students, to help participants deepen their understanding of patients’ experiences of illness, and patients’ and doctors’ experiences of each other. Most readings will be done in class, followed by comments and discussion. Each student will complete a creative project reflecting on some aspect of their experience as medical students at the end of the class.

Read the Introduction to Medical Humanities

Course Objectives: At the end of this rotation the student will be able to:

  • Stimulate empathy for and understanding of the condition of patients confronted with serious illness
  • Develop insights into the doctor-patient relationship
  • Understand how narrative is useful in addressing ethical issues
  • Be more comfortable with ambiguity, uncertainty, and multiple perspectives
  • Deepen understanding of and respect for colleagues and teachers
  • Use literature as a method for reflecting on and coping with stresses and strains of professional training

Comments: Students’ Creative Projects

Examples of Teaching Guides

 

Writing Elective 2011-2012

 

Examine the Painting/Examine the Patient 2013-current
Examine the Painting/Examine the Patient
1st year elective

Instructors: Joel Shallit, M.D. and Johanna Shapiro, Ph.D.

Course Description: The objective of this course is to improve the visual skills needed in clinical diagnosis and the emotional sensitivity needed in compassionate care through techniques learned in examining works of art

Course Objectives: The student will be able to:

  • The student will be able to develop visual analysis skills related to interviewing, physical diagnosis, communication, and clinical reasoning through the study of art
  • The student will be better able to deal with complexity and diagnosis through the examination of paintings.
  • The student will be better able to interpret patient emotions, and thereby to feel empathy and compassion for patients, through the study of art.
  • The student will be better able to understand patients of different backgrounds through the study of art.

Course Competencies:

  • Improved visual clinical observation
  • Greater sensitivity to the nuances of how the patient initially presents to the physician and how the underlying illness effects the look, mood, and attitude of the patient
  • Enhanced ability to recognize, read, and interpret emotions
  • Ability to combine visual clues to physical exam when arriving at diagnosis
  • Interactive class discussion will simulate discussion similar to ward rounds and help prepare student for collaborative treatment plans learned during the clinical years

Course Attitudes and Commitments:

  • Understanding the importance of connecting with the patient
  • Attitudes of empathy and compassion toward patients from different backgrounds
  • Recognizing the importance of story in medicine

Lecture Topics:

  • ART LITERACY: Basic art concepts and definitions including color, symmetry, line, shadow, story, interpretation
  • WHAT IS GOING ON? Session 1 Getting the feel for the painting using examples in portrait, narrative, landscape, and modern painting. Students write down their initial observations
  • WHAT IS GOING ON? Session 2. C Compare notes from previous session for greater detail
  • WHY DO YOU FEEL THAT WAY? Session 1. Learning to describe/analyze your thought process from what you see. Various paintings; initial notes
  • WHY DO YOU FEEL THAT WAY? Session 2 compare notes for greater detail
  • ART GALLERY VISIT. Appreciate the real painting in museum setting
  • GUEST ARTIST(s) LECTURE. Explaining how a painting is created. Getting the right look. Comparing artist’s feeling and meaning of the work with the observers
  • ANALYZE PHOTOGRAPHS of healthy people vs the patient using art concepts
  • CASE HISTORIES. Clinical cases. Pictures. Looking for clues as to why patient is sick
  • FINAL BRUSHSTROKES. Put it all together. Examples of paintings and patients. What else do you see?

 

History of Medicine (elective) 2016-current
Student run, Johanna Shapiro PhD, faculty advisor

Course Description: This elective will survey significant themes in the study of the history of medicine and health care through the prism of the humanities. Each session will be devoted to the discussion of one of the themes. Each student will be asked to lead a session of his or her choice, which will entail prior review of articles and other resources, as well as development of a class plan for discussion. Preparation and leading one session and completing one written assignment on one of the other topics will provide the student an opportunity to explore these topics personally and to develop their critical assessment, discussion and writing skills.

Course Objectives:

  • Students will discern and discuss major themes present in the study of the history of medicine and health care and their relative interactions with one another.
  • Students will be able to develop and articulate – verbally and in writing – their understanding of these themes and their relation to current medical care and healthcare delivery issues.

 

Improvisational Theater Elective 2018-current
Playing Doctor: Improvisational Theater Techniques to Improve Clinical Presence and Communication
Joel Veenstra, MFA

This curriculum in theater arts emphasizes improvisational skills as a way of teaching how to cultivate mindful, attentive, creative verbal and nonverbal communication and presence in clinical settings. It teaches risk-taking in a context of safety, cognitive and emotional agility, working constructively with a partner or team, and creativity.
In this particular seminar, students will learn how improvisational theater skills can improve their ability to communicate with patients and teammates, and can help shy medical students speak up on the wards. There will be a focus on respect and compassion for others in the way they view and interpret challenging situations; commitment to teamwork in a nonjudgmental and creative manner; comfort with discomfort. Every doctor-patient encounter is to some degree improvised, because physicians often don’t know who will walk in the room, or what that patient will say or do. Like professional improvisers, physicians must have the confidence and ability to listen and observe, then spontaneously respond in stressful or confusing circumstances.

Course Competencies:

  • “Deep listening” – listening to words, tone of voice, body language, and silences as a complete communicative package.
  • Collaborative story creation – speaking in short chunks of information, so you always contribute your share while leaving space open for others to contribute also.
  • Increased comfort with both displaying emotion and responding to others who are displaying emotion.
  • Improved ability to generate new ideas – a decrease in fear and self-consciousness, and increase in confidence and spontaneity.

Sessions:

Session 1: Introduction to Improvisation Concepts
Session 2: Improvisation Concepts Embodied
Session 3: Exploring the Power of Storytelling
Session 4: Exploring the Power of Character – seeing through someone else’s eyes
Session 5: Exploring Thinking on your Feet
Session 6: Exploring Juggling Multiple Goals
Session 7: Coping with Emotion and Ambiguity
Session 8: Exploring Deep Listening and Finding the Focal Point
Session 9: Exploring Status
Session 10: Translations and Applications to Medicine

 

Introduction to Clinical Humanities

Reflective Writing Comments to Students

 

Student-Senior Partners Elective Program, Optional Creative Projects 2011-2012

Year Two

 

Human Kindness curriculum 2014-current
Johanna Shapiro PhD; Julie Youm PhD; Aaron Kheriaty MD; Ralph Clayman MD

Course Description: This year emphasizes the development of empathy through a series of professional videos that focus on the definition and neurobiology of empathy; breaking bad news; and dealing with difficult clinical encounters. In addition, each session will incorporate a physician and patient to speak from a personal perspective about how these topics have intersected with their clinical care. The final session will focus on end of life from both clinician and patient perspectives.

Course Objectives:

Students will be able to demonstrate the following:

  • Specific communicative skills relevant to breaking bad news
  • Specific interactional approaches in difficult student-patient encounters
  • Deepening of knowledge about neurobiology of empathy including ability to reference specific research
  • Active knowledge of how breaking bad news and challenging clinical situations are addressed and resolved in actual clinical encounters with patients.
  • Active knowledge of how end of life issues affect patients, families, and physicians
  1. Lecture 1: Pediatrics and Empathy: Empathetics training tape: Introduction to the Neuroscience and the Practice of Empathy (Empathetics videos eliminated 2016; this session was switched to year 1 as a model of empathic interaction in 2018)
  2. Lecture 2: Chronic disease and Empathy: Empathetics training tape: Managing Difficult Medical Interactions (this session changed to a panel discussion plus physician demonstration 2018)
  3. Lecture 3: Breaking Bad News and empathy: Empathetics training tape: Delivering Bad News (this session was revised to include a panel discussion of BBN and small group role-plays 2018)
  4. Lecture 4: Death: palliative care specialist and a hospice patient (this was modified to include small group role plays 2018)

Curriculum:

Objectives:

Discussion Questions

 

Mindful Medicine

 

Reflective Reading and Writing for Medical Students (2003 – current)
Johanna Shapiro, Ph.D.

Course Description: This course provides an introduction to reflective reading and writing that links these skills with professional development and patient care. In Week 1, an introductory presentation orients student to the theoretical and empirical work on therapeutic and health-promoting aspects of reflective reading and writing. Each subsequent week (2-9) consists of in-class readings by medical student and physician-authors focusing on the socialization experience of medical students; professionalism; and the doctor-patient relationship. These readings will also provide models for different writing approaches. In addition, most sessions will include an in-class writing assignment examining such features as voice and point of view, parallel charting, free writing, and write-it-thrice techniques. Students will come prepared to discuss readings and participate in writing exercises and class discussion that link writing to their ongoing patient care experiences. A final session (Week 10) will summarize the course and present student writing projects.

Course Objectives: After participation in this elective, the student will:

  • Understand and be able to explain theoretical and empirical evidence for the therapeutic value of reflective reading and writing
  • Become familiar with and practice various reflective writing techniques
  • Understand and be able to explain how to use reflective reading and writing as: a) methods of observing and paying attention to patients b) tools to reduce frustration, anger, helplessness, and burn out c) ways of developing increased empathy for the patient’s perspective d) means of developing additional insights into patients.

 

More Doctor Stories, Patient Stories

Course Description: This elective is thematically linked to Patient-Doctor II in that its content closely parallels that of the larger course and meetings occur monthly after each final module session of Patient-Doctor II.  The class is intended to supplement exposure to the medical humanities for students with a particular interest in this area. Readings consist of poetry and brief excerpts from longer works that will help participants deepen their understanding of patients’ experience of illness, and patients’ and doctors’ experience of each other.

Course Objectives: At the end of this elective, students will

  • Develop increased empathy for people experiencing illness
  • Develop increased empathy for physicians
  • Improve their ability to pay attention to language, tone, and point of view
  • Be better able to explore personal feelings evoked by different illness experiences and different doctor-patient relationships
  • Develop new insights into understanding doctor-patient dynamics

Format: Students meet monthly with faculty for a total of eight one-hour sessions to discuss readings.  No outside reading is required.  Typically, a role-play, an excerpt from a short story, or poetry is read aloud.

 

Clinical Foundations: Medical Humanities Component.
Johanna Shapiro, Ph.D.

Comments

Year Three

 

Clinical Humanities Year Three

Pediatrics Reflections: Pediatric Clerkship (2000-Current) required
Penny Murata, M.D., Johanna Shapiro, Ph.D.

Session Description: There are six Pediatrics Clerkship rotations per academic year, with approximately 18 students per rotation. Students are required to complete a “humanities” project for a student conference held near the end of their eight-week Pediatrics Clerkship. The project may be based on child advocacy, ethics, physician-patient-family relationship, or any other aspect of the clinical experience. Students may choose the format. They may work individually or in pairs, as long as each student participates. Instructions for the project are provided during the Pediatrics orientation and are included in the clerkship manual. The humanities conference is the final conference and usually lasts for two hours. After each presentation, other students are free to comment. Comments and discussion points are made or facilitated by the Director of Medical Humanities and the Pediatrics Clerkship Director.

Projects can be presented in a variety of formats – poetry, skits, song, point of view narrative, patient education pamphlets, scrapbook or artistic collage of pediatric patient experiences, narrative, drawings, readings – and can focus on a variety of topics –e.g., child’s fear of upcoming surgery, frustrations in the outpatient clinic, dealing with death and dying. Students discuss their feelings about taking care of patients (including patients with chronic medical conditions and victims of abuse), interacting with parents and caregivers, being students, interacting with residents, and ethical issues.

Session Objectives:

  • Students will understand how medical humanities can promote empathy for pediatric patients and their families
  • Students will understand how medical humanities can promote child advocacy
  • Students will be able to describe ethical issues in pediatrics
  • Students will be able to reflect on their clinical experiences in a creative manner that facilitates their understanding of the patient-caregiver-physician interaction

Peds Creative Projects Comments

 

Reflections: Difficult and Cross-Cultural Encounters Family Medicine Clerkship (2005 – current)
Johanna Shapiro, Ph.D., Felicia Cohn, Ph.D., Desiree Lie, M.D., M.S. Ed., Wadie Najm, M.D.

Session Description: We have incorporated a required Reflective Practice writing assignment and discussion session that focuses on practicing medicine across cultures as part of the 4 week Family Medicine clerkship. The 9-10 students rotating through the clerkship each month first complete a written assignment reflecting on various aspects of patient and medical culture. Students are asked to write about two different clinical settings that they have experienced during the clerkship, chosen from the following: a) Outpatient clinic; b) Visit to community botanicas (a shop that sells herbs, charms, and spiritual items, especially marketed to Latinos); c) Home visits; d) Group Medical Visits. They are asked about how cultural differences enhance or complicate the medical encounter, what lessons they learned about practicing medicine across cultures, ,and characteristics of positive and negative physician role-models treating patients from different cultural backgrounds. They subsequently participate in a facilitated session, which meets for 1 ½ hours, to exchange and examine different points of view, and interrogate their own assumptions and biases.

Session Objectives: The goals of this session are to:

  • Help students understand that medicine is its own culture
  • Examine and challenge students’ unconscious assumptions about patients from diverse backgrounds
  • Compare and contrast different student views about the value and challenges of cross-cultural medical encounters
  • Explore different ways of addressing cross-cultural encounters that students perceive to be frustrating and that can result in barriers to optimal healthcare
  • Identify positive and negative physician role-models and what students can learn from each in terms of cross-cultural interactions
  • Analyze the sources of difficulty in a clinical encounter, including factors of the physician, the patient, and the societal and healthcare systems in which both are embedded.
  • Identify special issues that arises in delivering healthcare across language, culture, race/ethnicity, gender, disability, and class.
  • Formulate specific self-awareness and interactional strategies to de-escalate and redirect a difficult encounter toward more positive outcomes.

Comments on Student Essays:

Medical Readers Theater: Family Medicine Clerkship (2009-current)
Johanna Shapiro, Ph.D.

Session Description: Readers’ theater (RT) is a minimal form of theatrical performance in which there are no or negligible sets or costumes, and scripts are used in staging. It was developed as an efficient and effective way to present literature in dramatic form. It has been used in a variety of educational settings from university to elementary school.

More recently, medically-themed readers’ theater (MRT) has generated interest in medical education circles as a method of engaging students and other learners with the human side of medicine. MRT is an effective way of bringing together individuals with different backgrounds and life experiences and getting them to share their perspectives on various topics. Although the content addressed by MRT is wide-ranging, some programs have focused on issues of aging, debility, death and dying and have involved senior citizen groups. In collaboration with the UC Irvine Program in Geriatrics and residents from a local assisted living facility we have incorporated a required MRT session as part of the 4 week Family Medicine clerkship. 9-10 students participate in each session. Students meet for 1 ½ hours with facility residents to participate in 1-2 brief skits highlighting issues of importance to older patients, including ageism, multiple, chronic health problems, disability, dementia and Alzheimers disease, and end-of-life issues. The role-plays are followed by facilitated discussion.

Session Objectives:

  • Through an interactive process, learn about different perspectives on sensitive issues of significance to both older individuals and physicians: aging and ageism, doctor-patient communication, disability, loss of independence, dementia, end-of-life, and how best to provide healthcare for individuals as they experience these life events and transitions.
  • Develop greater empathy for the life events, including health issues, that older persons experience.
  • Improved interaction and communication with older persons, including improved active listening and reflection
  • Have greater appreciation for the performing arts as a way to develop empathy and insight into patients’ situations.

 

Poetry in the Clinic – Family Medicine Clerkship

 

The Patient’s Voice: Humanities Component of the Family Medicine Third Year Clerkship
Aexandra Duke, D.O., Johanna Shapiro, Ph.D.

Description: The family medicine third year clerkship is a required longitudinal experience in which all third year students are assigned to the practice of a board-certified family physician, either at university practice sites or in the community, one-half day per week for the entire year.  In addition to learning basic skills of physical examination, assessment, diagnosis, and intervention, over the year students are also expected to review 14 standard case vignettes with their preceptors (see below). These topics are also discussed at 5 didactic sessions, at which time students are expected to have completed  SOAP notes on actual patients with the problems in question.

Humanities Component: Each case vignette has an accompanying literary reading (see below).  Students are expected to read each selection and be prepared to discuss them with both their preceptor and during the small group didactic sessions.  In writing their SOAP notes, students must explicitly note how the literary selection influenced the plan they developed for each particular patient.

Objectives:

  • To provide additional perspectives on the patient experience of illness for 14 common medical disorders seen in family practice settings
  • To encourage students to make concrete links between humanities and practical clinical applications

Read the full description

 

Medical Humanities Medicine Clerkship 1999-2007

Comments

 

Critical Reflection: Medicine Clerkship (2007-current)
Ron Koons, M.D., Elena Bezzubova, M.D., Johanna Shapiro, Ph.D.

Session Description: This required one hour session employs an intimate, small group setting with a 2:1 student/faculty ratio to engage in narrative medicine, i.e., telling stories about memorable patient encounters. Students present patient care situations that troubled, angered, confused, or inspired them. Subsequent discussion explores in a nonjudgmental way various relational, ethical, and communication issues raised. Emphasis is on self-awareness, reflective practice, and translation of values into language and behavior.

Session Objectives:

  • Help students to better understand the clinical situation they present during the class
  • Improve students’ ability to constructively reflect on difficult patient-doctor encounters and ethical dilemmas
  • Help students learn how to more effectively problem-solve difficult clinical and professional encounters
  • Improve students’ ability to understand patients and families and how to develop relationships with them
  • Facilitate student adaption to the challenges of the third year environment
  • Help students to clarify their professional identity as a student-physician
  • Address important aspects of patient care ethics which have not been addressed previously

Supplemental Materials

Year Four

 

699E Research Elective in Medical Humanities and Social Sciences (2003-current)
Johanna Shapiro, Ph.D.

Course Description: Medical Humanities encompass a broad range of subjects and activities, including history, anthropology, and literature. This elective provides an opportunity for students to explore and engage in analysis of various clinical issues in medicine through the development of a specific medical humanities-based project related to the art of medicine.

Course Objectives: At the end of this rotation the student will:

  • Participate in a meaningful way in the implementation and completion of a humanities creative project/research project related to the art of medicine
  • Understand and be able to state the intellectual basis for developing this humanities project as an aspect of medical education
  • Complete a written document describing the goals and outcomes of the project
  • Identify an appropriate mentor, and expert on the topic of choice, who can evaluate and guide the student’s work

Competencies:

  • Instill methods of rigorous analytic thinking
  • Learn how to formulate a research question and conduct independent, humanities or social science investigation, analysis, and research
  • Develop foundational skills in qualitative research
  • Develop foundational skills in quantitative, social science research
  • Improve content knowledge in a particular area of interest (i.e., research topic)

Attitudes and Commitments:

  • Improve awareness that the humanities and social sciences can be used effectively to investigate certain categories of clinically relevant issues in medicine
  • Develop increased empathy for and understanding of patients’ and physician’s experiences of illness and health care
  • Enhance commitment to lifelong learning
  • Encourage standards of the highest professional honesty and integrity

Educational Activities: The elective is a research elective and the educational activities listed below are suggestions only, meant to encourage further independent thought.

  • Interviewing patients to explore anthropological perspectives and health beliefs
  • Engaging in original historical research on topics in medicine
  • Writing project about the experience of being a medical student
  • Using photography/art/drama to explore the experience of a specified number of patients during a particular 3rd or 4th year rotation
  • Working with UC Irvine Medical Center’s patient education department to help develop innovative humanities-based educational material
  • Developing narrative and arts-based approaches to mastery of the basic sciences in medical education.
  • Developing curriculum modules for pre-clinical students focused on the patient’s perspectives for various disease processes.
  • Conducting and writing up in-depth narrative interviews with chronically ill or dying patients.

 

 

647A Art of Doctoring (2003 – current)
Johanna Shapiro, Ph.D., Dan Robitshek, M.D., Felicia Cohn, Ph.D.

Course Description: Art of Doctoring is a small group experience to enhance the physician-patient relationship, expand students’ communication skills, and provide strategies to promote compassion and empathy as core physician values. The class uses self-reflective practices, role-modeling, readings, and case-based problem solving discussion.

Course Objectives: At the end of this elective students will:

  • Understand the usefulness of reflection and imaginative perspectives in a) cultivating compassion and empathy for patients, patients’ family members, peers, self, and others b) developing insight into how best to convey compassion and caring in the doctor-patient relationship.
  • Be able to identify and assimilate compassionate attitudes and behaviors modeled by others.
  • Know how to use mindfulness and other re-centering techniques to maintain an attitude of compassion in difficult and stressful situations.
  • Know how to use reflective writing and other humanities-based techniques to develop and maintain compassion and empathy.
  • Implement these strategies to enhance physician-patient communication and improve patient care.
  • Implement strategies to promote self-awareness and to enhance their own career satisfaction.

Key Topics:

  • Identifying personal core values and how to maintain them in the practice of medicine.
  • Learning how to identify and emulate attitudes and behaviors of compassion and empathy in physician and peer role-models
  • Developing attitudes of emotional equilibrium, attentive presence, and mindfulness during stressful patient encounters.
  • Working with difficult emotions toward patients
  • Learning acknowledgement of, reflection on, and forgiveness for mistakes
  • Using reflective writing, reading, and other humanities-based techniques to develop and maintain compassion and empathy

Competencies:

  • Improve ability to listen carefully, accurately, and precisely to patients.
  • Improve ability to accurately reflect and paraphrase patient statements
  • Improve self-awareness and self-knowledge
  • Ability to work through emotional responses of anger, frustration, defensiveness, and detachment.
  • Ability to convey empathy, understanding, respect, and caring toward patients
  • Increased ability to re-center or restore emotional equilibrium in stressful situations.
  • Ability to use writing, reading and other humanities-based techniques to reflect on difficult patients and situations for the purpose of gaining new insight and developing new courses of actions.

Attitudes and Commitments:

  • Increased compassion, empathy toward patients
  • Attitudes of service
  • Renewed commitment to the practice of medicine generally, and in particular toward patients often stigmatized in the medical system.

Teaching Pearls

Comments on Student Essays

Humanities Consultation:
Through The Patient’s Eyes: 4th Year Humanities Consultation (2002, 2004, 2010) Consult with students about specific patients from a reflective, empathic perspective, emphasizing communication and intervention alternatives.

Curricular ideas

 

Patient-Doctor IV – Medical Professionalism

  1. How are the traits of humanism reflective of professionalism? I would say that humanism, the ability to care about, as well as care for the patient, is the heart of professionalism. Humanism emphasizes empathy, compassion, a willingness to engage emotionally with patients. Professionalism focuses more on accountability, duty, skill, and expertise. Without humanism, professional runs the risk of degenerating into mere competence.
  2. How should physicians honestly assess their strengths and weaknesses of professional behaviors in residency and practice? This question could easily take an hour or more to adequately address. But the short answer is that, in terms of humanistic qualities, physicians need first to reflect on their own attitudes and behavior, to not be afraid to honestly self-interrogate: How did I feel about this patient? And at least as important, why did I feel this way? Did I treat this patient with respect and dignity? If not, why not? Physicians also need to pay attention to how their patients react toward them: Does this patient seem comfortable in my presence? Does this patient trust me? Can the patient talk openly with me? And if not, why not? Finally, physicians can elicit feedback trusted others, both colleagues and friends and significant others. They need to be able to ask, Do I seem more impatient to you these days? More judgmental? More harried? Dr. Martha Sosa-Johnson regularly asks a colleague, “How does my compassion fatigue seem today?”
  3. How should physicians promote professionalism for their colleagues and future physicians? All the research we have suggests that role-modeling is one of the most effective ways physicians have of conveying desired attitudes and behaviors to learners and peers. Ideally, we should have a health care and medical education system based on the principle of parallel process, so that attendings and residents would treat medical students humanely and respectfully, in a virtuous manner, while modeling these same qualities in their interactions with patients. Systemic change in this direction is possible, but glacially slow. In the meantime, I would advocate that each of you consider being a personal change agent in your upcoming residencies and then in your medical practices.  Be a role model to your colleagues, your patients, and yourself of the values you say are important to you.  Make a promise to yourself to do one kind thing for a patient; say one encouraging word to a student or fellow resident; make one loving gesture toward your significant other on a daily basis.  Ask one question every day that allows you to see your patient as a person, rather than a walking constellation of disease.  Share something with a colleague that shows you are more than a body with whom she can switch call.
  4. How does reflection and self-awareness influence ethical behavior? I’m not an ethicist, but I believe reflection and self-awareness promote ethical behavior in several ways: 1) reflection enables us to recognize the existence in any situation of multiple and often competing values, and therefore work to reconcile these values 2) reflection allows novel 3rd alternative solutions to emerge that often have a better ethical foundation than our initial knee-jerk reactions 3) reflection requires respect for persons in and of themselves, an ethical position 4) reflection reconnects us with virtuous behavior that we value but may have overlooked – it reminds us that the right thing to do is not always the easy thing.
  5. How is the practice of this reflection and self-awareness limited by time constraints, personal commitments, and feelings of burnout? The opportunity for reflection and self-awareness are clearly limited by all these things – lack of time, personal obligations, burn-out. But reflection and self-awareness may also contain the kernel of solutions to these dilemmas.  For example, by taking a little space it is possible to reconsider priorities, to reevaluate whether your time is really being spent consistent with your values.  Reflection may also help you remember the importance of nurturing and not taking for granted your personal relationships. And finally, awareness of burn-out and reflecting on what burn-out is trying to make you aware of is the important first step toward rekindling a passion for your profession.

 

Humanism: Personal Characteristics Professionalism: Role Identity
Empathy Altruism**
Compassion- a commitment to decrease pain and suffering** Responsiveness to the needs of patients and society that supercedes self-interest**
Respect for others** Accountability to patients, society and the profession**
Integrity** Commitment to ongoing professional development**
Authenticity Sensitivity to patient’s age, gender, culture and disability**
Spirituality Commitment to excellence**
Fidelity Ethical behavior**
Virtue Honor

 

 

 

 

Residency Education

 

Physical Medicine and Rehabilitation Residency Course:

Rehabilitation of Body, Mind, and Spirit: The Humanities Component of the PM&R Rotation (2001-2003)

Rehabilitation of Body, Mind, and Spirit: The Humanities Component of the PM&R Rotation
Johanna Shapiro, Ph.D., Jerome Tobis, M.D.
2001-2003

Description: As part of the residency program in Physical Medicine and Rehabilitation, a monthly humanities reading and discussion session is offered.

Purpose: The goals of this experience are to 1) help residents learn to see through their patients’ eyes 2) provide residents with literary tools that can help them think differently about their patients 3) explore and at times challenge conventional wisdom about a) disability b) noncompliance c) the doctor-patient relationship.

Participants: 5-6 PM&R residents, the clerkship medical student, 3-4 faculty.

Topics: On Being a Cripple, Stroke, Caregivers, Being a Doctor, Diabetes, Paraplegia and Quadriplegia, Personal Life, Caring for Family Members, The Sick Physician

Example of a reading discussion guide.

 

Family Medicine Residency Course:

The Uses of Literature in Behavioral Science Training (1999-Current)

The Uses of Literature in Behavioral Science Training (1999 – 2010)
Johanna Shapiro, Ph.D., Director of Medical Humanities;Patricia Lenahan, LCSW, Behavioral Science Director;UC Irvine Department of Family Medicine

Description: Literature and medicine is a required component of the behavioral sciences curriculum in the UC Irvine Department of Family Medicine. The curriculum is organized in a three year cycle (corresponding to the residency training period) and covers topics such as doctor-patient relationship, common psychological disorders, domestic violence, death and dying. Each behavioral science topic is explored during a weekly noon conference for either a 4 or 8 week period, during which time a series of lecture/discussion groups is presented examining the topic at hand from a variety of perspectives. For each topic, at least one of the required presentations is a literature and medicine session.

Participants: All 36 family practice residents.

Faculty: Johanna Shapiro, Ph.D., Director of Medical Humanities in Family Medicine; and guest faculty, including the program’s behavioral science director and family physician faculty.

Objectives: The goals for participants in this component of the behavioral science training program are as follows:

  • To learn how reading fictional work can supplement understanding of common psychosocial aspects of primary care medicine
  • To learn about behavioral science topics from a perspective that is particular, local, and subjective
  • To develop skills of emotional self-exploration and self-disclosure
  • To develop increased empathy for patients and medical situations that are often perceived as difficult and frustrating
  • To link insights of literature to clinical experience

Format: Approximately 15 residents per session participate in a monthly, 50 minute noon “conference.” During this time, brief fictional literary selections that can be read on-site are distributed. Sometimes a “mini-lecture” (10 minutes) is presented that highlights the main teaching points for each selection. Residents take turns reading aloud and discussing. Readings favor contemporary poetry and role-plays developed from longer fictional works.

Families in Family Medicine:

 

Family Medicine Nurse Practitioner Program:

Exploring The Cross-Cultural Clinician-Patient Encounter Through Literature 1999-2000
Johanna Shapiro, Ph.D.

3 hour session taught to approximately 10 post-masters nursing students as part of a year-long certificate program training family nurse practitioners sponsored by the UC Irvine Department of Family Medicine

Learning Objectives

In this session, students will achieve the following:

  • Develop greater empathy for patients in cross-cultural encounters
  • Learn how point of view, tone of voice, and use of language can express different perspectives and emotional responses
  • Identify a range of emotions evoked in clinicians in difficult cross-cultural interactions
  • Develop problem-solving strategies for dealing with a range of difficult cross-cultural encounters

Teaching Points

Fathering Bharati Mukherjee

  • Family dynamics; how these are affected by cross-cultural dimensions; how Jason is triangulated between daughter and wife
  • Different views of the cross-cultural “other”; how Jason views Eng; how Sharon sees her; and how Dr. Kearns sees her
  • Relationship of war/trauma on immigrant populations: effect of Vietnam war on Eng; how she understands her current world
  • Three-way culture clash: between Eng, Sharon and Dr. Kearns, and Jason as mediator
  • Common ground between apparent “others”: commonalities between Sharon and Eng
  • Significance of Jason’s choice: supports daughter against his own culture

The Appointment L.J. Schneiderman

  • Family relations in the Latino culture
  • Differing views of American medicine (Modesta, Serafina)
  • Modesta’s view of Anglo culture
  • Clinic’s view of Latino patients
  • Cross-cultural insensitivities and misunderstandings

Jamal Rafael Campo

  • Feelings toward child; toward mother
  • Contrast of initial views of mother with views at end of poem
  • Attitude and judgment of speaker

What Is Lost Peter Pereira

  • Traumas of refugee immigrant population – theme of overwhelming, incomprehensible loss
  • Communication difficulties
  • Attitude of physician to patient; of patient to physician
  • Physician’s knowledge of his patient
  • What constitutes healing – pills vs. reconnecting with culture

Maria Rafael Campo

  • Frustrations with patient (communication, poor prenatal care, poor historian, single; undocumented status)
  • Attitude of physician toward patient

H.I. Vato Alberto Antonio Araiza

  • Discordancy between the narrator’s reality and the clinic and safe sex video
  • View of doctor as a witch, voodoo magician, white man, patronising, antiseptic, artificial
  • Coping with the clinic setting -giving up being himself
  • Safety and sanctuary in the culture of gay, mestizo, Buddhist home-boy in the gang of HIV, symbolized by his home

Medicine Stone Jack Coulehan

  • Contrast between Navajo healing ceremony and Western medicine
  • Different views of suffering in the two cultures
  • Different views of the stone, and its different symbolism in each culture
  • Navigating between two cultures – keeping the stone

Getting Back To Barra Iris Litt

  • Contrast between views of death in traditional Latin American village and U.S.

Strong Horse Tea Alice Walker

  • Conflict between folk and “doctor” medicine
  • The role that racism, poverty play in this conflict
  • Relationships viewed through the prism of race: Rannie and mailman; Rannie and Sarah
  • Cross-cultural misunderstandings and miscommunications

 

Can Poetry Improve the Difficult Clinician-Patient Relationship? 1999-2003
Johanna Shapiro, Ph.D.

3 hour session taught to approximately 10 post-masters nursing students as part of a year-long certificate program training family nurse practitioners sponsored by the UC Irvine Department of Family Medicine

  • INTRODUCTION
  • OBJECTIVES
    • Understand the rationale for using imaginative literature/creative writing as tools for professional development
    • Understand how literature and writing can increase clinician empathy for patients’ experiences and clinician experiences
    • Demonstrate how literature-based approaches can help change our attitudes towards patients and can even help us develop new problem-solving strategies for dealing with difficult clinician-patient encounters
  • THE IMPORTANCE OF PATIENT STORIES
    • Human beings think narratively
    • Illness disrupts our expected life narratives
    • Stories have therapeutic power to heal
  • TWO MODES OF THINKING: LOGICO-SCIENTIFIC AND NARRATIVE.
    • Both scientific and narrative thinking are useful for achieving certain ends, but they differ in important ways from each other.
    • Narrative emphasizes the primacy of storytelling in the way we construct and make sense of our experience.
  • HOW CAN WE UNDERSTAND THE PATIENT’S REALITY?
    • Logico-scientific – Particulars of personal experience are eliminated in favor of abstractions, generalizations, systems of classification and diagnosis
    • Narrative – emphasis is on particulars of individual experience
  • WHOSE POINT OF VIEW AND VOICE ARE IMPORTANT?
    • Logico-scientific – the patient’s point of view is subjective, therefore suspect; the patient’s voice often disappears from the medical record
    • Narrative – the patient’s point of view is subjective, therefore essential to help the physician develop an empathic stance toward the patient
  • WHAT IS THE PROPER RELATIONSHIP BETWEEN CLINICIAN AND PATIENT?
    • Logico-scientific – Emphasis is on objective stance, detachment
    • Narrative – requires emotional engagement and participation in the event
  • THE CRAFT AND ARTISTRY OF LITERATURE
    • Because of its craft, literature can articulate insights and feelings in ways that often the rest of us ordinary people, including our patients, cannot
    • Gives voice to what is submerged and suppressed
    • Defamiliarizes the familiar (helps us see familiar experiences, like our 500th newly diagnosed diabetic patient, in new ways)
  • THE DIFFERENT ASSUMPTIONS AND INTERESTS OF LITERATURE
    • Goal is storytelling, not differential diagnosis: so reminds us of the patient’s story
    • Emphasis is on character and relationships, not on treatment: so gets us to think about the effects of treatment on the person and on her relationships with others
    • Orientation is toward discovery of meaning, not problem-solving: so reminds us to investigate the meaning to the patient of the solutions we suggest
  • THE SAFETY OF LITERATURE
    • In psychodynamic terms, literature can be viewed as a transitional object
    • The playpen effect
    • Helps us reconnect to a state of child-like wonder and openness
    • Lack of clinical responsibility
  • WHAT IMPORTANT CLINICAL SKILLS CAN LITERATURE HELP US DEVELOP?
    • Develops creative imagination and curiosity
    • Gives us empathy for multiple perspectives (dr, pt, nurse, orderly, family)
    • Encourages us to risk emotional connectivity and engagement
    • Reminds us of whole person understanding
    • Teaches skills of close “textual” reading; similar to paying close attention to patients
    • Stimulates reflection on experience, what we might have done differently, how we would act
  • SIMILARITIES BETWEEN CLINICIANS AND POETS
    • Struggle against mortality and death
    • Create order from chaos
    • Relief of suffering
    • Concern with healing
    • Combine emotional distance (steadiness) with emotional engagement (tenderness)
  • POINT OF VIEW WRITING: DEFINITION
    • Adopts the patient’s point of view
    • Describes key life events and clinician-patient encounters.
  • POINT OF VIEW WRITING: TECHNIQUE
    • Select a patient on basis of perceived difficulty or highly charged affect
    • Commit to 10 minutes of writing time
    • Write in the first person voice (“I”), relating the patient’s perspective, thoughts, feelings about a recent clinician-patient encounter, illness episode, or other major life event
    • Use information actually known about the patient from past encounters, but also try to imagine aspects of the patient’s life that are unknown
  • POINT OF VIEW WRITING: PURPOSE
    • To develop increased understanding of and empathy for the patient’s situation.
    • To encourage playful, imaginative, and creative thinking about patients
    • To stimulate compassionate curiosity about and greater appreciation for patients
    • To decrease feelings of frustration, irritation, anger, and helplessness toward patients
    • To develop innovative strategies for patient interaction and management

 

Faculty Development

Pre-Health Professional Education

Surveys and Evaluations