IJCAIP Commentary

The Poetry of Practice
Medical Students Voice the Inexpressible through Poetry
Maureen Rappaport MD, FCCFP, McGill University, Montreal, Quebec

“It is difficult to get the news from poems
yet men die miserably every day
for lack of what is found there”¹
William Carlos Williams

I offer a creative writing course as an elective to fourth year medical students at McGill, entitled “The Poetry of Practice.” We meet for two and a half hours twice a week for four weeks, to read, write, and discuss “medical literature” radically different from what is found in medical textbooks, clinical case notes, and scientific journals. The literature I am referring to are stories of sickness and healing, patient pathographies and doctor stories as well as great artistic literary works written by ordinary people, healthcare professionals, medical students, poets and writers. I use various sources including anthologies and websites.^2,3 The course grew out of my own personal experience with creative writing, backed up by a flourishing growth of interest in the Medical Humanities in Medical Schools across North America.

Our medical schools have done a great job in training clinicians ‘heads’, in preparing doctors in the ‘trade’ of medicine but as Sir William Osler tells us, “The practice of medicine is an art, not a trade; not a business, a calling in which your heart will be exercised equally with your head.”⁴ We have been criticized for a failure of heart, for lacking in the art of practice. Reading and writing short stories and poetry in a supportive group setting is one way for some students to discover what is in their hearts and remember why they went into medicine.

Medical educators often debate ‘if we can and how we can’ teach the attitudes, values, and skills necessary to aid in our patients’ healing process. Much has been written about the hidden curriculum in medical school and how the journey in medical education can diminish the level of our students’ empathy or create wounded healers.

My main objective in this course was to listen to and honour the voices of medical students through creative writing. To quote Rita Charon, an internist, literary theorist, and leader in the field of Narrative Medicine, “It is not enough for residents and staff to examine what we do in medicine, but we must be cognizant of what medicine, the training process and practice, has done to us.”⁵ In my course “The Poetry of Practice” a safe space was created to allow students to discover their own training stories; to use the power of non-scientific, literary, and poetic language to articulate insights and feelings related to any aspect of medical training.

In my sessions with the students, we wrote freely for about thirty minutes. The rules were simple. We primed ourselves by first reading and discussing a poem or two, and then we wrote. I told them to write about specific incidents, to remember details, sounds, smells, colours, and faces. To write freely, without editing, to write nonsense if that’s what came out, and to know all writing could be torn up or shared. We did various creative writing exercises to stimulate the right side of our brains, to allow non-linear narrative thinking to over-ride logical scientific process. Pens flew in our little classroom and by the second week all participants were reading their writing out loud to each other. The ground rules were to treat all writing respectfully and confidentially, but to treat it as fiction. An example below,

“Strange, how the first time I had taken a patient’s history I could have written a novel. And now, just a few months later, here I was like every doctor before me, weeding out everything that made this person human until I had her life, or all that I needed to know of it, tapered into a single piece of recycled hospital paper. Almost eighty years, and this was it. She was“77F, advanced CRC”. - J Howe (Med4)

Language is very powerful, and for many of the writers in my groups, the permission to expand their medical selves out of the constraints of a brief case note humanized both the patient and the doctor. A second example,

“I take notes. Reams of fiber with names, ages, aches, fevers, and cures to be filed away in some cabinet or another. My wrist moves in time with the litany of discomforts and deficiencies, a metronome to suffering and loss. Sound etches the paper with ink, indelible, unforgiving. Your words and my paper, but it doesn’t touch me.” - Lily Chu (Med4)

The speaker in the above piece states she is not touched, but I as the reader, am very touched by these few lines and can feel the suffering and loss of both student and patient. In the poem “Many Nights” (printed below), the same student writes about another experience in a way which is not just ‘a metronome to loss and suffering’.

MANY NIGHTS
I watched her in her fractured sleep
I listened to her breath hanging
moistly in the catacombs of her lungs
her ribs the strings of an ivory
harp played by cruel gods
she would ask for water sometimes
and skim it with her tongue
her lips and hair chalky in the moonlight
then she would lean back gingerly
though her mass was already insubstantial
to the sheets and the coiled metal beneath
she had the most incredible skin
a parchment sheath growing
more translucent by the hour, as if
underneath thin layers of white wax fell
away with the grinding of her bones
I knew that one day soon, in the moon
light I would be able to see through her
- Lily Chu (Med4)

Watching a patient die, the moment of bearing witness, takes its form as poetic elegy. The first stanza contains some medical words, fractured, breath, lungs; words that mix hauntingly yet beautifully with catacombs, ivory harp, and cruel gods. As the poem progresses the patient, her ‘insubstantial mass’, becomes more ethereal, more translucent by the hour, melting wax, until the student knows she would see through her. One cannot watch death and suffering and not be touched, but these feelings are hard to express, hard to articulate and many times impossible to acknowledge as students run around the hospital not quite sure of what they’re supposed to do as student doctors. For those who can access it, poetry offers a language to express the inexpressible. For those who wrote, shared, and listened in this context, these moments of bearing witness became medical acts.

The issues my students wrote about were more or less universal, the same issues American researchers in Narrative Medicine have reported, fear of death and suffering, loss of personal identity, fear of ignorance, role models (good and bad), and the joy of doctor patient relationship.(6,7) The students in the two years I’ve held this course told me verbally and in written evaluations that they found the course healing, a stress relieving activity, meaningful, a way to maintain a sense of humanity, a way to resolve conflict and disturbing feelings, and a wonderful way to bond with classmates and feel less alone about common experiences.

This course was healing and cathartic for my students and me; both the poetic and the group processes were necessary. Looking at the words written by the physician poet William Carlos Williams, I’d like to say, it’s hard to get the diagnosis from poems, yet many suffer daily for lack of what is found there.

References

1. Williams WC. The Doctor Stories. 1938. New Directions Publishing Co.
2. Reynolds R. and Stone J (Eds). On Doctoring. 1995. Simon and Schuster.
3. Literature, Arts, and Medicine Database. http://endeavor.med.nyu.edu/lit-med/lit-med-db/
4. Osler Sir W. Classics and Ideals and selected Aphorisms of Osler. The Classics of Medicine Library, Birmingham, Alabama.
5. Charon Rita. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA 2001;286;1897-1902
6. Rucker L. and Shapiro J. Becoming a Physician: Student’s Creative Projects in a Third-year IM Clerkship. Acad Med 2003;78(4);391-397
7. Ferrara E and Hatem D. Becoming a Doctor: Fostering Humane Caregivers through Creative Writing. Patient Education and Counseling 2001;45;13-22

This article was reprinted with author permission. Originally published in CCAHTE, Canadian Creative Arts in Health, Training and Education Journal, Issue 3, September 2006.

Biography

Maureen Rappaport MD FCCFP is a family doctor working in a community practice in Montreal, Quebec, who teaches family medicine residents and medical students at McGill University. She is also a writer of short stories and poetry mostly about caring for older persons and dying patients. Her work has been published in medical journals and anthologies.