Poetry On Rounds: A Model for the Integration of Humanities into Residency Training

by Harold W. Horowitz

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In medical training, humanity takes second place to scientific achievement. The realization that we are producing a generation of less than humane doctors has begun to trouble both medical educators and clinicians. Might the study of the humanities, especially the reading of literature, in medical training help doctors to be more humane? Some proponents certainly think so (American Board of Internal Medicine; Association of American Medical Colleges; Baker; Barnard; Charon et al; McManus; Risse;), and the multifaceted contributions of literature to clinical practice have been recently reviewed (Association of American Medical Colleges). Although the study of humanities in medical school curricula is one way to encourage humanistic qualities in the practice of medicine (Association of American Medical Colleges; Almy et al), less attention has been paid to models for teaching humanistic qualities in residency training (Arnold et al; Barnard). Lack of time, of leader expertise, and of residentsâ interest have been cited as barriers to the study of liberal sits in residency training programmes (Povar and Keith). Furthermore, few robust models have been proposed for the integration of such training into residency programmes.

During rounds, attending physicians and medical trainees interact and influence both each other and patientsâ care. However, the process of humanizing rounds as a method to create physicians who art more caring, and perhaps alleviate the burnout that often occurs among overworked housestaff and awed medical students, has received little attention.

An experiment
I decided to try a small "experiment" and use about 20 min of the 90 min allotted to daily rounds for the reading and discussion of a poem that was to be selected and brought in by team members on a rotational basis. Participants were encouraged to choose a poem from their country of origin whenever possible. Some of the team members laughed at the proposed idea of poetry reading; several were somewhat nervous about the idea. To lessen anxiety, I brought in the first few poems.

Apart from two attending physicians there were 11 team members, of whom six were housestaff and five were medical students. Trainees were from seven countries÷ Haiti, Korea, Japan, Russia, India, Pakistan, and the USA. In total, 18 poems were discussed. One individual who did not find a poem brought in a photographic account of her native city.

Poems that were about illness and the nature of being a physician were most commonly chosen for presentation. However, poems on a variety of subjects were discussed, and not all poems were profound. A poem written by Michelangelo on the painting of the Cistine Chapel and another about falling asleep during lectures were among the "lighter" poems that were read. To my surprise, seven poems were written by a team member or one of their friends or family members. What was most remarkable about the experience was not the poems themselves, but the character of the discussion that followed. As might be expected, during the first several days people tended nor to venture very far from fairly strict interpretations of the poems. However, by the second week, as the team warmed to each other and to the notion that this experience was going to be a part of the rounds, the discussions blossomed.

The poems
Some samples from pocus that were presented and discussions that followed will help to explain the nature of our experience. A medical student front Japan brought in a Haiku that he had written:

Feel the wind!
Feel the dreams!
In the world
Phil feels loneliness in the ward

Various team members spoke about the loneliness of being on call away from home, the loneliness experienced by patients in hospital, and the experience of aloneness while trudging into yet another patientâs room late at night to draw blood or perform an electrocardiogram. The discussion of this poem, at least for a few moments, allowed us to share each otherâs experience of loneliness.

A stanza from a larger part of The Rubaiyar of 0mar Khayyam that was brought in by a resident from India reads:

Drink wine, you will lie long enough under the ground
without companion, friend or comrade.
Take care you tell no one this hidden secret,
No lily that withers will bloom again.

After initial silence, there was a flurry of opinions and questions. One attending physician asked team members whether they thought that a strong religious belief in the afterlife would lead to more rational approaches to the withdrawal of medical care. For instance, were religious Catholics or Hindus more likely to sign "do not resuscitate" orders or press for less aggressive management of the terminally ill patient? A medical student commented that this poem spoke to the notion of "eat, drink, and be merry". This stimulated a conversation about the stresses of medical education and the loss of personal time and hobbies at all levels of training because of the grueling workload and the need to "keep up" with published medical research. I advised students to try to develop patterns now for ensuring that they keep some control over their extracurricular time and to consider carefully she sacrifices they were making.

An anonymous poem entitled Since I Lay Ill included the following stanza:

Since I lay ill, how long has passed?
Almost a hundred heavy-hanging days·
How can I bear, when the Earth renews her light,
To watch from a pillow the beauty of Spring unfold?

This poem contrasts the gloominess of death with the rebirth of the spring season. How much more poignant these lines became when we learned that they were written in 840 in Korea. Reading these lines, now written across centuries and continents, was humbling for us all. We discussed the commonality of the experience of illness by patients from different cultures and possibly in different times. I raised the question of the aggressiveness of treatment for severely ill patients in the USA and contrasted this with the resources available in other countries. Several foreign residents and students noted that in their countries lengthy stays in hospital for terminally ill patients was frowned upon and that, generally, people died at home. We compared this poem to other poems we had read that had been written within the past few years by or about patients with AIDS.

The last illustrative example Comes the Dawn, a love poem, created the most lively discussion. This anonymous work was brought in by a resident from Haiti. It begins:

After awhile you learn the subtle difference
Between holding a hand and chaining a soul,
And you learn that love doesnât mean leaning
and company doesnât mean security,
and you begin to learn that kisses arenât contracts ...

This poem led to a conversation about the need for the self-satisfaction required for a strong relationship. Furthermore, it was the springboard for a discussion about the effects of the emotional and physical demands of medicine on physiciansâ personal relationships. Issues such as the high divorce rate among physicians and drug dependency were also raised in relation to this poem.

The verdict
On the last day of rounds an anonymous survey was distributed to get a sense of the individual impressions of the experience of reading and discussing poetry on rounds. Five team members thought the idea of presenting poetry on rounds was "excellent", three "good", and three "so-so". No-one felt that the idea was a waste of time. All respondents "enjoyed the few minutes respite from didactic teaching during rounds". It is noteworthy that the process of finding a poem also was thought to be worthwhile; nine individuals said they were given the opportunity to read or think about something that they would otherwise not have done. Eight people felt that this process was "enjoyable" or "overall worthwhile". Not everyone thought that the experience was useful; one person said that finding a poem prevented him from doing or thinking about something he would have otherwise liked to do, and two felt that the process was "burdensome". All but one person said they would enjoy doing something like this again.

The comments by team members on the questionnaire focused on three main themes: humanization, exploration of feelings, and change from the routine. Specifically individuals wrote:

"I felt nourished by the attention to deeper insight, to words themselves, to feelings, impressions, all easily lost despite their value in medicine."

"It was a nice respite from medical mundane÷donât get me wrong, I love medicine, but poetry allows you to explore yourself, your feelings, and it reminds you that you are human [and] have different sides to yourself other than just an academic side."

"The few minutes spent in poetry reading were like breath of fresh air during rounds."

"It was refreshing for me."

"Poems are important conceptually and help us to be what we are÷humane."

"To tell you the truth, I found excellent meanings to the poems on rounds. And I noticed that the Haiku translated into English sounds better than in Japanese."

Discussion
The idea of expanding the scope of physicians' intellectual and emotional lives through art and literature is not unique (Baker; Charon et al; Risse; Verghese). Several major medical journals now include regular art or literary features. The Annals of Internal Medicine publishes original poems, an "Ad Libitum" piece, and recommendations for readings in "The Literature of Medicine". The Journal of the America; Medical Association weekly presents a work of art on the cover with an associated commentary, and publishes poem for the readerâs perusal. The American Journal of Medicine contains reviews of books In "Reading for Survival", and literary pieces in the section "Medicine Science, and Society". The New England Journal of Medicine publishes artistic photographs. And, The Lancet now publishes original poetry, as well as articles on medicine and art, and medicine and literature. Such attempts to integrate arts and humanities with medicine are important. Attending physicians rarely ask trainees to report on the humanistic articles in medical journals. Perhaps more importantly, if these humanistic writing are not discussed among physicians and trainees they cannot provide an area for further exploration of the potential issues that they raise.

The exercise of reading non-medical material on medical rounds was intended to allow people to discuss their feelings about aspects of medical care parallel to, but not specifically about, medical diagnosis and treatment. The openness of the discussions that ensued during rounds was remarkable. Attending physicians, housestaff and students all took part in conversations, each with somewhat different perspectives, some being culture dependent, others not. It is noteworthy that many of the hierarchical distinctions that typically exist during didactic rounds were dismissed; attending physicians and trainees discussed emotional and intellectual responses to poem on an equal footing. Concerns, disappointments, and accomplishments found at each level of training were also raised during discussions.

Whether the novelty of reading poetry on rounds was the main factor in the positive responses by team members is open to question. Reading poetry month after month could wear thin. However, perhaps a session or two weekly would provide a moment of reflection and respite from didactic training. Clearly, different groups will interact differently and choose different readings, thereby sustaining at least some of the initial enthusiasm. Other models that have been used to teach humanistic qualities to housestaff have used the formal teaching of medical ethics and communication skills (American Board of Internal Medicine; Povar and Keith). However, advantages of reading poetry include less time commitment and the provision of a format in which teachers and students communicate in non-didactic manner so that humanism is experienced, not taught.

Poetry readings seemed to allow highly motivated, often narrowly focused, medical trainees to step back and discuss facets of literature and life outside of those traditionally entertained on medical rounds. Most importantly, rounds became a time when the team shared not only medical knowledge, but also life and emotional experiences. It is also my impression that poetry discussion facilitated better interpersonal relationships among team members as individuals became more aware of the feelings of both each other and patients. I look forward to next yearâs rounds and an opportunity to explore poetry with another team.

I thank Dr Nicholas H Fiebach for stimulating conversations about humanities in medicine and helpful suggestions regarding the manuscript, Dr Abraham Verghese for critical review of the manuscript, and the medical students and housestaff who took part in this experiment of life.

References
Almy TP, Colby KK, Zubkoff M, Gephart DS, Moore-West M, Lundquist LL. Health, society, and the physician: problem-based learning of the social sciences and humanities. Ann Intern Med 1992; 116: 569÷74.

American Board of Internal Medicine. Evaluation of humanistic qualities in the internist, Ann Intern Med 1983; 99: 720÷24.

Arnold RM, Povar GJ, Howell JD. The humanities, humanistic behavior, and the humane physician; a cautionary note. Ann Intern Med 1987; 106: 315÷18.

Association of American Medical Colleges. Report of the working group on personal qualities, values, and attitudes: physician in the twenty-first century. J Med Educ 1984; 59 (suppl): 177÷89.

Baker; NJ. Literary medicine. Minn Med 1990; 73; 19÷20.

Barnard D. Making a place for the humanities in residency education. Acad Med 1994; 69: 628-30

Charon R, Traucmann Banks J, Connnelly JE, et al. Literature and medicine; contributions to clinical practice. Ann Intern Med 1995; 122: 599÷606.

McManus C Humanity and the medical humanities. Lancet 1995; 346: 1143-45.

Povar GJ. Keith KJ. The teaching of liberal arts in internal medicine residency training. J Med Educ 1984; 59: 714÷21.

Risse GB. Literature and medicine. West J Med 1992; 156: 431.

Verghese A. The internistâs reading one kind of "success". Ann Intern Med 1994; 121:821÷22.

Reprinted from Lancet, Feb 17, 1996, 347(8999) 4470-449.with the kind permission of the author and Lancet.

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