The Craft of Writing: A Physician-Writer's Workshop for Resident Physicians

Abstract

INTRODUCTION

How can residency programs help trainees address conflicting emotions about their professional roles and cultivate a curiosity about their patients' lives beyond their diseases? We drew on the medical humanities to address these challenges by creating an intensive writing workshop for internal medicine residents.

AIM

To help participants become better physicians by reflecting on their experiences and on what gives meaning to work and life. This paper describes the workshop and how residents were affected by the focus on the craft of writing.

SETTING

A group of 15 residents from 3 training programs affiliated with 1 institution.

PROGRAM DESCRIPTION

We engaged the expertise of physician-writer Abraham Verghese in planning and facilitating the 2 and one-half day workshop. Residents' submissions were discussed with a focus on the effectiveness of the writing. We also conducted a focus group with participants to evaluate the workshop.

PROGRAM EVALUATION

Themes in the writing included dysphoria, impotence of the physician, and the healing power of compassion. Our focus group data suggested that this workshop served as a creative outlet from the rigors of medicine, created a sense of community among participants, enhanced both self-awareness and awareness of their patients' lives, and increased intra-institutional and extra-institutional interest in writing and the residency program.

DISCUSSION

Teaching creative writing to residents in an intensive workshop may deepen interactions with peers and patients, improve writing skills, and increase interest in writing and the residency program.

Contemporary medical education can have negative effects on resident physicians, including disillusionment, a lack of emotional engagement with the mission of medicine, and a corollary lack of commitment to patients as persons.^1–3 Such individual reactions can have systemic effects, such as the breakdown of trust between physicians and patients.⁴ Programs focused on reflection and self-awareness, such as Balint groups, personal awareness groups, and support groups have been associated with better healing relationships with patients.⁵ Writing narratives is another method for triggering reflection, self-awareness, and empathy.^6–10 Writing can stimulate residents to listen to the patient's story, appreciate the joy and fascination in the doctor-patient relationship, and cultivate the attitude that a patient is more than his or her disease.

In our program, we engaged the well-known physician-writer Abraham Verghese to help us create an intensive creative writing workshop for resident physicians. According to Dr. Verghese, joy, fascination, and empathy stem from the right brain's capacity for imagination, whereas medical training generally focuses on the left brain. Learning the craft of writing is one way to develop skills of observation and empathetic projection. As Verghese has asked, “Can a writer's bag of tricks improve the quality of our own lives, [and] satisfaction in what we do?”¹¹

His focus on the craft of writing diverges from approaches that deliberately integrate creative writing with clinical duties, such as personal journals, parallel charts, and critical incident reports, in which the emphasis tends to be on the description of an event and the clinician's personal reaction.^7,10,12–15 Our focus, in contrast, was on the writing itself: to express emotion effectively through language, to develop characters and lay out plots, and to avoid common mistakes that break the reader's engagement with the writing. The very process of refining a passage about a difficult experience can be part of the process of making sense of it: as Bolton says, “a clumsy and involved passage usually indicates a confused or poorly grasped incident in the writer's mind; so advice about rewriting is sometimes given to help writer face vital issues.”¹⁶

AIM

The aim of the workshop was to help participants become better physicians by reflecting on their experiences and on what gives meaning to work and life. In this paper, we describe the writing workshop and how the focus on the craft of writing affected residents.

SETTING

All 114 postgraduate year (PGY)-2 through 4 internal medicine and medicine/pediatric residents from 3 Yale-New Haven Medical Center training programs received a letter that described the workshop and invited them to submit a piece of writing (fiction or nonfiction, up to 4,000 words, on the topic “being a doctor”). Eighteen expressed interest and 15 submitted pieces. All 15 were invited to participate; 10 were female. Formal writing experience varied widely. The workshop took place over 2 ½ days. Residents were relieved of clinical duties during the workshop.

In order to assess participants' opinions on whether the goals of the workshop had been achieved, the authors collected qualitative data through 2 focus group discussions. In the first focus group, 1 month before the workshop, we solicited participants' motivations and expectations for the workshop. The second focus group (4 months after the workshop) centered on participants' impressions of how the workshop affected their professional and personal lives as well as the environment of the internal medicine department. We received a waiver of written consent from the Yale University Institutional Review Board.

Analysis

Our analysis was exploratory in nature and was done through an iterative consensus-building process. Each of 2 evaluators (A.B.R., H.H.) independently coded the writing samples and focus group transcripts (separately) for emergent themes, compared analyses, and came to consensus on a final set of themes.

PROGRAM DESCRIPTION

The workshop was modeled in the style of the Iowa Writers' Workshop, in which a sample of each writer's work is discussed and that writer is instructed to be “a fly on the wall”—that is, to listen to but not participate in the conversation. At the end of the discussion, the writer has the opportunity to comment.

The craft of writing was presented primarily through a conceptual strategy introduced to assist residents in analyzing writing. Participants were instructed to evaluate how well the writing awakened the reader's imagination, the assumption being that good writing triggers a “fictional dream” in which the reader takes the author's words and creates her own images. It follows that when a writer explains too much, it crowds out the reader's own fictional dream; when she explains too little, no fictional dream is formed. In addition, imprecision of sense, description, or meaning will cause the fictional dream to crack. The purpose of the “second eye” of other readers is to identify where the fictional dream has been achieved and where it is broken.

Two months after the workshop, the leader presented a Grand Rounds lecture on writing and the practice of medicine. An anthology (“Capsules”) of workshop pieces (http://info.med.yale.edu/intmed/prog/writers_workshop/index.html) was compiled and distributed at Grand Rounds, after which several participants read their work to internal medicine department residents and faculty.

Themes from the Residents' Writing

Three main themes were identified in the writing samples and during the workshop discussion. The first was dysphoria. Residents wrote about such topics as their own insecurity, discomfort with breaking bad news, conflicting emotions, and burnout (Table 1).

Table 1.

Themes from Residents' Writing: Dysphoria

“I find myself in a tailspin pondering what I want to do with my life and whether medicine is the right choice for me. Do I want to spend it being surrounded by sick people all day and filled with a cacophony of farts, coughs, vomiting, and help me's by senile old people?”

“I suspect the infant will end up on ECMO, be tortured for a few weeks, have a massive brain bleed from DIC and end up a vegetable on a vent, stay here in the hospital for months and months, only to be discharged as a severely disabled child completely dependent on government support. ‘We're doing everything we can, ma'am. No one except God knows if she will survive.’ But I am lying.”

“My attending gave me a high-five in the hallway, so good to feel successful about something [inserting a central venous catheter]. Is that why I am doing everything?”

The second theme, the impotence of the physician, emerged from pieces that addressed the moral dilemmas of medical intervention, the futility of ICU care, and the awareness of how little physicians know their patients (Table 2).

Table 2.

Themes from Residents' Writing: Impotence of the Physician

“And I know that at this weight, we're fighting a losing battle. We can tweak the lasix and the insulin and the neurontin, but Tony will never really get better …. But I don't tell him that because it would break him. Tony is calm now.”

“This is the best of modern medicine, I tell myself. We are monitoring heart rate, breaths taken per minute, and blood pressures in 2 locations. I am watching his urine drip out of him in real time. Every day I can recite his sodium and potassium, and I write down his white blood cell count together with exactly how many cubic centimeters of fluid went in and came out … I am producing a man too tired to speak, a man who is exhausted after just turning his head to stare into the eyes of his wife.”

The third theme was the healing power of compassion and its capacity to renew one's interest in and passion for medicine (Table 3).

Table 3.

Themes from Residents' Writing: Healing Power of Compassion

“I see what Kimberly is trying to show me [a normal delivery of a healthy infant]. I think I will need to recover from this place, the way people need to recover from other crises, like war. I think it will take a lot of healthy deliveries.”

“We came in to change my father's code status … It was the end of the third week in the ICU and I must have looked exhausted and ragged. Dr. L. took a step towards me and embraced me with both arms as if I were his son. I looked up and thought I saw his eyes moisten. In a sense he had absorbed some of my emotion and I felt bolstered by this gesture.”

PROGRAM EVALUATION

Of the 15 residents who participated in the workshop, 10 attended each focus group. Focus group data revealed that the central theme, writing as a creative outlet from the rigors of practicing medicine, affected 4 additional themes: (1) peer and group relations; (2) self-awareness; (3) awareness of patients' humanity through the recording of their stories; and (4) the possibility of effecting larger institutional changes through the sharing of patient's stories. Table 4 provides representative quotes from each theme.

Table 4.

Writing Affects Four Themes

Themes	Participant Responses
I. Peers	“We had similar experiences in residency … how do we conceptualize and describe these experiences differently?”
II. Self	“I didn't realize some of the emotions I was feeling until writing it down … not processed until writing.”
III. Patients	“Individual words that you would never use in a progress note … what the patient looked like, smelled like … makes you look at them in a different way … the act of writing changes the way you look at patients.”
IV. Institution	“Part of the ripple was having had Grand Rounds and distributing our writing. It infuses the culture of this place … I've talked to faculty, and also to other residents who wished they'd been brave enough to sign up.
	“I've been interviewing for jobs … every single place asked about the workshop, more than the other things on my resume.”

DISCUSSION

Teaching creative writing to residents in an intensive workshop led by a physician-writer affected residents' views of self, peers, and patients. The workshop also inspired interest related to writing both within and beyond the institution.

How did this workshop differ from other modes of writing in medical education such as critical incident reports and parallel charts? The latter 2 focus on the recording of experiences and reactions in ordinary language, rather than with a focus on the craft and skills of writing. Pennebaker has pointed out that writing a narrative can help a person organize complex emotional experiences, which is critical to reaching understanding.¹⁷ Residents who take a step beyond and learn to craft narratives into polished and nuanced pieces have the unique opportunity both to understand their own experiences more deeply and to imagine more fully the experiences of those they write about. Focusing on the craft of writing, in other words, provides a means of increasing one's powers of observation and improving one's understanding of both self and others.

The therapeutic nature of group discussion of the emotional impact of residency was an unanticipated effect of the workshop. Residents reported that sharing writing led to a group cohesiveness, which has been noted in other modes of using writing in medical education, such as critical incident reports. When every member of the group writes, a shared vulnerability is created; the resulting openness of discussion can help dissolve the hierarchy that might otherwise prevent group members from speaking up.

Whether this particular type of workshop should ultimately be expanded to include a larger portion of a residency program is not clear. Barriers such as funding (the total cost for our workshop was approximately $9,000), time constraints, coverage issues, and the recruitment of established physician-writers as leaders may present significant challenges. Some residents may be intimidated by working with a well-known physician-writer or the focus on writing skills and opt not to participate. It is unclear how much residents without a particular interest in the craft of writing would gain from such a workshop, though it can be argued that training in writing well is relevant to all physicians.¹⁶

Clearly, our initial experience was with a highly selected group of residents participating voluntarily. The actual effect of the workshop on practice is not known. Finally, it is unclear whether the process of writing, the specific structure of the workshop or, more generally, the time and space for reflection and social interaction between residents afforded by the workshop accounts for the rich feedback received from participants. We have continued to present the workshop annually (with a different physician-writer leader). In the most recent workshop, we included several residents from another specialty, with the goal of helping residents appreciate one another's perspectives and to promote more effective partnering in patient care.