On this episode of the Academic Medicine Podcast, Andrew Orr, MD, MSEd, and Dorene Balmer, PhD, join host Toni Gallo to discuss their study of a longitudinal arts and humanities curriculum for internal medicine interns, which is part of this year’s Research in Medical Education (RIME) collection. Also joining the conversation are RIME Committee member Pilar Ortega, MD, MGM, and AAMC MedEdSCHOLAR Nicole Findlay-Richardson, MD, MPH.
This episode is the final one in this year’s 3-part series of discussions with RIME authors about their medical education research and its implications for the field. Check out last month’s episode on medical students’ experiences of failure and remediation.
This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.
A transcript is below.
Read the article discussed in this episode:
Transcript
Toni Gallo:
Welcome to the Academic Medicine Podcast. I’m Toni Gallo. Every year, Academic Medicine publishes the proceedings of the annual Research in Medical Education or RIME sessions that take place at the AAMC’s Learn Serve Lead meeting. This year, the RIME papers, including the one we’ll be talking about today, will be presented throughout the Learn Serve Lead meeting, which is taking place in Atlanta next week.
The RIME papers are available now to read for free on academicmedicine.org as part of the November issue. As in previous years, I’ll be talking to some of the RIME authors on this podcast about their medical education research and its implications for the field. On last month’s episode, I spoke to the authors of a qualitative study of medical students’ experiences of failure and remediation, and you can find that episode in our archive.
Today, for the third and final of this year’s RIME conversations, I’m joined by Drs Andrew Orr and Dorene Balmer, two of the authors of “Patients, Peers, and Personal Identity: A Longitudinal Qualitative Study Exploring the Transformative Potential of the Arts and Humanities in Intern Training.” Joining us today for our conversation are RIME Committee member Dr. Pilar Ortega and MedEdSCHOLAR Dr. Nicole Findlay.
We’ll talk about the professional and personal benefits for learners of experiencing the arts and humanities during residency training, including as an antidote to burnout and as a tool for professional identity formation. And then, we’ll get into some of the differences in the role of the arts and humanities in the residency curriculum versus the medical school curriculum. So, to get us started today, I’d like to do some introductions. Andrew, could you go first?
Andrew Orr:
Sure. Hi. Thanks for having us. So I am an academic hospitalist, and when the work was being done for this article, I was working at UPenn. I have since moved to UCSF, and I work at the San Francisco VA Medical Center.
Toni Gallo:
Great. Welcome. Dorene?
Dorene Balmer:
Hello, I’m Dorene Balmer. I’m a Professor of Pediatrics at the Perelman School of Medicine, University of Pennsylvania.
Toni Gallo:
Thanks for joining us. And Pilar?
Pilar Ortega:
Hi. It’s great to be here. I’m Pilar Ortega. I’m Vice President, Diversity, Equity, and Inclusion at the Accreditation Council for Graduate Medical Education, and I am an emergency medicine physician.
Toni Gallo:
Wonderful. Hi, Nicole.
Nicole Findlay-Richardson:
So my name is Nicole Findlay-Richardson. I am an OB/GYN physician. I work at the University of Tennessee Health Science Center in Memphis as the Director of Simulation Education for OB/GYN. So that’s a little bit about me.
My interest in medical education is mostly with simulation, but I am involved in other aspects of the educational program with interns, residents, fellows, medical students. So this article is super interesting and kind of touches on what we call the soft side of medicine that we often underappreciate, but it’s important, and so I’m really excited to be here.
Toni Gallo:
Great, thank you. We’re happy you’re here too. Let’s start with a little bit about Andrew and Dorene’s paper. Could you walk us through what you did for this study and maybe describe some of the key findings for our listeners?
Andrew Orr:
Yeah, I mean, the bottom line is our study is really about exploring the effects of arts and humanities-based instruction in graduate medical education in particular because there’s historically been a gap here compared to how arts and humanities have been studied in UME. And then, also, a lot of the assessment that has been done involves things like learner satisfaction or self-reported pre- and post-survey data without really trying to identify the full potential of arts and humanities instruction. And so, as a result, we know less about how these interventions work or, frankly, if they do at all for the GME population.
And then that becomes a problem because, without this understanding, it’s hard to design interventions that are effective or advocate to program directors to get the time or the funding to start these interventions. So, with that as the background, we set out to find a way to really dig into this question of what are the arts and humanities trying to affect in graduate medical education. And we ultimately decided that the approach of longitudinal qualitative research, which I’ll let Dorene say more about in a moment, would allow us to best explore this.
And we ended up using longitudinal audio diaries and semi-structured interviews to closely follow a group of internal medicine interns as they progressed through a year-long curriculum that incorporated several arts and humanities-based interventions during their intern year. But before we actually talk about what we learned, Dorene, maybe we can pause here to say a bit about longitudinal qualitative research in general because it was such a helpful approach for us.
Dorene Balmer:
Sure. Anything… anytime I get to talk about longitudinal qualitative research, I never say no. So longitudinal qualitative research is an approach to research where you’re collecting data, generating data with the same participants through time, typically over the course of a year. Although there’s no chronological start and stop time. The one thing about longitudinal qualitative research that distinguishes it from something like a follow-up study is longitudinal qualitative research is sort of this slow crawl through time, walking with the same participants through time.
In this study that we’ll talk about more, it was over the course of a year. And longitudinal qualitative research is unique, I think, in other… amongst other methodologies in its real focus on time and it’s time chronologically, but we’ll also see sort of seasons of time. January doldrums come, and then they pick back up. So there’s that rhythmic, the seasonality of time, there’s high points, best days, worst days, all those different kinds of time.
And the last thing I’d like to say about longitudinal qualitative research is when you’re using that approach, like Andrew did, it’s not really a single… you’re not so much studying the effect alone, in his case, the effect of an arts-based intervention or humanities and arts-based intervention, but that effect through time. So it always situates a phenomena of interest in the context… in the more temporal context. Andrew, you want to say a little bit more about how you use longitudinal qualitative research?
Andrew Orr:
Yeah. So we, like Dorene is mentioning, looked at how things were evolving over time, over that period of the year where the interns were going through this curriculum. And what we found were that there were some stable themes throughout that kept showing up, which pointed us to think that these are probably longer-standing effects of the arts and humanities interventions that the interns were experiencing. And then those themes were essentially how the arts and humanities interventions seemed to rekindle a sense of personal identity for the interns.
And then, out of that rekindled personal sense of self seemed to flow greater connections with their peers, renewed empathy for their patients despite the demands of the job. So then we’ve summarized those in the paper and then also included two of the intern’s stories that represented… they were the most salient for those themes. And you really get a sense using the longitudinal qualitative research piece of how those themes change through time or don’t and how that can vary for different individuals.
Dorene Balmer:
And one thing I failed to say was a little bit more detail about the methodology of this particular study. So there was really collected in two ways… data collected in two ways, one through in-depth interviews, which were done sort of midway and then towards the end. And then, there was a series of audio diaries where residents or interns were clicking on their little memo app on their phone and just recording a two to three-minute audio diary.
So the data that were generated were qualitative data in the form of interviews, interviews transcripts, and audio diaries, the transcripts of those audio diaries, which we then analyzed qualitatively. And sometimes, you start with some kind of themes because we generated those themes that Andrew shared. So there’s a little bit of that paradigmatic way of knowing.
But with longitudinal work, you’re really getting story, right. When you follow somebody over a year or two years, you’re getting story. So there’s also oftentimes, not only that coding and themes but the telling of story, which Andrew did of sort of two stories at the end of… after the themes.
Andrew Orr:
And I’ll add to that. For context of the audio diaries and what that looked like, I would send each intern a prompt after they had just experienced a particular arts and humanities-based intervention or session. And the prompt was always a variation of what did that activity have to do with entering the field of internal medicine.
And then we would let them expound on that. Usually, it was two or three minutes long. Sometimes, they talk about personal life stuff. Sometimes, they talk about their professional lives, and then we kind of put it all together at the end.
Toni Gallo:
So I want to dig in a little bit to some of the themes that Andrew and Dorene mentioned from this study and a number of them, whether it was thinking about fostering empathy or building community or reclaiming this sense of self we can really think about in terms of being antidotes to burnout in residency. And this is a question for everyone. I’d like to talk about why that’s so important and maybe what this really looks like or how we can think about it for residents specifically. So anybody’s welcome to jump in.
Andrew Orr:
I’m happy to start just because I think thinking about burnout is where a lot of people start when they start… want to get involved in the arts and humanities space. And it seems like a natural fit that those themes that you just mentioned that we found could really be useful in combating depersonalization, emotional exhaustion, low personal accomplishment. My thinking on this has evolved a little bit, and I do think it’s important to just specify that it’s the themes and the lessons of the arts and humanities-based interventions, and it’s really not the interventions themselves, I think, that are the important piece.
So whenever I’m facilitating one of these interventions, I’m really careful to say upfront, especially in GME where residents are really, on a daily basis, experiencing a health care system that is in a lot of ways in need of a lot of structural change, it’s not a half-day… it’s not that a half day at the art museum is meant to fix burnout, and that’s not the goal of the session to promote career-long skills and kind of philosophies that the participants can use. I also think that there’s a misconception out there sometimes about the arts and humanities in that they’re meant to soothe us into making peace with a system that doesn’t necessarily work for all of us or for all of our patients.
But this is where my thinking has landed is I think in reality when done well, these interventions should actually do the opposite of soothe us and they should challenge us and unsettle us, make us think just because philosophically the arts and humanities pose really provocative questions about the current state of health care. They pose paradoxes. They pose contradictions that encourage critical understanding, and I found that they really can reorient people in direction of their personal north stars and be kind of a democratizing force for change.
So even within our study, we’re seeing how the arts and humanities seem to pose challenging questions that the interns then have to grapple with for themselves, things like, “How does my daily work fit in with the larger vision that I had for my life? Or how is the system in which I work changing me, and am I okay with that? Or even just how do we collectively form a community of support?” And I think that just kind of scratches the surface of this really deeper level of what the arts and humanities-based interventions can do in terms of raising the questions that might help GME learners critically reflect and then take action to make change and realign their experiences with their goals and values.
Pilar Ortega:
That’s fascinating, Andrew. And I love what you shared about building skills, lifelong and career-long skills that residents can take with them throughout their career. And I think in graduate medical education, that is so critical to consider. And what we do in the educational space has the potential to set up those lifelong and career-long habits that will define the… peoples’ career potentially.
And so I feel like, to some degree, providing that dedicated time and space for self-reflection through arts and humanities and making that a consistent part and this intentional decision to make this longitudinal rather than maybe short and intensive. Maybe this is something that you all considered at the time when you were creating the intervention. Really sends the message you have permission to make the space. You really have that, that’s a need, that’s part of your educational journey.
For me, a few years ago, one of the parts of my career that’s a little bit off the beaten path is I decided to embark on doing a master’s degree in graphic medicine. That was, I think, a step for me to say the fact that I’m not only taking the time to do something that I haven’t done for years and kind of re-looking at that aspect of myself, which I love, but also I’m going to get a degree out of this.
And in a way that, like a course or a degree, these are ways to legitimize an activity that sometimes is perceived as fluff. Right? So I’m curious if you could share a bit about that aspect of the legitimization of this work, and did you hear from participants at all about that aspect that it felt good to be, I don’t know, supported, I guess institutionally, to be able to do this work?
Andrew Orr:
Absolutely. And just to piggyback on what you’re saying about the messaging. Part of the problem I think right now is when you have the bulk of the interventions that use arts and humanities in education in the UME world, and then there’s a steep drop-off when you enter GME, the message that learners do receive is that this is fluff, and this is for when you’re not in the real world of clinical practice. But when you enter clinical practice, it’s no longer useful, practical, or important for you to have that space.
And to your last point, did we hear from our participants that they enjoyed having that dedicated time to actually think about themselves? Overwhelmingly, yes. We had people say that they had the chance to just exist, and that felt precious. And they could actually have the time and the space to be vulnerable with their peers, which there’s a whole… I think it’s hard in medical culture, in GME, and even in independent practice afterwards to be vulnerable for a lot of reasons. I mean, some on a fundamental level, we have to project confidence for our patients.
But again, if you did want to be vulnerable, there’s not really time during the workday as a resident to talk about it. So just carving out the space and doing it at regular intervals. And we actually had the intern cohorts, they were in the same group of people, so they could build bonds over time and do all the interventions with the same… their same cohort. I think that sends a huge message too that, yes, this is important, this is valuable, this is how you are navigating your identities, and you’re going to figure it out together, and we have to help you along the way.
Nicole Findlay-Richardson:
As a follow-up question to that, did you guys get any feedback from the program in general about just the reception of this? Because in terms of the recruitment email was sent out to everyone, and only 20% actually volunteered. So, in a sense, we may be self-selecting for people who want to talk and people who think that this is important or think that it’s valuable.
Was there in the interviews, any talk about what people outside of… I know it’s a little bit outside the scope of the study, but just to get a sense of did this work really well because we self-selected the people who like this type of thing versus those who think that this is not important and if they were forced to participate probably would not have done so well with it. Was there any sense of that in terms of with the program? Did you guys get any feedback about that?
Andrew Orr:
That’s a great… I think that’s one of the main questions of this study and then an area where future work is going to be needed. We didn’t… We don’t have any formal responses from the program or anything like that, but we did hear a lot from our interns. And in the interviews, we probed deeply into, “Okay, what exactly was happening? What were you experiencing?”
And what we heard from many of our interns was how they have made really strong and lasting friendships and relationships in their group, even with people who were not in our study, and how they’re able to talk about things in their group and kind of figure out what does it mean to be a doctor? What does it mean to be a good doctor? What does it mean to be a human being? And they’re figuring out together, “How much of myself can I bring into work, and is it okay for me to do things that fill my own cup after work?”
And these are things that they’re all learning from each other in their own approaches. So I do think that even the people who didn’t sign up for our study to go through with sending audio diary responses in over the course of a whole year and do interviews, it seems like they’re talking about the same things that we were hearing about.
Dorene Balmer:
And we had a fairly good representation of people who were… enjoyed arts in medical school or were maybe an MFA background or something in those who didn’t. So their exposure to some of the humanities and arts was different among the group. And when we talk about the effects of the program or what is the program doing, I think it’s important to remember that it’s not a set point in time.
This is not a cross-sectional study. It moves with time. And so some participants were pretty much like gung-ho from the start and others sort of, “Well, is this really going to…” They sort of… Their interest of falls off and they swing back up. So it is not only different between people and participants, but it’s different within the participant based on when you speak to them. And that’s captured nicely in the stories at the end of the paper.
Pilar Ortega:
I wonder also about the potential effects that are not direct on the participants themselves but how there might be impact on the overall culture of the residency program just by the fact that X number of residents in that class participated in this intervention. Are they bringing with them some of the skills that they learned, and how is that affecting the overall sense of community? And are they sharing some of the things they learned with their peers who maybe aren’t participating?
So I think those are really exciting ideas to consider for future research and maybe in other specialties as well, and how this kind of work could impact not only those who are participating in it but the overall environment. Because I think a lot of the work in well-being, in diversity, equity, and inclusion, a lot of it is so dependent on that overall institutional culture, the culture of the learning environment, the culture of all of the individuals involved.
And we tend to focus on individual factors more so than we do kind of the overall community. So it would be really cool to see how even having this, even if you don’t participate, but having this around in the culture could possibly be a good thing or produce positive results in terms of the institutional environment.
Andrew Orr:
That’s such a great point. In my mind, that’s what it’s all about. It’s about can these interventions spark those skills and lessons that then translate from what… the museum into your clinic or on the wards and how you are with your colleagues and with your patients. Totally. So even for those who don’t necessarily have an affinity for the humanity… the arts and humanities, so to speak, they’re able to get the valuable lessons as well. And culture is a huge part of it.
Toni Gallo:
One of the other things that a number of the participants mentioned was having the benefit of, in their reflections, feeling like they’re not alone anymore or that these are… there are shared feelings. These are things that other… experiences that other people have had too.
And this is actually a theme that’s come up in a number of podcast conversations we’ve had here over the last year or so, and I hope you can all reflect on that and the value of helping residents not feel so alone, giving them that sense of community and what that might… what benefit that might have, what that might mean for them as individuals and maybe for their class as a whole.
Andrew Orr:
Yeah. I mean, I totally remember feeling this myself when I was a resident, and then just hearing from the interns in our cohort, it’s still a prevalent thing. One of the interns that we heard from characterized this feeling, I think, really well by describing how they were shocked that they were doing the same job, living in the same city at the same time as so many other people, and yet still felt so alone. And that was early on in the year, but we heard from people halfway through the year and beyond that they were still feeling alone despite being in this cohort of their peers.
And it took some time for that… the community bonds to emerge essentially. I think we’ve touched on a few reasons why that might be the case already, but I do think one of the powerful things that the arts and humanities may have to offer here is some progress in this space. A lot of people talk about third things when they’re talking about the arts and humanities, which refers to a term that I think the author Parker Palmer coined. And third things describe poems, stories, songs, works of art as ways to allow people to express their truth through metaphor or indirectly through the work of art. That’s the third thing.
And it just feels safer doing that through the work of art than directly saying your deepest truth to a work colleague. So I think that’s a unique ability that arts and humanities-based instruction can bring to GME, where it’s hard to get that truth to come out just because they can facilitate truth and vulnerability here. So we’re thinking maybe instead of dedicating curricular time to lectures about moral distress or burnout or imposter syndrome, what have you. Maybe we’ll get more honest conversations if it starts from a place of facilitated discussion through works of art. And I think that’s an interesting thing for us to think about.
Nicole Findlay-Richardson:
Yeah, that’s a really great point. A lot of… I find that a lot of residents, when you have the… you send them up for didactics for burnout or some sort of well-being didactic time, and they often complain that, “If you really wanted us to not be burnt out, why don’t you give us the morning off or give us some time to do something other than sit in a lecture hall and do all of that?”
So have it be structured but not be your standard didactic time that that’d be really interesting thing to explore in a way that kind of… to have it become part of the curriculum so that there is some dedicated time for it and that they actually have protected time for it because that’s the other issue too is when you… if you give an arts and humanities assignment or something that they have to listen to, read, or write a reflection for it but you don’t actually protect their time for it, it actually adds to their burden of work and will potentially have the opposite effect.
So if it could become part of a didactic curriculum where there’s protected time, they don’t have to answer their pagers, they have time away to actually engage with this, that would be really cool.
Andrew Orr:
And I think there’s a way to… So there’s a weak inclusion of these types of interventions in residency curricula, or there’s strong inclusion. And especially early on, it seems like many of the interventions were tacked on as optional add-ons that didn’t necessarily fit with the rest of the curriculum. And that… it sends a message that they’re not that important.
But to your point, I think there is a way to really be thoughtful about what are the structural pieces that we need to have aligned correctly here to give people the protected time and space that they need to really be engaged in this type of intervention and make sure that it’s aligned with the goals of the rest of the curriculum.
It fits well with the scheduling, et cetera, et cetera. It’s kind of framed as a synergistic piece to biomedical knowledge, which usually takes a priority as opposed to just being fluff. I think this is all part of how do you mitigate that conception.
Dorene Balmer:
Andrew, that reminds me of something we’ve heard from a lot of the participants is, “Using the other side of my brain or the other part of my brain,” which it was still part of their brain. It was just not the biomedical science part that’s often being hacked into.
Andrew Orr:
Yeah, they relished getting to use that creativity or just thinking in a new way as opposed to the thinking that comes … pre-rounding, rounding on a daily basis as an internal medicine intern is very rote and algorithmic. So it was very nice for them to have an opportunity to do something different.
Pilar Ortega:
Yeah. I mean, for me, personally, that kind of thing will make me feel refreshed and actually even more effective at doing the biomedical thinking and those pieces. So I think too often we kind of treat them as separate, separate brains, separate side, separate skills, but how do these actually intersect and feed into each other, and can we be more effective at the skills that doctors use when we also nourish and pay attention to additional skills other than maybe what has traditionally been considered that doctor’s toolkit?
I mean, one of the things that I do primarily is communication skills. We know how under-recognized and undervalued communication skills are, yet it’s the number one thing doctors do with patients is communicate with them. So, to me, there’s kind of discrepancy in what doctors actually do in their day-to-day job for the most part and what medical education is often valuing as how we want residents to spend their time.
So I think I wonder if there are opportunities to even further integrate and if you’ve thought about kind of what are some of those next steps with your work and how this could be further integrated into really as a way to potentiate the skills that doctors actually need to do their job, to your point, about really highlighting it as something that’s core not extra.
Andrew Orr:
I think that’s exactly where we’re going, and we have not yet conceptualized it, but to shout out the Prism Model that gives the different domains that arts and humanities instruction can be useful for in medical education. There’s I think the… There’s skill building, of course, and skill mastery. But then even the personal reflection domain gets to what you’re talking about, Pilar, about people engaging that different area of their brain.
But even if they’re reminded of, “Oh, this is why I went into medicine in the first place,” reminded of their why and they can stay grounded in their purpose. I think that allows people to bring their particular signature strengths that uniquely they are bringing to the table into their work. And we heard from interns that they might’ve been scared to do that and thinking that they had to fit into the stereotypical good doctor role.
But after some of the arts and humanities-based interventions and talking with their colleagues once they rediscovered, “This is why I went into the field, this is what I’m going to bring to my practice,” it didn’t take away anything from their practice. It made them feel more whole and that we heard from multiple interns that it made them more effective as well to your point. And I think that’s a really cool lesson to learn early on in training.
Pilar Ortega:
That’s awesome. And that was my favorite part of the paper, by the way, the quotes from the resident that says, “This helped me stay grounded as to my why.” I thought that was so powerful and really speaks to the fact that sometimes we are hiding pieces of ourselves in medicine or that we feel that we need to, especially people from marginalized identities, I think.
And that’s another opportunity for future work on this too, is to see what are the impacts on different people depending on their personal stories and where they come from, and whether or not they’ve experienced marginalization, et cetera. And I think staying grounded as to individuals’ why, why they went into medicine, that we can’t overemphasize that point.
I just feel like if we did that a little bit better, I think there would be a better satisfaction with careers in medicine because you really would remember every day why it is that you chose this path and rather than, as the resident also said, going through the motions. So I think that’s a really powerful way to connect to one’s identity and one’s values.
Andrew Orr:
I had a professor once who used to say, “That the purpose of life was to say your definitive message quite definitively.” And one cool way I like to think about the arts and humanities in GME is that they give us a chance to help our learners rediscover those definitive messages and then, with the help of a supportive community behind them, help them find the courage to speak them.
Toni Gallo:
Let’s talk a little bit about the arts and humanities in GME versus UME. Something that a number of the participants mentioned was they really valued some of the more abstract skills or aspects of the arts and humanities, whether that was the community building or professional identity formation, being able to bring in their personal and professional lives together instead of maybe something like learning observation skills.
And you all in the discussion talk about that’s probably a difference between UME and GME and where residents are just in their journey to being physicians. So what are some of the other things or ways that you think about the arts and humanities in GME specifically? I think we’ve talked about some aspects of that here, but anything else that anybody wants to mention kind of in that space?
Andrew Orr:
I think there’s an underlying tension with what to do with arts and humanities-based interventions that hits on what you mentioned, Toni, which is, do you use them as instruments or tools for building clinical skills, or is there something else about them? Something about maybe their avenues to understand yourself, your life, or the world, and what’s the optimal way? And it probably is different depending on who the learner is going to be.
So a big part of the paper was seeing if the Prism Model still applied to GME learners. And, like you mentioned, what we heard from our cohort was that really was the abstract kind of more human lens, as some people would call it, of the arts and humanities that they found more helpful. So I think that does potentially lead us in a direction away from using arts and humanities-based interventions for skills like close observation or even improving clinical reasoning for GME learners. And I think that in UME, the practice… I mean the focus is on preparing for clinical practice. That’s the goal.
Whereas residents in GME are living clinical practice every day. So probably they’ll find interventions more useful as spaces to explore other things like dedicated time to reengage with their personal identity, or if the intervention is staying clinical in GME, maybe it’s more effective if it’s geared toward processing the experiences that they’re having on a daily basis, again in clinic or on the wards that they don’t have time to process because things are so hectic.
Or maybe it’s useful for reflecting on how they’re going to lead their lives as new physicians and try to navigate both personal and professional identities. Or maybe it is a… it’s a really transformative space for entertaining questions on, “How am I going to practice medicine better or what should the practice of medicine on a more… on a bigger scale look like?” I think there’s a lot of different ways you can take it.
Pilar Ortega:
Yeah. I mean, I think you said that beautifully, Andrew, and the reality is that medical students are students. Residents are not students. They’re learners, yes. But they have that responsibility for direct clinical care almost all the time. So I think when you are in that space where you are learning medicine but also have that responsibility to get the job done, and you start thinking about, “Okay, how am I going to actually do this with my life, right?” Because it’s not any longer just like going to school. This is now part of your actual career and how… what your life is potentially going to look like for the rest of your career.
So I think that just takes a very different… I don’t know. It gives you a different perspective as a learner than you had as a medical student. And not to mention you have less time as well. So I think the priorities of learning are different. And I think the realities of your life and future career, the proximity to that, is way, way different. And so, I think I’m not surprised that there is a change in how learners perceive arts and humanities education depending on where in the pathway of their career they experience it.
Nicole Findlay-Richardson:
And I also thought it was interesting what you mentioned too about processing some of the things that are happening to them now. Because as… in undergraduate medical education, a lot of those things are in theory. At some point, I will have my… the first patient I took care of actually … you know have them pass away or witness my first… a patient who had a complication or needing to be put on life support. All just different things that are kind of… for the family that’s going through it and for that patient life-altering things and really traumatic things.
And as physicians, we kind of see them from a secondary… We kind of keep some distance just for our own well-being, there’s a little bit of distance there. But for them to be able to navigate that kind of switching over from being a medical student to now being the physician and how do they navigate that and how do they protect their own well-being while having to deal with that? But it’d be interesting to see how doing arts and humanities interventions in the different specialties, how that can protect their own burnout.
Like for example, how would this work for emergency medicine interns and residents who are working in trauma bays and doing all of that sort of thing versus internal medicine residents and interns who have to work up in the ICU and just the different ways that they’re exposed to what are pretty traumatic events for your non-physician person and how do they now make that transition from now you are the physician and rather than somebody witnessing something happening to this in their life or within their close circle of people maybe once or twice in their lifetime, this is something that’s happening to you on a pretty regular basis.
How do you process that, and how can the… have these interventions provide a structured space for them to kind of come to terms with this aspect of their career? Because now, it’s no longer a theoretical thing. It’s real life, and there’s some people who are really good at making that adjustment, and others who struggle with it. And because of, as you talked about this… in the article, is that the shiny exterior that we have to kind of put up and the confidence that we have to portray, a lot of people don’t want to be vulnerable.
So this could provide a nice structured space to actually discuss these things. And it’s part of learning how to be a doctor. Residency is supposed to be taking what you learned in medical school and all the theoretical and all of this sort of book knowledge and theory of all of this and now putting it into actual practice. And part of the actual practice is now, “Okay, how do I deal with traumatic events being a regular part of life?”
Andrew Orr:
Oh yeah, if you’ve learned to speak the language of medicine in medical school, but now you’re actually speaking it in residency and facing all the challenges that come along with that and the expectations now that the rubber is meeting the road, so to speak, I think it totally makes sense to repurpose the arts and humanities-based interventions with that in mind.
Toni Gallo:
So we’re just about at the end of our time. I want to give each of you a chance if you have any final thoughts you want to share, or any other takeaways from this paper, or ways that you’re going to think about your own practice differently. We’ll just go around the room here. Pilar, we’ll start with you.
Pilar Ortega:
Sure. Well, this has been just a fascinating time learning about this work, and I’m left with a lot of thoughts around how can programs, residency programs potentially implement something in this space. If they are excited by what they’ve heard and they’re thinking, “Geez, this is great. We’d love to do something really substantive and meaningful around well-being for our residents and helping with that process of identity formation and development as they go through residency.” Are there some simple ways that people could get started that you would recommend? And I’d love it if we could kind of close with something on that front.
Toni Gallo:
Nicole?
Nicole Findlay-Richardson:
I also am really interested to see how this could be implemented in a residency program as part of protected time for residents to actually engage in this type of curriculum. I’m OB/GYN so I think about how residents often feel, especially the residents who don’t want to go into oncology, how they come after that rotation being in GYN oncology. And they tend to… They’ve now seen several patients die. They’ve been dealing with a lot of this heaviness. The patient… The ones who really want to go into onc, they’re more excited. Tired, but excited. But there’s a lot of residents who don’t want to go into that.
And when they come off of those rotations, they often go through a little bit of a slump of just being… feeling a little bit burnt out and burnt down. And just thinking about how some of these kinds of interventions could potentially help ward off some of that and give them a space to reflect and process what they’ve been through. So that’s kind of how I’m thinking about it in my specialty. But I’m sure there are other specialties that also have specific rotations because, within residency, there’s some rotations that are light and some rotations that are pretty heavy.
And I was just thinking about how maybe these interventions can be tailored to the residency curriculum in the year and what the residents go through to actually kind of put them in proximity to the rotations that they’re most, I guess, applicable to or that they would get the most benefit from so that the residents actually feel like it’s not fluff and it’s actually something super relevant to what they just went through.
Toni Gallo:
Dorene?
Dorene Balmer:
I just would say that I hope all of us who work with medical trainees and learners and who are interested in knowing if our interventions that are broad-reaching, meaning they are intended to or perhaps not intended, but indeed do shape things like the identity we construct, our sense of self, our sense of well-being, the difficult balance between work and life outside of work, and what happens when that balance is thrown off kilter.
I would hope that we would take a lesson from Andrew’s work and understand that those aren’t singular static outcomes, that that’s a process. And so that when you’re looking at does your intervention work, how do you sort of study that longitudinally just really understand the process and the change that happens through time?
Toni Gallo:
And Andrew?
Andrew Orr:
Two things come to mind. So first off, just thinking about next steps for where does the field go of arts and humanities in medical education. I think we are still just scratching that surface of what are they trying to do in medical education and then also scratching the surface of how can we capture those things to articulate them. And from this work with Dorene, I’m really appreciating how powerful a tool longitudinal qualitative research can be to help us study the things that are not just easy to measure but also actually meaningful in this space and see how they change over time and how that can help us design our interventions to be more effective. And I’m hopeful that more longitudinal work in this space will help us better define a theory of the case for the arts and humanities in medical education.
And then second thing, as we’re… as that work is going on, and we’re still coming to that understanding, even in the past year or so, there have been some really great articles that have come out that essentially present a recipe for if you wanted to design something like this for your program, how would you do it? So basically it comes down to picking a learning domain. The Prism Model that I mentioned before can be really helpful, but where do you want to focus your intervention? On skill mastery, perspective taking, personal reflection or personal insight, or social advocacy and just to keep it focused.
And then you pick a pedagogy, and there’s a number of different visual art-based ones out there, narrative medicine, what have you. And then, you can plan a translational debrief. And there’s a really great article by Meg Chisholm about that to help make sure that your learners are getting what they need for their clinical practice out of it. And then the other thing I think we can do to be helpful is this is a little bit out of our wheelhouse at times when we’re diving into the world of arts and humanities. So it’s great to partner with other people at your institution who may have expertise in the humanities. That’s something that I think is being done more and more frequently and is probably a good thing too.
Toni Gallo:
Another resource for listeners is Andrew and Dorene’s paper, which is in the November issue of Academic Medicine. Definitely make sure you check that out if you haven’t read it already. Thank you all so much for being here on the podcast today. I appreciate it. This was a great conversation. Definitely also listen to the other episodes in this year’s RIME series. Those are all available now in our archive.
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