Health & Humanities Pop Up Institute 2018

Medical educators increasingly have embraced literary and narrative means of pedagogy, such as the use of learning portfolios, reading works of literature, reflective writing, and creative writing, to teach interpersonal and reflective aspects of medicine. Outcomes studies of such pedagogies support the hypotheses that narrative training can deepen the clinician's attention to a patient and can help to establish the clinician's affiliation with patients, colleagues, teachers, and the self. In this article, the authors propose that creative writing in particular is useful in the making of the physician. Of the conceptual frameworks that explain why narrative training is helpful for clinicians, the authors focus on aesthetic theories to articulate the mechanisms through which creative and reflective writing may have dividends in medical training. These theories propose that accurate perception requires representation and that representation requires reception, providing a rationale for teaching clinicians and trainees how to represent what they perceive in their clinical work and how to read one another's writings. The authors then describe the narrative pedagogy used at the College of Physicians and Surgeons of Columbia University. Since faculty must read what their students write, they receive robust training in close reading. From this training emerged the Reading Guide for Reflective Writing, which has been useful to clinicians as they develop their skills as close readers. This institution-wide effort to teach close reading and creative writing aims to equip students and faculty with the pre-requisites to provide attentive, empathic clinical care.

Recognizing clinical medicine as a narrative undertaking fortified by learnable skills in understanding stories has helped doctors and teachers to face otherwise vexing problems in medical practice and education in the areas of professionalism, medical interviewing, reflective practice, patient-centered care, and self-awareness. The emerging practices of narrative medicine give clinicians fresh methods with which to make contact with patients and to come to understand their points of view. This essay provides a brief review of narrative theory regarding the structure of stories, suggesting that clinical texts contain and can reveal information in excess of their plots. Through close reading of the form and content of two clinical texts—an excerpt from a medical chart and a portion of an audio-taped interview with a medical student—and a reflection on a short section of a modernist novel, the author suggests ways to expand conventional medical routines of recognizing the meanings of patients' situations. The contributions of close reading and reflective writing to clinical practice may occur by increasing the capacities to perceive and then to represent the perceived, thereby making available to a writer that which otherwise might remain out of awareness. A clinical case is given to exemplify the consequences in practices of adopting the methods of narrative medicine. A metaphor of the activated cellular membrane is proposed as a figure for the effective clinician/patient contact.

OBJECTIVES:
The rise of medical humanities teaching in medical education has introduced pressure to prove efficacy and utility. Review articles on the available evidence have been criticised for poor methodology and unwarranted conclusions. To support a more nuanced discussion of how the medical humanities work, we conducted a scoping review of quantitative studies of medical humanities teaching.

METHODS:
Using a search strategy involving MEDLINE, EMBASE and ERIC, and hand searching, our scoping review located 11 045 articles that referred to the use of medical humanities teaching in medical education. Of these, 62 studies using quantitative evaluation methods were selected for review. Three iterations of analysis were performed: descriptive, conceptual, and discursive.

RESULTS:
Descriptive analysis revealed that the medical humanities as a whole cannot be easily systematised based on simple descriptive categories. Conceptual analysis supported the development of a conceptual framework in which the foci of the arts and humanities in medical education can be mapped alongside their related epistemic functions for teaching and learning. Within the framework, art functioned as expertise, as dialogue or as a means of expression and transformation. In the discursive analysis, we found three main ways in which the relationship between the arts and humanities and medicine was constructed as, respectively, intrinsic, additive and curative.

CONCLUSIONS:
This review offers a nuanced framework of how different types of medical humanities work. The epistemological assumptions and discursive positioning of medical humanities teaching frame the forms of outcomes research that are considered relevant to curriculum decision making, and shed light on why dominant review methodologies make some functions of medical humanities teaching visible and render others invisible. We recommend the use of this framework to improve the rigor and relevance of future explorations of the efficacy and utility of medical humanities teaching.

Health care institutions and medical educators assert that empathy is essential to optimum patient care, yet medical education and the practice of medicine often neglect empathy in favor of biomedical approaches to disease and injury. This essay discusses the development in medical literature of the concept of "clinical empathy"—which attempts to reorient a biomedical, disease-centered approach to treating illness by accounting for an increasing fluency within the interpersonal relations between physician and patient—and examines arguments for supplementing medical training with the study of literature and the practice of reflective writing as a means of developing empathy in physicians. In order to interrogate the problems as well as the possibilities of clinical empathy, I turn to theories of sympathy produced in the eighteenth century, when innovations in medical technology and knowledge had only begun to create separate categories that would ultimately untwine the body from mind and culture. The eighteenth century was also a time when philosophy and literature, rather than being compartmentalized from medicine as distinct disciplines, informed medical understandings before medicine became specialized as a "science." A critical approach to the theory and literature of the eighteenth century can help to formulate a productive critique of clinical empathy in contemporary medicine and to suggest possibilities for a reconfigured and strengthened understanding of empathy within the larger social context of institutions, systems, and access to care.

Compassion is central to person centred clinical care. Medical Humanities have developed both as an academic discipline and as a resource for education over the past 30 years. The article will discuss what compassion is in a clinical context, and explore whether compassionate clinical practice can be enhanced by using the humanities in medical education in primary care.

PURPOSE:
The primary focus of the study was to determine whether coursework in the medical humanities would ameliorate students' loss of and failure to develop empathy, a problem known to be common during medical education.
METHODS:
Students were offered an elective course in the Medical Humanities for academic credit. The Jefferson Scale of Empathy Student Version (JSE-S) was administered at the beginning and end of an academic year in which humanities courses were offered. Changes in JSE-S scores among students who studied Medical Humanities were compared with changes in student who did not take any humanities coursework.
RESULTS:
Medical humanities coursework correlated with superior empathy outcomes among the medical students. Of students not enrolled in humanities courses, 71% declined or failed to increase in JSE-S score over the academic year. Of those who took humanities coursework, 46% declined or failed to increase in JSE-S scores. The difference was statistically significant (P = .03). The medical humanities curriculum correlated with favorable empathy outcomes as measured by the JSE-S.
CONCLUSIONS:
Elective medical humanities coursework correlated with improved empathy score outcomes in a group of US medical students. This may reflect a direct effect of the humanities coursework. Alternately, students' elective choice to take medical humanities coursework may be a marker for students with a propensity to favorable empathy outcomes.

In this essay, I look back at some of the earliest attempts by the first generation of literature-and-medicine scholars to answer the question: Why teach literature and medicine? Reviewing the development of the field in its early years, I examine statements by practitioners to see whether their answers have held up over time and to consider how the rationales they articulated have expanded or changed in the following years and why. Greater emphasis on literary criticism, narrative ethics, narrative theory, and reflective writing has influenced current work in the field in ways that could not have been foreseen in the 1970s. The extraordinary growth of interest and work in the field nationally and, especially since 1996, internationally has included practitioners in many additional areas such as disability studies, film studies, therapeutic writing, and trauma studies. Along with the emergence of narrative medicine, this diverse community of scholars and practitioners-affiliated more through their use of narrative methodologies than the teaching of literature-makes the perennial challenge of evaluation and assessment even more complicated.

Abstract
Historians of medicine have struggled for centuries to make the case for history in medical education. They have developed many arguments about the value of historical perspective, but their efforts have faced persistent obstacles, from limited resources to curricular time constraints and skepticism about whether history actually is essential for physicians. Recent proposals have suggested that history should ally itself with the other medical humanities and make the case that together they can foster medical professionalism. We articulate a different approach and make the case for history as an essential component of medical knowledge, reasoning, and practice. History offers essential insights about the causes of disease (e.g., the non-reductionistic mechanisms needed to account for changes in the burden of disease over time), the nature of efficacy (e.g., why doctors think that their treatments work, and how have their assessments changed over time), and the contingency of medical knowledge and practice amid the social, economic, and political contexts of medicine. These are all things that physicians must know in order to be effective diagnosticians and caregivers, just as they must learn anatomy or pathophysiology. The specific arguments we make can be fit, as needed, into the prevailing language of competencies in medical education.

Since the emergence of the field in the 1970s, several trends have begun to challenge the original assumptions, claims, and practices of what became known as the medical humanities. In this article, the authors make the case for the health humanities as a more encompassing label because it captures recent theoretical and pedagogical developments in higher education such as the shift from rigid disciplinary boundaries to multi- and interdisciplinary inquiry, which has transformed humanities curricula in health professions. Calling the area of study health humanities also underscores the crucial distinction between medicine and health. Following a brief history of the field and the rationales that brought humanities disciplines to medical education in the first place-the "why" of the medical humanities-the authors turn to the "why" of the health humanities, using disability studies to illuminate those methodologies and materials that represent the distinction between the two. In addition, the authors make note of how humanities inquiry has now expanded across the landscape of other health professions curricula; how there is both awareness and evidence that medicine is only a minor determinant of health in human populations alongside social and cultural factors; and finally, how the current movement in health professions education is towards interdisciplinary and interprofessional learning experiences for students.

“What the heck does Impressionist art have to do with medical communication?”

It’s a question that Dr. Michael Flanagan often gets after telling people about “Impressionism and the Art of Communication,” the seminar he teaches to fourth-year medical students at the Penn State College of Medicine.

In the course, students complete exercises inspired by 19th-century painters like Vincent van Gogh and Claude Monet, ranging from observation and writing activities to painting in the style of said artists. Through the process, they learn to better communicate with patients by developing insights on subjects like mental illness and cognitive bias.

Abstract
BACKGROUND:
There is a strong and growing interest in biomedical ethics and medical humanities (BEMH) within medical education for facilitating key components of medical professionalism and ethics, clinical communication and observational skills, and self-care and reflective practices. Consequently, United States (US) medical institutions have begun to incorporate BEMH through formal Scholarly Concentrations (SCs). This is the first study to examine the impact of a US BEMH SC, from student experience in medical school to post-graduate development, as perceived by graduate physicians.

METHODS:
Graduated students who participated in the BEMH SC or did extensive BEMH research prior to the BEMH SC's establishment (n = 57) were sampled for maximum variation across graduating years. In telephone surveys and interviews, participants discussed the perceived impact of the BEMH SC on (a.) student experience during medical school and (b.) post-graduate development. Interviews were audiotaped, transcribed, and de-identified. The authors iteratively generated a codebook; two raters coded independently, adjudicated codes, and completed inter-rater reliability (IRR) tests. The authors subsequently conducted a team-based thematic analysis, identifying emergent themes.

RESULTS:
Nineteen BEMH graduates were interviewed. Results were analyzed according to (a.) student experience and (b.) post-graduate development. Overall, respondents perceived impacts in reinforcing knowledge and skills in clinical ethics; solidifying self-care and reflective practices; refining a sense of professional identity and integrity for ethically challenging situations; and promoting student skills, productivity, and later careers involving BEMH.

CONCLUSION:
A comprehensive US BEMH SC achieved the purported aims of BEMH in medical education, with graduate physicians perceiving persisting effects into clinical practice. Furthermore, the structure and format of a SC may offer additional advantages in promoting student scholarly skill and productivity, career development, and professional identity formation-core competencies identified across clinical training and ethics programs. Our findings indicate that a BEMH SC is effective in achieving a range of desired immediate and post-graduate effects and represent a particularly promising venue for BEMH in medical education. We believe these findings to be of critical significance to medical educators and administrators when considering how best to incorporate BEMH into SCs and medical curricula.

BACKGROUND:
Literature, music, theater, and visual arts play an uncertain and limited role in medical education. One of the arguments often advanced in favor of teaching the humanities refers to their capacity to foster traits that not only improve practice, but might also reduce physician burnout-an increasing scourge in today's medicine. Yet, research remains limited.

OBJECTIVE:
To test the hypothesis that medical students with higher exposure to the humanities would report higher levels of positive physician qualities (e.g., wisdom, empathy, self-efficacy, emotional appraisal, spatial skills), while reporting lower levels of negative qualities that are detrimental to physician well-being (e.g., intolerance of ambiguity, physical fatigue, emotional exhaustion, and cognitive weariness).

DESIGN:
An online survey.

PARTICIPANTS:
All students enrolled at five U.S. medical schools during the 2014-2015 academic year were invited by email to take part in our online survey.

MAIN MEASURES:
Students reported their exposure to the humanities (e.g., music, literature, theater, visual arts) and completed rating scales measuring selected personal qualities.

KEY RESULTS:
In all, 739/3107 medical students completed the survey (23.8%). Regression analyses revealed that exposure to the humanities was significantly correlated with positive personal qualities, including empathy (p < 0.001), tolerance for ambiguity (p < 0.001), wisdom (p < 0.001), emotional appraisal (p = 0.01), self-efficacy (p = 0.02), and spatial skills (p = 0.02), while it was significantly and inversely correlated with some components of burnout (p = 0.01). Thus, all hypotheses were statistically significant, with effect sizes ranging from 0.2 to 0.59.

CONCLUSIONS:
This study confirms the association between exposure to the humanities and both a higher level of students' positive qualities and a lower level of adverse traits. These findings may carry implications for medical school recruitment and curriculum design. "[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]... in any other light than complemental." (William Osler, Br Med J. 1919;2:1-7).

For years, I prowled the medical wards of Bellevue Hospital, the pockets of my white coat stuffed not only with my stethoscope and prescription pad but with poems, essays, and short stories. If I happened upon unsuspecting medical students or interns, I’d press some elevator reading onto them—an Ed Hirsch poem, a Chekhov story, a Sontag essay, something from our own Bellevue Literary Review. If I was feeling less bound by social mores that day, I’d hop on the elevator with them, extolling the virtues of the photocopied literature I’d dispensed to them.
It wasn’t always artful, and more than a few students thought I’d sprung a cerebral leak, but I was convinced that our medical trainees needed literature. They were up to their ears in renal tubular acidosis and eosinophilic esophagitis, after all. If there was anyone who needed a stat dose of alliteration, or an emergent infusion of metaphor, it was these medical trainees.
Of course, we in medicine have been burned numerous times doing things that we are convinced are correct, only to be bitten by clinical trials that prove us wrong and then wrong again (think estrogen-replacement therapy). So it’s good to see some data supporting the role of humanities in medical education. The studies will never be as grand as the multinational megatrials for cardiac interventions (not much interest in Bulgakov from Big Pharma), but the trickles of evidence that are coming in are heartening. . .

"Compressing undergraduate and medical studies into six years, as proposed by the University of Texas System for a select group of students, is a bad idea. . . . . . . The well-educated newly minted physician will be better prepared to blend all these stories into a coherent medical history if he or she has a strong background in the humanities and social sciences."

In this essay the author describes the status of the humanities within United States research universities, and notes that there is a place in the research university for clinical analysts with non-quantitative research interests, who are seen as humanities scholars by other humanities specialists. He discusses the current trend in psychoanalytic research in the United States, which perpetuates an historically well-known divide between quantitative and non-quantitative investigators, and causes non-quantitative clinician-researcher analysts to seek a workplace outside organized analysis, as it exists within the American Psychoanalytic Association. He goes on to describe the way a clinical analyst with a strong non-quantitative research commitment has found a supportive home for his investigations in a humanities institute in a research university. That analyst has been welcomed as a colleague by university-based humanities scholars, and has found that those collegial relationships offer creative freedom and interdisciplinary stimulation. The author notes that a cadre of analysts, enriched by such experiences, will be better equipped to bridge the divide which exists between non-quantitative and quantitative analytic researchers, for the benefit of psychoanalytic research in the future. The author also illustrates the benefits experienced by university-based humanities scholars when they collaborate with clinical analysts, and suggests this makes stronger ties between psychoanalysis and research universities more likely in the future.

The issue of "physicians of the future" is best addressed in terms of the larger, less parochial issue of "What is the best combination of systems, tools, and people for solving any health-care problem in the context of the individual patient's life?" To proceed we need first to articulate guiding principles, then to describe the tasks of medical practice and the people best equipped to perform them collaboratively, and finally to fit the physician into the overall scheme. If we proceed in this manner, our vision of what is best for the patient will not be restricted or clouded by fixed notions of the present role of the physician or any other member of the health-care team.

How might we characterize the benefits of interdisciplinary programs for students, faculty and the university?

In the video for this post, Dr. Phillip Barrish (English, Humanities Institute) considers this question and discusses the ways in which initiatives in “health humanities” at UT are developing important cross-campus conversations and opportunities for students.

In the past several decades dystopian literature and film have emphasized the dangers posed to individuals and societies by new developments in biomedical technology, including, for example, genetic engineering, cloning, organ transplantation, and increasingly sophisticated machine-human interfaces. In this essay I wish to focus on a related but different aspect of medical dystopian imagining. Rather than societies that have been deformed by the use—or misuse—of advanced medical technologies, the works of speculative fiction I will discuss imagine future dystopias defined by issues of health care access, distribution, and funding: defined, that is, by questions of policy or what might also be thought of as the political economy of health care. Who gets quality medical care, and who doesn’t? How, and by whom, is health care provided? How and by whom is it paid for? Who has the power to make these decisions? The political economy of health care might seem an inherently less sexy topic—and hence one less likely to capture writers’ and filmmakers’ imaginations—than the often-disturbing implications of headline grabbing advances on the biomedical frontier. But the works I consider here confront these policy-wonk questions of health care distribution and funding in startlingly dramatic ways and, in doing so, bring out their radical importance to any future we might seek to imagine.

Chang-Rae Lee's 2014 novel On Such a Full Sea uses the genre of speculative fiction to reflect on longstanding healthcare debates in the United States that have recently crystalized around the Affordable Care Act. The novel imagines the political economy of healthcare in a future America devastated by environmental illness. What kind of care is available and to whom? Who provides it? Who pays for it? What about distribution and access? The different healthcare systems governing each of three geo-social zones in Lee's future society represent exaggerated versions of the scenarios participants in the ACA debate claim their opponents' health policies would produce. The essay argues that Lee's novel ultimately favors a version of universal government-funded care over a system based on supposed free-market principles, even as the novel also tries to make room for conservative Americans' fears about the specter of so-called "socialized medicine." More broadly, the essay contends that the health humanities should devote more attention to literary and artistic engagements with healthcare as a system: a complex set of financial models, public and private institutions, government policies, and actors whose roles range well beyond patient and care provider.

Robert Herrick’s novel The Web of Life (1900), a self-proclaimed work of literary realism, opens a critical window onto an urban “web” of intersecting practices, institutions, and professional formations at a moment when key dimensions of the US health-care system as we know it today were first taking shape. At this fluid historical moment, Herrick stages a competition between two contrasting possibilities for what that system would, or should, look like in the new century. One possibility consists of a democratic profusion of health-care providers and options, all of which jostle against one another in a marketplace largely unregulated by any external authority. Herrick implicitly associates this energizing, though unsettling, model of US health care with both the labor movement (the novel is set in the same year as Chicago’s Pullman strike) and certain aspects of the New Woman movement. The second possibility the novel showcases, which is closer to the model that would historically prevail, envisions a health-care system that is centralized, rationalized, and directed from the top down by the so-called orthodox profession. Herrick aligns this model with powerful banks, trusts, and corporations. The book presents the competition between these alternative paradigms by following the shifting career choices and internal conflicts of its protagonist, Dr. Howard Sommers, as he strives to satisfy his own vision—at times itself contradictory—of medical professionalism. By the end of the novel, both Sommers and The Web of Life have been forced to acknowledge if not the desirability, then the practical necessity, of the orthodox profession’s monopoly on health care. This reluctant endorsement on Herrick’s part also offers an important perspective on why large-scale systemic reform in US health care has proven so difficult to achieve in the more than a century that has passed since the novel was written.

In the Rede Lecture for 1959, Sir Charles Snow analyzes the problem of the cultural divide between scientist and non-scientist.

Grounded in four theoretical positions-structural, cognitive, phenomenological, and ethical-the present review demonstrates the empirical evidence for the incremental validity of narrative identity as a cross-sectional indicator and prospective predictor of well-being, compared with other individual difference and situational variables. In doing so, we develop an organizational framework of four categories of narrative variables: (a) motivational themes, (b) affective themes, (c) themes of integrative meaning, and (d) structural elements. Using this framework, we detail empirical evidence supporting the incremental association between narrative identity and well-being, a case that is strongest for motivational, affective, and integrative meaning themes. These categories of themes serve as vital complimentary correlates and predictors of well-being, alongside commonly assessed variables such as dispositional personality traits. We then use the theoretically grounded review of the empirical literature to develop concrete areas of future research for the field.

When people complete psychotherapy, they carry the story of the experience with them. This retrospective reconstruction serves several psychological purposes, including contributing to narrative identity and influencing the maintenance of therapeutic gains after termination. Based on a prior qualitative investigation of therapy narratives (Adler & McAdams, 2007a), a new sample of 104 former clients wrote about their psychotherapy after treatment end. Quantitative analyses indicated that the retrospective narratives of participants high in subjective well-being focused on the protagonist's agency in struggling with a discrete problem. In addition, the narratives of participants high in ego development described a coherent story of growth. These findings suggest that the stories clients construct about psychotherapy reliably vary depending on their psychological health.

This paper presents two longitudinal studies designed to assess the relationship between variability in narrative identity and trajectories of mental health over several years. In Study 1, core scenes from 89 late-mid-life adults’ life stories were assessed for several narrative themes. Participants’ mental health and physical health were assessed concurrently with the narratives and once a year for the subsequent four years. Concurrent analyses indicated that the themes of agency, redemption, and contamination were significantly associated with mental (but not physical) health. Longitudinal analyses indicated that these same three themes were significantly associated with participants’ trajectories of mental health over the course of four years. Exploratory analyses indicated that narratives of challenging experiences may be central to this pattern of results. In Study 2, similar longitudinal analyses were conducted on a sample of 27 late-mid-life adults who received a major physical illness diagnosis between the baseline assessment and six months later and a matched sample of 27 control participants who remained healthy throughout the study. Participants’ mental health and physical health were assessed every six months for two years. In this tightly controlled study, the themes of agency, communion, redemption, and contamination in participants’ life narratives collected at Baseline (before any participant got sick) were significantly positively associated with mental health in the group of participants who went on to receive a medical diagnosis, but not in the control group. Taken together, the results of these two studies indicate that the way an individual constructs personal narratives may impact his or her trajectory of mental health over time.

Narrative identity is the internalized, evolving story of the self that each person crafts to provide his or her life with a sense of purpose and unity. A proliferation of empirical research studies focused on narrative identity have explored its relationship with psychological well-being. The present study is the first prospective, multiwave longitudinal investigation to examine short-term personality change via an emphasis on narrative identity as it relates to mental health. Forty-seven adults wrote rich personal narratives prior to beginning psychotherapy and after every session over 12 assessment points while concurrently completing a measure of mental health. Narratives were coded for the themes of agency and coherence, which capture the dual aims of narrative identity: purpose and unity. By applying in-depth thematic coding to the stories of participants, the present study produced 47 case studies of intraindividual personality development and mental health. By employing multilevel modeling with the entire set of nearly 600 narratives, the present study also identified robust trends of individual differences in narrative changes as they related to improvements in mental health. Results indicated that, across participants, the theme of agency, but not coherence, increased over the course of time. In addition, increases in agency were related to improvements in participants' mental health. Finally, lagged growth curve models revealed that changes in the theme of agency occurred prior to the associated improvements in mental health. This finding remained consistent across a variety of individual-difference variables including demographics, personality traits, and ego development.

Writing about traumatic, stressful or emotional events has been found to result in improvements in both physical and psychological health, in non-clinical and clinical populations. In the expressive writing paradigm, participants are asked to write about such events for 15–20 minutes on 3–5 occasions. Those who do so generally have significantly better physical and psychological outcomes compared with those who write about neutral topics. Here we present an overview of the expressive writing paradigm, outline populations for which it has been found to be beneficial and discuss possible mechanisms underlying the observed health benefits. In addition, we suggest how expressive writing can be used as a therapeutic tool for survivors of trauma and in psychiatric settings.

Narrative Medicine has emerged as a discipline
from within the medical humanities1 and takes
inspiration from philosophy, literature, poetry, art
and social sciences theories. In particular, it is
underpinned by philosophical approaches such as
phenomenology, postmodernism and narratology,
proposing that clinicians must attend to the lived
experience of their patients and apply the science
to the person.2 Meanwhile, the link between medicine
and literature is evident in the growing volume
of texts written about professionals’, or lay
people’s experiences of illness and disease.3–8 In
exploring this link further, Charon9 has contributed
greatly to consolidate the theory of Narrative
Medicine. She defines it as ‘medicine practiced
with the narrative competencies to recognise,
absorb, interpret and be moved by the stories of
illness’.
9 She suggests that, in exploring texts and
reading them closely, one finds the tools of language
such as metaphor, plot, character and temporality.
She suggests that learning such skills
enables clinicians to recognise that same language
when it appears in clinical interaction practice. This
‘narrative competence’ can be fostered through
education initiatives that particularly explore literature,
creative and reflective writing, storytelling and
poetry.9

OBJECTIVE:
Divorce is a common stressor that is associated with increased risk for poor long-term physical and mental health. Using an experimental design, the current study examined the impact of expressive writing (EW) on average heart rate (HR), HR variability (HRV), and blood pressure (BP) 7.5 months later.

METHODS:
Participants from a community sample of recently separated adults (N = 109) were assigned to one of three conditions: traditional EW, narrative EW, or a control writing condition, and were assessed three times for an average of 7.5 months. Each study visit included 27 minutes of physiological assessment; the primary outcomes at each assessment were mean-level HR, HRV, BP scores averaged across six different tasks.

RESULTS:
Participants in the traditional EW condition did not significantly differ from control participants in their later HR, HRV, or BP. However, relative to control participants, those in the narrative EW condition had significantly lower HR (B = -3.41, 95% confidence interval = -5.76 to -1.06, p = .004) and higher HRV 7.5 months later (B = 0.41, 95% confidence interval = 0.16 to 0.74, p = .001). When comparing narrative EW participants to those in the traditional EW and control writing as a single group, these effects remained and were moderately sized, Cohen d values of -0.61 and 0.60, respectively, and durable across all task conditions when analyzed in independent models. The writing condition groups did not differ in their later BP.

CONCLUSIONS:
Narrative EW decreased HR and increased HRV after marital separation but did not affect BP. We discuss the possible disconnect between psychology and physiology in response to EW, as well as possible future clinical applications after marital separation.

Medical educators increasingly have embraced literary and narrative means of pedagogy, such as the use of learning portfolios, reading works of literature, reflective writing, and creative writing, to teach interpersonal and reflective aspects of medicine. Outcomes studies of such pedagogies support the hypotheses that narrative training can deepen the clinician's attention to a patient and can help to establish the clinician's affiliation with patients, colleagues, teachers, and the self. In this article, the authors propose that creative writing in particular is useful in the making of the physician. Of the conceptual frameworks that explain why narrative training is helpful for clinicians, the authors focus on aesthetic theories to articulate the mechanisms through which creative and reflective writing may have dividends in medical training. These theories propose that accurate perception requires representation and that representation requires reception, providing a rationale for teaching clinicians and trainees how to represent what they perceive in their clinical work and how to read one another's writings. The authors then describe the narrative pedagogy used at the College of Physicians and Surgeons of Columbia University. Since faculty must read what their students write, they receive robust training in close reading. From this training emerged the Reading Guide for Reflective Writing, which has been useful to clinicians as they develop their skills as close readers. This institution-wide effort to teach close reading and creative writing aims to equip students and faculty with the pre-requisites to provide attentive, empathic clinical care.

Recognizing clinical medicine as a narrative undertaking fortified by learnable skills in understanding stories has helped doctors and teachers to face otherwise vexing problems in medical practice and education in the areas of professionalism, medical interviewing, reflective practice, patient-centered care, and self-awareness. The emerging practices of narrative medicine give clinicians fresh methods with which to make contact with patients and to come to understand their points of view. This essay provides a brief review of narrative theory regarding the structure of stories, suggesting that clinical texts contain and can reveal information in excess of their plots. Through close reading of the form and content of two clinical texts—an excerpt from a medical chart and a portion of an audio-taped interview with a medical student—and a reflection on a short section of a modernist novel, the author suggests ways to expand conventional medical routines of recognizing the meanings of patients' situations. The contributions of close reading and reflective writing to clinical practice may occur by increasing the capacities to perceive and then to represent the perceived, thereby making available to a writer that which otherwise might remain out of awareness. A clinical case is given to exemplify the consequences in practices of adopting the methods of narrative medicine. A metaphor of the activated cellular membrane is proposed as a figure for the effective clinician/patient contact.

Mrs. N. announced triumphantly that she had become a U.S. citizen. Her husband — on whose English she depended, though she'd arrived from Albania 5 years earlier — said, “She took the test, and then she said the words with her hand like this.” He put his hand over his heart. She grinned and blushed, seeming younger than her 50 years. When she answered one of my questions with a quick “79,” I startled. Wait a minute, I thought, she doesn't speak English.

It was then that she shyly pointed to the hearing aid in her left ear. I remembered in a flash how hard the social worker and I had worked to arrange an ENT evaluation despite Mrs. N.'s lack of insurance and citizenship. I remembered the couple barging into my office some weeks later, terrified, crying, breathless, convinced that she was going to die. They had been told she needed an MRI to rule out a brain tumor, but they'd left the ENT clinic believing she had a brain tumor. Happily, I could reassure them otherwise. Now, hearing her say “79,” I realized that she was hearing and on her way to speaking fluent English. I wasn't surprised to find her blood pressure normal, her dizzy spells and headaches gone.

Narrative humility acknowledges that our patients' stories are not objects that we can comprehend or master, but rather dynamic entities that we can approach and engage with, while simultaneously remaining open to their ambiguity and contradiction, and engaging in constant self-evaluation and self-critique about issues such as our own role in the story, our expectations of the story, our responsibilities to the story, and our identifications with the story-how the story attracts or repels us because it reminds us of any number of personal stories.

Narrative persists in medicine, as it does in the human sciences
generally, as both a source of information and a means of organizing
its interpretation. Unscientific though narrative may seem, the case is
not only a record of medical attention provided a patient, but the fundamental
unit of medical discourse and the pattern for clinical reasoning.
With its hypothetical, testable, diagnostic plot, it enables the physician
to apply the nomothetic principles of biomedical science to the patient's
idiographic manifestations of illness.1 Like thinkers in other fields that
rely on cases—law, moral theology, criminal detection—physicians reason
backward from effect to cause by constructing from the signs (or
clues, facts, evidence) a probable narrative whose validity can be tested
by further interrogation of the phenomena. Neither so satisfyingly coherent
as fictional narrative nor so epistemologically secure as the replicable
demonstration of scientific fact, the medical case lies somewhere between the two. It is, in short, history. As a working part of the process of diagnosing and treating disease, the case aspires to scientific rigor. But the epistemological shift that in the late twentieth century has called into question the simple, objective, logical-positivist view of knowledge—medicine's working epistemology—has affected the way we think about case history, too. No longer taking the Newtonian physical sciences as the sole pattern of rationality, thinkers have turned in recent years to the contextual, interpretive methods of knowing that are characteristic of the social sciences and the humanities. Narrative is one of the chief of these. Not surprisingly, then, recent changes in the case history and proposals for its improvement reflect many of the concerns of contemporary historiography and literary theory.

Cultural competency has become a fashionable term for clinicians and researchers. Yet no one can define this term precisely enough to operationalize it in clinical training and best practices.

It is clear that culture does matter in the clinic. Cultural factors are crucial to diagnosis, treatment, and care. They shape health-related beliefs, behaviors, and values [1,2]. But the large claims about the value of cultural competence for the art of professional care-giving around the world are simply not supported by robust evaluation research showing that systematic attention to culture really improves clinical services. This lack of evidence is a failure of outcome research to take culture seriously enough to routinely assess the cost-effectiveness of culturally informed therapeutic practices, not a lack of effort to introduce culturally informed strategies into clinical settings [3].

Regulatory Focus Theory (Higgins, 1997) outlines the ways in which people attempt to achieve the presence of positive outcomes (promotion) or preserve the absence of negative outcomes (prevention), suggesting that individuals may differ in chronic orientations. The present work examines regulatory outlooks within a multilayered model of personality composed of dispositional traits, characteristic goals, and life stories (narrative identity). Foregrounding the concept of narrative identity, the current study investigates how narrative themes of prevention and promotion relate to regulatory focus as expressed in dispositional traits and characteristic goals and explores the relative contribution of each layer of personality to psychological well-being and physical health. The findings suggest that dispositional traits, personal goals, and life narratives cohere loosely around the central themes of prevention and promotion. Moreover, promotion focus across layers of personality was related to higher levels of self-reported quality of life, compared to prevention focus. Illustrating the incremental validity of different layers of personality, promotion focus in life stories independently predicted psychological health above and beyond promotion focus in dispositional traits.

This introduction provides an overview of the themes of this Special Section on Illness Narratives, Networked Subjects, and Intimate Publics. Drawing on the intersection of illness narratives and human-technological assemblages, the introduction frames this section’s consideration of how illness, disability, dying, and death are mediated within emerging digital spaces.

The current study assessed main effects and moderators (including emotional expressiveness, emotional processing and ambivalence over emotional expression) of the effects of expressive writing in a sample of healthy adults. Young adult participants (N = 116) were randomly assigned to write for 20 minutes on four occasions about deepest thoughts and feelings regarding their most stressful/traumatic event in the past five years (expressive writing) or about a control topic (control). Dependent variables were indicators of anxiety, depression, and physical symptoms. No significant effects of writing condition were evident on anxiety, depressive symptoms, or physical symptoms. Emotional expressiveness emerged as a significant moderator of anxiety outcomes, however. Within the expressive writing group, participants high in expressiveness evidenced a significant reduction in anxiety at three-month follow-up, and participants low in expressiveness showed a significant increase in anxiety. Expressiveness did not predict change in anxiety in the control group. These findings on anxiety are consistent with the matching hypothesis, which suggests that matching a person’s naturally elected coping approach with an assigned intervention is beneficial. These findings also suggest that expressive writing about a stressful event may be contraindicated for individuals who do not typically express emotions.

This paper presents a broad overview of the expressive writing paradigm. Since its first use in the 1980s, dozens of studies have explored the parameters and boundary conditions of its effectiveness. In the laboratory, consistent and significant health improvements are found when individuals write or talk about personally upsetting experiences. The effects include both subjective and objective markers of health and well-being. The disclosure phenomenon appears to generalize across settings, many individual difference factors, and several Western cultures, and is independent of social feedback.

When people are asked to write about emotional upheavals for as little as fifteen minutes a day for three days, their physical and mental health often improves. Not a particularly shocking finding. But in 1986, when the first expressive writing study was published, the idea caused quite a stir. . . .

"I do not attempt to deal in this paper with the whole problem of the part taken by repression in the production and maintenance of the war-neuroses. Repression is so closely bound up with the pathology and treatment of these states that the full consideration of its role would amount to a complete study of neurosis in relation to the war." . . .

Literature and Medicine has been in the vanguard of publication on illness narratives in general and cancer narratives in particular. As a contribution to the conversation in the journal, I would like to describe research I have done recently on how the most popular and most available stories of cancer are received by people with cancer and those close to them. My "data" was collected recently, during the course of my own radiation treatments for breast cancer; I will soon explain why I have placed "data" in quotation marks.

In this essay I am influenced by several important trends in the thinking of psychoanalysts in the United States. These trends include the heightened interest in the analyst's use of self-analysis throughout his or her life; the recent interest in the process of writing about psychoanalysis, and its role in analytic education throughout the analyst's career; and the nature of various specific forms of resistance which affect analysts as they work. The central issue I seek to explore concerns an aspect of self-analysis, and can be stated in the form of two related questions: (1) What is the potential positive impact of writing about psychoanalysis on an analyst's self-analysis? (2)What role might the product of analytic writing playas a resistance to self-analysis? There are many important related questions which are beyond the scope of this essay, though I hope others will consider
what I say here when answering them in the future. Two obvious ones are: (1) What might be the role of resistance to self-analysis in the work life of the analyst who wishes to write, but cannot? (2) In what ways might resistance to self-analysis influence the writing analyst as he writes?

The mission of Safe Space Radio is to inspire courageous conversations, break down the barriers that divide us, and create compassionate communities.
Founded in 2008 by psychiatrist Anne Hallward, Safe Space Radio offers listeners practical tools for navigating challenges in their own lives and is used in training programs for healthcare professionals, therapists, and teachers as they learn to address the needs of underserved populations.
The podcasts combine compelling storytelling with empathy and expertise.
The podcasts are organized in 6 categories: mental health, social justice, family, emotions, sexuality, and conflict.

Abstract
BACKGROUND:
There is a strong and growing interest in biomedical ethics and medical humanities (BEMH) within medical education for facilitating key components of medical professionalism and ethics, clinical communication and observational skills, and self-care and reflective practices. Consequently, United States (US) medical institutions have begun to incorporate BEMH through formal Scholarly Concentrations (SCs). This is the first study to examine the impact of a US BEMH SC, from student experience in medical school to post-graduate development, as perceived by graduate physicians.

METHODS:
Graduated students who participated in the BEMH SC or did extensive BEMH research prior to the BEMH SC's establishment (n = 57) were sampled for maximum variation across graduating years. In telephone surveys and interviews, participants discussed the perceived impact of the BEMH SC on (a.) student experience during medical school and (b.) post-graduate development. Interviews were audiotaped, transcribed, and de-identified. The authors iteratively generated a codebook; two raters coded independently, adjudicated codes, and completed inter-rater reliability (IRR) tests. The authors subsequently conducted a team-based thematic analysis, identifying emergent themes.

RESULTS:
Nineteen BEMH graduates were interviewed. Results were analyzed according to (a.) student experience and (b.) post-graduate development. Overall, respondents perceived impacts in reinforcing knowledge and skills in clinical ethics; solidifying self-care and reflective practices; refining a sense of professional identity and integrity for ethically challenging situations; and promoting student skills, productivity, and later careers involving BEMH.

CONCLUSION:
A comprehensive US BEMH SC achieved the purported aims of BEMH in medical education, with graduate physicians perceiving persisting effects into clinical practice. Furthermore, the structure and format of a SC may offer additional advantages in promoting student scholarly skill and productivity, career development, and professional identity formation-core competencies identified across clinical training and ethics programs. Our findings indicate that a BEMH SC is effective in achieving a range of desired immediate and post-graduate effects and represent a particularly promising venue for BEMH in medical education. We believe these findings to be of critical significance to medical educators and administrators when considering how best to incorporate BEMH into SCs and medical curricula.

UT faculty, staff, and students can access the full text article here: https://utexas.box.com/s/z8gr6mc96aq5ki0c7cdp4kxspvaup0am

UT faculty, staff and students can access the video from https://catalog.lib.utexas.edu/record=b8981057~S29