Abstract

While the medical humanities have long been part of the training of doctors, and narrative medicine in particular is increasing in curricular influence, creative writing practice within medical education is considered a recent innovation. UH Scripts is a narrative medicine collaboration between the Tilman J. Fertitta Family College of Medicine and the Creative Writing Program of the College of Liberal Arts and Social Sciences at the University of Houston. Its shared goals highlight reciprocal gains: 1) to improve the education of doctors-in-training by increasing diagnostic skills and fostering greater attention, empathy, cultural humility, self-care, and facility in crafting written and spoken language, and 2) to provide doctoral student poets and fiction writers with an experience of new pedagogies that offers them equal opportunity for enhanced self-development. We are aware of no other institutions that support an ongoing collaboration between medical students and doctoral students of literature and creative writing.

Keywords: narrative health, narrative medicine, lyric, creative writing, medical education

Introduction

Ricardo Nuila—a writer, teacher, and physician—sat across the table from one of us during a community narrative medicine reading and prompted, “a collaboration between a top-rated Creative Writing Program and the new College of Medicine at UH is a natural.” Director of the Humanities Expression and Arts Lab (HEAL) at Baylor College of Medicine, Dr. Nuila saw the potential of two innovative units working together under the shared calling of enhancing wellbeing and deepening the well-lived life. Both the humanities and medicine recognize that improved communication—clarity, specificity, and respect for audience—is necessary for the health of persons and community. Healing is an art as well as a science. Observation and experimentation are the foundations of both.

Narrative medicine reflects the natural connections between patient-clinician interactions and those between literary reader and writer. In addition to “narrative medicine,” our program, UH Scripts, also uses the phrase “narrative and lyric health” to highlight the breadth of the healing arts beyond the physician and to acknowledge that meaning is conveyed through metaphor, image, and sound, not only narrative. Through UH Scripts, students engage with many questions. What is the patient’s story? How does it align and contrast with the physician’s story? What metaphors is the patient offering to foster understanding? What is the tenor (meaning) of those metaphors? How do the emotions physicians feel when reading or listening help them form a clear interpretation? How can reading and discussing literature help physicians become more attentive diagnosticians and caregivers?

In the clinic, office, hospital, physicians are the creative writers and the readers, both interpreting a patient’s story and then “writing” metaphors and vignettes to help patients understand their illnesses and how their team will care for them.

“Once one donates one’s own creative powers towards discovering it, one finds oneself in the patient’s presence—absorbed, committed, and newly aware of the complexity and potential meaning of that which is seen.” (Charon, Hermann, and Devlin 2016)

Learners have embraced the UH Scripts curriculum. After the medical students’ first narrative and lyric health experience, one wrote: “Narrative health concepts and skills are a vital asset to the medical field…For me, it’s important to allow patients to tell me their full story, instead of creating one for them.”

Another student wrote, “We are more than our synapses. As a future practicing doctor, I recognize the healing powers of being acknowledged and feeling heard. I realize that I cannot begin to resolve a problem if I do not understand it through the eyes of the person affected. To serve you, I need to understand you. To work effectively with one another, we must establish rapport through mutual authenticity and defined roles. The shared vulnerability between two persons, whether speaking or listening, allows both to heal.”

The students’ responses followed close readings and discussions of poems and stories about illness and healing. Students were able to respond in writing as well as compose their own narratives and poems. The class discussed narrative structure and appropriate metaphor and considered what clinical skills would be enhanced by continued practice. In the absence of mutual understanding, careful listening, and effective cultural communication, patients are reduced to assumptions, stereotypes, and projections. Students also learned that, by applying the concepts of narrative and lyric health, physicians can appreciate the complexity and humanity of their patients.

Rationale for the UH Scripts Program

We developed UH Scripts to further integrate the humanities into the medical school curriculum, a strategy important for improving the effectiveness of clinical care and reducing burnout among healthcare professionals. The Association of American Medical Colleges has affirmed its fundamental role in medical education: “The arts and humanities are intrinsically connected to teaching and learning in medicine, and pedagogical approaches should be woven into the fabric of 21st-century medical students’ education, resident physicians’ training, and physicians’ ongoing development” (Howley, Gaufberg, and King 2020).

Facing multiple, overlapping crises, the US healthcare system is simultaneously error-prone, inefficient, fragmented, and inequitable (Institute of Medicine 2003, 2001; National Research Council 2013). In response, there has been a greater emphasis on evidence-based guidelines, quality measurement, and the appropriate use of technology. Unfortunately, these forces have contributed to an epidemic of burnout, which leads to dehumanization, compromised safety, and attrition from the workforce (Shanafelt et al. 2019). As a result, physicians are increasingly isolated from their peers and disconnected from patients.

Stronger relationships offer an antidote to these crises. For example, continuity between physicians and patients is associated with lower costs and better care, while a high-quality physician-patient relationship is associated with improved health (Bazemore et al. 2018; Olaisen et al. 2020). Integrating the humanities into medical school curricula can give students the tools to provide more humane and individualized care.

The UH Scripts partnership also provides the opportunity for the medical school to collaborate with the highly regarded UH Creative Writing Program. UH Scripts is staffed by two narrative health fellows who were competitively selected from the cohort of doctoral creative writing students. For these two fellows, UH Scripts offers the chance to enhance a range of teaching topics, pedagogies, and settings. Ultimately, these experiences can elevate their writing and expand the academic and professional opportunities available to them. Reflecting on their experience with UH Scripts, one of the fellows wrote, “Becoming a Scripts fellow allowed me to participate in a field in which the concept of ‘narrative’ is reimagined, expanding in scope to encompass nonliterary forms: the story a patient tells a doctor about his past; the story the doctor tells her partner when she finally gets home; the neutral but ominous march of measurements across the patient’s chart. Telling and listening to stories, digging into ‘the human condition’: these, as narrative health shows us, are the tasks of writers and practitioners of medicine alike.”

Overview of UH Scripts

The two-year teaching fellows spend roughly 0.5 full-time equivalent (FTE), or twenty hours a week, preparing teaching materials; conferring with medical students, faculty, and staff; curating a literary journal; and shaping the program’s vision. The program is jointly funded by the College of Liberal Arts and Social Sciences (CLASS) and the Tilman J. Fertitta Family College of Medicine (TJFFCOM), demonstrating the shared commitment to and benefit from the partnership. The UH Creative Writing Program was founded in 1979 by Cynthia Macdonald and Stanley Plumly, and its doctoral program in literature and creative writing was one of the first of its kind. It consistently ranks in the top three PhD programs in creative writing. The TJFFCOM is a new medical school, which matriculated its first class in 2020. It has a mission to graduate a diverse cohort of physicians who can deliver high-quality primary care to underserved communities. These factors and its proximity to the breadth of expertise at UH contributed to its interest in reimaging how medical education could be delivered.

The teaching fellows have the potential to contribute to a wide range of courses, including numerous sessions in Physicians, Patients, and Populations (Table 1; an 18-month, required, pre-clerkship course that teaches students about clinical skills, interpersonal relationships, evidence-based medicine, and health systems science); Household-centered Care (a required, longitudinal course where students work in interdisciplinary teams and follow households with complex medical and social needs); and clinical rotations.

In Physicians, Patients, and Populations, the fellows play a pivotal role in a session titled “Narrative and Lyric Health,” which introduces students to narrative health and its application to the practice of medicine (Table 2). For this session, they teach narrative health concepts, contribute to the session’s design, and lead small group discussions. In addition, they help develop prompts for reflective writing assessments in the aforementioned courses, read and respond to those assignments, and participate in the Arts and Health Practicum (Table 3 and Table 4), an elective that focuses on narrative and visual arts.

Concurrently, the teaching fellows are creating an online literary journal that will feature creative work from College of Medicine students, faculty, and staff, and from community members beyond campus. These pieces will allow readers to experience the medical school from multiple perspectives. The journal’s shape and contents will reinforce patient-clinician parity and will concretize an alternative to power inequalities that inhibit quality care. To cultivate these pieces, the teaching fellows hold office hours and drop-in workshops and advertise these opportunities through a monthly newsletter (Figure 1).

Figure 1: Sample UH Scripts Newsletter

Origin of the UH Scripts Program

We, the authors, first met to discuss the program in 2018, long before UH Scripts officially began. Realizing the unique opportunity presented to us, we created a proposal that outlined the rationale and structure of UH Scripts. After funding attempts and leadership changes, we gained traction with Dean Stephen Spann (TJFFCOM) and Dean Dan O’Connor (CLASS) and received approval to launch the program in the fall semester of 2022. To gain support, we articulated how the program could benefit both colleges, and we engaged relevant stakeholders. These included course directors who would be working with the teaching fellows and TJFFCOM faculty who already incorporate narrative health in their instruction.

The National Academy of Sciences declares that today’s complex problems require transdisciplinary work, which not only integrates approaches but creates fundamentally new conceptual frameworks that ultimately extend beyond preexisting disciplinary boundaries (National Research Council 2015). While this goal is aspirational, the combination of medicine and creative writing has contributed to the creation of new ideas and insights, such as a renewed acknowledgement of the importance of humanism (Thibault 2019). Both groups bring their unique processes, culture, knowledge, and skills. By meeting regularly and working on shared goals, medical students and creative writers inevitably teach each other about their respective disciplines, uncover areas of overlap, and co-create products, like the planned, online literary journal.

Significance of the UH Scripts Program

Narrative and lyric health is particularly powerful when viewed through the lens of relationship-centered care (RCC). RCC comes from the idea that interactions among people are the foundation of any therapeutic activity. The founders of RCC believed that healthcare encounters involve reciprocal influences and that clinicians need to be open to the possibility that encounters will be mutually transformative. When clinicians recognize the common humanity within these interactions, they are reminded of their commitment to service and that they are renewed by their service (Weiss and Swede 2019). These interactions take place with patients, colleagues, community members, and within themselves. Narrative and lyric health provides a tool for examining these relationships because of its relevance to cultural humility, interprofessional education, shared decision making, critical thinking, bias-free care, recognition of emotion, and professionalism. All of these topics are emphasized in the curriculum at TJFFCOM, facilitating the integration of creative writing into relevant courses.

While narrative and lyric health is theorized to have wide-ranging effects, the literature base is still maturing. One systematic review concluded that curricula that teach narrative health have an impact on attitudes, knowledge, and skills; however, less is known about how this content affects interactions with colleagues and patients in real-world settings (Milota, van Thiel, and van Delden 2019). Another systematic review assessed the impact of narrative-based interventions on patients. While the authors found that these interventions reduced pain and increased wellbeing, they were only able to identify ten research articles and stopped short of declaring that there is a generalizable effect due to the heterogeneity of the interventions (Fioretti et al. 2016). Taken together, these studies suggest the potential for narrative health curricula to impact health and the need for ongoing evaluation.

At a time when creative work feels more and more circumscribed to audiences of practitioners, UH Scripts allows writers (the teaching fellows) to see their skills affect quality-of-life changes for doctors-in-training, patients, and community members. The enhanced attributes that narrative and lyric health promise to future clinicians are the same we value in writers, especially those who will go on to teach in the humanities. Through UH Scripts, both groups of students can see similarities between their educational and professional pursuits, which will ready them for other transdisciplinary opportunities.

Houston, home to the Texas Medical Center and to a long history of literary arts support, is a model city for a program like UH Scripts. The University of Houston is located in Third Ward, an area rich in arts collectives and platforms, such as Project Row Houses, the Gite Gallery, Texas Southern University’s University Museum, and UH’s Blaffer Art Museum. UH Scripts aims, through its journal and activities, to bring the creative work of community members, students, and practitioners together for the enrichment of all.

Conclusion: Outlook

As the student body at TJFFCOM grows, we hope to increase the number of teaching fellows commensurately. RCC requires relationship-centered apprenticeship. The teaching fellows become part of the students’ community for two years, and we hope that they will teach both medical students and the next generation of narrative health educators as well as poets and fiction writers. Other professional schools, such as optometry, have begun exploring narrative medicine’s benefits (Glass and Bennett 2013), and we believe this model can be applied to the other colleges that train health professionals on our campus. Integrating creative writing into health education is difficult. Given the depth of knowledge students must master, narrative health programs must continuously demonstrate their value. Despite this challenge, the debate is healthy, for reminding students of their own humanity and the humanity of their patients is crucial to solving the crises facing our healthcare system.

Acknowledgments

We would like to thank the 2022-2024 UH Scripts Teaching Fellows, Nick Almeida and Stephanie Pushaw, for their inspiring work; the Creative Writing Program faculty for their support; our close collaborators, Dr. Woods Nash, Dr. Bill Elder, and Dr. Jerome Crowder; and our deans at the time of the program’s approval, Dean Daniel O’Connor (CLASS) and Dean Stephen Spann (TJFFCOM).

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