Reflecting on medicine

Having medical students write about their experiences is a technique that has been used for decades to produce doctors with more empathy and compassion and is increasingly being adopted here.

Doctor [Illustrative] (photo credit: INGIMAGE)
Doctor [Illustrative]
(photo credit: INGIMAGE)
What does it take to make a good doctor? A keen diagnostic sense? The ability to lead and inspire others? Technical skill? Professionalism? Teaching abilities? Thoroughness and exactitude? Familiarity with the latest medical research? All these are important traits.
But in an era when machines – from MRI scanners to surgical robots – take on increasing role in medical care while physicians are not always able to fix patients’ chronic conditions, medical schools and hospital and clinic administrators increasingly look for people with empathy and compassion to understand and relate to the patient as a whole person.
Just as teachers of previous generations were idealistic and dedicated to educating children instead of seeking a job with long vacations, general practitioners tended to go into the profession because they wanted to heal rather than just spend their afternoons and early evenings in private practice. Many health fund doctors who must fill a quota of some 20 patients per morning spend on average seven minutes for each one and are focused on entering their particulars into the computer, barely touching them or looking directly at their faces. Hospital doctors on the rounds too often regard the people in the wards as “diseases” to be treated rather than as individuals.
To them, “touchy-feely” approaches are beyond the pale.
So today, how does one measure empathy and compassion? Is a young person born with it, and if not, can it be taught in medical school and nurtured in a hospital setting? NARRATIVE MEDICINE and reflective writing to foster compassion for patients and self-awareness have increasingly become an integral part of medical education in the US and other advanced countries, and Israel’s medical faculties have in recent years begun to adopt them as well to explore and manage the complexity of healing.
According to experts in the field, reflective writing is defined at “the process of internally examining and exploring an issue of concern, triggered by an experience that creates and clarifies meaning in terms of self and results in a changed conceptual perspective.”
Medical students have to learn how to write, about themselves, their motivations, feelings, fears and conflicts; doctor/patient and doctor/colleague relationships and other topics. Reflective writing involves purposeful thinking about an experience through which learning takes place. Putting their thoughts down on paper is a more effective way of exploring their thoughts and feelings instead of just thinking about them, according to Prof. Hedy Wald, a veteran clinical psychologist, clinical associate professor of family medicine and director of the reflective writing curriculum at the Warren Alpert Medical School of Brown University in Providence, Rhode Island.
She earned her doctorate in clinical psychology from Yeshiva University and completed a post-doctoral fellowship in neuropsychology a the Boston Veterans Administration Boston University School of Medicine. She underwent training in narrative medicine facilitator training at Columbia University-College of Physicians and Surgeons and is a Fulbright Scholar.
A traditional Jew, daughter of a Holocaust survivor and a frequent visitor to Israel, Wald was here recently to participate in a Ben-Gurion University conference on Strategies to Promote Resiliency, Empathy and Wellbeing in the Health Care Professions. It was sponsored by the Israel Association for Medical Education, headed by Dr. Shmuel Reis, who is head of the faculty development unit at Bar-Ilan University’s Faculty of Medicine in the Galilee in Safed. Reis has known and collaborated with Wald for years, as he is also an adjunct professor of family medicine at her medical school at Brown University.
Her techniques are currently being used not only in the North America and Israel but also in various European capitals, and their efficacy has been proven in quantitative and qualitative studies.
The conference was attended not only by physicians but also by nurses and nursing school faculty members.
“I have been working with Hedy on our techniques since 2008,” Reis told The Jerusalem Post in an email communication. “I have been using them in the new Safed medical school, where we require students to write reflectively in the clinical skills course and in a few other modules (such as community service, the Holocaust and Medicine and other subjects). The Hebrew University’s medical school has also adopted this approach; in their Man and Medicine course, reflective writing is required.
I have run workshops there several times.
These are powerful techniques that support the students’ reflective capacity and identity formation,” Reis said.
Married to Mark, a 60-year-old neurologist, the clinical psychologist knows medical care from both sides. Her husband was diagnosed with a malignant glioblastoma brain tumor a few years ago and has since undergone more than one operation that removed the cancer and stabilized his condition but left him unable to practice medicine.
However, he has relearned how to ride his bicycle and uses it intensively with great enjoyment.
“He regards himself as a fortunate person and thriving,” said Hedy. “We march on,” she told the Post in an interview.
They have four grown children, including a 33-year-old pediatric hematologist, a 31-year-old dentist, a 28-year-old in marketing and a 24-year-old in the second year of Albert Einstein Medical School.
She writes personal articles and even poetry in medical and other journals and lectures around the world, actively promoting the use of humanities in medical education. BGU and Tel Aviv University’s Sackler Medical School, said Wald, “have elective courses on student wellness and burnout, while the Technion’s Rappaport also has courses on art and narrative. I teach how to use interactive reflective writing, get personalized feedback from faculty and hear from peer groups.” “In family medicine courses, I write about challenging and emotional patient encounters. What medical students take away from these sessions influences their future in medicine.”
AS CANDIDATES for medical school here and abroad have to undergo simulators with actors serving as “patients,” the results of testing them for empathy and compassion would be difficult to verify. “I remember a student who said that undergoing narrative medicine, he ‘felt he was acting.’ It may initially feel like acting, but it can become internalized and become part of you. You don’t have to be born with it,” Wald said.
She especially cited BGU’s School of Health Sciences for its stress on teaching humanistic care.
Medical students doing such writing produce about a page or so on each subject.
“It’s not literature but more about reflecting on experience, resiliency and wellness,” said Wald. “Clinical care can be like a marathon; you have to train for it in various ways, so reflective writing is a workout, sweating your mind and heart to become a physician. There are two pockets in the white coat – one for medical training and the other for one’s reflective capacity.”
Many doctors and nurses the world over suffer from dissatisfaction with their work, hostility, a lack of empathy, and cynicism, continued Wald.
“Substance abuse and suicide has been well documented. Patients whose doctors are less empathic have been shown to follow their advice, including taking medications, less than when the physicians are empathic. We don’t have magic wands, but raising awareness of issues is important.
The bottom line should be to promote patient satisfaction and compliance and having less medical error.”
Many older doctors come to her workshops “because they say they are interested in staying vital, enriched and humanized. I have heard veteran doctors say they wished they had had reflecting writing when going to medical school.”
Reflective writing by medical students and doctors is important to develop skills that will be required for their future work, dealing with multifaceted problems for which there is no ideal solution; to recognize the importance of being able to frame a problem before trying to solve it; to understand that problems and situations can be viewed in many different ways, depending on the perspective of the person involved; and to be able to stand back from yourself and question your behaviors and attitudes.
Training in the subject have been shown to make medical students and doctors more empathic and have more compassion for other people, including patients. It also reduces medical errors, Wald said.
WALD AND Reis have jointly written several articles in medical journals on the effects of teaching the role of Nazi physicians in the Holocaust to medical students, whether they are Jewish or not.
“Contrary to former theories, it is now widely accepted that many physicians who worked for the Third Reich were not lone psychopaths but rather ordinary people propelled into abhorrent behaviors. Understanding how the medical profession and individual physicians supplied the ideas, programs and infrastructure to make the Final Solution a reality is germane to medical education.”
Specific examples in the Nazi era, they continued, “can have a profound educational effect. Only a physician was allowed to open the gas faucet to ensure the ‘mercy killing’ of mentally ill and disabled Germans.”
Dr. Josef Mengele’s “experimentation” on Jewish concentration camp prisoners and doctors’ assistance to Nazi firing squads and “selections” are, of course, notorious.
“My commitment to educating future physicians about the tragic role of the medical profession during the Holocaust, highlighting abuse of power and its contemporary messages, fuels my work,” Wald has written. “So does being the daughter of a survivor of three concentration campus including Auschwitz, the man with the number on his arm who lost his entire family, my father, Maurice Wald.”