Introducing Humanities Into the Oncology Curriculum

It seems that every year, the list of Accreditation Council for Graduate Medical Education (ACGME) requirements grows longer and more bewildering. That’s no surprise in oncology. Our patients are increasingly complex, our therapies are more numerous and more sophisticated, and the ACGME’s reach extends beyond medicine into patient safety, quality improvements, and understanding medical systems. In addition, there is the burgeoning list of required conferences, institutional demands, and the dawning of the electronic age, complete with electronic medical records, electronic admission, electronic discharge, electronic sign-in and sign-out, and electronic communication, all of which conspire to keep us at our laptops far longer than at the bedsides of our patients.

Add to this the stress of our clinical work. We try to satisfy the needs of our patients and their families, many of whom are facing life’s biggest crisis. They deserve more attention than our crowded and fragmented schedules will allow; this only heightens our stress. For the fellow, this stress can be still greater. There are the additional burdens of being less experienced, being less appreciated by families, struggling with difficult decision-making and poor outcomes, and managing the competing demands of patients, faculty, the fellowship program, and the fellow’s own family life.

Given the stresses and demands of our field, it is not surprising that the prevalence of burnout is high. Burnout is defined as emotional exhaustion, depersonalization (ie, treating patients as objects), and a low sense of accomplishment. However, there are many ways to maintain the deep satisfaction that comes with working with patients with cancer and their families and with our colleagues. Incorporating medical humanities into one’s medical practice and the fellowship curriculum is one such way. Medical humanities is simply application of history, literature, art, music, and other fine arts to the practice of medicine and the care of the patient.¹

There is not much literature on this approach, particularly in oncology. Gilewski describes a forum for fellows at Memorial Sloan-Kettering Cancer Center that focuses on end-of-life care and the stresses of such care on fellows and other caregivers.² Sands et al reported on a narrative training course, in which members of a pediatric oncology team wrote about their own personal experiences with their patients.³ The 19 participants in this course displayed improved perspective on their patients’ problems, higher empathy scores, and better teamwork.

‘Narratives in Oncology’ Seminar

In 2009, we introduced a seminar at the James P. Wilmot Cancer Center in Rochester, New York, titled “Narratives in Oncology,” which was designed for medical and pediatric oncology fellows and radiation oncology residents. Our goal was to introduce our trainees to literature, poetry, and essays in the lay press as well as in the medical literature that focus on the human side of patient care. We hoped that such literature would open the eyes of our fellows to a rich source of thought-provoking material on patient and physician perspectives on life, death, and medical care. We also hoped that discussion of these essays would stimulate dialogue among us about subjects we seldom discuss: what to tell (or not to tell) our patients, the challenges of communicating bad news, how to deal with difficult families, coping with loss, and our own personal stresses caring for so many medically and emotionally needy patients.

The seminar was designed so that we would meet in a 1-hour session once a month for 6 months. The faculty preceptors and the fellowship director chose articles to review, and 1 week prior to each session 1 or 2 essays/articles were distributed to the fellows. We chose articles that provided the patient’s perspective and that highlighted common clinical dilemmas. For example, for our first session we read an essay by Stephen Jay Gould called “The Median Isn’t the Message,” which discusses how a patient might look at odds of survival very differently than would a physician.⁴ In another session, we read a Glamour magazine excerpt, “I Want My Life Back,” by Andrea Coller, a young patient with multiply recurrent Hodgkin lymphoma, and learned what it feels like to be 27 years old and go through intensive chemotherapy and how we physicians look from the perspective of a young adult. (It wasn’t pretty!)⁵ We read a painful essay called “Facing Our Mistakes” by David Hilfiker⁶ and watched Casey’s Legacy, a video of a physician who tearfully describes a mistake he made in caring for a child.⁷ For the last session, fellows were asked to write an essay about a moving interaction with a patient, and selected essays were read at that session.

The seminar was quite successful. Attendance ranged from 11 to 18 fellows and it was clear they had read the assigned material. Discussion was lively and almost all the fellows actively participated. Faculty preceptors guided the discussion, but little stimulation was needed to provoke conversation. Fellows frequently cited their own patient scenarios that related to articles we reviewed. They frequently brought up the unique aspects of being a fellow and dealing with stressful patient encounters. They cited such examples as not feeling comfortable with the attending physician’s communication skills, their own lack of experience when patients ask difficult questions, their discomfort when delivering bad news, and their unhappiness about knowing that, as a trainee, they cannot always speak freely. As the word spread about the seminar, we were joined by other faculty members, nurses, and nurse practitioners.

For the final session, fellows and faculty were asked to write a brief essay. One fellow wrote a moving piece about running into a very grateful couple in the grocery store and how he just could not remember who they were. He explained how embarrassed he was to have no memory of them. Was one a former patient? Were they bereaved family members? But at the same time, it made him realize that through his actions he can have a real impact on his patients’ lives. Another fellow wrote about her interactions with a demanding daughter, a hospital executive who tested the limits of the fellow’s patience. The fellow described how, tough as the executive in her power suit seemed, deep down she was scared of losing her mom, who eventually died of cancer. The fellow said that she knows how this feels because she, too, lost her mother.⁸

At the conclusion of the seminar series, we formally surveyed the fellows for feedback on the course. Ten of the 11 fellows who returned the survey felt that the course was a useful part of their curriculum. The fellows “repeatedly cited the openness to discussion of issues that typically are not part of the traditional oncology curriculum, as well as the relevance of the specific articles chosen.”⁸ As one of the fellows said, the course “provided a forum in which we could discuss our experiences and explore difficult issues with others who have shared similar experiences.”⁸ Ten of the 11 fellows said the course had a positive impact on their interaction with patients, enabling them to have a more “humanistic approach,” be “more aware of patients’ feelings,” and hang on to empathy when it might otherwise have been lost. The majority of fellows felt that the writing exercise was useful, albeit difficult. It should be noted that 1 respondent did not find the course helpful at all; hence, a reminder that this is not an approach that is useful for everyone, and that we need to be sensitive to the needs of individuals who may choose to deal with patient care dilemmas more privately.

Overall, there was consensus among the fellows and faculty that the “Narratives in Oncology” seminar is a valuable part of the fellowship curriculum, and that the principles and practices we discuss can be incorporated into patient care, help to improve patient-physician communication, and make care of the patient with cancer more gratifying. As we move into year 2 of the seminar, we hope to expand to include other forms of artistic expression, such as art, music, and video, and perhaps expand our audience to other healthcare providers and other subspecialists.

*This article is adapted by the authors from: Khorana AA, Shayne M, Korones DN. Can literature enhance oncology training? A pilot humanities curriculum. J Clin Oncol. 2011;29:468-471.

This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.

David N. Korones, MD, is professor of pediatrics, oncology, and neurology at University of Rochester School of Medicine and Dentistry in Rochester, New York. He is also a pediatric hematologist/oncologist and palliative care specialist. Michelle Shayne, MD, is assistant professor of medicine and oncology at University of Rochester School of Medicine and Dentistry in Rochester, New York. She is a medical oncologist with expertise in breast cancer and is the Hematology/Oncology Fellowship Program director. Alok A. Khorana, MD, is associate professor of medicine and oncology at University of Rochester School of Medicine and Dentistry in Rochester, New York. He is a medical oncologist with expertise in GI oncology and thrombosis.

References

1. University of Rochester Medical Center. Medical Humanities Web site. http://www.urmc.rochester.edu/smd/medical-humanities. Accessed May 8, 2011.
2. Gilewski T. The art of medicine: teaching oncology fellows about the end of life. Crit Rev Oncol Hematol. 2001;40:105-113.
3. Sands SA, Stanley P, Charon R. Pediatric narrative oncology: interprofessional training to promote empathy, build teams, and prevent burnout. J Support Oncol. 2008;6:307-312.
4. Gould SJ. Full House: The spread of Excellence From Plato to Darwin. New York, NY: Harmony Books; 1996:45-56.
5. Coller A. Non-fiction contest winner: I want my life back. Glamour magazine Web site. http://www.glamour.com/magazine/2008/05/essay-winner-surviving-cancer. Accessed May 11, 2011.
6. Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118-122.
7. Boyte WR. Casey’s legacy. Health Aff (Millwood). 2001;20:250-254.
8. Khorana AA, Shayne M, Korones DN. Can literature enhance oncology training? A pilot humanities curriculum. J Clin Oncol. 2011;29:468-471.