Reflective MedEd

Bearing Witness:  Storytelling by Healthcare Professionals and Learners During Times of Uncertainty

Lisa Howley, PhD¹; Virginia Bush¹; Elizabeth Gaufberg, MD, MPH^1,2

1. Association of American Medical Colleges
2. Harvard Medical School

Corresponding Author: Elizabeth Gaufberg, Elizabeth_gaufberg@hms.harvard.edu

When the coronavirus pandemic hit North America in March of 2020 the medical profession was plunged into a crisis more devastating than any it had faced in the previous century. Trainees and physicians were called to the frontlines to care for extremely ill patients for long hours in the context of inadequate knowledge, skills, and equipment; patients were dying without loved ones to hold their hands and ease their passage. Ethical dilemmas around distribution of limited resources permeated each medical decision and led to moral injury for providers who could not deliver the quality of care that was standard just weeks prior. Healthcare professional burnout and suicide increased from the already significant pre-pandemic rates^.1 Many medical schools limited students to virtual learning to protect them from exposure to the virus; yet a byproduct of this prudent decision was that many students found themselves isolated from peers and teachers, and in living situations suboptimal for class attendance and studying. Some questioned whether they were getting an education that would allow them to become good doctors.

Amid the first surge, following mounting protests over policing practices in communities of color, the murder of George Floyd on May 25, 2020, ignited a period of civil unrest with urgent calls for structural change within policing and other societal institutions. Racial disparities in Covid-related hospitalizations and deaths drew attention to inequities in health and healthcare. Academic medicine embarked on a period of self-examination around issues of race, resulting in efforts to address racism in medical schools and health systems. Ideological divides within our profession and nation were intensified at a time when uniting around a common purpose was never more critical. And yet for many, an enhanced sense of meaning and rededication to one’s calling permeated the chaos; among them were medical students who assumed the mantle of advocate, discovering avenues for self-expression and collective action.  In a time of devastating illness, social upheaval, and economic ruin, we invited the academic medicine community to tell their stories.

AAMC FRAHME AND CREATIVE EXPRESSIONS DURING TIMES OF UNCERTAINTY

In 2017, the Association of American Medical Colleges launched a new initiative called FRAHME (the Fundamental Role of the Arts and Humanities in Medical Education). This initiative advances the powerful and transformative role of the arts and humanities in achieving core 21^st century outcomes for medical learners. FRAHME has produced a robust and diverse portfolio of programs and resources.² Well-designed and integrated arts and humanities educational experiences can foster many core skills of doctoring, including close observation and interpretation, reflection and metacognitive awareness, empathy, teamwork, well-being practices, and the ability to engage respectfully in difficult conversations. Some of the desired outcomes of arts and humanities integration have come to the fore during the pandemic. Those include improving the capacity of health professionals to be adaptive, resilient, lifelong learners who appreciate the impact of social factors on health and illness and can respond effectively to complex challenges.

In the Spring of 2020, with the support of the National Endowment for the Arts, FRAHME established a creative forum for healthcare professionals and trainees to bear witness to these unimagined and rapidly unfolding challenges. Making stories, narrative, or poetic, spoken or written, or performed as music or movement, is an essential part of being human.  Storytelling allows us to give form to complex or ambiguous experiences; we may then metaphorically walk around that form, stand back or come closer, examine curves and imperfections and possibilities.  Engaging both the head and the heart, stories allow us to share our personally unique vantage points as well as our shared humanity with one another. Listening to stories within a community enables us to identify common values and goals, and to bridge ideological divides. Perhaps most important in these times of adversity, story sharing reminds us that we are not alone in our suffering.

Creative Works

Three distinct opportunities to share —55-word stories and poems, The Good Listening Project collaborative poems and StoryCorps recordings — have resulted in a repository of oral and written creations, providing opportunities for current reflection and an historical imprint of these uniquely challenging times. This repository can be found at https://frahme-aamc.org/.³

• 1. 55-word stories and poems: The 55-word story or poem activity has been used in many U.S. medical schools to encourage reflection and meaning-making in support of professional identity formation.⁴ The exact word count specification invites attention to language choice as well as the creation of a narrative arc that may not emerge from a more open-ended format. In June 2020, we launched a broad call for 55-word submissions and original poetry and collected over 300 submissions over the course of one year.

• 2. Listening Poet Sessions with the Good Listening Project:  In partnership with The Good Listening Project, FRAHME provided a creative opportunity for members of the academic medicine community to take part in a private conversation with a trained Listener Poet.⁵ Listener Poets engaged in brief virtual sessions with hundreds of volunteers who each shared their unique experiences during this period of upheaval and suffering.  The poet then produced a custom poem based on the conversation, which was emailed to the recipient within 24 hours. In the words of one recipient “When I received the poem the next day, it brought me to tears. It put everything into words that I was feeling; it was very healing for me.”

Figure 3

One Listener Poet shares the following example which emerged from a conversation with a faculty member who had been a Professor of Integrative Physiology for almost four decades. The Professor brought the tools of mindfulness and self-care to medical students, many of whom had been studying long hours, day after day, in isolation for the past year.  

Caregiver, Care for Yourself

You have come here to help others

and yet it has been a year of

unrelenting work

isolation

stress.

Your chest tight, tired, heart hungry for touch.

We were born to engage

but can you embrace

and be held through a screen?

Here, here are the tools:

ancient and intimate as a whisper

known in every mindful moment.

Rise, take your precious body

and walk,

run,

race back to yourself.

Rise, taste hope in another’s eyes.

Here is the first patient.

Caregiver, care for yourself.

Listen, you are here, you are held in hope,

made whole in a moment of awareness and connection.

You asked to serve, to heal others,

but you were swallowed by a pandemic

and in the fearful dark

you leaned to breathe, to wait,

to trust, and believe.

Caregiver, care for yourself.

Anonymous, Professor

Through our partnership, we conducted 254 listening poet sessions and a curated collection of the poetry is available online and in a TGLP published hardback set of books. In the 15-series The Good Listening Podcast, a Listener Poet brings three poems along with the stories shared in the conversations that inspired each work.⁶

• 3. Oral History Project with StoryCorps: The AAMC also established a partnership with StoryCorps, one of the largest digital collections of human voices, featuring conversations recorded across the United States and around the world.⁷ Healthcare trainees and professionals were audio-recorded telling their own stories or engaging in meaningful dialogue with one another.  These stories are now preserved in a special AAMC collection within the StoryCorps Archive, which is housed in the American Folklife Center at the Library of Congress. As of the time of this essay, a total of 13 recordings are included in this collection.⁸ In addition, several longer clips were edited into a set of 4-minute offerings which may be shared in educational settings and on social media.⁹

Closing Reflections

The AAMC FRAHME story collection has opened a window into the emotions and lived experiences of our pandemic storytellers. One story at a time, we have learned something about grief and loss, guilt and shame, racism and poverty, and the enormous power of loving relationships, spirituality, gratitude, and resilience.  The intensity of the pandemic continues to wax and wane to this day, and we have intermittently returned to somewhat more normal educational, professional and life circumstances. Yet burnout and post-traumatic symptoms are likely to plague our healthcare learners and workforce for a long time to come. Story-sharing may allow us to greet each other in places of honesty and hope, and to begin to heal.

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Funding: The authors received financial support from the National Endowment for the Arts (NEA) for work described in this article.

Acknowledgement: The authors extend their gratitude to the following individuals and organizations for their efforts to make this story sharing initiative a reality: StoryCorps; The Good Listening Project; Alison Whelan, MD; John Nash; Brandy King and Adrien Barrios.

References:

1. Linzer M, Stillman, M, Brown, R, et al. American Medical Association – Hennepin Healthcare System Coping with COVID Investigators. Preliminary report: US physician stress during the early days of the COVID-19 pandemic. Mayo Clinic Proc Innov Qual Outcomes. 2021;5)1):127-136. https://doi.org/10.1016/j.mayocpiqo.2021.01.005

2. The fundamental role of arts and humanities in medical education. AAMC. June 30, 2020. Accessed April 12, 2022. https://www.aamc.org/what-we-do/mission-areas/medical-education/frahme

3. Creative expressions during times of uncertainty. AAMC. October 15, 2020. Accessed April 12, 2022. https://frahme-aamc.org

4. Scheetz A, Fry ME. The stories. JAMA 2000;283(15):1934. https://doi.org/10.1001/jama.283.15.1934

5. The Good Listening Project. Accessed April 12, 2022. https://www.goodlistening.org

6. The Good Listening Podcast. The Good Listening Project. Accessed April 12, 2022. https://www.goodlistening.org/podcast

7. StoryCorps. Accessed April 12, 2022. https://www.storycorps.org

8. AAMC. StoryCorps Archive. May 2020. Accessed April 12, 2022. https://archive.storycorps.org/communities/aamc

9. AAMC. On the front lines: stories recorded with the Association of American Medical Colleges. StoryCorps. July 13, 2021. Accessed April 12, 2022. https://storycorps.org/on-the-front-lines-stories-recorded-with-the-association-of-american-medical-colleges