Address for correspondence
Kamil Konrad Hozyasz E-mail: khozyasz@gmail.com Funding sources None declared Conflict of interest None declared Received on January 1, 2020 Reviewed on January 23, 2020 Accepted on March 16, 2020
Abstract
In English-speaking countries, the analysis of literary texts describing patients and their diseases as well as medical professionals is an integral component of the curricular training of medical students and residents, and also students of nursing, physical therapy and dietetics. The aims are to develop in students the abili-ty to reflect on their knowledge and professional experience, to improve their communication skills in their relations with patients, and to promote a patient-centered approach in medical care. Several literary works written in prose were presented – Exit Lines by Jane Barfoot, Bed Number Ten by Sue Baier and Mary Zim-meth Schomaker, and No Laughing Matter by Joseph Heller and Speed Vogel – as helpful in preparing tra-ining modules. This paper also reviews the literature reporting on the role of poetry in practicing nursing and the ways it can be manifested in nursing. Poetry is regarded to enrich medical professionals and prevent burnout. Adam Gorczyński’s poem W grudniu! (In December!) was presented as a literary text for a guided discussion with students and healthcare workers on empathy and professional burnout.
Key words: nurse education, anthologies of literature, critical assessment, communication skills
This is a translated article. Please cite the original Polish-language version as
Hozyasz KK. Rola literatury pięknej w edukacji medycznej.
Piel Zdr Publ. 2020;10(3):171–177. doi:10.17219/pzp/119058 DOI
10.17219/pzp/119058
Copyright
© 2020 by Wroclaw Medical University This is an article distributed under the terms of the Creative Commons Attribution 3.0 Unported License (https://creativecommons.org/licenses/by/3.0/)
Role of literary works in medical education
Rola literatury pięknej w edukacji medycznej
Kamil Konrad Hozyasz
A–FFaculty of Health Sciences, Pope John Paul II State School of Higher Education in Biała Podlaska, Biała Podlaska, Poland A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation; D – writing the article; E – critical revision of the article; F – final approval of the article
Streszczenie
W krajach anglojęzycznych analiza dzieł literatury pięknej na temat chorych i ich dolegliwości oraz postaci profesjonalistów medycznych stanowi integralną część edukacji studentów medycyny i lekarzy rezydentów, jak również studentów pielęgniarstwa, rehabilitacji i dietetyki. Za cel tego działania stawia się pobudzenie stu-dentów do refleksji o zdobywanej wiedzy i doświadczeniu praktycznym, doskonalenie umiejętności komunikacji z chorymi i uwrażliwienie na napływające od nich sygnały, budowanie nawyku podtrzymywania pacjentocentryzmu w opiece medycznej. Przedstawiono wybrane utwory prozatorskie – Exit Lines Joan Barfoot, Bed Number Ten Sue Baier i Mary Zimmeth Schomaker oraz Nie ma z czego się śmiać Josepha Hellera i Speeda Vogela – jako pomocne w opracowaniu modułów szko-leniowych. W artykule dokonano także przeglądu publikacji naukowych dotyczących roli poezji w szeroko pojętym pielęgniarstwie i możliwości jej przenikania do codziennej aktywności zawodowej. Dominuje pogląd, że poezja ubogaca profesjonalistów medycznych i może ich chronić przed wypaleniem zawodowym. Zapre-zentowano wiersz Adama Gorczyńskiego W grudniu! jako przykład utworu pomocnego w dyskusji ze studentami i pracownikami ochrony zdrowia o empatii i wy-paleniu zawodowym.
Słowa kluczowe: edukacja pielęgniarska, antologie literatury, krytyczna ocena, umiejętności komunikacyjne
The importance of literary works to nursing is that they may educate, support and liberate the intuitive, connected knowl-edge of human responses… Good books can be a gift of wisdom to our students – the experience of life without its costs.
Janet B. Younger1 American Professor of Nursing
In recent years, non-fiction stories about medical pro-fessionals and their problems became popular among Polish readers. As a result, many books have been written about the professional work of doctors,2–4 nurses,
includ-ing books written by nurses themselves,5,6 and
paramed-ics.3 Such literature provides the workers of the healthcare
sector with an opportunity to confront their personal ex-periences and professional observations with the percep-tion of reality and evaluapercep-tion of the people from outside their own environment, frequently from the pro-patient perspective. The main subject of these volumes are usu-ally the reviled aberrations of the system. However, ma-ture and non-tabloidizing accounts of relations between the patient and the medical professional, the universe of emotions and, insightful, yet non-scientific descriptions of illnesses and the characters of doctors and nurses can be found in belles lettres.
Disease stimulates the imagination of thinkers and its symbolism permeates the society.7,8 It is not without
rea-son that contestators in an intriguing way concluded that it is not the scientific literature, but the prose by promi-nent authors that enables learning about the nature of the human being.2 A philosopher and psychiatrist,
Ka-zimierz Dąbrowski, formulated a bold, yet convincingly supported by the attribution of ill people from the pages of novels and novellas to detailed clinical diagnoses, hy-pothesis on a talented literary author who... “as an expert in the human nature, its manifestations and processes, is a much better diagnostician than most psychiatrists and psychologists...”.10 The abundance of the subject of
medi-cine in poetry and prose has been attracting the attention of many researchers. In practice, it has usually concerned works written in English or translated into it.11–13
Even though Polish literature lacks publications dis-cussing literary portraits of nurses, there are several pub-lications which critically and in an interesting way juxta-posed several “curricular items” of prose with portraits of doctors, accompanied by the following foreword: ”...phy-sicians frequently became the main protagonists of nov-els, as it is in them that the answer to the questions: Who is a physician? What is medicine and what should it be? can be found.14 Both Polish and foreign doctors-writers
(1,207 biograms) were collected in an encyclopedic dic-tionary which, albeit ambitious, was not free of substan-tive and editorial errors.15 Recently in our country,
nu-merous scientific conferences and literary monographs have been dedicated to various links between literature and medicine.16,17
The aim of the paper was to analyze knowledge con-cerning the impact of reading selected literary works and their interpretation on medical professionals, with par-ticular emphasis on nursing students and professionals.
Literature
and professional medical training
In English-speaking countries, the analysis of literature constitutes a fixed component of professional medical education. The legitimacy of such an approach has also been noticed in other countries, e.g., German-speaking ones.18–25 It is emphasized that, among others, even the
Greek father of medicine, Hippocrates, as well as Ga-len, the physician of Roman emperors, believed that the knowledge of the classical drama was desirable in phy-sicians.18 Targeted studies of literature make it possible
to strengthen empathy and limit professional pride, open the human mind to a better understanding of the needs of patients and their loved ones, raise awareness regard-ing the complexity of human experiences, teach about the emotions present and admired in the artistic world, but eliminated in scientific descriptions, bring the ethi-cal discourse closer, stimulate imagination, and prompt
self-reflection.18,19,26,27 Moreover, the language of literary
works is diverse and personalized, which stands in op-position to the formalized scientific message – and good communication with patients is that which responds to their abilities and expectations.27–29 An interesting
obser-vation was made by Shapiro and Rucker – they observed that discussing a clinical problem on the basis of its liter-ary description provides more room for free expression for students than typical clinical cases, which are sub-consciously associated with far-reaching cautiousness and the knowledge of medical and legal consequences as well as with the sense of the lack of own safe space dur-ing a discussion with an experienced teacher-clinician.26
Readings, for example, a Hasidic fairy tale about A prince
who turned into a rooster,25,30 can sometimes prepare
stu-dents for the contact with mentally disturbed patients. Many researchers express the opinion that properly se-lected readings shape the habit of a holistic approach to patients.21,31 In accordance with the vision of the leaders
of the so-called medical humanities,32 a medical
profes-sional should be characterized by an imaginative insight into problems and contexts of patients’ lives, which is a postulate by Jane Macnaughton from Durham University that has become permanently rooted in the literature.19,33
Researchers emphasize the necessity to intensify the activities in the field of a separate discipline dealing with the development of educational tools and with studies on the impact of the contact with literature on medical professionals.22 The aim of the above is to extend the
cur-riculum of studies and post-graduate trainings as well as fight a serious problem of the public health sector, namely professional burnout.20,22 Work in this sector is very often
associated with the need to improvise. Personal contact with art and literature, which stimulate imagination, pre-pares for it.34,35
An important task is to create lists of works as well as identify those parts of these works,31 the reading of which
would not be time-consuming and would translate into increasing professional competencies. Such lists have been created in English-speaking countries – first for phy-sicians,36,37 then for nurses,38 dietitians,31 physical
thera-pists, and occupational therapists.39 In the long term, it is
expected that different anthologies will be developed for various sub-specializations or for specific conditions of work,20,21,31 or specific subjects, such as pregnancy, birth,
death, loneliness, institutionalization, or special health needs of women.12,26,27 Due to thoroughly selected
read-ings, specialists can develop their cultural competencies and have a better understanding of the reality of the pa-tient’s life, which includes, among other things, their food choices, with regard to, for example, their ethnic origin and socioeconomic conditions, which constitutes an im-portant issue in the practical training of dietitians.31
Ahl-zen even postulated that special catalogues, called LOMS (literature on medical situations), be created in order to allow clinicians to learn in detail about the experiences of
patients with a given disease entity and prevent limiting the disease process to a mere label, i.e., the name of the disease, as well as to prevent limiting oneself exclusively, or almost exclusively, to the biomedical perspective.13
Popular crime novels, patients’
memoirs and a novella
about a retirement home
as examples of works
of educational value
A police investigator, Kurt Wallander, the main pro-tagonist of a series of Swedish crime novels, has become an example of a literary character unable to deal with his health challenges who was used for the analysis of the metabolic syndrome.21 It is worth noting that these crime
novels, written by a novelist Henning Mankell, who died in 2015, enjoy great popularity among readers and have been translated into many languages, which enables the implementation of the educational module of the analysis of the character in many countries as well as subsequent scientific validation.
In the United States, the memoirs of Sue Baier, a house-wife and a mother of 2 teenagers from Houston, were used to teach students about caring for critically ill pa-tients. The memoirs, written down with the help of Mary Zimmeth Schomaker, were entitled Bed Number Ten and were first published by CRC Press in 1985.40 The
protago-nist of the book experienced extreme muscle weakness as a result of the Guillain–Barré syndrome and required years-long rehabilitation, which improved her condi-tion slowly. The descripcondi-tions of the nurse treating the patient like an object without trying to empathize with the needs of a person extremely dependent on the help of others constitute an emotional and intellectual challenge for nursing students.40 Alas, Baier’s memoirs have never
been translated into Polish. Nevertheless, students in our country can learn about the problem of a sudden dete-rioration of health and the loss of physical independence in patients suffering from the Guillain–Barré syndrome from the book entitled No Laughing Matter, written by an exquisite writer, Joseph Heller, the author of such books as Catch 22, and Speed Vogel.
An interesting educational model for nursing students was developed in Canada on the basis of the novel Exit
Lines by Joan Barfoot. The protagonists of the novel are 4
residents of a newly-open small-town retirement home.41
The work, filled with internal monologues, transports the reader to a world of daily monotony, recollections, impres-sions, people awaiting death and dealing with thoughts of ending their own life. The author, valued for her writing skills, created a literary work constituting somewhat of an academic teacher’s dream, which enabled young
peo-ple to peek at the spiritual inner life of peopeo-ple at the end of their lives and at the ethical challenges related to it.41
The work of the Canadian writer has not been translated into Polish yet.
Special role of poetry
in medical education
Works of poetry have become an acknowledged ele-ment of the armaele-mentarium used in clinical medicine, also in the case of diseases and conditions within the area of interest of public health, such as, for example, post-stroke rehabilitation42 or palliative care.43 It seems
obvious that if poetry is to constitute a therapeutic tool, physicians and nurses, who spend the most time with the patients,44 should be personally encountering
litera-ture.18 Moreover, a medical professional interacting with
poetry improves the ability to interpret the language of the patients and their behaviors, increases the ability of evaluation, not only from the perspective of the patient, but also the members of the patient’s family, penetrates controlled emotional dependencies and gains interest in emotions, and appreciates reflection, self-reflection and intuition, known as the neglected hallmark of nursing knowledge.1,25,45,46 It is worth to keep in mind the stanza
of the poem Wrogom poezji (To the enemies of poetry) by Zenon Przesmycki, a.k.a. Miriam, who at the beginning of the 20th century rediscovered the poetry of Norwid for
the Polish society:
Thus, a song is a lie? Oh, thou defenders of truth! When the cold sun of knowledge shines, Is the task you have fulfilled human?47
Poetic descriptions of suffering are more moving than passages in biomedical textbooks.1 Reading poetry trains
sensitivity and linguistic flexibility, and teaches the read-er about linguistic nuances, opening their minds to am-biguity and paradox.13 Properly selected readings make
the reader aware of the power of language in shaping the reality in an imperceptible way.13 An advantage of works
of poetry is the fact that they can be read very quickly, which cannot be said about, for example, The Death of
Ivan Ilyich by Tolstoy or the fictionalized memoir
enti-tled No Laughing Matter. Even a very busy and reluctant student can be expected to quickly answer a question concerning an attached poem via email.48 As described
by Horowitz 49 in “The Lancet”, residents will empathize
with a poem if the initiative to read it comes from the head of the ward round.49
Moreover, during discussions concerning poetry, the staff is temporarily freed from excessive hierarchiza-tion. Educational theorists are of the opinion that the humanization of studies and the use of poetry are essen-tial during transition from the stage of learning about the
nursing profession to nursing practice and the acquisi-tion of the skill of providing personalized, holistic care to patients.26,45,50 Students who are prepared for the contact
with patients through literature and other disciplines of art, not only social sciences, have a chance to restore the space for empathy instead of applying the stereotypical classification of patients and their health problems.51,52
For a rehabilitation student, reading through several doz-ens of stanzas on loneliness and depression constitutes a valuable alternative to an extensive chapter from a text-book, which students usually consider to be useless in fu-ture professional practice.39 The Canadian market, which
is considered to be exemplary, shows that the choice of the profession of a nurse is primarily guided not only by salary, but also by the sense of pride of the job as well as its autonomy.53 Establishing adequate proportions between
conveying scientific, biomedical knowledge and the de-velopment of competencies necessary during the contact with patients in the education of nursing students as well as enhancing their sense of autonomy, also with regard to doctors, among others through the humanization of their studies, constitutes a priority for the successful evolution of the profession on the job market.22,45,51,53
Poetry as a cure
for professional burnout
The discourse concerning the impact of poetry and sharing the reflection regarding it with other employees of the healthcare sector emphasizes its role in the preven-tion of professional burnout,19,22 which has been recently
confirmed by Schoonover et al.54 in their critical review
of original papers published in English. The issue of pro-fessional burnout and self-contempt for being selfless as well as the sense of depersonalization constitute a serious problem,55,56 especially given the fact that paramedics,
nurses and doctors in Poland have been recently dealing with unjustified and ineffectively restrained aggression of patients. This motivates to identify works that could help the employees of the healthcare sector restore the sense that opening to the needs of the patient is a value, not an anachronistic lack of social adaptation. As early as 30 years ago, Younger postulated that employees of the healthcare sector be given a selection of literary works, adapted to the current needs.1 She wrote that “the story
that would be useful to a particular nurse would depend on the nurse’s stage of professional development and the problems that are most pressing at the moment”.1
The life and work of Adam Gorczyński (1805–1876), a writer, a translator of Schiller and Goethe, a painter, the co-founder of the Cracow Society of Friends of Fine Arts, a social activist, and a philanthropist has been recently enjoying great interest.57–60 In the years 1835–1845,
es-pecially in the region of Lesser Poland, which was experi-encing the greatest social and political freedom. His own poetic work was forgotten. Interestingly, a prominent literary critic and poet, Paweł Hertz, chose the poem entitled W grudniu! (In December!) as the first among 4 poems by Gorczyński selected for Hertz’s monumental collection Zbiór Poetów Polskich XIX wieku (Collection of
Polish Poets of the 19th Century) (Appendix 1).61,62 During
the classes conducted by the author of this article, cover-ing the issue of professional burnout, the poem evoked very positive emotions in students, as it emphasized the value of providing the patient with help against objective difficulties.
In December! constitutes a proposal to be included in
a Polish anthology for medical students, the develop-ment and validation of which is undoubtedly needed.13,23
Another issue is the development of medical libraries in terms of increasing their resources and the development of the technology of interactive sharing, which serves the purpose of the multidirectional humanization of medi-cal professionals,63 as well as changes in the editorial
concept of scientific magazines, including, among other things, enriching the publications with the perspective of patients – as it was done in “The British Medical Journal” – or with the artistic expression of problems.64
The analysis of literary works may become an impor-tant element of medical training also in Poland. However, in order for that to happen, it is necessary to undertake creative discourse, select works and validate the devel-oped educational modules.
ORCID iD
Kamil Konrad Hozyasz https://orcid.org/0000-0001-8606-2509
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In December!
A December day – storm, Biting winds blow
And a blizzard hits the eyes – Joyless and tedious ride, Wheels so smeared with mud That the carriage is barely rolling. “Stop! my cigar is out” – As the carter so heard, he stopped In front of a tavern well known To all men riding the highroad. “Wicked rain today,
Fire, please”. And the girl
Lights up the match despite Saturday, Catholic is the family
From the tavern,
Faces known to the traveler. Even though my stop was short, I did notice,
The chamber was filled with silence And there was woe on everyone’s faces,. Has some ill fate come to this place? Has something bad come to this home? Yes, indeed,
The husbandman’s ill and lies feverish – No money to fetch the doctor,
And Cracow’s so far away, But good mister Wróblewski Did come to the tavern
And gave the man some medicine. Will he come to see the patient again? To see a poor man?
Appendix 1. Adam Gorczyński’s poem W grudniu! (In December!) from a poetry book62 published posthumously in 1883 Załącznik 1. Wiersz Adama Gorczyńskiego W grudniu! z tomiku62 wydanego pośmiertnie w 1883 r.
Thus, the wife the day before Had gone to see the doctor; She’d come with some advice,
She’d come with some herbs or medicine, But Cracow’s so far away.
I keep riding farther,
Reach the toll house in Przegorzały*, Storm,
Biting winds blow
Snowflakes fall on the ground. No one rides such a road In such misery. Still!
I can see on the white road Something is coming from Cracow. A small cart moves slowly, With a man and a woman And someone else; Wrapped in his coat and in the snow,
Riding through the storm. As the cart gets closer to me, A familiar face I see;
I remove my hat and bow my head Before the virtue ahead,
Which shows to us, neighbors A display of neighborly love.
* Przegorzały was formerly a small village located near the city of Cracow; it is currently located within the borders of a Cracow district, Zwierzyniec. After finishing his studies and buying his family estate back, Gorczyński settled in Brzeźnica,58 35 km away from Cracow. As a social activist, who held the position of an antiquity restorer in the area of Western Galicia, he was the President of the Galician Forestry Society, he co-founded the Cracow Society
