Using the Arts in Teaching GP Trainees

Using the Arts to teach GP Trainees

Why?

l imagine the idea of using ‘The Arts’ in GP training will intrigue a few GP trainers and a few will think it is a ridiculous idea. Others may well feel the curriculum is crowded enough already. Surely since the European Working Time Directive has reduced trainees’ hours they are struggling to find enough time to learn about ‘real’ medicine and practice management while assiduously filling in their eportfolios, without indulging in such fripperies as reading novels or poetry, watching films or looking at pictures?

And yet, and yet... so many of the problems that present to us in General Practice do not fit into our medical model or the GP curriculum. Even in those patients that do present with proper textbook illnesses, the symptoms are filtered or distorted through the prism of their personal or cultural beliefs and life experiences. I believe we can use the arts as a practical short cut to help trainees develop their empathy and communication skills; to help them move to a higher level of consulting. To develop that connection with the patient which allows the doctor to understand their fears by understanding a bit of their world.

This can mean developing a deep understanding of another human being at a psychological level, as a great novelist can portray a characters innermost thoughts fears and fantasies very powerfully (e.g. Dostoyevsky’s Crime and Punishment).By reading and talking about novels, or extracts from novels or short stories a trainee can gain a deeper understanding of people, and how they react under extreme circumstances.They can start to develop a sense of the ‘narrative’ of a persons life – they may be presenting with dizziness now but how does that fit in with their bereavement 12 months ago/ upcoming wedding /threat of unemployment/neighbour with a brain tumour/ fear of getting old or getting MS?

At a more practical level, a doctor who for example was born and bred in a middle class home in the Shire counties, and went straight to from school to medical school might gain great insight into the other lives by reading books set in working class or immigrant communities (e.g. ‘Heartland’ by Anthony Cartwright;‘Brick Lane’ – Monica Ali, or ‘Some Lives’ by David Widgery’)

I believe knowing a bit about the history of General Practice is important for trainee GPs. I think it helps develop humility (what will future generations look back on with horror about the way we treat people?)– read, for example ‘The Magic Mountain’ – Thomas Mann. Maybe it can also help us think about and develop professionalism and a sense of duty, I usually recommend A Fortunate Man – John Berger/ The Citadel – A J Cronin.

Often, as experienced GP’s with stable lists we have seen people over many years changing from healthy vigorous middle aged people to become increasingly frail elderly and ill patients. Some doctors find this aspect of our job very difficult, but it certainly alters the way we feel about, and possibly treat, the elderly – as we know the person they once were. As a trainee this understanding can be harder to achieve. Of course intellectually any doctor is aware that, for instance, the demented patient in front of them has not always been like that. But watching a film like ‘Iris’, where Judi Dench plays Iris Murdoch’s descent into dementia, while in flashback Kate Winslett is the young Iris, full of life and intellectual vigour – is a reminder to us all to look for the human being behind the illness.

A further reason for using the Arts in teaching GP trainees is that it can be fun for trainer and trainee – it is something a bit different, maybe just outside the comfort zone of both. Trainer and trainee can come to works of art, films or literature as equals – rather than as an expert and pupil and can both learn from each other equally – enriching the learning relationship.

How

So, how can we practically go about using the arts in teaching? There are some broad principles which might be helpful.

As always, it depends on the trainee, or the group of trainees. Where some may be very comfortable , say , writing poetry about a difficult relationship with a patient – others may be very uncomfortable or even feel threatened by an approach which is outside a traditional medical school teaching approach. The best results might be working just within the trainees ‘zone of proximal development’, where they are being pushed or pushing themselves to do something a bit different and challenging but not out of their depth.
Because basically this seems a woolly, touchy –feely approach to most scientifically minded GP trainees, I’ve found it helps to have a clearly structured teaching session. There is detailed advice on this in ‘The Arts in Medical Education- a Practical Guide’ – now sadly out of print but still available through medical libraries. Start with a clear aim – what do you hope to achieve educationally? Then show, say, a clip from a film, or give the group or individual trainee a short story to read or a picture to look at. As a trainer you have to ‘sell’ this a bit by being enthusiastic and then encouraging and facilitating discussion and reflection – trainees nearly always respond and come up with amazing insights and share personal feelings – sometimes more readily than they might while discussing a consultation.

Importantly then look at the practical application of what has been discussed in terms of their day to day work. How will this help the trainee understand their patients better or communicate more effectively – is there a specific patient with similar problems – or who evoked similar feelings in the doctor?Or how does the ethical dilemma we have just been talking about relate to ethical dilemmas in our practice?

What

So, what ‘art ‘ should we be using in our teaching? The answer is pretty much anything – from books, short stories, films, TV shows, opera, paintings, episodes of soaps, music, and poetry. I think it helps if you start at least by using material you feel comfortable with or inspired by. I also often start by using resources which have an obvious medical link(so trainees can see a clear relevance) and which are short so don’t take up too much time in the session.

For example, in John Salinsky’s book ‘Medicine and Literature’ there is arecommended short story; ‘Indian Camp’ by Ernest Hemingway. This is a very short short story which can be read by the group or individual trainee very quickly and easily – written as it is in Hemingway’s deceptively simple descriptive style. It is also about a doctor and is shocking and dramatic. It really is a short cut to feeling, and then talking about, many important and subtle issues which come up in our day to day work. Each group or trainee will probably learn different things from this story – just one example:

“He was feeling excited and talkative as football players are in the dressing room after a game. “That’s one for the medical journal, George,” he said…”

In the context of this story, I see this as the danger and callousness of that buzz of excitement when you have done something really rather clever – say made a brilliant diagnosis – and then the reminder to yourself that your response of ‘ Yes!’ and punching the air when the ultrasound confirms a huge aneurysm or liver may be tempered by the realisation of the impact this will have on a human being.

Some trainees seem to have a resistance to a perceived ‘ponciness’ or inaccessibility of ‘art’ – in which case you could work with episodes from TV or modern films . For example, to illustrate the communication problems of two people with different agendas, trainees were recently shown on a local course Eddie Izzards Darth Vader canteen sketch as interpreted withLego figures(look it up on YouTube).

Using the arts in medical education is not a vital part of every trainees experience, but in these days when the science of medicine and a tick box approach can tend to dominate (yes I’m thinking of QUOF, guidelines and the eportfolio – I am a fan of all three of these – but they do not tell the whole story); I think we should try to preserve the Art of medicine itself – the softer skills of reassurance, the importance of the drug ‘The Doctor’, the importance of touch and awareness of your own feelings and prejudices; of ethics , professionalism and tolerating uncertainty. I believe all these can be highlighted , discussed and learned through using the arts in teaching – and while it is challenging for the teacher – give it a go -it’s a lot more fun than going through the latest set of NICE guidelines.