Abstract

Poetry is a powerful tool to promote communication, develop insight and empathy, examine ethical issues, and challenge assumptions. We have been using poetry in health professions education for many years and wished to capture its impact on healthcare learners and professionals, with a focus on competencies essential to healthcare providers. A three-hour poetry workshop was conducted during the National Conference for Health Professions Educators, 2022, for volunteers from the health professions. Poems were curated beforehand to highlight ethics concepts, and social and structural healthcare barriers. Participant responses suggested that they connected with the struggles depicted, noticed ethical issues, and experienced empathy. Online feedback from participants after the workshop revealed that the poems motivated self-reflection, gave voice to feelings, and helped understand patient perspectives. Our findings suggest that integrating poetry into the curriculum can improve educational competencies, enhance understanding of illness, and facilitate creativity, reflective learning, and discussions on self-care and burnout.

Keywords: poetry, communication, competency-based education, empathy, ethics.

Introduction

Poetry reading has been found to foster engagement with one’s own feelings and thoughts as well as with the feelings and thoughts of others [1]. Its use in medical education allows learners to bridge the gap between the theoretical teaching of empathy and learning by actually experiencing it. Poetry can cultivate students’ critical thinking on socially relevant aspects of healthcare, challenge their assumptions, help them recognise ethical issues, and appreciate that there could be multiple perspectives [2, 3]. It may also prevent provider cynicism, detachment, and burnout [1]. We are medical educators and proponents of the health humanities and have been using poetry in the classroom and during conference workshops. While we have received encouraging feedback from classroom learners [4], we were curious to explore how workshop participants viewed the modality. This article describes our experience with a three-hour poetry workshop for volunteers from the health professions. The data collected during the workshop, and later, from the feedback, was analysed to determine how poetry intersects with the ABCDE attributes (attitude, advocacy, behaviour, communication, diversity, ethics and empathy) of healthcare providers [5]; and also, how it could contribute to achieving curricular competencies [6, 7].

The workshop

Fifteen participants [learners and teachers from the medical and nursing professions] volunteered for the poetry workshop at the National Conference on Health Professions Education (NCHPE) hosted at the Himalayan Institute of Medical Sciences (HIMS), Dehradun in October-November 2022.

The resource material comprised of poems curated by the authors beforehand to showcase ethics concepts like autonomy, care-giving, cultural barriers, decisional capacity, dementia, disability, discrimination, paternalism, patient perspectives, structural barriers, surrogate decision making, and triage; and poems brought to the workshop by participants.

Participant experiences were captured during the workshop as reactions to the poems (in writing, without identifying themselves) in terms of feelings and thoughts. After the workshop, they were requested to complete an anonymous, online feedback form as soon as they could within the following week so that feedback remained relevant and recent. The items in the feedback questionnaire are displayed in column 1, Table 1. Feedback sought to explore if the poems were successful in drawing attention to the ABCDE attributes; helpful in identifying struggle, and expressing feelings and emotions; and likely to add value to the curriculum.

Table 1: Results of the online feedback provided by the participants soon after the workshop (response rate 8/15; 53.3%)

Examining participant responses

The reactions generated after the reading of each poem were examined by the authors for key attributes of a healthcare provider (Table 2, keywords derived from the ABCDE attributes and from competency roles prescribed for healthcare learners) [5, 6, 7]. The table displays quotes from responses that point to specific attributes.

Table 2: Excerpts of participant responses to the curated poems read during the workshop, and the attributes they point to

Participant engagement

Some participants read out a favourite poem, written by themselves or by another poet, that highlighted burnout, care giving, chronic illness, dignity, empathy, healthcare-related struggles, joy, love, nature, palliative care, positivity, and self-compassion (Supplementary file 1, available online only).

One participant wrote a poem on the spot while listening to a recitation of the first author’s experience of care giving for a parent with dementia; the authors found the poem to be representative of advocacy, responsiveness, dignity, empathy and compassion (Supplementary file 2, available online only).

Feedback

Eight participants provided online feedback after the workshop. They found that the poetry workshop motivated them to examine their own attitudes, identify ethical behaviour, view different perspectives, and empathise with others, besides helping communicate feelings and evoke emotions (Table 1). They felt that poetry could enhance the understanding of illness and improve personal well-being, and most agreed that it should be included in the curriculum. The one respondent who did not think poetry should be included in the curriculum imagined it being included as a subject rather than as a teaching tool. Including poetry as an additional subject, they felt, would add a burden instead of enjoyment (Table 1).

The relatively low response rate to the post-workshop feedback form (where participants could respond in English or in Hindi) points to a reluctance or inability to engage. Poetry can be a powerful teaching-learning strategy in healthcare education; however, some people find it difficult to engage with a medium that often employs metaphors and can use abstract imagery that forces them to think outside of their comfort zones. There is also the problem that the language in which the poem is written might make it difficult for learners who are not well-versed in it. Participants did list language as a barrier to using poetry in the classroom (Table 1: “I prefer English. I don’t think students prefer English poems.”) Still others might find some poems triggering unpleasant past experiences. In fact, researchers have noted that poetry may [inadvertently] serve to oppress [8]. The possibility that a poem may be triggering should be kept in mind by facilitators and they should take measures to prevent it, like using trigger warnings before sharing, and employing incremental exposure to distressing content [9].

Outcomes of the workshop

The poems curated for the workshop were able to draw attention to ethical dilemmas and many of the factors known to affect patients’ healthcare experiences. Chosen with that intent, the poems generated points of discussion around aspects of the provider-patient relationship that may not be captured in a routine diagnostic interview during a clinical posting [10]. Table 1 demonstrates that the participants picked up on the patient’s perspective, thus looking beyond the disease to the impact it had on the patient’s life. They noticed the struggle depicted in the poems and responded with compassionate suggestions to mitigate it. They considered biases and preconceived notions that they may have internalised and seemed willing to change. They attributed some of the struggle to attitudinal and behavioural causes, and to ineffective communication, and seemed to accept perspectives that were different from their own. Ethical concerns did not escape their attention (Table 2: patient autonomy, human rights, privacy), nor did culturally driven problems (gender norms, patriarchy). They reported that their emotions were stirred by some of the poems (see last row, Table 1), and they were able to connect with the protagonists’ struggles. Their responses showed traits of leadership and advocacy, and a keenness to improve the quality of the healthcare experience. That a poetry session can uncover these reactions is an important learning. It makes poetry an ally for those who wish to hone competencies to create compassionate, patient-centred healthcare providers.

When participants write their own poems

Poetry verbalises complex emotions through the use of figurative, symbolic language [11]. When the poet is a person with experience of illness, or is a healthcare provider, one may get valuable insights into what the world looks like to them, and what their lived experiences are [12]. Poetry, in this way, becomes a way to transfer experiential knowledge [13].

Writing poetry is like giving voice to that which is in our unconscious minds [14]. Putting the words down impels one to reflect and uncover the deeper meanings of experiences, pleasant and unpleasant, and to give a shape to the things one has learned over the years. Writing brings clarity to the poet who must dig deeper to better understand and articulate their experiences [15], while also allowing others to witness a perspective they hadn’t considered before. This understanding is the reason that we always invite participants of poetry endeavours to write their own poems about the topic under consideration. Invariably, some of them do, and it reinforces our belief that more opportunities need to be provided in healthcare training institutions for people to creatively express themselves. This is a unique form of learning: “embodied learning” through lived experience.

Practitioners often struggle with the feelings and emotions that they experience during a clinical interaction and, with no forum to express them, they risk suppressing them. As our study shows, poetry sessions can be the forum — poems can be used to help practitioners acknowledge their own struggles, and then examine them in order to find means to mitigate them. The literature shows that poetry can improve the personal well-being of those who work in healthcare [16, 17]. With respect to participants who brought their own poems to the workshop, it appeared that self-care was important to them. Their poems demonstrated positions at both ends of the spectrum: vulnerability, despair, burnout and resignation on the one hand, and resilience, ambition, self-care and optimism on the other. Such poems, used in a classroom, could open up conversations around a subject that is seldom formally addressed — the mental wellbeing of our learners [18]. Poetry could thus be used to augment other structural interventions to examine and mitigate stress and burnout among healthcare providers.

Our learning

Based on the positive feedback from participants, it would seem that there is a need to leverage the untapped potential of the supportive spaces now created in the new curriculum, such as medical humanities, the AETCOM (Attitude, Ethics and Communication) module, Early Clinical Exposure, and reflections for poetry. This could foster creativity and reflective learning for individuals in the healthcare professions. Our commentary may serve as an impetus to others in the profession who are looking for creative ways to fulfil curricular objectives.