For patients with brain tumors, the route to the radiation room can be anxiety-producing — particularly the first time, when they go to be fitted with a moldable, plastic mesh mask that will anchor their head in the same position each time they receive radiation therapy.
Annie LaVigne, chief resident in radiation oncology at The Johns Hopkins Hospital, thinks a lot about her patients. To lift their mood, she envisions them being greeted along the corridor by unique wall hangings: mesh masks-turned-art projects. Something similar has been done at Johns Hopkins for some pediatric patients, but LaVigne wants to make the artwork a more prominent collection in her department.
“To make the process less anxiety-producing, I want to ground these foreign objects in something familiar to our patients,” she says, “something we share in common that’s unrelated to cancer, like Old Bay and crabs and the Ravens.”
This ongoing project began when LaVigne was a fourth-year resident and a scholar in the yearlong Health Humanities distinction track for residents and fellows at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. During her time in the track, LaVigne realized that the health humanities were the overarching theme connecting her academic and clinical interests. “In college, I minored in studio art, but I didn’t have much time for it once I started residency,” she says. “The track helped me find my way back to my art and connect it with improving patient care.”
She was also inspired to begin “Reflection Rounds” for her department. Each month, an assortment of doctors, nurses, other care providers and administrative staff come together for half an hour to speak about important and challenging topics that don’t often get discussed, like the power of words to heal and to harm, and what wellness looks like — for patients and for participants. The “rounds” begin with quiet reflection on a work of art or a poem. Then, LaVigne invites participants to share their viewpoints and build upon each other’s thinking. Based on feedback she’s received, many leave feeling rejuvenated and more connected to their colleagues. “Wellness, in my mind, is bred by a sense of belonging and of being valued,” says LaVigne, “and art has a powerful way of enabling that.”
Rx for High-Tech, Low-Touch
LaVigne’s efforts are emblematic of a larger trend in U.S. medical education and training, one that comes in response to the high-tech, low-touch landscape of contemporary health care, where burnout among clinicians is reaching crisis proportions and urgent challenges — public health crises like COVID-19, health disparities and an erosion of patient trust — loom large.
In response to these forces, the Association of American Medical Colleges (AAMC) released a monograph, The Fundamental Role of Arts and Humanities in Medical Education (FRAHME), last December. It calls on academic medical centers to better equip students and trainees with “emotional intelligence and critical thinking skills” through deeper “integrative experiences” with the arts and humanities.
Jeremy Greene, internist and director of the Department of the History of Medicine, served on the national panel that developed FRAHME. “The dual pandemic — of COVID-19 and structural racism — has underscored the vital role that the humanities and social sciences must play in the training of good doctors today — doctors who can think critically and be effective advocates for patients and for the communities they serve,” he says.
Greene recalls the deep roots the humanities have at Johns Hopkins, where the Department of the History of Medicine was founded in 1929 as the first humanities department in any school of medicine in North America. Today at Johns Hopkins, efforts are underway at every level — from premed to fellowship training — to make the arts and humanities a vital part of the learner experience.
Where Society and Medicine Collide
LaVigne’s project grew out of initiatives spearheaded by Kamna Balhara, an assistant professor of emergency medicine and assistant program director for the emergency medicine residency program.
In her previous position as a faculty member at the University of Texas Health Science Center at San Antonio, Balhara helped to provide humanities-based education for medical students, “but there is a dearth of humanities-based education at the graduate medical education level. So, when I started at Hopkins, I looked for ways to support that,” she says.
Since the health humanities broaden the concept of illness to encompass health holistically, they naturally incorporate social, political and historical factors, Balhara says. “Focusing on health equity and social justice is a natural progression, and especially apt for us in emergency medicine who see so many patients from vulnerable populations.” So she teamed up with colleague
Nathan Irvin, assistant professor of emergency medicine, who has expertise in social emergency medicine and health disparities, to found the Center for Health Humanities of Hopkins Emergency Medicine, or H3EM.
Irvin says he chose the field of emergency medicine because that’s where society and medicine collide. “Data suggest that our biomedical interventions only determine about 20 percent of a patient’s outcome. The larger pieces are social factors, like food, housing and job insecurity, and health behaviors, like diet and substance use disorder,” he says.
Through H3EM — which includes art- and literature-based discussions, museum visits, and community immersion experiences — Balhara and Irvin say they aim for residents to better understand the human aspects of health and illness, and to see their patients as individuals within a concrete social context, so that they can deliver more patient-centered care while also serving the local community more effectively.
H3EM is now beginning its fourth year, and Irvin says the response has been encouraging. “Graduates report being more aware of their own humanity and that of everyone around them,” he says. For example, one resident noted, “I try to stop and think more about a patient’s social situation and background and how it could be impacting their health.” And another wrote, “I have conversations with my patients prior to discharge about prescriptions, their home life and how it will impact their recovery process.”
In a second initiative, funded in part by a grant from AAMC’s FRAHME project, Balhara teamed up with neurologist Rachel Salas and novelist Lauren Small, assistant professor of pediatrics at Johns Hopkins Children’s Center, to create the Health Humanities distinction track in which LaVigne participated. Launched in 2020, the track has had 22 participants so far and is especially geared toward those who want to build the health humanities into their careers.
“Residents and fellows in the track analyze core readings in the health humanities as well as curated collections of literature, nonfiction and visual art in a virtual forum. They also attend monthly meetings where they practice different humanities-based pedagogical approaches and have more in-depth conversations,” says Balhara, whose own background includes a master’s degree in French cultural studies from Columbia University.
Those in the track also complete a mentored project, she says, with some focused on developing humanities-based curricula, others doing research in areas relevant to health equity, and some who complete a work of art or a writing portfolio.
Cultivating Empathy — and a Sense of Wonder
One important pillar of Balhara’s initiatives is narrative medicine, which is based on the premise that doctors, nurses and other clinicians live in a world of stories, often mysteries, with their patients as storytellers. By developing the tools to listen attentively to those stories — stories immersed in pain and suffering, illness, injury and joy — health care providers learn to catch important clues and connect more with their patients, consequently improving the care they provide and coping better with stress and burnout.
To cultivate those listening skills, practitioners of narrative medicine bring clinicians together to discuss all forms of narrative: poems, nonfiction, novels, plays, memoir and films. “This isn’t some ‘squishy’ feel-good stuff,” physician Suzanne Koven ’86, the first writer-in-residence at Massachusetts General Hospital, told Hopkins Medicine magazine last fall. “By reading literature closely, you become better able to elicit, interpret and respond to patient stories, which really affects diagnosis and treatment.”
At Johns Hopkins, narrative medicine has been prominently featured since the 2014 founding of the AfterWards program, co-created and now run by Small, a novelist. To date, she’s led more than 70 sessions for Johns Hopkins clinicians.
A second key pillar of the Health Humanities distinction track is an inquiry-based teaching method — known as visual thinking strategies (VTS) — which asks learners to observe and discuss visual art. The idea is to build participants’ ability to describe, analyze and interpret imagery and information, and to have them engage in collaborative discussions, which is all aimed at developing critical thinking skills.
At Johns Hopkins Medicine, psychiatrist Meg Chisolm is a leading advocate of this approach. She says VTS gave her dramatically new ways of thinking and changed the entire course of her medical career, as she pivoted from directing the Johns Hopkins’ Center for Addiction and Pregnancy to become associate director of the Paul McHugh Program for Human Flourishing, whose mission is to help clinicians practice in a more humanistic way.
“What I have come to care about most in life is art museum-based medical education,” says Chisolm, vice chair for education for the Department of Psychiatry and Behavioral Sciences. “I’ve seen its power to cultivate a sense of wonder about oneself and one’s patients, resulting in physicians who are able to deliver more humanized care.”
As an example of the VTS approach, Chisolm describes a popular class she developed for medical students, called Professional Identity Transformation: An Art Museum-Based Elective.
She always begins the first class with this prompt: “Pair up. Then, choose a work of art with which to introduce yourself to your partner. After you exchange introductions, introduce your partner to the rest of the class.” Chisolm says the exercise requires students to listen attentively to their partners, and it replaces dry, formulaic introductions with ones like: “This painting reminded me of the old trumpet my father had, which inspired me to learn to play. In college, I ended up being in the marching band, which is where I met my best friend and my husband.”
In a field rife with the competitive acquisition of knowledge, where students spend years sharpening their individual acumen, Chisolm says this course increases a sense of community and reteaches the value of collaboration and teamwork.
One former student wrote, “It was amazing how someone else would point out something that I had completely missed in studying the same picture or poem.” And another noted, “Since I was young, I have always been afraid to answer questions in class because I did not want to get them wrong, but this class allowed me to express my thoughts without that kind of fear.”
“These art museum-based methods support skills important to physicians, like observation, communication, critical thinking, tolerance of ambiguity, comfort with uncertainty and personal insight,” says Chisolm, who has used VTS and other arts-based teaching methods with Johns Hopkins pre-health professions students, residents/fellows and faculty members, in addition to medical students.
She’s found the course can also help learners process the strong emotions and stressors that arise during training and medical practice. “The class helped me interrogate my feelings about my career in medicine and about patient experiences I had had,” says fourth-year medical student Diane Jung, who took the class last winter. “It gave me time and space to reflect on why I wanted to go into medicine and to realize I still had hope and found purpose in my future as a physician.”
Chisolm’s class is just one opportunity that Johns Hopkins medical students have to learn from the arts and humanities. Another comes in the form of the scholarly concentrations that first-year students must choose from, two of which are humanities based. The concentrations are yearlong courses that pair students with mentors and equip them to do independent research in an area of interest to them. In addition to the more standard options of clinical, basic and public health research, students can choose a concentration in the history of medicine, directed by Nathaniel Comfort, professor of history of medicine, or in Humanism, Ethics and the “Art” of Medicine (HEART), directed by Gail Geller, director of education initiatives at the Berman Institute of Bioethics.
“The HEART concentration allows medical students to pursue research in bioethics and the social sciences or do a creative project,” says Geller, who holds professorships in the schools of medicine, public health, and arts and sciences. “We’ve had students write short stories and plays for both stage and screen, and conduct projects in photography, poetry and graphic medicine.”
Apparently, when given permission to deviate from the sciences, many of today’s aspiring physicians appreciate the value-add of the humanities.
At the Homewood campus, the medicine, science and the humanities major, launched in 2015 and directed until recently by Jeremy Greene, is the fastest-growing major for undergraduates, with more than 100 students currently enrolled. Many would traditionally have followed the lab-heavy “premed” curriculum at Johns Hopkins but instead are choosing this as a more effective and meaningful way to prepare for a career in health care, says Greene. Additionally, he adds, “The major better prepares them for the revised MCAT, which now includes more critical analysis, reasoning skills and social sciences.”
So, instead of analyzing more molecules in more beakers, undergrads can choose to take courses like Representations of Pain and Suffering in Contemporary Culture or Lives in Medicine: Exploring the Personal Writing of Patients and Practitioners.
“Today’s students understand it’s not sufficient to think about health as something purely defined by the sciences,” Greene says.Roy Ziegelstein, the school of medicine’s vice dean for education and a physician-painter himself, is enthusiastic about the elevating power of the arts and humanities for learners at all stages. “Our medical humanities programs and courses are important,” he says, “but what’s more important, from my perspective, is that humanism is embedded in our culture, and that we respect the humanity of each other and of the people we take care of. And I do believe this is the case at Hopkins. Humanism is part of our value system.”