Dear Editor,

We were interested to read your recently published paper describing the need for storytelling and poetry for clinicians in the time of coronavirus (Barrett et al. Reference Barrett, Dickson, Hayes-Brady and Wheelock2020). As medical students, this necessity for storytelling strongly resonated with us: helping us become emotionally literate clinicians whilst enabling a better understanding of patients’ experience.

In the original paper, it was highlighted that clinicians and patients can use poetry and storytelling to ‘support identification’, ‘to process experiences’ and ‘to promote coping’. This is especially important during the intense and emotional pandemic period, when this narrative approach to practicing medicine can aid in building resilience for clinicians. However, we feel when applied to the context of medical student education, these qualitative mediums enable us to develop self-knowledge and to deepen the insight required as clinicians to have effective and compassionate patient communication.

For medical students, the COVID-19 pandemic has introduced new challenges for existing curricula and in gaining adequate clinical experiences. In a learning environment now dominated by virtual lectures, self-directed learning and a lack of patient contact, a narrative approach for learning medicine is more important than ever. We believe integrating narratives robustly into the curriculum is a priority; fostering these important skills early will help our future doctors become more reflective, conscientious and resilient in their practice.

Narrative is fundamental to understanding human experience. In medicine, ‘players’ are regularly put in situations that challenge emotions and conceptions of self; often requiring difficult decisions. Clinicians’ actions should balance the rational mechanisms of procedural medicine and the requirement to understand the meaning of our roles and interactions. Thus, as clinicians, it is fundamental to develop narrative competence (Charon Reference Charon2001). Literature and poetry allow us to ‘sharpen listening, attentiveness, observation and analytical skills’, whilst also enhancing ‘empathy, self-awareness and introspection’ (Bromberg Reference Bromberg2008). Literature and poetry are, therefore, an ideal instrument to develop one’s narrative competence.

Barrett et al., explain that narrative competence can be sought and practiced using several approaches, including poetry, storytelling and literature in addition to Schwartz Rounds and Balint groups. We will analyse and discuss these techniques for medical students – for whom the utility and benefits likely differ from those of a clinician.

Literature and poetry are a valuable tool in developing medical students into self-realised, emotionally conscious clinicians. Existing programmes have improved communication skills and clinician-patient relationships (Brown Reference Brown2015). Used in combination with narrative learning in modern medical curricula, such as Balint groups and Schwartz Rounds – this offers an opportunity for students to develop skills that will serve both patients and their future emotional wellbeing. Implementing medical humanities into the curriculum allows reflections upon the transformations that inevitably arise with the job, and the multifaceted professionalism these require (Shafer et al. Reference Shafer, Maxwell, Strauss and Kopp2007). The value of literature within medical education is its focus on empathy from cognitive and affective perspectives, beyond just the active component of feeling listened to and understood (Wolters and Wijnen-Meijer Reference Wolters and Wijnen-Meijer2012). Notable examples of medical students’ poetry have been produced by Bristol students (Gardner et al. Reference Gardner, Golestaneh, Dhillon and Shafer2010; Thompson et al. Reference Thompson, van de Klee, Lamont-Robinson and Duffin2010). An appreciation of poetry in medicine exists throughout the profession with poetry published in scientific journals and the success of the Hippocrates Prize for Poetry and Medicine. With such pivotal roles for sustaining empathy and communication skills, poetry and literature are a powerful adjunct to reflective and clinical practice and medical curricula should prioritise them as such.

As undergraduates, we were fortunate to experience Balint groups. These were a valuable forum to discuss and reflect upon emotionally challenging clinical situations, develop interpersonal skills and to view the patient beyond a clinical problem-solving exercise. Patient narratives at medical school can sadly exist merely as simplified ‘cases’ and patient presentations are only discussed at surface level. To develop meaningful doctor–patient relationships, exploring patient narratives should be prioritised alongside learning communication and history taking skills. Recent research has highlighted the value of Balint groups for undergraduates, improving personal and professional development, stress management and reducing burnout (Yazdankhahfard et al. Reference Yazdankhahfard, Haghani and Omid2019). Awareness of the doctor–patient relationship, communication skills and reflecting on our own prejudices and psychological factors can also be effectively explored in this setting (Yakeley et al. Reference Yakeley, Shoenberg, Morris and Sturgeon2011; O’Neill et al. Reference O’Neill, Foster and Gilbert-Obrart2016).

Schwartz Rounds foster a compassionate culture; through which clinicians feel patient-centred care is prioritised (Goodrich Reference Goodrich2012; Francis Reference Francis2013). Incorporating rotating students into Schwartz Rounds within a longstanding clinical team may challenge the safe environment created for open discussion. Nonetheless, implementing Schwartz Rounds into the undergraduate curriculum has been well-received by medical students, promoting empathy, resilience and communication skills (Shield et al. Reference Shield, Tong, Tomas and Besdine2011; Barker et al. Reference Barker, Cornwell and Gishen2016; Gishen et al. Reference Gishen, Whitman, Gill, Barker and Walker2016; Stocker et al. Reference Stocker, Cooney, Thomas, Kumaravel, Langlands and Hearn2018). This approach is especially pertinent when a loss of empathy has been reported by medical students as they progress through clinical phases of training (Hojat et al. Reference Hojat, Shannon, DeSantis, Speicher, Bragan and Calabrese2020).

Balint groups and Schwartz Rounds can therefore be seen as effective for students to develop self-awareness, in addition to promoting personal growth and well-being. Whilst these techniques promote self-exploration in a safe setting, literature and poetry allow the first-hand experience of multiple and diverse voices, fostering creativity and acceptance of ambiguity. Medical schools should promote these values to prepare our future doctors to face the uncertainties and pressures of the clinical workplace (Novack et al. Reference Novack, Epstein and Paulsen1999; Schön Reference Schön2017).

Barrett et al., express the need for ‘new frameworks of systemic support’ in response to increasing clinician burnout. In response, we would like to highlight increasing burnout amongst medical students: a recent study found 29% of respondents were given a mental health diagnosis during medical school, and 85% could be classified as ‘disengaged’ and 85% ‘exhausted’ (Farrell et al. Reference Farrell, Kadhum, Lewis, Singh, Penzenstadler and Molodynski2019). Many medical students are at risk of or already suffering from burnout before qualifying (Cecil et al. Reference Cecil, McHale, Hart and Laidlaw2014). As students progress through training, beyond the risk to clinician’s own personal health, this also has implications for patient care, communication and outcomes (Dyrbye et al. Reference Dyrbye, Thomas, Huntington, Lawson, Novotny, Sloan and Shanafelt2006; Halbesleben and Rathert Reference Halbesleben and Rathert2008; Brown et al. Reference Brown, Dunn, Byrnes, Morris, Heinrich and Shaw2009). Preventative intervention is key to stop burnout before its initiation.

Thus, establishing narrative learning is paramount for medical students, this should be done not only through Balint groups and Schwartz Rounds, but more importantly through the cultivation of a culture of self-knowledge and lifelong learning. It is our view, motivated by Barrett et al., that learning narrative techniques at medical school will help students develop not only into effective, compassionate clinicians, but also into self-realised human beings.