The day after the U.S. presidential election, I sat for my hospice and palliative medicine board exam along with a colleague, one of my partners. During one long day, we worked our way through 240 questions over a 10-hour timeframe. During a break, my partner observed: “It’s unsatisfying to test our skills in multiple-choice format.” Now one could easily quibble that knowledge of opioid conversions and medication side effects are quite adequately tested via multiple choice. But that’s not what she meant. Measuring competence in relational work, in patient connection, in language use, and in the monitoring of suffering—these skills are honed and practiced at the bedside and not in a test bank.
A couple weeks later, a colleague forwarded me an article—a painful read on many fronts—about the final months of a teenager who died from liver cancer in 2023. Her mother, New York Times writer Sarah Wildman, described a year’s worth of poor communication and obfuscation of potentially meaningful conversation from her daughter’s cancer team as well as from palliative care and hospice clinicians: “…not telling families where they are in the process stalls or stymies important conversations,” Wildman writes. “How to live well, even when facing death, requires knowledge” (Wildman). Given that Wildman thinks her daughter was facing her own mortality more clear-eyed than the adults around her, my colleague’s frustration about the relative unsuitability of testing relational skills via multiple choice seems more pressing.
Suspend for a moment any argument about the logistical, practical, and financial challenges in adding a standardized patient simulation to a subspecialty board exam to test those relational skills. A recent global consensus statement on the use of simulation in healthcare training argued that simulation should be used “throughout all phases and levels of a caregiver’s career” and promote lifelong learning (Diaz-Navarro et al. 58). Such experiences are hardly novel. Most medical schools, after all, use standardized patients in their curricula (Brin).
In the absence of formal patient simulation experiences with structured feedback, humanities-based continuing medical education (CME) could provide a training ground to remediate or fine tune one’s relational skills. Take the practice of “medical improv,” developed by instructor Katie Watson. She uses the elements of improvisation to help medical students grapple with patient encounters that can be dynamic and unpredictable (Watson 1260). Through medical improv, palliative care physician Suzanne Mitchell learned to align herself better with others: “Improv makes the power of empathy visible,” she explained. “It helps me appreciate mistakes, foster self-compassion, and learn quickly how my behaviors affect others” (Mehta et al. 264). Hospitalist Ankit Mehta drew on improv skills to turn around a family meeting that had soured. He pulled back from his own internal script, read the emotional cues in front of him, and acknowledged the suffering of his patient’s caregiver: “As her daughter spoke, I could see her pride and love, and the torment of seeing her mother reduced to dependence on others for the most basic human needs” (Mehta et al. 265). For Mehta, improv skills provided the substrate for connection and recalibration at a pivotal moment.
Connection with patients and caregivers not only occurs through thoughtful language, but also through well-timed pauses. Researchers at the University of Vermont sifted through recorded conversations between palliative care clinicians and patients with advanced cancer. They found that pauses, what they termed “connectional silence,” occurred frequently and were associated with moving the needle on decision making and improving quality of life in the short term (Gramling et al. 2008-2010). Looking more deeply at these spaces may find humanities-based inspiration through graphic medicine texts. Mining the meaning of the gutter, that space between comic panels, demands a lot from readers, according to cartoonist and comics theorist Scott McCloud. He explains: “The comics creator asks us to join in a silent dance of the seen and the unseen. The visible and the invisible” (McCloud 92). The silence in a family meeting that seems to stretch forever?—these moments mirror the space between panels before the eye and brain sync up to see how well they imagined what happens next.
My students frequently tell me they seek out a palliative care rotation because they are terrified of saying the wrong thing to seriously ill patients. While dispelling the myth that palliative care practitioners say the right thing all the time, I often lead them toward illness and grief memoirs for guidance on how to sidestep unhelpful platitudes. Kate Bowler in her memoir about her experience with metastatic cancer, Everything Happens for a Reason and Other Lies I’ve Loved, provides a list of things not to say (Bowler 169-172). In her brief grief memoir about the loss of her father, novelist Chimamanda Ngozi Adichie reminds us about the paradox of language during terrible times—both its primacy and inadequacy: ”You learn how much grief is about language, the failure of language and the grasping of language,” (Adichie 6). Her observations remind us to proceed with caution and care when counseling patients in the midst of serious illness and loss.
Probing fiction alongside memoirs may also be instructive. I just started a novel, Florence Adler Swims Forever, about a young woman who drowns while ocean swimming and her family’s decision to keep her death from her sister, pregnant on bedrest in a local hospital in the 1930s. The hospital staff joins the ruse, everyone hoping the delayed stress will avoid a preterm birth for Fannie, who suffered the loss of an infant the year before. My self-spoiler?—anticipating that this paternalistic patient care plan and inherent lack of transparency will not go well.
Each day of practice in medicine, I am reminded of the necessity of infusing my practice with humility; engaging with the humanities helps me with that, reminds me that I cannot predict how suffering might manifest. In the days following the election and my exam, a couple colleagues mentioned that they were taking care of women in their 90s who lamented that these days were among the worst of their lives—not because of a change in health status requiring hospitalization; no, they suffered because of the outcome of the election. These comments did not come from eye-rolling, gum-smacking teenagers, but from women staring down nearly 100 years of existence. No multiple choice question has prepared me to tussle with that scenario. Without the humanities in palliative care training and without continuing medical education opportunities rooted in the arts throughout other specialties, we risk shoehorning our professional development into narrow spaces, trying to find the “one best answer,” when what we really need is a collision with creative practices, those ostensibly not found in answers A, B, C or D.
Works Cited
Adichie, Chimamanda Ngozi. Notes on Grief. Alfred A. Knopf, 2021.
Beanland, Rachel. Florence Adler Swims Forever. Simon and Schuster, 2020.
Brin, Dinah Wisenberg. “Standardized Patients Teach Skills and Empathy.” AAMC News, 27, November 2017. https://www.aamc.org/news/standardized-patients-teach-skills-and-empathy
Bowler, Kate. Everything Happens for a Reason and other Lies I’ve Loved. Random House, 2018.
Diaz-Navarro, Cristina et al. “Global Consensus Statement on Simulation-based Practice in Healthcare.” Advances in Simulation (London, England) vol. 19, no. 3, June 2024, pp. e52-e59. doi:10.1186/s41077-024-00288-1
Gramling, Cailin J et al. “Epidemiology of Connectional Silence in Specialist Serious Illness Conversations.” Patient Education and Counseling vol. 105, no. 7, 2022, pp. 2005-2011. doi:10.1016/j.pec.2021.10.032
McCloud, Scott. Understanding Comics. William Morrow, 1993.
Mehta, Ankit et al. “Improv: Transforming Physicians and Medicine.” Medical Science Educator vol. 31, no. 1, 1 Dec. 2020, pp. 263-266. doi:10.1007/s40670-020-01174-x
Watson, Katie. “Perspective: Serious Play: Teaching Medical Skills with Improvisational Theater Techniques.” Academic Medicine: Journal of the Association of American Medical Colleges vol. 86, No. 10, 2011, pp. 1260-1265. doi:10.1097/ACM.0b013e31822cf858
Wildman, Sarah. “If My Daughter Could Face Her Mortality, Why Couldn’t the Rest of Us?” The New York Times, 25 November 2024, https://www.nytimes.com/2024/11/25/opinion/children-cancer-grief.html?searchResultPosition=1