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552 September 2003 Family Medicine

L iteratu reand theArts in Medical Education

Johanna Shapiro, PhDFeature Edito r

Editors Note: In this column, teachers who are currently using literary and artistic materials as part oftheir curricula will briefly summarize specific works, delineate their purposes and goals in using thesemedia, describe their audience and teaching strategies, discuss their methods of evaluation, and speculateabout the impact of these teaching tools on learners (and teachers).

Submissions should be three to five double-spaced pages with a minimum of references. Sendyour submissions to me at Univers ity of California, Irvine, Department of Family Medicine, 101 CityDrive South, Building 200, Room 512, Route 81, Orange, CA 92868-3298. 949-824-3748. Fax: 714-456-7984. jfshapir@uci.edu.

(Fam Med 2003;35(8):552-4.)

Talking about death and end-of-lifecare is too often an uncomfortableand taboo subject for physicians andtheir patients. The American Acad-

emy of Family Physicians (AAFP),however, strongly recommendsend-of-life training for physicians.The AAFP published Recom -mended Core Educational Guide-lines for Family Practice Residentsin End-of-life Care in 1998.1A com-prehensive medical education pro-gram of palliative and end-of-lifecare must address physician com-fort level, self-awareness, and com-munication skills, such as in theAmerican Medical Associations

Education for Physicians on End-of-life Care (EPEC) curriculum.2

This article describes a humanities-based component of our familymedicine end-of-life training cur-

riculum. It facilitates discussionsamong our learners of issues em-phasized by EPEC with sensitivity,enthusiasm, and creativity. The spe-

cific teaching tool we use is a bookclub discussion generated by thereading of the text Tuesdays WithMorrie.3

Tuesdays With Morrie is a re-markable book with powerful les-sons for patients and doctors alikeabout living and dying. First pub-lished in 1997, it quickly jumpedto the New York Times BestsellerList for a lengthy stay. The text re-counts the intimate conversationsbetween retired professor Morrie

Schwartz and a past student, MitchAlbom. Their discussions revolvearound Morries increasing infir-mity and weakness as he ap-proaches death. Morrie has amyo-trophic lateral sclerosis (ALS), alsoknown as Lou Gehrigs disease.

For the past 5 years, we havemailed a copy of Tuesdays WithMorrie to our incoming class offamily medicine interns with a

cover letter welcoming them to ourprogram. We instruct them that thebook is a gift and ask them to readthe text and bring their thoughts,

reflections, and impressions to abook club meeting we will holdduring orientation. During our ap-proximately 60-minute conversa-tion over lunch, the residents are en-couraged to share their reactionsand to read aloud from the text thosepassages that have touched them insome way. As instructors, we allowthe discussion to develop its owncourse and momentum. Our inter-ventions are mostly to underscoreconsideration of the themes of love,

family, and endings and to exploreimplications of the text forresidents training and work withpatients.

We have found our residents tobe enthusiastic about sharing theirreactions to the book. Many of thembring the books dog-eared and high-lighted with passages that theyfound especially moving orthought-provoking.

Tuesdays WithMorrie: A Humanities Teaching

ExerciseinPalliativeandEnd-of-lifeCare

Jeffrey M. R ing, PhD; JoMarieReilly, MD

From the Family Practice Residency Program,White Me morial Medica l Center, Los Angeles.

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553Vol. 35, No. 8Literature and the Arts in Medical Education

If you hold back on the emo-

tionsif you dont allow your-

self to go all the way through

themyou can never get to be-

ing detached, youre too busy

being afraid. Youre afraid of the

pain, youre afraid of the grief.

Youre afraid of the vulnerabil-

ity that loving entails. (p. 104)3

As long as we can love each

other, and remember the feeling

of love we had, we can die with-

out ever really going away. All

the love you created is sti ll there.

All the memories are still there.

You live onin the hearts of ev-

eryone you have touched and nur-

tured while you were here.

(p.174)3

The themes raised in our discus-sion range from an appreciation ofMorries joy for life to commentson the role of spirituality and reli-gion at the end of life to observa-tions of his striking mindfulness ashe faces his impending death (Table1). Our residents have raised the

question of cultural privilege, won-dering whether Morrie is especiallyable to be so mindful, present, andat peace with his death because of

his wealth and comfortable socio-economic level. Additionally, thetext opens discussions of hospicecare, including the appropriatenessof hospice referrals and potentialcultural and social barriers to ac-cessing hospice care. We feel thatthe exercise gives our learners in-creased comfort with and access tobreaking the social taboo of talk-ing about death, even when it is sooften at the forefront of patientsand doctors minds. It provideslearners with a personal and colle-gial opportunity to reflect on themeaning of their own life, considertheir humanity, and explore path-ways to compassion as a physician.

With great consistency over theyears, the discussion moves to atheme we did not initially anticipateas part of the activity objectives.Our residents comment on the jux-

taposition of reading a book thatinspires them to live life fully justas they begin an intensive residencytraining program that will severelyinterfere with life, sleep, and rela-tionships. This provides a forum fordialogue on physician well-being,stress reduction techniques, andsupport systems. We believe thatthis activity, held during orientation,sets a precedent for reading litera-ture outside of medicine. It indicatesour eagerness to directly, albeit cre-

atively, address the challenges facedby physicians (both personal andprofessional) in providing excellentend-of-life care. Further, it sets this

tone and priority very early in theirtraining.

We always ask our residentsabout their experience of receivingthe book and assignment (Table 2).They have told us of the pleasantsurprise of receiving a gift in themail from the place they will soonbegin training (and it was hard-

cover!). Others have added thatthey appreciate that we did not se-lect a book that was fat with smallprint! Over the years, several resi-dents have told us that the book hadbeen previously recommended tothem, but they never had the timeor motivation to actually sit downand read it. Some have commentedthat they enjoyed the uplifting andfast-paced reading. Others havetold us that it was the first non-medical text they had read in sev-

eral years and appreciated the op-portunity and creativity of the as-signment. Some are motivated toread other literature that they had

been meaning to get to for a while.Palliative care remains an impor-

tant and often unrecognized com-ponent in medical education andtraining. Further, it is a challengingtopic to teach compassionately andcreatively. We have found that, as ateaching tool, a book club discus-sion ofTuesdays With Morrie is

Table 1

Examples of Discussion Themes From Tuesdays With Morrie

Finding joy in life, even in the face of pending mortality Mindfulness and fearlessness in the face of death Privilege, attitudes, and disparities in end-of-life care

Spiritual issues at the end of life Roles of f amily, love, and social support when facing a chronic, debilitating illness Potential benefits of hospice care Physician self-awareness of mortality Personal anecdotes of c hallenges facing residents as they have discussed death with their patients

and/or faced death in their own lives

Table 2

Resident Reactions to the Tuesdays With Morrie Exercise

Pleasure and surprise at receiving a book in the mail Appreciation of the creativity of the assignment Increased compassion in working with severely and terminally ill patients Increased awareness of the challenges that physicians and family members have in caring for the

terminally ill Eagerness to share their thoughts, feelings, and experiences with their peer and faculty colleagues Openness to the marr iage of art and humanities in medicine

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554 September 2003 Family Medicine

simple to prepare and facilitate.Moreover, it is a positive and hu-mane way to teach end-of-life care.

Our residents report that the ex-perience of reading and discussingthe book has made an importantpositive impact on their ability todevelop compassionate doctor-patient relationships. They also tellus that their parallel reading of thesame text is a rich aspect of theirbonding as a class. As instructors,

we look forward to our annual bookclub gathering and encourage youto adopt this learning format withthis or other appropriate texts thatbring the richness of the humani-ties to the field of medical educa-tion.

Corresponding Author: Address correspondenceto Dr Ring, White Memorial Medical Center,Family Practice Residency Program, 1720 CesarChavez Avenue, Los Angeles, CA 90033. 323-226-1100. ring@usc.edu.

REFERENCES

1. American Academy of Family Physicians.Core educational guidelines for fa mily prac-tice residents in end-of-life care. Leawood,Kan: American Academy of Family Physi-cians, 1998.

2. American Medical Association. Educationfor physicians on end-of-life care: trainersguide. Chicago: American Medical Associa-

tion, 1999.3 Albom M. Tuesdays with Morrie. New York:

Bantam Doubleday Publishing Group, 1997.